A feasibility study on preoperative carbohydrate loading in older patients undergoing hip fracture surgery.

BACKGROUND: Preoperative carbohydrate loading in Enhanced Recovery After Surgery is an independent predictor of postoperative outcomes. By reducing the impact of surgical stress response, fasting-induced insulin resistance is modulated. As a clear fluid, consuming carbohydrate drink is safe up to 2 h preoperatively. Widely practiced in abdominal surgeries, its implementation in hip fracture surgeries is yet to be recognized. This study aimed to identify the feasibility of preoperative carbohydrate loading in hip fracture surgery and assess its clinical effects. METHODS: This was a randomized controlled, open labelled trial. Patients ≥ 65 years old without diabetes mellitus, has hip fracture were recruited in a tertiary hospital between November 2020 and May 2021. The intervention was carbohydrate loading versus standard preoperative fasting. RESULTS: Thirty-four ASA I-III patients (carbohydrate loading and control, n = 17 each), mean age 78 years (SEM ± 1.5), mean body mass index 23.7 (SEM ± 0.6 kg/m2) were recruited. Analysis for feasibility of carbohydrate loading (n = 17) demonstrated attrition rate of 29% (n = 5). Otherwise, all recruited patients were compliant (100% compliance) with no adverse events reported. There was no significant difference among groups in the postoperative nausea and vomiting, pain score, fatigue level, muscle strength, postoperative infection and length of hospital stay assessed at 24-48 h postoperatively. CONCLUSION: The implementation of preoperative carbohydrate loading was found to be feasible preoperatively in hip fracture surgeries but requires careful coordination among multidisciplinary teams. An adequately powered randomized controlled study is needed to examine the full benefits of preoperative carbohydrate loading in this group of patients. TRIAL REGISTRATION: This study was registered in ClinicalTrial.gov (ClinicalTrials.gov identifier: NCT04614181, date of registration: 03/11/2020).

The handling of safety concerns among anaesthetists when restarting full surgical lists during the COVID-19 pandemic.

Around June 2020, many institutions restarted full operating schedules to clear the backlog of postponed surgeries because of the first wave in the COVID-19 pandemic. In an online survey distributed among anaesthestists in Asian countries at that time, most of them described their safety concerns and recommendations related to the supply of personal protective equipment and its usage. The second concern was related to pre-operative screening for all elective surgical cases and its related issues. The new norm in practice was found to be non-standardized and involved untested devices or workflow that have since been phased out with growing evidence. Subsequent months after reinstating full elective surgeries tested the ability of many hospitals in handling the workload of non-COVID surgical cases together with rising COVID-19 positive cases in the second and third waves when stay-at-home orders eased.

A Developing Nation's Experience in Using Simulation-Based Training as a Preparation Tool for the Coronavirus Disease 2019 Outbreak.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic affected and overwhelmed many health care systems around the world at an unprecedented speed and magnitude with devastating effects. In developing nations, smaller hospitals were unprepared to face this outbreak nor had strategies in place to do so at the beginning. Here, we describe the preparation in an anesthetic department using simulation-based training over 2 weeks, as the number of cases rose rapidly. METHODS: Three areas of priority were identified as follows: staff safety, patient movement, and possible clinical scenarios based on simulation principles in health care education. Staff was rostered and rotated through stations for rapid-cycle deliberate practice to learn donning and doffing of personal protective equipment (PPE) and powered air-purifying respirator (PAPR). For difficult airway management, Peyton's 4 steps for skills training and Harden's Three Circle model formed the structure in teaching the core skills. Several clinical scenarios used system probing to elicit inadequacies followed by formal debriefing to facilitate reflection. Finally, evaluation was both immediate and delayed with an online survey after 1 month to examine 4 levels of reaction, learning, behavior, and impact based on the Kirkpatrick Model. Frequency and thematic analysis were then conducted on the quantitative and qualitative data, respectively. RESULTS: A total of 15 of 16 (93%) consultants, 16 (100%) specialists, and 81 (100%) medical officers in the department completed training within 2 consecutive weeks. Reaction and part of the learning were relayed immediately to trainers during training. In total, 42 (39%) trained staff responded to the survey. All were satisfied and agreed on the relevance of training. A total of 41 respondents (98%; 95% confidence interval [CI], 87-99) answered 16 of 20 questions correctly on identifying aerosol-generating procedures (AGP), indications for PPE, planning and preparation for airway management to achieve adequate learning. About 43% (95% CI, 27-59) and 52% (95% CI, 36-68) recalled donning and doffing steps correctly. A total of 92 responses from 33 respondents were analyzed in the thematic analysis. All respondents reported at least 1 behavioral change in intended outcomes for hand hygiene practice (20%), appropriate use of PPE (27%), and airway management (10%). The emerging outcomes were vigilance, physical distancing, planning, and team communication. Finally, the impact of training led to the establishment of institutional guidelines followed by all personnel. CONCLUSIONS: Simulation-based training was a useful preparation tool for small institutions with limited time, resources, and manpower in developing nations. These recommendations represent the training experience to address issues of "when" and "how" to initiate urgent "medical education" during an outbreak.

Effects of antiemetic doses of dexamethasone on plasma mediators of inflammation resolution and pain after surgery in women.

BACKGROUND: Dexamethasone is commonly given as an antiemetic during surgical procedures. It has immunosuppressive effects and can affect key enzymes involved in the synthesis of specialised lipid mediators of inflammation resolution (SPM) that direct inflammation resolution and have anti-nociceptive actions. This study examined the effect of dexamethasone on plasma SPM, and the relationship between SPM and perceived pain in women undergoing surgery. METHODS: Plasma SPM were measured in samples obtained from two double-blind controlled interventions. The first, included 51 women mean age 53 ± 1.5 years, undergoing breast surgery allocated to either intravenous saline, or dexamethasone (4 mg or 8 mg) after induction of anaesthesia. The second study included 31 women of mean age 44 ± 0.5 years undergoing laparoscopic gynecological surgery that were allocated to either saline, or dexamethasone (4 mg). SPM (18-HEPE, 17-HDHA, RvE2, RvD1 17R-RvD1 and RvD2) were measured in plasma collected prior to induction of anaesthesia and at 24 h, and 6 weeks post-surgery. Pain was assessed using a verbal analogue scale at discharge from the post-anaesthesia recovery unit. The data from each study was combined to examine the effect of dexamethasone on plasma SPM. The relationship between pain score and SPM was examined using ordinal logistic regression. RESULTS: The SPM 18-HEPE, 17-HDHA, RvE2, RvD1 17R-RvD1 and RvD2 were detectable in all plasma samples. There was no significant difference in any SPM due to dexamethasone over the duration of the study. There was a fall in 17-HDHA between baseline and 24 h in both the dexamethasone and saline groups (P = 0.003) but no change in the downstream SPM (RvD1, 17R-RvD1 and RvD2) or 18-HEPE and RvE2. Pain score was negatively related to levels of RvE2 measured prior to induction of anaesthesia (rho = -0.2991, P = 0.006) and positively related to BMI (rho = 0.279, P = 0.011). In ordinal logistic regression the odds ratio for RvE2 was 0.931 (CI 0.880, 0.986; P = 0.014); after adjusting for the effect of BMI indicating that an increase in RvE2 of 1 pg/ml would result in a 6.9 % fall in pain score. Allocation to a dexamethasone group did not influence the pain score or the relationship between RvE2 and pain score. CONCLUSION: Dexamethasone administered as an anti-emetic does not affect plasma SPM levels. An elevated RvE2 level prior to surgery is predictive of a lower perceived pain score post-anaesthesia.

Antiemetic doses of dexamethasone and their effects on immune cell populations and plasma mediators of inflammation resolution in healthy volunteers.

INTRODUCTION: The synthetic glucocorticoid dexamethasone is a commonly administered antiemetic. It has immunosuppressive effects and may alter postoperative blood glucose concentrations. Dexamethasone can effect key enzymes involved in inflammation resolution that is an active process driven by specialised lipid mediators of inflammation resolution (SPM). The purpose of this study in healthy volunteers was to examine whether dexamethasone effects cell populations and synthesis of SPM that are critical for the resolution of inflammation. METHODS: Thirty-two healthy volunteers were randomly allocated to receive saline (Control) or dexamethasone 2 mg, 4 mg or 8 mg intravenously. Venous blood samples were collected at baseline before administration of treatment, and at 4 h, 24 h and one-week post-treatment. At each time point, measurements included blood glucose and macrophage migration inhibition factor (MMIF), full blood count including lymphocyte subsets, monocytes, neutrophils, eosinophils and basophils by flow cytometry, and plasma SPM using liquid chromatography tandem mass spectrometry. The effect of dexamethasone dose and time on all measures was analysed using linear mixed models. RESULTS: There was a dose-dependent increase in neutrophil count after dexamethasone that persisted for 24 h. In contrast, there was a dose-dependent reduction in counts of monocytes, lymphocytes, basophils and eosinophils 4 h after dexamethasone, followed by a rebound increase in cell counts at 24 h. Seven days after administration of dexamethasone, all cell counts were similar to baseline levels. MMIF concentration, glucose and natural killer cell counts were not significantly affected by dexamethasone. There was a significant gender effect on plasma SPM such that levels of 17-HDHA, RvD1, 17R-RvD1 and RvE2 in females were on average 14%-50% lower than males. In a linear mixed model that adjusted for neutrophil count, there was a significant interaction between the dose of dexamethasone and time, on plasma 17R-RvD1 such that plasma 17R-RvD1 fell in a dose-dependent manner until 4 h after administration of dexamethasone. There were no significant effects of dexamethasone on the other plasma SPM (18-HEPE, RvE2, 17-HDHA, RvD1, RvD2 and 14-HDHA) measured. DISCUSSION: This is the first study in healthy volunteers to demonstrate that commonly employed antiemetic doses of dexamethasone affect immune cell populations and plasma levels of 17R-RvD1 an SPM with anti-nociceptive properties. If similar changes occur in surgical patients, then this may have implications for acute infection risk in the post-operative period.

Ambu® AuraGain™ versus LMA Supreme™ Second Seal™: a randomised controlled trial comparing oropharyngeal leak pressures and gastric drain functionality in spontaneously breathing patients.

Newer second generation supraglottic airway devices may perform differently in vivo due to material and design modifications. We compared performance characteristics of the Ambu® AuraGain™ and LMA Supreme™ Second Seal™ in 100 spontaneously breathing anaesthetised patients in this randomised controlled study. We studied oropharyngeal leak pressures (OLP) (primary outcome) and secondarily, ease of insertion, success rates, haemodynamic response, time to insertion, and complications of usage. We found no significant difference in OLP between the AuraGain versus the LMA Supreme, mean (standard deviation, SD) 24.1 (7.4) versus 23.6 (6.2) cmH2O, P=0.720. First-attempt placement rates of the AuraGain were comparable to the LMA Supreme, 43/50 (86%) versus 39/50 (78%), P=0.906, with an overall 98% insertion success rate for the AuraGain and 88% for the LMA Supreme after three attempts, P=0.112. However, the AuraGain was deemed subjectively harder to insert, with only 24/50 (48%) versus 37/50 (74%) of AuraGain insertions being scored 1 = easy (on a 5 point scale), P=0.013, and also took longer to insert, 33.4 (SD 10.9) versus 27.3 (SD 11.4) seconds, P=0.010. The AuraGain needed a smaller volume of air (16.4 [SD 6.8] versus 23.0 [SD 7.4] ml, P <0.001) to attain intracuff pressures of 60 cmH2O, facilitated more successful gastric tube insertion (100% versus 90.9%, P=0.046), and had significantly decreased sore throat incidence (10% versus 38%, P=0.020). One AuraGain and six LMA Supremes failed to be placed within the stipulated 120 seconds trial definition of 'success'; these patients had risk factors for failed supraglottic insertion. In conclusion, both devices had similar OLPs and performed satisfactorily. However, the AuraGain resulted in less postoperative sore throat despite being harder to and taking longer to, insert.

Validation of the Malay version of the Amsterdam Preoperative Anxiety and Information Scale (APAIS).

BACKGROUND: Preoperative anxiety is a significant problem worldwide that may affect patients' surgical outcome. By using a simple and reliable tool such as the Amsterdam Preoperative Anxiety and Information Scale (APAIS), anaesthesiologists would be able to assess preoperative anxiety adequately and accurately. OBJECTIVE: The purpose of this study was to develop and validate the Malay version of APAIS (Malay-APAIS), and assess the factors associated with higher anxiety scores. METHODS: The authors performed forward and backward translation of APAIS into Malay and then tested on 200 patients in the anaesthetic clinic of University Malaya Medical Centre. Psychometric analysis was performed with factor analysis, internal consistency and correlation with Spielberger's State-Trait Anxiety Inventory (STAI-state). RESULTS: A good correlation was shown with STAI-state (r = 0.59). Anxiety and need for information both emerged with high internal consistency (Cronbach's alpha 0.93 and 0.90 respectively). Female gender, surgery with a higher risk and need for information were found to be associated with higher anxiety scores. On the other hand, previous experience with surgery had lower need for information. CONCLUSION: The Malay-APAIS is a valid and reliable tool for the assessment of patients' preoperative anxiety and their need for information. By understanding and measuring patient's concerns objectively, the perioperative management will improve to a much higher standard of care.