Elective Major Abdominal Surgery Research Articles

Cardiac index-guided therapy to maintain optimised postinduction cardiac index in high-risk patients having major open abdominal surgery: the multicentre randomised iPEGASUS trial.

It is unclear whether optimising intraoperative cardiac index can reduce postoperative complications. We tested the hypothesis that maintaining optimised postinduction cardiac index during and for the first 8 h after surgery reduces the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. In three German and two Spanish centres, high-risk patients having elective major open abdominal surgery were randomised to cardiac index-guided therapy to maintain optimised postinduction cardiac index (cardiac index at which pulse pressure variation was <12%) during and for the first 8 h after surgery using intravenous fluids and dobutamine or to routine care. The primary outcome was the incidence of a composite outcome of moderate or severe complications within 28 days after surgery. We analysed 318 of 380 enrolled subjects. The composite primary outcome occurred in 84 of 152 subjects (55%) assigned to cardiac index-guided therapy and in 77 of 166 subjects (46%) assigned to routine care (odds ratio: 1.87, 95% confidence interval: 1.03-3.39, P=0.038). Per-protocol analyses confirmed the results of the primary outcome analysis. Maintaining optimised postinduction cardiac index during and for the first 8 h after surgery did not reduce, and possibly increased, the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. Clinicians should not strive to maintain optimised postinduction cardiac index during and after surgery in expectation of reducing complications. NCT03021525.

Hypotension prediction index guided goal-directed therapy to reduce postoperative acute kidney injury during major abdominal surgery: study protocol for a multicenter randomized controlled clinical trial

BackgroundAcute kidney injury (AKI) is a significant postoperative complication associated with increased mortality and hospital costs. Hemodynamic strategies, such as goal-directed therapy, might reduce AKI risk. Predicting and proactively managing intraoperative hypotension may be helpful. This trial aims to investigate if a preemptive hemodynamic strategy guided by the hypotension prediction index (HPI) can decrease the incidence of moderate-to-severe AKI within 30 days following major elective abdominal surgery.MethodsThis is an open-label, controlled, multicenter, randomized clinical trial that involves daily patient follow-up until hospital discharge. Inclusion criteria are patients aged over 65 and/or categorized as ASA III or IV physical status, undergoing major elective abdominal surgery (general, urological, or gynecological procedures) via laparoscopic or open approach under general or combined anesthesia.InterventionIn the intervention group, hemodynamic management will be based on the HPI and the advanced functional hemodynamic variables provided by the Hemosphere platform and the AcumenIQ® sensor (Edwards Lifesciences). The primary outcome is the incidence of moderate-to-severe AKI within 7 days post-surgery. Secondary outcomes include postoperative complications and 30-day mortality.DiscussionThis study explores the potential of HPI-guided hemodynamic management in reducing AKI after major elective abdominal surgery, with implications for postoperative outcomes and patient care.Trial registrationClinicalTrials.gov NCT05569265. Registered on October 6, 2022.

Fried Frailty Phenotype Questionnaire scores and postoperative patient-reported outcomes of patients undergoing major abdominal cancer surgery: A secondary analysis.

This study aimed to evaluate the effects of Fried Frailty Phenotype Questionnaire (FFPQ) scores on patient-reported postoperative outcomes. This secondary analysis of a prospective observational study included 230 inpatients aged ≥65 years undergoing elective abdominal cancer surgery. The primary outcome was the Quality of Recovery-15 score on postoperative days 2, 4 and 7. The secondary outcomes included disability-free survival, defined as a 12-item World Health Organization Disability Assessment Schedule 2.0 score of <16% at 3 months. The associations of the FFPQ scores, ranging from 0 (robust) to 5 (frailty), with the primary and secondary outcomes were assessed using multiple analysis. After confirming the linearity of the FFPQ score for the outcomes, multiple regression analysis adjusted for prominent factors showed that the FFPQ score was a significant factor influencing the decrease in the Quality of Recovery-15 score on postoperative day 2 (β = -2.67, 95% confidence interval -5.20, -0.15), 4 (β = -3.54, 95% confidence interval -5.77, -1.30) and 7 (β = -3.70, 95% confidence interval -5.75, -1.65). The adjusted odds ratio of the FFPQ score for disability-free survival postoperatively was 0.66 (95% confidence interval 0.49-0.90). Patients with higher FFPQ scores before elective major abdominal cancer surgery were likely to have lower postoperative Quality of Recovery-15 scores and poor disability-free survival. Geriatr Gerontol Int 2024; 24: 464-469.

Comparison of combined intravenous and inhalation anesthesia and total intravenous anesthesia in laparoscopic surgery and the identification of predictive factors influencing the delayed recovery of neurocognitive function.

Compare the anesthesia effects of combined intravenous and inhalation anesthesia (CIVIA) and total intravenous anesthesia (TIVA) in laparoscopic surgery. Furthermore, our objective is to examine the elements that contribute to the delay in postoperative recovery of neurocognitive function and anticipate the manifestation of delayed recovery by analyzing serum cytokines. The CIVIA group and the TIVA group both consisted of 130 patients who were scheduled to have elective major abdominal surgery through laparoscopy. The criteria taken into account by the observational and record-keeping study were the patients' ages, sexes, body masses, heights, and the presence or absence of any preexisting problems. Both groups also had their anesthetic depth, duration, and per-unit-of-time muscle relaxant and analgesic dosages recorded. Finally, the length of each patient's stay in the hospital as well as their overall length of stay were tracked. By using the Mini-Mental State Examination (MMSE) to measure cognitive function, we assessed the mental states of the subjects. Additionally, we wanted to identify any biomarkers that could be linked to postoperative cognitive decline or delays in neurocognitive recovery. A total of 51 participants from the CIVIA group and 53 participants from the TIVA group satisfactorily completed the necessary neuropsychological exam for identifying delayed neurocognitive recovery at the study's completion. In the initial data of the two groups, no significant discrepancies were found (p > 0.05). The CIVIA group exhibited noteworthy reductions in the quantity of administered analgesics and muscle relaxants per unit of time in comparison to the TIVA group (p < 0.05). In addition to this, the duration from the sevoflurane tank being closed to the extubation period demonstrated a significant reduction in the CIVIA group compared to the TIVA group (p < 0.05). Moreover, no statistically notable distinction was observed in terms of postoperative hospitalization duration and overall hospitalization duration among both groups (p > 0.05). According to the study, both the CIVIA group and the TIVA group had a total of 7 (13.72%) and 17 (32.07%) individuals, respectively, who met the criteria for neurocognitive delayed recovery (Odds Ratio: 0.336; 95% CI: 0.134-0.864; p = 0.026). According to the research findings, it is indicated that there is a possibility for an increased presence of IL-6 in the bloodstream within 60 min following the incision made on the skin. This occurrence subsequently leads to the prolonged restoration of neurocognitive capabilities. The CIVIA technique outperforms the TIVA method in terms of overall assessment in the setting of laparoscopic surgery. It's also important to remember that an increased blood IL-6 level during laparoscopy may operate as a separate risk factor for a delay in the restoration of neurocognitive function.

Cost saving in implementing ERAS protocol in emergency abdominal surgery

IntroductionERAS (Enhanced Recovery After Surgery) protocol is now proposed as the standard of care in elective major abdominal surgery. Implementation of the ERAS protocol in emergency setting has been proposed but his economic impact has not been investigated. Aim of this study was to evaluate the cost saving of implementing ERAS in abdominal emergency surgery in a single institution.MethodsA group of 80 consecutive patients treated by ERAS protocol for gastrointestinal emergency surgery in 2021 was compared with an analogue group of 75 consecutive patients treated by the same surgery the year before implementation of ERAS protocol. Adhesion to postoperative items, length of stay, morbidity and mortality were recorded. Cost saving analysis was performed.Results50% Adhesion to postoperative items was reached on day 2 in the ERAS group in mean. Laparoscopic approach was 40 vs 12% in ERAS and control group respectively (p ,002). Length of stay was shorter in ERAS group by 3 days (9 vs 12 days p ,002). Morbidity and mortality rate were similar in both groups. The ERAS group had a mean cost saving of 1022,78 € per patient.ConclusionsERAS protocol implementation in the abdominal emergency setting is cost effective resulting in a significant shorter length of stay and cost saving per patient.

Excessive Oxygen Administration in High-Risk Patients Admitted to Medical and Surgical Wards Monitored by Wireless Pulse Oximeter.

The monitoring of oxygen therapy when patients are admitted to medical and surgical wards could be important because exposure to excessive oxygen administration (EOA) may have fatal consequences. We aimed to investigate the association between EOA, monitored by wireless pulse oximeter, and nonfatal serious adverse events (SAEs) and mortality within 30 days. We included patients in the Capital Region of Copenhagen between 2017 and 2018. Patients were hospitalized due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or after major elective abdominal cancer surgery, and all were treated with oxygen supply. Patients were divided into groups by their exposure to EOA: no exposure, exposure for 1-59 min or exposure over 60 min. The primary outcome was SAEs or mortality within 30 days. We retrieved data from 567 patients for a total of 43,833 h, of whom, 63% were not exposed to EOA, 26% had EOA for 1-59 min and 11% had EOA for ≥60 min. Nonfatal SAEs or mortality within 30 days developed in 24%, 12% and 22%, respectively, and the adjusted odds ratio for this was 0.98 (95% CI, 0.96-1.01) for every 10 min. increase in EOA, without any subgroup effects. In conclusion, we did not observe higher frequencies of nonfatal SAEs or mortality within 30 days in patients exposed to excessive oxygen administration.

Prognostic significance of preoperative nutritional status for postoperative acute kidney injury in older patients undergoing major abdominal surgery: a retrospective cohort study.

The association between malnutrition and postoperative acute kidney injury (AKI) has not been well studied. In this study, the authors examined the association between preoperative nutritional status and postoperative AKI in older patients who underwent major abdominal surgery, as well as the predictive value of malnutrition for AKI. The authors retrospectively included patients aged 65 or older who underwent major elective abdominal surgery. The nutritional status of the patient was evaluated using three objective nutritional indices, such as the geriatric nutritional risk index (GNRI), the prognostic nutritional index (PNI), and the controlling nutritional status (CONUT). AKI was determined using the KDIGO criteria. The authors performed logistic regression analysis to investigate the association between preoperative nutritional status and postoperative AKI, as well as the predictive value of nutritional scores for postoperative AKI. A total of 2775 patients were included in the study, of which 707 (25.5%), 291 (10.5%), and 517 (18.6%) had moderate to severe malnutrition according to GNRI, PNI, and CONUT calculations. After surgery, 144 (5.2%) patients developed AKI, 86.1% at stage 1, 11.1% at stage 2, and 2.8% at stage 3 as determined by KDIGO criteria. After adjustment for traditional risk factors, worse nutritional scores were associated with a higher AKI risk. In addition to traditional risk factors, these nutritional indices improved the predictive ability of AKI prediction models, as demonstrated by significant improvements in integrated discrimination and net reclassification. Poor preoperative nutritional status, as assessed by GNRI, PNI, and CONUT scores, was associated with an increased risk of postoperative AKI. Incorporating these scores into AKI prediction models improved their performance. These findings emphasize the need for screening surgical patients for malnutrition risk. Further research is needed to determine whether preoperative malnutrition assessment and intervention can reduce postoperative AKI incidence.

Using heart rate variability to develop a predictive model for post-operative cardiovascular complications following major abdominal surgery: A pilot study.

Heart Rate Variability (HRV) is a dynamic reflection of heart rhythm regulation by various physiological inputs. HRV deviations have been found to correlate with clinical outcomes in patients under physiological stresses. Perioperative cardiovascular complications occur in up to 5% of adult patients undergoing abdominal surgery and are associated with significantly increased mortality. This pilot study aimed to develop a predictive model for post-operative cardiovascular complications using HRV parameters for early risk stratification and aid post-operative clinical decision-making. Adult patients admitted to High Dependency Units after elective major abdominal surgery were recruited. The primary composite outcome was defined as cardiovascular complications within 7days post-operatively. ECG monitoring for HRV parameters was conducted at three time points (pre-operative, immediately post-operative, and post-operative day 1) and analyzed based on outcome group and time interactions. Candidate HRV predictors were included in a multivariable logistic regression analysis incorporating a stepwise selection algorithm. 89 patients were included in the analysis, with 8 experiencing cardiovascular complications. Three HRV parameters, when measured immediately post-operatively and composited with patient age, provided the basis for a predictive model with AUC of 0.980 (95% CI: 0.953, 1.00). The negative predictive value was 1.00 at a statistically optimal predicted probability cut-off point of 0.16. Our model holds potential for accelerating clinical decision-making and aiding in patient triaging post-operatively, using easily acquired HRV parameters. Risk stratification with our model may enable safe early step-down care in patients assessed to have a low risk profile of post-operative cardiovascular complications.

Can perioperative pCO2 gaps predict complications in patients undergoing major elective abdominal surgery randomized to goal-directed therapy or standard care? A secondary analysis

The difference between venous and arterial carbon dioxide pressure (pCO2 gap), has been used as a diagnostic and prognostic tool. We aimed to assess whether perioperative pCO2 gaps can predict postoperative complications. This was a secondary analysis of a multicenter RCT comparing goal-directed therapy (GDT) to standard care in which 464 patients undergoing high-risk elective abdominal surgery were included. Arterial and central venous blood samples were simultaneously obtained at four time points: after induction, at the end of surgery, at PACU/ICU admission, and PACU/ICU discharge. Complications within the first 30 days after surgery were recorded. Similar pCO2 gaps were found in patients with and without complications, except for the pCO2 gap at the end of surgery, which was higher in patients with complications (6.0 mmHg [5.0–8.0] vs. 6.0 mmHg [4.1–7.5], p = 0.005). The area under receiver operating characteristics curves for predicting complications from pCO2 gaps at all time points were between 0.5 and 0.6. A weak correlation between ScvO2 and pCO2 gaps was found for all timepoints (ρ was between − 0.40 and − 0.29 for all timepoints, p < 0.001). The pCO2 gap did not differ between GDT and standard care at any of the selected time points. In our study, pCO2 gap was a poor predictor of major postoperative complications at all selected time points. Our research does not support the use of pCO2 gap as a prognostic tool after high-risk abdominal surgery. pCO2 gaps were comparable between GDT and standard care. Clinical trial registration Netherlands Trial Registry NTR3380.

Incidence of perioperative morbidity by anaesthesia depth

The prognostic value of age, physical status, and duration of surgery on perioperative course has been extensively studied. However, the impact of deep hypnotic time (time when Bispectral Index values are less than 40) has not been well evaluated. Methods.We designed an observational study to clarify the relative influence of deep hypnotic time (DHT) on outcome. Eligible participants were mentally stable patients over 18 years old scheduled for elective major abdominal surgery. In total, 248 patients enrolled. Data were analyzed using Fisher’s exact test and multiple logistic regression. Results. Five variables (DHT, hypotension, age, comorbidity, and duration of surgery) showed statistically significant association with complications, when examined independently. However, when all variables were examined together in a multiple logistic regression model, age and comorbidity were no longer associated with the outcome. DHT, hypotension, and duration of surgery were significant predictors of “complications,” and “hypotension” was a significant predictor of prolonged hospital stay (𝑃 &lt; 0.001). Conclusion. Deep hypnotic time emerged as a new factor associated with outcome, and its impact compared to other factors such as age, surgery duration, hypotension, and comorbidity is redefined. Monitoring and managing depth of anesthesia during surgery are important and should be part of careful operation planning

Association between preoperative frailty and surgical Apgar score in abdominal cancer surgery: a secondary analysis of a prospective observational study

IntroductionThe surgical Apgar score is useful for predicting postoperative morbidity and mortality. However, its applicability in frail patients with minimal hemodynamic variation remains unknown. This study aimed to investigate the association between frailty and surgical Apgar score.MethodsThis secondary analysis included 210 patients ≥ 65 years of age undergoing elective major abdominal surgery for cancer. Frailty was assessed using the Fried Frailty Phenotype Questionnaire and defined as a total score of ≥ 3. The surgical Apgar score (range, 0−10; including mean blood pressure, heart rate, and blood loss volume) was compared between patients with or without frailty using the Mann–Whitney U test. Postoperative severe complications and length of postoperative stay were compared between patients with surgical Apgar scores ≤ 7 and > 7.ResultsAmong the included patients, 45 were classified as frail. The median [1st quartile, 3rd quartile] surgical Apgar scores in patients with and without frailty were 7.0 [7.0, 8.0] and 8.0 [7.0, 8.0], respectively (P = 0.03). Patients with surgical Apgar score ≤7 had a higher incidence of serious postoperative complications (P = 0.03) and longer hospital stays (P < 0.001) compared with patients with surgical Apgar score >7.ConclusionFrail patients have lower SAS, and patients with lower SAS have higher postoperative complication rates and longer hospital stays in patients who underwent cancer surgery.

Goal-directed fluid therapy using stroke volume variation on length of stay and postoperative gastrointestinal function after major abdominal surgery-a randomized controlled trial

Background and objectiveThe effectiveness of goal-directed fluid therapy (GDFT) in promoting postoperative recovery remains unclear, the aim of this study was to evaluate the effect of GDFT on length of hospital stay and postoperative recovery of GI function in patients undergoing major abdominal oncologic surgery.MethodsIn this randomized, double- blinded, controlled trial, adult patients scheduled for elective major abdominal surgery with general anesthesia, were randomly divided into the GDFT protocol (group G) or conventional fluid therapy group (group C). Patients in group C underwent conventional fluid therapy based on mean arterial pressure (MAP) and central venous pressure (CVP) whereas those in group G received GDFT protocol associated with the SVV less than 12% and the cardiac index (CI) was controlled at a minimum of 2.5 L/min/m2. The primary outcomes were the length of hospital stay and postoperative GI function.ResultsOne hundred patients completed the study protocol. The length of hospital stay was significantly shorter in group G compared with group C [9.0 ± 5.8 days versus 12.0 ± 4.6 days, P = 0.001]. Postoperative gastrointestinal dysfunction (POGD) occurred in two of 50 patients (4%) in group G and 16 of 50 patients (32%) in the control group (P < 0.001). GDFT significantly also shorten time to first flatus by 11 h (P = 0.009) and time to first tolerate oral diet by 2 days (P < 0.001).ConclusionsGuided by SVV and CI, the application of GDFT has the potential to expedite postoperative recovery of GI function and reduce hospitalization duration after major abdominal surgery.Trial registrationThis study was registered on www.clinicaltrials.gov on 07/05/2019 with registration number: NCT03940144.

High versus standard blood pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: a study protocol for the HISTAP randomized clinical trial

BackgroundThe intraoperative period is often characterized by hemodynamic instability, and intraoperative hypotension is a common complication. The optimal mean arterial pressure (MAP) target in hypertensive patients is still not clear. We hereby describe the protocol and detailed statistical analysis plan for the high versus standard blood pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: the HISTAP randomized clinical trial. The HISTAP trial aims at addressing whether the use of a higher intraoperative MAP target in high-risk hypertensive surgical patients scheduled for elective abdominal surgery would improve postoperative outcomes, as compared to the standard and recommended perioperative MAP, by using a composite outcome including a 30-day mortality from surgical intervention and at least one major organ dysfunction or new onset of sepsis and septic shock occurring 7 days after surgery.MethodsThe HISTAP trial is an investigator-initiated, pragmatic, parallel-grouped, randomized, stratified, analyst-blinded trial with adequate allocation sequence generation, and allocation concealment. We will allocate 636 patients to a MAP target ≥ 80 mmHg (treatment group) or to a MAP target ≥65 mmHg (control group). The primary outcome is a composite outcome including a 30-day mortality from the operation and major organ complications. Secondary outcomes are mortality at 30 days, intensive care unit (ICU) length of stay, ICU readmission, Sequential Organ Failure Assessment (SOFA) scores recorded up to postoperative day 7, overall intraoperative fluid balance, vasopressors use, and the need for reoperation. An unadjusted χ2 test will be used for the primary outcome analysis. A Cox proportional hazards model will be used to adjust the association between the primary outcome and baseline covariates.ConclusionsThe HISTAP trial results will provide important evidence to guide clinicians’ choice regarding the intraoperative MAP target in high-risk hypertensive patients scheduled for elective abdominal surgery.

Abdominal surgery induces long-lasting changes in expression and binding of CTCF with impact on Major Histocompatibility Complex II transcription in circulating human monocytes.

Postoperative immunosuppression has been recognized as an important driver of surgery-related morbidity and mortality. It is characterized by lymphocyte depression and impaired monocyte capability to present foreign antigens to T-cells via Major Histocompatibility Complex, Class II (MHC-II) molecules. In patients with postoperative abdominal sepsis, we previously detected a persisting differential binding of the CCCTC-Binding Factor (CTCF), a superordinate regulator of transcription, inside the MHC-II region with specific impact on human leucocyte antigen (HLA) gene expression. In this prospective exploratory study, we investigated to which extent major surgery affects the MHC-II region of circulating CD14+-monocytes. In non-immunocompromised patients undergoing elective major abdominal surgery, a postoperative loss of monocyte HLA-DR surface receptor density was accompanied by a decline in the transcription levels of the classical MHC-II genes HLA-DRA, HLA-DRB1, HLA-DPA1 and HLA-DPB1. The surgical event decreased the expression of the transcriptional MHC-II regulators CIITA and CTCF and led to a lower CTCF enrichment at an intergenic sequence within the HLA-DR subregion. During the observation period, we found a slow and only incomplete restoration of monocyte HLA-DR surface receptor density as well as a partial recovery of CIITA, HLA-DRA and HLA-DRB1 expression. In contrast, transcription of HLA-DPA1, HLA-DPB1, CTCF and binding of CTCF within the MHC-II remained altered. In circulating monocytes, major surgery does not globally affect MHC-II transcription but rather induces specific changes in the expression of selected HLA genes, followed by differential recovery patterns and accompanied by a prolonged reduction of CTCF expression and binding within the MHC-II region. Our results hint toward a long-lasting impact of a major surgical intervention on monocyte functionality, possibly mediated by epigenetic changes that endure the life span of the individual cell.

A preoperative ultrasound-based protocol for optimisation of fluid therapy to prevent early intraoperative hypotension: a randomised controlled study

BackgroundIntraoperative hypotension is a risk factor for postoperative complications. Preoperative dehydration is a major contributor, although it is difficult to estimate its severity. Point-of-care ultrasound offers several potential methods, including measurements of the inferior vena cava. The addition of lung ultrasound may offer a safety limit. We aimed to evaluate whether the implication of an ultrasound-based preoperative fluid therapy protocol can decrease the incidence of early intraoperative hypotension.MethodsRandomised controlled study in a tertiary university department involves elective surgical patients of ASA 2–3 class, scheduled for elective major abdominal surgery under general anaesthesia with intubation. We randomised 40–40 patients; 38–38 were available for analysis. Conventional fluid therapy was ordered on routine preoperative visits. Ultrasound-based protocol evaluated the collapsibility index of inferior vena cava and lung ultrasound profiles. Scans were performed twice: 2 h and 30 min before surgery. A high collapsibility index (≥ 40%) indicated a standardised fluid bolus, while the anterior B-profile of the lung ultrasound contraindicated further fluid. The primary outcome was the incidence of postinduction and early intraoperative (0–10 min) hypotension (MAP < 65 mmHg and/or ≥ 30% of decrease from baseline). Secondary endpoints were postoperative lactate level, urine output and lung ultrasound score at 24 h.ResultsThe absolute criterion of postinduction hypotension was fulfilled in 12 patients in the conventional group (31.6%) and 3 in the ultrasound-based group (7.9%) (p = 0.0246). Based on composite criteria of absolute and/or relative hypotension, we observed 17 (44.7%) and 7 (18.4%) cases, respectively (p = 0.0136). The incidence of early intraoperative hypotension was also lower: HR for absolute hypotension was 2.10 (95% CI 1.00–4.42) in the conventional group (p = 0.0387). Secondary outcome measures were similar in the study groups.ConclusionWe implemented a safe and effective point-of-care ultrasound-based preoperative fluid replacement protocol into perioperative care.Trial registrationThe study was registered to ClinicalTrials.gov on 10/12/2021, registration number: NCT05171608 (registered prospectively on 10/12/2021).

Early Postoperative Fever and Atelectasis in Patients Undergoing Upper Abdominal Surgery.

Atelectasis is a common complication after upper abdominal surgery and considered as a cause of early postoperative fever (EPF) within 48 hours after surgery. However, the pathophysiologic mechanism of how atelectasis causes fever remains unclear. Data for adult patients who underwent elective major upper abdominal surgery under general anesthesia at Seoul National University Hospital between January and December of 2021 were retrospectively analyzed. The primary outcome was the association between fever and atelectasis within 2 days after surgery. Of 1,624 patients, 810 patients (49.9%) developed EPF. The incidence of atelectasis was similar between the fever group and the no-fever group (51.6% vs 53.9%, p = 0.348). Multivariate analysis showed no significant association between atelectasis and EPF. Culture tests (21.7% vs 8.8%, p < 0.001) and prolonged use of antibiotics (25.9% vs 13.9%, p < 0.001) were more frequent in the fever group compared to the no-fever group. However, the frequency of bacterial growth on culture tests and postoperative pulmonary complications within 7 days were similar between the two groups. EPF after major upper abdominal surgery was not associated with radiologically detected atelectasis. EPF also was not associated with the increased risk of postoperative pulmonary complications, bacterial growth on culture studies, or prolonged length of hospital stay.

Why Wait Until After Surgery? The Case for Pre-habilitation in Head and Neck Cancer Care.

The LaryngoscopeEarly View Triological Society Best Practice Why Wait Until After Surgery? The Case for Pre-habilitation in Head and Neck Cancer Care Marna A. List MD, Marna A. List MD orcid.org/0000-0003-2742-7496 Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorJason P. Calligas MD, Jason P. Calligas MD Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorJohn Pang MD, John Pang MD orcid.org/0000-0002-4952-6711 Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorAmeya A. Asarkar MD, FACS, Ameya A. Asarkar MD, FACS Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorCherie-Ann O. Nathan MD, FACS, Corresponding Author Cherie-Ann O. Nathan MD, FACS [email protected] orcid.org/0000-0001-7386-318X Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USA Ochsner LSU Health- Feist-Weiller Cancer Center, Shreveport, Louisiana, USA Send correspondence to Cherie-Ann O. Nathan, Department of Otolaryngology/Head & Neck surgery, Louisiana State University Health Sciences Center, Shreveport. 1501 Kings Hwy, Shreveport, LA 71103, USA. Email: [email protected]Search for more papers by this author Marna A. List MD, Marna A. List MD orcid.org/0000-0003-2742-7496 Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorJason P. Calligas MD, Jason P. Calligas MD Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorJohn Pang MD, John Pang MD orcid.org/0000-0002-4952-6711 Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorAmeya A. Asarkar MD, FACS, Ameya A. Asarkar MD, FACS Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorCherie-Ann O. Nathan MD, FACS, Corresponding Author Cherie-Ann O. Nathan MD, FACS [email protected] orcid.org/0000-0001-7386-318X Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USA Ochsner LSU Health- Feist-Weiller Cancer Center, Shreveport, Louisiana, USA Send correspondence to Cherie-Ann O. Nathan, Department of Otolaryngology/Head & Neck surgery, Louisiana State University Health Sciences Center, Shreveport. 1501 Kings Hwy, Shreveport, LA 71103, USA. Email: [email protected]Search for more papers by this author First published: 19 June 2023 https://doi.org/10.1002/lary.30827 Editor's Note: This Manuscript was accepted for publication on June 05, 2023. The authors have no funding, financial relationships, or conflicts of interest to disclose. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. BIBLIOGRAPHY 1Barberan-Garcia A, Ubré M, Roca J, et al. Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomized blinded controlled trial. Ann Surg. 2018; 267(1): 50- 56. 2Steegmann J, Bartella AK, Kloss-Brandstätter A, Kamal M, Hölzle F, Lethaus B. A randomized clinical trial on the efficacy of a patient-adapted autonomous exercise regime for patients with head and neck cancer. J Craniomaxillofac Surg. 2020; 48(3): 187- 192. 3Zhang B, Najarali Z, Ruo L, et al. Effect of perioperative nutritional supplementation on postoperative complications—systematic review and meta-analysis. J Gastrointest Surg. 2019; 23: 1682- 1693. 4Gillis C, Fenton TR, Sajobi TT, et al. Trimodal prehabilitation for colorectal surgery attenuates post-surgical losses in lean body mass: a pooled analysis of randomized controlled trials. Clin Nutr. 2018; 38: 1053- 1060. 5Nett H, Steegmann J, Tollkühn-Prott B, Hölzle F, Modabber A. A prospective randomized comparative trial evaluating postoperative nutritional intervention in patients with oral cancer. Sci Rep. 2022; 12:14213. Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

Deviating vital signs in continuous monitoring prior to discharge and risk of readmission: an observational study.

Premature discharge may result in readmission while longer hospitalization may increase risk of complications such as immobilization and reduce hospital capacity. Continuous monitoring detects more deviating vital signs than intermittent measurements and may help identify patients at risk of deterioration after discharge. We aimed to investigate the association between deviating vital signs detected by continuous monitoring prior to discharge and risk of readmission within 30days. Patients undergoing elective major abdominal surgery or admitted with acute exacerbation of chronic obstructive pulmonary disease were included in this study. Eligible patients had vital signs monitored continuously within the last 24h prior to discharge. The association between sustained deviated vital signs and readmission risk was analyzed by using Mann-Whitney's U test and Chi-square test. A total of 51 out of 265 patients (19%) were readmitted within 30days. Deviated respiratory vital signs occurred frequently in both groups: desaturation < 88% for at least ten minutes was seen in 66% of patients who were readmitted and in 62% of those who were not (p = 0.62) while desaturation < 85% for at least five minutes was seen in 58% of readmitted and 52% of non-readmitted patients (p = 0.5). At least one sustained deviated vital sign was detected in 90% and 85% of readmitted patients and non-readmitted patients, respectively (p = 0.2). Deviating vital signs prior to hospital discharge were frequent but not associated with increased risk of readmission within 30days. Further exploration of deviating vital signs using continuous monitoring is needed.

Variation in prescribing for the prevention of postoperative nausea, vomiting, and pain following abdominal surgery: A retrospective study.

Adequate postoperative analgesia and prevention of post-op nausea and vomiting (PONV) are core components of modern day anaesthesia and peri-operative care. As well as contributing to overall morbidity, postoperative pain and PONV are frequently cited as one of the most unpleasant and distressing aspects of surgery for patients. Variation in healthcare delivery is known to exist but has often been poorly described. A first step to understanding the consequences of variation is to describe the extent of variation. We aimed to assess variation in pharmacological strategies to prevent postoperative pain, nausea and vomiting in patients undergoing elective major abdominal surgery at a tertiary hospital in Perth, Western Australia, over a three-month period. Retrospective cross-sectional study. We observed considerable variation in prescribing of postoperative analgesia and PONV prophylaxis and suggest that despite adequate evidence based guidelines, they are often overlooked in practice. Measurement of the consequences of variation requires randomised clinical trials that evaluate differences in outcome and cost, associated with the strategies that exist within the spectrum of variation.

Intraoperative hemodynamic optimization using the hypotension prediction index vs. goal-directed hemodynamic therapy during elective major abdominal surgery: the Predict-H multicenter randomized controlled trial

BackgroundIntraoperative hypotension (IOH) is associated with increased morbidity and mortality after major abdominal surgery but remains significant even when using goal-directed hemodynamic therapy (GDHT) protocols. The Hypotension Prediction Index (HPI) is a machine learning-derived parameter that predicts arterial hypotension. We tested the hypothesis that an HPI-based protocol reduces the duration and severity of hypotension compared with a GDHT protocol during major abdominal surgery.MethodsThis is a parallel-arm double-blinded multicenter randomized trial involving adult patients undergoing elective major abdominal surgery at five centers. Patients were optimized according to a previously recommended GDHT protocol (GDHT group) or the HPI value (HPI group). Hemodynamic optimization in both groups started 15 min after the surgical incision. The primary outcome was the intraoperative time-weighted average of mean arterial pressure under 65 mmHg (TWA-MAP &amp;lt; 65 mmHg). Other metrics for IOH and secondary outcomes, including TWA below individual baseline values of intraoperative tissue oxygenation (StO2), postoperative AKIRisk, postoperative complications, length of stay, and 30-day mortality, were explored.ResultsEighty patients were randomized (40 patients in each group). TWA-MAP &amp;lt; 65 mmHg was 0.06 (25th–75th interquartile range: 0–0.27) mmHg in the GDTH group vs. 0 (0–0.04) mmHg in the HPI group (p = 0.015). Total time with MAP &amp;lt; 65 mmHg per patient was 4.6 (0–21) min in the GDHT group and 0 (0–3) min in the HPI group (p = 0.008). The TWA below the baseline StO2 was 0.40% (0.12%–2.41%) in the GDHT group and 0.95% (0.15%–3.20%) in the HPI group (p = 0.353). The AKIRisk values obtained in the GDHT group were 0.30 (0.14–0.53) and 0.34 (0.15–0.67) in the GDHT and HPI groups (p = 0.731), respectively. Both groups had similar postoperative complications, length of stay, and 30-day mortality.ConclusionsAn HPI-based protocol reduced intraoperative hypotension compared with a standard GDHT protocol, with no differences in tissue oxygenation and postoperative AKIRisk.