External validation of the CARDOT score for predicting respiratory complications after thoracic surgery.

BACKGROUND: The CARDOT scores have been developed for prediction of respiratory complications after thoracic surgery. This study aimed to externally validate the CARDOT score and assess the predictive value of preoperative neutrophil-to-lymphocyte ratio (NLR) for postoperative respiratory complication. METHODS: A retrospective cohort study of consecutive thoracic surgical patients at a single tertiary hospital in northern Thailand was conducted. The development and validation datasets were collected between 2006 and 2012 and from 2015 to 2021, respectively. Six prespecified predictive factors were identified, and formed a predictive score, the CARDOT score (chronic obstructive pulmonary disease, American Society of Anesthesiologists physical status, right-sided operation, duration of surgery, preoperative oxygen saturation on room air, thoracotomy), was calculated. The performance of the CARDOT score was evaluated in terms of discrimination by using the area under the receiver operating characteristic (AuROC) curve and calibration. RESULTS: There were 1086 and 1645 patients included in the development and validation datasets. The incidence of respiratory complications was 15.7% (171 of 1086) and 22.5% (370 of 1645) in the development and validation datasets, respectively. The CARDOT score had good discriminative ability for both the development and validation datasets (AuROC 0.789 (95% CI 0.753-0.827) and 0.758 (95% CI 0.730-0.787), respectively). The CARDOT score showed good calibration in both datasets. A high NLR (≥ 4.5) significantly increased the risk of respiratory complications after thoracic surgery (P < 0.001). The AuROC curve of the validation cohort increased to 0.775 (95% CI 0.750-0.800) when the score was combined with a high NLR. The AuROC of the CARDOT score with the NLR showed significantly greater discrimination power than that of the CARDOT score alone (P = 0.008). CONCLUSIONS: The CARDOT score showed a good discriminative performance in the external validation dataset. An addition of a high NLR significantly increases the predictive performance of CARDOT score. The utility of this score is valuable in settings with limited access to preoperative pulmonary function testing.

Optimal techniques of ultrasound-guided superficial and deep parasternal intercostal plane blocks: a cadaveric study.

INTRODUCTION: The optimal techniques of a parasternal intercostal plane (PIP) block to cover the T2-T6 intercostal nerves have not been elucidated. This pilot cadaveric study aims to determine the optimal injection techniques that achieve a consistent dye spread over the second to sixth intercostal spaces after both ultrasound-guided superficial and deep PIP blocks. We also investigated the presence of the transversus thoracis muscle at the first to sixth intercostal spaces and its sonographic identification agreement, as well as the location of the internal thoracic artery in relation to the lateral border of the sternum. METHODS: Ultrasound-guided superficial or deep PIP blocks with single, double, or triple injections were applied in 24 hemithoraces (three hemithoraces per technique). A total volume of dye for all techniques was 20 mL. On dissection, dye distribution over the first to sixth intercostal spaces, the presence of the transversus thoracis muscle at each intercostal space and the distance of the internal thoracic artery from the lateral sternal border were recorded. RESULTS: The transversus thoracis muscles were consistently found at the second to sixth intercostal spaces, and the agreement between sonographic identification and the presence of the transversus thoracis muscles was >80% at the second to fifth intercostal spaces. The internal thoracic artery is located medial to the halfway between the sternal border and costochondral junction along the second to sixth intercostal spaces. Dye spread following the superficial PIP block was more localized than the deep PIP block. For both approaches, the more numbers of injections rendered a wider dye distribution. The numbers of stained intercostal spaces after superficial block at the second, fourth, and fifth intercostal spaces, and deep block at the third and fifth intercostal spaces were 5.3±1.2 and 5.7±0.6 levels, respectively. CONCLUSION: Triple injections at the second, fourth, and fifth intercostal spaces for the superficial approach and double injections at the third and fifth intercostal spaces for the deep approach were optimal techniques of the PIP blocks.

Effectiveness of enhanced recovery after surgery protocol in open gynecologic oncology surgery: A randomized controlled trial.

OBJECTIVE: To examine the effectiveness of applying the recommended enhanced recovery after surgery (ERAS) protocol compared with our usual care in women with gynecologic malignancy undergoing elective laparotomy. METHODS: From June 2020 to May 2021, 93 women with gynecologic cancers (cervix, endometrium, and ovary) undergoing elective laparotomy at our institution were randomly assigned into an intervention group (ERAS protocol, 46 women) or control group (usual care, 47 women). For the intervention group, each woman was brought through the pre-specified ERAS protocol starting from preoperative counseling to postoperative management. For the control group, participants underwent routine standard care. The primary outcomes were length of hospital stay and postoperative pain. RESULTS: The intervention group demonstrated shorter hospital stay by 20 h (47.48 h vs 67.17 h, P = 0.02) with lower postoperative pain score at postoperative day 0 (1.58 vs 4.00, P < 0.01) and day 1 (1.00 vs 2.67, P < 0.01) while having decreased opioid consumption (P < 0.01). The intervention group also had faster recovery of gastrointestinal function. Overall, good compliance to most of the ERAS pathway domains was obtained. CONCLUSION: The ERAS protocol demonstrates benefits on shortening hospital stay, reducing pain, and bowel function recovery without increasing complications in our population. CLINICAL TRIAL REGISTRATION: The present study was registered at clinicaltrials.gov (NCT04201626) on December 3, 2019. Initial participant enrollment began on June 1, 2020. Access through URL of the registration site: https://clinicaltrials.gov/ct2/show/NCT04201626?cond=ERAS&cntry=TH&draw=2&rank=3.