Preoperative multidisciplinary team decisions for high-risk patients scheduled for noncardiac surgery-a retrospective observational study.

PURPOSE: Preoperative multidisciplinary team (MDT) meetings are recommended for patients at high risk for perioperative complications and mortality, although the underlying evidence is scarce. We aimed to investigate the effect of MDT decisions on patient management and patient outcome. METHODS: We conducted a single-centre retrospective cohort study including all noncardiac surgical patients selected for discussion at preoperative MDT meetings from January 2017 to December 2019 (N = 120). We abstracted preoperative data, MDT decisions, and patient outcomes from the electronic health records for analysis. RESULTS: Of the 120 patients registered for an MDT meeting, 43% did not undergo their initially planned surgery. Only 27% of patients received perioperative management as planned before the MDT meeting. Most surgery cancellations were the MDT's decision (22%) or the patient's decision before or after the MDT discussion (10%). Postoperative complications occurred in 28% of operated patients, and postoperative mortality was 4% at 30 days and 10% at three months, most of which was attributable to postoperative complications. Non-operated patients had a 7% mortality rate at 30 days and 9% at three months. Alterations of perioperative management following MDT discussion were associated with fewer cases of extended length of hospital stay (> ten days). CONCLUSION: This study shows that preoperative MDT meetings for high-risk noncardiac surgical patients altered the management of most patients. Management alterations were associated with fewer hospital admissions of long duration. These results should be interpreted with appropriate caution given the methodological limitations inherent to this small study.

RéSUMé: OBJECTIF: Les réunions préopératoires d'une équipe multidisciplinaire (EMD) sont recommandées pour les patients présentant un risque élevé de complications périopératoires et mortalité, bien que les données probantes sous-jacentes soient rares. Notre objectif était d'étudier l'effet des décisions d'une EMD sur la prise en charge et les issues des patients. MéTHODE: Nous avons mené une étude de cohorte rétrospective monocentrique incluant tous les patients chirurgicaux non cardiaques retenus pour discussion lors des réunions préopératoires de l'EMD de janvier 2017 à décembre 2019 (N = 120). Pour notre analyse, nous avons extrait les données préopératoires, les décisions de l'EMD et les issues des patients des dossiers de santé électroniques. RéSULTATS: Sur les 120 patients inscrits pour discussion dans une réunion de l'EMD, 43 % n'ont pas subi la chirurgie initialement prévue. Seulement 27 % des patients ont bénéficié de la prise en charge périopératoire prévue avant la réunion de l'EMD. La plupart des annulations de chirurgie étaient dues à la décision de l'EMD (22 %) ou à la décision du patient avant ou après la discussion de l'EMD (10 %). Des complications postopératoires sont survenues chez 28 % des patients opérés, et la mortalité postopératoire était de 4 % à 30 jours et de 10 % à trois mois, en majorité attribuable à des complications postopératoires. Les patients non opérés avaient un taux de mortalité de 7 % à 30 jours et de 9 % à trois mois. Les modifications de prise en charge périopératoire à la suite des discussions de l'EMD ont été associées à une réduction des cas de prolongation du séjour à l'hôpital (> dix jours). CONCLUSION: Cette étude montre que les réunions préopératoires de l'EMD pour les patients chirurgicaux non cardiaques à haut risque ont modifié la prise en charge de la plupart des patients. Les modifications apportées à la prise en charge ont été associées à une diminution du nombre d'admissions à l'hôpital pour une longue durée. Ces résultats doivent toutefois être interprétés avec prudence compte tenu des limites méthodologiques inhérentes à cette petite étude.

Impaired microcirculatory perfusion in a rat model of cardiopulmonary bypass: the role of hemodilution.

Although hemodilution is attributed as the main cause of microcirculatory impairment during cardiopulmonary bypass (CPB), this relationship has never been investigated. We investigated the distinct effects of hemodilution with or without CPB on microvascular perfusion and subsequent renal tissue injury in a rat model. Male Wistar rats (375-425 g) were anesthetized, prepared for cremaster muscle intravital microscopy, and subjected to CPB (n = 9), hemodilution alone (n = 9), or a sham procedure (n = 6). Microcirculatory recordings were performed at multiple time points and analyzed for perfusion characteristics. Kidney and lung tissue were investigated for mRNA expression for genes regulating inflammation and endothelial adhesion molecule expression. Renal injury was assessed with immunohistochemistry. Hematocrit levels dropped to 0.24 ± 0.03 l/l and 0.22 ± 0.02 l/l after onset of hemodilution with or without CPB. Microcirculatory perfusion remained unaltered in sham rats. Hemodilution alone induced a 13% decrease in perfused capillaries, after which recovery was observed. Onset of CPB reduced the perfused capillaries by 40% (9.2 ± 0.9 to 5.5 ± 1.5 perfused capillaries per microscope field; P < 0.001), and this reduction persisted throughout the experiment. Endothelial and inflammatory activation and renal histological injury were increased after CPB compared with hemodilution or sham procedure. Hemodilution leads to minor and transient disturbances in microcirculatory perfusion, which cannot fully explain impaired microcirculation following cardiopulmonary bypass. CPB led to increased renal injury and endothelial adhesion molecule expression in the kidney and lung compared with hemodilution. Our findings suggest that microcirculatory impairment during CPB may play a role in the development of kidney injury.

Side-by-Side Alterations in Glycocalyx Thickness and Perfused Microvascular Density During Acute Microcirculatory Alterations in Cardiac Surgery.

OBJECTIVES: Endothelial glycocalyx injury causes microcirculatory perfusion disturbances in experimental studies, but the relevance in a clinical setting remains unknown. We investigated whether glycocalyx dimensions are reduced after onset of CPB and whether this is associated with alterations in microvascular perfusion. METHODS: The current observational study included 36 patients undergoing cardiac surgery without or with CPB, using either nonpulsatile or pulsatile flow. Sublingual microcirculatory perfusion was assessed perioperatively and analyzed for perfused vessel density and PBR, an inverse parameter of endothelial glycocalyx dimensions. RESULTS: Perfused vessel density decreased after onset of CPB in parallel with an increase in PBR in both pulsatile and nonpulsatile groups. In the nonpulsatile CPB group, these alterations were still persistent in the ICU (PVD: T1 19.8 ± 2.8 mm/mm(2) vs. T3 15.3 ± 2.6 mm/mm(2) ; p = 0.004. PBR: T1 2.40 ± 0.35 µm vs. T3 2.60 ± 0.31 µm; p = 0.020). In the off-pump group, perfused vessel density remained unaltered. An inverse correlation between perfused vessel density and PBR was detected. CONCLUSIONS: This study shows that endothelial glycocalyx dimensions decrease after onset of CPB and are closely related to microvascular perfusion when assessed with a novel, noninvasive technique.

Microcirculatory perfusion during different perioperative hemodynamic strategies.

OBJECTIVE: We investigated whether hemodynamic optimization of systemic tissue perfusion based on PPV and CI improves microcirculatory perfusion when compared to a MAP-based strategy in patients undergoing elective abdominal surgery. METHODS: Patients were randomized into a PPV/CI guided group (n = 13, target PPV <12%, CI >2.5 L/min/m(2) , and MAP >70 mmHg) or MAP-guided group (n = 18, target MAP >70 mmHg). PPV, CI, and MAP were measured using noninvasive arterial blood pressure measurements. Sublingual microcirculatory perfusion was measured at one, two, and three hours following anesthesia induction, and quantified as TVD, PVD or the proportion of perfused vessels. Data were analyzed using ANOVA RM. RESULTS: Patients in the PPV/CI group required more fluid administration than control patients (1927 ± 747 mL versus 1283 ± 582 mL, respectively; p = 0.01). Despite this difference, we observed similar values for TVD (RM; F(1.28) = 0.01; p = 0.92), PVD (RM; F(1.28) = 0.09; p = 0.77) and the proportion of perfused vessels (RM; F(1.28) = 0.01; p = 0.76) in both groups. CONCLUSION: Hemodynamic optimization of systemic tissue perfusion is not associated with improvement of microcirculatory perfusion compared to a MAP-guided protocol in patients undergoing abdominal surgery.

Reduced effect of percutaneous retrogasserian glycerol rhizolysis in trigeminal neuralgia affecting the third branch.

INTRODUCTION: The objective of this study was to determine the long-term efficacy of percutaneous glycerol rhizolysis of the trigeminal ganglion for treating patients with trigeminal neuralgia and search for predictors associated with (long-term) benefit to improve patient selection. METHODS: A retrospective study in 60 consecutive patients treated with percutaneous glycerol rhizolysis of the trigeminal ganglion for trigeminal neuralgia. Charts were reviewed in combination with follow-up by questionnaire (n = 55, 92% response). RESULTS: Initial pain relief was achieved in 92% of the patients. Pain-free survival was 59% of the patients at 12 months and 53% at 24 months. Most common side effects were hypesthesia (15%), dry eye (5%), and meningitis (2%). In patients without involvement of the third branch of the trigeminal nerve, the initial effect was 79%, of which 90% achieved more than 2 years pain-free survival, compared with 97% initial effect and less than 40% pain-free survival of more than 2 years when the third trigeminal branch was involved. DISCUSSION: The present study demonstrates that involvement of the third branch is a negative predictor for long-term outcome in percutaneous glycerol rhizolysis of the trigeminal ganglion in patients with classical trigeminal neuralgia. However, in the absence of third-branch involvement, glycerol rhizolysis yields excellent long-term results when initial positive effect is obtained.

Systemic microvascular shunting through hyperdynamic capillaries after acute physiological disturbances following cardiopulmonary bypass.

Previously we showed that cardiopulmonary bypass (CPB) during cardiac surgery is associated with reduced sublingual microcirculatory perfusion and oxygenation. It has been suggested that impaired microcirculatory perfusion may be paralleled by increased heterogeneity of flow in the microvascular bed, possibly leading to arteriovenous shunting. Here we investigated our hypothesis that acute hemodynamic disturbances during extracorporeal circulation indeed lead to microcirculatory heterogeneity with hyperdynamic capillary perfusion and reduced systemic oxygen extraction. In this single-center prospective observational study, patients undergoing cardiac surgery with (n = 18) or without (n = 13) CPB were included. Perioperative microcirculatory perfusion was assessed sublingually with sidestream darkfield imaging, and recordings were quantified for microcirculatory heterogeneity and hyperdynamic capillary perfusion. The relationship with hemodynamic and oxygenation parameters was analyzed. Microcirculatory heterogeneity index increased substantially after onset of CPB [0.5 (0.0-0.9) to 1.0 (0.3-1.3); P = 0.031] but not during off-pump surgery. Median capillary red blood cell (RBC) velocity increased intraoperatively in the CPB group only [1,600 (913-2,500 µm/s) vs. 380 (190-480 µm/s); P < 0.001], with 31% of capillaries supporting high RBC velocities (>2,000 µm/s). Hyperdynamic microcirculatory perfusion was associated with reduced arteriovenous oxygen difference and systemic oxygen consumption during and after CPB. The current study provides the first direct human evidence for a microvascular shunting phenomenon through hyperdynamic capillaries following acute physiological disturbances after onset of CPB. The hypothesis of impaired systemic oxygen offloading caused by hyperdynamic capillaries was supported by reduced blood arteriovenous oxygen difference and low systemic oxygen extraction associated with CPB.

Microcirculatory perfusion is preserved during off-pump but not on-pump cardiac surgery.

OBJECTIVE: This study investigated the perioperative course of microcirculatory perfusion in off-pump compared with on-pump surgery. Additionally, the impact of changes in systemic hemodynamics, hematocrit, and body temperature was studied. DESIGN: Prospective, nonrandomized, observational study. SETTING: Tertiary university hospital. PARTICIPANTS: Patients undergoing coronary artery bypass grafting with (n = 13) or without (n = 13) use of cardiopulmonary bypass. INTERVENTIONS: Microcirculatory measurements were obtained at 5 time points ranging from induction of anesthesia to ICU admission. MEASUREMENTS AND MAIN RESULTS: Microcirculatory recordings were performed with sublingual sidestream dark field imaging. Despite a comparable reduction in intraoperative blood pressure between groups, the perfused vessel density decreased more than 20% after onset of extracorporeal circulation but remained stable in the off-pump group. The reduction in microvascular perfusion in the on-pump group was further paralleled by decreased hematocrit and temperature. Although postbypass hematocrit levels and body temperature were restored to similar levels as in the off-pump group, the median microvascular flow index remained reduced after bypass (2.4 [2.3-2.7]) compared with baseline (2.8 [2.7-2.9]; p = 0.021). CONCLUSIONS: Microcirculatory perfusion remained unaltered throughout off-pump surgery. In contrast, microvascular perfusion declined after initiation of cardiopulmonary bypass and did not recover in the early postoperative phase.

Relationship between Sensory Stimulation and Side Effects in Percutaneous Radiofrequency Treatment of the Trigeminal Ganglion.

INTRODUCTION: The objective of this study was to determine the efficacy of percutaneous radiofrequency (RF) treatment of the trigeminal ganglion for treating patients with trigeminal neuralgia, to determine which patients have a long-term benefit, and to evaluate the effect of RF parameters. METHODS: A retrospective study in 28 consecutive patients in combination with a follow-up questionnaire (n = 26, 93% response). RESULTS: An initial treatment effect of 89% was observed, 60% sustained at 12-month follow-up. Major side effects were hypesthesia (56%), dry eye (20%), and masseter muscle weakness (12%). A lower sensory stimulation threshold during treatment was associated with better patient satisfaction (P = 0.016), improved pain relief (P = 0.039), and trended toward more hypesthesia (P = 0.077). DISCUSSION: This low-volume study reported treatment effects in an older population that were similar to previous studies. Only a higher incidence of hypesthesia was detected by long-term follow-up. This study supported the high efficiency of RF treatment, but there was a high level of side effects. Most notable, low sensory stimulation was associated with increased hypesthesia, whereas higher stimulation levels yielded less effectiveness. Further investigation of an optimal sensory stimulation range for percutaneous RF treatment of the trigeminal ganglion was found to be warranted.

Introduction of a Post-Anaesthesia Care Unit in a Teaching Hospital Is Associated with a Reduced Length of Hospital Stay in Noncardiac Surgery: A Single-Centre Interrupted Time Series Analysis.

BACKGROUND: A post-anaesthesia care unit (PACU) may improve postoperative care compared with intermediate care units (IMCU) due to its dedication to operative care and an individualized duration of postoperative stay. The effects of transition from IMCU to PACU for postoperative care following intermediate to high-risk noncardiac surgery on length of hospital stay, intensive care unit (ICU) utilization, and postoperative complications were investigated. METHODS: This single-centre interrupted time series analysis included patients undergoing eleven different noncardiac surgical procedures associated with frequent postoperative admissions to an IMCU or PACU between January 2018 and March 2019 (IMCU episode) and between October 2019 and December 2020 (PACU episode). Primary outcome was hospital length of stay, secondary outcomes included postoperative complications and ICU admissions. RESULTS: In total, 3300 patients were included. The hospital length of stay was lower following PACU admission compared to IMCU admission (IMCU 7.2 days [4.2-12.0] vs. PACU 6.0 days [3.6-9.1]; p < 0.001). Segmented regression analysis demonstrated that the introduction of the PACU was associated with a decrease in hospital length of stay (GMR 0.77 [95% CI 0.66-0.91]; p = 0.002). No differences between episodes were detected in the number of postoperative complications or postoperative ICU admissions. CONCLUSIONS: The introduction of a PACU for postoperative care of patients undergoing intermediate to high-risk noncardiac surgery was associated with a reduction in the length of stay at the hospital, without increasing postoperative complications.

Is a preoperative multidisciplinary team meeting (cost)effective to improve outcome for high-risk adult patients undergoing noncardiac surgery: the PREPARATION study-a multicenter stepped-wedge cluster randomized trial.

BACKGROUND: As a result of increased life expectancy and improved care for patients suffering from chronic disease, the number of patients with multimorbidity requiring surgical intervention is increasing. For complex surgical patients, it is essential to balance the potential benefits of surgical treatment against the risk of permanent loss of functional capacity and quality of life due to complications. European and US guidelines on perioperative care recommend preoperative multidisciplinary team (MDT) discussions for high-risk noncardiac surgical patients. However, the evidence underlying benefits from preoperative MDT meetings with all relevant perioperative specialties present is limited. The current study aims to investigate the effect of implementation of preoperative MDT discussions for high-risk patients undergoing noncardiac surgery on serious adverse events. METHODS/DESIGN: PREPARATION is a stepped-wedge cluster randomized trial in 14 Dutch hospitals without currently established preoperative MDT meeting. The intervention, preoperative MDT meetings, will be implemented sequentially with seven blocks of 2 hospitals switching from control (preoperative screening as usual) to the intervention every 3 months. Each hospital will be randomized to one of seven blocks. We aim to include 1200 patients. The primary outcome is the incidence of serious adverse events at 6 months. Secondary outcomes include (cost)effectiveness, functional outcome, and quality of life for up to 12 months. DISCUSSION: PREPARATION is the first study to assess the effectiveness of a preoperative MDT meeting for high-risk noncardiac surgical patients in the presence of an anesthesiologist. If the results suggest that preoperative MDT discussions for high-risk patients are (cost)-effective, the current study facilitates implementation of preoperative MDT meetings in clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT05703230. Registered on 11/09/2022.

Multimodal analgesia practices for knee and hip arthroplasties in the Netherlands. A prospective observational study from the PAIN OUT registry.

INTRODUCTION: Different multimodal pain management strategies following total hip arthroplasty(THA) and total knee arthroplasty (TKA) surgery are used in clinical practice. The optimal pain management strategy, however, remains unclear. This study aims to evaluate the differences in perioperative multimodal pain management strategies for THA and TKA in the Netherlands, and studies the associations between patient- and therapy related factors and pain outcomes. METHODS: Data from the Dutch hospitals in the PAIN OUT network were used in this study. Demographic data, pain management strategy including perioperative medication use and anesthetic techniques were recorded and used in a multivariable regression analysis to study the association with maximum pain intensity, the duration of severe pain, pain interference in bed and postoperative nausea. RESULTS: In 343 hip arthroplasty patients and 301 knee arthroplasty patients in seven hospitals, respectively 28 and 35 different combinations of analgesic regimens were used. The number of different drugs prescribed was not related to postoperative pain intensity. Female sex, younger age and spinal anesthesia were associated with higher postoperative maximum pain scores (Numeric Rating Scale (NRS) > 5). Hip surgery and ketamine use were associated with lower postoperative pain scores. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids, higher age, higher body mass index (BMI) and male gender were associated with less postoperative nausea (NRS < 3). CONCLUSION: In conclusion, our study demonstrated a large diversity of analgesic strategies following total joint arthroplasties in the Netherlands. Although no ideal strategy was identified, the use of NSAIDs, ketamine and dexamethasone were associated with less pain and less side effects.

Enriched Air Nitrox Breathing Reduces Venous Gas Bubbles after Simulated SCUBA Diving: A Double-Blind Cross-Over Randomized Trial.

OBJECTIVE: To test the hypothesis whether enriched air nitrox (EAN) breathing during simulated diving reduces decompression stress when compared to compressed air breathing as assessed by intravascular bubble formation after decompression. METHODS: Human volunteers underwent a first simulated dive breathing compressed air to include subjects prone to post-decompression venous gas bubbling. Twelve subjects prone to bubbling underwent a double-blind, randomized, cross-over trial including one simulated dive breathing compressed air, and one dive breathing EAN (36% O2) in a hyperbaric chamber, with identical diving profiles (28 msw for 55 minutes). Intravascular bubble formation was assessed after decompression using pulmonary artery pulsed Doppler. RESULTS: Twelve subjects showing high bubble production were included for the cross-over trial, and all completed the experimental protocol. In the randomized protocol, EAN significantly reduced the bubble score at all time points (cumulative bubble scores: 1 [0-3.5] vs. 8 [4.5-10]; P < 0.001). Three decompression incidents, all presenting as cutaneous itching, occurred in the air versus zero in the EAN group (P = 0.217). Weak correlations were observed between bubble scores and age or body mass index, respectively. CONCLUSION: EAN breathing markedly reduces venous gas bubble emboli after decompression in volunteers selected for susceptibility for intravascular bubble formation. When using similar diving profiles and avoiding oxygen toxicity limits, EAN increases safety of diving as compared to compressed air breathing. TRIAL REGISTRATION: ISRCTN 31681480.

Correction: Enriched Air Nitrox Breathing Reduces Venous Gas Bubbles after Simulated SCUBA Diving: A Double-Blind Cross-Over Randomized Trial.

[This corrects the article DOI: 10.1371/journal.pone.0154761.].

Pulsatile flow during cardiopulmonary bypass preserves postoperative microcirculatory perfusion irrespective of systemic hemodynamics.

The onset of nonpulsatile cardiopulmonary bypass is known to deteriorate microcirculatory perfusion, but it has never been investigated whether this may be prevented by restoration of pulsatility during extracorporeal circulation. We therefore investigated the distinct effects of nonpulsatile and pulsatile flow on microcirculatory perfusion during on-pump cardiac surgery. Patients undergoing coronary artery bypass graft surgery were randomized into a nonpulsatile (n = 17) or pulsatile (n = 16) cardiopulmonary bypass group. Sublingual mucosal microvascular perfusion was measured at distinct perioperative time intervals using sidestream dark field imaging, and quantified as the level of perfused small vessel density and microvascular flow index (vessel diameter < 20 µm). Microcirculation measurements were paralleled by hemodynamic and free hemoglobin analyses. The pulse wave during pulsatile bypass estimated 58 ± 17% of the baseline blood pressure waveform. The observed reduction in perfused vessel density during aorta cross-clamping was only restored in the pulsatile flow group and increased from 15.5 ± 2.4 to 20.3 ± 3.7 mm/mm(2) upon intensive care admission (P < 0.01). The median postoperative microvascular flow index was higher in the pulsatile group [2.6 (2.5-2.9)] than in the nonpulsatile group [2.1 (1.7-2.5); P = 0.001]. Pulsatile flow was not associated with augmentation of free hemoglobin production and was paralleled by improved oxygen consumption from 70 ± 14 to 82 ± 16 ml·min(-1)·m(-2) (P = 0.01) at the end of aortic cross-clamping. In conclusion, pulsatile cardiopulmonary bypass preserves microcirculatory perfusion throughout the early postoperative period, irrespective of systemic hemodynamics. This observation is paralleled by an increase in oxygen consumption during pulsatile flow, which may hint toward decreased microcirculatory heterogeneity during extracorporeal circulation and preservation of microcirculatory perfusion throughout the perioperative period.