Preoperative dipstick albuminuria is associated with acute kidney injury in high-risk patients following non-cardiac surgery: a single-center prospective cohort study.

PURPOSE: This study aimed to investigate the association between preoperative dipstick albuminuria (DA) and acute kidney injury (AKI) in high-risk patients following non-cardiac surgery. METHODS: This was a single-center prospective cohort study. Adult patients with high risk of AKI undergoing non-cardiac surgery were enrolled. The primary outcome was AKI, defined according to KDIGO criteria within 7 days following non-cardiac surgery. DA status was determined by urinalysis performed within 24 h of hospital admission. Multivariate logistic regression model was used to analyze the association between preoperative DA and postoperative AKI. RESULTS: During the study period, 552 patients were enrolled and 8.5% of them developed postoperative AKI. The overall rate of preoperative positive DA was 26.4% with 30 and ≥ 100 mg/dL DA accounting for 19.2% and 7.2%, respectively. Patients with more severe preoperative DA had much higher rate of postoperative AKI (5.2% in patients with negative or trace DA, 13.2% in patients with 30 mg/dL DA and 30.0% in patients with ≥ 100 mg/dL DA, P < 0.001). After adjusting for several perioperative variables, preoperative 30 mg/dL DA (OR 2.575; 95% CI 1.049-6.322; P = 0.039) and ≥ 100 mg/dL DA (OR 3.868; 95% CI 1.246-12.010; P = 0.019) showed an independent association with postoperative AKI. In addition, patients with higher DA status demonstrated significantly increased level of postoperative urine biomarkers and their ratio to urine creatinine. CONCLUSIONS: Preoperative DA was independently associated with AKI in high-risk patients following non-cardiac surgery. Preoperative routine urinalysis for determination of DA status was suggested in early risk stratification.

Preoperative intravenous rehydration for patients with pheochromocytomas and paragangliomas: is it necessary? A propensity score matching analysis.

BACKGROUND: Preoperative intravenous rehydration for patients with pheochromocytomas and paragangliomas (PPGLs) is widely used in many medical centers, but its usefulness has not been well evaluated. The objective of this study was to compare the perioperative hemodynamics and early outcome between patients who received preoperative intravenous rehydration and those without for resection of PPGLs. METHODS: In this retrospective propensity score-matched cohort study, the data of patients who underwent surgery for PPGLs were collected. Patients were divided into two groups depending on whether they received or did not receive intravenous rehydration preoperatively. The primary endpoint was intraoperative hypotension, described as the cumulative time of mean arterial pressure < 65 mmHg averaged by surgery duration. RESULTS: Among 231 enrolled patients, 113 patients received intravenous rehydration of ≥2000 ml daily for ≥2 days before surgery and 118 patients who did not have any intravenous rehydration before surgery. After propensity score matching, 85 patients remained in each group. The median cumulative time of mean arterial pressure < 65 mmHg averaged by surgery duration was not significantly different between rehydrated patients and non-rehydrated patients (median 3.0% [interquartile range 0.2-12.2] versus 3.8% [0.0-14.2], median difference 0.0, 95%CI - 1.2 to 0.8, p = 0.909). The total dose of catecholamines given intraoperatively, volume of intraoperative fluids, intraoperative tachycardia and hypertension, percentage of patients who suffered from postoperative hypotension, postoperative diuretics use, and postoperative early outcome between the two groups were not significantly different either. CONCLUSIONS: For patients with PPGLs, preoperative intravenous rehydration failed to optimize perioperative hemodynamics or improve early outcome.

Correction to: Multimodal analgesia with ropivacaine wound infiltration and intravenous flurbiprofen axetil provides enhanced analgesic effects after radical thyroidectomy: a randomized controlled trial.

Following publication of the original article [1], the authors reported that there has been a mistake regarding the unit of duration of surgery, consciousness recovery time, and extubation time in Table 1; the correct unit is minute.

Multimodal analgesia with ropivacaine wound infiltration and intravenous flurbiprofen axetil provides enhanced analgesic effects after radical thyroidectomy: a randomized controlled trial.

BACKGROUND: Thyroidectomy is a common procedure that causes mild trauma. Nevertheless, postoperative pain remains a major challenge in patient care. Multimodal analgesia comprising a combination of analgesics and analgesic techniques has become increasingly popular for the control of postoperative pain. The present study tested the hypothesis that multimodal analgesia with combined ropivacaine wound infiltration and intravenous flurbiprofen axetil after radical thyroidectomy provided better analgesia than a single dosage of tramadol. METHODS: This randomized controlled trial was conducted in a tertiary hospital. Forty-four patients (age, 18-75 years; American Society of Anesthesiologists status I or II; BMI < 32 kg/m2) scheduled for radical thyroidectomy were randomly assigned to a multimodal analgesia group (Group M) or a control group (Group C) by random numbers assignments, and 40 patients completed the study. All participants and the nurse in charge of follow-up observations were blinded to group assignment. Anesthesia was induced with sufentanil, propofol, and cisatracurium. After tracheal intubation, Group M received pre-incision wound infiltration with 5 ml of 0.5% ropivacaine mixed with epinephrine at 1:200,000 (5 µg/ml); Group C received no wound infiltration. Anesthesia was maintained with target-controlled infusion of propofol, remifentanil, sevoflurane, and intermittent cisatracurium. Twenty minutes before the end of surgery, Group M received 100 mg flurbiprofen axetil while Group C received 100 mg tramadol. Postoperative pain was evaluated with the numerical rating scale (NRS) pain score. Remifentanil consumption, heart rate, and noninvasive blood pressure were recorded intraoperatively. Adverse events were documented. The primary outcome was analgesic effect according to NRS scores. RESULTS: NRS scores at rest were significantly lower in Group M than in Group C before discharge from the postoperative anesthetic care unit (P = 0.003) and at 2 (P = 0.008), 4 (P = 0.020), and 8 h (P = 0.016) postoperatively. Group M also had significantly lower NRS scores during coughing/swallowing at 5 min after extubation (P = 0.017), before discharge from the postoperative anesthetic care unit (P = 0.001), and at 2 (P = 0.002) and 4 h (P = 0.013) postoperatively. Compared with Group C, NRS scores were significantly lower throughout the first 24 h postoperatively in Group M at rest (P = 0.008) and during coughing/swallowing (P = 0.003). No serious adverse events were observed in either group. CONCLUSION: Multimodal analgesia with ropivacaine wound infiltration and intravenous flurbiprofen axetil provided better analgesia than tramadol after radical thyroidectomy. TRIAL REGISTRATION: Chinese Clinical Trial Registry (registration number # ChiCTR1800020290 ; date of registration: 22/12/2018).

Efficacy of preoperative single-dose dexamethasone in preventing postoperative pulmonary complications following minimally invasive esophagectomy: a retrospective propensity score-matched study.

BACKGROUND: The study was performed to investigate the efficacy and safety of preoperative dexamethasone (DXM) in preventing postoperative pulmonary complications (PPCs) after minimally invasive esophagectomy (MIE). METHODS: Patients who underwent total MIE with two-field lymph node dissection from February 2018 to February 2023 were included in this study. Patients who were given either 5 mg or 10 mg DXM as preoperative prophylactic medication before induction of general anesthesia were assigned to the DXM group, while patients who did not receive DXM were assigned to the control group. Preoperative evaluations, intraoperative data, and occurrence of postoperative complications were analyzed. The primary outcome was the incidence of PPCs occurring by day 7 after surgery. RESULTS: In total, 659 patients were included in the study; 453 patients received preoperative DXM, while 206 patients did not. Propensity score-matched analysis created a matched cohort of 366 patients, with 183 patients each in the DXM and control groups. A total of 24.6% of patients in the DXM group and 30.6% of patients in the control group had PPCs (P = 0.198). The incidence of respiratory failure was significantly lower in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). Fewer patients were re-intubated during their hospital stay in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). CONCLUSIONS: Preoperative DXM before induction of anesthesia did not reduce overall PPC development after MIE. Nevertheless, the occurrence of early respiratory failure and the incidence of re-intubation during hospitalization were decreased. TRIAL REGISTRATION: Chinese Clinical Trial Registry (No. ChiCTR2300071674; Date of registration, 22/05/2023).

Perioperative Risk Factors for Postoperative Pulmonary Complications After Minimally Invasive Esophagectomy.

Background: Postoperative pulmonary complications (PPCs) are the most prevalent complication after esophagectomy and are associated with a worse prognosis. This study aimed to investigate the perioperative risk factors for PPCs after minimally invasive esophagectomy (MIE). Methods: Seven hundred and sixty-seven consecutive patients who underwent McKeown MIE via thoracoscopy and laparoscopy were retrospectively studied. Patient characteristics, perioperative data, and postoperative complications were analyzed. Results: The incidence of PPCs after MIE was 25.2% (193/767). Univariate analysis identified age (odds ratio [OR] 1.022, P = 0.044), male sex (OR 2.955, P < 0.001), pulmonary comorbidities (OR 1.746, P = 0.032), chronic obstructive pulmonary disease (COPD) (OR 2.821, P = 0.003), former smoking status (OR 1.880, P = 0.001), postoperative albumin concentration (OR 0.941, P = 0.007), postoperative creatinine concentration (OR 1.011, P = 0.019), and perioperative transfusion (OR 2.250, P = 0.001) as risk factors for PPCs. In multivariate analysis, the independent risk factors for PPCs were male sex (OR 3.135, P < 0.001), body mass index (BMI) (OR 1.088, P = 0.002), COPD (OR 2.480, P = 0.012), neoadjuvant chemoradiotherapy (OR 2.057, P = 0.035), postoperative albumin concentration (OR 0.929, P = 0.002), and perioperative transfusion (OR 1.939, P = 0.013). The area under the receiver operating characteristic curve for the predictive model generated by multivariate logistic regression analysis was 0.671 (95% confidence interval 0.628-0.713). Conclusions: Male sex, BMI, COPD, neoadjuvant chemoradiotherapy, postoperative albumin concentration, and perioperative transfusion were independent predictors of PPCs after MIE.

Comparison of early postoperative pulmonary complications between two-lung ventilation with artificial pneumothorax and one-lung ventilation with bronchial blockade in patients undergoing minimally invasive esophagectomy: a retrospective propensity score-matched cohort study.

Background: Two-lung ventilation (TLV) with artificial carbon dioxide (CO2) pneumothorax is used during the thoracoscopic phase of minimally invasive esophagectomy (MIE). However, the impact of TLV with artificial pneumothorax on postoperative pulmonary complications (PPCs) after MIE is unclear. This study aimed to compare the incidence of early PPCs between TLV with CO2 pneumothorax and one-lung ventilation (OLV) with bronchial blockade in patients undergoing MIE. Methods: Five hundred ninety-three patients with esophageal cancer who underwent elective MIE with two-field lymph node dissection were analyzed. Patients in the TLV group were intubated using a single-lumen endotracheal tube and underwent surgery using TLV with artificial CO2 pneumothorax. Patients in the OLV group underwent surgery using OLV with a bronchial blocker. Patient characteristics and intraoperative and PPC data were collected and analyzed. Propensity score matching (PSM) was performed to reduce confounding bias. Results: The TLV and OLV group comprised 513 and 80 patients, respectively. PSM matched 197 TLV group and 73 OLV group patients. Incidence of pneumonia within the first 3 days of surgery was higher in the TLV group (11.7% vs. 4.1%) but the difference was not significant (P=0.06). The incidence of infiltrates on chest radiography was 36.0% in the TLV group and 28.8% in the OLV group (P=0.26). Incidence of other major PPCs requiring treatment and major non-pulmonary postoperative complications did not significantly differ between the groups. Length of hospital stay was significantly longer in the TLV group (13.0 vs. 11.0 days; P=0.03). Conclusions: Compared with OLV with bronchial blockade, TLV with CO2 pneumothorax did not reduce the incidence of early PPCs after MIE.

Dosage effect of cisatracurium on intubation and intraoperative neuromonitoring during thyroidectomy: a randomized controlled trial.

BACKGROUND: Intraoperative neuromonitoring (IONM) reduces the risk of recurrent laryngeal nerve (RLN) injury during thyroid surgery. However, the use of neuromuscular blocking agents (NMBAs), which are essential to improve intubation conditions, may hinder the electromyographic response during IONM. The aim of this prospective, double-blind, randomized controlled trial was to explore the optimal dosage of cisatracurium to produce adequate muscle relaxation for tracheal intubation without significantly affecting evoked potentials of IONM during thyroidectomy. METHODS: Patients undergoing thyroidectomy with IONM in our institution, with an American Society of Anesthesiologists grade of I-II, aged 18-75 years, and with a body mass index below 32 kg/m2 were enrolled and randomly assigned (by random numbers) to receive 1× (group C1) or 2× (group C2) the effective dose (ED95) of cisatracurium for tracheal intubation. The patients, surgeons, and anesthesiologists in charge were blinded to group assignment. Anesthesia was induced with sufentanil, propofol, and cisatracurium (0.05 mg/kgin group C1, 0.1 mg/kg in group C2). Ease of intubation was evaluated with the intubation condition score (Cooper score) and the intubation difficulty scale (IDS). Amplitudes of evoked potentials during intermittent IONM were compared between groups. The primary outcomes were the Cooper score, the IDS score, and the evoked potentials of IONM. RESULTS: Fifty-three patients were randomized from October 2019 to November 2020, and 52 were analyzed (with 26 patients in each group). The Cooper score was significantly lower in group C1 [median, 8.0 (interquartile range, 7.0-8.3)] than in group C2 [9.0 (9.0-9.0), P<0.001]. The rate of difficult laryngoscopy without external laryngeal pressure was significantly higher in group C1 than in group C2 (61.5% vs. 11.5%, P<0.001). More patients in group C1 required assistance to complete tracheal intubation (16 vs. 4, P=0.001). The IDS score was significantly higher in group C1 [3.0 (0.0-4.0) vs. 1.0 (0.0-1.0), P=0.045]. There were no significant differences between groups in amplitudes of evoked potentials. No serious adverse events were observed. CONCLUSIONS: A dose of 2× ED95 of cisatracurium provided better intubation conditions and easier tracheal intubation than 1× ED95, without disturbing IONM. TRIAL PROTOCOL: Chinese Clinical Trial Registry (No. ChiCTR1900022884).

Influence of Sevoflurane-Based Anesthesia versus Total Intravenous Anesthesia on Intraoperative Neuromonitoring during Thyroidectomy.

OBJECTIVE: To examine the influence of sevoflurane-based combined intravenous and inhaled anesthesia versus propofol-based total intravenous anesthesia (TIVA) on intraoperative neuromonitoring (IONM) during thyroidectomy. STUDY DESIGN: A randomized controlled trial. SETTING: The present study was conducted in a tertiary hospital. SUBJECTS AND METHODS: Forty patients were randomly assigned to a sevoflurane-based combined intravenous and inhalation group (group S) or a propofol-based total intravenous group (group P). Anesthesia was induced with midazolam, sufentanil, propofol, and cisatracurium in both groups and was maintained with sevoflurane and remifentanil in group S and with TIVA with propofol and remifentanil in group P. IONM was performed intermittently according to the IONM formula standard. RESULTS: The time until detection of the first positive electromyographic (EMG) signal was significantly longer in group S (median, 41.0 minutes [interquartile range, 37.5-49.3]) than in group P (37.0 minutes [33.3-41.5], P = .028). All patients in group P had a positive EMG signal at initial monitoring, whereas 8 patients (40.0%) in group S did not. The rate of positive EMG signal at initial monitoring was significantly higher in group P than in group S (P = .006). The amplitude of the evoked potentials at V1, R1, R2, and V2 were similar between the groups. CONCLUSION: Combined intravenous and inhaled anesthesia based on sevoflurane-remifentanil prolonged the time until detection of a positive EMG signal during IONM as compared with TIVA with propofol-remifentanil in patients undergoing thyroidectomy.