Spinal anesthesia in ambulatory patients.

PURPOSE OF THIS REVIEW: To assess current practice in the use of spinal anesthesia in major ambulatory surgery, highlighting its advantages over general anesthesia and identifying potential areas for improvement to facilitate a transition to a sustainable healthcare system. RECENT FINDINGS: Spinal anesthesia might be preferred in selected populations when compared to general anesthesia providing the highest standards of healthcare quality.The use of local anesthetics with short half-life has proven to be efficient in achieving high anesthesia success rates. Spinal anesthesia does not increase perioperative complications; instead, it has shown a reduction in postoperative nausea and vomiting, an improvement in patient comfort, and a favorable economic impact when compared to general anesthesia. SUMMARY: Spinal anesthesia is an appropriate method for anesthesia in ambulatory patients, offering advantages over general anesthesia in selected populations.The use of spinal anesthesia is expanding to meet surgical needs. Therefore, it is crucial to plan ahead and anticipate organizational failures in the ambulatory setting to maintain safety and efficiency during outpatient procedures and surgeries.

Adjuvant Analgesics in Acute Pain - Evaluation of Efficacy.

PURPOSE OF THE REVIEW: Acute postoperative pain impacts a significant number of patients and is associated with various complications, such as a higher occurrence of chronic postsurgical pain as well as increased morbidity and mortality. RECENT FINDINGS: Opioids are often used to manage severe pain, but they come with serious adverse effects, such as sedation, respiratory depression, postoperative nausea and vomiting, and impaired bowel function. Therefore, most enhanced recovery after surgery protocols promote multimodal analgesia, which includes adjuvant analgesics, to provide optimal pain control. In this article, we aim to offer a comprehensive review of the contemporary literature on adjuvant analgesics in the management of acute pain, especially in the perioperative setting. Adjuvant analgesics have proven efficacy in treating postoperative pain and reducing need for opioids. While ketamine is an established option for opioid-dependent patients, magnesium and α2-agonists have, in addition to their analgetic effect, the potential to attenuate hemodynamic responses, which make them especially useful in painful laparoscopic procedures. Furthermore, α2-agonists and dexamethasone can extend the analgesic effect of regional anesthesia techniques. However, findings for lidocaine remain inconclusive.

Association of Indoleamine 2,3-Dioxygenase (IDO) Activity with Outcome after Cardiac Surgery in Adult Patients.

Indoleamine 2,3-deoxygenase (IDO) plays an important role in the catabolism of the amino acid tryptophan. Tryptophan and its metabolites are key immune modulators. Increased IDO activity has been observed in various diseases and is associated with worse clinical outcomes. However, comprehensive research regarding its role in cardiac surgery remains limited. Therefore, we aimed to investigate perioperative changes in IDO activity and pathway metabolites, along with their impact on clinical outcomes in adult patients undergoing cardiac surgery. As an observational cohort study conducted at the Inselspital in Bern from January to December 2019, we retrospectively analyzed the data of prospectively collected biobank samples of patients undergoing cardiac surgery with the use of cardiopulmonary bypass. IDO pathway metabolite analysis was conducted by mass spectrometry. Perioperative dynamics were descriptively assessed and associated with pre-defined clinical outcome measures (30-day mortality, 1-year mortality, incidence of stroke and myocardial infarction, and length of hospital stay) through a multi-step exploratory regression analysis. A cohort of 192 adult patients undergoing cardiac surgery with the use of cardiopulmonary bypass were included (median age 67.0, IQR 60.0-73.0, 75.5% male). A significant perioperative decrease in the kynurenine/tryptophan (Kyn/Trp) ratio (-2.298, 95% CI -4.028 to -596, p = 0.009) and significant perioperative dynamics in the associated metabolites was observed. No association of perioperative changes in IDO activity and pathway metabolites with clinical outcomes was found. A significant decrease in the Kyn/Trp ratio among adult patients undergoing cardiac surgery indicates a perioperative downregulation of IDO, which stands in contrast to other pro-inflammatory conditions. Further studies are needed to investigate IDO in the setting of perioperative immunomodulation, which is a key driver of postoperative complications in cardiac surgery patients.

Modern Approaches to the Treatment of Acute Facial Pain.

PURPOSE OF REVIEW: Acute facial pain presents a complex challenge in medical practice, requiring a comprehensive and interdisciplinary approach to its management. This narrative review explores the contemporary landscape of treating acute facial pain, delving into pharmacological, non-pharmacological, and advanced interventions. The significance of tailored treatment strategies, rooted in the diverse etiologies of facial pain, such as dental infections, trigeminal neuralgia, temporomandibular joint disorders, sinusitis, or neurological conditions like migraines or cluster headaches, is underscored. We particularly emphasize recent advances in treating trigeminal neuralgia, elucidating current treatment concepts in managing this particular acute facial pain. RECENT FINDINGS: Recent research sheds light on various treatment modalities for acute facial pain. Pharmacotherapy ranges from traditional NSAIDs and analgesics to anticonvulsants and antidepressants. Non-pharmacological interventions, including physical therapy and psychological approaches, play pivotal roles. Advanced interventions, such as nerve blocks and surgical procedures, are considered in cases of treatment resistance. Moreover, we explore innovative technologies like neuromodulation techniques and personalized medicine, offering promising avenues for optimizing treatment outcomes in acute facial pain management. Modern management of acute facial pain requires a nuanced and patient-centric approach. Tailoring treatment strategies to the individual's underlying condition is paramount. While pharmacotherapy remains a cornerstone, the integration of non-pharmacological interventions is essential for comprehensive care. Advanced interventions should be reserved for cases where conservative measures prove inadequate. Furthermore, leveraging innovative technologies and personalized medicine holds promise for enhancing treatment efficacy. Ultimately, a holistic approach that considers the diverse needs of patients is crucial for effectively addressing acute facial pain.

Regulatory effects of microRNAs on monocytic HLA-DR surface expression.

Decreased monocytic HLA-DR expression is the most studied biomarker of immune competency in critically ill and autoimmune disease patients. However, the underlying regulatory mechanisms remain largely unknown. One probable HLA-DR dysregulation is through microRNAs. The aim of this study was to investigate the effects of specific microRNAs on HLA-DR expression in human monocytic cells. Four up- and four down-HLA-DR-regulating microRNAs were identified, with hsa-miR-let-7f-2-3p showing the most significant upregulation and hsa-miR-567 and hsa-miR-3972 downregulation. Anti-inflammatory glucocorticoid medication Dexamethasone-decreased HLA-DR was significantly restored by hsa-miR-let-7f-2-3p and hsa-miR-5693. Contrarily, proinflammatory cytokines IFN-γ and TNF-α-increased HLA-DR were significantly reversed by hsa-miR-567. Clinically, paired plasma samples from patients before and one day after cardiac surgery revealed up-regulated expression of hsa-miR-5693, hsa-miR-567, and hsa-miR-3972, following the major surgical trauma. In silico approaches were applied for functional microRNA-mRNA interaction prediction and candidate target genes were confirmed by qPCR analysis. In conclusion, novel monocytic HLA-DR microRNA modulators were identified and validated in vitro. Moreover, both the interaction between the microRNAs and anti- and proinflammatory molecules and the up-regulated microRNAs identified in cardiac surgery highlight the potential clinical relevance of our findings.

Cannabinoids for Acute Pain Management: Approaches and Rationale.

PURPOSE OF THE REVIEW: Acute pain management remains a challenge and postoperative pain is often undermanaged despite many available treatment options, also including cannabinoids. RECENT FINDINGS: In the light of the opioid epidemic, there has been growing interest in alternative care bundles for pain management, including cannabinoids as potential treatment to decrease opioid prescribing. Despite the lack of solid evidence on the efficacy of cannabinoids, their use among patients with pain, including those using opioids, is currently increasing. This use is supported by data suggesting that cannabinoids could potentially contribute to a better pain management and to a reduction in opioid doses while maintaining effective analgesia with minimum side effects. The scientific basis for supporting the use of cannabis is extensive, although it does not necessarily translate into relevant clinical outcomes. The use of cannabinoids in acute pain did not always consistently show statistically significant results in improving acute pain. Large randomized, controlled trials evaluating diverse cannabis extracts are needed in different clinical pain populations to determine safety and efficacy.

Nerve Blocks for Craniotomy.

PURPOSE OF REVIEW: Postcraniotomy headache (PCH) is a common adverse event and can lead to various complications and decreased quality of life. RECENT FINDINGS: To reduce postcraniotomy pain and associated complications, a multimodal pain therapy including analgesics, analgesic adjuncts, and regional anesthesia is essential. The use of opioids should be minimized to facilitate prompt postoperative neurosurgical assessment. Here, we provide an update on the latest evidence regarding the role of scalp nerve blocks in the pain management of patients undergoing craniotomy procedure. Nerve blocks are effective in alleviating postoperative pain after craniotomy. Scalp blocks contribute to lower pain levels and less opioid consumption in the first 48 h following surgery. Moreover, there is a significant decrease in patients suffering from PONV among patients who receive scalp block.

Gender-specific prolactin thresholds to determine prolactinoma size: a novel Bayesian approach and its clinical utility.

Background: In clinical practice, the size of adenomas is crucial for guiding prolactinoma patients towards the most suitable initial treatment. Consequently, establishing guidelines for serum prolactin level thresholds to assess prolactinoma size is essential. However, the potential impact of gender differences in prolactin levels on estimating adenoma size (micro- vs. macroadenoma) is not yet fully comprehended. Objective: To introduce a novel statistical method for deriving gender-specific prolactin thresholds to discriminate between micro- and macroadenomas and to assess their clinical utility. Methods: We present a novel, multilevel Bayesian logistic regression approach to compute observationally constrained gender-specific prolactin thresholds in a large cohort of prolactinoma patients (N = 133) with respect to dichotomized adenoma size. The robustness of the approach is examined with an ensemble machine learning approach (a so-called super learner), where the observed differences in prolactin and adenoma size between female and male patients are preserved and the initial sample size is artificially increased tenfold. Results: The framework results in a global prolactin threshold of 239.4 µg/L (95% credible interval: 44.0-451.2 µg/L) to discriminate between micro- and macroadenomas. We find evidence of gender-specific prolactin thresholds of 211.6 µg/L (95% credible interval: 29.0-426.2 µg/L) for women and 1,046.1 µg/L (95% credible interval: 582.2-2,325.9 µg/L) for men. Global (that is, gender-independent) thresholds result in a high sensitivity (0.97) and low specificity (0.57) when evaluated among men as most prolactin values are above the global threshold. Applying male-specific thresholds results in a slightly different scenario, with a high specificity (0.99) and moderate sensitivity (0.74). The male-dependent prolactin threshold shows large uncertainty and features some dependency on the choice of priors, in particular for small sample sizes. The augmented datasets demonstrate that future, larger cohorts are likely able to reduce the uncertainty range of the prolactin thresholds. Conclusions: The proposed framework represents a significant advancement in patient-centered care for treating prolactinoma patients by introducing gender-specific thresholds. These thresholds enable tailored treatment strategies by distinguishing between micro- and macroadenomas based on gender. Specifically, in men, a negative diagnosis using a universal prolactin threshold can effectively rule out a macroadenoma, while a positive diagnosis using a male-specific prolactin threshold can indicate its presence. However, the clinical utility of a female-specific prolactin threshold in our cohort is limited. This framework can be easily adapted to various biomedical settings with two subgroups having imbalanced average biomarkers and outcomes of interest. Using machine learning techniques to expand the dataset while preserving significant observed imbalances presents a valuable method for assessing the reliability of gender-specific threshold estimates. However, external cohorts are necessary to thoroughly validate our thresholds.

Transitional Pain Service: An Update.

PURPOSE OF REVIEW: Chronic Postsurgical Pain (CPSP) and the risk for long-term opioid dependency are known complications following major surgery. The idea of Transitional Pain Service (TPS) has been introduced as an interdisciplinary setting to manage pain in the perioperative continuum. We expand on the basic framework and principles of TPS and summarize the current evidence of the TPS and possible interventions to adress postoperative pain. Areas of future work in TPS-related research are discussed. RECENT FINDINGS: Several studies support the effectiveness of TPS in reducing opioid consumption in the perioperative period and following discharge. Some studies also show an improvement in functional outcome with TPS with patients reporting lower pain severity and pain interference. The TPS aims to halt the progress of acute postoperative pain to CPSP by providing longitudinal support with patient-centered care. While some studies suggest a positive impact of TPS implementation in terms of reduction in postoperative opioid consumption and improvement of some functional outcomes, direct evidence in terms of reduction in the incidence of CPSP is still missing. The cost-effectiveness of TPS and the expansion of TPS through e-health services and digital applications also need to be evaluated.

Levels of Circulating Ketone Bodies in Patients Undergoing Cardiac Surgery on Cardiopulmonary Bypass.

Ketone bodies (KBs) are energy-efficient substrates utilized by the heart depending on its metabolic demand and substrate availability. Levels of circulating KBs have been shown to be elevated in acute and chronic cardiovascular disease and are associated with severity of disease in patients with heart failure and functional outcome after myocardial infarction. To investigate whether this pattern similarly applies to patients undergoing cardiac surgery involving cardiopulmonary bypass (CPB), we analysed prospectively collected pre- and postoperative blood samples from 192 cardiac surgery patients and compared levels and perioperative changes in total KBs with Troponin T as a marker of myocardial cell injury. We explored the association of patient characteristics and comorbidities for each of the two biomarkers separately and comparatively. Median levels of KBs decreased significantly over the perioperative period and inversely correlated with changes observed for Troponin T. Associations of patient characteristics with ketone body perioperative course showed notable differences compared to Troponin T, possibly highlighting factors acting as a "driver" for the change in the respective biomarker. We found an inverse correlation between perioperative change in ketone body levels and changes in troponin, indicating a marked decrease in ketone body concentrations in patients exhibiting greater myocardial cell injury. Further investigations aimed at better understanding the role of KBs on perioperative changes are warranted.

Novel para-aortic cardiac assistance using a pre-stretched dielectric elastomer actuator.

OBJECTIVES: We propose an evolution of a dielectric elastomer actuator-based cardiac assist device that acts as a counterpulsation system. We introduce a new pre-stretched actuator and implant the device in a graft bypass between the ascending and descending aorta to redirect all blood through the device (ascending aorta clamped). The objective was to evaluate the influence of these changes on the assistance provided to the heart. METHODS: The novel para-aortic device and the new implantation technique were tested in vivo in 5 pigs. We monitored the pressure and flow in the aorta as well as the pressure-volume characteristics of the left ventricle. Different activation timings were tested to identify the optimal device actuation. RESULTS: The proposed device helps reducing the end-diastolic pressure in the aorta by up to 13 ± 4.0% as well as the peak systolic pressure by up to 16 ± 3.6%. The early diastolic pressure was also increased up to 10 ± 3.5%. With different activation, we also showed that the device could increase or decrease the stroke volume. CONCLUSIONS: The new setup and the novel para-aortic device presented here helped improve cardiac assistance compared to previous studies. Moreover, we revealed a new way to assist the heart by actuating the device at different starting time to modify the left ventricular stroke volume and stroke work.

Decision Curve Analysis of In-Hospital Mortality Prediction Models: The Relative Value of Pre- and Intraoperative Data For Decision-Making.

BACKGROUND: Clinical prediction modeling plays a pivotal part in modern clinical care, particularly in predicting the risk of in-hospital mortality. Recent modeling efforts have focused on leveraging intraoperative data sources to improve model performance. However, the individual and collective benefit of pre- and intraoperative data for clinical decision-making remains unknown. We hypothesized that pre- and intraoperative predictors contribute equally to the net benefit in a decision curve analysis (DCA) of in-hospital mortality prediction models that include pre- and intraoperative predictors. METHODS: Data from the VitalDB database featuring a subcohort of 6043 patients were used. A total of 141 predictors for in-hospital mortality were grouped into preoperative (demographics, intervention characteristics, and laboratory measurements) and intraoperative (laboratory and monitor data, drugs, and fluids) data. Prediction models using either preoperative, intraoperative, or all data were developed with multiple methods (logistic regression, neural network, random forest, gradient boosting machine, and a stacked learner). Predictive performance was evaluated by the area under the receiver-operating characteristic curve (AUROC) and under the precision-recall curve (AUPRC). Clinical utility was examined with a DCA in the predefined risk preference range (denoted by so-called treatment threshold probabilities) between 0% and 20%. RESULTS: AUROC performance of the prediction models ranged from 0.53 to 0.78. AUPRC values ranged from 0.02 to 0.25 (compared to the incidence of 0.09 in our dataset) and high AUPRC values resulted from prediction models based on preoperative laboratory values. A DCA of pre- and intraoperative prediction models highlighted that preoperative data provide the largest overall benefit for decision-making, whereas intraoperative values provide only limited benefit for decision-making compared to preoperative data. While preoperative demographics, comorbidities, and surgery-related data provide the largest benefit for low treatment thresholds up to 5% to 10%, preoperative laboratory measurements become the dominant source for decision support for higher thresholds. CONCLUSIONS: When it comes to predicting in-hospital mortality and subsequent decision-making, preoperative demographics, comorbidities, and surgery-related data provide the largest benefit for clinicians with risk-averse preferences, whereas preoperative laboratory values provide the largest benefit for decision-makers with more moderate risk preferences. Our decision-analytic investigation of different predictor categories moves beyond the question of whether certain predictors provide a benefit in traditional performance metrics (eg, AUROC). It offers a nuanced perspective on for whom these predictors might be beneficial in clinical decision-making. Follow-up studies requiring larger datasets and dedicated deep-learning models to handle continuous intraoperative data are essential to examine the robustness of our results.

Perioperative Evaluation of Brain Health.

As the global population is aging and surgical needs rise, the occurrence of perioperative neurocognitive disorders (PND) is becoming a significant concern. PND refers to cognitive changes that occur before or after surgery, including neurocognitive disorders, postoperative delirium, and delayed neurocognitive recovery. To address this issue, a brain health assessment initiative within a multidisciplinary team is an emerging concept. Assessing cognitive function, comorbidities, severity of neurocognitive disorders, medications, nutritional status, sleep quality, and other factors can help mitigate the risk of PND and improve patient outcomes.

Beyond the Consulting Room and Telemedicine: Unveiling the Future of Anesthesiology with Virtual Preoperative Assessment.

Telemedicine has rapidly evolved, offering expanded applications including virtual consultations, remote patient education, and therapeutic options. It provides advantages such as increased accessibility, reduced travel time, and convenience. Challenges include privacy concerns, the digital divide, and the need for regulatory frameworks. Virtual preoperative assessment shows promise in safely identifying patients who do not require in-person consultations. Legal considerations and liability issues need to be addressed. While the COVID-19 pandemic has accelerated the adoption of telemedicine, it has also highlighted the need for comprehensive policies and equitable access to maximize its potential in health care delivery.

Lower alpha frequency of intraoperative frontal EEG is associated with postoperative delirium: A secondary propensity-matched analysis.

BACKGROUND: Postoperative delirium (POD) is a serious complication of surgery, especially in the elderly patient population. It has been proposed that decreasing the amount of anesthetics by titrating to an EEG index will lower POD rate, but clear evidence is missing. A strong age-dependent negative correlation has been reported between the peak oscillatory frequency of alpha waves and end-tidal anesthetic concentration, with older patients generating slower alpha frequencies. We hypothesized, that slower alpha oscillations are associated with a higher rate of POD. METHOD: Retrospective analysis of patients` data from a prospective observational study in cardiac surgical patients approved by the Bernese Ethics committee. Frontal EEG was recorded during Isoflurane effect-site concentrations of 0.7 to 0.8 and peak alpha frequency was measured at highest power between 6 and 17 Hz. Delirium was assessed by chart review. Demographic and clinical characteristics were compared between POD and non-POD groups. Selection bias was addressed using nearest neighbor propensity score matching (PSM) for best balance. This incorporated 18 variables, whereas patients with missing variable information or without an alpha oscillation were excluded. RESULT: Of the 1072 patients in the original study, 828 were included, 73 with POD, 755 without. PSM allowed 328 patients into the final analysis, 67 with, 261 without POD. Before PSM, 8 variables were significantly different between POD and non-POD groups, none thereafter. Mean peak alpha frequency was significantly lower in the POD in contrast to non-POD group before and after matching (7.9 vs 8.9 Hz, 7.9 vs 8.8 Hz respectively, SD 1.3, p < 0.001). CONCLUSION: Intraoperative slower frontal peak alpha frequency is independently associated with POD after cardiac surgery and may be a simple intraoperative neurophysiological marker of a vulnerable brain for POD. Further studies are needed to investigate if there is a causal link between alpha frequency and POD.