Practice Changing Updates in Perioperative Medicine Literature 2022. A Systematic Review.

Perioperative medicine is a rapidly growing multidisciplinary field with significant advances published each year. In this review, we highlight important perioperative publications in 2022. A multi-database literature search from January to December of 2022 was undertaken. Original research articles, systematic reviews, meta-analyses, and guidelines were included. Abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature were excluded. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont, Canada). A modified Delphi technique was used to identify 8 practice-changing articles. We identified another 10 articles for tabular summaries. We highlight why these articles have the potential to change clinical perioperative practice and areas where more information is needed.

Practice-Changing Updates in Perioperative Medicine Literature 2020-2021: A Systematic Review.

Recent literature published in a variety of multidisciplinary journals has significantly influenced perioperative patient care. Distilling and synthesizing the clinically important literature can be challenging. This review summarizes practice-changing articles in perioperative medicine from the years 2020 and 2021. Embase, Ovid, and EBM reviews databases were queried from January 2020 to December 2021. Inclusion criteria were original research, systematic review, meta-analysis, and important guidelines. Exclusion criteria were conference abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont., Canada). A modified Delphi technique was used to identify 9 practice-changing articles. We identified another 13 articles for tabular summaries, as they were relevant to an internist's perioperative evaluation of a patient. Articles were selected to highlight the clinical implications of new evidence in each field. We have also pointed out limitations of each study and clinical populations where they are not applicable.

Perioperative care of geriatric patients.

The older population is expected to nearly double across the globe by 2050, and the baby boom cohort is expected to represent at least 20% of the US population by 2030. Geriatric patients will increasingly utilize the health-care system, and therefore surgical and perioperative care must be tailored to this sensitive group given the increased risk for perioperative complications. The literature was reviewed to highlight fundamental components of the preoperative evaluation as well as cardiac, pulmonary, and renal complications. Frailty is a multidimensional process that can lead to the physiologic effects of aging and estimates the risk of perioperative morbidity and mortality better than chronologic age alone. Health-care providers should assess a geriatric patient's cognitive status, decision-making capacity, frailty, advance care planning, medications, and anesthetic approach in a multidisciplinary fashion to ensure optimal care. The risks of postoperative cardiac, pulmonary, and renal complications should be evaluated and optimized preoperatively to reduce the potential for adverse outcomes.

Characteristics and Outcomes of Fasting Orders Among Medical Inpatients.

While many hospitalized patients have orders to fast in preparation for interventions, the extent to which these orders are necessary or adhere to evidence-based durations is unknown. In this study, we analyzed the length, indication, and associated outcomes of nil per os (NPO) orders for general medicine patients at an academic institution in the United States, and compared them to the best available evidence for recommended length of NPO. Of 924 NPO orders assessed, the indicated intervention was not performed for 183 (19.8%) orders, largely due to a change in plan (75/183, 41.0%) or scheduling barriers (43/183, 23.5%). When analyzed by indication, the median duration of NPO orders ranged from 8.3 hours for kidney ultrasound to 13.9 hours for upper endoscopy. For some indications, the literature suggested NPO orders may be unnecessary. Furthermore, in indications for which NPO was deemed necessary in the literature, the duration of most NPO orders was much longer than minimally required. These results suggest the need for establishing more robust practice guidelines or institutional protocols for NPO orders. Journal of Hospital Medicine 2017;12:36-39.

Frequency and Appropriateness of Fasting Orders in the Hospital.

OBJECTIVE: To evaluate the frequency and appropriateness of nil per os (nothing by mouth) (NPO) orders and determine the number of meals missed because of these orders among hospitalized patients. PATIENTS AND METHODS: We retrospectively analyzed inpatient NPO orders at an academic institution in the United States. The frequency and duration of NPO orders and the number of meals missed because of these orders were assessed for adult patients admitted to the hospital medicine services from January 1, 2013, through December 31, 2013, with a hospital stay of 2 or more and 30 or fewer days. Two blinded reviewers assessed if the order could be avoided or the period shortened for a random sample of NPO orders of 120 or more minutes' duration that were written for patients on the general medicine ward. RESULTS: A total of 3641 NPO orders were identified. At least one NPO order was placed in 46.6% of the admissions (2211 of 4743). The median duration of NPO orders was 12.8 hours (interquartile range, 9.2-17.3 hours), resulting in 2 (interquartile range, 1-4) missed meals. Of 1130 NPO orders reviewed, 263 (23.3%; 95% CI, 20.9%-25.8%) were deemed avoidable (κ statistic, 0.68), and 482 (42.7%) were unavoidable but led to more missed meals than needed. Taken together, patients could have had 44.8% of the meals (1085 of 2424; 95% CI, 42.8%-46.7%) missed due to NPO orders. CONCLUSION: Approximately half of the patients admitted to the hospital medicine services experienced a period of fasting. One in 4 NPO orders and nearly half of missed meals could have been avoided. Further study is warranted to assess the generalizability of our findings.

Incorporation of secretory immunoglobulin A into biofilms can decrease their resistance to ciprofloxacin.

Extracellular matrices utilized by biofilms growing on inert surfaces are generally produced entirely by the bacteria growing within those biofilms, whereas symbiotic (mutualistic) biofilms growing in or on a wide range of plants and animals utilize host-derived macromolecules, such as mucoid substances, as components of their extracellular matrix. Incorporation of host-derived molecules may have a profound effect on the resistance to antibiotics of symbiotic biofilms, which may have important implications for medicine and biology. As an initial probe of the potential effects of host-derived molecules in the extracellular matrix on the sensitivity of biofilms to antibiotics, an in vitro model was used to evaluate the effects of ciprofloxacin on biofilms grown in the presence and absence of SIgA, a host-derived glycoprotein associated with biofilms in the mammalian gut. In five out of six strains of Escherichia coli tested, the incorporation of SIgA into the biofilms apparently reduced the resistance of the bacteria to ciprofloxacin. On the other hand, SIgA generally increased the resistance of planktonic bacteria to ciprofloxacin, perhaps due in part to the SIgA-mediated aggregation of the bacteria. These findings suggest that incorporation of host-derived molecules into the extracellular matrix of symbiotic biofilms might profoundly alter the properties of those biofilms, including the resistance of those biofilms to antibiotics.

Altering and assessing persistence of genetically modified E. coli MG1655 in the large bowel.

One of the primary factors limiting the efficacy of probiotic therapies is short persistence time. Utilizing a novel method for assessment of persistence in the large bowel independent of survival of the organisms in the upper GI tract, we tested whether overexpression of the type 1 pilus, a colonization factor, or the presence of secretory immunoglobulin A (sIgA) might increase the persistence time of a laboratory strain of E. coli in the gut. For this purpose, cecal ostomies were created in mice and bacteria were placed in the ostomies, with or without sIgA. The persistence of the bacteria was assessed by evaluating the length of time after placement in which the bacteria were found in fecal samples. E. coli MG1655 expressing pili with the mannose-specific adhesin persisted in vivo significantly longer [mean (hours) +/- SEM: 91.50 +/- 15.98, n = 12] than bacteria expressing pili without adhesin [43.67 +/- 8.22, n = 12] (P = 0.01) and significantly longer than bacteria expressing neither pili nor adhesin [22.00 +/- 4.22, n = 12] (P = 0.0004). Although the persistence time of bacteria was not significantly affected by the presence of sIgA, the sIgA did cause a relative increase in retention of inert particles. These results, combined with an acute increase in stool production and stool water content in those animals not receiving sIgA following introduction of bacteria, suggest that sIgA might have anti-inflammatory properties in the gut when administered with enteric bacteria. Modifying expression of probiotic colonization factors may provide substantial benefit to patients with digestive tract diseases by virtue of increased persistence of the probiotic and, in the case of sIgA, an anti-inflammatory effect. This novel in vivo model may be useful in evaluating persistence time in a variety of current and future probiotic regimens.

Increased IL-4 production and attenuated proliferative and pro-inflammatory responses of splenocytes from wild-caught rats (Rattus norvegicus).

Wild animals, unlike their laboratory counterparts, live amidst an abundance of pathogens and parasites. The presence of such immune stimulation from the time of birth likely has a profound effect on the development and stasis of the immune system. To probe potential differences between the immune systems of wild and laboratory animals, the response to mitogen (Con A) of splenocytes from wild rats was evaluated in vitro and compared with results from lab-rat-derived splenocytes. Although the response to mitogen is ubiquitous in splenocytes from laboratory animals regardless of strain or even species, splenocytes derived from wild rats were unresponsive to mitogen as judged by upregulation of activation markers and proliferation. Further, splenocytes from wild rats produced almost 10-fold less IL-2 and TNF-alpha in response to mitogen than did splenocytes from laboratory rats. In addition, mitogen stimulation resulted in an almost 100-fold greater production of IL-4 in wild-rat-derived splenocytes than in lab-rat-derived splenocytes. Perhaps surprisingly, these differences were observed in the absence of differences between wild and laboratory animals in the ratio of CD4+/CD8+ T cells or in the relative numbers of T cells, B cells and monocytes in the splenocyte population. These observations may have substantial implications for the hygiene hypothesis and provide considerable insight into the roles played by the environment during immune system development and modulation.