Working conditions during pregnancy: a survey of 3590 European anaesthesiologists and intensivists.

BACKGROUND: Pregnancy adds challenges for healthcare professionals, regardless of gender. We investigated experiences during pregnancy, attitudes towards pregnant colleagues, family planning decisions, and awareness of regulations among European anaesthesiologists and intensivists. METHODS: A cross-sectional online survey was conducted among 3590 anaesthesiologists and intensivists from 47 European countries. The survey, available for 12 weeks, collected data on demographics, working conditions, safety perceptions, and the impact of clinical practice and training demands on family planning. Quantitative data were analysed using descriptive statistics, whereas qualitative data underwent thematic content analysis. RESULTS: Only 41.4% (n=678) of women were satisfied with their working conditions during pregnancy, and only 38.5% (n=602) considered their working environment safe. The proportion of women who changed their clinical practice during pregnancy and who took sick leave to avoid potentially harmful working conditions increased over time (P<0.001 for both). Men had children more often during residency than women (P<0.001). Pregnant colleagues' safety concerns influenced clinical practice, with women and men who had experience with their own and partner's pregnancy being more likely to modify their practices. Work and training demands discouraged plans to have children, particularly among women, leading to consideration of leaving training. Awareness of national regulations was limited, and respondents highlighted a need for better support and flexible working conditions. CONCLUSIONS: Improved support and working environments for pregnant colleagues and ability to express preferred clinical areas for work are needed. Department heads should commit to safety and family friendliness, and men transitioning to parenthood should not be neglected.

Preoperative Carbohydrate Load Does Not Alter Glycemic Variability in Diabetic and Non-Diabetic Patients Undergoing Major Gynecological Surgery: A Retrospective Study.

Background/Objectives: Elevated glycemic variability (GV) has been associated with postoperative morbidity. Traditional preoperative fasting guidelines may contribute to high GV by driving the body into catabolism. Enhanced recovery after surgery (ERAS) protocols that include a preoperative carbohydrate load (PCL) reduce hospital length of stay and healthcare costs; however, it remains unclear whether PCL improves GV in surgical patients. The aim of this retrospective study was to determine the effect of a PCL on postoperative GV in diabetic and non-diabetic patients having gynecological surgery. Methods: Retrospective data were collected on patients who had gynecological surgery before and after the rollout of an institutional ERAS protocol that included PCL ingestion. The intervention group included patients who underwent surgery in 2019 and were enrolled in the ERAS protocol and, therefore, received a PCL. The control group included patients who underwent surgery in 2016 and, thus, were not enrolled in the protocol. The primary endpoint was GV, calculated by the coefficient of variance (CV) and glycemic lability index (GLI). Results: A total of 63 patients in the intervention group and 45 in the control were analyzed. GV was not statistically significant between the groups for CV (19.3% vs. 18.6%, p = 0.65) or GLI (0.58 vs. 0.54, p = 0.86). Postoperative pain scores (4.5 vs. 5.2 p = 0.23) and incentive spirometry measurements (1262 vs. 1245 p = 0.87) were not significantly different. A subgroup analysis of patients with and without type 2 diabetes mellitus revealed no significant differences in GV for any of the subgroups. Conclusions: This retrospective review highlights the need for additional GV research, including consensus agreement on a gold standard GV measurement. Large-scale prospective studies are needed to test the effectiveness of the PCL in reducing GV.

A Patient-Level Meta-Analysis of Intensive Glucose Control in Critically Ill Adults.

BACKGROUND: Whether intensive glucose control reduces mortality in critically ill patients remains uncertain. Patient-level meta-analyses can provide more precise estimates of treatment effects than are currently available. METHODS: We pooled individual patient data from randomized trials investigating intensive glucose control in critically ill adults. The primary outcome was in-hospital mortality. Secondary outcomes included survival to 90 days and time to live cessation of treatment with vasopressors or inotropes, mechanical ventilation, and newly commenced renal replacement. Severe hypoglycemia was a safety outcome. RESULTS: Of 38 eligible trials (n=29,537 participants), 20 (n=14,171 participants) provided individual patient data including in-hospital mortality status for 7059 and 7049 participants allocated to intensive and conventional glucose control, respectively. Of these 1930 (27.3%) and 1891 (26.8%) individuals assigned to intensive and conventional control, respectively, died (risk ratio, 1.02; 95% confidence interval [CI], 0.96 to 1.07; P=0.52; moderate certainty). There was no apparent heterogeneity of treatment effect on in-hospital mortality in any examined subgroups. Intensive glucose control increased the risk of severe hypoglycemia (risk ratio, 3.38; 95% CI, 2.99 to 3.83; P<0.0001). CONCLUSIONS: Intensive glucose control was not associated with reduced mortality risk but increased the risk of severe hypoglycemia. We did not identify a subgroup of patients in whom intensive glucose control was beneficial. (Funded by the Australian National Health and Medical Research Council and others; PROSPERO number CRD42021278869.).

Implementation of perioperative blood glucose monitoring and insulin infusion protocol can decrease postoperative infection rate in diabetic patients undergoing elective craniotomy: An observational study.

BACKGROUND: Severe perioperative hyperglycemia (SH) is a proven risk factor for postoperative complications after craniotomy. To reduce this risk, it has been proposed to implement the standardized clinical protocol for scheduled perioperative blood glucose concentration (BGC) monitoring. This would be followed by intravenous (IV) insulin infusion to keep BGC below 180 mg/dl in the perioperative period. The aim of this prospective observational study was to assess the impact of this type of protocol on the postoperative infection rate in patients undergoing elective craniotomy. METHODS: A total of 42 patients were prospectively enrolled in the study. Protocol included scheduled BGC monitoring in the perioperative period and rapid-acting insulin IV infusion when intraoperative SH was detected. The diagnosis of infection (wound, pulmonary, blood stream, urinary tract infection or central nervous system infection) was established according to CDC criteria within the first postoperative week. A previously enrolled group of patients with sporadic BGC monitoring and subcutaneous insulin injections for SH management was used as a control group. RESULTS: An infectious complication (i.e., pneumonia) was diagnosed only in one patient (2 %) in the prospective group. In comparison with the control group, a decrease in the risk of postoperative infection was statistically significant with OR = 0.08 [0.009 - 0.72] (p = 0.02). Implementation of the perioperative BGC monitoring and the correction protocol prevented both severe hyperglycemia and hypoglycemia with BGC < 70 mg/dl. CONCLUSION: Scheduled BGC monitoring and the use of low-dose insulin infusion protocol can decrease the postoperative infection rate in patients undergoing elective craniotomy. Future studies are needed to prove the causality of the implementation of such a protocol with an improved outcome.

Aspirin interruption before neurosurgical interventions: A controversial problem.

Aspirin is widely used for primary or secondary prevention of ischemic events. At the same time, chronic aspirin consumption can affect blood clot formation during surgical intervention and increase intraoperative blood loss. This is especially important for high-risk surgery, including neurosurgery. Current European Society of Cardiology guidelines recommend aspirin interruption for at least 7 d before neurosurgical intervention, but this suggestion is not supported by clinical evidence. This narrative review presents evidence that challenges the necessity for aspirin interruption in neurosurgical patients, describes options for aspirin effect monitoring and the clinical implication of these methods, and summarizes current clinical data on bleeding risk associated with chronic aspirin therapy in neurosurgical patients, including brain tumor surgery, cerebrovascular procedures, and spinal surgery.

Automatic detection of obstructive sleep apnea based on speech or snoring sounds: a narrative review.

Background and Objective: Obstructive sleep apnea (OSA) is a common chronic disorder characterized by repeated breathing pauses during sleep caused by upper airway narrowing or collapse. The gold standard for OSA diagnosis is the polysomnography test, which is time consuming, expensive, and invasive. In recent years, more cost-effective approaches for OSA detection based in predictive value of speech and snoring has emerged. In this paper, we offer a comprehensive summary of current research progress on the applications of speech or snoring sounds for the automatic detection of OSA and discuss the key challenges that need to be overcome for future research into this novel approach. Methods: PubMed, IEEE Xplore, and Web of Science databases were searched with related keywords. Literature published between 1989 and 2022 examining the potential of using speech or snoring sounds for automated OSA detection was reviewed. Key Content and Findings: Speech and snoring sounds contain a large amount of information about OSA, and they have been extensively studied in the automatic screening of OSA. By importing features extracted from speech and snoring sounds into artificial intelligence models, clinicians can automatically screen for OSA. Features such as formant, linear prediction cepstral coefficients, mel-frequency cepstral coefficients, and artificial intelligence algorithms including support vector machines, Gaussian mixture model, and hidden Markov models have been extensively studied for the detection of OSA. Conclusions: Due to the significant advantages of noninvasive, low-cost, and contactless data collection, an automatic approach based on speech or snoring sounds seems to be a promising tool for the detection of OSA.

Trends in preoperative carbohydrate load practice: A systematic review.

BACKGROUND: The preoperative carbohydrate load (PCL) is intended to improve surgical outcomes by reducing the catabolic state induced by overnight fasting. However, there is disagreement on the optimal PCL prescription, leaving local institutions without a standardized PCL recommendation. Results from studies that do not prescribe PCL in identical ways cannot be pooled to draw larger conclusions on outcomes affected by the PCL. The aim of this systematic review is to catalog prescribed PCL characteristics, including timing of ingestion, percentage of carbohydrate contribution, and volume, to ultimately standardize PCL practice. METHODS: A comprehensive search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials were included if they studied at least one group of patients who were prescribed a PCL and the PCL was described with respect to timing of ingestion, carbohydrate contribution, and total volume. RESULTS: A total of 67 studies with 6551 patients were included in this systematic review. Of the studies, 49.3% were prescribed PCL on the night before surgery and morning of surgery, whereas 47.8% were prescribed PCL on the morning of surgery alone. The mean prescribed carbohydrate concentration was 13.5% (±3.4). The total volume prescribed was 648.2 ml (±377). CONCLUSION: Variation in PCL practices prevent meaningful data pooling and outcome analysis, highlighting the need for standardized PCL prescription. Efforts dedicated to the establishment of a gold standard PCL prescription are necessary so that studies can be pooled and analyzed with respect to meaningful clinical end points that impact surgical outcomes and patient satisfaction.

Verbal Glasgow Coma Scale as predictor of persistent disorder of consciousness: Insights for improving accuracy and reliability in clinical practice.

This brief report discusses the relationship between verbal function, disorders of consciousness, and neurological follow-up after acute brain injury. It provides valuable insights for improving the accuracy and reliability of Verbal Glasgow Coma Scale scoring in clinical practice. The report addresses the need for standardized training and underlines the importance of physiological stabilization before assessment. Clarity in communication, recognition of non-verbal cues, and serial assessments are emphasized as critical factors to reduce the Verbal Glasgow Coma Scale inconsistencies. It also promotes interdisciplinary collaboration and cultural sensitivity to refine the Verbal Glasgow Coma Scale evaluation, improving the prediction of long-term neurological outcomes after acute brain injury and optimizing effective rehabilitation programs. Possible strategies to implement in the routine clinical practice the provided tips are discussed.

Machine learning in the prediction and detection of new-onset atrial fibrillation in ICU: a systematic review.

Atrial fibrillation (AF) stands as the predominant arrhythmia observed in ICU patients. Nevertheless, the absence of a swift and precise method for prediction and detection poses a challenge. This study aims to provide a comprehensive literature review on the application of machine learning (ML) algorithms for predicting and detecting new-onset atrial fibrillation (NOAF) in ICU-treated patients. Following the PRISMA recommendations, this systematic review outlines ML models employed in the prediction and detection of NOAF in ICU patients and compares the ML-based approach with clinical-based methods. Inclusion criteria comprised randomized controlled trials (RCTs), observational studies, cohort studies, and case-control studies. A total of five articles published between November 2020 and April 2023 were identified and reviewed to extract the algorithms and performance metrics. Reviewed studies sourced 108,724 ICU admission records form databases, e.g., MIMIC. Eight prediction and detection methods were examined. Notably, CatBoost exhibited superior performance in NOAF prediction, while the support vector machine excelled in NOAF detection. Machine learning algorithms emerge as promising tools for predicting and detecting NOAF in ICU patients. The incorporation of these algorithms in clinical practice has the potential to enhance decision-making and the overall management of NOAF in ICU settings.

Preoperative Risk Assessment Before Elective Craniotomy: Are Aspirin, Arrhythmias, Deep Venous Thromboses, and Hyperglycemia Contraindications to Surgery?

OBJECTIVE: Perioperative risk assessment and stratification before craniotomy is necessary to identify and optimize modifiable risk factors. Due to the high costs of diagnostic testing and concerns for delaying surgery, some have questioned whether and when surgery delays are warranted and supported by the current body of literature. The objective of this scoping review was to evaluate the available evidence on the prognostic value of preoperative risk assessment before anesthesia for elective craniotomy. METHODS: In this scoping review, we reviewed 156 papers that assess preoperative risk assessment before elective craniotomy, of which 27 papers were included in the final analysis. RESULTS: There is little high-quality evidence to suggest significant risk reduction when 4 common preexisting abnormalities are present: preoperative chronic aspirin therapy, cardiac arrhythmias, deep vein thrombosis, or hyperglycemia. CONCLUSIONS: The risk of delaying craniotomy should ultimately be weighed against the perceived risks associated the patient's comorbid conditions and should be considered on an individualized basis.

The Predictive Value of the Verbal Glasgow Coma Scale in Traumatic Brain Injury: A Systematic Review.

BACKGROUND: Traumatic brain injury (TBI) is a major global health concern, imposing significant burdens on individuals and healthcare systems. The Glasgow Coma Scale (GCS), a widely utilized instrument for evaluating neurological status, includes 3 variables: motor, verbal, and eye opening. The GCS plays a crucial role in TBI severity stratification. While extensive research has explored the predictive capabilities of the overall GCS score and its motor component, the Verbal Glasgow Coma Scale (V-GCS) has garnered less attention. OBJECTIVE: To examine the predictive accuracy of the V-GCS in assessing outcomes in patients with TBI, with a particular focus on functional outcome and mortality. In addition, we intend to compare its predictive performance with other components of the GCS. METHODS: A systematic review, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was conducted utilizing the PubMed, Scopus, and Web of Science databases. Inclusion criteria encompassed 10 clinical studies involving patients with TBI, wherein the level of consciousness was assessed using the verbal GCS score. Predominant statistical measures employed were odds ratios (ORs) and area under the curve (AUC). RESULTS: Recorded findings consistently underscore that lower V-GCS scores are associated with adverse functional outcomes and mortality in patients with TBI. Despite the predictive accuracy of the V-GCS, the Motor Glasgow Coma Scale (M-GCS) emerges as a superior predictor. CONCLUSION: In the context of TBI outcome prediction, the V-GCS demonstrates its efficacy as a prognostic tool. However, the M-GCS exhibits superior performance compared with the V-GCS. These insights underscore the multifaceted nature of TBI assessment and emphasize the necessity of considering distinct components of the Glasgow Coma Scale for comprehensive evaluation. Further research is warranted to refine and improve the application of these predictive measures in clinical practice.

How much does it cost to be fit for operation? The economics of prehabilitation.

PURPOSE OF REVIEW: Prehabilitation before elective surgery can include physical, nutritional, and psychological interventions or a combination of these to allow patients to return postoperatively to baseline status as soon as possible. The purpose of this review is to analyse the current date related to the cost-effectiveness of such programs. RECENT FINDINGS: The current literature regarding the economics of prehabilitation is limited. However, such programs have been mainly associated with either a reduction in total healthcare related costs or no increase. SUMMARY: Prehabilitation before elective surgery has been shown to minimize the periprocedural complications and optimization of short term follow up after surgical procedures. Recent studies included cost analysis, either based on hospital accounting data or on estimates costs. The healthcare cost was mainly reduced by shortening the number of hospitalization day. Other factors included length of ICU stay, place of the prehabilitation program (in-hospital vs. home-based) and compliance to the program.

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.