Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study.

Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.

Pain-autonomic interaction after work-induced sleep restriction.

BACKGROUND AND PURPOSE: Poor sleep is commonly associated with alterations in pain perception. However, there is a lack of studies that address work-associated sleep restriction (SR) and changes in non-nociceptive perception and autonomic responses after work-induced SR. METHODS: This study was performed with 19 medical students after a normal-sleep night (NS phase) and after a night shift at the local emergency room (SR phase). We performed clinical assessment, quantitative sensory testing for electrical and temperature sensation, RR interval analysis, and recorded sudomotor skin responses (SSRs). RESULTS: The total mean duration of sleep was 436 ± 18 min in the NS group and 120 ± 28 min in the SR group (P<0.001). The anxiety scores were higher following the SR phase compared with those after the NS phase (P<0.01). After SR, there was a decrease in heat-pain threshold, but neither warm nor electrical thresholds were affected. Following SR, subjects showed higher SSR amplitudes and an increased number of double responses at an interstimulus interval of 2 s. We also observed a moderate inverse correlation between heat-pain thresholds and SSR amplitude (r= -0.46; P<0.01). However, there was no correlation between anxiety scores and SSR parameters. CONCLUSIONS: The effects of SR in the context of work stress on pain are specific and appear unrelated to general changes in sensory perception. Hyperalgesia was associated with abnormal autonomic responses, but not with increased anxiety, which suggests an association between the nociceptive and autonomic nervous systems that is independent of the emotional state.