Effects of nonintubated thoracoscopic surgery on postoperative neurocognitive function: a randomized controlled trial.

OBJECTIVES: Postoperative neurocognitive disorder following thoracoscopic surgery with general anaesthesia may be linked to reduced intraoperative cerebral oxygenation and perioperative inflammation, which can potentially be exacerbated by mechanical ventilation. However, nonintubated thoracoscopic surgery, which utilizes regional anaesthesia and maintains spontaneous breathing, provides a unique model for studying the potential benefits of avoiding mechanical ventilation. This approach allows investigation into the impact on perioperative neurocognitive profiles, inflammatory responses and intraoperative cerebral oxygen levels. METHODS: In total, 110 patients undergoing thoracoscopic surgery were randomly equally assigned to the intubated group and the nonintubated group. Regional cerebral oxygenation was monitored during surgery. Serum neuroinflammatory biomarkers, including interleukin-6 and glial fibrillary acidic protein, were measured at baseline (before surgery) and 24 h after surgery. Postoperative complication severity was compared using the Comprehensive Complication Index. The primary outcome was perioperative changes in neurocognitive test score, which was assessed at baseline, 24 h and 6 months after surgery. RESULTS: Patients in the nonintubated group had higher neurocognitive test scores at 24 h (69.9 ± 10.5 vs 65.3 ± 11.8; P = 0.03) and 6 months (70.6 ± 6.7 vs 65.4 ± 8.1; P < 0.01) after surgery and significantly higher regional cerebral oxygenation over time during one-lung ventilation (P = 0.03). Patients in the intubated group revealed a significantly higher postoperative serum interleukin-6 level (group by time interaction, P = 0.04) and a trend towards a significantly higher serum glial fibrillary acidic protein level (group by time interaction, P = 0.11). Furthermore, patients in the nonintubated group had a significantly lower Comprehensive Complication Index (9.0 ± 8.2 vs 6.1 ± 7.1; P < 0.05). CONCLUSIONS: Nonintubated thoracoscopic surgery was associated with improved postoperative neurocognitive recovery, more stable intraoperative cerebral oxygenation, ameliorated perioperative inflammation and attenuated postoperative complication severity.

Effects of Goal-Directed Hemodynamic Therapy Using a Noninvasive Finger-Cuff Monitoring Device on Intraoperative Cerebral Oxygenation and Early Delayed Neurocognitive Recovery in Patients Undergoing Beach Chair Position Shoulder Surgery: A Randomized Controlled Trial.

BACKGROUND: Perioperative cerebral desaturation events (CDEs) and delayed neurocognitive recovery are common among patients undergoing beach chair position (BCP) shoulder surgery and may be caused by cerebral hypoperfusion. This study tested the hypothesis that the application of goal-directed hemodynamic therapy (GDHT) would attenuate these conditions. METHODS: We randomly assigned 70 adult patients undergoing BCP shoulder surgery to GDHT group or control at a 1:1 ratio. Cerebral oxygenation was monitored using near-infrared spectroscopy, and GDHT was administered using the ClearSight pulse wave analysis system. The primary outcome was CDE duration, whereas the secondary outcomes were CDE occurrence, delayed neurocognitive recovery occurrence, and Taiwanese version of the Quick Mild Cognitive Impairment (Qmci-TW) test score on the first postoperative day (T 2 ) adjusted for the baseline score (on the day before surgery; T 1 ). RESULTS: CDE duration was significantly shorter in the GDHT group (0 [0-0] vs 15 [0-75] min; median difference [95% confidence interval], -8 [-15 to 0] min; P = .007). Compared with the control group, fewer patients in the GDHT group experienced CDEs (23% vs 51%; relative risk [95% confidence interval], 0.44 [0.22-0.89]; P = .025) and mild delayed neurocognitive recovery (17% vs 40%; relative risk [95% confidence interval], 0.60 [0.39-0.93]; P = .034). The Qmci-TW scores at T 2 adjusted for the baseline scores at T 1 were significantly higher in the GDHT group (difference in means: 4 [0-8]; P = .033). CONCLUSIONS: Implementing GDHT using a noninvasive finger-cuff monitoring device stabilizes intraoperative cerebral oxygenation and is associated with improved early postoperative cognitive scores in patients undergoing BCP shoulder surgery.

Influence of Catheter-Incision Congruency in Epidural Analgesia on Postcesarean Pain Management: A Single-Blinded Randomized Controlled Trial.

Patient-controlled epidural analgesia (PCEA) or epidural morphine may alleviate postcesarean pain; however, conventional lumbar epidural insertion is catheter-incision incongruent for cesarean delivery. METHODS: In total, 189 women who underwent cesarean delivery were randomly divided into four groups (low thoracic PCEA, lumbar PCEA, low thoracic morphine, and lumbar morphine groups) for postcesarean pain management. Pain intensities, including static pain, dynamic pain, and uterine cramp, were measured using a 100 mm visual analog scale (VAS). The proportion of participants who experienced dynamic wound pain with a VAS score of >33 mm was evaluated as the primary outcome. Adverse effects, including lower extremity blockade, pruritus, postoperative nausea and vomiting, sedation, and time of first passage of flatulence, were evaluated. RESULTS: The low thoracic PCEA group had the lowest proportion of participants reporting dynamic pain at 6 h after spinal anesthesia (low thoracic PCEA, 28.8%; lumbar PCEA, 69.4%; low thoracic morphine, 67.3%; lumbar morphine group, 73.9%; p < 0.001). The aforementioned group also reported the most favorable VAS scores for static, dynamic, and uterine cramp pain during the first 24 h after surgery. Adverse effect profiles were similar among the four groups, but a higher proportion of participants in the lumbar PCEA group (approximately 20% more than in the other three groups) reported prolonged postoperative lower extremity motor blockade (p = 0.005). In addition, the first passage of flatulence after surgery reported by the low thoracic PCEA group was approximately 8 h earlier than that of the two morphine groups (p < 0.001). CONCLUSIONS: Epidural congruency is essential to PCEA for postcesarean pain. Low thoracic PCEA achieves favorable analgesic effects and may promote postoperative gastrointestinal recovery without additional adverse effects.

Accuracy of Heparin-Binding Protein in Diagnosing Sepsis: A Systematic Review and Meta-Analysis.

OBJECTIVES: Existing studies evaluating the accuracy of heparin-binding protein for the diagnosis of sepsis have been inconsistent. We conducted a systematic review and meta-analysis to assess the totality of current evidence regarding the utility of heparin-binding protein to diagnose sepsis in patients with presumed systemic infection. DATA SOURCE: PubMed, Embase, the China National Knowledge infrastructure, and WangFang electronic database were searched from inception to December of 2019. STUDY SELECTION: Two independent reviewers identified eligible studies. Cohort and case-control studies, which measured serum levels of heparin-binding protein among adult patients with suspected sepsis, were eligible for inclusion. DATA EXTRACTION: Two reviewers independently extracted data elements from the selected studies. A bivariate random-effects meta-analysis model was used to synthesize the prognostic accuracy measures. Risk of bias of studies was assessed with Quality Assessment of Diagnostic Accuracy Studies 2 tool. DATA SYNTHESIS: We identified 26 studies with 3,868 patients in the meta-analysis. Heparin-binding protein had a pooled sensitivity of 0.85 (95% CI, 0.79-0.90) and a pooled specificity of 0.91 (95% CI, 0.82-0.96) for the diagnosis of sepsis. There was low heterogeneity between the studies (I2 = 12%), and no evidence of publication bias was detected. Heparin-binding protein had a higher sensitivity and specificity when compared with procalcitonin (0.75 [95% CI, 0.62-0.85] and 0.85 [95% CI, 0.73-0.92]) as well as C-reactive protein (0.75 [95% CI, 0.65-0.84] and 0.71 [95% CI, 0.63-0.77]). Serial measurements of heparin-binding protein also showed that heparin-binding protein levels rose significantly at least 24 hours before a diagnosis of sepsis. CONCLUSIONS: The diagnostic ability of heparin-binding protein is favorable, demonstrating both high sensitivity and specificity in predicting progression to sepsis in critically ill patients. Future studies could assess the incremental value that heparin-binding protein may add to a multimodal sepsis identification and prognostication algorithm for critically ill patients.

Clinical predictors and outcome impact of community-onset polymicrobial bloodstream infection.

OBJECTIVES: Very few studies have characterised community-onset polymicrobial bloodstream infections (BSIs). This study determined the incidence, risk factors, and outcomes of polymicrobial BSI as compared with monomicrobial BSI in a cohort of patients with community-onset BSIs. METHODS: This prospective cohort study enrolled consecutive patients with laboratory confirmed BSIs who were admitted to two tertiary emergency departments in Taiwan between 1 January 2015 and 31 December 2016. It assessed the independent impact of polymicrobial BSIs on survival by a propensity score weighting method. Subsequently, independent clinical predictors were identified with multivariate logistic regression model analysis with internal validation by 10-fold cross validation. RESULTS: Among 1166 patients with community-onset BSI, 133 (10.9%) episodes of polymicrobial BSIs occurred. Anaerobe, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Enterococcus spp., and Candida spp. were the most common isolated microorganisms in polymicrobial BSI. Polymicrobial BSIs were associated with an increased 90-day mortality rate (OR 2.20, 95% CI 1.98-2.60). A prediction model was built to predict polymicrobial BSI with moderate predictability (c statistic = 0.78). Significant predictors included biliary tract infection, nosocomial infection, nursing home residence, stroke, and afebrile presentation. CONCLUSIONS: Polymicrobial BSI occurred in approximately 1 in 10 episodes of community-onset BSI and was independently associated with excess mortality. Clinical predictors identified in this study may help guide the prescription of empiric broad-spectrum antibiotics.