[Epidural block associated with improved long-term survival after surgery for colorectal cancer: A retrospective cohort study with propensity score matching].

OBJECTIVE: To investigate the effect of epidural anesthesia on the long-term prognosis of patients after selective colorectal cancer resection surgery. METHODS: This was a retrospective cohort study and approved by local institution review board. Patients who underwent selective colorectal cancer resection surgery from August 2011 to December 2012 in Peking University First Hospital were enrolled. The patients were divided into general anesthesia (GA) group and combined epidural-general anesthesia (EGA) group according to anesthesia type. Primary outcome was patient's long-term survival status. Secondary outcome included the overall incidence of in-hospital complications and length of postoperative in-hospital stay. Propensity score was used to match cases between the two groups based on the probability of receiving EGA. Survival was analyzed by Kaplan-Meier analysis and compared by Log-rank test between the two groups. Multivariate Cox regression analysis was used to investigate the relationship between epidural anesthesia and other variables with long-term survival status. RESULTS: A total of 264 patients were entered into final analysis, including 166 cases in GA group and 98 cases in EGA group. Mean age of the patients was (63.3±12.1) years and mean survival time was 47.2 (95%CI 45.7-48.7) months. Before the propensity score match, the mortality in EGA group was 16.9% (28/166) and 9.2% (9/98) in GA group. But comparison between the two groups had no statistical significance (P=0.091). After the propensity score match, 87 paired cases were matched and analyzed. The risk of long-term mortality in EGA group was lower than that of GA group by Kaplan-Meier analysis (5.7% vs.16.1%, HR=0.344, 95%CI 0.124-0.955, P=0.041). Mean survival time of EGA group was longer than that of GA group (50.3 months vs. 42.9 months, P=0.032). Multivariate Cox regression ana-lysis showed that EGA, in comparison with GA, was related with lower risk of long-term mortality (HR=0.326, 95%CI 0.117-0.909, P=0.032). Age (HR=1.042, 95%CI 1.001-1.085, P=0.046) and preoperative lymph node metastasis (HR=2.924, 95%CI 1.162-7.356, P=0.023) were also related with increased risk of long-term mortality. CONCLUSION: Present study found that perioperative use of epidural anesthesia and analgesia was associated with improvement of the patient's long-term survival. Well-designed studies are needed to verify this hypothesis.

[The correlation between tissue oxygen saturation and postoperative cognitive dysfunction in elderly patients with one lung ventilation].

Objective: To investigate the correlation between tissue oxygen saturation during one lung ventilation and postoperative neuro cognitive dysfunction (PND) in elderly patients in thoracic surgery. Methods: One hundred and twenty-eight elderly patients who underwent selective lobectomy from August 2017 to September 2018 in the Forth Hospital of Hebei Medical University were enrolled. The patients were divided into PND group (n=34) and non-PND group (n=94) according to whether PND occurred 3 days after surgery. Tissue oxygenation was monitored at bilateral forebrain, brachioradialis muscle and quadriceps. Cognitive function was assessed by the Montreal Cognitive Assessment (MoCA) at baseline and the third day after the operation. Postoperative cognitive dysfunction was diagnosed if postoperative MoCA decreased at least 2 scores compared with preoperative baseline value. Outcomes included the incidence of PND, the incidence of tissue oxygen desaturation during one lung ventilation, postoperative complications within 30 days and length of postoperative in-hospital stay. Logistic regression was used to screen independent risk factors of PND. Results: The incidence of postoperative cognitive dysfunction was 26.6% (34/128). The two groups had no significant difference in the incidence of non-neurogenic complications (new occurred arrhythmia, pulmonary infection, pulmonary embolism, acute renal insufficiency, sepsis, deep vein thrombosis, all P>0.05). However, the length of postoperative in-hospital stay of PND group was 7.0 (6.0, 8.5) d, which was longer than that of non-PND group [6.0 (5.0, 8.0) d]. There was significant difference (U=2.394, P=0.017) . There was no correlation between the two groups within the minimum of SmtO(2) in upper limbs (OR=0.988, 95%CI: 0.954-1.024, P=0.519) and the range of desaturation (OR=1.010, 95%CI: 0.979-1.042, P=0.514) , as well as the minimum of SmtO(2) in legs (OR=0.996, 95%CI: 0.961-1.032, P=0.832) and the range of desaturation (OR=0.997, 95%CI: 0.971-1.025, P=0.851) . Multivariate logistic regression analysis showed that the high ASA grade (OR=2.617, 95%CI: 1.112-6.157, P=0.029) and the minimum of cerebral oxygen saturation during one lung ventilation (OR=0.931, 95%CI: 0.880-0.986, P=0.014) were independent risk factors of PND. There was no statistical correlation between muscle oxygen saturation and PND. Conclusion: Cerebral desaturation during one lung ventilation increased the risk of PND in elderly patients, while the muscle desaturation has no statistical correlation with PND.

Randomized clinical trial of intraoperative dexmedetomidine to prevent delirium in the elderly undergoing major non-cardiac surgery.

BACKGROUND: Delirium is common in elderly patients after surgery and is associated with poor outcomes. This study aimed to investigate the impact of intraoperative dexmedetomidine on the incidence of delirium in elderly patients undergoing major surgery. METHODS: This was a randomized double-blind placebo-controlled trial. Elderly patients (aged 60 years or more) scheduled to undergo major non-cardiac surgery were randomized into two groups. Patients in the intervention group received a loading dose of dexmedetomidine 0·6 µg/kg 10 min before induction of anaesthesia followed by a continuous infusion (0·5 µg per kg per h) until 1 h before the end of surgery. Patients in the control group received volume-matched normal saline in the same schedule. The primary outcome was the incidence of delirium during the first 5 days after surgery. Delirium was assessed with the Confusion Assessment Method (CAM) for non-ventilated patients and CAM for the Intensive Care Unit for ventilated patients. RESULTS: In total, 309 patients who received dexmedetomidine and 310 control patients were included in the intention-to-treat analysis. The incidence of delirium within 5 days of surgery was lower with dexmedetomidine treatment: 5·5 per cent (17 of 309) versus 10·3 per cent (32 of 310) in the control group (relative risk (RR) 0·53, 95 per cent c.i. 0·30 to 0·94; P = 0·026). The overall incidence of complications at 30 days was also lower after dexmedetomidine (19·4 per cent (60 of 309) versus 26·1 per cent (81 of 310) for controls; RR 0·74, 0·55 to 0·99, P = 0·047). CONCLUSION: Intraoperative dexmedetomidine halved the risk of delirium in the elderly after major non-cardiac surgery. Registration number: ChiCTR-IPR-15007654 ( www.chictr.org.cn).

ANTECEDENTES: El delirio después de la cirugía es frecuente en los pacientes de edad avanzada y se asocia con malos resultados. El objetivo de este estudio fue investigar el impacto de la administración intraoperatoria de dexmedetomidina en la incidencia de delirio en pacientes mayores sometidos a operaciones de cirugía mayor. MÉTODOS: Se trataba de un ensayo aleatorizado, doble ciego y controlado con placebo. Un total de 620 pacientes mayores (60 años o más) fueron programados para ser sometidos a intervenciones (no cardiacas) de cirugía mayor y se aleatorizaron a dos grupos. Los pacientes en el grupo de intervención recibieron una dosis de carga de dexmedetomidina (0,6 µg/kg, 10 minutos antes de la inducción anestésica) seguida de una infusión continua (0,5 µg/kg/h) hasta 1 h antes de la finalización de la cirugía. Los pacientes del grupo control recibieron el mismo volumen de suero salino siguiendo la misma pauta. El resultado principal era la incidencia de delirio durante los primeros 5 días postoperatorios. Para la valoración del delirio se utilizó el método para la evaluación de la confusión (Confusion Assessment Method, CAM) en pacientes no intubados y el CAM-UCI para los pacientes intubados. RESULTADOS: En total, 309 pacientes que recibieron dexmedetomidina y 310 del grupo control se incluyeron en el análisis por intención de tratar. La incidencia de delirio durante los primeros 5 días tras la cirugía fue inferior en presencia de tratamiento con dexmedetomidina que en ausencia del mismo: 5,5% (17/309) versus 10,3% (32/310); riesgo relativo (RR) 0,53, i.c. del 95% 0,30-0,94, P = 0,026. La incidencia global de complicaciones a los 30 días excluyendo el delirio también fue inferior en presencia que en ausencia de tratamiento con dexmedetomidina (19,4% (60/309) versus 26,1% (81/301), RR 0,74, i.c. del 95% 0,55-0,99, P = 0,047). CONCLUSIÓN: La administración intraoperatoria de dexmedetomidina reduce la presencia de delirio en los pacientes mayores tras cirugía mayor no cardiaca.

[Impact of oliguria during lung surgery on postoperative acute kidney injury].

OBJECTIVE: To explore the influence of intraoperative urine volume on postoperative acute kidney injury (AKI) and the independent risk factors of AKI. METHODS: This was a retrospective cohort study recruiting patients who received selective pulmonary resection under general anesthesia in Peking University First Hospital from July, 2017 to June, 2019. The patients were divided into the AKI group and the control group according to whether they developed postoperative AKI or not. Firstly, univariate analysis was used to analyze the relationship between perioperative variables and postoperative AKI. Secondly, receiver operating characteristic (ROC) curve was used to explore the predictive value of intraoperative urine output for postoperative AKI. The nearest four cutoff values [with the interval of 0.1 mL/(kg·h)] at maximum Youden index were used as cutoff values of oliguria. Then univariate analysis was used to explore the relationship between oliguria defined by these four cutoff values and the risk of AKI. And the cutoff value with maximum OR was chosen as the threshold of oliguria in this study. Lastly, the variables with P < 0.10 in the univariate analysis were selected for inclusion in a multivariate Logistic model to analyze the independent predictors of postoperative AKI. RESULTS: A total of 1 393 patients were enrolled in the study. The incidence of postoperative AKI was 2.2%. ROC curve analysis showed that the area under curve (AUC) of intraoperative urine volume used for predicting postoperative AKI was 0.636 (P=0.009), and the cutoff value of oliguria was 0.785 mL/(kg·h) when Youden index was maximum (Youden index =0.234, sensitivity =48.4%, specificity =75.0%). Furthermore, 0.7, 0.8, 0.9, 1.0 mL/(kg·h) and the traditional cutoff value of 0.5 mL/(kg·h) were used to analyze the influence of oliguria on postoperative AKI. Univariate analysis showed that, when 0.8 mL/(kg·h) was selected as the threshold of oliguria, the patients with oliguria had the most significantly increased risk of AKI (AKI group 48.4% vs. control group 25.3%, OR=2.774, 95%CI 1.357－5.671, P=0.004). Multivariate regression analysis showed that intraoperative urine output < 0.8 mL/(kg·h) was one of the independent risk factors of postoperative AKI (OR=2.698, 95%CI 1.260－5.778, P=0.011). The other two were preoperative hemoglobin ≤120.0 g/L (OR=3.605, 95%CI 1.545－8.412, P=0.003) and preoperative estimated glomerular filtration rate < 30 mL/(min·1.73 m2) (OR=11.009, 95%CI 1.813－66.843, P=0.009). CONCLUSION: Oliguria is an independent risk fact or of postoperative AKI after pulmonary resection, and urine volume < 0.8 mL/(kg·h) is a possible screening criterium.

[Predictive value of umbilical arterial cord pH on complications during hospitalization in neonates after cesarean section].

OBJECTIVE: To analyze the predictive value of umbilical arterial cord pH on complications of hospitalized neonates after cesarean section. METHODS: This was a retrospective cohort study and carried out in Peking University First Hospital from January 1, 2017 to June 30, 2017. Neonates who were delivered by cesarean section were enrolled. The primary endpoint was the incidence of complications during in-hospital stay (including infection, aspiration pneumonia, myocardial damage, etc.). The subjects were divided into two groups:with or without complication. The umbilical arterial cord pH values were compared between the two groups. Perinatal baseline characteristics of maternal and neonatal data were recorded. The ROC curve was used to analyze the value of umbilical arterial cord pH in predicting neonatal complications during hospitalization. Multivariate Logistic regression was employed to analyze the potential risk factors of neonatal complications. RESULTS: In the study, 872 neonates were included in the final analysis (541 in elective surgery and 331 in emergency surgery). The overall incidence of neonatal complications during hospitalization was 14.1%. The first three higher incidences were infection, aspiration pneumonia and myocardial damage. The average pH value in neonates without complication was 7.31 while 7.29 in neonates with complication. There was statistical significance between the two groups (P<0.001). The overall incidence of pH≤7.20 was 3.1% (27/872). The patients in neonates without complication had higher incidence of pH≤7.20 than those in neonates with complication (1.6% vs. 12.2%, P<0.001). Multivariate Logistic regression showed 6 risk factors of neonatal hospitalized complications including preterm delivery (OR=8.224, 95%CI: 4.910-13.777, P<0.001), pregnancy-induced hypertension (OR=1.886, 95%CI: 1.004-3.546, P=0.049), intrauterine growth restriction (OR=4.429, 95%CI: 1.280-15.330, P=0.019), emergency cesarean section (OR=2.711, 95%CI: 1.682-4.369, P<0.001), umbilical arterial blood gas pH≤7.20 (OR=7.420, 95%CI: 2.951-18.655, P<0.001) and 5-minute Apgar score <10 scores (OR=11.849, 95%CI: 3.977-35.128, P<0.001). The areas under the ROC curve of umbilical arterial blood gas pH in all neonatal, elective and emergency cesarean section were 0.570 (95%CI: 0.508-0.633, P=0.012), 0.559 (95%CI: 0.465-0.652, P=0.189) and 0.617 (95%CI: 0.538-0.697, P=0.002), respectively. CONCLUSION: Umbilical arterial cord pH≤7.20 was related with increased incidence of neonatal complications after cesarean section,but ROC curve analysis showed a lower predictive value.

[Dexmedetomidine combined with ropivacaine for continuous femoral nerve block improved postoperative sleep quality in elderly patients after total knee arthroplasty].

Objective: To investigate the effect of dexmedetomidine adding to ropivacaine for continuous femoral nerve block on the improvement of postoperative sleep quality in elderly patients after total knee arthroplasty. Methods: One hundred and sixty patients aged 60 years or older in Jishuitan Hospital scheduled for single total knee arthroplasty between Nov. 2016 and Jun. 2017 were recruited. All patients received spinal anesthesia and were randomized to receive either combined ropivacaine and dexmedetomidine (0.2% ropivacaine 250 ml and 5 µg/kg dexmedetomidine, at a rate of 5 ml/h or 0.1 µg·kg-1·h-1 dexmedetomidine, dexmedetomidine group) or only ropivacaine (0.2% ropivacaine, at a rate of 5 ml/h, controlled group) for continuous femoral nerve block as postoperative analgesia after surgery. The severity of postoperative pain was assessed with numeric rating scale at 4, 24, and 48 hours after surgery both at rest and with movement. Subjective sleep quality and delirium were evaluated daily during the first 3 days postoperatively. Results: The subjective sleep quality scores were 2(1-4), 2(1-4) and 4(2-8), 4(2-7) in dexmedetomidine group and controlled group respectively on the 1st and 2nd days after surgery. The scores of dexmedetomidine group were much better than those of controlled group (Z=-4.597, -4.183, both P<0.05). The difference was statistically significant. The NRS pain scores at rest were 2(1-2), 2(1-4), and 3(2-5), 3(2-6) in dexmedetomidine group and controlled group respectively at 24 and 48 hours after surgery. The scores of dexmedetomidine group were lower than those of controlled group (Z=-6.671, -4.010, both P<0.05). The difference was statistically significant. The NRS pain scores with movement were 1(1-2), 3(2-4), 3(2-3) and 3(2-4), 5(3-6), 5(4-7)in dexmedetomidine group and controlled group respectively at 4, 24 and 48 hours after surgery. The scores of dexmedetomidine group were lower than those of controlled group (Z=-7.167, -6.824, -7.473, all P<0.05). The difference was statistically significant. The incidence of 3-day delirium was lower in dexmedetomidine group (5%) than that in controlled group (15%) (χ2=4.444, P<0.05). The difference was statistically significant. There were no significant differences between groups regarding the incidences of adverse events. Conclusion: Dexmedetomidine combined with ropivacaine for continuous femoral nerve block may improve subjective sleep quality, postoperative analgesia, and reduce delirium in the elderly after total knee arthroplasty.

[Prevalance of peri-anesthesia allergy and its related risk factor: a retrospective survey from 2012-2017].

OBJECTIVE: To investigate the incidence of peri-anesthesia allergy in a tertiary teaching hospital. METHODS: This was a retrospective cohort study. Patients who received anesthesia in operation rooms at Peking University First Hospital from January 2012 to April 2017 were enrolled. Researchers reviewed all the patients' electronic records and screened suspect allergy cases. Allergy was diagnosed according to the definition in Consensus on Management of Perioperative Allergy (China) and Scandinavian Clinical Practice Guidelines on the Diagnosis, Management and Follow-up of Anaphylaxis during Anesthesia. After obtaining the electronic records, two researchers began to screen and supplement missing data according medical records independently, then they checked out each other's data. The final data were reviewed by another two researchers. We collected the patients' basic characteristics, surgery type, anesthesia type, peri-anesthesia use of drugs, prognosis and other data. Univariate logistic regression was employed to screen potential factors of allergy. Factors with statistical significance (P<0.05) in univariate Logistic regression were entered into multivariate Logistic regression to identify independent risk factors of allergy. RESULTS: In the study, 106 074 patients entered final statistic analysis. The incidence of peri-anesthesia allergy was about 1.5/1 000 (156/106 074). The incidence of Grades I, II and III allergy was 64.1% (100/156), 30.1% (47/156), and 5.8% (9/156) respectively. Multivariate logistic regression showed 5 independent risk factors of allergy including history of allergy (OR=6.836, 95%CI: 4.461-10.474, P<0.001), intraoperative use of sufentanil (OR=1.993, 95%CI: 1.228-3.232, P=0.005), intraoperative use of cis-atracuronium (OR=2.495, 95%CI: 1.599-3.893, P<0.001), intraoperative infusion of antibiotics (OR=2.005, 95%CI: 1.375-2.924, P<0.001) and frozen fresh plasma (OR=3.055, 95%CI: 1.842-5.068, P<0.001). CONCLUSION: The incidence of peri-anesthesia allergy is high and further attempt is needed to establish standard operation process of diagnosis and treatment of allergy.