Intraoperative Blood Pressure Lability Acts as a Key Mediator in the Impacts of Goal-Directed Fluid Therapy on Postoperative Complications in Patients Undergoing Major Spine Surgery.

Objective Although goal-directed fluid therapy (GDFT) has been proven to be effective in reducing the incidence of postoperative complications, the underlying mechanisms remain unknown. The aim of this study was to examine the mediating role of intraoperative hemodynamic lability in the association between GDFT and the incidence of postoperative complications. We further tested the role of this mediation effect using mean arterial pressure, a hemodynamic indicator. Methods This secondary analysis used the dataset of a completed nonrandomized controlled study to investigate the effect of GDFT on the incidence of postoperative complications in patients undergoing posterior spine arthrodesis. We used a simple mediation model to test whether there was a mediation effect of average real variability between the association of GDFT and postoperative complications. We conducted mediation analysis using the mediation package in R (version 3.1.2), based on 5,000 bootstrapped samples, adjusting for covariates. Results Among the 300 patients in the study, 40% (120/300) developed postoperative complications within 30 days. GDFT was associated with fewer 30-day postoperative complications after adjustment for confounders (odds ratio: 0.460, 95% CI: 0.278, 0.761; P = 0.003). The total effect of GDFT on postoperative complications was -0.18 (95% CI: -0.28, -0.07; P < 0.01). The average causal mediation effect was -0.08 (95% CI: -0.15, -0.04; P < 0.01). The average direct effect was -0.09 (95% CI: -0.20, 0.03; P = 0.17). The proportion mediated was 49.9% (95% CI: 18.3%, 140.0%). Conclusions The intraoperative blood pressure lability mediates the relationship between GDFT and the incidence of postoperative complications. Future research is needed to clarify whether actively reducing intraoperative blood pressure lability can prevent postoperative complications.

[Standard Process for Palliative Sedation in Peking Union Medical College Hospital].

End-stage patients experience unbearable pain because of refractory symptoms.Palliative sedation is a form of palliative care which relieves patients' agony by lowering their consciousness.Standard palliative sedation can help patients die with dignity.It is distinct from euthanasia and does not alter the survival of patients.Sufficient palliative care is the premise of palliative sedation.Repeated and detailed clinical evaluation,as well as multidisciplinary involvement,is necessary for the standardized implementation of palliative sedation.Here,we proposed the standard process and specifications of palliative sedation in Peking Union Medical College Hospital.Furthermore,we reported a case of palliative sedation for an advanced cancer patient with refractory delirium and living pain to demonstrate its application in clinical practice.

Using ketamine in a patient with a near-occlusion tracheal tumor undergoing tracheal resection and reconstruction: A case report.

BACKGROUND: Tracheal tumors may cause airway obstruction and pose a significant risk to ventilation and oxygenation. Due to its rarity, there is currently no established protocol or guideline for anesthetic management of resection of upper tracheal tumors, therefore individualized strategies are necessary. There are limited number of reports regarding the anesthesthetic management of upper tracheal resection and reconstruction (TRR) in the literature. We successfully used intravenous ketamine to manage a patient with a near-occlusion upper tracheal tumor undergoing TRR. CASE SUMMARY: A 25-year-old female reported progressive dyspnea and hemoptysis. Bronchoscopy showed an intratracheal tumor located one tracheal ring below the glottis, which occluded > 90% of the tracheal lumen. The patient was scheduled for TRR. Considering the risk of complete airway collapse after the induction of general anesthesia, we decided to secure the airway with a tracheostomy with spontaneous breathing. The surgeons needed to transect the trachea 1-2 cartilage rings below and above the tumor borders: a time-consuming process. Coughing and movement needed be minimized; thus, we added intravenous ketamine to local anesthetic infiltration. After tracheostomy, an endotracheal tube was placed into the distal trachea, and general anesthesia was induced. The surgeons resected four cartilage rings with the tumor attached and anastomosed the posterior tracheal wall. We performed a video-laryngoscopy to place a new endotracheal tube. Finally, the surgeons anastomosed the anterior tracheal walls. The patient was extubated uneventfully. CONCLUSION: Ketamine showed great advantages in the anesthesia of upper TRR by providing analgesia with minimal respiratory depression or airway collapse.

[Association of Perioperative Allogeneic Red Blood Cell Transfusion with Postoperative Infections].

Allogeneic red blood cell transfusion can induce transfusion-related immunomodulation while correcting anemia and improving oxygenation,and thus may be associated with the increased risk of postoperative infections.However,the available studies have conflicting conclusions.Preclinical studies demonstrate transfusion-related immunomodulation is associated with transfusion amounts.Stored red blood cells can cause more significant immunosuppression than fresh blood products,while leukoreduction alleviates the negative effect on immune system.However,clinical studies do not reach agreements on these issues.Recently,accumulating multi-center,large-sample-size,real-world studies have reported significant associations of all ogeneic red blood cell transfusion in cardiac,orthopedic,hepatic,pancreatic,gastrointestinal,and vesical surgeries with postoperative infections.Considering the limitations of previous studies,future research should focus on multiple operations,prolong the time interval between transfusion and surgery,include different infections into outcomes,and define the postoperative infections accurately in the premise of adequate samples.High-quality clinical evidence could help to optimize the utilization of blood products and improve the postoperative outcomes.

Propofol Augments Paclitaxel-Induced Cervical Cancer Cell Ferroptosis In Vitro.

Introduction: Cervical cancer is common in women. The present standardized therapies including surgery, chemotherapy, and radiotherapy are still not enough for treatment. Propofol is the most commonly used intravenous anesthetic agent for induction and maintenance of anesthesia and has been shown to exert anti-malignancy effects on cancer cells, inducing oxidative stress and apoptosis. However, the biological effects of propofol have not yet been systematically assessed. In this study, we examined the ferroptosis-related changes caused by propofol and the chemotherapeutic agent paclitaxel besides apoptosis in vitro. Methods: Cervical cancer cell lines (C-33A and HeLa) were treated with propofol alone (1, 2, 5, 10, and 20 µg/ml) or in combination with paclitaxel (0.5, 1, and 5 µg/ml). The viability was assessed using cell counting kit-8 (CCK8), apoptosis was detected by flow cytometry, morphological changes of mitochondria were examined using transmission electron microscope (TEM), cellular reactive oxygen species (ROS), and intracellular ferrous ions were determined by fluorescence microscope or confocal microscopy. The expression and cellular localization of apoptosis and ferroptosis-related molecules were detected by Western blot and multiplex immunohistochemistry (mIHC), respectively. Calcusyn software was used to determine whether propofol has a synergistic effect with paclitaxel. Results: Propofol and paclitaxel inhibited C-33A and HeLa cell viability. There were also synergistic effects when propofol and paclitaxel were used in combination at certain concentrations. In addition, propofol promoted paclitaxel-induced cervical cancer cell death via apoptosis. ROS level and Fe2+ concentrations were also influenced by different drug treatments. Furthermore, propofol, propofol injectable emulsion, and paclitaxel induced ferroptosis-related morphological changes of mitochondria in C-33A and HeLa cells. Ferroptosis-related signaling pathways including SLC7A11/GPX4, ubiquinol/CoQ10/FSP1, and YAP/ACSL4/TFRC were found to be changed under drug treatments. Conclusion: Propofol showed synergistic anticancer effects with paclitaxel in cervical cancer cells. Propofol and paclitaxel may induce ferroptosis of cervical cancer cells besides apoptosis.

[Risk Factors of Bleeding-related Perioperative Cardiac Arrest].

Objective To reveal the incidence,mortality,and risk factors of bleeding-related perioperative cardiac arrest(POCA). Methods We carried out a single-center retrospective case-control study which enrolled all the POCA cases reported from January 2010 to September 2020 in the patient safety incident reporting system of Peking Union Medical College Hospital.For the screening of risk factors,the patients were respectively assigned into the POCA group and the control group at a ratio of 1∶3 according to the same sex,age,American Society of Anesthesiologists(ASA)physical status,and type of surgery in the same month.Potential risk factors for POCA were first selected by univariate analysis.The significant risk factors were then checked based on the clinical experience and further included in the multivariate Logistic regression model. Results Totally 16 bleeding-related POCA cases were collected from the patient safety incident reporting system among the study period,with an overall incidence of 0.36/10 000.The blood loss volume of POCA group and control group was(7 037.50±5 477.70)ml and(375.63±675.14)ml,respectively(P<0.001),and 14(87.5%)patients suffering from bleeding-related POCA died within three days after anesthesia.According to the univariate analysis,patients' body mass index[(21.79±3.57)kg/m2 vs.(24.26±3.91)kg/m2,P=0.043],hemoglobin level[(113.44±31.08)g/L vs.(131.75±19.70)g/L,P=0.039],and alanine aminotransferase level[(17.31±7.73)U/L vs.(26.91±24.73)U/L,P=0.022]were significantly lower in the POCA group than in the control group.Further Logistic regression analysis showed that smaller body mass index and lower preoperative hemoglobin level were independently associated with the occurrence of bleeding-related POCA. Conclusions Bleeding-related POCA rarely occurred but had high mortality.Adequate precautions should be taken for the patients who are to receive surgeries with high risk of intraoperative massive bleeding.Elevating preoperative hemoglobin level might decrease the incidence of bleeding-related POCA.

[Deep Learning-based Risk Prediction Model for Postoperative Healthcare-associated Infections].

Objective To develop a risk prediction model combining pre/intraoperative risk factors and intraoperative vital signs for postoperative healthcare-associated infection(HAI)based on deep learning. Methods We carried out a retrospective study based on two randomized controlled trials(NCT02715076,ChiCTR-IPR-17011099).The patients who underwent elective radical resection of advanced digestive system tumor were included in this study.The primary outcome was HAI within 30 days after surgery.Logistic regression analysis and long short-term memory(LSTM)model based on iteratively occluding sections of the input were used for feature selection.The risk prediction model for postoperative HAI was developed based on deep learning,combining the selected pre/intraoperative risk factors and intraoperative vital signs,and was evaluated by comparison with other models.Finally,we adopted the simulated annealing algorithm to simulatively adjust the vital signs during surgery,trying to explore the adjustment system that can reduce the risk of HAI. Results A total of 839 patients were included in this study,of which 112(13.3%)developed HAI within 30 days after surgery.The selected pre/intraoperative risk factors included neoadjuvant chemotherapy,parenteral nutrition,esophagectomy,gastrectomy,colorectal resection,pancreatoduodenectomy,hepatic resection,intraoperative blood loss>500 ml,and anesthesia time>4 h.The intraoperative vital signs significantly associated with HAI were in an order of heart rate>core body temperature>systolic blood pressure>diastolic blood pressure.Compared with multivariable Logistic regression model,random forest model,and LSTM model including vital signs only,this deep learning-based prediction model performed best(ACC=0.733,F1=0.237,AUC=0.728).The simulation via simulated annealing algorithm reduced the incidence of postoperative HAI.Moreover,the incidence decreased most in the case of reducing the initial annealing temperature and choosing the last 20% of surgery procedure. Conclusions This study developed a risk prediction model for postoperative HAI based on deep learning,which combined pre/intraoperative risk factors and intraoperative basic vital signs.Using simulated annealing algorithm to adjust intraoperative vital signs could reduce the incidence of postoperative HAI to some extent.

Intraoperative thromboelastography-guided transfusion in a patient with factor XI deficiency: A case report.

BACKGROUND: Factor XI (FXI) deficiency, also known as hemophilia C, is a rare bleeding disorder of unpredictable severity that correlates poorly with FXI coagulation activity. This often poses great challenges in perioperative hemostatic management. Thromboelastography (TEG) is a method for testing blood coagulation using a viscoelastic hemostatic assay of whole blood to assess the overall coagulation status. Here, we present the successful application of intraoperative TEG monitoring in an FXI-deficient patient as an individualized blood transfusion strategy. CASE SUMMARY: A 21-year-old male patient with FXI deficiency was scheduled to undergo reconstructive surgery for macrodactyly of the left foot under general anesthesia. To minimize his bleeding risk, he was scheduled to receive fresh frozen plasma (FFP) as an empirical prophylactic FXI replacement at a dose of 15-20 mL/kg body weight (900-1200 mL) before surgery. Subsequent FFP transfusion was to be adjusted according to surgical need. Instead, TEG assessment was used at the beginning and toward the end of his surgery. According to intraoperative TEG results, the normalization of coagulation function was achieved with an infusion of only 800 mL FFP, and blood loss was minimal. The patient showed an uneventful postoperative course and was discharged on postoperative day 8. CONCLUSION: TEG can be readily applied in the intraoperative period to individualize transfusion needs in patients with rare inherited coagulopathy.

Risk Factors for Anesthesia-Related Airway Patient Safety Incidents: A Single-Center Retrospective Case-Control Analysis from 2009 to 2022.

Objective Airway-related patient safety incident (PSI) has always been the top concern of anesthesiologists because this type of incidents could severely threaten patient safety if not treated immediately and properly. This study intends to reveal the composition, prognosis, and to identify risk factors for airway related incidents reported by anesthesiologists. Methods All airway related PSIs reported by anesthesiologists in a Chinese academic hospital between September 2009 and May 2022 were collected from the PSI reporting system. Patients with airway incidents reported were matched 1:1 with controls based on sex and type of surgery. Univariable and multivariable analysis were performed to find risk factors associated with airway incident occurrence, and to evaluate influence of airway PSIs on patient prognosis. Results Among 1,038 PSIs voluntarily reported by anesthesiologists during the study period, 281 cases (27.1%) were airway-related incidents, with an overall reporting incidence of 4.74 per 10,000 among 592,884 anesthesia care episodes. Only ASA physical status was found to be significant independent predictor of these airway PSIs (P = 0.020). Patients with airway PSIs reported had longer extubation time (0.72 ± 1.56 d vs. 0.16 ± 0.77 d, 95%CI: 0.29 to 0.82, P < 0.001), longer ICU length of stay (LOS) (1.63 ± 5.71 d vs. 0.19 ± 0.84 d, 95%CI: 0.57 to 2.32, P= 0.001), longer post operative LOS (10.56 ± 13.09 d vs. 7.59 ± 10.76 d, 95%CI: 0.41 to 5.53, P = 0.023), and longer total in-hospital LOS (14.99 ± 15.18 d vs. 11.62 ± 11.88 d, 95%CI: 0.46 to 6.27,P = 0.024). Conclusions This single-center retrospective case-control study describes the composition of airway-related PSIs reported by anesthesiologists within thirteen years. Airway incidents might influence patient prognosis by elongating extubation time and LOS. Airway PSI data were worth analyzing to improve patient safety.

Regional anesthesia and cancer recurrence in patients with late-stage cancer: a systematic review and meta-analysis.

BACKGROUND: Whether regional anesthesia may help to prevent disease recurrence in cancer patients is still controversial. The stage of cancer at the time of diagnosis is a key factor that defines prognosis and is one of the most important sources of heterogeneity for the treatment effect. We sought to update existing systematic reviews and clarify the effect of regional anesthesia on cancer recurrence in late-stage cancer patients. METHODS: Medline, Embase, and Cochrane Library were searched from inception to September 2020 to identify randomized controlled trials (RCTs) and cohort studies that assessed the effect of regional anesthesia on cancer recurrence and overall survival (OS) compared with general anesthesia. Late-stage cancer patients were primarily assessed according to the American Joint Committee on Cancer Cancer Staging Manual (eighth edition), and the combined hazard ratio (HR) from random-effects models was used to evaluate the effect of regional anesthesia. RESULTS: A total of three RCTs and 34 cohort studies (including 64,691 patients) were identified through the literature search for inclusion in the analysis. The risk of bias was low in the RCTs and was moderate in the observational studies. The pooled HR for recurrence-free survival (RFS) or OS did not favor regional anesthesia when data from RCTs in patients with late-stage cancer were combined (RFS, HR = 1.12, 95% confidence interval [CI]: 0.58-2.18, P = 0.729, I2 = 76%; OS, HR = 0.86, 95% CI: 0.63-1.18, P = 0.345, I2 = 48%). Findings from observational studies showed that regional anesthesia may help to prevent disease recurrence (HR = 0.87, 95% CI: 0.78-0.96, P = 0.008, I2 = 71%) and improve OS (HR = 0.88, 95% CI: 0.79-0.98, P = 0.022, I2 = 79%). CONCLUSIONS: RCTs reveal that OS and RFS were similar between regional and general anesthesia in late-stage cancers. The selection of anesthetic methods should still be based on clinical evaluation, and changes to current practice need more support from large, well-powered, and well-designed studies.

[Risk Factors for Patients Using Intraoperative Vasopressor Infusions During Carotid Body Tumor Excision].

Objective To investigate the risk factors for patients using intraoperative vasopressor infusions during carotid body tumor(CBT)excision.Patients' mean arterial pressure(MAP)and heart rate(HR)fluctuations as well as their requirements for vasoactive agents during surgery were assessed. Methods The patients receiving CBT excision in Peking Union Medical College Hospital from May 1,2013 to July 31,2017 were included for a retrospective cohort study.The potential factors of intraoperative requirement for vasopressor infusions were investigated using univariate analysis and Logistic multivariate analysis.Furthermore,the relationships of Shamblin types of CBT with intraoperative MAP/HR fluctuations and requirements for vasoactive agents were analyzed. Results A total of 108 patients with 116 CBTs were included.Univariate analysis revealed that maximum tumor diameter >4 cm,intraoperative internal carotid artery injury,internal carotid artery reconstruction,malignant pathology,advanced Shamblin types(type Ⅱ and Ⅲ),estimated blood loss ≥400 ml,and operation duration >4 hours were associated with intraoperative requirements for vasopressor infusions.Logistic analysis showed that Shamblin type Ⅲ(OR=2.286,95% CI=1.324-14.926,P=0.016)and operation duration >4 hours(OR=3.874,95% CI=1.020-14.623,P=0.046)were risk factors for intraoperative requirements for vasopressor infusions during CBT surgery.In addition,Shamblin type Ⅲ was associated with intraoperative abnormal HR elevation and requirements for vasopressors.Conclusions Shamblin type Ⅲ and operation duration>4 hours are risk factors for intraoperative requirements of patients for using vasopressor infusions during CBT surgery.Shamblin type Ⅲ is associated with intraoperative abnormal HR elevation and requirements for vasopressors.

Remimazolam tosilate in upper gastrointestinal endoscopy: A multicenter, randomized, non-inferiority, phase III trial.

BACKGROUND AND AIM: Remimazolam tosilate (RT) is a new short-acting GABA(A) receptor agonist, having potential to be an effective option for procedural sedation. Here, we aimed to compare the efficacy and safety of RT with propofol in patients undergoing upper gastrointestinal endoscopy. METHODS: This positive-controlled, non-inferiority, phase III trial recruited patients at 17 centers, between September 2017 and November 2017. A total of 384 patients scheduled to undergo upper gastrointestinal endoscopy were randomly assigned to receive RT or propofol. Primary endpoint was the success rate of sedation. Adverse events (AEs) were recorded to evaluate safety. RESULTS: The success rate of sedation in the RT group was non-inferior to that in the propofol group (97.34% vs 100.00%; difference in rate -2.66%, 95% CI -4.96 to -0.36, meeting criteria for non-inferiority). Patients in the RT group had longer time to adequate sedation (P < 0.0001) but shorter time to fully alert (P < 0.0001) than that in the propofol group. The incidences of hypotension (13.04% vs 42.86%, P < 0.0001), treatment-related hypotension (0.54% vs 5.82%, P < 0.0001), and respiratory depression (1.09% vs 6.88%, P = 0.0064) were significantly lower in the RT group. AEs were reported in 74 (39.15%) patients in the RT group and 114 (60.32%) patients in the propofol group, with significant difference (P < 0.0001). CONCLUSION: This trial established non-inferior sedation success rate of RT compared with propofol. RT allows faster recovery from sedation compared with propofol. The safety profile is favorable and appears to be superior to propofol, indicating that it was feasible and well tolerated for patients.

Infection Prevention Strategy in Operating Room during Coronavirus Disease 2019 (COVID-19) Outbreak.

A novel coronavirus that emerged in late 2019 rapidly spread around the world. Most severe cases need endotracheal intubation and mechanical ventilation, and some mild cases may need emergent surgery under general anesthesia. The novel coronavirus was reported to transmit via droplets, contact and natural aerosols from human to human. Therefore, aerosol-producing procedures such as endotracheal intubation and airway suction may put the healthcare providers at high risk of nosocomial infection. Based on recently published articles, this review provides detailed feasible recommendations for primary anesthesiologists on infection prevention in operating room during COVID-19 outbreak.

Phrenic Nerve Injury Is a Differential Diagnosis of Hypoxemia after Video-Assisted Thoracoscopic Thymectomy: 2 Cases Report and Literature Review.

Hypoxemia after general anesthesia is not uncommon. For patients after thoracotomy, the differential diagnosis is usually difficult. Surgical, anesthetic, and patient-associated factors may contribute to postoperative hypoxemia. We described two patients who underwent video-assisted thoracoscopic thymectomy and developed hypoxemia immediately after extubation. Phrenic nerve injury was suspected in both patients. One case recovered spontaneously without intervention. The second case who had been demonstrated as bilateral phrenic nerve injury after the operation was continuously on ventilator after physical therapy and respiratory training for 2 months.

[Factors Contributing Successful Ultrasound-guided Radial Artery Cannulation and Its Complications When Using the Short-axis Out-of-plane Procedure].

Objective To identify the possible factors that may influence the success and the complications of ultrasound-guided out-of-plane radial arterial cannulation. Methods Multivariate Logistic regression analysis was used to analyze the clinical data of 131 patients undergoing elective surgery and ultrasound-guided out-of-plane radial artery cannulation,dynamic needle tip positioning(DNTP) technique or angular distance(AD) technique and to find out the factors associated with the one-attempt success rate,overall success rate,posterior arterial wall perforation,and local hematoma. Results The depth of the anterior arterial wall≥3 mm was the factor associated with posterior arterial wall perforation(OR=0.314,95%CI:0.143-0.691,P=0.004) and local hematoma(OR=0.250,95%CI:0.107-0.585,P=0.001).The use of DNTP method was significantly associated with posterior arterial wall perforation(OR=0.303,95%CI:0.138-0.667,P=0.003). Conclusions During ultrasound-guided out-of-plane radial cannulation,puncture at the arterial anterior wall sites with a depth of≥3 mm can reduce the incidence of posterior arterial wall perforation and local hematoma.Compared with AD,DNTP can lower the incidence of posterior arterial wall perforation.

[Efficacy of Oxycodone Hydrochloride for Patient-controlled Intravenous Analgesia after General Surgery].

Objective To evaluate the value of oxycodone hydrochloride for postoperative pain management in patients undergoing patient-controlled intravenous analgesia(PCIA). Methods The medical records on postoperative pain management in our department from January 1 to June 30,2018,were retrospectively analyzed.Totally 136 patients were assigned into oxycodone,sufentanil,or morphine groups according to the opioid used in the PCIA.Patients were assessed for postoperative pain severity(scored with NRS)and adverse reactions 24,36,and 48 hours after surgery.The area under curve(AUC)was calculated. Results The score of pain at exercise was significantly lower in the oxycodone group(2.2±2.4)than in the sufentanil group(3.4±2.1)(t=0.305,P=0.0126)or the morphine group(3.4±1.7)(t=0.104,P=0.0277)36 hours after surgery.AUC at rest was significantly lower in the oxycodone and morphine groups than in the sufentanil group(29.00,27.00,and 40.01,respectively);in contrast,AUC at exercise was significantly lower in the oxycodone group(63.17)than in the sufentanil and morphine groups(82.00 and 80.93,respectively).The consumption of opioids was significantly higher in the sufentanil group[(37.2±16.1),(46.1±24.3),(64.4±33.4)mg]than in the oxycodone group[(20.4±14.8)(t=3.571,P=0.001),(24.2±16.1)(t=4.63,P<0.0001),(34.4±25.1)mg(t=6.409,P<0.0001)]or the morphine group[(16.6±11.7)(t=4.233,P<0.0001),(20.5±14.1)(t=5.250,P<0.0001),(28.8±19.0)mg(t=7.354,P<0.0001)]24,36,48 hours after surgery.The oxycodone group experienced less vomiting(χ 2=11.360,P=0.003)and early termination of PCIA(χ 2=7.914,P=0.019)compared with the other two groups. Conclusions Oxycodone can be used for postoperative PCIA.It can alleviate a variety of postoperative pain,with superior analgesic efficiency and safety to sufentanil and morphine.

[Clinical Utility of Revised Cardiac Risk Index to Predict Perioperative Cardiac Events in Elderly Patients with Coronary Heart Disease Undergoing Non-cardiac Surgery].

Objective To explore the predictive ability of the revised cardiac risk index(RCRI)in elderly patients with coronary heart disease(CHD)undergoing non-cardiac surgery. Methods We performed a retrospective study including a total of 2100 patients,aged≥65 with a history of CHD who underwent non-cardiac surgery form January 2013 to September 2019.The preoperative,intraoperative and postoperative clinical data were extracted from an electronic database.The RCRI and reconstructed-RCRI(R-RCRI)score of each patient were calculated.The primary end point was defined as an occurrence of perioperative MACE.Multivariate logistic regression analysis was performed to evaluate the risk factors of perioperative MACE.The area under the receiver operating characteristic(ROC)curve was used to compare the predictive value of RCRI,R-RCRI,and the new risk scoring system of the study for perioperative MACE. Results The incidence of perioperative MACE in elderly patients with CHD was 5.4%.Six independent risk factors of perioperative MACE for this population were identified:age≥80 years;female;history of heart failure;insulin-depended diabetes mellitus;preoperative ST segment abnormality;American Society of Anesthesiologists grade≥Ⅲ,and the risk index was 2,2,2,2,2 and 3 respectively.The area under ROC curve of RCRI,R-RCRI and risk scoring system in this study were 0.586,0.552 and 0.741. Conclusion The correlation between RCRI score and perioperative MACE was poor in elderly patients with CHD undergoing non-cardiac surgery,and a better cardiac risk assessment method should be established for this population.

Ultrasound-Guided Transmuscular Quadratus Lumbar Block Reduces Opioid Consumption after Laparoscopic Partial Nephrectomy.

Objectives Transmuscular quadratus lumborum block (TQLB) may provide postoperative analgesia in patients undergoing intraperitoneal surgeries. The purpose of this study was to examine the potential efficacy of TQLB among patients undergoing retroperitoneal procedures, such as the laparoscopic partial nephrectomy (LPN). Methods This prospective, randomized, controlled study was conducted from August 2017 to November 2018 at Peking Union Medical College Hospital (Beijing, China). Patients who were scheduled for a LPN, aged 18-70 years old with an ASA physical status score of I - II were randomly assigned to receive either TQLB with 0.6 ml/kg of 0.5% ropivacaine plus general anesthesia (TQLB group) or general anesthesia alone (control group). Patient-controlled intravenous analgesia with morphine was initiated immediately upon surgery completion. The primary outcome was the cumulative consumption of morphine within 8 h after surgery. The secondary outcome included postoperative consumptions of morphine at other time points, pain score at rest and during activity, postoperative nausea and vomitting (PONV), and recovery related parameters. Results Totally 30 patients per group were recruited in the study. The 8 h consumption of morphine was lower in the TQLB group than in the control group (median, 0.023 mg/kg vs. 0.068 mg/kg, U=207.5, P<0.001). No significant differences were observed in postoperative pain scores between the two groups. Patients in the TQLB group had fewer episodes of PONV (20% vs. 47%, χ2=4.8, P=0.028) in the first 24 h after surgery and higher scores for quality of recovery (mean, 138.6 vs. 131.9, t=-2.164, P=0.035) 120 h after surgery than the controls. Conclusions TQLB resulted in an opioid-sparing effect during the early postoperative period following LPN, as well as a lower incidence of PONV and improved quality of recovery.

[Perioperative Restrictive Red Blood Cell Transfusion:Recent Advances in Research and Clinical Guidelines].

Perioperative restrictive red blood cell(RBC)transfusion strategy,in which a trigger of hemoglobin(Hb)<7 g/dl is used,is of great benefits to save blood storage and reduce transfusion-related adverse events including infections,immunologic risks,and circulatory overload.Human body can display a series of compensatory mechanisms to acute anemia,including increased cardiac output,favored oxyhemoglobin dissociation,and lung vascular dilation.Therefore,moderate Hb decrease does not necessarily lead to hypoxemia.Patients undergoing hip surgery or suffering from septic shock and/or upper gastrointestinal bleeding can benefit from restrictive RBC transfusion;however,restrictive transfusion may be associated with adverse outcomes in patients with coronary heart disease or undergoing cardiac surgery.Restrictive RBC transfusion strategies have been included in described in many different guidelines.Most of them recommended Hb<7 g/dl to be a trigger for allogeneic RBC transfusion.For patients with an Hb of 7-10 g/dl,the application of restrictive RBC transfusion should be based on the expected blood loss,compensatory ability,and metabolic rate.