Effect of lidocaine on intraoperative blood pressure variability in patients undergoing major vascular surgery.

BACKGROUND: Dynamic fluctuations of arterial blood pressure known as blood pressure variability (BPV) may have short and long-term undesirable consequences. During surgical procedures blood pressure is usually measured in equal intervals allowing to assess its intraoperative variability, which significance for peri and post-operative period is still under debate. Lidocaine has positive cardiovascular effects, which may go beyond its antiarrhythmic activity. The aim of the study was to verify whether the use of intravenous lidocaine may affect intraoperative BPV in patients undergoing major vascular procedures. METHODS: We performed a post-hoc analysis of the data collected during the previous randomized clinical trial by Gajniak et al. In the original study patients undergoing elective abdominal aorta and/or iliac arteries open surgery were randomized into two groups to receive intravenous infusion of 1% lidocaine or placebo at the same infusion rate based on ideal body weight, in concomitance with general anesthesia. We analyzed systolic (SBP), diastolic (DBP) and mean arterial blood (MAP) pressure recorded in 5-minute intervals (from the first measurement before induction of general anaesthesia until the last after emergence from anaesthesia). Blood pressure variability was then calculated for SBP and MAP, and expressed as: standard deviation (SD), coefficient of variation (CV), average real variability (ARV) and coefficient of hemodynamic stability (C10%), and compared between both groups. RESULTS: All calculated indexes were comparable between groups. In the lidocaine and placebo groups systolic blood pressure SD, CV, AVR and C10% were 20.17 vs. 19.28, 16.40 vs. 15.64, 14.74 vs. 14.08 and 0.45 vs. 0.45 respectively. No differences were observed regarding type of surgery, operating and anaesthetic time, administration of vasoactive agents and intravenous fluids, including blood products. CONCLUSION: In high-risk vascular surgery performed under general anesthesia, lidocaine infusion had no effect on arterial blood pressure variability. TRIAL REGISTRATION: ClinicalTrials.gov; NCT04691726 post-hoc analysis; date of registration 31/12/2020.

Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery?

BACKGROUND: International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes. METHODS: This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records. MAIN RESULTS: A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year. CONCLUSIONS: This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.

Automatic Max-Likelihood Envelope Detection Algorithm for Quantitative High-Frame-Rate Ultrasound for Neonatal Brain Monitoring.

OBJECTIVE: Post-operative brain injury in neonates may result from disturbed cerebral perfusion, but accurate peri-operative monitoring is lacking. High-frame-rate (HFR) cerebral ultrasound could visualize and quantify flow in all detectable vessels using spectral Doppler; however, automated quantification in small vessels is challenging because of low signal amplitude. We have developed an automatic envelope detection algorithm for HFR pulsed wave spectral Doppler signals, enabling neonatal brain quantitative parameter maps during and after surgery. METHODS: HFR ultrasound data from high-risk neonatal surgeries were recorded with a custom HFR mode (frame rate = 1000 Hz) on a Zonare ZS3 system. A pulsed wave Doppler spectrogram was calculated for each pixel containing blood flow in the image, and spectral peak velocity was tracked using a max-likelihood estimation algorithm of signal and noise regions in the spectrogram, where the most likely cross-over point marks the blood flow velocity. The resulting peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistivity index (RI) were compared with other detection schemes, manual tracking and RIs from regular pulsed wave Doppler measurements in 10 neonates. RESULTS: Envelope detection was successful in both high- and low-quality arterial and venous flow spectrograms. Our technique had the lowest root mean square error for EDV, PSV and RI (0.46 cm/s, 0.53 cm/s and 0.15, respectively) when compared with manual tracking. There was good agreement between the clinical pulsed wave Doppler RI and HFR measurement with a mean difference of 0.07. CONCLUSION: The max-likelihood algorithm is a promising approach to accurate, automated cerebral blood flow monitoring with HFR imaging in neonates.

Targets for De-implementation of Unnecessary Testing Before Low-Risk Surgery: A Qualitative Study.

INTRODUCTION: Despite multispecialty recommendations to avoid routine preoperative testing before low-risk surgery, the practice remains common and de-implementation has proven difficult. The goal of this study as to elicit determinants of unnecessary testing before low-risk surgery to inform de-implementation efforts. METHODS: We conducted focused ethnography at a large academic institution, including semi-structured interviews and direct observations at two preoperative evaluation clinics and one outpatient surgery center. Themes were identified through narrative thematic analysis and mapped to a comprehensive and integrated checklist of determinants of practice, the Tailored Implementation for Chronic Diseases framework (TICD). RESULTS: Thirty individuals participated (surgeons, anesthesiologists, primary care physicians, physician assistants, nurses, and medical assistants). Three themes were identified: (1) Shared Values (TICD Social, Political, and Legal Factors), (2) Gaps in Knowledge (TICD Individual Health Professional Factors, Guideline Factors), and (3) Communication Breakdown (TICD Professional Interactions, Incentives and Resources, Capacity for Organizational Change). Shared Values describe core tenets expressed by all groups of clinicians, namely prioritizing patient safety and utilizing evidence-based medicine. Clinicians had Gaps in Knowledge related to existing data and preoperative testing recommendations. Communication Breakdowns within interdisciplinary teams resulted in unnecessary testing ordered to meet perceived expectations of other providers. CONCLUSIONS: Clinicians have knowledge gaps related to preoperative testing recommendations and may be amenable to de-implementation efforts and educational interventions. Consensus guidelines may streamline interdisciplinary communication by clarifying interdisciplinary needs and reducing testing ordered to meet perceived expectations of other clinicians.

The Quantitative Impact of Using 3D Printed Anatomical Models for Surgical Planning Optimization: Literature Review.

3D printing has entered the medical field as a visualization tool that allows the manufacture of three-dimensional (3D) models that physically represent the anatomy of a patient in need of analysis to improve surgical results. This article analyzes the literature around reported study cases that make use of anatomical models for their surgical processes' planning, focusing on obtaining the quantitative results of each one of them. A search of case studies was carried out in the main medical databases such as PubMed, ScienceDirect, SpringerLink, among others; to obtain the most relevant results of the 56 selected articles, the information of each study was analyzed and categorized. These articles presented figures and data about the benefits that are considered more representative to measure the positive impact of this technology. These benefits are summarized in variables such as the decrease in surgical time, greater accuracy in the diagnosis of pathology, blood loss reduction, and decreasing operating room costs; owed to an improvement in the surgery planning. It was found that in all the cases analyzed there was an improvement in the surgical results related to these variables, which were summarized in macro figures that combine this improvement quantitatively. In the analyzed studies, it was evident that there is great potential in the use of 3D printing for presurgical planning, being as the results of these analyzed interventions were better when using this technology. In addition, it was found that the results obtained initially, before applying the inclusion and exclusion criteria, were mostly of a qualitative nature; expressing the perception of researchers regarding the positive use of this tool in the field and evidencing an opportunity for this research to focus on concrete and technical information to show in numerical terms the effectiveness of this tool, to demonstrate the cost-benefit that it has for the field.

Beyond high-risk: analysis of the outcomes of extreme-risk patients in the National Emergency Laparotomy Audit.

Patients who require emergency laparotomy are defined as high risk if their 30-day predicted risk of mortality is ≥ 5%. Despite a large difference in the characteristics of patients with a mortality risk score of between 5% and 50%, these outcomes are aggregated by the National Emergency Laparotomy Audit (NELA). Our aim was to describe the outcomes of the cohort of patients at extreme risk of death, which we defined as having a NELA-predicted 30-day mortality of ≥ 50%. All patients enrolled in the NELA database between December 2012 and 2020 were included. We compared patient characteristics; length of hospital stay; rates of unplanned return to the operating theatre; and 90-day survival in extreme-risk groups (predicted ≥ 50%) and high-risk patients (predicted 5-49%). Of 161,337 patients, 5193 (3.2%) had a predicted mortality of ≥ 50%. When patients were further subdivided, 2437 (47%) had predicted mortality of 50-59% (group 50-59); 1484 (29%) predicted mortality of 60-69% (group 60-69); 840 (16%) predicted mortality of 70-79% (group 70-79); and 423 (8%) predicted mortality of ≥ 80% (group 80+). Extreme-risk patients were significantly more likely to have been admitted electively than high-risk patients (p < 0.001). Length of stay increased from a median (IQR [range]) of 26 (16-43 [0-271]) days in group 50-59 to 35 (21-56 [0-368]) days in group 80+, compared with 17 (10-30 [0-1136]) days for high-risk patients. Rates of unplanned return to the operating theatre were higher in extreme-risk groups compared with high-risk patients (11% vs. 8%). The 90-day survival was 43% in group 50-59, 34% in group 60-69, 27% in group 70-79 and 17% in group 80+. These data underscore the need for a differentiated approach when discussing risk with patients at extreme risk of mortality following an emergency laparotomy. Clinicians should focus on patient priorities on quantity and quality of life during informed consent discussions before surgery. Future work should extend beyond the immediate postoperative period to encompass the longer-term outcomes (survival and function) of patients who have emergency laparotomies.

Short-term mechanical support with the Impella 5.x for mitral valve surgery in advanced heart failure-protected cardiac surgery.

Introduction: Surgical treatment of patients with mitral valve regurgitation and advanced heart failure remains challenging. In order to avoid peri-operative low cardiac output, Impella 5.0 or 5.5 (5.x), implanted electively in a one-stage procedure, may serve as a peri-operative short-term mechanical circulatory support system (st-MCS) in patients undergoing mitral valve surgery. Methods: Between July 2017 and April 2022, 11 consecutive patients underwent high-risk mitral valve surgery for mitral regurgitation supported with an Impella 5.x system (Abiomed, Inc. Danvers, MA). All patients were discussed in the heart team and were either not eligible for transcatheter edge-to-edge repair (TEER) or surgery was considered favorable. In all cases, the indication for Impella 5.x implantation was made during the preoperative planning phase. Results: The mean age at the time of surgery was 61.6 ± 7.7 years. All patients presented with mitral regurgitation due to either ischemic (n = 5) or dilatative (n = 6) cardiomyopathy with a mean ejection fraction of 21 ± 4% (EuroScore II 6.1 ± 2.5). Uneventful mitral valve repair (n = 8) or replacement (n = 3) was performed via median sternotomy (n = 8) or right lateral mini thoracotomy (n = 3). In six patients, concomitant procedures, either tricuspid valve repair, aortic valve replacement or CABG were necessary. The mean duration on Impella support was 8 ± 5 days. All, but one patient, were successfully weaned from st-MCS, with no Impella-related complications. 30-day survival was 90.9%. Conclusion: Protected cardiac surgery with st-MCS using the Impella 5.x is safe and feasible when applied in high-risk mitral valve surgery without st-MCS-related complications, resulting in excellent outcomes. This strategy might offer an alternative and comprehensive approach for the treatment of patients with mitral regurgitation in advanced heart failure, deemed ineligible for TEER or with need of concomitant surgery.

Comparison of two frailty indices in predicting life-threatening morbidity and mortality among older patients undergoing elective high-risk abdominal surgery.

Background: Frailty predicts an increased risk of postoperative morbidity and mortality. Comparison of the predictive performance between two deficit accumulation models of frailty, the modified frailty index (mFI) and the revised-Risk Analysis Index (RAI-rev), is poorly understood. This study compared the predictive abilities of the above two frailty indices in predicting life-threatening morbidity and mortality among older patients following elective high-risk abdominal surgery. Methods: This retrospective cohort study extracted perioperative data of older patients (age ≥65 years) undergoing elective high-risk abdominal surgery at a single institution between January 2018 and December 2020. Preoperative frailty was screened by mFI and RAI-rev scoring systems. The primary outcome was the composite of postoperative life-threatening morbidity and mortality during hospitalization. Multivariable logistic regression analyses were performed to investigate the association of the two frailty indices with the primary outcome. Receiver-operating characteristic (ROC) curve was employed to test the predictive performances of the two frailty instruments in predicting the composite primary outcome. The difference between the area under the curves (AUCs) was assessed by DeLong's test. Results: 1,132 older patients (mean age, 73.4 ± 6.2 years; 63.9% male) were included. Of these, 107 (9.5%) developed postoperative life-threatening morbidity and mortality. In multivariable logistic regression analyses, rising continuous frailty scores (mFI: adjusted OR 1.319 per 0.09-point increase in score, 95% CI 1.151-1.511, p < 0.001; RAI-rev: adjusted OR 1.052 per 1-point increase in score, 95% CI 1.018-1.087, p = 0.002) as well as dichotomized frailty measures (mFI ≥0.27: adjusted OR 2.059, 95% CI 1.328-3.193, p = 0.001; RAI-rev ≥45: adjusted OR 1.862, 95% CI 1.188-2.919, p = 0.007) were associated with increased odds of the primary outcome separately. ROC curve analysis showed that the discrimination of mFI and RAI-rev scores for the life-threatening morbidity and mortality was poor and comparable (AUC: 0.598 [95% CI 0.569-0.627] vs. 0.613 [95% CI 0.583-0.641]; DeLong's test: Z = 0.375, p = 0.7075). Conclusion: High mFI and RAI-rev scores were associated with an increased risk of life-threatening morbidity and mortality in older patients undergoing elective high-risk abdominal surgery. However, both frailty indices displayed poor discrimination for postoperative life-threatening morbidity and mortality.

Efficacy of Lidocaine Infusion in High-Risk Vascular Surgery-A Randomized, Double-Blind, Placebo-Controlled Single-Center Clinical Trial.

BACKGROUND: In perioperative pain control, adjuvants such as lidocaine can reduce opioid consumption in a specific type of surgery. The aim of this single-center prospective double-blinded randomized controlled trial was to determine opioid consumption in the perioperative period in patients receiving continuous lidocaine infusion. METHODS: Patients undergoing elective abdominal aorta and/or iliac arteries open surgery were randomized into two groups to receive 1% lidocaine or placebo at the same infusion rate based on ideal body weight (bolus of 0.15 mL/kg during the induction of anesthesia followed by continuous infusion of 0.2 mL/kg/h during surgery; postoperatively 0.1 mL/kg/h for 24 h) additionally to standard opioid analgesia. RESULTS: Total opioid consumption within 24 h after surgery was 89.2 mg (95%CI 80.9-97.4) in the lidocaine and 113.1 mg (95%CI 102.5-123.6) in the placebo group (p = 0.0007). Similar findings were observed in opioid consumption intraoperatively (26.7 mg (95%CI 22.2-31.3) vs. 35.1 mg (95%CI 29.1-41.2), respectively, p = 0.029) and six hours postoperatively (47.5 mg (IQR 37.5-59.5) vs. 60 mg (IQR 44-83), respectively, p = 0.01). CONCLUSIONS: In high-risk vascular surgery, lidocaine infusion as an adjunct to standard perioperative analgesia is effective. It may decrease opioid consumption by more than 20% during the first 24 h after surgery, with no serious adverse effects noted during the study period.

Respiratory Exchange Ratio guided management in high-risk noncardiac surgery: The OPHIQUE multicentre randomised controlled trial.

BACKGROUND: There is a need to develop non-invasive markers to identify the occurrence of anaerobic metabolism in high-risk surgery. Our objective was to demonstrate that a goal-directed therapy algorithm incorporating the respiratory exchange ratio (ratio between CO2 production and O2 consumption) can reduce postoperative complications. METHODS: We conducted a randomized, multicenter, controlled clinical trial in four university medical centers and one non-university hospital from December 26, 2018, to September 9, 2021. 350 patients with a high risk of postoperative complications undergoing high-risk noncardiac surgery lasting 2 h or longer under general anesthesia were enrolled. The control group was treated according to current hemodynamic guidelines. The interventional group was treated according to an algorithm based on the measurement of the respiratory exchange ratio. The primary outcome was a composite of major complications or death within seven days of surgery. The secondary outcomes were the length of hospital stay, 30-day mortality, and the total intraoperative volume of fluids administered. RESULTS: The primary outcome occurred for 78 patients (45.6%) in the interventional group and 83 patients (48.8%) in the control group (relative risk: 0.93, 95% confidence interval [CI]: 0.75-1.17; p = 0.55). There were no clinically relevant differences between the two groups for secondary outcomes. CONCLUSIONS: In high-risk surgery, a goal-directed therapy algorithm integrating the measurement of the respiratory-exchange ratio did not reduce a composite outcome of major postoperative complications or death within seven days after surgery compared to routine care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03852147.

Perioperative outcomes in intermediate and high-risk patients after major surgery following introduction of a dedicated perioperative medicine team: A single centre cohort study.

Intermediate and high-risk patients undergoing surgery are often managed on a surgical ward in the absence of haemodynamic or ventilatory support requirements necessitating intensive care unit or high dependency unit admission. We describe a model of care for the multidisciplinary management of selected postoperative patients and the epidemiology of patients managed using this model at a tertiary Australian hospital.Of 25,139 patients undergoing inpatient surgery at our institution over a two-year period, 506 (2%) were referred to the Perioperative Medicine team. The median age of patients referred was 74 years; 85% had an American Society of Anesthesiologists physical status ≥3, and 44% underwent emergency surgery. Major complication or death within 30 days was 44.2% (213/482). The most common complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program were transfusion within 72 h (17.4%), pneumonia/aspiration pneumonitis (11.3%), and acute renal failure (10.6%); median time to Medical Emergency Team call was 146 (interquartile range 77-279) h.Sixty-six percent of referred patients (280/423) required an intervention during their time under the service. This high incidence indicates that this population of patients merits closer attention, including routine measurement and reporting of postoperative outcomes to monitor and improve quality of care at our institution as part of an integrated perioperative service. We believe that with so much current focus on perioperative medicine, it is important we translate this to clinical care by evolving traditional models of management into more innovative strategies to meet the complex demands of today's surgical patients.

Surgical and transcatheter aortic valve replacement for severe aortic stenosis in low-risk elective patients: Analysis of the Aortic Valve Replacement in Elective Patients From the Aortic Valve Multicenter Registry.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) remains the preferred strategy for high-risk or elderly individuals with aortic valve (AV) stenosis who are not considered to be optimal surgical candidates. Recent evidence suggests that low-risk patients may benefit from TAVI as well. The current study evaluates midterm survival in low-risk patients undergoing elective surgical AV replacement (SAVR) versus TAVI. METHODS: The Aortic Valve Replacement in Elective Patients From the Aortic Valve Multicenter Registry (AVALON) compared isolated elective transfemoral TAVI or SAVR with sternotomy or minimally invasive approach in low-risk individuals performed between 2015 and 2019. Propensity score matching was conducted to determine SAVR controls for TAVI group in a 1-to-3 ratio with 0.2 caliper. RESULTS: A total of 2393 patients undergoing elective surgery (1765 SAVR and 629 TAVI) with median European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) score 1.81 (interquartile range [IQR], 1.36 to 2.53]) were initially included. Median follow-up was 2.72 years (IQR, 1.32-4.08; max 6.0). Propensity score matching returned 329 TAVI cases and 593 SAVR controls. Thirty-day mortality was 11 out of 329 (3.32%) in TAVI and 18 out of 593 (3.03%) in SAVR (risk ratio, 1.10; 95% CI, 0.52-2.37; P = .801) groups, respectively. At 2 years, survival curves began to diverge in favor of SAVR, which was associated with 30% lower mortality (hazard ratio, 0.70; 95% CI, 0.496-0.997; P = .048). CONCLUSIONS: Our data did not demonstrate a survival difference between TAVI and SAVR during the first 2 postprocedure years. After that time, SAVR is associated with improved survival. Extended observations from randomized trials in low-risk patients undergoing elective surgery are warranted to confirm these findings and draw definitive conclusions.

A Pilot Study Assessing a Closed-Loop System for Goal-Directed Fluid Therapy in Abdominal Surgery Patients.

Background: This prospective multicentre pilot study of patients scheduled for elective major abdominal surgery aimed to validate the fluid challenge (FC) proposed by the closed-loop (CL) system via anaesthesiologist assessment. Methods: This was a phase II trial consisting of two inclusion stages (SIMON method). Each FC (250 mL saline solution for 10 min) proposed by the CL was systematically validated by the anaesthesiologist who could either confirm or refuse the FC or give FC without the CL system. A ≥ 95% agreement between the CL and the anaesthesiologist was considered acceptable. Results: The study was interrupted after interim analysis of the first 19 patients (10 men, median age = 61 years, median body mass index = 26 kg/m2). The anaesthesiologists accepted 165/205 (80%) of fluid boluses proposed by the CL. Median cardiac index (CI) was 2.9 (interquartile: IQ (2.7; 3.4) L/min/m2) and the median coefficient of variation (CV) for CI was 13% (10; 17). Fifteen out of nineteen patients (79%) had a mean CI > 2.5 L/min/m2 or spent > 85% surgery time with pulse pressure variation < 13%. No adverse events related to the CL were reported. Conclusion: In this study of patients scheduled for elective major abdominal surgery, the agreement between CL and anaesthesiologist for giving fluid challenge was 80%, suggesting that CL cannot replace the physician but could help in decision making.

Perineal stapled prolapse resection in combination with Thiersch operation for relapsed rectal prolapse: a case report.

BACKGROUND: Treatment options for complete rectal prolapse include over 100 procedures. In previous reports, operative rectal prolapse repair, regardless of the technique by perineal approach, was associated with high recurrence rates. However, there is no consensus on the optimal surgical procedure for relapsed rectal prolapse. CASE PRESENTATION: A 97-year-old woman was admitted to our hospital with a chief complaint of complete rectal prolapse measuring > 5 cm. The patient had a history of laparoscopic anterior suture rectopexy without sigmoid resection under general anesthesia for complete rectal prolapse one year prior. The patient's postoperative course was uneventful. However, her dementia worsened (Hasegawa's dementia scale: 5/30 points) after the first operation. Further, moderate-to-severe aortic valve stenosis was first diagnosed with heart failure 6 months after the operation. Nine months after the initial surgery, she experienced a recurrence of complete rectal prolapse measuring approximately 5 cm. Considering the coexistence of advanced age, severe dementia, and aortic valve stenosis, surgery under general anesthesia was not indicated. Perineal stapled prolapse resection in combination with the t operation was planned because of its minimal invasiveness and shortened hospital stay. The procedure was performed by a team of two surgeons in the jack knife position, under spinal anesthesia. The prolapse was cut along the long-axis direction with three linear staplers and resected along the short-axis direction with four linear staplers. The cross-section of the linear stapler was reinforced with 3-0 Vicryl sutures. After rectal resection, the Thiersch operation using 1-0 nylon thread 1 cm away from the anal verge was additionally performed. The operative time was 24 min, and intraoperative blood loss was 1 mL. The postoperative course was uneventful. Three months after the operation, no recurrence was observed, and defecation function was good with improvements of Wexner score. CONCLUSIONS: Perineal stapled prolapse resection in combination with the Thiersch operation could be a useful option for patients with relapsed rectal prolapse and with poor general condition, who are not indicated for other surgical procedures.

Limited Utility of Routine Tests Prior to Ophthalmologic Surgery: An Observational Study in a Japanese Hospital.

INTRODUCTION: Routine preoperative testing for low-risk surgeries without a clinical indication should be avoided; however, such tests are still frequently performed in Japan. This study was performed to assess the impact of routine preoperative tests in low-risk surgery in a Japanese medical setting. METHODS: We performed a retrospective chart review to examine the utility of routine tests with respect to anesthetic management and postoperative complications in all patients aged ≥ 18 years whom ophthalmologists consulted with anesthesiologists before ophthalmologic surgery under general anesthesia. RESULTS: During the 10-year study period, 1,234 anesthetic consultations and 1,211 routine preoperative tests (laboratory tests, chest X-rays, and electrocardiograms) were performed in Toyama University Hospital. In total, 59 patients (4.8% of the study population) canceled surgery after a battery of preoperative evaluation. Among them, 10 patients had incidental abnormalities that necessitated additional tests, and only three patients (0.2%) canceled surgery. In-hospital postoperative complications developed in nine patients (0.7%) whose routine test results made it difficult to predict development of these adverse events. No severe life-threatening events were noted in this survey. CONCLUSIONS: Routine tests prior to eye surgery for adults were of low value for perioperative management and prediction of development of in-hospital complications in this Japanese medical setting. Anesthesiologists and ophthalmologists should selectively order preoperative tests based on the medical interview and physical examination.

Expressions of conflict following postoperative complications in older adults having major surgery.

BACKGROUND: After serious postoperative complications, patients and families may experience conflict about goals of care. METHODS: We performed a multisite randomized clinical trial to test the effect of a question prompt list on postoperative conflict. We interviewed family members and patients age ≥60 who experienced serious complications. We used qualitative content analysis to analyze conflict and characterize patient experiences with complications. RESULTS: Fifty-six of 446 patients suffered a serious complication. Participants generally did not report conflict relating to postoperative treatments and expressed support for the care they received. We did not appreciate a difference in conflict between intervention and usual care. Respondents reported feeling unprepared for complications, witnessing heated interactions among team members, and a failure to develop trust for their surgeon preoperatively. CONCLUSION: Postoperative conflict following serious complications is well described but its incidence may be low. Nonetheless, patient and family observations reveal opportunities for improvement.

Perioperative hemodynamic optimization: from guidelines to implementation-an experts' opinion paper.

Despite a large body of evidence, the implementation of guidelines on hemodynamic optimization and goal-directed therapy remains limited in daily routine practice. To facilitate/accelerate this implementation, a panel of experts in the field proposes an approach based on six relevant questions/answers that are frequently mentioned by clinicians, using a critical appraisal of the literature and a modified Delphi process. The mean arterial pressure is a major determinant of organ perfusion, so that the authors unanimously recommend not to tolerate absolute values below 65 mmHg during surgery to reduce the risk of postoperative organ dysfunction. Despite well-identified limitations, the authors unanimously propose the use of dynamic indices to rationalize fluid therapy in a large number of patients undergoing non-cardiac surgery, pending the implementation of a "validity criteria checklist" before applying volume expansion. The authors recommend with a good agreement mini- or non-invasive stroke volume/cardiac output monitoring in moderate to high-risk surgical patients to optimize fluid therapy on an individual basis and avoid volume overload. The authors propose to use fluids and vasoconstrictors in combination to achieve optimal blood flow and maintain perfusion pressure above the thresholds considered at risk. Although purchase of disposable sensors and stand-alone monitors will result in additional costs, the authors unanimously acknowledge that there are data strongly suggesting this may be counterbalanced by a sustained reduction in postoperative morbidity and hospital lengths of stay. Beside existing guidelines, knowledge and explicit clinical reasoning tools followed by decision algorithms are mandatory to implement individualized hemodynamic optimization strategies and reduce postoperative morbidity and duration of hospital stay in high-risk surgical patients.

The effect of compliance with a perioperative goal-directed therapy protocol on outcomes after high-risk surgery: a before-after study.

Perioperative goal-directed therapy is considered to improve patient outcomes after high-risk surgery. The association of compliance with perioperative goal-directed therapy protocols and postoperative outcomes is unclear. The purpose of this study is to determine the effect of protocol compliance on postoperative outcomes following high-risk surgery, after implementation of a perioperative goal-directed therapy protocol. Through a before-after study design, patients undergoing elective high-risk surgery before (before-group) and after implementation of a perioperative goal-directed therapy protocol (after-group) were included. Perioperative goal-directed therapy in the after-group consisted of optimized stroke volume variation or stroke volume index and optimized cardiac index. Additionally, the association of protocol compliance with postoperative complications when using perioperative goal-directed therapy was assessed. High protocol compliance was defined as ≥ 85% of the procedure time spent within the individual targets. The difference in complications during the first 30 postoperative days before and after implementation of the protocol was assessed. In the before-group, 214 patients were included and 193 patients in the after-group. The number of complications was higher in the before-group compared to the after-group (n = 414 vs. 282; p = 0.031). In the after-group, patients with high protocol compliance for stroke volume variation or stroke volume index had less complications compared to patients with low protocol compliance for stroke volume variation or stroke volume index (n = 187 vs. 90; p = 0.01). Protocol compliance by the attending clinicians is essential and should be monitored to facilitate an improvement in postoperative outcomes desired by the implementation of perioperative goal-directed therapy protocols.

Perioperative shared decision-making in the Bay of Plenty, New Zealand: Audit results from a complex decision pathway quality improvement initiative using a structured communication tool.

Patients presenting for elective surgery in the Bay of Plenty area in New Zealand are increasingly elderly with significant medical comorbidities. For these patients the risk-benefit balance of undergoing surgery can be complex. We recognised the need for a robust shared decision-making pathway within our perioperative medicine service. We describe the setup of a complex decision pathway within our district health board and report on the audit data from our first 49 patients. The complex decision pathway encourages surgeons to identify high-risk patients who will benefit from shared decision-making, manages input from multiple specialists as needed with excellent communication between those specialists, and provides a patient-centred approach to decision-making using a structured communication tool.