American Society Of Anesthesiologists Physical Status Research Articles

Risk assessment in equine anesthesia: a first evaluation of the usability, utility and predictivity of the two-part CHARIOT

IntroductionAn accurate risk score that can predict peri-anesthetic morbidity and mortality in equine patients could improve peri-operative management, outcome and client communication.Materials and methodsThree hunded horses underwent pre-anesthetic risk assessment using the American Society of Anesthesiologists-Physical Status augmented with equine-specific diseases (ASA-PS-Equine), a multifactorial 10-part rubric risk scale (10-RS), and a combination of both, the Combined horse anesthetic risk identification and optimization tool (CHARIOT). Intra-and post-anesthetic complications, the recovery phase and mortality were recorded over a period of 7 days following general anesthesia. To compare the utility and predictive power of the 3 scores, data were analyzed using binominal logistic regression (p ≤ 0.05) and receiver operating characteristic curve analysis. In addition, inter-observer reliability, speed, safety, ease of use and face validity of the ASA-PS-Equine and the 10-RS were analyzed based on five hypothetical patients.ResultsAll scores showed statistically significant associations with various intra-anesthetic complications and parameters of the recovery phase. The discriminant ability of the scores related to the occurrence of intra-anesthetic (AUC = 0.6093–0.6701) and post-anesthetic (AUC = 0.5373–0.6194) complications was only low. The highest diagnostic accuracy for all scores was observed for overall mortality (AUC = 0.7526–0.7970), with the ASA-PS-Equine differentiating most precisely (AUC = 0.7970; 95% CI 0.7199–0.8741). Inter-observer reliability was fair for the 10-RS (κ = 0.39) and moderate for the ASA-PS-Equine (κ = 0.52). Patient assignment to the CHARIOT was predominantly rated as rather easy and quick or very quick.Limitations and conclusionThe main limitations of the study are the monocentric study design and failure to obtain the full range of points. In conclusion, all 3 scores provide useful information for predicting the mortality risk of equine patients undergoing general anesthesia, whereas intra-and postoperative complications cannot be predicted with these scores.

Improvement in Accuracy and Concordance of American Society of Anesthesiologist’s Physical Status (ASA-PS) Scoring Assignment over a 11 Year Time Period Using Patient BMI as a Comorbidity Finding

Background. Anesthesia providers categorize patients utilizing the American Society of Anesthesiologists Physical Status (ASA-PS) classification originally created by the ASA in 1941. There is published variability and discordance among providers when assigning patient ASA scores in part due to the subjectivity of scoring utilizing patient medical conditions, but variability is also found using objective findings like BMI. To date, there are few studies evaluating the accuracy of anesthesia providers’ ASA assignment based on objective body mass index (BMI) alone. The aim of this retrospective chart review is to determine improvement in accuracy of anesthesia providers to correctly assign patient ASA scores, based on BMI criteria added to the ASA-PS in October of 2014, utilizing a multifaceted strategy including creation of an active finance committee in the fall of 2015, multiple e-mail communications about the updated definitions and recommendations for ASA-PS scoring in the fall of 2015 and spring of 2016, a department grand rounds presentation in February 2016, placement of laminated copies of the ASA definitions and recommendations in the anesthesia chartrooms, and the development of a tool embedded into our EMR providing a recommendation of ASA-PS based on patient comorbidity findings. Methods. After attaining IRB approval, all eligible patients over the age of 18 who had surgical procedures under general anesthesia at Mayo Clinic in Rochester, MN, between January 1, 2010, and December 31, 2020, were retrospectively analyzed. A segmented logistic regression model was used to estimate the trends (per-year change in odds) of ASA under classification according to severity of obesity during 3 epochs: preimplementation (2010–2014), implementation (2015), and postimplementation (2016–2020). Results. A total of 16,467 patients of the 200,423 (8.2%) patients with obesity (class 1, 2, and 3) were underscored based on BMI alone. Accuracy of ASA-PS classification, as it pertains to BMI alone, was found to show meaningful improvement year-to-year following the updated ASA-PS guidelines with examples released in October of 2014 (P<0.001). Most of the improvement occurred in 2015–2017 with relatively little between-year variability in the rate of underscoring from 2017–2020. Conclusion. Despite updated ASA-PS published guidelines, providers may still be unaware of the updated guidelines and inclusion of examples used within the ASA-PS classification system. Accuracy of scoring did improve annually following the release of the updated guidelines with examples as well as department-wide educational activities on the topic. Additional education and awareness should be offered to those responsible for preanesthesia evaluation and assignment of ASA-PS in patients to improve accuracy as it pertains to BMI.

Pericapsular Nervous Group Block versus Suprainguinal Fascia Iliaca Block Using the Same Injection Volume in Primary HIP Arthroplasty Prospective Observational Study

Objectives. To determine the pericapsular nerve group (PENG) block’s postoperative analgesic efficacy and safety compared to the suprainguinal fascia iliaca (SFI) block in patients undergoing primary hip arthroplasty using the same injectate volume. Material and Methods. Between January 2021 and March 2022, American Society of Anesthesiologists Physical Status (ASA-PS) classification I–III patients scheduled for hip arthroplasty were included in this study. After standard monitoring and subarachnoid anesthesia, an ultrasound-guided PENG or SFI block with 20 ml of 0.25% levobupivacaine was performed for postoperative analgesia. All patients were assessed with a numerical rating scale (NRS) at presurgery, upon arrival at the postanesthesia care unit (PACU), and in the postoperative period at 2, 4, 12, and 24 hours. The need for analgesic rescue and adverse effects was also assessed. Results. A total of 130 patients were included in the study (62 PENG block and 68 SFI block). Both blocks were equally effective in managing postoperative pain without any statistically significant differences except at 12 h (p=0.023), where the deviation found was not clinically relevant. The median total morphine consumption was 0 mg [0–2] in the PENG block group and 0 mg [0–2] in the SFI block group. A more significant motor block was found in the first 6 hours in the SFI block group (p=0.001). There was no significant difference in the ease of performing PENG (79%) or SFI (85%) blocks. No major complications were recorded in both groups, and patient satisfaction was high (83.9% for the PENG block group vs. 91.2% for the SFI block group). Discussion. Both blocks have been demonstrated to be effective for postoperative analgesia in hip arthroplasty and should be integrated as a multimodal analgesic strategy. The lesser degree of motor block recorded in the first hours with the PENG block makes it the most suitable option for early recovery. Both techniques were easy and safe to perform.

Efficacy and Advantages of Spinal Anesthesia in Lumbar Disk Surgery.

Quality of life (QoL) may be affected due to various reasons such as low back or leg pains with accompanying neurologic problems. Lumbar disk surgery is one of the most common performed surgeries to relieve those symptoms. Various anesthetic techniques can be used safely to perform lumbar disk surgeries. Properties that make an anesthetic technique good are mainly the quick onset and returning of the effects. This large retrospective study with patients who have undergone lumbar disk surgery under spinal anesthesia aims to evaluate the perioperative and postoperative parameters of the spinal anesthesia and review the literature. Cases operated under spinal anesthesia between January 2017 and December 2020 were investigated, and 617 patients who underwent simple lumbar disk surgery were included in the study. Demographic characteristics and American Society of Anesthesiologists (ASA) physical status of the patients were recorded. Visual analog scale (VAS) and QoLscores were obtained before and after the operation. There were 282 (45.7%) male and 335 (54.3%) female patients with a mean age of 39.48 ± 16.71 years (range: 18-58 years) at symptom onset. The mean operating time was 46.3 minutes (range: 22-68 minutes). Average blood loss was 85 mL (range: 55-125 mL). All the patients were mobilized 6 to 12 hours after surgery. In our patient group, there were both high- and normal-risk groups in terms of the ASA physical status. During the clinical follow-up, a statistically significant improvement was found for the VAS and QoL scores (p < 0.05). In this large retrospective study, our results have confirmed that spinal anesthesia is at least comparable to general anesthesia and even superior to it in some aspects.

Comparison of the Effects of Rocuronium Bromide and Cisatracurium Besylate on Intubating Conditions and Haemodynamic Response.

Background General anaesthesia (GA) is predominantly important for conducting tracheal intubation; it should be quick and precise, having a prudent performance. It is preferable to use a neuromuscular blocking drug, which ideally should be highly potent, with a rapid onset and a short duration clinical effect in order to prevent the development of hypoxia during laryngoscopy and tracheal intubation and also avoid any changes in haemodynamics caused by the release of histamine, ganglion block, and anti-muscarinic actions. Thenon-depolarizing muscle relaxants rocuronium and cisatracurium don't have any noticeable independent side effects when used within the recommended dosage levels. Aim The aim was to compare the clinical efficacy of rocuronium bromide and cisatracurium besylate with respect to their property as muscle relaxants in producing favourable intubating conditions and to assess their haemodynamic stability.The objectives of the study were to evaluate the onset of action and any undesirable effects. Methods Between the ages of 20 to 60 years, 60 patients of either gender, divided randomly into groups of 30 each, of American Society of Anesthesiologists(ASA) physical status classification I and II, were put for elective surgical procedures to be done under general anaesthesia. Patients were given 0.6 mg kg-1 IV of rocuronium in Group R and 0.15 mg kg-1 IV of cisatracurium in Group C. After injecting the muscle relaxants, parameters were measured 60, 90, 120, 150, 180, 240, and 300 seconds later. Result Demographical variables like age, gender, and ASA physical status of the two groups were analogous. Group R had good to excellent/favourable intubating conditions by 90 seconds, and Group C by 240 seconds with comparable haemodynamic stability. The onset of action was significantly faster in Group R (92 ± 7.61 seconds) than in Group C (188 ± 40.88 seconds). Conclusion Rocuronium produced favourable intubating conditions having good haemodynamic stability and a statistically significant (p < 0.00001) faster onset of action in comparison to cisatracurium.

Patient Anxiety in Endoscopy: A Comparative Analysis of Single vs. Dual Procedure Effects.

This study aimed to investigate the difference in anxiety levels between patients undergoing gastroscopy only and those subjected to both gastroscopy and colonoscopy. Despite known preoperative anxiety impacts, no prior research has compared these specific patient groups. A total of 150 patients were divided equally into two groups: Group I, undergoing gastroscopy only, and Group II, undergoing gastroscopy and colonoscopy. Inclusion criteria were patients in the age range 18-70 years and having an ASA (American Society of Anesthesiologists) physical status classification of I-III. Exclusion criteria were patients outside the age range, and patients with hearing disorders, psychiatric disorders, dementia, or recent anxiolytic drug use. Anxiety was analysed using the Beck Anxiety Inventory Scale before procedures, without any premedication. Patients in Group II had significantly higher anxiety levels, with particular increases noted in symptoms such as leg weakness and tremors, inability to relax, and fears of adverse events and death. These results highlighted a considerable elevation in anxiety among patients anticipating or undergoing combined endoscopic procedures. The findings revealed that undergoing combined gastroscopy and colonoscopy procedures significantly elevated patient anxiety levels compared to gastroscopy alone. This suggests a critical need for healthcare providers to implement more strong preoperative counselling and anxiety reduction strategies for patients facing multiple procedures. Addressing this increased anxiety could lead to better patient experiences, reduced procedural complications, and improved satisfaction and outcomes.

Postoperative Outcomes After Emergency Surgery in COVID-19 Patients: An Ambispective Matched Cohort Study.

Purpose There is limited data from the Indian subcontinent regarding the surgical outcomes of coronavirus disease (COVID-19) patients. In this observational study, we aimed to evaluate the postoperative outcomesafter emergency surgery in COVID-19 patients compared to concurrent age and gender-matched controls. We also sought to analyze the possible predictors of postoperative mortality in COVID-19 patients. Methods This matched cohort study was conductedin a tertiary care teaching hospital in central India, between 1st July 2021 and 30th June 2022. COVID-19-positive patients undergoing emergency surgery under anesthesia were recruited as cases. Age and gender-matched COVID-19-negative patients undergoing a similar nature of surgery in the same period served as concurrent controls. The cases and controls were compared for the 30-day mortality and perioperative complications. Results The COVID-19-positive surgical cohort had a 12.3 times greater 30-day postoperative overall mortality risk as compared to a matched cohort of patients with a negative COVID-19 test. A positive COVID-19 status was associated with more postoperative complications of acute respiratory distress syndrome (ARDS), sepsis, shock, and persistent hyperglycemia. On analysis of predictors of mortality, the presence of preoperative dyspnea, ARDS, American Society of Anesthesiologists Physical Status (ASA-PS) Class IIIE/IVE, increase in sequential organ failure assessment (SOFA) score, Quick SOFA>1, higher creatinine, bilirubin, and lower albumin were observed to be associated with increased mortality. Conclusions Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients undergoing emergency surgery is significantly associated with higher postoperative complications and increased 30-day postoperative mortality.

Comparison of Acute Physiology and Chronic Health Evaluation (APACHE) II and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) scoring system in predicting postoperative mortality in patients undergoing emergency laparotomy: A retrospective study.

There is paucity of studies on preoperative risk assessment tools in patients undergoing emergency surgery. The present study evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and American Society of Anesthesiologists (ASA) physical status (PS) classification system in patients undergoing emergency exploratory laparotomy. This retrospective study included 60 adult patients who underwent emergency exploratory laparotomy for perforation peritonitis. The clinical details, ASA PS classification, laboratory investigations and postoperative course of patients were retrieved from their medical records. Based on these details, APACHE II and ACS-NSQIP were calculated for the patients. The study's primary outcome was the accuracy of the preoperative APACHE II, ACS-NSQIP risk calculator and ASA PS class in predicting the postoperative 30-day mortality of patients. The area under the curve (AUC) of APACHE II, ACS-NSQIP score, and ASA PS classification for mortality 30 days after surgery was 0.737, 0.694 and 0.601, respectively. The P value for the Hosmer-Lemeshow (H-L) test of scoring systems was 0.05, 0.25 and 0.05, respectively. AUC for postoperative complications was 0.799 for APACHE II, 0.683 for ACS-NSQIP and 0.601 for ASA PS classification. H-L test of these scoring systems for complications after surgery revealed P values of 0.62, 0.36 and 0.53, respectively. Compared to the ACS-NSQIP and ASA PS classification system, the APACHE II score has a better discriminative ability for postoperative complications and mortality in adult patients undergoing emergency exploratory laparotomy.

Does anesthesia duration or number of cases per patient predict safety events?

The need for dental rehabilitation under general anesthesia is increasing, with varying needs between patients. Mortality has been found to be a rare event in these patients; however other perioperative events can and do occur. Previous studies have established increased incidence of perioperative events with younger, sicker children, and longer anesthetics, however, no studies to date have evaluated if the incidence of perioperative events is more closely associated with one long anesthetic or multiple anesthetics per patient. To evaluate the association of perioperative events related to single anesthetic duration or number of anesthetics per patient for dental rehabilitation. After Children's Wisconsin Human Research Protection Program determined this quality activity did not meet the definition of human subjects research, we performed an epidemiologic observational evaluation by extracting all dental related cases (dental alone or with oral surgeon vs. dental with other specialties) with an associated general anesthesia encounter from Children's Wisconsin electronic data warehouse from June 1, 2015 to December 31, 2021. These cases occurred at a free-standing children's hospital or associated pediatric-only ambulatory surgery center. The risk of perioperative safety events was analyzed for previously identified risk groups such as American Society of Anesthesiologists Physical Status (ASA-PS), patient age, anesthesia case time with the addition of number of dental cases per patient. In this study, 8468 procedures were performed on 8082 patients. Of this cohort, 7765 patients underwent one procedure for dental care while 317 patients underwent a total of 703 dental-related procedures, ranging from two to five procedures per patient. Multivariable logistic regression identified increased risk of perioperative events in patients with ASA-PS 3 (n = 1459, rate 1.78%, p value .001, OR 5.7, CI 2.1-15.5) and ASA-PS 4 (n = 86, rate 5.8%, p < .001, OR 17.2, CI 4.4-67.3), anesthesia duration (p < .001, OR 1.46, CI 1.21-1.76), but no increased risk with number of anesthetics per patient (p value .54, OR 0.81, CI 0.4-1.61). Limiting dental care under general anesthesia to multiple short cases may decrease the risk of perioperative events when compared to completing all treatment in one long operative session.

Incidence, risk factors, and outcomes of acute kidney injury in patients undergoing emergency laparotomy - A prospective observational exploratory study.

Acute kidney injury (AKI) can occur in post-laparotomy patients, with a variable incidence. This study aimed to determine the incidence of AKI in patients undergoing emergency laparotomy under general anaesthesia, the effect of preoperative variables on the development of AKI, and the association of post-operative AKI with patient outcomes. This prospective exploratory study in patients undergoing emergency laparotomy was followed up for 7 days to determine the incidence of post-operative AKI. We determined the patients developing different severity of AKI based on kidney disease improving global outcome staging. Fisher's exact test or Chi-squared test was used to study the association of demographic variables, and various periopertaive variables on the development of postoperative AKI. The association of AKI with the duration of hospital stay was estimated using the Wilcoxon-Mann-Whitney U Test, and Fisher's exact test was used to study the association between AKI and mortality. No patient had AKI in the pre-operative period. On day 3, 18 patients; on day 5, 28 patients; and on day 7, 24 patients developed AKI. Overall, a maximum of 33 patients (out of 100) developed AKI at any time. Our study found that the American Society of Anesthesiologists (ASA) IV and sepsis were independent risk factors for post-operative AKI. Our results also show a moderate-to-high independent association between AKI and duration of hospital stay and mortality (within 30 days). Incidence of post-operative AKI following emergency laparotomy was 33%. Higher preoperative ASA physical status and sepsis were significantly associated with postoperative AKI development.

The Role of TAP/RS Block in Minor Gynecologic Laparoscopic Surgery: A Randomized Clinical Trial

Objectives: The aim of the study was to compare, in patients undergoing minor gynecological laparoscopic procedures, the effects of ultrasound (US)-guided transversus abdominis plane (TAP) + rectus sheath (RS) block versus no TAP/RS block in terms of post-surgical pain control using the numeric pain rating scale (NRS) and the degree of patient satisfaction, according to the main goals of Early Recovery After Surgery (ERAS) programs. The primary outcome is to value the postoperative abdominal pain using NRS in both groups. Secondary outcomes are to evaluate blood values, presence of postoperative nausea and vomiting (PONV), postoperative ileus, level of patient expected satisfaction, time of discharge, length of stay (LOS), and the amounts of additional analgesics required. Design: In this prospective randomized controlled trial, patients were randomly assigned to loco-regional anesthesia (LRA) group, who received TAP and RS block under US guidance, or no loco-regional anesthesia (N-LRA) group. Enrolled patients were randomized 1:1 to either receive bilateral TAP/RS block with ropivacaine or sham treatment (patches were applied on the abdominal wall of the patients under general anesthesia). Participants: All patients aged between 18 and 75 years, with ASA (American Society of Anesthesiologists) physical status 1-2, undergoing laparoscopic minor gynecological surgery, were enrolled. Setting: The study was conducted to the University of Campus Bio-Medico Hospital of Rome. Methods: Half an hour before surgery, all patients received gabapentin 300 mg per os. Once the patient underwent general anesthesia, US-guided bilateral TAP/RS block was performed by the anesthesiology team, while the uterine manipulator was positioned by a gynecology resident (not involved in the study). In the operative room, all patients received the same standardized anesthetic regimen. Postoperative abdominal pain was assessed at rest, after palpation, during movement, and after a cough by evaluating the patient at 6, 12, 18, 24, 36, 48, and 72 h after surgery, using the NRS from 0 to 10 in both groups. The amount of drug used for analgesia in the first 48 h after surgery was recorded. Moreover, hemoglobin, white blood cells, and c-reactive protein levels were recorded at 24, 48, and 72 h. The presence of PONV and the postoperative ileus was recorded throughout convalescence. The expected level of patient satisfaction at discharge and finally the LOS were assessed. Limitations: The major weakness of this study is that 60 mL of 0.5% ropivacaine was administered to each patient, without considering weight differences, yet contemporary literature rarely suggests volume/dose titration in fascial blocks. Results: A total of 104 women, undergoing gynecological minor laparoscopic surgery, were enrolled and assigned to LRA group (53 pts) and N-LRA group (51 pts). Postoperative pain was significantly reduced in patients who received TAP/RS block. A reduction in the intake of non-steroidal anti-inflammatory drugs after surgery was registered in LRA group (p p p Conclusions: US-guided TAP and RS block significantly reduces postoperative pain after minor gynecologic laparoscopic surgery and improves patients’ post-operative recovery.

Efficacy and safety of negative wound pressure in the treatment of surgical complications after radical cystectomy: a retrospective cohort study

Background: Negative pressure wound treatment (NPWT) is a relatively new, but promising method for management of surgical site infection (SSI). The literature data on the use of NPWT for complications in oncology surgery, and after radical cystectomy (RC) in particular, is scarce.&#x0D; Aim: To evaluate the short-term results of NPWT dressings in the management of SSI after RC.&#x0D; Materials and methods: We retrospectively analyzed data from 446 patients who had RC with various uroderivation types in the Department of Oncourology of the N. N. Petrov National Medical Research Center of Oncology from January 2012 to December 2021. A total of 62 cases of SSI emerging up to day 30 after RC were identified with complete data. Thirty six (36) cases of SSI were managed according to standard procedures, and 26 patients with SSI were treated with NPWT (VivanoTec® S 042) at constant negative pressure mode. The physical condition of the patients before RC was assessed according to the American Society of Anesthesiology (ASA) classification, and the severity of the patient's condition at SSI diagnosis within APACHE II scale. The following parameters were also analyzed: body mass index, median number of days in the hospital, number of program wound sanitations (surgical debridement) or frequency of changing NPWT dressings, changes over time in C-reactive protein and leukocyte index of intoxication, and events of clinical interest (intestinal fistulas and lateralization of the median wound margins, hernias).&#x0D; Results: Most cases of post-RC SSIs were identified in men (57/62, 91.93%). The standard management and NPWT study groups were well balanced for age, body mass index, and ASA physical status. The median time from the first surgical debridement of the wound to its closure was significantly shorter in the standard surgical management group: 4 days (0; 8.75) versus 8.5 days (3.25; 12.0) in the NPWT group (p = 0.026). However, this did not negatively affect the length of hospitalization (28.08 ± 12.80 and 30.03 ± 16.27 days, respectively, p = 0.599). The 30-day mortality rates were not significantly different between the groups (p = 0.137). In our series with NPWT dressings, there were no cases of intestinal fistulas in the early and late postoperative periods.&#x0D; Conclusion: Negative pressure wound treatment is a safe and effective method of SSI management. It is not inferior to the generally accepted treatment standard with surgical wound debridement, staged sanitations or dressings. NPWT dressings allow for early primary muscular-fascial closure of the abdominal cavity and does not increase the duration of hospital stay, postoperative death rates and the risk of intestinal fistulas.

The diagnostic accuracy of preoperative perfusion index as a predictor of postspinal anesthesia hypotension in parturients undergoing cesarean delivery: A prospective non-blinded observational study.

Spinal anesthesia is the technique of choice for elective cesarean section with a prominent side effect of postspinal anesthesia hypotension (PSH). This needs an early prediction to avoid feto-maternal complication. This study aimed to assess the diagnostic accuracy of perfusion index (PI) and inferior vena cava collapsibility index (IVCCI) in the prediction of PSH. Thirty parturients of American Society of Anesthesiologists Physical Status (ASA-PS) 1 and two undergoing cesarean delivery participated in the study. IVCCI, PI, baseline systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), and heart rate (HR) were noted in the preoperative period. The fall of MBP by 20% from baseline or below 65 mm Hg was considered PSH. After spinal anesthesia, SBP, DBP, MBP, and HR were noted again for diagnosing PSH. It did not show any statistical difference when comparing the PI between the PSH and non-PSH groups in both the PSH definition groups. IVCCI was significantly higher when PSH was considered MBP <65 mm Hg (P = 0.01). However, IVCCI was found to be statistically insignificant if PSH was considered a 20% reduction in baseline MBP. The correlation matrix between IVCCI and PI showed Pearson's r-value of 0.525, indicating a substantial relationship between the two (P = 0.003). Multivariate logistic regression analysis had shown that neither IVCCI nor PI was a good predictor of PSH in parturients for both definition groups for PSH. Although there is a modest correlation between PI and IVCCI, both cannot be used to predict postspinal hypotension in parturients undergoing elective lower-segment cesarean section (LSCS).

Comparison of Fat-Free Mass and Ideal Body Weight Scalar for Anesthetic Induction Dose of Propofol in Patients with Morbid Obesity: A Double-Blind, Randomized Clinical Trial.

Obesity is a growing problem worldwide and can affect both the pharmacodynamics and pharmacokinetics of various drugs, including anesthetics, resulting in the under-or overdosing of certain drugs. There is no consensus on the ideal dosing regimen for obese populations. In this study, 2 weight-based dosing of propofol used for induction of anesthesia were compared in terms of the onset of action time, adequacy of anesthesia, and effects on hemodynamic indices (eg, heart rate [HR] and blood pressure). In this randomized, double-blind clinical trial, 40 patients with morbid obesity (MO) scheduled for bariatric surgery with body mass index (BMI) > 35, age 18 - 59 years, American Society of Anesthesiologists physical status (ASA-PS) II and III were randomly divided into 2 groups, using block randomization method, to receive 2 mg/kg of propofol for induction of anesthesia based on either fat-free mass (FFM) group or ideal body weight (IBW) group. The primary outcome was the time duration to reach the bispectral index (BIS) ≤ 60. Time to the disappearance of eyelash reflex, signs of inadequate anesthesia (ie, BIS > 60, straining during intubation, or eye-opening), requirements for additional doses, and hemodynamic indices (including HR and mean arterial pressure [MAP]) were also compared. The mean time to reach BIS ≤ 60 was 134.1 s in the FFM group and 148.7 s in the IBW group. This difference was not statistically significant (P = 0.334). The time of disappearance of eyelash reflex was also not significantly different between the study groups (P = 0.814). However, 2 patients in the FFM group and 8 patients in the IBW group showed signs of inadequate anesthesia and required additional doses. This difference was statistically significant (P = 0.032). Hemodynamic variables, before and 2 min after propofol induction dose administration were comparable between the study groups (P = 0.520, P = 0.327, P = 0.847, P = 0.516 for pre-intervention MAP, post-intervention MAP, pre-intervention HR, and post-intervention HR, respectively). Propofol dosing, based on FFM and IBW, for induction of anesthesia, provides comparable onset time of action and hemodynamic effects; however, in terms of the adequacy of anesthesia, the dosing based on FFM is more favorable compared to the dosing based on IBW.

A Prospective Multicenter Comparison of Trauma and Injury Severity Score, American Society of Anesthesiologists Physical Status, and National Surgical Quality Improvement Program Calculator's Ability to Predict Operative Trauma Outcomes.

Trauma outcome prediction models have traditionally relied upon patient injury and physiologic data (eg, Trauma and Injury Severity Score [TRISS]) without accounting for comorbidities. We sought to prospectively evaluate the role of the American Society of Anesthesiologists physical status (ASA-PS) score and the National Surgical Quality Improvement Program Surgical Risk-Calculator (NSQIP-SRC), which are measurements of comorbidities, in the prediction of trauma outcomes, hypothesizing that they will improve the predictive ability for mortality, hospital length of stay (LOS), and complications compared to TRISS alone in trauma patients undergoing surgery within 24 hours. A prospective, observational multicenter study (9/2018-2/2020) of trauma patients ≥18 years undergoing operation within 24 hours of admission was performed. Multiple logistic regression was used to create models predicting mortality utilizing the variables within TRISS, ASA-PS, and NSQIP-SRC, respectively. Linear regression was used to create models predicting LOS and negative binomial regression to create models predicting complications. From 4 level I trauma centers, 1213 patients were included. The Brier Score for each model predicting mortality was found to improve accuracy in the following order: 0.0370 for ASA-PS, 0.0355 for NSQIP-SRC, 0.0301 for TRISS, 0.0291 for TRISS+ASA-PS, and 0.0234 for TRISS+NSQIP-SRC. However, when comparing TRISS alone to TRISS+ASA-PS ( P = .082) and TRISS+NSQIP-SRC ( P = .394), there was no significant improvement in mortality prediction. NSQIP-SRC more accurately predicted both LOS and complications compared to TRISS and ASA-PS. TRISS predicts mortality better than ASA-PS and NSQIP-SRC in trauma patients undergoing surgery within 24 hours. The TRISS mortality predictive ability is not improved when combined with ASA-PS or NSQIP-SRC. However, NSQIP-SRC was the most accurate predictor of LOS and complications.

Remimazolam: A Retrospective Study of Initial Safety and Recovery Data in Diverse Procedural Sedation

PurposeThe new ultra-short-acting benzodiazepine, remimazolam, offers a pharmacokinetic and pharmacodynamic advantage over commonly used procedural sedation medication. This retrospective study explored the real-world utilization of remimazolam during procedural sedation to support the development of a nurse sedation protocol. The primary outcome was to identify associations between recovery time, adverse reactions, and dose-response in expanded patient populations. MethodsThis study reviewed charts of 292 adult patients from 3 hospitals within one institution who received remimazolam during procedural sedation between June 1, 2021 and December 31, 2021. Data were analyzed using logistic and linear regression. FindingsThe median time to alert in patients receiving remimazolam alone was 12 minutes (interquartile range 10, 17) and increased when additional sedation medications were utilized. Receiving additional sedative medication significantly increased the odds of hypoxia (OR 2.77, 95% CI 1.30–5.91, P = 0.008) after adjusting for body mass index (BMI), American Society of Anesthesiologists physical status (ASA-PS), and total remimazolam dose. There was a 25% increase in odds of experiencing hypoxia for every 5 kg/m2 increase in BMI (95% CI 1.01–1.54, P = 0.037). ImplicationsRemimazolam presents as a promising option for nurse procedural sedation, offering minimal impact on hemodynamics and respirations, quick recovery, and no residual sedative effects.

The Effect of Laterality in Modified Radical Neck Dissection on the Risk of Intraoperative Bradycardia: A Retrospective Cohort Study.

Background Intraoperative bradycardia is a hardly studied complication of modified radical neck dissection (MRND). Methods Using convenient sampling, we retrospectively studied a cohort (n = 159) of patients who underwent MRND at Papanikolaou General Hospital, Thessaloniki, Greece between 2019 and 2020 to investigate whether MRND laterality (bilateral vs. unilateral) affects the occurrence of intraoperative bradycardia (a pulse rate lower than 50 bpm). Results Roughly two-thirds of the patients underwent unilateral MRND, and the rest underwent bilateral MRND. Bradycardia was observed in 25.8% of the cohort. We used logistic regression and investigated several potential confounding factors. Unilateral MRND was associated with a lower risk of intraoperative bradycardia compared to bilateral MRND in the simple regression model (relative risk (RR): 0.555, 95% confidence interval (CI): 0.331-0.932, p = 0.027). MRND laterality was not significantly associated with intraoperative bradycardia (p = 0.082) in the multiple regression model, whereas an American Society of Anesthesiologists physical status (ASA-PS) score of 3 vs. 4 (adjusted odds ratio (aOR) = 0.125, 95% CI: 0.0340-0.457, p = 0.002), the presence of atrial fibrillation (aOR = 11.4, 95% CI: 4.10-31.8, p < 0.001) and induction of anesthesia with dexmedetomidine (aOR = 4.57, 95% CI: 1.34-15.6, p = 0.015) were significantly associated with intraoperative bradycardia. Conclusions MRND laterality was close to statistical significance. Bigger sample sizes may provide more definitive information since the effect of MRND laterality on intraoperative bradycardia remains unclear. Our findings can inform clinical practice so that clinicians know when to expect bradycardia and are better prepared to manage it.

Long-term outcomes after endoscopic submucosal dissection for colorectal epithelial neoplasms in patients with severe comorbidities.

Long-term outcomes after endoscopic submucosal dissection (ESD) for colorectal epithelial neoplasms (CENs) in patients with severe comorbidities have not been clarified; the current study aimed to examine these long-term outcomes and compared them with those in patients with non-severe comorbidities. We included 231 patients with CENs who underwent ESD between April 2005 and March 2023. Patients with comorbidities were categorized according to the American Society of Anesthesiologists Physical Status (ASA-PS). We conducted a propensity score-matched analysis and compared long-term outcomes of the two groups after ESD for CENs. Of the 156 patients enrolled in the study, 43 and 113 had severe (ASA-PS III) and non-severe (ASA-PS I/II) comorbidities, respectively. The 1:1 propensity score analysis matched 36 patients with severe comorbidities to 36 patients with non-severe comorbidities. After matching, there was no difference in the procedural outcomes of ESD between both groups. Regarding long-term outcomes, the 5-year overall survival rates after matching in the ASA-PS I/II and III groups were 100% and 73.5%, respectively, and patients in the ASA-PS III group exhibited significantly shorter overall survival than those in the ASA-PS I/II group (hazard ratio 7.209; 95% confidence interval 1.592-32.646; P = 0.010). No colorectal cancer-related deaths were noted in either group. Overall survival after ESD for CENs was shorter in patients with severe comorbidities than in those with non-severe comorbidities. Clinicians should carefully determine whether the benefits of CEN resection with ESD outweigh the procedural risks in patients with severe comorbidities.

The Impact of Fluid Therapy on Glycemic Variation in Non-diabetic Patients Undergoing Laparoscopy.

Background Hyperglycemia is a risk factor for perioperative morbidity and mortality. A surgical procedure triggers a physiological stress response, which culminates in insulin resistance by activating the sympathetic autonomic system. The impact of fluid management in the perioperative period on the glycemic variation of patients has not been thoroughly investigated. Methods This study, which included 42 non-diabetic patients undergoing laparoscopic surgeries, was an observational, prospective cohort study. The sample was split into two groups according to the type of fluid used intraoperatively: polyelectrolyte and 5% glucose polyelectrolyte. Results No significant differences were found between the groups in demographic and baseline data, including age, BMI, and American Society of Anesthesiologists (ASA) physical status. There were no differences in glycemic variation between the two groups. Blood glucose varied over time with statistical significance in the perioperative period but with no difference between the two groups. Conclusion Using 5% glucose polyelectrolyte in laparoscopic surgery for non-diabetic patients with ASA physical status 3 or lower did not significantly affect glycemic variation compared to polyelectrolyte. These results suggest the possibility of optimizing resources and minimizing waste without compromising patient homeostasis in perioperative care.

American society of anesthesiologists physical status classification significantly affects the performances of machine learning models in intraoperative hypotension inference

Study objectiveTo explore how American Society of Anesthesiologists (ASA) physical status classification affects different machine learning models in hypotension prediction and whether the prediction uncertainty could be quantified. DesignObservational Studies SettingUofL health hospital PatientsThis study involved 562 hysterectomy surgeries performed on patients (≥ 18 years) between June 2020 and July 2021. InterventionsNone MeasurementsPreoperative and intraoperative data is collected. Three parametric machine learning models, including Bayesian generalized linear model (BGLM), Bayesian neural network (BNN), a newly proposed BNN with multivariate mixed responses (BNNMR), and one nonparametric model, Gaussian Process (GP), were explored to predict patients' diastolic and systolic blood pressures (continuous responses) and patients' hypotensive event (binary response) for the next five minutes. Data was separated into American Society of Anesthesiologists (ASA) physical status class 1– 4 before being read in by four machine learning models. Statistical analysis and models' constructions are performed in Python. Sensitivity, specificity, and the confidence/credible intervals were used to evaluate the prediction performance of each model for each ASA physical status class. Main resultsASA physical status classes require distinct models to accurately predict intraoperative blood pressures and hypotensive events. Overall, high sensitivity (above 0.85) and low uncertainty can be achieved by all models for ASA class 4 patients. In contrast, models trained without controlling ASA classes yielded lower sensitivity (below 0.5) and larger uncertainty. Particularly, in terms of predicting binary hypotensive event, for ASA physical status class 1, BNNMR yields the highest sensitivity of 1. For classes 2 and 3, BNN has the highest sensitivity of 0.429 and 0.415, respectively. For class 4, BNNMR and GP are tied with the highest sensitivity of 0.857. On the other hand, the sensitivity is just 0.031, 0.429, 0.165 and 0.305 for BNNMR, BNN, GBLM and GP models respectively, when training data is not divided by ASA physical status classes. In terms of predicting systolic blood pressure, the GP regression yields the lowest root mean squared errors (RMSE) of 2.072, 7.539, 9.214 and 0.295 for ASA physical status classes 1, 2, 3 and 4, respectively, but a RMSE of 126.894 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. RMSEs are 2.175, 13.861, 17.560 and 22.426 for classes 1, 2, 3 and 4 respectively for the BGLM. In terms of predicting diastolic blood pressure, the GP regression yields the lowest RMSEs of 2.152, 6.573, 5.371 and 0.831 for ASA physical status classes 1, 2, 3 and 4, respectively; RMSE of 8.084 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. Finally, in terms of the width of the 95% confidence interval of the mean prediction for systolic and diastolic blood pressures, GP regression gives narrower confidence interval with much smaller margin of error across all four ASA physical status classes. ConclusionsDifferent ASA physical status classes present different data distributions, and thus calls for distinct machine learning models to improve prediction accuracy and reduce predictive uncertainty. Uncertainty quantification enabled by Bayesian inference provides valuable information for clinicians as an additional metric to evaluate performance of machine learning models for medical decision making.