Performance and usability of pre-operative prediction models for 30-day peri-operative mortality risk: a systematic review.

Estimating pre-operative mortality risk may inform clinical decision-making for peri-operative care. However, pre-operative mortality risk prediction models are rarely implemented in routine clinical practice. High predictive accuracy and clinical usability are essential for acceptance and clinical implementation. In this systematic review, we identified and appraised prediction models for 30-day postoperative mortality in non-cardiac surgical cohorts. PubMed and Embase were searched up to December 2022 for studies investigating pre-operative prediction models for 30-day mortality. We assessed predictive performance in terms of discrimination and calibration. Risk of bias was evaluated using a tool to assess the risk of bias and applicability of prediction model studies. To further inform potential adoption, we also assessed clinical usability for selected models. In all, 15 studies evaluating 10 prediction models were included. Discrimination ranged from a c-statistic of 0.82 (MySurgeryRisk) to 0.96 (extreme gradient boosting machine learning model). Calibration was reported in only six studies. Model performance was highest for the surgical outcome risk tool (SORT) and its external validations. Clinical usability was highest for the surgical risk pre-operative assessment system. The SORT and risk quantification index also scored high on clinical usability. We found unclear or high risk of bias in the development of all models. The SORT showed the best combination of predictive performance and clinical usability and has been externally validated in several heterogeneous cohorts. To improve clinical uptake, full integration of reliable models with sufficient face validity within the electronic health record is imperative.

Nurses' experiences with continuous vital sign monitoring on the general surgical ward: a qualitative study based on the Behaviour Change Wheel.

BACKGROUND: To support early recognition of clinical deterioration on a general ward continuous vital signs monitoring (CMVS) systems using wearable devices are increasingly being investigated. Although nurses play a crucial role in successful implementation, reported nurse adoption and acceptance scores vary significantly. In-depth insight into the perspectives of nurses regarding CMVS is lacking. To this end, we applied a theoretical approach for behaviour change derived from the Behaviour Change Wheel (BCW). AIM: To provide insight in the capability, opportunity and motivation of nurses working with CMVS, in order to inform future implementation efforts. METHODS: A qualitative study was conducted, including twelve nurses of a surgical ward in a tertiary teaching hospital with previous experience of working with CMVS. Semi-structured interviews were audiotaped, transcribed verbatim, and analysed using thematic analysis. The results were mapped onto the Capability, Opportunity, Motivation - Behaviour (COM-B) model of the BCW. RESULTS: Five key themes emerged. The theme 'Learning and coaching on the job' linked to Capability. Nurses favoured learning about CVSM by dealing with it in daily practice. Receiving bedside guidance and coaching was perceived as important. The theme 'interpretation of vital sign trends' also linked to Capability. Nurses mentioned the novelty of monitoring vital sign trends of patients on wards. The theme 'Management of alarms' linked to Opportunity. Nurses perceived the (false) alarms generated by the system as excessive resulting in feelings of irritation and uncertainty. The theme 'Integration and compatibility with clinical workflow' linked to Opportunity. CVSM was experienced as helpful and easy to use, although integration in mobile devices and the EMR was highly favoured and the management of clinical workflows would need improvement. The theme 'Added value for nursing care' linked to Motivation. All nurses recognized the potential added value of CVSM for postoperative care. CONCLUSION: Our findings suggest all parts of the COM-B model should be considered when implementing CVSM on general wards. When the themes in Capability and Opportunity are not properly addressed by selecting interventions and policy categories, this may negatively influence the Motivation and may compromise successful implementation.

Paravertebral catheter versus EPidural analgesia in Minimally invasive Esophageal resectioN: a randomized controlled multicenter trial (PEPMEN trial).

BACKGROUND: Thoracic epidural analgesia is the standard postoperative pain management strategy in esophageal cancer surgery. However, paravertebral block analgesia may achieve comparable pain control while inducing less side effects, which may be beneficial for postoperative recovery. This study primarily aims to compare the postoperative quality of recovery between paravertebral catheter versus thoracic epidural analgesia in patients undergoing minimally invasive esophagectomy. METHODS: This study represents a randomized controlled superiority trial. A total of 192 patients will be randomized in 4 Dutch high-volume centers for esophageal cancer surgery. Patients are eligible for inclusion if they are at least 18 years old, able to provide written informed consent and complete questionnaires in Dutch, scheduled to undergo minimally invasive esophagectomy with two-field lymphadenectomy and an intrathoracic anastomosis, and have no contra-indications to either epidural or paravertebral analgesia. The primary outcome is the quality of postoperative recovery, as measured by the Quality of Recovery-40 (QoR-40) questionnaire on the morning of postoperative day 3. Secondary outcomes include the QoR-40 questionnaire score Area Under the Curve on postoperative days 1-3, the integrated pain and systemic opioid score and patient satisfaction and pain experience according to the International Pain Outcomes (IPO) questionnaire, and cost-effectiveness. Furthermore, the groups will be compared regarding the need for additional rescue medication on postoperative days 0-3, technical failure of the pain treatment, duration of anesthesia, duration of surgery, total postoperative fluid administration day 0-3, postoperative vasopressor and inotrope use, length of urinary catheter use, length of hospital stay, postoperative complications, chronic pain at six months after surgery, and other adverse effects. DISCUSSION: In this study, it is hypothesized that paravertebral analgesia achieves comparable pain control while causing less side-effects such as hypotension when compared to epidural analgesia, leading to shorter postoperative length of stay on a monitored ward and superior quality of recovery. If this hypothesis is confirmed, the results of this study can be used to update the relevant guidelines on postoperative pain management for patients undergoing minimally invasive esophagectomy. TRIAL REGISTRATION: Netherlands Trial Registry, NL8037. Registered 19 September 2019.

Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine initiative: patient-centred outcomes.

BACKGROUND: Patient-centred outcomes are increasingly used in perioperative clinical trials. The Standardised Endpoints in Perioperative Medicine (StEP) initiative aims to define which measures should be used in future research to facilitate comparison between studies and to enable robust evidence synthesis. METHODS: A systematic review was conducted to create a longlist of patient satisfaction, health-related quality of life, functional status, patient well-being, and life-impact measures for consideration. A three-stage Delphi consensus process involving 89 international experts was then conducted in order to refine this list into a set of recommendations. RESULTS: The literature review yielded six patient-satisfaction measures, seven generic health-related quality-of-life measures, eight patient well-being measures, five functional-status measures, and five life-impact measures for consideration. The Delphi response rates were 92%, 87%, and 100% for Rounds 1, 2, and 3, respectively. Three additional measures were added during the Delphi process as a result of contributions from the StEP group members. Firm recommendations have been made about one health-related quality-of-life measure (EuroQol 5 Dimension, five-level version with visual analogue scale), one functional-status measure (WHO Disability Assessment Schedule version 2.0, 12-question version), and one life-impact measure (days alive and out of hospital at 30 days after surgery). Recommendations with caveats have been made about the Bauer patient-satisfaction measure and two life-impact measures (days alive and out of hospital at 1 yr after surgery, and discharge destination). CONCLUSIONS: Several patient-centred outcome measures have been recommended for use in future perioperative studies. We suggest that every clinical study should consider using at least one patient-centred outcome within a suite of endpoints.

Haematoma and abscess after neuraxial anaesthesia: a review of 647 cases.

Although rare, spinal haematoma and abscess after central neuraxial blocks may cause severe permanent neurological injury. Optimal treatment and outcome remain unclear. In order to identify possible predisposing patient characteristics and describe the ensuing clinical course, we searched Medline, Embase, and the Cochrane Library for reports of spinal haematomas and abscesses associated with central neuraxial blocks. Extracted data included patient characteristics, symptoms, treatment, and outcome. We analysed 409 reports, including 647 patients (387 patients with spinal haematoma and 260 patients with spinal abscess). Spinal haematoma and abscess occurred predominantly after epidural anaesthesia (58% and 83%, respectively). Neurological recovery was correlated with the severity of initial neurological deficit. When decompression of spinal haematoma was delayed for >12 h after clinical diagnosis, neurological outcome was worse compared with earlier decompression (odds ratio 4.5, 95% confidence interval 2.1-9.9, P<0.001, n=163). After spinal haematoma, 47% of published patients had full recovery, 28% had partial recovery, and in 25% no recovery was observed. Good outcome after conservative management was observed in patients with mild symptoms or with spontaneous recovery during the diagnostic and therapeutic workup. After spinal abscess, 68% of reported patients recovered fully, 21% showed partial recovery, and no recovery was reported in 11%. Persistent neurological symptoms after spinal haematoma and abscess are common and correlate with the severity of initial neurological deficit. Neurological outcome seems worse when decompressive surgery of haematoma is delayed. Notwithstanding the considerable risk of selection bias and publication bias, conservative management may be feasible in patients with mild symptoms or spontaneous recovery.

Association between delirium and cognitive change after cardiac surgery.

BACKGROUND: Previous studies provide inconsistent data on whether postoperative delirium (POD) is a risk factor for postoperative cognitive decline (POCD). We thus investigated the relationship between POD and cognitive change after cardiac surgery and assessed the relationship between preoperative cognitive domain scores and POD. METHODS: Postoperative delirium was assessed with the Confusion Assessment Method (CAM) adapted for the intensive care unit and the conventional CAM accompanied by chart review. Cognitive function was assessed with a neuropsychological test battery before elective cardiac surgery and 1 month and 1 yr afterwards. Cognitive change was calculated using the Reliable Change Index (RCI). Multiple linear regression was used to adjust for confounding. RESULTS: Of the 184 patients who completed baseline assessment, 23 (12.5%) developed POD. At 1 month, the decline in cognitive performance was worse in patients with POD [median composite RCI -1.00, interquartile range (IQR) -1.67 to 0.28] than in patients without POD (RCI -0.04, IQR -0.70 to 0.63, P =0.02). At 1 yr, both groups showed cognitive improvement on average compared with baseline (POD patients median composite RCI 0.25, IQR -0.42 to 1.31, vs non-POD patients RCI 0.92, IQR 0.18-1.53; P =0.08). Correction for differences in age and level of education did not change the results. Patients with POD performed less well than patients without POD on the preoperative Trailmaking test part A ( P =0.03). CONCLUSIONS: Postoperative delirium is independently associated with cognitive decline 1 month after surgery, but cognitive performance generally recovers in 1 yr. Patients with a predisposition to POD can be identified before surgery by worse performance in an attention task. CLINICAL TRIAL REGISTRATION: NCT00293592.

Variations in assessment and certification in postgraduate anaesthesia training: a European survey.

BACKGROUND: Postgraduate specialty training has traditionally been based on a time- and rotation-based model, but competency-based models are emerging. Because anaesthesia training evolves differently across Europe, variations in assessment and certification processes are expected, but the extent of similarities and differences is unknown. The aim of this study was to compare anaesthesia training programmes in Europe, focusing on assessment and certification processes. METHODS: We performed an online survey among national representatives of the Union of European Medical Specialists/European Board of Anaesthesiology. RESULTS: All 36 countries participated. Duration of training had a median of 5 yr (range 2.75-7). Mean number of different assessment tools was 7.45 (range 4-13), with more tools being used in competency-based programmes [mean 9.1 (sd 2.97) vs 7.0 (sd 1.97); P=0.03]. Most countries had a nationally uniform certification process. Based on a qualitative analysis of the survey findings, a categorization of countries emerged, reflecting the approach to assessment and certification. We observed two main streams of countries with an underlying knowledge or procedural focus within a time- and rotation-based apprenticeship model. These main streams are evolving, to different extents, towards a third orientation, competency-based training. CONCLUSIONS: Assessment and certification processes in European anaesthesia training are diverse. In many countries, a time-based apprenticeship model is evolving towards a competency-based certification process. This diversity precludes comparison of competence of graduating anaesthetists across Europe.

Long-term outcomes and cost effectiveness of high-dose dexamethasone for cardiac surgery: a randomised trial.

Prophylactic intra-operative administration of dexamethasone may improve short-term clinical outcomes in cardiac surgical patients. The purpose of this study was to evaluate long-term clinical outcomes and cost effectiveness of dexamethasone versus placebo. Patients included in the multicentre, randomised, double-blind, placebo-controlled DExamethasone for Cardiac Surgery (DECS) trial were followed up for 12 months after their cardiac surgical procedure. In the DECS trial, patients received a single intra-operative dose of dexamethasone 1 mg.kg-1 (n = 2239) or placebo (n = 2255). The effects on the incidence of major postoperative events were evaluated. Also, overall costs for the 12-month postoperative period, and cost effectiveness, were compared between groups. Of 4494 randomised patients, 4457 patients (99%) were followed up until 12 months after surgery. There was no difference in the incidence of major postoperative events, the relative risk (95%CI) being 0.86 (0.72-1.03); p = 0.1. Treatment with dexamethasone reduced costs per patient by £921 [€1084] (95%CI £-1672 to -137; p = 0.02), mainly through reduction of postoperative respiratory failure and duration of postoperative hospital stay. The probability of dexamethasone being cost effective compared with placebo was 97% at a threshold value of £17,000 [€20,000] per quality-adjusted life year. We conclude that intra-operative high-dose dexamethasone did not have an effect on major adverse events at 12 months after cardiac surgery, but was associated with a reduction in costs. Routine dexamethasone administration is expected to be cost effective at commonly accepted threshold levels for cost effectiveness.

Wireless non-invasive continuous respiratory monitoring with FMCW radar: a clinical validation study.

Altered respiratory rate is one of the first symptoms of medical conditions that require timely intervention, e.g., sepsis or opioid-induced respiratory depression. To facilitate continuous respiratory rate monitoring on general hospital wards a contactless, non-invasive, prototype monitor was developed using frequency modulated continuous wave radar. We aimed to study whether radar can reliably measure respiratory rate in postoperative patients. In a diagnostic cross-sectional study patients were monitored with the radar and the reference monitor (pneumotachograph during mechanical ventilation and capnography during spontaneous breathing). Eight patients were included; yielding 796 min of observation time during mechanical ventilation and 521 min during spontaneous breathing. After elimination of movement artifacts the bias and 95 % limits of agreement for mechanical ventilation and spontaneous breathing were -0.12 (-1.76 to 1.51) and -0.59 (-5.82 to 4.63) breaths per minute respectively. The radar was able to accurately measure respiratory rate in mechanically ventilated patients, but the accuracy decreased during spontaneous breathing.

Impact of adding therapeutic recommendations to risk assessments from a prediction model for postoperative nausea and vomiting.

BACKGROUND: In a large cluster-randomized trial on the impact of a prediction model, presenting the calculated risk of postoperative nausea and vomiting (PONV) on-screen (assistive approach) increased the administration of risk-dependent PONV prophylaxis by anaesthetists. This change in therapeutic decision-making did not improve the patient outcome; that is, the incidence of PONV. The present study aimed to quantify the effects of adding a specific therapeutic recommendation to the predicted risk (directive approach) on PONV prophylaxis decision-making and the incidence of PONV. METHODS: A prospective before-after study was conducted in 1483 elective surgical inpatients. The before-period included care-as-usual and the after-period included the directive risk-based (intervention) strategy. Risk-dependent effects on the administered number of prophylactic antiemetics and incidence of PONV were analysed by mixed-effects regression analysis. RESULTS: During the intervention period anaesthetists administered 0.5 [95% confidence intervals (CIs): 0.4-0.6] more antiemetics for patients identified as being at greater risk of PONV. This directive approach led to a reduction in PONV [odds ratio (OR): 0.60, 95% CI: 0.43-0.83], with an even greater reduction in PONV in high-risk patients (OR: 0.45, 95% CI: 0.28-0.72). CONCLUSIONS: Anaesthetists administered more prophylactic antiemetics when a directive approach was used for risk-tailored intervention compared with care-as-usual. In contrast to the previously studied assistive approach, the increase in PONV prophylaxis now resulted in a lower PONV incidence, particularly in high-risk patients. When one aims for a truly 'PONV-free hospital', a more liberal use of prophylactic antiemetics must be accepted and lower-risk thresholds should be set for the actionable recommendations.

Is "really conscious" sedation with solely an opioid an alternative to every day used sedation regimes for colonoscopies in a teaching hospital? Midazolam/fentanyl, propofol/alfentanil, or alfentanil only for colonoscopy: a randomized trial.

BACKGROUND: We investigated the satisfaction of patients and endoscopists and concurrently safety aspects of an "alfentanil only" and two clinically routinely used sedation regimes in patients undergoing colonoscopy in a teaching hospital. METHODS: One hundred and eighty patients were prospectively randomized in three groups: M (midazolam/fentanyl), A (alfentanil), and P (propofol/alfentanil); M and A were administered by an endoscopy nurse, P by an anesthesia nurse. Interventions, heart rate, saturation, electrocardiogram, noninvasive blood pressure, and expiratory CO2 were monitored using video assistance. After endoscopy, patients and gastroenterologists completed questionnaires about satisfaction. RESULTS: A high level of satisfaction was found in all groups, with patients in group P being more satisfied with their sedation experience (median 1.75, p < 0.001). Gastroenterologist satisfaction varied not significantly between the three alternatives. Patients in group A felt less drowsy, could communicate more rapidly than patients in both other groups, and met discharge criteria immediately after the end of the procedure. Respiratory events associated with sedation were observed in 43% patients in group M, 47% in group P, but only 13% in group A (p < 0.001). CONCLUSIONS: These results suggest that alfentanil could be an alternative for sedation in colonoscopy even in the setting of a teaching hospital. It results in satisfied patients easily taking up information, and recovering rapidly. Although one might expect to observe more respiratory depression with an "opioid only" sedation technique without involvement of anesthesia partners, respiratory events were less frequent than when other methods were used.

Occurrence and determinants of poor response to short-term pre-operative erythropoietin treatment.

BACKGROUND: This study aimed to explore the occurrence and determinants of poor response to short-term pre-operative erythropoietin treatment and the effect of such poor response on transfusion in total hip arthroplasty patients. METHODS: We studied total hip arthroplasty patients who received erythropoietin before surgery. The primary outcome was the pre-operative increase in haemoglobin (delta haemoglobin) as response to erythropoietin therapy. Additionally, patients were classified in tertiles based on this delta haemoglobin: poor responders (cases), responders and good responders (controls) to erythropoietin. Patient characteristics, comedication and co-morbidity were collected as potential determinants of erythropoietin response. Regression techniques were used to estimate the strength of the associations and to assess the effect of poor response on transfusion requirement. RESULTS: A total of 379 patients receiving erythropoietin were eligible to enter the study. Mean delta haemoglobin was 19.3 g/l (standard deviation 9.4). Factors significantly associated with delta haemoglobin were the use of angiotensin II antagonists [-3.1 g/l; 95% confidence interval (CI) -5.7 to -0.6] and vitamin K antagonists (-6.9 g/l; 95% CI -10.0 to -0.2), together with body mass index (BMI) (-0.3 g/l per unit>; 95% CI -0.5 to -0.2). The additional case-control analysis yielded comparable results. Poor response to erythropoietin was associated with an increased transfusion risk (odds ratio 4.6, 95% CI 2.0-11). CONCLUSION: Use of angiotensin II receptor antagonists and vitamin K antagonists, and having a high BMI were determinants of poor response to short-term pre-operative erythropoietin treatment in total hip arthroplasty patients. Poor responders had a higher risk for perioperative blood transfusion.

Near-infrared light to aid peripheral intravenous cannulation in children: a cluster randomised clinical trial of three devices.

Intravenous cannulation can be difficult in children. Recently, new devices using near-infrared light to make blood vessels visible have become available. We aimed to evaluate the effectiveness of three such devices in facilitating peripheral intravenous cannulation in children. In this cluster randomised clinical trial, daily operating rooms at a tertiary childrens' hospital were randomised to the use of the VeinViewer®, AccuVein® AV300, VascuLuminator Vision® or to a control group. We included 1913 children between birth and 18 years scheduled for elective surgery. Suitable veins for cannulation were more easily visible with the VeinViewer (307/322 (95.3%)) and AccuVein (239/254 (94.1%)) devices than with VascuLuminator (229/257 (89.1%)) (p = 0.03). However, success at the first attempt was not significantly different among groups, ranging from 73.1% to 75.3% (p = 0.93). We conclude that although vein visibility is enhanced, near-infrared devices do not improve cannulation.

Quality of recovery after day care surgery with app-controlled remote monitoring: study protocol for a randomized controlled trial.

BACKGROUND: The majority of surgical interventions are performed in day care and patients are discharged after the first critical postoperative period. At home, patients have limited options to contact healthcare providers in the hospital in case of severe pain and nausea. A smartphone application for patients to self-record pain and nausea when at home after day care surgery might improve patient's recovery. Currently patient experiences with smartphone applications are promising; however, we do not know whether remote monitoring with such an application also improves the patient's recovery. This study aims to evaluate the experienced quality of recovery after day care surgery between patients provided with the smartphone application for remote monitoring and patients receiving standard care without remote monitoring. METHODS: This non-blinded randomized controlled trial with mixed methods design will include 310 adult patients scheduled for day care surgery. The intervention group receives the smartphone application with text message function for remote monitoring that enables patients to record pain and nausea. An anaesthesia professional trained in empathetic communication, who will contact the patient in case of severe pain or nausea, performs daily monitoring. The control group receives standard care, with post-discharge verbal and paper instructions. The main study endpoint is the difference in perceived quality of recovery, measured with the QoR-15 questionnaire on the 7th day after day care surgery. Secondary endpoints are the overall score on the Quality of Recovery-15 at day 1, 4 and 7-post discharge, the perceived quality of hospital aftercare and experienced psychological effects of remote monitoring during postoperative recovery from day care surgery. DISCUSSION: This study will investigate if facilitating patients and healthcare professionals with a tool for accessible and empathetic communication might lead to an improved quality of the postoperative recovery period. TRIAL REGISTRATION: The 'Quality of recovery after day care surgery with app-controlled remote monitoring: a randomized controlled trial' is approved and registered on 23 February 2022 by Research Ethics Committees United with registration number R21.076/NL78144.100.21. The protocol NL78144.100.21, 'Quality of recovery after day care surgery with app-controlled remote monitoring: a randomized controlled trial', is registered at the ClinicalTrials.gov public website (registration date 16 February 2022; NCT05244772).

Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study.

OBJECTIVE: To evaluate the effect of implementation of the WHO's Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance. BACKGROUND: Marked reductions in postoperative complications after implementation of a surgical checklist have been reported. As compliance to the checklists was reported to be incomplete, it remains unclear whether the benefits obtained were through actual completion of a checklist or from an increase in overall awareness of patient safety issues. METHODS: This retrospective cohort study included 25,513 adult patients undergoing non-day case surgery in a tertiary university hospital. Hospital administrative data and electronic patient records were used to obtain data. In-hospital mortality within 30 days after surgery was the main outcome and effect estimates were adjusted for patient characteristics, surgical specialty and comorbidity. RESULTS: After checklist implementation, crude mortality decreased from 3.13% to 2.85% (P = 0.19). After adjustment for baseline differences, mortality was significantly decreased after checklist implementation (odds ratio [OR] 0.85; 95% CI, 0.73-0.98). This effect was strongly related to checklist compliance: the OR for the association between full checklist completion and outcome was 0.44 (95% CI, 0.28-0.70), compared to 1.09 (95% CI, 0.78-1.52) and 1.16 (95% CI, 0.86-1.56) for partial or noncompliance, respectively. CONCLUSIONS: Implementation of the WHO Surgical Checklist reduced in-hospital 30-day mortality. Although the impact on outcome was smaller than previously reported, the effect depended crucially upon checklist compliance.

Decontamination of the digestive tract and oropharynx in ICU patients.

BACKGROUND: Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS: We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS: A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS: In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

Difficult arterial cannulation in children: is a near-infrared vascular imaging system the answer?

BACKGROUND: Arterial cannulation is a common anaesthetic procedure that can be challenging and time-consuming in small children. By visualizing the position of the radial artery, near-infrared vascular imaging systems (NIRVISs) might be of assistance in arterial cannulation. The present study evaluates the effectiveness of an NIRVIS in arterial cannulation in infants. METHODS: An observational study was conducted in patients up to 3 yr old, undergoing arterial cannulation before cardiothoracic surgery. Arterial cannulation was performed as usual in 38 patients, and subsequently with the NIRVIS in 39 patients. RESULTS: The time to successful cannulation was 547 s (171-1183) without and 464 s (174-996) with the NIRVIS (P=0.76) and the time to first flashback of blood was 171 s (96-522) and 219 s (59-447), respectively (P=0.38). There was a tendency in favour of the NIRVIS in success at first attempt: 12/38 and 7/39, respectively (P=0.29) and in the number of punctures: 6 (2-12) and 3 (1-7), respectively (P=0.10). CONCLUSIONS: The present study did not show a significant clinical improvement when NIR light was used during arterial cannulation in small children. There is a large difference between time to first flashback of blood and time to successful cannulation, indicating that inserting the cannula, and not localizing the artery, is the main difficulty in arterial cannulation in children.

Determination of moderate-to-severe postoperative pain on the numeric rating scale: a cut-off point analysis applying four different methods.

BACKGROUND: Cut-off points (CPs) of the numeric rating scale (NRS 0-10) are regularly used in postoperative pain treatment. However, there is insufficient evidence to identify the optimal CP between mild and moderate pain. METHODS: A total of 435 patients undergoing general, trauma, or oral and maxillofacial surgery were studied. To determine the optimal CP for pain treatment, four approaches were used: first, patients estimated their tolerable postoperative pain intensity before operation; secondly, 24 h after surgery, they indicated if they would have preferred to receive more analgesics; thirdly, satisfaction with pain treatment was analysed, and fourthly, multivariate analysis was used to calculate the optimal CP for pain intensities in relation to pain-related interference with movement, breathing, sleep, and mood. RESULTS: The estimated tolerable postoperative pain before operation was median (range) NRS 4.0 (0-10). Patients who would have liked more analgesics reported significantly higher average pain since surgery [median NRS 5.0 (0-9)] compared with those without this request [NRS 3.0 (0-8)]. Patients satisfied with pain treatment reported an average pain intensity of median NRS 3.0 (0-8) compared with less satisfied patients with NRS 5.0 (2-9). Analysis of average postoperative pain in relation to pain-related interference with mood and activity indicated pain categories of NRS 0-2, mild; 3-4, moderate; and 5-10, severe pain. CONCLUSIONS: Three of the four methods identified a treatment threshold of average pain of NRS≥4. This was considered to identify patients with pain of moderate-to-severe intensity. This cut-off was indentified as the tolerable pain threshold.

Hand-hygiene practices in the operating theatre: an observational study.

BACKGROUND: The current prevalence of healthcare-associated infections (HCAIs) is a major public health concern. Patient contact in the operating theatre (OT) can contribute to HCAI via microbial contamination. The application of hand hygiene is effective in reducing infection rates. Limited data are available on adherence to hand-hygiene guidelines by OT staff. METHODS: Covert direct observations of OT staff at an academic medical centre were performed by a single, trained observer. The primary outcome was the frequency of hand-hygiene application by OT staff, including anaesthesiologists, anaesthesia nurses, surgeons, surgical nurses, and medical students. 'Sterile' scrubbed staff members were excluded. The following hand-hygiene opportunities were monitored: (i) entering or leaving the OT; and (ii) before patient contact. Furthermore, the frequency of 'potential contamination' was recorded (touching OT implements after contact with patient/patient body fluids without the subsequent application of hand hygiene). We recorded non-surgical glove usage for invasive procedures, for example, intubation or insertion of intravascular devices. Finally, we collected qualitative data on incentives for hand hygiene. RESULTS: A total of 28 operations were observed (60 h of observations). On average, 0.14 hand-hygiene applications per hour per staff member were witnessed. Upon entering or leaving the OT, hand hygiene was performed in 2% (7/363) and 8% (28/333) of opportunities. CONCLUSIONS: Frequent interactions between patient, staff, and OT environment were observed. Adherence to hand-hygiene guidelines by OT staff was extremely low. This potentially exposes patients to microbial transmission, HCAIs, and patient harm.

Postoperative urinary retention: risk factors, bladder filling rate and time to catheterization: an observational study as part of a randomized controlled trial.

BACKGROUND: Knowledge of risk factors for postoperative urinary retention may guide appropriate and timely urinary catheterization. We aimed to determine independent risk factors for postoperative urinary catheterization in general surgical patients. In addition, we calculated bladder filling rate and assessed the time to spontaneous voiding or catheterization. We used the patients previously determined individual maximum bladder capacity as threshold for urinary catheterization. METHODS: Risk factors for urinary catheterization were prospectively determined in 936 general surgical patients. Patients were at least 18 years of age and operated under general or spinal anesthesia without the need for an indwelling urinary catheter. Patients measured their maximum bladder capacity preoperatively at home, by voiding in a calibrated bowl after a strong urge that could no longer be ignored. Postoperatively, bladder volumes were assessed hourly with ultrasound. When patients reached their maximum bladder capacity and were unable to void, they were catheterized by the nursing staff. Bladder filling rate and time to catheterization were determined. RESULTS: Spinal anesthesia was the main independent modifiable risk factor for urinary catheterization (hyperbaric bupivacaine, relative risk 8.1, articaine RR 3.1). Unmodifiable risk factors were a maximum bladder capacity < 500 mL (RR 6.7), duration of surgery ≥ 60 min (RR 5.5), first scanned bladder volume at the Post Anesthesia Care Unit ≥250mL (RR 2.1), and age ≥ 60 years (RR 2.0). Urine production varied from 100 to 200 mL/h. Catheterization or spontaneous voiding took place approximately 4 h postoperatively. CONCLUSION: Spinal anesthesia, longer surgery time, and older age are the main risk factors for urinary retention catheterization. Awareness of these risk factors, regularly bladder volume scanning (at least every 3 h) and using the individual maximum bladder capacity as volume threshold for urinary catheterization may avoid unnecessary urinary catheterization and will prevent bladder overdistention with the attendant risk of lower urinary tract injury. TRIAL REGISTRATION: Dutch Central Committee for Human Studies registered trial database: NL 21058.099.07. Current Controlled Trials database: Preventing Bladder Catheterization after an Operation under General or Spinal Anesthesia by Using the Patient's Own Maximum Bladder Capacity as a Limit for Maximum Bladder Volume. ISRCTN97786497 . Registered 18 July 2011 -Retrospectively registered. The original study started 19 May 2008, and ended 30 April 2009, when the last patient was included.