Fast-track Score Research Articles

Fast-Track Score to Predict the Feasibility of Early Extubation Post Liver Transplant

Background Over the past several years, the liver transplant community has embraced the concept of fast-tracking patients to facilitate earlier postoperative recovery. Aim Derive and validate a novel “fast-track” risk score that captures the demographic and clinical characteristics of DDLT patients to predict the likelihood of early extubation after surgery. Design Adult patients who underwent non-fulminant DDLT between January 2014 and July 2019 were included. The cohort was divided in 2 groups: patients extubated within 4 hours of surgery vs extubated after 4 h. Logistic regression was performed to identify the independent predictors of early extubation. The area under the curve (AUC) was calculated to measure the ability of the risk score to predict early extubation. The score was validated by applying coefficients of the regression model to the validation cohort and calculating the AUC. Results A total of 290 DDLT patients were included, of which 175 (60%) were in the “delayed extubation” group and 115 (40%) were in the “fast-track” group. Patients with a MELD <29, transfused <4 units of pRBCs, and transfused <5 units of FFP during surgery were 2.30 times, 5.74 times, and 3.09 times more likely to be extubated early, respectively. A risk score with an integer point scale was derived and exhibited an AUC of .80. The proportion of patients who were extubated early increased from 2.78% at a score of 0 to 66.67% at a score of 4. Conclusions The proposed score provides a fast and easy method to help identify DDLT patients suitable for early extubation.

Comparison of three scoring criteria to assess recovery from general anesthesia in the postanesthesia care unit in the indian population.

Different discharge criteria are available for shifting patients out from postanesthesia care room following surgery. This study was done to compare the three-scoring system namely traditional time-based criteria, Fast track criteria and modified Aldrete score, in Indian population patients who recover after general anesthesia in postanesthesia care unit (PACU). Three hundred and seventy-five patients scheduled for general anesthesia were included in this study. Induction of anesthesia was done with intravenous (IV) propofol and maintained with sevoflurane inhalation with oxygen and nitrous oxide. Reversal of residual neuromuscular blockade was done with IV neostigmine and glycopyrrolate. Patients were shifted to PACU following tracheal extubation and recovery was assessed using the traditional time-based criteria, fast track criteria, and modified Aldrete score. As per modified Aldrete score, mean time of shift out is 19 min with median of 15 min and standard deviation of 21.7 min. As per fast-track score, mean time of shift out is 187 min with median of 30 min and standard deviation of 243.7 min. As per the time-based criteria, mean time of shift out is 222 min with median of 240 min and standard deviation of 136.8 min. While using modified Aldrete score, majority of patients had a shorter stay in PACU and faster time to shift out as compared to fast-track criteria and traditional time-based criteria. Modified Aldrete score when compared to fast-track scoring and time-based criteria shows early recovery and reduces the length of stay in PACU.

Remimazolam-based anesthesia with flumazenil allows faster emergence than propofol-based anesthesia in older patients undergoing spinal surgery: A randomized controlled trial.

Remimazolam is a novel, ultrashort-acting benzodiazepine that can be antagonized by flumazenil. This study aimed to determine whether remimazolam-based anesthesia with flumazenil provides a more rapid emergence than propofol-based anesthesia in older patients undergoing spinal surgery. This was a prospective, single-blind, randomized controlled trial. Forty-four patients > 75 years old who had undergone spinal surgery were enrolled in this study. They were randomly assigned to the remimazolam or propofol group (1:1) using a computer randomization system stratified by age and body weight. For anesthesia induction and maintenance, remifentanil was administered at a defined dose in both groups, and remimazolam or propofol was adjusted to maintain the bispectral index or state entropy monitoring within 40-60. All anesthetics were discontinued simultaneously after the postoperative X-ray and 0.5 mg flumazenil was administered to the remimazolam group. The primary outcome was extubation time after discontinuing anesthesia, and the secondary outcomes were time to eye opening, obeying commands, and achieving a white fast-track score (WFTS) of 12. Thirty-nine patients were finally analyzed: remimazolam group (n = 20), propofol group (n = 19). There were no significant differences in intraoperative variables, such as operative time, anesthesia time, and patient background, between the 2 groups. Extubation times were significantly shorter in the remimazolam group than in the propofol group (4 vs 8 minutes, P < .001). The time to eye opening, obeying commands, and achieving a WFTS of 12 were significantly shorter in the remimazolam group (P < .001, for all comparisons). Remimazolam-based anesthesia with flumazenil resulted in a faster emergence than propofol-based anesthesia in older patients undergoing spinal surgery.

Fast track triage for COVID-19 based on a population study: the SODA score

Abstract Background Healthcare systems are under prominent stress due to the COVID-19 pandemic. A fast and simple triage is mandatory to screen patients who will benefit from early hospitalization, from those that can be managed as outpatients. There is a lack of all-comers scores, and no score has been proposed for western-world population. Aims To develop a fast-track risk score valid for every COVID-19 patient at diagnosis. Methods Single-center, retrospective study based on all the inhabitants of a healthcare area. Logistic regression was used to identify simple and wide-available risk factors for adverse events (death, intensive care admission, invasive mechanical ventilation, bleeding &amp;gt;BARC3, acute renal injury, respiratory insufficiency, myocardial infarction, acute heart failure, pulmonary emboli, or stroke). Results Of the total healthcare area population, 447.979 inhabitants, 965 patients (0.22%), were diagnosed with COVID-19. A total of 124 patients (12.85%) experienced adverse events. The novel SODA score (based on sex, peripheral O2 saturation, presence of diabetes, and age) demonstrated good accuracy for adverse events prediction (area under ROC curve 0.858, CI: 0.82–0.98). A cut-off value of &amp;lt;2 points identifies patients with low risk (positive predictive value [PPV] for absence of events: 98.9%) and a cut-off of &amp;gt;5 points, high-risk patients (PPV 58.8% for adverse events). Conclusions This quick and easy score allows fast-track triage at the moment of diagnosis for COVID-19 using four simple variables: age, sex, SpO2, and diabetes. SODA score could improve preventive measures taken at diagnosis in high-risk patients and also relieve resources by identifying very low-risk patients. Funding Acknowledgement Type of funding sources: None. Figure 1. Receiver Operating Characteristic curve of SODA score to predict: A, adverse events (death, ICU admission, invasive mechanical ventilation, bleeding &amp;gt;BARC3, acute renal injury, respiratory insufficiency, myocardial infarction, acute heart failure, pulmonary emboli or stroke). Area under curve 0.858, CI: 0.82–0.98, p&amp;lt;0.001. B, mortality. Area under curve 0.89, CI: 0.58–0.94, p&amp;lt;0.001.Figure 2. Percentage of adverse events in each punctuation of the SODA score (green) and percentage of patients without adverse events (blue). Adverse events: death, ICU admission, invasive mechanical ventilation, bleeding &amp;gt;BARC3, acute renal injury, respiratory insufficiency, myocardial infarction, acute heart failure, pulmonary emboli, or stroke.

Predicting Early Extubation After Liver Transplantation: External Validation and Improved Generalizability of a Proposed Fast-track Score.

Early extubation of liver transplantation recipients is a cornerstone of fast-track (FT) pathways. Identifying suitable candidates has previously been accomplished using perioperative variables to develop a FT probability score. The objective of this study was to externally validate a proposed FT score. Following Research Ethics Board approval, data were extracted on liver transplants conducted at a single center from 2009 to 2017. Data extracted included patient characteristics, intraoperative variables, and postoperative outcome variables. The proposed FT score utilized 9 variables: age, gender, body mass index, model of end-stage liver disease, retransplant, preoperative hospital admission, blood transfusion, operative time, and vasopressor use. We calculated the FT score in our cohort, and assessed the discrimination and calibration of the model. Score performance was explored by subgroup analyses, customization and altering the outcome definition. The FT score was found to predict higher rates of successful FT than was observed in the external cohort (n = 1385) and had reduced discrimination (area under the receiver operating curve, 0.711; 95% confidence interval, 0.682-0.741) compared with the original internal validation cohort (area under the receiver operating curve, 0.830; 95% confidence interval, 0.789-0.871; P < 0.0001). Discrimination was improved by customizing the transfusion (P < 0.0001) components of the simplified score or by level 1 customization of all regression model coefficients (P < 0.0001). A time-based definition of FT (early extubation) did not alter the accuracy of the prediction score (P = 0.914), improving the model's generalizability. The proposed FT score may help identify patients suitable for early extubation and FT pathways after liver transplantation in conjunction with clinical judgment.

The effects of pregabalin and adductor canal block on postoperative pain in arthroscopic anterior cruciate ligament reconstruction

Background/aimTo determine the effectiveness of pregabalin and adductor canal block on opioid consumption, postoperative pain, and fast-tracking.Materials and methodsA total of 51 American Society of Anaesthesiologists (ASA) classification I–II patients aged 18–70 years who were scheduled to undergo elective anterior cruciate ligament reconstruction were included in the study. Patients were randomized into groups P, A, and C. Patients in group P (n = 16), received 150 mg of preoperative oral pregabalin, patients in group A (n = 17) received postoperative adductor canal blockade, and patients in group C (n = 18) received neither adductor canal block nor pregabalin. Surgeries were performed under spinal anaesthesia with hyperbaric bupivacaine following monitorization. Demographic data along with block features, hemodynamic data, mean opioid consumption, numerical rating scale score, White’s fast-track score, and postoperative adverse effects were recorded.ResultsFifty-seven patients were enrolled in the study, and 6 patients were excluded from the study; the data of 51 patients were included in the final analyses. Demographic characteristics and hemodynamic data were similar between the 3groups. Postoperative opioid consumption was significantly lower in groups A and P compared with group C (group P = 178.75 mg, group C = 318.61 mg, group A = 236.47 mg; P < 0.05). The regression of sensory block was significantly slower in group P (P < 0.05). The first analgesic requirement was earlier in group C than in groups P and A (P < 0.05). Patients in group P had higher fast-track scores at 8 h and 12 h compared with group C (P < 0.05); however, group A fast-track scores were similar to those of the other 2groups (P > 0.05). The rate of postoperative adverse effects was similar between the groups (P > 0.05).Conclusion Preoperative pregabalin (150 mg) reduced postoperative opioid consumption as much as adductor canal block in patients undergoing anterior cruciate ligament reconstruction. The first analgesic requirement was earlier in group C than in groups P and A. In addition, pregabalin can prolong the duration of spinal sensory block and shorten the time required to achieve high fast-tracking scores. We recommend the use of both methods as a part of multimodal analgesia.

Do cardiopulmonary exercise testing results correlate with a fast track score developed to predict early extubation after liver transplant?

Do cardiopulmonary exercise testing results correlate with a fast track score developed to predict early extubation after liver transplant?

Recovery Profile After General Anaesthesia in Paediatric Ambulatory Surgeries: Desflurane Versus Propofol.

Paediatric ambulatory surgeries warrant a speedy recovery of patients without compromising their safety. Short-acting agents such as propofol and desflurane help facilitate these objectives. In this prospective, randomised study we compared the recovery profile in paediatric patients undergoing ambulatory surgeries who received entropy guided general anaesthesia (GA) using desflurane and propofol as maintenance anaesthetics. We enrolled 80 children (3-10 years of age), ASA I and II, scheduled for elective surgeries of <60 minutes duration requiring GA between March 2015 and June 2016. We used entropy to monitor adequate depth of anaesthesia and to ensure equipotency of anaesthetic administration in both groups. The state and response entropy was maintained between 40 and 60 by titrating the anaesthetic agents and opioid analgesics. The time of awakening, perioperative haemodynamics, postoperative recovery profile, adverse events and comparative cost of anaesthetic agents were analysed. The mean heart rate in the desflurane group was significantly higher. There was no difference between the blood pressure, end tidal carbon dioxide, or oxygen saturation in the two groups. There was a trend towards faster awakening, spontaneous respiration and extubation, quicker time to achieve a fast track score >12 and shift out of the post-anaesthesia care unit in the desflurane group, but the difference was not statistically significant. There were no serious adverse events. The mean cost of desflurane was significantly higher than propofol. Desflurane and propofol provided similar recovery profiles in children receiving GA for ambulatory surgeries. However, propofol was more cost effective compared to desflurane.

A prospective observational study comparing criteria-based discharge method with traditional time-based discharge method for discharging patients from post-anaesthesia care unit undergoing ambulatory or outpatient minor surgeries under general anaesthesia

Background and Aims:Mostly, institutions in India have single post-anaesthesia care unit (PACU) which follows traditional time-based discharge (TBD) method. Recently, it has been classified into PACU Phase I and Phase II, and criteria-based discharge (CBD) method has been used. This study primarily compares CBD versus TBD methods in moving patients through PACU, and other non-clinical factors causing delay in shifting.Methods:One hundred patients, aged 18–65 years, American Society of Anesthesiologist's physical status I and II, scheduled for elective minor surgeries under general anaesthesia were studied. White's fast-track score in operating room (OR) and modified Aldrete's score (CBD time) in PACU were recorded. Patients were scheduled to discharge at 60 min based on TBD method. The mean CBD time and actual discharge time from PACU were statistically compared with TBD time. Other non-clinical factors delaying the discharge were also studied.Results:Eighty-five percent of patients achieved acceptable White's fast-track score in OR. The TBD time (60 min) was compared with the mean CBD time (10.70 ± 2.56 min) and actual discharge time (79.75 ± 12.98 min), which were found to be statistically significant. Primarily, anaesthesiologists' busy schedule was accountable for delay in discharge.Conclusion:The study concluded that in patients undergoing ambulatory minor surgeries, discharge times based on Criterion Based Discharge scoring systems such as modified Aldrete's and White's-fast are significantly lower in PACU Phase I as compared to the traditional Time Based Discharge method.

Comparison of bispectral index and end-tidal anaesthetic concentration monitoring on recovery profile of desflurane in patients undergoing lumbar spine surgery

Background and Aims:Several techniques have evolved over time to monitor depth of anesthesia and ensure enhanced recovery. This randomized double-blinded trial was designed to compare bispectral index (BIS) or end-tidal anaesthetic concentration (ETAC) monitoring on the recovery characteristics of patients undergoing thoracolumbar spine surgeries.Methods:Seventy American Society of Anesthesiologist I–II patients of either sex were randomized to Group B – BIS-guided protocol, Group E – ETAC-guided protocol, or Group S – Standard protocol. After intravenous induction, anaesthesia was maintained with desflurane in O2/N2O (50:50) mixture. In BIS, ETAC and Standard groups, inspired end-tidal desflurane concentration was varied to achieve BIS of 45–55, 0.8–1.0 age-corrected minimum alveolar concentration, and haemodynamic parameters within 20% of the baseline, respectively. Time to eye opening (emergence time, the primary outcome), time to extubation, and time to name recall from the discontinuation of the anaesthetic agent were recorded. Incidence of nausea, vomiting, and total analgesic consumption was noted for 24 h.Results:Emergence time (mean ± SD) in ETAC (5.1 ± 1.53 min) and BIS (5.0 ± 2.12 min)-guided groups was significantly lower than Standard group (7.5 ± 2.90 min). Extubation time in ETAC (6.3 ± 2.22 min) and BIS-guided group (6.5 ± 1.78 min) was significantly lower than Standard group (9.0 ± 3.20 min) (P < 0.001). Time to achieve fast track score of more than 12 was significantly less in BIS-guided group (13.12 ± 2.59 min).Conclusion:ETAC-guided anaesthesia is comparable to BIS-guided anaesthesia in achieving early recovery.

Recovery and prediction of postoperative muscle power \u2013 is it still a problem?

BackgroundIn the postoperative period, immediate recovery of muscular power is essential for patient safety, but this can be affected by anaesthetic drugs, opioids and neuromuscular blocking agents (NMBA). In this cohort study, we evaluated anaesthetic and patient-related factors contributing to reduced postoperative muscle power and pulse oximetric saturation.MethodsWe prospectively observed 615 patients scheduled for minor surgery. Premedication, general anaesthesia and respiratory settings were standardized according to standard operating procedures (SOP). If NMBAs were administered, neuromuscular monitoring was applied to establish a Train of four (TOF)-Ratio of >0.9 before extubation. After achieving a modified fast track score > 10 at 4 time points up to 2 h postoperatively, we measured pulse oximetric saturation and also static and dynamic muscle power, using a high precision digital force gauge. Loss of muscle power in relation to the individual preoperative baseline value was analysed in relation to patient and anaesthesia-related factors using the T-test, simple and multiple stepwise regression analysis.ResultsDespite having achieved a TOF ratio of >0.9 a decrease in postoperative muscle power was detectable in most patients and correlated with reduced postoperative pulse oximetric saturation. Independent contributing factors were use of neuromuscular blocking agents (p < 0.001), female gender (p = 0.001), TIVA (p = 0.018) and duration of anaesthesia >120 min (p = 0.019).ConclusionSignificant loss of muscle power and reduced pulse oximetric saturation are often present despite a TOF-Ratio > 0.9. Gender differences are also significant. A modified fast track score > 10 failed to predict recovery of muscle power in most patients.Trial registrationGerman Clinical Trial Register DRKS-ID DRKS00006032; Registered: 2014/04/03

Titration of sevoflurane in elderly patients: blinded, randomized clinical trial, in non-cardiac surgery after beta-adrenergic blockade

Monitoring depth of anesthesia via the processed electroencephalogram (EEG) has been found useful in reducing the amount of anesthetic drugs, optimizing wake-up times, and, in some studies, reducing awareness. Our goal was to determine if titrating sevoflurane as the maintenance anesthetic to a depth of anesthesia monitor (SEDLine™, Masimo, CA) would shorten time to extubation in elderly patients undergoing non-cardiac surgery while on beta-adrenergic blockade. This patient population was selected because the usual cardiovascular signs of inadequate general anesthesia may be masked by beta-blocker therapy. Surgical patients older than 65years of age receiving beta-adrenergic blockers for a minimum of 24h preoperatively were randomized to two groups: a group whose titration of sevoflurane was based on SEDLine™ data (SEDLine™ group) and a group whose titration was based on usual clinical criteria (control group) where SEDLine™ data were concealed. The primary endpoint was time from skin closure to time to extubation. Aldrete score, White Fast Track score and QoR-40 were also assessed. There was no significant difference in time to extubation [12.5 (SD 7.4)min in the control group versus 13.0 (SD 5.9)min for the treatment group]. The control group used more fentanyl [339 mcg (SD 205)] than did the treatment group [238 mcg (SD 123)] (P<0.02). There was no difference in sevoflurane utilization, Aldrete, White Fast Track scores, time to PACU discharge, or QoR-40 assessments between the groups. Use of the SEDLine™ monitor's data to titrate sevoflurane did not improve the time to extubation or change short-term outcome of geriatric surgical patients receiving beta-adrenergic blockers. (ClinicalTrials.gov number, NCT00938782).

Desflurane Versus Sevoflurane for Maintenance of Outpatient Anesthesia: The Effect on Early Versus Late Recovery and Perioperative Coughing

There is controversy regarding the relative perioperative benefits of desflurane versus sevoflurane when used for maintenance of anesthesia in the ambulatory setting. Although studies have consistently demonstrated a faster emergence with desflurane (versus sevoflurane), the impact of this difference on the later recovery end points has not been definitively established. Furthermore, the effect of desflurane (versus sevoflurane) on the incidence of coughing is also controversial. We randomized 130 outpatients undergoing superficial surgical procedures requiring general anesthesia to one of two maintenance anesthetic treatment groups. All patients were induced with propofol, 2 mg/kg IV, and after placement of a laryngeal mask airway, anesthesia was maintained with either sevoflurane 1%-3% or desflurane 3%-8% in an air/oxygen mixture. The inspired concentration of the volatile anesthetic was varied to maintain hemodynamic stability and a Bispectral Index value of 50-60. Analgesia was provided with local anesthetic infiltration and ketorolac (30 mg IV). Antiemetic prophylaxis consisted of a combination of ondansetron (4 mg), dexamethasone (4 mg), and metoclopramide (10 mg) at the end of surgery. Assessments included recovery times to eye opening, response to commands, orientation, fast-track score of 14, first oral intake, sitting, standing, ambulating unassisted, and actual discharge. Patient satisfaction with anesthesia, the ability to resume normal activities on the first postoperative day, adverse side effects (e.g., coughing, purposeful movement, oxygen desaturation <90%, sore throat, postoperative nausea, and vomiting), and the requirement for postoperative analgesic and antiemetic drugs were recorded in the early postoperative period and during the initial 24-h period after discharge. The two study groups had comparable demographic characteristics. Although the overall incidence of coughing during the perioperative period was higher in the desflurane group (60% versus 32% in the sevoflurane group, P < 0.05), the incidences of coughing during the actual administration of the volatile anesthetics (i.e., the maintenance period) did not differ between the two groups. Emergence from anesthesia was more rapid after desflurane; however, all patients achieved fast-track recovery criteria (fast-track score >or=12) before leaving the operating room. Finally, the time to discharge home (90 +/- 31 min in sevoflurane and 98 +/- 35 min in desflurane, respectively) and the percentage of patients able to resume normal activities on the first postoperative day (sevoflurane 48% and desflurane 60%) did not differ significantly between the two anesthetic groups. Use of desflurane for maintenance of anesthesia was associated with a faster emergence and a higher incidence of coughing. Despite the faster initial recovery with desflurane, no significant differences were found between the two volatile anesthetics in the later recovery period. Both volatile anesthetics should be available for ambulatory anesthesia.

Bispectral index-guided desflurane and propofol anesthesia in ambulatory arthroscopy: comparison of recovery and discharge profiles

In this prospective, randomized study we compared the recovery profiles of bispectral index (BIS)-guided anesthesia regimens with desflurane or propofol in ambulatory arthroscopy. Fifty ASA I-II adult patients who underwent knee arthroscopy were randomized to receive desflurane (D) or propofol (P) infusion accompanied by remifentanil and nitrous oxide during maintenance, titrated to maintain a bispectral index value between 50 and 60. Initial awakening, fast-track eligibility, and home readiness as well as intraoperative hemodynamics, were compared. The groups did not differ with respect to demographics, duration of operation, or intraoperative vital signs. Although the times for initial awakening parameters were shorter in group D, the differences between the groups were not significant. The time needed for the White fast-track score to reach 12 was shorter in group P than group D (9 +/- 3.5 min vs 12.5 +/- 5.3 min). However, home readiness did not differ significantly between the groups. Desflurane is an alternative to propofol for BIS-guided ambulatory anesthesia. Using desflurane in combination with opioid analgesics blunted its rapid emergence characteristics, and the higher frequency of emetic symptoms with desflurane diminished the success of its fast-track eligibility.

Bispectral index monitoring does not improve early recovery of geriatric outpatients undergoing brief surgical procedures

To assess if titration of sevoflurane using the bispectral index (BIS) monitor improves the early and intermediate recovery in geriatric outpatients undergoing brief urologic procedures under general anesthesia without muscle relaxants. After a standardized induction with propofol and fentanyl, a laryngeal mask airway was inserted and sevoflurane was administered in combination with 60% nitrous oxide in oxygen for maintenance of anesthesia in spontaneously breathing outpatients. In the Control group (n = 25), sevoflurane and fentanyl were titrated according to standard clinical practice. In the BIS-directed group (n = 25), sevoflurane was titrated to maintain a BIS value between 50 and 60, and supplemental fentanyl, 25 mug iv boluses were administered to treat tachypnea. The intraoperative anesthetic and analgesic requirements, as well as the times to eye opening, removal of the laryngeal mask airway device, response to simple commands, orientation to person and place, and postanesthesia care unit discharge eligibility (fast-track score of 14) were assessed at specific time intervals. The minimum alveolar concentration-hour of sevoflurane (0.25 +/- 0.15 and 0.31 +/- 0.2) and end-tidal concentrations of sevoflurane at the end of surgery (0.3 +/- 0.3 and 0.4 +/- 0.20%) did not differ significantly between the Control and BIS-directed groups, respectively. Although the percentage of patients requiring supplemental boluses of fentanyl was reduced in the BIS-directed group (16 vs 48%, P <0.05), the intraoperative BIS values and recovery times were similar in the two groups. In this non-paralyzed elderly outpatient surgery population, the use of BIS monitoring for titrating the maintenance anesthetic (sevoflurane) failed to improve the early recovery process.