Ventilatory efficiency as a prognostic factor for postoperative complications in patients undergoing elective major surgery: a systematic review.

BACKGROUND: Major surgery is associated with high complication rates. Several risk scores exist to assess individual patient risk before surgery but have limited precision. Novel prognostic factors can be included as additional building blocks in existing prediction models. A candidate prognostic factor, measured by cardiopulmonary exercise testing, is ventilatory efficiency (VE/VCO2). The aim of this systematic review was to summarise evidence regarding VE/VCO2 as a prognostic factor for postoperative complications in patients undergoing major surgery. METHODS: A medical library specialist developed the search strategy. No database-provided limits, considering study types, languages, publication years, or any other formal criteria were applied to any of the sources. Two reviewers assessed eligibility of each record and rated risk of bias in included studies. RESULTS: From 10,082 screened records, 65 studies were identified as eligible. We extracted adjusted associations from 32 studies and unadjusted from 33 studies. Risk of bias was a concern in the domains 'study confounding' and 'statistical analysis'. VE/VCO2 was reported as a prognostic factor for short-term complications after thoracic and abdominal surgery. VE/VCO2 was also reported as a prognostic factor for mid- to long-term mortality. Data-driven covariable selection was applied in 31 studies. Eighteen studies excluded VE/VCO2 from the final multivariable regression owing to data-driven model-building approaches. CONCLUSIONS: This systematic review identifies VE/VCO2 as a predictor for short-term complications after thoracic and abdominal surgery. However, the available data do not allow conclusions about clinical decision-making. Future studies should select covariables for adjustment a priori based on external knowledge. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42022369944).

Blood volume and hemodynamics during treatment of major hemorrhage with Ringer solution, 5% albumin, and 20% albumin: a single-center randomized controlled trial.

BACKGROUND: Volume replacement with crystalloid fluid is the conventional treatment of hemorrhage. We challenged whether a standardized amount of 5% or 20% albumin could be a viable option to maintain the blood volume during surgery associated with major hemorrhage. Therefore, the aim of this study was to quantify and compare the plasma volume expansion properties of 5% albumin, 20% albumin, and Ringer-lactate, when infused during major surgery. METHODS: In this single-center randomized controlled trial, fluid replacement therapy to combat hypovolemia during the hemorrhagic phase of cystectomy was randomly allocated in 42 patients to receive either 5% albumin (12 mL/kg) or 20% albumin (3 mL/kg) over 30 min at the beginning of the hemorrhagic phase, both completed by a Ringer-lactate replacing blood loss in a 1:1 ratio, or Ringer-lactate alone to replace blood loss in a 3:1 ratio. Measurements of blood hemoglobin over 5 h were used to estimate the effectiveness of each fluid to expand the blood volume using the following regression equation: blood loss plus blood volume expansion = factor + volume of infused albumin + volume of infused Ringer-lactate. RESULTS: The median hemorrhage was 848 mL [IQR: 615-1145]. The regression equation showed that the Ringer-lactate solution expanded the plasma volume by 0.18 times the infused volume while the corresponding power of 5% and 20% albumin was 0.74 and 2.09, respectively. The Ringer-lactate only fluid program resulted in slight hypovolemia (mean, - 313 mL). The 5% and 20% albumin programs were more effective in filling the vascular system; this was evidenced by blood volume changes of only + 63 mL and - 44 mL, respectively, by long-lasting plasma volume expansion with median half time of 5.5 h and 4.8 h, respectively, and by an increase in the central venous pressure. CONCLUSION: The power to expand the plasma volume was 4 and almost 12 times greater for 5% albumin and 20% albumin than for Ringer-lactate, and the effect was sustained over 5 h. The clinical efficacy of albumin during major hemorrhage was quite similar to previous studies with no hemorrhage. TRIAL REGISTRATION: ClinicalTrials.gov NCT05391607, date of registration May 26, 2022.

Reporting quality of randomized controlled trials in prehabilitation: a scoping review.

BACKGROUND: Inadequate study reporting precludes interpretation of findings, pooling of results in meta-analyses, and delays knowledge translation. While prehabilitation interventions aim to enhance candidacy for surgery, to our knowledge, a review of the quality of reporting in prehabilitation has yet to be conducted. Our objective was to determine the extent to which randomized controlled trials (RCTs) of prehabilitation are reported according to methodological and intervention reporting checklists. METHODS: Eligibility criteria: RCTs of unimodal or multimodal prehabilitation interventions. SOURCES OF EVIDENCE: search was conducted in March 2022 using MEDLINE, Embase, PsychINFO, Web of Science, CINAHL, and Cochrane. CHARTING METHODS: identified studies were compared to CONSORT, CERT & Modified CERT, TIDieR, PRESENT, and CONSORT-SPI. An agreement ratio (AR) was defined to evaluate if applicable guideline items were correctly reported. Data were analyzed as frequency (n, %) and mean with standard deviation (SD). RESULTS: We identified 935 unique articles and included 70 trials published from 1994 to 2022. Most prehabilitation programs comprised exercise-only interventions (n = 40, 57%) and were applied before oncologic surgery (n = 32, 46%). The overall mean AR was 57% (SD: 20.9%). The specific mean ARs were as follows: CONSORT: 71% (SD: 16.3%); TIDieR: 62% (SD:17.7%); CERT: 54% (SD: 16.6%); Modified-CERT: 40% (SD:17.8%); PRESENT: 78% (SD: 8.9); and CONSORT-SPI: 47% (SD: 22.1). CONCLUSION: Altogether, existing prehabilitation trials report approximately half of the checklist items recommended by methodological and intervention reporting guidelines. Reporting practices may improve with the development of a reporting checklist specific to prehabilitation interventions.

Impact of Intraoperative Fluid Balance and Norepinephrine on Postoperative Acute Kidney Injury after Cystectomy and Urinary Diversion over Two Decades: A Retrospective Observational Cohort Study.

The use of norepinephrine and the restriction of intraoperative hydration have gained increasing acceptance over the last few decades. Recently, there have been concerns regarding the impact of this approach on renal function. The objective of this study was to examine the influence of norepinephrine, intraoperative fluid administration and their interaction on acute kidney injury (AKI) after cystectomy. In our cohort of 1488 consecutive patients scheduled for cystectomies and urinary diversions, the overall incidence of AKI was 21.6% (95%-CI: 19.6% to 23.8%) and increased by an average of 0.6% (95%-CI: 0.1% to 1.1%, p = 0.025) per year since 2000. The fluid and vasopressor regimes were characterized by an annual decrease in fluid balance (-0.24 mL·kg-1·h-1, 95%-CI: -0.26 to -0.22, p < 0.001) and an annual increase in the amount of norepinephrine of 0.002 µg·kg-1·min-1 (95%-CI: 0.0016 to 0.0024, p < 0.001). The interaction between the fluid balance and norepinephrine levels resulted in a U-shaped association with the risk of AKI; however, the magnitude and shape depended on the reference categories of confounders (age and BMI). We conclude that decreased intraoperative fluid balance combined with increased norepinephrine administration was associated with an increased risk of AKI. However, other potential drivers of the observed increase in AKI incidence need to be further investigated in the future.

Multimodal prehabilitation for major surgery in elderly patients to lower complications: protocol of a randomised, prospective, multicentre, multidisciplinary trial (PREHABIL Trial).

INTRODUCTION: The global volume of surgery is growing and the population ageing, and economic pressure is rising. Major surgery is associated with relevant morbidity and mortality. Postoperative reduction in physiological and functional capacity is especially marked in the elderly, multimorbid patient with low fitness level, sarcopenia and malnutrition. Interventions aiming to optimise the patient prior to surgery (prehabilitation) may reduce postoperative complications and consequently reduce health costs. METHODS AND ANALYSIS: This is a multicentre, multidisciplinary, prospective, 2-arm parallel-group, randomised, controlled trial with blinded outcome assessment. Primary outcome is the Comprehensive Complications Index at 30 days. Within 3 years, we aim to include 2×233 patients with a proven fitness deficit undergoing major surgery to be randomised using a computer-generated random numbers and a minimisation technique. The study intervention consists of a structured, multimodal, multidisciplinary prehabilitation programme over 2-4 weeks addressing deficits in physical fitness and nutrition, diabetes control, correction of anaemia and smoking cessation versus standard of care. ETHICS AND DISSEMINATION: The PREHABIL trial has been approved by the responsible ethics committee (Kantonale Ethikkomission Bern, project ID 2020-01690). All participants provide written informed consent prior to participation. Participant recruitment began in February 2022 (10 and 8 patients analysed at time of submission), with anticipated completion in 2025. Publication of the results in peer-reviewed scientific journals are expected in late 2025. TRIAL REGISTRATION NUMBER: NCT04461301.

Impact of analgesic techniques on early quality of recovery after prostatectomy: A 3-arm, randomized trial.

BACKGROUND: Prostatectomy is associated with relevant acute postoperative pain. Optimal analgesic techniques to minimize pain and enhance recovery are still under investigation. We aimed to compare the effect of three different analgesic techniques on quality of recovery. METHODS: This investigator-initiated, prospective, randomized, three-arm, parallel-group, active-controlled, interventional superiority trial was performed in a Swiss teaching hospital from 2018 to 2021. Consecutive patients undergoing open or robotic-assisted radical prostatectomy were randomized to spinal anaesthesia (SSS, bupivacaine 0.5% + fentanyl), bilateral transversus abdominis plane block (TAP, ropivacaine 0.375% + clonidine) or systemic administration of lidocaine (SA, lidocaine 1%) in addition to general anaesthesia. Primary outcome was quality of recovery 15 (QoR-15) score on postoperative day one compared to baseline. Secondary outcomes were QoR-15 at discharge, postoperative nausea and vomiting, pain scores, return of gastrointestinal function and use of rescue analgesia. RESULTS: From 133 patients, 40 received spinal anaesthesia, 45 TAP block and 48 systemic analgesia. QoR-15 scores did not differ on day 1 (p = 0.301) or at discharge (p = 0.309) when compared to baseline. QoR-15 changes were similar in all groups. At discharge, median QoR-15 scores were considered as good (>122) in all groups: SSS 134 [IQR 128-138]; TAP 129 [IQR 122-136] and SA 128 [IQR 123-136]. There were no significant differences in the other secondary outcomes. CONCLUSIONS: Quality of recovery on postoperative day one compared to baseline did not differ if spinal anaesthesia, TAP block or systemic administration of lidocaine was added to general anaesthesia. SIGNIFICANCE: Optimal analgesic techniques to enhance recovery after prostatectomy are still under investigation. In this 3-arm randomized controlled trial, addition of spinal anaesthesia or transversus abdominis plane block to general anaesthesia did not improve quality of recovery after radical prostatectomy compared to less invasive intravenous lidocaine infusion (standard of care/control group). Quality of recovery at the time of discharge was considered as good in all three groups.

Impact of early postoperative creatinine increase on mid-term renal function after cystectomy.

OBJECTIVES: To determine whether early acute kidney injury affects mid-term renal function, to identify risk factors for impaired mid-term renal function, and to highlight the evolution of plasma creatinine and estimated glomerular filtration rate in the first 12 months after cystectomy and urinary diversion. METHODS: We conducted a single-center retrospective observational cohort study from 2000 to 2019. We included 900 consecutive patients undergoing cystectomy and urinary diversion. Patients with incomplete data and preoperative hemodialysis were excluded. Early acute kidney injury was defined as an increase in plasma creatinine of >50% or >26.5 µmol/L within 24 h after surgery. Multiple linear regression analysis was performed to model the association between risk factors and change in plasma creatinine and estimated glomerular filtration rate at 12 months. RESULTS: Early acute kidney injury was diagnosed in 183/900 patients (20.3%) and was associated with significant mid-term plasma creatinine increase compared to preoperative value (+10.0 µmol/L [95% confidence interval -1.5, 25.0] vs +4.0 µmol/L [-7.0, 13.0]; P < 0.001). Similarly, a significant estimated glomerular filtration rate change was found (-11.2 mL/min [95% confidence interval -19.8, 0.6] vs -4.9 mL/min [-15.6, 5.3]; P < 0.001). In the linear regression model, early acute kidney injury increased creatinine at 12 months by 9.8% (estimated glomerular filtration rate: decrease by 6.2 mL/min), male sex by 12.0%. Limitations include retrospective analysis from prospectively assessed data. CONCLUSIONS: Early acute kidney injury resulted in elevated plasma creatinine and decreased estimated glomerular filtration rate values 12 months postoperatively, albeit the clinical relevance remains questionable.

Plasma disappearance rate of albumin when infused as a 20% solution.

BACKGROUND: The transcapillary leakage of albumin is increased by inflammation and major surgery, but whether exogenous albumin also disappears faster is unclear. METHODS: An intravenous infusion of 3 mL/kg of 20% albumin was given over 30 min to 70 subjects consisting of 15 healthy volunteers, 15 post-burn patients, 15 patients who underwent surgery with minor bleeding, 10 who underwent surgery with major bleeding (mean, 1.1 L) and 15 postoperative patients. Blood Hb and plasma albumin were measured on 15 occasions over 5 h. The rate of albumin disappearance from the plasma was quantitated with population kinetic methodology and reported as the half-life (T1/2). RESULTS: No differences were observed for T1/2 between volunteers, post-burn patients, patients who underwent surgery with minor bleeding and postoperative patients. The T1/2 averaged 16.2 h, which corresponds to 3.8% of the amount infused per h. Two groups showed plasma concentrations of C-reactive protein of approximately 60 mg/L and still had a similarly long T1/2 for albumin. By contrast, patients undergoing surgery associated with major hemorrhage had a shorter T1/2, corresponding to 15% of the infused albumin per h. In addition, our analyses show that the T1/2 differ greatly depending on whether the calculations consider plasma volume changes and blood losses. CONCLUSION: The disappearance rate of the albumin in 20% preparations was low in volunteers, in patients with moderately severe inflammation, and in postoperative patients.

Postcraniotomy Headache: Etiologies and Treatments.

PURPOSE OF REVIEW: Postcraniotomy headache (PCH) is a highly underappreciated and very common adverse event following craniotomy. RECENT FINDINGS: Analgetic medication with opioids often interferes with neurologic evaluation in the acute phase of recovery and should be kept to a minimal, in general, in the treatment of chronic pain as well. We provide an update on the latest evidence for the management of acute and chronic PCH. Especially in the neurosurgical setting, enhanced recovery after surgery protocols need to include a special focus on pain control. Patients at risk of developing chronic pain must be identified and treated as early as possible.

Perioperative continuation of aspirin, oral anticoagulants or bridging with therapeutic low-molecular-weight heparin does not increase intraoperative blood loss and blood transfusion rate in cystectomy patients: an observational cohort study.

OBJECTIVE: To assess if uninterrupted anticoagulant agents' administration affects blood loss and blood transfusion during open radical cystectomy (RC) and urinary diversion. PATIENTS AND METHODS: We conducted an observational single-centre cohort study of a consecutive series of 1430 RC patients, between 2000 and 2020. Blood loss was depicted according to body weight and duration of surgery (mL/kg/h), and blood transfusion. The group 'with anticoagulant agents' was considered if surgery was performed with uninterrupted low-dose aspirin (ASS), oral anticoagulants (OAC) with an international normalised ratio (INR) goal of 2-2.5 or bridging with therapeutic low-molecular-weight heparin (LMWH). Outcomes were intraoperative blood loss, blood transfusion rate (separately analysed if administered within 24 h perioperatively or >24 h after surgery) and the 90-day major adverse cardiac events (MACE) rate. We used propensity score (PS)-matching analysis to adjust for imbalances between groups with or without anticoagulant agents. RESULTS: The PS-matched median (interquartile range [IQR]) blood loss was 2.10 (1.50-2.94) mL/kg/h in patients with anticoagulant agents vs 2.11 (1.47-2.94) mL/kg/h without anticoagulant agents (Padj > 0.99). The PS-matched blood transfusion rates were 26.2% vs 35.1% (Padj = 0.875) within 24 h perioperatively and 57.0% vs 55.0% (Padj = 0.680) if administered >24 h postoperatively. A sub-analysis of the three different anticoagulant agents could not detect any significance between ASS, OAC, or LMWH. The PS-matched incidence of MACE was 9.1% in the group with anticoagulant agents and 8.1% in those without anticoagulant agents (Padj > 0.99). Limitations include selection bias and retrospective analysis from prospectively assessed data. CONCLUSIONS: Perioperative continuation of ASS, uninterrupted OAC with low INR goal or bridging with LMWH had no impact on blood loss and transfusion rate in RC patients. Therefore, there might be no compulsory need for discontinuation of anticoagulant agents.

Dehydration before Major Urological Surgery and the Perioperative Pattern of Plasma Creatinine: A Prospective Cohort Series.

Preoperative dehydration is usually found in 30-50% of surgical patients, but the incidence is unknown in the urologic population. We determined the prevalence of preoperative dehydration in major elective urological surgery and studied its association with postoperative outcome, with special attention to plasma creatinine changes. We recruited 187 patients scheduled for major abdominal urological surgery to participate in a single-center study that used the fluid retention index (FRI), which is a composite index of four urinary biomarkers that correlate with renal water conservation, to assess the presence of dehydration. Secondary outcomes were postoperative nausea and vomiting (PONV), return of gastrointestinal function, in-hospital complications, quality of recovery, and plasma creatinine. The proportion of dehydrated patients at surgery was 20.4%. Dehydration did not correlate with quality of recovery, PONV, or other complications, but dehydrated patients showed later defecation (p = 0.02) and significant elevations of plasma creatinine after surgery. The elevations were also greater when plasma creatinine had increased rather than decreased during the 24 h prior to surgery (p < 0.001). Overall, the increase in plasma creatinine at 6 h after surgery correlated well with elevations on postoperative days one and two. In conclusion, we found preoperative dehydration in one-fifth of the patients. Dehydration was associated with delayed defecation and elevated postoperative plasma creatinine. The preoperative plasma creatinine pattern could independently forecast more pronounced increases during the early postoperative period.

Clinical recommendations for in-hospital airway management during aerosol-transmitting procedures in the setting of a viral pandemic.

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to severe pneumonia and multiorgan failure. While most of the infected patients develop no or only mild symptoms, some need respiratory support or even invasive ventilation. The exact route of transmission is currently under investigation. While droplet exposure and direct contact seem to be the most significant ways of transmitting the disease, aerosol transmission appears to be possible under circumstances favored by high viral load. Despite the use of personal protective equipment (PPE), this situation potentially puts healthcare workers at risk of infection, especially if they are involved in airway management. Various recommendations and international guidelines aim to protect healthcare workers, although evidence-based research confirming the benefits of these approaches is still scarce. In this article, we summarize the current literature and recommendations for airway management of COVID-19 patients.

Leadership in a time of crisis: Lessons learned from a pandemic.

The current COVID-19 pandemic is testing political leaders and healthcare systems worldwide, exposing deficits in crisis communication, leadership, preparedness and flexibility. Extraordinary situations abound, with global supply chains suddenly failing, media communicating contradictory information, and politics playing an increasingly bigger role in shaping each country's response to the crisis. The pandemic threatens not just our health but also our economy, liberty, and privacy. It challenges the speed at which we work, the quality of our research, and the effectiveness of communication within the scientific community. It can impose ethical dilemmas and emotional stress on healthcare workers. Nevertheless, the pandemic also provides an opportunity for healthcare organizations, leaders, and researchers to learn from their mistakes and to place their countries and institutions in a better position to face future challenges.

Predictors for Perioperative Blood Transfusion in Patients Undergoing Open Cystectomy and Urinary Diversion and Development of a Nomogram: An Observational Cohort Study.

Open radical cystectomy is associated with a substantial rate of perioperative blood transfusion. Early detection of potentially modifiable perioperative factors could reduce the need for perioperative blood transfusion and thus positively impact the outcome. We conducted an observational, single-center cohort study of 1168 patients undergoing cystectomy. Perioperative blood transfusion was defined as the need for packed red blood cells and/or fresh frozen plasma units within the first 24 h after the initiation of surgery. Multiple logistic regression analysis was performed to model the association between risk factors and blood transfusion, and a nomogram was developed. Blood transfusion occurred in 370/1168 patients (31.7%). Significant predictors were age (OR: 1.678, (95% CI: 1.379-2.042); p < 0.001), blood loss ratio (6.572, (4.878-8.853); p < 0.001), preoperative hemoglobin (0.316, (0.255-0.391); p < 0.001), tumor stage (2.067, (1.317-3.244); p = 0.002), use of oral anticoagulants (2.70, (1.163-6.270), p = 0.021), and interaction between female sex and blood loss ratio (1.344, (1.011-1.787); p = 0.042). Of the major predictors found to affect perioperative blood transfusion, two can be influenced: blood loss ratio by meticulous surgery and hemoglobin by preoperative optimization. Others such as age or advanced disease are not modifiable. This emphasizes the importance of optimal management of patients prior to surgery.

Automated Fluid Management for Treatment of Rhabdomyolysis.

Purpose. Fluid therapy aimed at increasing urine output is a commonly employed strategy to prevent acute kidney injury (AKI) in critically ill patients with rhabdomyolysis. Automated fluid management has the potential to optimise urine output while avoiding fluid accumulation in rhabdomyolysis patients. Methods. In a single centre clinical service evaluation we compared a convenience sample of critically ill adults with rhabdomyolysis treated with automated fluid management using the RenalGuard® device to patients managed with manual fluid adjustment following our standard rhabdomyolysis protocol. Primary outcome was number of hours with urine output >2 mL/kg during first 48 h of therapy. Results. Eight patients treated with RenalGuard were compared to 28 patients treated with manual fluid management. Number of hours of target urine output was greater in the RenalGuard versus the Standard group (176/312 (56.4%) versus 534/1305 (40.9%); p < 0.01). Urine output was significantly higher in the first 24 h in the RenalGuard group (median (IQR) 4033 mL (3682-7363) versus 2913 mL (2263-4188 mL); p < 0.01). Fluid balance, electrolyte, diuretics, and bicarbonate use were comparable between groups. Conclusions. Automated fluid management resulted in a higher urine output more quickly in the treatment of rhabdomyolysis. Further research is needed to analyse the effect of diuresis-matched hydration for the prevention of AKI in rhabdomyolysis.