Exploration and practice of Enhanced Recovery after Surgery and Perioperative Management course in postgraduate teaching / 基础医学与临床

Objective To explore the practice and significance of the new course of"Enhanced Recovery after Sur-gery(ERAS)and Perioperative Management"for graduate students under multidisciplinary cooperation.Methods The Department of Anesthesiology collaborated with the Department of Clinical Nutrition,Department of Geriatrics and six related surgical departments to develop a course of 30 credit hours on"ERAS and Perioperative Manage-ment"in Peking Union Medical College Hospital.Researchers analyzed the teaching effectiveness of the course by collecting survey questionnaires and evaluating scheme report of ERAS case.Results Researchers found that ten graduates joined this course and they believed that learning improved their understanding of ERAS related knowl-edge,such as preoperative nutrition and functional state optimization,intraoperative volume and temperature man-agement,prevention of postoperative nausea and vomiting,and perioperative pain management.Students had high satisfaction with the course and believed that it would help improve their clinical literacy.Conclusions The new course of"ERAS and Perioperative Management"for graduates may support capacity building in terms of clinical logic and thinking about ERAS and promotion of skills for perioperative management.Our experience of graduates′training with"Enhanced Recovery after Surgery and Perioperative Management"course can be shared by other trainers of health institution of China.

Progress in ERAS-based anesthetic management for patients undergoing deep inferior epigastric perforator flap breast reconstruction / 复旦学报（医学版）

At present,the development of enhanced recovery after surgery(ERAS)pathways in deep inferior epigastric perforator(DIEP)flap breast reconstruction is still in the initial stage worldwide,lacking established guidelines.In the multidisciplinary ERAS pathways,the department of anesthesiology is responsible for some core elements such as optimizing anestheticprotocols,perioperative fluid management and homeostasis regulation,prevention of hypothermia,improvement of perioperative analgesia,and postoperative nausea and vomiting prophylaxis.We summarized the anesthetic management in the ERAS pathways for patients undergoing DIEP flap breast reconstruction in Fudan University Shanghai Cancer Center,along with the recent progress,aiming to establish and improve the perioperative strategy based on ERAS pathways in DIEP flap breast reconstruction.

The present situation and advance of red blood cell transfusion triggers / 中国输血杂志

In clinical practice, red blood cell infusion needs to be based on the patient′s hemoglobin level. However, different guidelines recommend different thresholds for red blood cell infusion and the timing of blood transfusion initiation is still controversial due to the presence of these different thresholds. Meanwhile, the use of allogeneic blood products carries a certain risk of transfusion-related infections or organ damage. Therefore, initiating red blood cell infusion requires more evidence. This review discusses some new methods, namely central venous oxygen saturation, arterial venous oxygen difference, near-infrared spectroscopy, and perioperative transfusion trigger score. It aims to help evaluate blood transfusion trigger and provide reference for doctors when making transfusion decisions.

Guidelines for clinical diagnosis and treatment of combined liver and kidney transplantation / 器官移植

Combined liver and kidney transplantation has been steadily applied in major transplantation centers, saving the lives of many patients with end-stage liver and renal failure. However, there are still multiple unresolved problems in the clinical diagnosis, treatment and long-term prognosis of combined liver and kidney transplantation. By referring to "Technical Operating Standards for Combined Liver and Kidney Transplantation (2019 Edition)" and the latest published literature and guidelines at home and abroad, "Guidelines for Clinical Diagnosis and Treatment of Combined Liver and Kidney Transplantation" was formulated. Recommendations and suggestions were delivered regarding the surgical indications and contraindications, preoperative preparation and evaluation, the timing of transplantation for end-stage liver and kidney diseases, the selection of surgical approaches and postoperative follow-up, specific pathophysiology, surgical techniques, complication management and immunosuppressive treatment of combined live and kidney transplantation, aiming to enhance the utilization rate of grafts and improve the survival and prognosis of combined liver and kidney transplant recipients.

Case report on perioperative management of combined factor V and VIII deficiency in a patient with prolapse uterus

Combined factor V and factor VIII deficiency is a rare autosomal recessive disorder with incidence of one in 10,00,000. We reported a case of seventy-one-year-old patient with third degree uterovaginal prolapse, diagnosed as combined factor V and VIII deficiency and the successful perioperative management during vaginal hysterectomy. With our experience in this, we conclude that for the patient's with factor V and VIII deficiency that the correction should be given for at least 2 weeks post operatively.

Assessment and management of perioperative cardiovascular risk in elderly patients undergoing noncardiac surgery / 解放军医学杂志

With aging of population and improvement of medical technology,the number of elderly patients receiving surgical treatment is increasing.Cardiovascular events after noncardiac surgery are one of the leading causes of death.Perioperative cardiovascular events have a high risk and incidence rate,thus severely affecting the prognosis of patients.In recent years,a growing number of studies have focused on the prevention and treatment of perioperative cardiovascular events in elderly patients.Assessing the risk of perioperative cardiovascular events and using effective interventions can effectively reduce the incidence of cardiovascular events and improve the prognosis of elderly patients.This article discusses cardiovascular risk assessment and management in elderly patients during noncardiac surgeries from the perspective of preoperative,intraoperative,postoperative periods,and perioperative medication used to provide assistance to clinical practice.

Perioperative management of cerebral revascularization of moyamoya disease / 临床外科杂志

Moyamoya disease(MMD)is a bilateral stenosis occlusional disease that selectively affects the superior segment of clinoid of the internal carotid artery with secondary abnormal vascular network formation at the base of the skull.Intracranial and extracranial vascular reconstruction is the main treatment of moyamoya disease.However,moyamoya disease revasectomy still faces many challenges,with high requirements of surgical techniques and high risk of complications.In this paper,the perioperative management of cerebrovascular reconstruction in moyamoya disease was discussed in terms of surgical indications,surgical timing,patient management,surgical methods of cerebrovascular reconstruction and postoperative complications,so as to provide reference for improving the prognosis of patients.

Clinical pathway for transcatheter mitral valve edge-to-edge repair in China (abbreviated version 2022) / 中国胸心血管外科临床杂志

@#Transcatheter mitral valve edge-to-edge repair (TEER) has become an important treatment opinion for patients with severe mitral regurgitation (MR) at high risk for surgery. The devices and procedural techniques of TEER are complex and require excellent team cooperation. However, there is still a lack of standardized clinical pathways in China. Based on the latest evidence, the expert group wrote this clinical pathway to guide and optimize TEER therapy in clinical practice. It demonstrates the following key issues of clinical concern: (1) TEER team building; (2) preoperative clinical evaluation of TEER patients; (3) imaging assessment before TEER procedure; (4) standardized procedures for TEER; (5) TEER for complex MR; (6) the standard process of perioperative comprehensive management; and (7) full life-cycle rehabilitation and follow-up. This clinical pathway might be helpful to facilitate the standardized development of TEER therapy and application, and promote the improvement of management and life quality for patients with MR.

Development history of enhanced recovery after surgery and its applications during perioperative period of organ transplantation / 中华器官移植杂志

This systematical review focuse upon the development history of enhanced recovery after surgery(ERAS)and summarized its core strategies and developments in the field of organ transplantation, Clinicians should pay more attention to applying ERAS for perioperative management of transplantation and guiding clinical diagnoses and treatments.

Research advances of portal vein thrombosis in perioperative period of liver transplantation / 中华器官移植杂志

Correlated with such hepatic-systemic factors as cirrhosis, inflammation and immunity, portal vein thrombosis (PVT) is common in perioperative period of liver transplantation (LT) recipients.It affects negatively surgical procedures and outcomes due to its insidious onset and atypical clinical symptoms.With continuous improvements of LT techniques and refining of medical imaging, researchers have gained further insights into the pathophysiological processes, screening, diagnoses, evaluations, classifications and perioperative managements of PVT.This review focused upon perioperative managements of LT recipients with PVT to enhance the clinical problem-solving capability and long-term patient survival.

Frontiers in liver transplantation for liver cancer: sarcopenia / 中华器官移植杂志

Liver cancer patients scheduled for liver transplantation (LT) are frequently accompanied by liver cirrhosis.Within a state of long-term malnutrition and inflammatory stress, they are prone to sarcopenia with a poor efficacy of LT.Influenced by such multiple factors as surgery, infections and metabolic disorders, there is an elevated risk of exacerbation or a new onset of sarcopenia after LT.Therefore meticulous managements of sarcopenia are required throughout all aspects and periods of LT.A refined recipient stratification system of sarcopenia can accurately predict the efficacy of LT and its evaluating system has been becoming more precise, diverse and intelligent.Currently basic researches of sarcopenia have remained in infancy and its interactions with the related organs have become a novel research field.Sarcopenia has become an emerging challenge of LT for liver cancer.Further mechanistic explorations of sarcopenia are warranted and clinical precision managements should be further optimized.

Expert recommendations for standardized perioperative management after transapical transcatheter aortic valve implantation / 中国胸心血管外科临床杂志

@#The technique of transcatheter aortic valve implantation has become increasingly mature. Although the transapical approach has a certain degree of minimally invasive trauma, it still has the characteristics such as heart beating without cardiopulmonary bypass, and the low technical requirements of catheter guide wire. In particular, the valve path is short and coaxial, which is easy to manipulate, and pure regurgitation and stenosis can be easily operated and are not subject to the limit of peripheral artery stenosis. It is still one of China's main approaches for transcatheter aortic valve replacement. Its perioperative management still has specific features and differs from the femoral artery approach. In addition, there is little relevant literature abroad. Therefore, domestic experts in this field were organized to discuss the development of perioperative management specifications to provide reference and techniques support for developing this field in China and further improve the quality of clinical operation and perioperative management. It will provide more safe and more effective medical services to these patients.

Management of liver transplantation perioperative period in acute-on-chronic liver failure / 中华肝脏病杂志

Acute-on-chronic liver failure (ACLF) is a potentially reversible entity that occurs in patients with chronic liver disease accompanied with or without cirrhosis and is characterized by extrahepatic organ failure and high short-term mortality. Currently, the most effective treatment method for patients with ACLF is liver transplantation; therefore, admission timing and contraindications must be emphasized. The function of vital organs such as the heart, brain, lungs, and kidneys should be actively supported and protected during the liver transplantation perioperative period in patients with ACLF. Focusing on the anesthesia management level during anesthesia selection, intraoperative monitoring, three-stage management, prevention and treatment of post-perfusion syndrome, monitoring and management of coagulation function, volume monitoring and management, and body temperature monitoring management for liver transplantation should strengthen anesthesia management. Additionally, standard postoperative intensive care treatment should be recommended, and grafts and other vital organ functions should be monitored throughout the perioperative period to promote early postoperative recovery in patients with ACLF.

Interpretation of "The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS)" / 中华消化外科杂志

In the past decade, the technology of minimally invasive pancreatic surgery (MIPS) has developed rapidly, and now has become an important part of pancreatic surgery. In the context of the minimally invasive era, how to guide surgeons to operate in a standardized manner and mini-mize the surgical risks has become an urgent difficulty to be overcome. Following the 2019 Miami consensus, a more authoritative European guideline for MIPS, The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery, has emerged. The Brescia Guideline mainly includes eight fields, such as professional terminology formulation, surgical indication evalua-tion, selection of high-risk patients, and key points of intraoperative operation. Combined with the latest literature, the Brescia Guideline puts forward authoritative recommendations in various fields and reflects the status quo and research progress of MIPS.

Dialysis and dialysis access issues in hemophilia patients with end-stage renal disease: a report of 6 cases and literature review / 中华肾脏病杂志

Renal replacement therapy and perioperative management have difficulties in hemophilia patients with end-stage renal disease. The paper summarized the diagnosis and treatment experience of six hemophilia patients complicated with end-stage renal disease from January 1, 2000 to March 31, 2023 in Peking Union Medical College Hospital. Among 6 patients treated with peritoneal dialysis, 3 were treated with hemodialysis or continuous venous-venous hemodialysis. Altogether 11 dialysis access procedures were conducted successfully, and no serious bleeding or thrombotic events. In further conjunction with literature review, the paper summarized the key points of dialysis access appliance relevant to such patients, to provide reference for renal replacement treatment paths.

Perioperative benzodiazepine use in the pediatric population: A narrative review / Benzodiacepinas en población pediátrica

BACKGROUND: Pediatric patients undergoing surgery under anesthesia may experience anxiety and distress during the perioperative period, for which benzodiazepines (BZD) can be employed as premedication in these scenarios. For this reason, it is important to highlight the pharmacological profile, use, and possible side effects in the pediatric perioperative population. METHODS: Narrative Review using the Pubmed, Scopus and Embase databases for articles between 2000 and 2021 in English and Spanish using the keywords "Benzodiazepines", "Pediatric Anesthesiology", "Pharmacology", "Adverse Effects", and "Cerebral Apoptosis" RESULTS: The principal side effects seen with BZD use in children mainly revolves around neurological manifestations, which include sedation, respiratory depression and prolonged awakening. There is evidence on the effectiveness of BZD in the pediatric population, which is used in a limited number of situations, such as surgical procedures that trigger acute anxiety. CONCLUSION: BZD has been widely studied in the literature, however it is important to highlight the possible complications and level of safety in the pediatric population. It has been evidenced that prolonged treatments not only increase the severity of neurodegeneration in the most vulnerable cerebral regions, but also trigger certain connectomic pathologies through wallerian and transneuronal degeneration.

ANTECEDENTES: Los pacientes pediátricos sometidos a cirugía bajo anestesia pueden experimentar ansiedad y angustia durante el período perioperatorio, por lo que las benzodiazepinas (BZD) pueden emplearse como premedicación en estos escenarios. Por ello, es importante destacar el perfil farmacológico, uso y posibles efectos secundarios en la población perioperatoria pediátrica. MÉTODOS: Revisión narrativa utilizando las bases de datos Pubmed, Scopus y Embase para artículos entre 2000 y 2021 en inglés y español utilizando las palabras clave "Benzodiazepines", "Pediatric Anesthesiology", "Pharmacology", "Adverse Effects" y "Cerebral Apoptosis" RESULTADOS: Los principales efectos secundarios observados con el uso de BZD en niños giran principalmente entorno a las manifestaciones neurológicas, que incluyen sedación, depresión respiratoria y despertares prolongados. Existe evidencia sobre la efectividad de las BZD en la población pediátrica, que se utiliza en un número limitado de situaciones, como procedimientos quirúrgicos que desencadenan ansiedad aguda. CONCLUSIÓN: Las BZD han sido ampliamente estudiadas en la literatura, sin embargo, es importante resaltar las posibles complicaciones y el nivel de seguridad en la población pediátrica. Se ha evidenciado que los tratamientos prolongados no solo aumentan la severidad de la neurodegeneración en las regiones cerebrales más vulnerables, sino que también desencadenan ciertas patologías conectómicas a través de la degeneración walleriana y transneuronal.

Total laryngectomy in neonate with laryngeal sarcoma: perioperative management: Case report / Laringectomía total en un neonato con sarcoma laringeo congénito: Manejo perioperatorio; reporte de un caso y revisión de la literatura

Newborn airway related diseases are one of the biggest challenges that an anesthesiologist can face during his medical practice. This case report describes a complete airway obstruction in a neonate with a laryngeal sarcoma who underwent various diagnostic procedures, finally receiving a total laryngectomy as part of his oncological treatment. We document the perioperative care during the laryngectomy, a procedure that has not yet been reported in literature to the date. We share our experience on how to confront such challenge and review the current literature on laryngeal cancer in the pediatric population.

La patología relacionada con la vía aérea en el recién nacido es uno de los grandes retos a los que se enfrenta un anestesiólogo; en este reporte de caso se presenta un neonato con obstrucción completa de la vía aérea por un fibrosarcoma laríngeo sometido a varios procedimientos diagnósticos bajo anestesia general y finalmente se le realiza una laringectomia total. Como parte de su manejo oncológico. Se documenta el manejo perioperatorio de la laringectomia; procedimiento hasta el momento no reportado en neonatos, se comparte la experiencia de enfrentar un reto complejo y se hace una revisión de literatura del cáncer laríngeo en la población pediátrica.

Perioperative management of split liver transplantation / 器官移植

In the context of shortage of donor livers, split liver transplantation has achieved the goal of "one donor liver for two recipients", which effectively alleviates the shortage of donor livers and has promising development prospect. With the advancement of liver transplant techniques, split liver transplantation may yield clinical prognosis equivalent to total liver transplantation. However, perioperative management of split liver transplantation still encounters multiple challenges, with demanding techniques requirement and high-risk postoperative complications. Besides, there is a possibility of dividing one high-quality donor liver into two marginal donor livers, which will affect the development of liver transplantation. In this article, perioperative management of split liver transplantation was discussed from the perspectives of preoperative evaluation, recipient management and postoperative complication management, aiming to provide reference for promoting the development of split liver transplantation and enhancing clinical prognosis of recipients after split liver transplantation.

Deep Learning-based Risk Prediction Model for Postoperative Healthcare-associated Infections / 中国医学科学院学报

Objective To develop a risk prediction model combining pre/intraoperative risk factors and intraoperative vital signs for postoperative healthcare-associated infection(HAI)based on deep learning. Methods We carried out a retrospective study based on two randomized controlled trials(NCT02715076,ChiCTR-IPR-17011099).The patients who underwent elective radical resection of advanced digestive system tumor were included in this study.The primary outcome was HAI within 30 days after surgery.Logistic regression analysis and long short-term memory(LSTM)model based on iteratively occluding sections of the input were used for feature selection.The risk prediction model for postoperative HAI was developed based on deep learning,combining the selected pre/intraoperative risk factors and intraoperative vital signs,and was evaluated by comparison with other models.Finally,we adopted the simulated annealing algorithm to simulatively adjust the vital signs during surgery,trying to explore the adjustment system that can reduce the risk of HAI. Results A total of 839 patients were included in this study,of which 112(13.3%)developed HAI within 30 days after surgery.The selected pre/intraoperative risk factors included neoadjuvant chemotherapy,parenteral nutrition,esophagectomy,gastrectomy,colorectal resection,pancreatoduodenectomy,hepatic resection,intraoperative blood loss>500 ml,and anesthesia time>4 h.The intraoperative vital signs significantly associated with HAI were in an order of heart rate>core body temperature>systolic blood pressure>diastolic blood pressure.Compared with multivariable Logistic regression model,random forest model,and LSTM model including vital signs only,this deep learning-based prediction model performed best(ACC=0.733,F1=0.237,AUC=0.728).The simulation via simulated annealing algorithm reduced the incidence of postoperative HAI.Moreover,the incidence decreased most in the case of reducing the initial annealing temperature and choosing the last 20% of surgery procedure. Conclusions This study developed a risk prediction model for postoperative HAI based on deep learning,which combined pre/intraoperative risk factors and intraoperative basic vital signs.Using simulated annealing algorithm to adjust intraoperative vital signs could reduce the incidence of postoperative HAI to some extent.

Application value evaluation of bedside non-invasive hemodynamic monitoring in the perioperative management of neonatal gastrointestinal surgery / 中国小儿急救医学

Objective:To explore the value of ultrasonic cardiac output monitor(USCOM) in guiding perioperative hemodynamic management of neonatal gastrointestinal surgery.Methods:Seventy-five neonates with hemodynamic changes after gastrointestinal surgery admitted to the Department of Neonatology, Xiamen Children′s Hospital from January 2017 to December 2020 were enrolled, of which the non-USCOM group had 34 cases from January 2017 to December 2018, mainly based on clinical indicators such as heart rate, blood pressure, blood lactate acid to evaluate the hemodynamic status of children after surgery.The USCOM group had 41 cases from January 2019 to December 2020, used USCOM to assist in the evaluation of hemodynamics of children after surgery dynamic state.Another 40 cases were set up as the control group, included neonates with hyperbilirubinemia.The USCOM group and the control group were examined by USCOM to record cardiac output(CO), cardiac index(CI), and systemic vascular resistance(SVR). The changes in CO, CI, SVR between the USCOM group and the control group, the changes in USCOM group before and after the operation were compared, respectively.Changes in heart rate, blood pressure, and lactic acid in the USCOM group before and after the operation were compared.And the differences of vasoactive drug dosage and time of first use after operation, postoperative first expansion time, volume expansion, incidence of anuria or oliguria within 24 hours after operation, and length of hospital stay between USCOM group and non-USCOM group were analyzed.Results:The CO, CI, SVR, heart rate, blood pressure before operation in USCOM group were not significantly different compared with those in the control group and 12 h after the operation.The CO and CI in USCOM group at 1 h after operation were lower than those before operation, and the lactic acid increased, the differences were statistically significant( P<0.05). The SVR of USCOM group at 1 h after operation was higher than that before operation, but there was no significant difference ( P>0.05). The CO and CI at 12 h after operation in USCOM group were higher than those at 1 h after operation, and the SVR at 12 h was lower than that at 1 h after operation , the differences were all statistically significant( P<0.05). There were no significant differences in heart rate and blood pressure in USCOM group before and 1 h after operation ( P>0.05). The blood pressure at 12 h after operation was significantly higher than that at 1 h after operation( P<0.05). The time of first volume expansion and use of vasoactive drugs in USCOM group were significantly earlier than those in non-USCOM group[0.75(0.50, 1.37)h vs.7.00(5.00, 13.25)h, Z=-7.041, P<0.001; (1.39±1.33)h vs.(8.61±5.15)h, t=-7.917, P<0.001], the total volume of expansion was significantly reduced[17.50(10.00, 30.00)mL vs.30.00(20.00, 30.00)mL, t=-3.045, P=0.002], the dosage of dopamine was significantly reduced[8.40(6.20, 10.40)mg/kg vs.8.90(7.20, 14.40)mg/kg, Z=-2.475, P=0.013], the incidence of oliguria or anuria within 24 hours after operation was significantly reduced(12.2% vs.32.3%, t=4.500, P=0.034), the length of hospital stay was significantly shortened[25.00(15.50, 31.00)d vs.28.00(21.75, 34.00)d, Z=-1.985, P=0.047], and the dosage of dobutamine and epinephrine was not significantly changed( P>0.05). Conclusion:Non-invasive hemodynamic monitoring can monitor the hemodynamic changes of the neonatal gastrointestinal tract in real time during the perioperative period, which is helpful to guide the management of vasoactive drugs and fluids after surgery.