Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery.

BACKGROUND: Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS: This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS: A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS: This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.

A Survey Study of Surgeons and Anesthesiologists Regarding Perioperative Multimodal Analgesia for Opioid-Tolerant Patients.

PURPOSE: Perioperative pain management of opioid-tolerant patients can be challenging. Although regional anesthesia and multimodal analgesics may be beneficial, these modalities are often underused. It is unclear whether practice patterns for perioperative pain management are determined by the knowledge, attitudes, and beliefs of surgeons and anesthesiologists. DESIGN: Descriptive survey. METHODS: Using a Qualtrics survey, we polled a randomly selected group of 25 surgeons and 25 anesthesiologists regarding their knowledge, attitudes, beliefs, and practices for pain management in an opioid-tolerant patient. FINDINGS: Of 25, 23 anesthesiologists and 18/25 surgeons responded to the survey. Demographics were similar between the 2 groups. Most of the participant surgeons and anesthesiologists believed that pain management may be challenging in an opioid-tolerant patient. However, only 56% of surgeons would recommend a preoperative pain consultation. Most surgeons and anesthesiologists believed in the efficacy of regional anesthetics. However, 43% of surgeons would not advocate for a regional block, perhaps due to their perception of the added perioperative time. Multimodal analgesics were widely accepted by both surgeons and anesthesiologists. CONCLUSIONS: There is an urgent need to reinforce the importance of patient-centered care, with a specific focus on addressing knowledge gaps and improving perceptions for all the members of the team, including surgeons, anesthesiologists, and perioperative nursing teams, if optimal outcomes are to be achieved for our patients.

A comparison of steroid dose with or without local anesthetic in lumbar interlaminar epidural steroid injections.

INTRODUCTION: Epidural steroid injections (ESIs) are commonly used as a treatment for lumbar radiculopathy. Currently, most research on comparative efficacy of various steroids in epidural steroid injections is focused on transforaminal ESIs (TFESIs). Through this study, we aimed to compare various steroid doses with or without local anesthetic in interlaminar ESIs (ILESIs). METHODS: We reviewed charts for all adult patients who received ILESIs identified by CPT code 62323 between January 2017 to April 2021. Baseline demographic data including age, sex, BMI, and smoking status were recorded. NRS pain scores before the injection and percentage of pain relief at 1-month follow-up were recorded. We compared percentage of patients reporting pain relief at 1 month follow-up of low-dose dexamethasone alone (5 mg), to low-dose dexamethasone mixed with local anesthetic, and to high-dose dexamethasone (10 mg) mixed with local anesthetic, specifically for ILESIs. RESULTS: Data were available for 311 patients. There was no significant difference in pain relief between the 3 groups at 1 month follow-up. The majority of patients had moderate to significant improvement in pain, supporting the use of ILESIs. Moreover, low-dose steroid with local anesthetic was found to be as efficacious as high-dose steroid alone. Although not statistically significant, the addition of local anesthetic to low-dose or high-dose steroid increased the percentage of patients reporting moderate to significant pain relief. CONCLUSION: ILESIs with non-particulate steroids provide moderate to significant pain improvement in the short term, with low-dose steroid mixed with local anesthetic being as efficacious as a high-dose steroid.

Comparison between the Rotational Thromboelastometry (ROTEM) Delta device against the Cartridge-based Thromboelastography 6s and Quantra in a healthy third trimester pregnant cohort.

Rotational Thromboelastometry (ROTEM) Delta has been described in several postpartum hemorrhage algorithms, but this device requires pipetting and careful mixing of reagents to initiate the clotting reaction. In contrast, thromboelastography (TEG 6s) and the Quantra devices operate utilizing an automated pre-mixed cartridge that only requires a blood sample to start the clot strength analysis. We compared the correlation between 3 point of care viscoelastic testing (POCVT) devices to laboratory Clauss fibrinogen and platelets, their inter-device correlation, and the total running time difference between Quantra and ROTEM. A high correlation was noted between the Clauss fibrinogen and the fibrinogen parameters from ROTEM (r = 0.76-0.84, P < 0.0001), TEG6s (r = 0.71, P < 0.0001) and Quantra (r = 0.72, P = 0.0001). A moderate correlation between laboratory platelets and the ROTEM (r = 0.54;0.45, P < 0.0001; P = 0.0013) and Quantra (r = 0.66, P = 0.0001) parameters was noted. The inter-device correlation showed to be high when comparing the fibrinogen parameters of TEG6s and Quantra to that of ROTEM (r = 0.88 and 0.74, P < 0.0001, respectively). In contrast, a moderate correlation was noted between the platelet parameters of Quantra and ROTEM (r = 0.51, p = 0.0036). The Quantra device resulted 20.9 min (95% CI -0.2 to 4.7, P = 0.07) faster than the ROTEM if the warming and pipetting of reagents of the latter were considered. All the POCVT devices demonstrated a high correlation to laboratory Clauss fibrinogen, making each beneficial for the early recognition and management of hypofibrinogenemia.

Muscular Tissue Oxygen Saturation and Posthysterectomy Nausea and Vomiting: The iMODIPONV Randomized Controlled Trial.

BACKGROUND: Suboptimal tissue perfusion and oxygenation during surgery may be responsible for postoperative nausea and vomiting in some patients. This trial tested the hypothesis that muscular tissue oxygen saturation-guided intraoperative care reduces postoperative nausea and vomiting. METHODS: This multicenter, pragmatic, patient- and assessor-blinded randomized controlled (1:1 ratio) trial was conducted from September 2018 to June 2019 at six teaching hospitals in four different cities in China. Nonsmoking women, 18 to 65 yr old, and having elective laparoscopic surgery involving hysterectomy (n = 800) were randomly assigned to receive either intraoperative muscular tissue oxygen saturation-guided care or usual care. The goal was to maintain muscular tissue oxygen saturation, measured at flank and on forearm, greater than baseline or 70%, whichever was higher. The primary outcome was 24-h postoperative nausea and vomiting. Secondary outcomes included nausea severity, quality of recovery, and 30-day morbidity and mortality. RESULTS: Of the 800 randomized patients (median age, 50 yr [range, 27 to 65]), 799 were assessed for the primary outcome. The below-goal muscular tissue oxygen saturation area under the curve was significantly smaller in patients receiving muscular tissue oxygen saturation-guided care (n = 400) than in those receiving usual care (n = 399; flank, 50 vs. 140% · min, P < 0.001; forearm, 53 vs. 245% · min, P < 0.001). The incidences of 24-h postoperative nausea and vomiting were 32% (127 of 400) in the muscular tissue oxygen saturation-guided care group and 36% (142 of 399) in the usual care group, which were not significantly different (risk ratio, 0.89; 95% CI, 0.73 to 1.08; P = 0.251). There were no significant between-group differences for secondary outcomes. No harm was observed throughout the study. CONCLUSIONS: In a relatively young and healthy female patient population, personalized, goal-directed, muscular tissue oxygen saturation-guided intraoperative care is effective in treating decreased muscular tissue oxygen saturation but does not reduce the incidence of 24-h posthysterectomy nausea and vomiting.

Randomised controlled trial of sugammadex or neostigmine for reversal of neuromuscular block on the incidence of pulmonary complications in older adults undergoing prolonged surgery.

BACKGROUND: Residual neuromuscular block has been associated with postoperative pulmonary complications. We hypothesised that sugammadex reduces postoperative pulmonary complications in patients aged ≥70 yr having surgery ≥3 h, compared with neostigmine. METHODS: Patients were enrolled in an open-label, assessor-blinded, randomised, controlled trial. At surgical closure, subjects were equally randomised to receive sugammadex 2 mg kg-1 or neostigmine 0.07 mg kg-1 (maximum 5 mg) for rocuronium reversal. The primary endpoint was incidence of postoperative pulmonary complications. Secondary endpoints included residual paralysis (train-of-four ratio <0.9 in the PACU) and Phase 1 recovery (time to attain pain control and stable respiratory, haemodynamic, and neurological status). The analysis was by intention-to-treat. RESULTS: Of the 200 subjects randomised, 98 received sugammadex and 99 received neostigmine. There was no significant difference in the primary endpoint of postoperative pulmonary complications despite a signal towards reduced incidence for sugammadex (33% vs 40%; odds ratio [OR]=0.74; 95% confidence interval [CI]=[0.40, 1.37]; P=0.30) compared with neostigmine. Sugammadex decreased residual neuromuscular block (10% vs 49%; OR=0.11, 95% CI=[0.04, 0.25]; P<0.001). Phase 1 recovery time was comparable between sugammadex (97.3 min [standard deviation, sd=54.3]) and neostigmine (110.0 min [sd=62.0]), difference -12.7 min (95% CI, [-29.2, 3.9], P=0.13). In an exploratory analysis, there were fewer 30 day hospital readmissions in the sugammadex group compared with the neostigmine group (5% vs 15%; OR=0.30, 95% CI=[0.08, 0.91]; P=0.03). CONCLUSIONS: In older adults undergoing prolonged surgery, sugammadex was associated with a 40% reduction in residual neuromuscular block, a 10% reduction in 30 day hospital readmission rate, but no difference in the occurrence of postoperative pulmonary complications. Based on this exploratory study, larger studies should determine whether sugammadex may reduce postoperative pulmonary complications and 30 day hospital readmissions. CLINICAL TRIAL REGISTRATION: NCT02861131.

Evaluation of the slurry management strategy and the integration of the composting technology in a pig farm - Agronomical and environmental implications.

The changes in livestock production systems towards intensification frequently lead to an excess of manure generation with respect to the agricultural land available for its soil application. However, treatment technologies can help in the management of manures, especially in N-surplus areas. An integrated slurry treatment system based on solid-liquid separation, aerobic treatment of the liquid and composting the solid fraction was evaluated in a pig farm (sows and piglets) in the South of Spain. Solid fraction separation using a filter band connected to a screw press had low efficiency (38%), which was greatly improved incorporating a rotatory sieve (61%). The depuration system was very efficient for the liquid, with total removal of 84% total solids, 87% volatile solids, and 98% phosphorus. Two composting systems were tested through mechanical turning of: 1- a mixture of solid fraction stored for 1 month after solid-liquid separation and cereal straw; 2- recently-separated solid fraction mixed with cotton gin waste. System 2 was recommended for the farm, as it exhibited a fast temperature rise and a long thermophilic phase to ensure compost sanitisation, and high recovery of nutrients (TN 77%, P and K > 85%) and organic matter (45%). The composts obtained were mature, stable and showed a high degree of humification of their organic matter, absence of phytotoxicity and concentrations of nutrients similar to other composts from pig manure or separated slurry solids. However, the introduction of slurry from piglets into the solid-liquid separation system should be avoided in order to reduce the content of Zn in the compost, which lowers its quality. The slurry separation followed by composting of the solid fraction using a passive windrow system, and aeration of the liquid phase, was the most recommendable procedure for the reduction of GHG emissions on the farm.

Relationship of pain relief with catastrophizing following interventional pain procedures for low back pain.

INTRODUCTION: Catastrophizing is associated with worse pain outcomes after various procedures suggesting its utility in predicting response. However, the stability of pain catastrophizing as a static predictor has been challenged. We assess, among patients undergoing steroid injections for chronic low back pain (cLBP), whether catastrophizing changes with the clinical response to pain interventions. METHODS: This prospective study enrolled patients undergoing fluoroscopic-guided injections for cLBP. Patients filled out Brief Pain Inventory (BPI) and Pain Catastrophizing Scale (PCS) at baseline and 1-month follow-up. We assessed the change in PCS scores from pre-injection to post-injection and examined its predictors. We also examined the correlation of various domains of BPI, such as pain severity and effect on Relationships, Enjoyment, and Mood (REM), with PCS scores at baseline and follow-up. RESULTS: 128 patients were enrolled. Mean (SD) PCS and pain severity scores at baseline were 22.38 (±13.58) and 5.56 (±1.82), respectively. Follow-up PCS and pain severity scores were 19.76 (±15.25) and 4.42 (±2.38), respectively. The change in PCS pre-injection to post-injection was not significant (p=0.12). Multiple regression models revealed baseline PCS and REM domain of BPI as the most important predictors of change in PCS after injection. Pain severity, activity-related pain, age, sex, insurance status, depression, prior surgery, opioid use, or prior interventions did not predict change in PCS score. In correlation analysis, change in PCS was moderately correlated with change in pain (r=0.38), but weakly correlated with baseline pain in all pain domains. CONCLUSIONS: PCS showed non-significant improvement following steroid injections; the study was not powered for this outcome. Follow-up PCS scores were predicted by the REM domain of BPI, rather than pain severity. Larger studies are needed to evaluate a statistically significant and clinically meaningful change in catastrophizing scores following pain interventions.

Neurocognitive Dysfunction After Short (<20 Minutes) Duration Hypothermic Circulatory Arrest.

BACKGROUND: It has long been held that the safe duration of hypothermic circulatory arrest (HCA) is at least 25-30 minutes. However, this is based primarily on clinical outcomes research and has not been systematically investigated using more sensitive brain imaging and neurocognitive assessments. METHODS: This exploratory sub-study of the randomized GOT ICE trial, which compared outcomes for deep versus moderate hypothermia during arch surgery, investigated the frequency of neurocognitive and structural and functional magnetic resonance imaging (MRI) deficits with short (<20 minutes) duration HCA. Neurocognitive deficit was defined as >1 standard deviation decline in >1 of 5 cognitive domains on neurocognitive testing. RESULTS: Of 228 GOT ICE patients with complete 4-week cognitive data, 74.6% (n=170/228) had HCA durations <20 minutes, including 59 randomized to deep (<20.0°C), 55 low-moderate (20.1-24.0°C), and 56 high-moderate (24.1-28.0°C) hypothermia. Of these, cognitive deficit was detected 4-weeks post-surgery in ∼40% of patients in all 3 groups [deep: 22/59 (37.3%); low-moderate: 23/55 (41.8%); high-moderate: 24/56 (42.9%)]. Furthermore, in a subset of patients with complete MRI data (n=43), baseline to 4-week post-surgery right frontal lobe functional connectivity change was inversely associated with HCA duration (range 8-17 minutes; p-FWE<0.01). CONCLUSIONS: Even short durations of HCA result in cognitive deficits in ∼40% of patients, independent of systemic hypothermia temperature. HCA duration was inversely associated with frontal lobe functional MRI connectivity, suggesting this brain region may be preferentially sensitive to HCA. Surgeons should be aware that even short durations of HCA may not provide complete neuroprotection following aortic arch surgery.

Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program.

OBJECTIVE: To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations. BACKGROUND: There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures. METHODS: The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010. RESULTS: Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63-2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41-2.3), and death (OR, 2.71; 95% CI, 1.72-4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72-1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89-1.89), or deaths (OR, 1.21; 95% CI, 0.61-2.42). A dose-effect relationship was found between the effectiveness of insulin-related glucose control (worst 180-250 mg/dL, best <130 mg/dL) and adverse outcomes. CONCLUSIONS: Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets.