A randomised controlled trial comparing deep neuromuscular blockade reversed with sugammadex with moderate neuromuscular block reversed with neostigmine.

Deep neuromuscular block aims to improve operative conditions during laparoscopic surgery with a lower intra-abdominal pressure. Studies are conflicting on whether meaningful improvements in quality of recovery occur beyond emergence, and whether lower intra-abdominal pressure is achieved. In this pragmatic randomised trial with 1:1 allocation, adults undergoing elective laparoscopic surgery were allocated to moderate neuromuscular block reversed with neostigmine, or deep neuromuscular block reversed with sugammadex. Allocation was revealed to the anaesthetist only. Primary outcome was cognitive recovery of the Postoperative Quality of Recovery Scale, 7 days after surgery. Secondary outcomes included recovery in other domains of the Postoperative Quality of Recovery Scale at 15 min and 40 min; days 1, 3, 7, 14; and 1 and 3 months after surgery. Chi-square test was used for the primary outcome, and generalised linear mixed model for recovery over time between groups. Of 350 participants randomised, 140 (deep) and 144 (moderate) were analysed for the primary outcome. There was no difference in the Postoperative Quality of Recovery Scale cognitive domain at day 7 (deep 92.9% vs. moderate 91.8%, OR 1.164; 95%CI 0.486-2.788, p = 0.826), or at any other time-point. No significant difference was observed for physiological, emotive, activities of daily living, nociception, or overall recovery. Length of stay in the recovery area (mean (SD) deep 108 (58) vs. moderate 109 (57) min, p = 0.78) and hospital (1.8 (1.9) vs. 2.6 (3.5) days, p = 0.019) was not different. Intra-abdominal pressure and surgical operating conditions were not different between groups. Deep neuromuscular block did not improve quality of recovery compared with moderate neuromuscular block in operative laparoscopic surgery over a 1-h duration.

Validation of the cognitive recovery assessments with the Postoperative Quality of Recovery Scale in patients with low-baseline cognition.

Patients with pre-surgery cognitive impairment cannot currently be assessed for cognitive recovery after surgery using the Postoperative Quality of Recovery Scale (PostopQRS), as they would mathematically be scored as recovered. We aimed to validate a novel method to score cognitive recovery in patients with low-baseline cognition, using the number of low-score tests rather than their numerical values. Face validity was demonstrated in 86 participants in whom both the Postoperative Quality of Recovery Scale and an 11-item neuropsychological battery were performed. The Postoperative Quality of Recovery Scale agreed with neuropsychological categorisation of low vs. normal cognition 74% of the time, with all but five incorrectly coded participants deviating by only one neurocognitive test. Cognitive recovery over time was comparable for groups with differing baseline cognitive function, irrespective of whether the Postoperative Quality of Recovery Scale or neuropsychological methods were used. Discriminant validation was demonstrated in a post-hoc analysis of the steroids in cardiac surgery substudy by allocating groups to normal (n = 246) or low-baseline cognition (n = 231) stratified by cognitive recovery on day 1. Recovery was similar for participants with low and normal baseline cognition. Postoperative length of stay was longer in patients with failed cognitive recovery whether they had normal mean (SD) (10.4 (10.0) vs. 8.0 (5.9) days, p = 0.02) or low-baseline cognition (12.0 (11.1) vs. 8.2 (4.7) days, p < 0.01). Overall quality, as well as cognitive, emotive and physiological recovery was independent of baseline cognition. The modified scoring method for the Postoperative Quality of Recovery Scale cognitive domain demonstrates acceptable face and discriminant validity.

Validation of a revised Mandarin Chinese language version of the Postoperative Quality of Recovery Scale.

The aim of the study was to validate a revised Mandarin version of the Postoperative Quality of Recovery Scale (PostopQRS) and to apply the revised version in a Chinese population. In a prospective design, bilingual volunteers completed the scale at baseline, day one, day seven, and day 14 in both languages, with the order of language and parallel forms randomised. In addition, lung cancer patients undergoing open or video-assisted thoracoscopic surgery (VATS) completed the Mandarin version prior to surgery, day one, day three, day seven, day 14, one month, and three months postoperatively. Sixty-eight volunteers participated in the validation part of the study and in the clinical application, 93 lung cancer patients were included. The scores in the Mandarin version were equal to the English version in all domains at all timepoints including the word generation task, when the Mandarin morpheme was included in any part of the Mandarin word. However, Mandarin scores were lower in the word generation task if the morpheme was only included in the first part of the word. In addition, the Mandarin version was able to identify lower rates of overall recovery (P <0.01), nociceptive (P <0.01), emotive (P <0.01), and activities of daily living recovery (P=0.02) after open surgery compared to after VATS. The revised Mandarin version is equivalent to the English version for the cognitive domain, if morpheme substitution for the word generation task is allowed as any part of the word, and it is able to discriminate quality of recovery in Chinese patients.

Competency-based assessment tools for regional anaesthesia: a narrative review.

Competency-based assessment tools are used in regional anaesthesia to measure the performance of study participants, trainees, and consultants. This narrative review was performed to appraise currently published assessment tools for regional anaesthesia. A literature search found 397 citations of which 28 peer-reviewed studies met the inclusion criteria of primary psychometric evaluation of assessment tools for regional anaesthesia. The included studies were diverse in the type of assessment and the skill set being assessed. The types of assessments included multiple-choice questions, hand-motion analysis, cumulative sum, visuospatial and psychomotor screening, checklists, and global rating scales. The skill sets that were assessed included holistic regional anaesthesia technical and non-technical performance observed at the bedside, to isolated part-tasks, such as needle tip visualisation under ultrasound. To evaluate validity and reliability, we compared the studies against published medical education consensus statements on ideal assessment tools. We discuss the relative merits of different tools when used to assess regional anaesthesia, the importance of psychometrically robust assessment tools in competency-based anaesthesia education, and directions for future education research in regional anaesthesia.

Pilot multi-centre randomised trial of the impact of pre-operative focused cardiac ultrasound on mortality and morbidity in patients having surgery for femoral neck fractures (ECHONOF-2 pilot).

Hip fracture surgery is common, usually occurs in elderly patients who have multiple comorbidities, and is associated with high morbidity and mortality. Pre-operative focused cardiac ultrasound can alter diagnosis and management, but its impact on outcome remains uncertain. This pilot study assessed feasibility and group separation for a proposed large randomised clinical trial of the impact of pre-operative focused cardiac ultrasound on patient outcome after hip fracture surgery. Adult patients requiring hip fracture surgery in four teaching hospitals in Australia were randomly allocated to receive focused cardiac ultrasound before surgery or not. The primary composite outcome was any death, acute kidney injury, non-fatal myocardial infarction, cerebrovascular accident, pulmonary embolism or cardiopulmonary arrest within 30 days of surgery. Of the 175 patients screened, 100 were included as trial participants (screening:recruitment ratio 1.7:1), 49 in the ultrasound group and 51 as controls. There was one protocol failure among those recruited. The primary composite outcome occurred in seven of the ultrasound group patients and 12 of the control group patients (relative group separation 39%). Death, acute kidney injury and cerebrovascular accident were recorded, but no cases of myocardial infarction, pulmonary embolism or cardiopulmonary arrest ocurred. Focused cardiac ultrasound altered the management of 17 participants, suggesting an effect mechanism. This pilot study demonstrated that enrolment and the protocol are feasible, that the primary composite outcome is appropriate, and that there is a treatment effect favouring focused cardiac ultrasound - and therefore supports a large randomised clinical trial.

Interpreting diaphragmatic movement with bedside imaging, review article.

The diaphragm is the most important muscle of respiration. At equilibrium, the load imposed on the diaphragmatic muscles from transdiaphragmatic pressure balances the force generated by diaphragmatic muscles. However, procedural and nonprocedural thoracic and abdominal conditions may disrupt this equilibrium and impair diaphragmatic function. Diaphragmatic dysfunction is associated with respiratory insufficiency and poor outcome. Therefore, rapid diagnosis and early intervention may be useful. Ultrasound imaging provides quick and accurate bedside assessment of the diaphragm. Various imaging techniques have been suggested, using 2-dimensional and M-mode technology. Diaphragm viewing depends on the degree of robe movement, determined by the angle of incidence of the ultrasound beam and by the direction of probe movement. In this review, we will discuss the function of the diaphragm focusing on clinically important anatomical and physiological properties of the diaphragm. We will review the literature regarding various sonographic techniques for diaphragm assessment. We will also explore the evidence for the role of the tidal displacement of subdiaphragmatic organs as a surrogate for diaphragm movement.

Focused echocardiography: a systematic review of diagnostic and clinical decision-making in anaesthesia and critical care.

Focused echocardiography is becoming a widely used tool to aid clinical assessment by anaesthetists and critical care physicians. At the present time, most physicians are not yet trained in focused echocardiography or believe that it may result in adverse outcomes by delaying, or otherwise interfering with, time-critical patient management. We performed a systematic review of electronic databases on the topic of focused echocardiography in anaesthesia and critical care. We found 18 full text articles, which consistently reported that focused echocardiography may be used to identify or exclude previously unrecognised or suspected cardiac abnormalities, resulting in frequent important changes to patient management. However, most of the articles were observational studies with inherent design flaws. Thirteen prospective studies, including two that measured patient outcome, were supportive of focused echocardiography, whereas five retrospective cohort studies, including three outcome studies, did not support focused echocardiography. There is an urgent requirement for randomised controlled trials.

Transthoracic and transoesophageal echocardiography: a systematic review of feasibility and impact on diagnosis, management and outcome after cardiac surgery.

Transthoracic and transoesophageal echocardiography are increasingly used as tools to improve clinical assessment following cardiac surgery. However, most physicians are not trained in echocardiography, and there is no widespread agreement on the feasibility, indications or effect on outcome of transthoracic or transoesophageal echocardiography for patients after cardiac surgery. We performed a systematic review of electronic databases for focused transthoracic and transoesophageal echocardiography after cardiac surgery which revealed 15 full-text articles. They consistently reported that echocardiography is feasible, whether performed by a novice or expert, and frequently resulted in important changes in diagnosis of cardiac abnormalities and their management. However, most were observational studies and there were no well-designed trials investigating the impact of echocardiography on outcome. We conclude that both transthoracic and transoesophageal echocardiography are useful following cardiac surgery.

A randomised controlled trial comparing meat-based with human cadaveric models for teaching ultrasound-guided regional anaesthesia.

The aim of this prospective, blinded, randomised controlled study was to compare novices' acquisition of the technical skills of ultrasound-guided regional anaesthesia using either a meat phantom model or fresh-frozen human cadavers. The primary outcome was the time taken to successfully perform an ultrasound-guided sciatic nerve block on a cadaver; secondary outcomes were the cumulative score of errors, and best image quality of the sciatic nerve achieved. After training, the median (IQR [range]) time taken to perform the block was 311(164-390 [68-600]) s in the meat model trained group and 210 (174-354 [85-600]) s in the fresh-frozen cadaver trained group (p = 0.24). Participants made a median (IQR [range]) of 18 (14-33 [8-55]) and 15 (12-22 [8-44]) errors in the two groups respectively (p = 0.39). The image quality score was also not different, with a median (IQR [range]) of 62.5 (59.4-65.6 [25.0-100.0])% vs 62.5 (62.5-75.0 [25.0-87.5])% respectively (p = 0.58). The training and deliberate feedback improved all participants' block performance, the median (IQR [range]) times being 310 (206-532 [110-600]) s before and 240 (174-354 [85-600]) s after training (p = 0.02). We conclude that novices taught ultrasound scanning and needle guidance skills using an inexpensive and easily constructed meat model perform similarly to those trained on a cadaveric model.

Postoperative recovery and outcomes--what are we measuring and for whom?

Recovery is an abstract quantity the definition of which varies according to the pre-dilection of individual institutions, clinicians or patients. While traditionally focused on immediate postoperative restitution of function and readiness for discharge, recovery assessment has progressively expanded its focus to include other clinically relevant time periods, each of which is influenced by specific factors. Assessment tools have progressed from assessing one dimension of recovery, such as physiological variables, to multidimensional assessment of physical, nociceptive, emotive, functional and cognitive performance. They should be validated ideally for repeat measures and should provide real-time recovery data, as recovery can be viewed as a continuous process.

Design and validation of the Regional Anaesthesia Procedural Skills Assessment Tool.

The aim of this study was to create and evaluate the validity, reliability and feasibility of the Regional Anaesthesia Procedural Skills tool, designed for the assessment of all peripheral and neuraxial blocks using all nerve localisation techniques. The first phase was construction of a 25-item checklist by five regional anaesthesia experts using a Delphi process. This checklist was combined with a global rating scale to create the tool. In the second phase, initial validation by 10 independent anaesthetists using a test-retest methodology was successful (Cohen kappa ≥ 0.70 for inter-rater agreement, scores between test to retest, paired t-test, p > 0.12). In the third phase, 70 clinical videos of trainees were scored by three blinded international assessors. The RAPS tool exhibited face validity (p < 0.026), construct validity (p < 0.001), feasibility (mean time to score < 3.9 min), and overall reliability (intraclass correlation coefficient 0.80 (95% CI 0.67-0.88)). The Regional Anaesthesia Procedural Skills tool used in this study is a valid and reliable assessment tool to score the performance of trainees for regional anaesthesia.

Benefits and risks of epidural analgesia in cardiac surgery.

BACKGROUND: Epidurals provide excellent analgesia for cardiac surgery and may reduce complications. However, their use has been tempered because of concern of the rare, but serious complication of epidural haematoma. The aim of this meta-analysis was to assess the effect of epidural on survival and the risk estimate of epidural haematoma. METHODS: A systematic review of the literature (Pubmed, Embase, Scopus and the Cochrane Register) and a meta-analysis of the available randomized and case-matched studies were performed to estimate the effect on survival. An international, directed and viral anonymous survey was performed to identify the incidence of haematomas with a corresponding estimate of the number of epidurals performed. RESULTS: Of 66 randomized and case-matched studies, 57 trials including 6383 patients reported the incidence of all-cause mortality at the longest follow up available, with a significant reduction with epidurals (59/3123 [1.9%] vs 108/3260 [3.3%] in the control arm, RR 0.65 [95% CI 0.48-0.86], P=0.003, NNT=70). No epidural haematoma was reported in these 66 trials (3320 epidurals). All other literature revealed nine haematomas in 13,100 patients. Through the anonymous, web-based, viral, international survey, we identified 16 further, non-published, epidural haematomas from 72,400 positioned epidurals. Therefore, a total of 25 haematomas have been identified from an estimate of 88,820 positioned epidurals, producing an estimated risk of 1:3552 (95% CI 1:2552-1:5841). CONCLUSIONS: The use of epidural analgesia in cardiac surgery is associated with a reduction in mortality (NNT=70), and with an estimated risk of epidural haematoma of 1:3552.

A review of the scope and measurement of postoperative quality of recovery.

To date, postoperative quality of recovery lacks a universally accepted definition and assessment technique. Current quality of recovery assessment tools vary in their development, breadth of assessment, validation, use of continuous vs dichotomous outcomes and focus on individual vs group recovery. They have progressed from identifying pure restitution of physiological parameters to multidimensional assessments of postoperative function and patient-focused outcomes. This review focuses on the progression of these tools towards an as yet unreached ideal that would provide multidimensional assessment of recovery over time at the individual and group level. A literature search identified 11 unique recovery assessment tools. The Postoperative Quality of Recovery Scale assesses recovery in multiple domains, including physiological, nociceptive, emotive, activities of daily living, cognition and patient satisfaction. It addresses recovery over time and compares individual patient data with base line, thus describing resumption of capacities and is an acceptable method for identification of individual patient recovery.

Knee surgery recovery: Post-operative Quality of Recovery Scale comparison of age and complexity of surgery.

BACKGROUND: Initial validation and feasibility for the Post-operative Quality of Recovery Scale (PQRS) was published in 2010. Ongoing validation includes studies to determine whether this scale can discriminate differences in recovery between cohorts. METHODS: A prospective cohort study included 61 patients, 18-40 years, and 61 patients, aged ≥ 65 years, undergoing knee arthroscopy under general anaesthesia; and 13 patients, aged ≥ 65 years, undergoing total knee replacement under general anaesthesia. Patients were assessed using the PQRS. Assessments were performed pre-surgery, at 15 and 40 min, 1 and 3 days, and 3 months after surgery. RESULTS: The effect of age was assessed by comparing young versus older arthroscopy patients. There were minimal differences in recovery profiles, other than for the nociceptive domain, where pain recovery was significantly better in the older arthroscopy patients (P < 0.001). The effect of surgery was assessed by comparing older patients undergoing knee arthroscopy with knee replacement patients. Recovery was significantly worse for the knee replacement group for cognition (P = 0.015), nociception (pain and nausea, P < 0.001), activities of daily living (P < 0.001), emotive recovery (P = 0.029), and all-domains recovery (P < 0.001). Despite differences in quality of recovery, satisfaction was high in all cohorts. CONCLUSIONS: Knee replacement had a large effect on recovery compared with knee arthroscopy. Age had minimal effect on recovery after knee arthroscopy. The study showed the ability of the PQRS to discriminate recovery in different domains.

Recovery after nasal surgery vs. tonsillectomy: discriminant validation of the Postoperative Quality of Recovery Scale.

BACKGROUND: Initial validation and feasibility of the Post-Operative Quality of Recovery Scale (PQRS) was published in 2010. Ongoing validation includes studies to determine whether this scale can discriminate differences in recovery in similar patients having different surgery. METHODS: A prospective observational study included 89 patients undergoing nasal surgery and 46 patients undergoing tonsillectomy as the primary surgical procedure. Patients were assessed using the PQRS. Assessments were performed pre-surgery, at 15 and 40 min, 1 and 3 days, and 3 months after surgery. RESULTS: Tonsillectomy patients were younger [25.0 standard deviation (SD) 17.8 vs. 32.1 SD 18.0 years, P = 0.031] and had shorter anaesthesia duration (29.5 SD 12.6 vs. 42.7 SD 15.8 min, P < 0.01). Tonsillectomy patients had worse recovery in the nociceptive (pain and nausea; P < 0.001), activities of daily living (P < 0.001) and overall recovery (P = 0.025) domains, but were not different in the cognitive, emotive (depression and anxiety) or physiological recovery domains. Complete satisfaction was lower for tonsillectomy (P < 0.001). At 3 months, there was equivalence between groups in all assessments. CONCLUSION: The study shows the ability of the PQRS to discriminate recovery in different domains. Tonsillectomy has a worse recovery profile over the first 3 days in nociceptive, activities of daily living and overall recovery, which is associated with poorer satisfaction than nasal surgery.

Assessment of early cognitive recovery after surgery using the Post-operative Quality of Recovery Scale.

BACKGROUND: Cognitive problems early after surgery are often considered transient in nature. Neuropsychological performance and its relation to other recovery parameters have rarely been systematically assessed during this period. METHODS: A subanalysis of the Post-operative Quality of Recovery Scale (PQRS) feasibility study included patients who completed the PQRS on day 3, and were categorised as recovered or not recovered in the cognitive domain using the revised scoring method. RESULTS: Of the 449 patients included in this paper, 388 (86.4%) recovered in the cognitive domain and 61 (13.6%) had not recovered at 3 days. Cognitive recovery in the early post-operative time points up to day 1 was significantly lower in patients who had not recovered at day 3 (P < 0.001). Of those not recovered on day 3, 59.1% had recovered on day 1, but lapsed to non-recovery on day 3. The non-recovered group demonstrated less recovery in the physiological (P = 0.019), activity of daily living (P = 0.049) and nociceptive (P = 0.033) domains, but no difference was found in the emotive domain. The non-recovered group had a higher incidence of major surgery (P = 0.021), a higher proportion of patients with difficulty eating (4.9% vs. 0.5%, P = 0.002 and a clinically unimportant but lower temperature (36.6° vs. 36.4°C, P = 0.010). CONCLUSION: Failure of cognitive recovery is reasonably common 3 days after surgery, can fluctuate and is associated with poorer early recovery in the activities of daily living, nociceptive and physiological domains.

Post-operative Quality of Recovery Scale: the impact of assessment method on cognitive recovery.

BACKGROUND: We measured cognitive performance and recovery with the Post-operative Quality of Recovery Scale (PQRS) at 30 and 90 min after elective ambulatory or short-stay surgery under general anaesthesia. The aim was to study the impact of the assessment algorithm, comparing the original and modified more liberal score assessment. METHOD: One hundred and ten ASA 1-2 patients scheduled for elective surgery in general anaesthesia responded to the five cognitive performance questions in the PQRS; pre-operatively, 30 and 90 min after end of anaesthesia. Assessment of cognitive recovered was performed according to the original and modified definition which includes a tolerance factor to account for performance variability. RESULTS: Cognitive recovery improved from 30 to 90 min. The modified score assessment decreased number of patients that were evaluated low because it excluded initial low scoring subjects and also dramatically increased number of patients assessed as cognitively recovered; original 9% at 30 min and 28% at 90 min vs. 54% at 30 min and 81% at 90 min, P < 0.001. There were no other significant differences identified when using either the original or modified scoring method for age > 50 years, orthopaedic vs. abdominal surgery, premedication or gender. CONCLUSIONS: The modified definition which includes a tolerance factor to account for performance variability has dramatic effects in increasing the number of patients assessed as recovered. It is from the present study not possible to comment on whether the more liberal assessment provides more or less accurate description of cognitive performance.