Effect of nociception level-directed analgesic management on opioid usage in robot-assisted laparoscopic radical prostatectomy: a single-center, single-blinded, randomized controlled trial.

PURPOSE: To assess the importance of appropriate opioid administration methods according to nociceptive monitoring. METHODS: We conducted a randomized controlled trial involving 54 patients who underwent robot-assisted laparoscopic radical prostatectomy at our hospital. Patients were randomly allocated to either receive nociception level (NOL)-directed intraoperative opioid management with a minimum flow of remifentanil (NOL group) or conventional intraoperative analgesic management (control group). The primary outcome was the mean intraoperative remifentanil infusion flow rate (intraoperative remifentanil usage [µg]/ideal body weight [kg]/operation time [min]). The main secondary outcomes were plasma concentrations of three perioperative inflammatory biomarkers (interleukin-6, C-reactive protein [CRP], and cortisol levels) and postoperative pain (Numeric Rating Scale [NRS]) scores 2 h postoperatively and on postoperative days 1, 2, 3, and 7. RESULTS: Compared with standard analgesia management, NOL-directed analgesic management reduced remifentanil consumption by 20% ( - 0.038; 95% confidence interval, - 0.059 to - 0.017; p = 0.0007). NOL-directed management did not lead to an increase in IL-6, CRP, or cortisol levels compared with conventional analgesic management. Furthermore, this protocol led to improvements in the NRS scores at rest 2 h postoperatively and upon movement up to postoperative day 3. CONCLUSION: NOL-directed analgesic management reduced remifentanil consumption by 20% and the NRS scores at rest 2 h postoperatively and upon movement up to postoperative day 3 without an increase in inflammatory marker levels. REGISTRY NUMBER: Japan Registry of Clinical Trials, JRCTs052220034.

Laparoscopic Gastrectomy Using External Oblique Intercostal Block Versus Wound Infiltration: A Trial Protocol.

OBJECTIVE: A novel external oblique intercostal block (EOIB) might have analgesic effects on T6-10 and be indicated for laparoscopic gastrectomy. However, EOIB effects on postoperative pain are unknown. We aim to generate evidence to support such EOIB application. We will compare the efficacy of EOIB and wound infiltration (WI) in a single-center, single-blind, randomized controlled trial. METHODS: We will assess plasma concentrations of levobupivacaine after EOIB, its pharmacokinetics, and the pinprick test in patients randomly assigned to receive EOIB or WI before laparoscopic or robot-assisted gastric distal or total gastrectomy. The EOIB and WI will start after general anesthesia induction with 20 and 40 mL of 0.25% levobupivacaine per side, respectively, before skin closure. The outcomes will be numeric rating scale (NRS) scores at 12 h postoperatively (primary) and postoperative NRS scores at 2, 24, and 48 h; fentanyl application; QoR-15 scores on postoperative days 1, 2, and 7; and World Health Organization Disability Assessment Schedule 2.0 scores at 3 months (secondary). CONCLUSIONS: We hope that our study will provide evidence to support EOIB application in laparoscopic surgery. Plasma concentrations will help determine levobupivacaine pharmacokinetics, which if similar to conventional nerve blocks, will indicate EOIB's safety.

Fried Frailty Phenotype Questionnaire scores and postoperative patient-reported outcomes of patients undergoing major abdominal cancer surgery: A secondary analysis.

AIM: This study aimed to evaluate the effects of Fried Frailty Phenotype Questionnaire (FFPQ) scores on patient-reported postoperative outcomes. METHODS: This secondary analysis of a prospective observational study included 230 inpatients aged ≥65 years undergoing elective abdominal cancer surgery. The primary outcome was the Quality of Recovery-15 score on postoperative days 2, 4 and 7. The secondary outcomes included disability-free survival, defined as a 12-item World Health Organization Disability Assessment Schedule 2.0 score of <16% at 3 months. The associations of the FFPQ scores, ranging from 0 (robust) to 5 (frailty), with the primary and secondary outcomes were assessed using multiple analysis. RESULTS: After confirming the linearity of the FFPQ score for the outcomes, multiple regression analysis adjusted for prominent factors showed that the FFPQ score was a significant factor influencing the decrease in the Quality of Recovery-15 score on postoperative day 2 (ß = -2.67, 95% confidence interval -5.20, -0.15), 4 (ß = -3.54, 95% confidence interval -5.77, -1.30) and 7 (ß = -3.70, 95% confidence interval -5.75, -1.65). The adjusted odds ratio of the FFPQ score for disability-free survival postoperatively was 0.66 (95% confidence interval 0.49-0.90). CONCLUSIONS: Patients with higher FFPQ scores before elective major abdominal cancer surgery were likely to have lower postoperative Quality of Recovery-15 scores and poor disability-free survival. Geriatr Gerontol Int 2024; 24: 464-469.

Early Quality of Recovery after Elective Cardiothoracic and Aortic Surgeries in Adult Patients: A Pilot Report.

BACKGROUND: Patient-centered outcome measures should be evaluated postoperatively as the recovery after surgery varies between patients. We aimed to evaluate the feasibility, reliability, and trajectory of the quality of recovery-15 (QoR-15) in patients undergoing cardiothoracic and aortic surgeries. MATERIALS AND METHODS: This retrospective study included adult patients who underwent elective cardiothoracic and aortic surgeries. The primary outcome was the QoR-15, with a minimal clinically important difference of 6.8, assessed on postoperative days (POD) 2, 4, and 7. The final analysis included patients with at least one valid outcome. Feasibility and reliability were assessed by the successful completion rate on each POD and using Cronbach's alpha of the QoR-15 on POD 4. A linear mixed model was used to evaluate the trajectory of the postoperative QoR-15 scores. RESULTS: Of the 36 eligible patients, 30 with a mean age of 70 years were included in the final analysis. The successful completion rates on POD 2, 4, and 7 were 72.7%, 87.8%, and 87.8%, respectively. The mean QoR-15 scores on POD 2, 4, and 7 were 89.9, 98.0, and 108.3, respectively. The QoR-15 scores on POD 2 and 4 were not statistically different (P = 0.06) but were clinically significant. The QoR-15 score on POD 7 was statically (P < 0.001) and clinically higher than the QoR-15 score on POD 2. Cronbach's alpha for the QoR-15 score measured on POD 4 was 0.85. CONCLUSION: The QoR-15 is a feasible and valid measurement after elective cardiothoracic surgery, which increases significantly over time after surgery.

Comparison of prophylaxis strategy for postoperative nausea and vomiting and its incidence before and after the implementation of 5-hydroxytryptamine 3 in surgical setting: a single-center, retrospective study.

PURPOSE: To investigate the association between adherence to guideline-recommended risk-based postoperative nausea and vomiting (PONV) prophylaxis, the antiemetics used for PONV prophylaxis, and the incidence of PONV in patients who were underwent general anesthesia before and after 5-HT3 receptor antagonists became available. METHODS: Patients (≥ 20 years old) who were extubated after scheduled surgery and returned to general wards between January 2021 and February 2022 and between June 2022 and July 2023 were included. Risk factors included age < 50, female, motion sickness, nonsmoker, surgical factors, and postoperative opioid use. Two and three or more prophylaxis were recommended for patients with one or two and three or more risk factors, respectively. The primary outcome was the number of patients who received adequate prophylaxis, and the secondary outcomes were antiemetic agents used during anesthesia and the incidence of PONV on postoperative days 0 and 1. PONV was defined as documented PONV or rescue antiemetic administration. RESULTS: From January 2021 to February 2022 and from June 2022 to July 2023, 2342 and 2682 patients were included, respectively. Before ondansetron became available, more D2 receptor antagonists were used (p < 0.001), and after ondansetron became available, both ondansetron (p < 0.001) and propofol (p < 0.001) were given more frequently. Before and after ondansetron became available, the number of patients with adequate prophylaxis was 3.7% and 9.2%, respectively (p < 0.001), and the incidence of PONV on postoperative days 0 and 1 was 44.6% and 44.0%, respectively (p = 0.67). CONCLUSION: The availability of ondansetron increased the number of patients with adequate PONV prophylaxis, but did not decrease the incidence of PONV.

Comparison of remimazolam-based and propofol-based total intravenous anesthesia on hemodynamics during anesthesia induction in patients undergoing transcatheter aortic valve replacement: a randomized controlled trial.

PURPOSE: This study aimed to compare the hemodynamic effects of remimazolam- and propofol-based total intravenous anesthesia in patients who underwent transcatheter aortic valve replacement. METHODS: This was a single-center, single-blind, randomized controlled trial set at Nara Medical University, Kashihara, Japan. We included 36 patients aged ≥ 20 years scheduled to undergo elective transfemoral transcatheter aortic valve replacement (TAVR) under general anesthesia. The participants were randomly assigned to the remimazolam and propofol groups (n = 18 each). Remimazolam- or propofol-based total intravenous anesthesia was initiated at 12 mg/kg/min or 2.5 mcg/mL via target-controlled infusion, respectively, along with remifentanil. After confirming the loss of consciousness, the administration rate was adjusted using electroencephalographic monitoring. The primary outcome was the rate of arterial hypotension, defined as a mean arterial pressure < 60 mmHg, from anesthesia induction until the beginning of the surgical incision. The total doses of ephedrine and phenylephrine were also assessed. RESULTS: During anesthesia induction, the arterial hypotension rates were 11.9% and 21.6% in the remimazolam and propofol groups, respectively (P = 0.01). The total dose of ephedrine was higher in the propofol group (14.4 mg) than in the remimazolam group (1.6 mg) (P < 0.001); however, the total dose of phenylephrine was not significantly different between the two groups (propofol 0.31 mg vs. remimazolam: 0.17 mg, P = 0.10). CONCLUSION: Remimazolam-based total intravenous anesthesia resulted in a lower hypotension rate than propofol-based total intravenous anesthesia during induction in patients undergoing TAVR. Remimazolam-based total intravenous anesthesia can be used safely during anesthetic induction in patients with severe aortic stenosis.

Comparison of Quality of Recovery between Modified Thoracoabdominal Nerves Block through Perichondrial Approach versus Oblique Subcostal Transversus Abdominis Plane Block in Patients Undergoing Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial.

Modified thoracoabdominal nerves block through a perichondrial approach (M-TAPA) provides a wide analgesic range. Herein, we examined the quality of recovery (QoR) of M-TAPA for total laparoscopic hysterectomy (TLH) compared with oblique subcostal transversus abdominis plane block (OSTAPB) and measured plasma levobupivacaine concentrations (PClevo). Forty female patients undergoing TLH were randomized to each group. Nerve blocks were performed bilaterally with 25 mL of 0.25% levobupivacaine administered per side. The primary outcome was changes in QoR-15 scores on postoperative days (POD) 1 and 2 from the preoperative baseline. The main secondary outcomes were PClevo at 15, 30, 45, 60, and 120 min after performing nerve block. Group differences (M-TAPA-OSTAPB) in mean changes from baseline in QoR-15 scores on POD 1 and 2 were -11.3 (95% confidence interval (CI), -24.9 to 2.4, p = 0.104; standard deviation (SD), 22.8) and -7.0 (95% CI, -20.5 to 6.6, p = 0.307; SD, 18.7), respectively. Changes in PClevo were similar in both groups. The post hoc analysis using Bayesian statistics revealed that posterior probabilities of M-TAPA being clinically more effective than OSTAPB were up to 22.4 and 24.4% for POD 1 and 2, respectively. In conclusion, M-TAPA may not be superior to OSTAPB for TLH.

Association between preoperative frailty and surgical Apgar score in abdominal cancer surgery: a secondary analysis of a prospective observational study.

INTRODUCTION: The surgical Apgar score is useful for predicting postoperative morbidity and mortality. However, its applicability in frail patients with minimal hemodynamic variation remains unknown. This study aimed to investigate the association between frailty and surgical Apgar score. METHODS: This secondary analysis included 210 patients ≥ 65 years of age undergoing elective major abdominal surgery for cancer. Frailty was assessed using the Fried Frailty Phenotype Questionnaire and defined as a total score of ≥ 3. The surgical Apgar score (range, 0-10; including mean blood pressure, heart rate, and blood loss volume) was compared between patients with or without frailty using the Mann-Whitney U test. Postoperative severe complications and length of postoperative stay were compared between patients with surgical Apgar scores ≤ 7 and > 7. RESULTS: Among the included patients, 45 were classified as frail. The median [1st quartile, 3rd quartile] surgical Apgar scores in patients with and without frailty were 7.0 [7.0, 8.0] and 8.0 [7.0, 8.0], respectively (P = 0.03). Patients with surgical Apgar score ≤7 had a higher incidence of serious postoperative complications (P = 0.03) and longer hospital stays (P < 0.001) compared with patients with surgical Apgar score >7. CONCLUSION: Frail patients have lower SAS, and patients with lower SAS have higher postoperative complication rates and longer hospital stays in patients who underwent cancer surgery.

Does a Positive Response to Transforaminal Epidural Steroid Injection Identify Patients Who Can Avoid Surgery for Two Years?

Background: Transforaminal epidural steroid injection (TFESI) is widely used to manage lumbar radiculopathy. In clinical settings, patients often undergo repeated transforaminal epidural injections with or without steroid administration. Objectives: To examine whether a positive response to TFESI at the first month, can in clinical settings, identify patients with radiculopathy who can avoid surgery for two years. Study Design/Setting. This prospective observational study was conducted at an academic medical center. Methods: Individuals aged ≥20 years who had been referred to our pain center by spine surgeons were enrolled. All patients were assessed using the Numerical Rating Scale (NRS) at baseline and 1 month after the first TFESI. Patients were divided into two groups according to the NRS decrement: the positive response (PR) group achieved a ≥2.0 decrease on the NRS 1 month after the first TFESI compared to baseline and the no response (NR) group achieved a <2.0 decrease on the NRS. The incidence rates of surgery over two years were compared between the two groups. In addition, we calculated the hazard ratio of the PR group to the NR group regarding the incidence of surgery over two years using the Cox proportional hazard model, adjusting for baseline NRS. Results: Seventy-six patients completed the two-year follow-up. In total, 8 and 68 patients had bilateral and unilateral radiculopathy, respectively. The PR and NR groups included 35 and 41 patients, respectively. The rate of surgery avoidance was 85.7% and 73.2% in the PR and NR groups, respectively. This difference was not statistically significant (p=0.26). After adjusting for baseline NRS, the hazard ratio of the PR group to the NR group regarding the incidence of surgery within two years was 0.35 (95% confidence interval: 0.11-1.11, p=0.08). Conclusion: A positive response to TFESI may not identify patients who can avoid surgery for two years.

Relationship between estimated and observed heparin sensitivity indices in cardiac and thoracic aortic surgery.

BACKGROUND: Little evidence exists on the relationship between the estimated heparin sensitivity index (HSI) based on commonly available clinical and laboratory data and observed HSI in the adult population. This retrospective study assessed the relationship between the observed and estimated HSIs. METHODS: This study was conducted in an academic, single-institution setting. Patients aged ≥ 20 years who underwent cardiac and thoracic aortic surgery and requiring cardiopulmonary bypass were included. Clinical and laboratory data, including age, sex, and platelet count, were collected. The fibrinogen-albumin ratio index was calculated by dividing the fibrinogen value by the albumin value, multiplied by 10.The HSI was calculated using the formula: (activated clotting time after initial heparin administration-baseline activated clotting time)/initial heparin dose (IU/kg). The estimated HSI was based on the results of multiple regression analysis that included clinically relevant factors. The intraclass correlation coefficient between the observed and estimated HSIs was used to assess. RESULTS: In total, 560 patients with valid activated clotting time (ACT) values after initial heparin administration were included in the final analysis to explore associated factors using the estimated HSI. Multiple regression analysis revealed that hemodialysis, platelet count, fibrinogen-to-albumin ratio index, baseline activated clotting time, and initial heparin dose were significantly associated with the HSI. The mean (standard deviation) observed and estimated HSIs were 1.38 (0.43) and 1.55 (0.13), respectively, with an intra-class correlation coefficient of 0.10. CONCLUSIONS: The correlation between the observed and estimated HSIs was low, and a formula with high accuracy for estimating the HSI is needed.

Impact of different doses of remifentanil on chronic postsurgical pain after video-assisted thoracic surgery: A propensity score analysis.

A remifentanil infusion dose of >0.2 µg/kg/min is associated with hyperalgesia, leading to acute postsurgical pain; however, its contribution to the development of chronic postsurgical pain after video-assisted thoracic surgery remains unclear. This study aimed to evaluate the impact of different remifentanil doses on chronic postsurgical pain after video-assisted thoracic surgery. This study included inpatients aged ≥ 55 years who underwent video-assisted thoracic surgery under general anesthesia between April 2016 and December 2018. An inverse probability of treatment weighted using stabilized inverse propensity scores was adopted to minimize bias. After adjustments based on patient data, the outcomes of interest were compared with intraoperative covariates using a generalized estimating equation. The primary study outcome was chronic postsurgical pain 1 year after surgery, defined as a pain score ≥1 on a numerical rating scale. Of the 262 eligible patients, 258 with a mean age of 71.2 years were included in this analysis. Chronic postsurgical pain occurred in 23.6% of patients. The generalized estimating equation revealed that a remifentanil infusion dose >0.2 µg/kg/min was associated with chronic postsurgical pain at 1 year after surgery (odds ratio [OR] 1.52; 95% confidence interval [CI] 1.03-2.27), while remifentanil infusion doses >0.15 µg/kg/min (OR 1.12; 95% CI 0.79-1.59) and >0.175 µg/kg/min (OR 1.17; 95% CI 0.83-1.64) were not associated with our primary outcome. Remifentanil infusions >0.2 µg/kg/min were associated with chronic postsurgical pain 1 year after video-assisted thoracic surgery.

Correlation between pain catastrophizing in acute herpes zoster and postherpetic neuralgia: a retrospective analysis.

PURPOSE: The objective of this study was to examine the association between pain catastrophizing in acute phase herpes zoster and the development of postherpetic neuralgia. METHODS: The medical records of all patients diagnosed with herpes zoster between February 2016 and December 2021 were retrieved. Inclusion criteria were patients aged > 50 years who visited our pain center within 60 days after rash onset and reported a pain intensity of ≥ 3 in a numerical rating scale. Patients with a score of 30 or more in the pain catastrophizing scale at baseline were assigned to the catastrophizer group, and those with a score < 30 were assigned to the non-catastrophizer group. We defined patients with "postherpetic neuralgia" and "severe postherpetic neuralgia" as those with a numerical rating scale score of 3 or more and 7 or more at 3 months after baseline, respectively. RESULTS: Data of 189 patients were available for complete analysis. Age, baseline numerical rating scale, and prevalence of anxiety and depression were significantly higher in the catastrophizer than those in the non-catastrophizer group. Incidence of postherpetic neuralgia did not differ significantly between the groups (p = 0.26). Multiple logistic regression analysis showed that age, severe pain at baseline, and immunosuppressive state were the factors which were independently associated with developing postherpetic neuralgia. Severe pain at baseline was the only factor related to developing severe postherpetic neuralgia. CONCLUSION: Pain catastrophizing in the acute phase of herpes zoster may not be related to the development of postherpetic neuralgia.

Quality of recovery in hospital and disability-free survival at three months after major abdominal surgery.

BACKGROUND: The Quality of Recovery-15 (QoR-15) and 12-item World Health Organization Disability Assessment Schedule 2.0 scales are post-surgery patient-reported outcome measures. We aimed to evaluate the association between immediate in-hospital postoperative recovery and mid-term disability-free survival (DFS) after discharge. METHODS: We conducted a prospective observational study at a university hospital and enrolled 260 patients aged ≥ 65 years with cancer who were undergoing elective major abdominal surgery. The association between poor postoperative recovery, defined as a QoR-15 score < 90 on postoperative day (POD) 2, and the DFS three months later was assessed using Fisher's exact test. The odds ratio of poor recovery on POD 2 to DFS was calculated using multiple logistic regression analysis adjusted for prominent factors (age, preoperative frailty, preoperative DFS, surgical duration, and intraoperative blood loss volume). RESULTS: A total of 230 patients completed the 3-month follow-up. On POD 2, 27.3% of the patients (63/230) had poor recovery. A greater number of patients without poor recovery on POD 2 had DFS at three months after surgery (79.6%) than those with poor recovery (65.1%) (P = 0.026). The adjusted odds ratio of poor recovery on POD 2 to DFS at three months was 0.481 (95% CI [0.233, 0.994]). CONCLUSIONS: Patients with poor recovery on POD 2 were less likely to have DFS three months after abdominal surgery. These findings may allow for early and effective interventions to be initiated based on each patient's condition after abdominal surgery.

Effects of preoperative nutritional status on postoperative quality of recovery: a prospective observational study.

Quality of Recovery-15 (QoR-15) has received attention as a postoperative patient-reported outcome measure. Preoperative nutritional status has negative effects on postoperative outcomes; however, these associations have not yet been investigated. We included inpatients aged ≥ 65 years who underwent elective abdominal cancer surgery under general anaesthesia between 1 June 2021 and 7 April 2022 at our hospital. Preoperative nutritional status was assessed using the Mini Nutritional Assessment Short-Form (MNA-SF), and patients with an MNA-SF score ≤ 11 were categorised into the poor nutritional group. The outcomes in this study were the QoR-15 scores at 2 d, 4 d and 7 d after surgery, which were compared between groups by unpaired t test. Multiple regression analysis was applied to assess the effects of poor preoperative nutritional status on the QoR-15 score on postoperative day 2 (POD 2). Of the 230 included patients, 33·9 % (78/230) were categorised into the poor nutritional status group. The mean QoR-15 value was significantly lower in the poor nutritional group than in the normal nutritional group at all postoperative time points (POD 2:117 v. 99, P = 0·002; POD 4:124 v. 113, P < 0·001; POD 7:133 v. 115, P < 0·001). Multiple analyses showed that poor preoperative nutritional status was associated with the QoR-15 score on POD 2 (adjusted partial regression coefficient, -7·8; 95 % CI -14·9, -0·72). We conclude that patients with a poor preoperative nutritional status were more likely to have a lower QoR-15 score after abdominal cancer surgery.

Association between Preoperative Hand Grip Strength and Postoperative Delirium after Cardiovascular Surgery: A Retrospective Study.

The association of frailty with postoperative delirium has not been fully investigated in patients undergoing cardiovascular surgery. Therefore, this study aimed to investigate whether preoperative hand grip strength is associated with postoperative delirium. This retrospective study included patients aged >65 years who had undergone elective cardiovascular surgery using cardiopulmonary bypass at a Japanese university hospital between April 2020 and February 2022. We defined low hand grip strength as hand grip values of <275 n and <177 n for men and women, respectively. Postoperative delirium was assessed using the confusion assessment method during patients' intensive care unit stay. The odds ratio of low hand grip strength for postoperative delirium was estimated using multiple logistic analysis, which was adjusted for prominent clinical factors. Ninety-five patients with a median age of 74 years were included in the final analysis, and 31.5% of them had low hand grip strength. Postoperative delirium occurred in 37% of patients, and the odds ratio of low preoperative hand grip strength for postoperative delirium was 4.58 (95% confidence interval: 1.57-13.2). Thirty-seven patients experienced postoperative delirium after cardiovascular surgery using cardiopulmonary bypass, and low preoperative hand grip strength was positively associated with its occurrence.