Dynamic Nomogram for Predicting the Risk of Perioperative Neurocognitive Disorders in Adults.

BACKGROUND: Simple and rapid tools for screening high-risk patients for perioperative neurocognitive disorders (PNDs) are urgently needed to improve patient outcomes. We developed an online tool with machine-learning algorithms using routine variables based on multicenter data. METHODS: The entire dataset was composed of 49,768 surgical patients from 3 representative academic hospitals in China. Surgical patients older than 45 years, those undergoing general anesthesia, and those without a history of PND were enrolled. When the patient's discharge diagnosis was PND, the patient was in the PND group. Patients in the non-PND group were randomly extracted from the big data platform according to the surgical type, age, and source of data in the PND group with a ratio of 3:1. After data preprocessing and feature selection, general linear model (GLM), artificial neural network (ANN), and naive Bayes (NB) were used for model development and evaluation. Model performance was evaluated by the area under the receiver operating characteristic curve (ROCAUC), the area under the precision-recall curve (PRAUC), the Brier score, the index of prediction accuracy (IPA), sensitivity, specificity, etc. The model was also externally validated on the multiparameter intelligent monitoring in intensive care (MIMIC) Ⅳ database. Afterward, we developed an online visualization tool to preoperatively predict patients' risk of developing PND based on the models with the best performance. RESULTS: A total of 1051 patients (242 PND and 809 non-PND) and 2884 patients (6.2% patients with PND) were analyzed on multicenter data (model development, test [internal validation], external validation-1) and MIMIC Ⅳ dataset (external validation-2). The model performance based on GLM was much better than that based on ANN and NB. The best-performing GLM model on validation-1 dataset achieved ROCAUC (0.874; 95% confidence interval [CI], 0.833-0.915), PRAUC (0.685; 95% CI, 0.584-0.786), sensitivity (72.6%; 95% CI, 61.4%-81.5%), specificity (84.4%; 95% CI, 79.3%-88.4%), Brier score (0.131), and IPA (44.7%), and of which the ROCAUC (0.761, 95% CI, 0.712-0.809), the PRAUC (0.475, 95% CI, 0.370-0.581), Brier score (0.053), and IPA (76.8%) on validation-2 dataset. Afterward, we developed an online tool (https://pnd-predictive-model-dynnom.shinyapps.io/ DynNomapp/) with 10 routine variables for preoperatively screening high-risk patients. CONCLUSIONS: We developed a simple and rapid online tool to preoperatively screen patients' risk of PND using GLM based on multicenter data, which may help medical staff's decision-making regarding perioperative management strategies to improve patient outcomes.

Advantages of Transmuscular Quadratus Lumborum Block via Subfascial Approach Versus Extrafascial Approach for Postoperative Analgesia After Laparoscopic Cholecystectomy: A Randomized Controlled Study.

OBJECTIVE: We aimed to compare the analgesic effect and incidence of lower limb weakness of transmuscular quadratus lumborum (TQL) block via subfascial approach with that via extrafascial after laparoscopic cholecystectomy (LC). METHODS: Eighty patients undergoing LC were randomized to receive ultrasound-guided bilateral TQL block via subfascial (subfascial group) or extrafascial (extrafascial group) using 30 mL of 0.33% ropivacaine unilaterally. Pain scores of port sites while rest and coughing at 1, 6, 12, 24, 36, and 48 hours postoperatively as primary outcome were compared. Modified Lovett Rating Scale, ambulatory dependency, and rescue analgesia requirement was also compared. RESULTS: The pain score of the subxiphoid and of the right subcostal port site for up to the postoperative 36 hours (2 [1 to 2]) and 24 hours (2 [2 to 3]) in the subfascial group was significantly lower than that in extrafascial group (2 [2 to 2] and 3 [2.25 to 4]). Up to postoperative 24 hours, the rescue analgesia requirement in subfascial group was significantly lower than that in extrafascial group, namely less fentanyl consumption and parecoxib (1.3 [±5.5] µg vs. 5.6 [±10.6] µg; 17.5% vs. 37.5%). The ratio of patients with LRS score of 6 at postoperative 1 hour (65.0%), and with dependent ambulation at postoperative 1 and 6 hours in subfascial group (15.0% and 0.0%) was significantly lower than that in extrafascial group (10.0%, 80.0%, and 17.5%). CONCLUSION: TQL block via subfascial had the advantages of better analgesic effect and less lower limbs weakness after LC over that via extrafascial.

A better method for the dynamic, precise estimating of blood/haemoglobin loss based on deep learning of artificial intelligence.

BACKGROUND: Dynamic and precise estimation of blood loss (EBL) is quite important for perioperative management. To date, the Triton System, based on feature extraction technology (FET), has been applied to estimate intra-operative haemoglobin (Hb) loss but is unable to directly assess the amount of blood loss. We aimed to develop a method for the dynamic and precise EBL and estimate Hb loss (EHL) based on artificial intelligence (AI). METHODS: We collected surgical patients' non-recycled blood to generate blood-soaked sponges at a set gradient of volume. After image acquisition and preprocessing, FET and densely connected convolutional networks (DenseNet) were applied for EBL and EHL. The accuracy was evaluated using R2, the mean absolute error (MAE), the mean square error (MSE), and the Bland-Altman analysis. RESULTS: For EBL, the R2, MAE and MSE for the method based on DenseNet were 0.966 (95% CI: 0.962-0.971), 0.186 (95% CI: 0.167-0.207) and 0.096 (95% CI: 0.084-0.109), respectively. For EHL, the R2, MAE and MSE for the method based on DenseNet were 0.941 (95% CI: 0.934-0.948), 0.325 (95% CI: 0.293-0.355) and 0.284 (95% CI: 0.251-0.317), respectively. The accuracies of EBL and EHL based on DenseNet were more satisfactory than that of FET. Bland-Altman analysis revealed a bias of 0.02 ml with narrow limits of agreement (LOA) (-0.47 to 0.52 mL) and of 0.05 g with narrow LOA (-0.87 to 0.97 g) between the methods based on DenseNet and actual blood loss and Hb loss. CONCLUSIONS: We developed a simpler and more accurate AI-based method for EBL and EHL, which may be more fit for surgeries primarily using sponges and with a small to medium amount of blood loss.

Combined ultrasound and nerve stimulator-guided deep nerve block may decrease the rate of local anesthetics systemic toxicity: a randomized clinical trial.

BACKGROUND: Ultrasound guidance might decrease the incidence of local anesthetics systemic toxicity (LAST) for many peripheral nerve blocks compared with nerve stimulator guidance. However, it remains uncertain whether ultrasound guidance is superior to nerve stimulator guidance for deep nerve block of the lower extremity. This study was designed to investigate whether deep nerve block with ultrasound guidance would decrease the incidence of LAST compared with that with nerve stimulator guidance, and to identify associated risk factors of LAST. METHODS: Three hundred patients undergoing elective lower limb surgery and desiring lumbar plexus blocks (LPBs) and sciatic nerve blocks (SNBs) were enrolled in this study. The patients were randomly assigned to receive LPBs and SNBs with ultrasound guidance (group U), nerve stimulator guidance (group N) or dual guidance (group M). The primary outcome was the incidence of LAST. The secondary outcomes were the number of needle redirection, motor and sensory block onset and nerve distribution restoration time, as well as associated risk factors. RESULTS: There were 18 patients with LAST, including 12 in group U, 4 in group N and 2 in group M. By multiple comparisons among the three groups, we found that the incidence of LAST in group U (12%) was significantly higher than that in group N (4%)(P = 0.037) and group M(2%)(P = 0.006). The OR of LAST with hepatitis B (HBV) infection and the female sex was 3.352 (95% CI,1.233-9.108, P = 0.013) and 9.488 (95% CI,2.142-42.093, P = 0.0004), respectively. CONCLUSIONS: Ultrasound guidance, HBV infection and the female sex were risk factors of LAST with LPBs and SNBs. For patients infected with HBV or female patients receiving LPBs and SNBs, we recommended that combined ultrasound and nerve stimulator guidance should be used to improve the safety. TRIAL REGISTRATION: This study was approved by the Ethical Committee of the First Affiliated Hospital of Army Medical University. The protocol was registered prospectively with the Chinese Clinical Trial Registry ( ChiCTR-IOR-16008099 ) on March 15, 2016.