PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management.

Arterial pressure monitoring and management are mainstays of haemodynamic therapy in patients having surgery. This article presents updated consensus statements and recommendations on perioperative arterial pressure management developed during the 11th POQI PeriOperative Quality Initiative (POQI) consensus conference held in London, UK, on June 4-6, 2023, which included a diverse group of international experts. Based on a modified Delphi approach, we recommend keeping intraoperative mean arterial pressure ≥60 mm Hg in at-risk patients. We further recommend increasing mean arterial pressure targets when venous or compartment pressures are elevated and treating hypotension based on presumed underlying causes. When intraoperative hypertension is treated, we recommend doing so carefully to avoid hypotension. Clinicians should consider continuous intraoperative arterial pressure monitoring as it can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring. Postoperative hypotension is often unrecognised and might be more important than intraoperative hypotension because it is often prolonged and untreated. Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension including choice of vasopressors. Research is also needed to guide monitoring and management strategies for recognising, preventing, and treating postoperative hypotension.

Testing Machine Learning Models to Predict Postoperative Ileus after Colorectal Surgery.

Background: Postoperative ileus (POI) is a common complication after colorectal surgery, leading to increased hospital stay and costs. This study aimed to explore patient comorbidities that contribute to the development of POI in the colorectal surgical population and compare machine learning (ML) model accuracy to existing risk instruments. Study Design: In a retrospective study, data were collected on 316 adult patients who underwent colorectal surgery from January 2020 to December 2021. The study excluded patients undergoing multi-visceral resections, re-operations, or combined primary and metastatic resections. Patients lacking follow-up within 90 days after surgery were also excluded. Eight different ML models were trained and cross-validated using 29 patient comorbidities and four comorbidity risk indices (ASA Status, NSQIP, CCI, and ECI). Results: The study found that 6.33% of patients experienced POI. Age, BMI, gender, kidney disease, anemia, arrhythmia, rheumatoid arthritis, and NSQIP score were identified as significant predictors of POI. The ML models with the greatest accuracy were AdaBoost tuned with grid search (94.2%) and XG Boost tuned with grid search (85.2%). Conclusions: This study suggests that ML models can predict the risk of POI with high accuracy and may offer a new frontier in early detection and intervention for postoperative outcome optimization. ML models can greatly improve the prediction and prevention of POI in colorectal surgery patients, which can lead to improved patient outcomes and reduced healthcare costs. Further research is required to validate and assess the replicability of these results.

Perioperative adverse events in adult patients with obstructive sleep apnea undergoing ambulatory surgery: An updated systematic review and meta-analysis.

BACKGROUND: The suitability of ambulatory surgery for patients with obstructive sleep apnea (OSA) remains controversial. This systematic review and meta-analysis aimed to evaluate the odds of perioperative adverse events in patients with OSA undergoing ambulatory surgery, compared to patients without OSA. METHODS: Four electronic databases were searched for studies published between January 1, 2011 and July 11, 2023. The inclusion criteria were: adult patients with diagnosed or high-risk of OSA undergoing ambulatory surgery; perioperative adverse events; control group included; general and/or regional anesthesia; and publication on/after February 1, 2011. We calculated effect sizes as odds ratios using a random effects model, and additional sensitivity analyses were conducted. RESULTS: Seventeen studies (375,389 patients) were included. OSA was associated with an increased odds of same-day admission amongst all surgery types (OR 1.94, 95% CI 1.46-2.59, I2:79%, P < 0.00001, 11 studies, n = 347,342), as well as when only orthopedic surgery was considered (OR 2.68, 95% CI 2.05-3.48, I2:41%, P < 0.00001, 6 studies, n = 132,473). Three studies reported that OSA was strongly associated with prolonged post anesthesia care unit (PACU) length of stay (LOS), while one study reported that the association was not statistically significant. In addition, four studies reported that OSA was associated with postoperative respiratory depression/hypoxia, with one large study on shoulder arthroscopy reporting an almost 5-fold increased odds of pulmonary compromise, 5-fold of myocardial infarction, 3-fold of acute renal failure, and 5-fold of intensive care unit (ICU) admission. CONCLUSIONS: Ambulatory surgical patients with OSA had almost two-fold higher odds of same-day admission compared to non-OSA patients. Multiple large studies also reported an association of OSA with prolonged PACU LOS, respiratory complications, and/or ICU admission. Clinicians should screen preoperatively for OSA, optimize comorbidities, adhere to clinical algorithm-based management perioperatively, and maintain a high degree of vigilance in the postoperative period.

Clinical practice guidelines for prevention and treatment of postoperative gastrointestinal disorder with Integrated Traditional Chinese and Western Medicine (2023).

Postoperative gastrointestinal disorder (POGD) was a common complication after surgery under anesthesia. Strategies in combination with Traditional Chinese Medicine and Western medicine showed some distinct effects but standardized clinical practice guidelines were not available. Thus, a multidisciplinary expert team from various professional bodies including the Perioperative and Anesthesia Professional Committees of the Chinese Association of Integrative Medicine (CAIM), jointly with Gansu Province Clinical Research Center of Integrative Anesthesiology/Anesthesia and Pain Medical Center of Gansu Provincial Hospital of Traditional Chinese Medicine and WHO Collaborating Center for Guideline Implementation and Knowledge Translation/Chinese Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Center/Gansu Provincial Center for Medical Guideline Industry Technology/Evidence-based Medicine Center of Lanzhou University, was established to develop evidence-based guidelines. Clinical questions (7 background and 12 clinical questions) were identified through literature reviews and expert consensus meetings. Based on systematic reviews/meta-analyses, evidence quality was analyzed and the advantages and disadvantages of interventional measures were weighed with input from patients' preferences. Finally, 20 recommendations were developed through the Delphi-based consensus meetings. These recommendations included disease definitions, etiologies, pathogenesis, syndrome differentiation, diagnosis, and perioperative prevention and treatment.

Comparison of the Efficacy of HSK3486 and Propofol for Induction of General Anesthesia in Adults: A Multicenter, Randomized, Double-blind, Controlled, Phase 3 Noninferiority Trial.

BACKGROUND: Propofol is an intravenous anesthetic associated with hypotension, respiratory depression, and injection-site pain. HSK3486 injectable emulsion (ciprofol) is a 2,6-disubstituted phenol derivative with fast onset and quick, stable recovery. Previous studies support HSK3486 as an effective, safe anesthetic with substantially less injection-site pain than propofol. The primary objective of this study was to investigate the noninferiority of HSK3486 compared with propofol in successful general anesthesia induction. METHODS: Two hundred fifty-five participants were enrolled in HSK3486-304, a multicenter, randomized (2:1), double-blind, propofol-controlled, phase 3 study evaluating HSK3486 for general anesthesia induction in adults undergoing elective surgery with tracheal intubation. The primary endpoint was successful anesthesia induction, defined as 1 or less on the Modified Observer's Assessment of Alertness/Sedation scale. Key secondary endpoints were proportion of participants with injection-site pain on the Numerical Rating Scale of 1 or greater and a composite endpoint, including the proportion of participants successfully induced while maintaining the desired anesthetic depth and without substantial cardiac and respiratory events. Safety endpoints included adverse events, abnormal vital signs, and injection-site pain. RESULTS: Two hundred fifty-one participants (HSK3486, n = 168; propofol, n = 83) were included in the analyses. General anesthesia was successfully induced in 97.0% versus 97.6% of participants with HSK3486 and propofol, respectively. The difference in success rate was -0.57% (95% CI, -5.4 to 4.2%); the noninferiority boundary of -8% was not crossed. Thirty participants (18.0%) had injection-site pain with HSK3486 versus 64 (77.1%) with propofol (P < 0.0001). Eighty-one participants (48.2%) with HSK3486 versus 42 (50.6%) with propofol (P = 0.8780) satisfied the composite endpoint. When injection-site pain was excluded, the incidence of treatment-emergent adverse events related to study drug was 17.9% for HSK3486 and 14.5% for propofol. CONCLUSIONS: The study met its primary objective and endpoint, demonstrating noninferiority of HSK3486 compared with propofol in successful anesthetic induction. Substantially less injection-site pain was associated with HSK3486 than with propofol.

Enhanced recovery protocols for ambulatory surgery.

INTRODUCTION: In the United States, ambulatory surgeries account for up to 87% of all surgical procedures. (1) It was estimated that 19.2 million ambulatory surgeries were performed in 2018 (https://www.hcup-us.ahrq.gov/reports/statbriefs/sb287-Ambulatory-Surgery-Overview-2019.pdf). Cataract procedures and musculoskeletal surgeries are the most common surgical interventions performed in ambulatory centers. However, more complex surgical interventions, such as sleeve gastrectomies, oncological, and spine surgeries, and even arthroplasties are routinely performed as day cases or in a model of an ambulatory extended recovery. (2-5) The ambulatory surgery centers industry has grown since 2017 by 1.1% per year and reached a market size of $31.2 billion. According to the Ambulatory Surgery Center Association, there is a potential to save $57.6 billion in Medicare costs over the next decade (https://www.ibisworld.com/industry-statistics/market-size/ambulatory-surgery-centers-united-states/). These data suggest an expected rise in the volume of ambulatory (same day) or extended ambulatory (23 h) surgeries in coming years. Similar increases are also observed in other countries. For example, 75% of elective surgeries are performed as same-day surgery in the United Kingdom. (6) To reduce costs and improve the quality of care after those more complex procedures, ambulatory surgery centers have started implementing patient-centered, high-quality, value-based practices. To achieve those goals, Enhanced Recovery After Surgery (ERAS) protocols have been implemented to reduce the length of stay, decrease costs, increase patients' satisfaction, and transform clinical practices. The ERAS fundamentals for ambulatory surgery are based on five pillars, including (1) preoperative patient counseling, education, and optimization; (2) multimodal and opioid-sparing analgesia; (3) nausea and vomiting, wound infection, and venous thromboembolism prophylaxis; (4) maintenance of euvolemia; and (5) encouragement of early mobility. Those pillars rely on interdisciplinary teamwork led by anesthesiologists, surgery-specific workgroups, and safety culture. (2) Research shows that a team of ambulatory anesthesiologists is crucial in improving postoperative nausea and vomiting (PONV) and pain control. (7) This review will summarize the current evidence on the elements and clinical importance of implementing ERAS protocol for ambulatory surgery.

Ability of the integrated pulmonary index to predict impending respiratory events in the early postoperative period.

BACKGROUND: In the early postoperative period, respiratory compromise is a significant problem. Standard-of-care monitoring includes respiratory rate (RR) and pulse oximetry, which are helpful; however, low SpO2 is often a late sign during decompensation. The FDA-approved Capnostream-20p monitor records four variables (SpO2, RR, End-tidal CO2, heart rate), which are combined by fuzzy logic into a single, unit-less value (range 1-10) called the integrated pulmonary index (IPI). No published studies have assessed the performance of a low IPI to predict impending respiratory events. METHODS: In this investigator-initiated study, adult patients undergoing general anesthesia were monitored with the Capnostream-20p monitor for up to 2 h during their recovery room stay. The study coordinator, who along with clinicians, was blinded to IPI values, recorded the time of any respiratory event, defined a priori as any one of eight respiratory-related interventions/conditions. The primary sensitivity endpoint (early detection success) was defined as at least 80% of events predicted by at least 2 consecutive low IPI (≤ 7) values within 2-15 min before an event occurred. Late detection was defined as low IPI values occurring with 2 min prior to or 2 min after the event occurred. DISCUSSION: Of 358 patients, ≥ 1 respiratory event occurred in 183 (51.1%) patients. Of 802 total events, 606 were detected early (within 2-15 min prior to the event), and 653 were detected either early or late. Therefore, the sensitivity for early detection was 75.6% (95% confidence interval [CI]: 72.6-78.5%), which differed significantly from the 80% sensitivity goal by 4.4% (p = 0.0016). Sensitivity for total success (early or late) was 81.4% (95% CI: 78.7-84.1%), which was significantly different from the 90% on time sensitivity goal by 8.6% (p < 0.0001). CONCLUSIONS: A low IPI was 75.6% sensitive for early detection (within 2-15 min) prior to respiratory events but did not achieve our preset threshold of 80% for success.

Total intravenous anesthesia versus inhalation anesthesia: how do outcomes compare?

RECENT FINDINGS: Surgical procedures that involve general anesthesia are performed with either volatile anesthetics or propofol-based total intravenous anesthesia. Both techniques are safe and provide appropriate conditions for surgery. Despite being a well established anesthetic, the use of propofol-based total intravenous anesthesia (TIVA) remains low. Possible explanations include the perceived increase risk of awareness, lack of target controlled infusion devices, increased turnover time for device set up and individual preference. SUMMARY: There are some scenarios where patients could potentially benefit from propofol-based TIVA rather than a volatile anesthetic (e.g. postoperative nausea and vomiting) and some other clinical scenarios where the use of propofol-based anesthesia remains controversial since the strength of the evidence remains low. PURPOSE: In this review we will summarize the clinical evidence comparing the effect of propofol-based TIVA and volatile anesthetic on postoperative outcomes such as postoperative nausea and vomiting, postoperative pain, quality of recovery, postoperative cognitive dysfunction and cancer outcomes.

Neurokinin-1 receptor antagonists for the prevention of postoperative nausea and vomiting.

Despite the availability of several classes of antiemetics, postoperative nausea and vomiting (PONV) remains a substantial burden for patients following surgery, resulting in patient dissatisfaction and prolonged stays in post-anesthesia care units and ultimately increasing the cost of care. Enhanced recovery protocols and PONV management guidelines are now centered on the assessment of the individual patient's risk for developing PONV, as well as multimodal prophylaxis using antiemetics targeting different mechanisms of action. Over the last two decades, the neurokinin-1 receptor (NK1R) has emerged as a therapeutic target for the management of PONV. This review of the literature explains the role of the NK1R and its ligand-substance P-in vomiting, describes the pharmacologic and pharmacokinetic properties of NK1R antagonists (NK1RAs) and summarizes the clinical evidence supporting NK1RAs for PONV prophylaxis in patients undergoing surgery. In particular, we discuss the therapeutic application of NK1RA in PONV prophylaxis protocols owing to their advantages over other antiemetic classes in efficacy, duration of efficacy, safety, pharmacology, and ease of administration. Future studies will be aimed at further investigating the efficacy and safety of NK1RA-based multimodal combinations, particularly among vulnerable populations (e.g., children and elderly).

Utilization of Wearable Pedometer Devices in the Perioperative Period: A Qualitative Systematic Review.

Functional capacity assessment is important for perioperative risk stratification; however, there are currently limited options for objective and economical functional capacity evaluation. Pedometer functions are now widely available in mobile devices and offer a nonintrusive and objective approach to measuring patient activity level over time. Therefore, we conducted this systematic review to assess the value of pedometer readings in predicting perioperative outcomes. We systematically searched PubMed, EMBASE (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science Citation Index for studies, which assessed the correlation between perioperative (30 days before to 30 days after surgery) pedometer data and perioperative outcomes. We identified a total of 18 studies for inclusion. Seven of the studies recorded preoperative pedometer data, and 13 studies recorded postoperative pedometer data. Notably, 10 of the studies covered oncologic surgery patients. The included studies consistently reported that preoperative pedometer readings correlated with postoperative complication rates. In addition, in-hospital postoperative pedometer readings correlated with postdischarge complications and readmissions. Perioperative pedometer data demonstrated consistent and biologically plausible association with perioperative outcomes. Further studies are needed to validate the use of pedometer in the perioperative period and to identify the optimal approach for its use to potentially improve patient outcomes.

Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society.

BACKGROUND: Opioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery. METHODS: An interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence. RESULTS: The panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices. CONCLUSIONS: Based on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population.

Perianal Paget's-an aggressive disease.

AIM: Perianal Paget's disease (PAPD) is a rare disorder with a predisposition to anal and colorectal malignancies and an unclear prognosis. Our previous 25-year series demonstrated a non-aggressive nature. This study aims to describe our updated institutional experience. METHODS: This is a retrospective review of all patients diagnosed with primary PAPD from 1991 to 2021. A prospectively maintained institutional database was searched which included demographics, clinical and pathological manifestations, treatment methods, recurrence, oncological outcome and mortality. RESULTS: Thirty patients were diagnosed with PAPD. Fifteen were women (50%); the average age at diagnosis was 71 ± 10.7 years, and the average lesion size was 3.7 ± 2.6 cm. At diagnosis, 12 (40%) were harbouring invasive anal adenocarcinoma. Eight (27%) developed adenocarcinomas concurrent with PAPD recurrence at a mean interval of 9 ± 4.4 years (range 1.9-14.8). The Kaplan-Meier curve estimated overall survival of 93%, 86%, 82%, 65% and 56% at 1, 3, 5, 10 and 15 years, respectively. Median survival was 16 years. Six (20%) had disease-related mortality. Initially, nine (30%) were treated with abdominoperineal resection (APR), 15 (50%) underwent local resection, three (10%) were treated with radiotherapy, two (7%) received only topical therapy and one (3%) chose observation. Fifteen (50%) experienced recurrence of PAPD, two after undergoing APR. Five (17%) had persistent disease until death. Only 10 (33%) did not experience PAPD recurrence, seven of whom underwent APR. The mean follow-up time was 9.2 ± 6.2 years. CONCLUSIONS: Perianal Paget's disease is an aggressive entity with high rates of synchronous anal adenocarcinoma at diagnosis and development of metachronous adenocarcinoma later in life.

Management of Diverticulitis in Renal Transplant Patients.

BACKGROUND: Renal transplant patients presenting with diverticulitis remain a clinical challenge for health care professionals. Secondary to immunosuppression, renal transplant recipients are often considered for early operative intervention due to concerns for an unreliable physical exam and feared morbidity and mortality associated with non-operative management. METHODS: This study aimed to evaluate trends in management of renal transplant patients with diverticulitis at a quaternary referral center. RESULTS: One hundred ninety-one renal transplant patients admitted to the hospital with diverticulitis were identified. Of this cohort, 71 (37%) underwent surgical resection, of which 20 (28%) were performed emergently. The overall 30-day operative mortality was 8% (6/71), of which there was a significant difference between emergent (25%, 5/20) and elective (2%, 1/51) groups (P = .006). Patients who underwent elective surgery were more likely to receive a minimally invasive approach (51%) and were significantly more likely to undergo stoma reversal (P = .006). DISCUSSION: Our study shows that not all renal transplants with diverticulitis will require operative intervention and many can be safely treated non-operatively. Elective resection and surgical management should be considered on an individual basis. Patients treated with elective resection were more likely to undergo a minimally invasive approach and restoration of intestinal continuity.

A novel long-acting local anesthetic - HTX-011 (ZYNRELEF™) for postoperative pain control.

INTRODUCTION: Pain following most surgical procedures is expected. However, the treatment and management of postoperative surgical pain have remained challenging. The use of opioid therapy has become increasingly controversial given the limited therapeutic window of these drugs, the adverse side effects, and the potential for abuse. A multimodal approach to the treatment of postoperative pain has been shown to improve pain outcomes after surgery and improve patient satisfaction. Here, we examine a new formulation of bupivacaine and meloxicam extended-release solution HTX-011 (ZYNRELEF®) and its efficacy in postoperative pain control. AREAS COVERED: HTX-011 exists as an extended-release polymer that controls the release of the active ingredients over 72 hours. A systematic approach was taken to review PubMed (Medline) for prospective and retrospective studies related to the use of HTX-011 for the management of postoperative pain. EXPERT OPINION: HTX-011 represents a new tool to help modulate postoperative pain. Although multimodal analgesia has been effective in managing postoperative pain, direct surgical infiltration with local anesthetics has had limited efficacy due to their short duration of action. The HTX-011 formulation provides a long-acting local anesthetic at the surgical site, which provides a longer period of analgesia while maintaining a favorable safety profile.

Rescue Treatment of Postoperative Nausea and Vomiting: A Systematic Review of Current Clinical Evidence.

Although prophylactic antiemetics are commonly used perioperatively, an estimated 30% of surgical patients still suffer from postoperative nausea and vomiting (PONV). Very few prospective trials have studied rescue treatment of PONV after failure of prophylaxis, providing limited evidence to support clinical management. In patients who have failed PONV prophylaxis, administering a rescue antiemetic from the same drug class has been reported to be ineffective. For many antiemetics currently used in PONV rescue, significant uncertainty remains around the effective dose range, speed of onset, duration of effect, safety, and overall risk-benefit ratio. As prompt, effective PONV rescue after failure of prophylaxis is important to optimize postoperative recovery and resource utilization, we conduct this systematic review to summarize the current evidence available on the topic.

Framework, component, and implementation of enhanced recovery pathways.

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss 'special cases' in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).