Perioperative Management Research Articles

Chronic subdural hematoma (CSDH), a condition with high recurrence rates, is traditionally attributed to trauma-induced inflammation and angiogenesis. Emerging evidence suggests an association between clinically unapparent low-grade infection and recurrence. The role of subclinical low-grade infection in untreated primary CSDH remains unknown. The aim of this study was to examine intraoperative swab results in de novo CSDH to assess its association with recurrence. In this prospective study, patients undergoing primary surgical evacuation for CSDH were enrolled and intraoperative swabs were collected for microbiological analysis. Patients were followed up for 6 months after surgery to assess recurrence. The presence or absence of a positive intraoperative swab was used to dichotomize the cohort. Relevant clinical parameters, including preoperative comorbidities, intra- and perioperative management, recurrence rates, and follow-up information were compared between the two groups. Eighty patients (60 male, median age 79 years) with CSDH were included in the analysis. Intraoperative swab cultures identified low-grade bacterial colonization, predominantly Cutibacterium acnes (69%), in 40% (32/80) of patients. Recurrence rates were significantly higher in patients with positive bacteria detection (31%, 10/32) compared with patients without bacteria detection (12.5%, 6/48) (OR 3.1, 95% CI 1.02-9.90; p < 0.039). These findings substantiate the hypothesis that subclinical low-grade infection contributes to CSDH origination. Further trials evaluating perioperative antibiotic interventions are warranted.

Congenital long QT syndrome (LQTS) and Catecholaminergic Polymorphic ventricular Tachycardia (CPVT) are inherited arrhythmogenic disorders leading to an increased risk of life-threatening arrhythmias. Left cardiac sympathetic denervation (LCSD), currently performed by video-assisted thoracoscopic surgery (VATS) is a well-established treatment for patients not fully protected by drugs. Peri-operative pain management represents a challenge. To assess the impact of a multimodal approach for perioperative pain management including combined regional anesthesia on postoperative pain scores, opioid requirements and neuropathic pain incidence in pediatric LQTS and CPVT patients undergoing VATS-LCSD. A retrospective analysis was conducted on consecutive children undergoing VATS-LCSD at a single center from 2021 to March 2025. Per protocol, they all received Erector Spinae Plane (ESP) and Serratus Plane (SP) block. A perifascial catheter was placed following ESP for continuous local anesthetic infusion. 15 patients were enrolled (median age 6.9 years, IQR 4.3-9.8, median weight 24 kg, IQR 18.3-35.5). Most (13, 87%) had LQTS and almost one third had a high-risk genotype. There were no major complications. There was only 1 case (7%) of accidental removal of the ESP catheter, in whom prophylactic morphine was used. Pain scores, as assessed by VAS, were below 2 in all patients; none needed additional doses of opioids nor ketorolac or developed neuropathic pain postoperatively. Our results support the use of a combined regional anesthesia protocol for peri-operative pain management in pediatric channelopathy patients undergoing VATS-LCSD. This approach may improve overall quality of care for this vulnerable population.

Chronic subdural haematoma (CSDH) is a common neurosurgical condition with an increasing incidence due to an aging population. Given the expanding research landscape, assessing the state of recent trials is essential. This systematic review updates a previous review, which included randomised controlled trials (RCTs) up to 2019, by summarizing recently published and ongoing RCTs in CSDH, highlighting key areas of investigation and identifying directions for future research. Clinical trial registries - including the Cochrane Controlled Register of Trials, WHO ICTRP, clinicaltrials.gov, and Clinical Trials Information System - were systematically searched for RCTs on CSDH from June 1, 2019, to February 18, 2025. Both published and ongoing trials were included in this review. This review identified 41 recently published RCTs and 54 ongoing RCTs, compared to 26 ongoing trials in 2019. Of the earlier review, eleven studies have been published, five remain active, and the remainder were either abandoned or did not adhere to their initial RCT design. Middle meningeal artery embolisation (MMAE) has become the most extensively studied intervention, with active trials increasing from 2 in 2019 to 21 in 2025. Trials investigating perioperative management (3 versus 7) and surgical techniques (5 versus 10) have also increased. In contrast, corticosteroid trials have decreased (7 versus 3), likely reflecting findings from recent high-impact studies. Research on tranexamic acid has increased (5 versus 7) as have studies on other pharmacological agents (4 versus 8). The number of ongoing RCTs in CSDH has increased substantially, with a notable shift in research focus. MMAE now dominates the field, though the surge in studies may suggest research saturation. Future investigations may benefit from more collaborative efforts, consolidating resources into fewer, but larger and adequately powered trials.

Postoperative sleep disturbance (PSD) is a common complication following surgery. Numerous factors can contribute to PSD, including personal factors, intraoperative factors, postoperative complications and environmental factors. PSD can lead to a range of adverse outcomes, severely impairing patients’ postoperative recovery and long-term prognosis. Esketamine, a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist and the dextrorotatory isomer of ketamine, which has stronger receptor affinity, more significant analgesic effects and better safety than ketamine. In recent years, in addition to the proven sedative, analgesic and antidepressant properties, emerging evidence highlights that esketamine may improve PSD through a variety of mechanisms, but the existing research results are still controversial. This article reviews the latest research progress of esketamine in improving PSD, and discusses its clinical efficacy and potential mechanism of action, in order to provide theoretical basis and practical guidance for optimizing perioperative anesthesia management and promoting postoperative rehabilitation of patients.

Total knee arthroplasty (TKA) is an effective treatment for end-stage knee osteoarthritis (KOA). Previous studies have found that KOA patients commonly experience sleep disorders during the perioperative period of TKA, which can significantly affect postoperative recovery, pain management, and quality of life. Sleep disturbances during the perioperative period of TKA are a complex issue influenced by multiple factors. Although clinical interventions have shown promising efficacy, the underlying mechanisms remain unclear and require further research. This article reviews the specific causes of sleep disturbances in TKA patients during the perioperative period, aiming to provide a reference for personalized sleep regulation interventions to improve postoperative outcomes. The article begins by searching public databases using selected keywords to identify recent studies on the management of sleep dysfunction during the perioperative period of TKA. Through a summary of the relevant literature, the review focuses on the incidence, influencing factors, interventions, and potential mechanisms of sleep dysfunction during the perioperative period of TKA. It aims to optimize perioperative management and support the future development of high-quality clinical intervention randomized controlled trials, ultimately contributing to the optimization of postoperative sleep management strategies and enhancing rapid recovery and long-term satisfaction in TKA patients.

Background/Objective: Diabetes mellitus (DM) is a highly prevalent condition that contributes to adverse outcomes in patients undergoing total hip arthroplasty (THA). This study applied machine learning clustering algorithms to identify comorbidity profiles among diabetic THA patients and evaluate their association with postoperative outcomes. Methods: The 2015–2021 National Inpatient Sample was queried using ICD-10 CM/PCS codes to identify DM patients undergoing THA. Forty-nine comorbidities, complications, and clinical covariates were incorporated into clustering analysis. The Davies–Bouldin and Calinski–Harabasz indices determined the optimal number of clusters. Multivariate logistic regression assessed risk of non-routine discharge (NRD), and Kruskal–Wallis H testing evaluated length-of-stay (LOS) differences. Results: A total of 73,606 patients were included. Six clusters were identified, ranging from 107 to 61,505 patients. Cluster 6, enriched for urinary tract infection and sepsis, had the highest risk of NRD (OR 7.83, p &lt; 0.001) and the longest median LOS (9.0 days). Clusters 1–4 had shorter recoveries with median LOS of 2.0 days and narrow variability, while Cluster 5 showed intermediate outcomes. Kruskal–Wallis and post hoc testing confirmed significant differences across clusters (p &lt; 0.001). Conclusions: Machine learning clustering of diabetic THA patients revealed six distinct groups with varied comorbidity profiles. Infection-driven clusters carried the highest risk for non-routine discharge and prolonged hospitalization. This approach provides a novel framework for risk stratification and may inform targeted perioperative management strategies.

Efanesoctocog alfa is a first-in-class high-sustained factor VIII therapy approved for prophylaxis, on-demand treatment, and peri-operative management of bleeding in hemophilia A. This analysis aimed to compare the cost effectiveness of efanesoctocog alfa prophylaxis with factor VIII extended half-life prophylaxis. A lifetime Markov model was developed from a US payer perspective, using clinical data from an indirect treatment comparison of phase III studies and inputs derived from the literature. A cohort of patients aged ≥ 12 years with severe hemophilia A without inhibitors, who received prophylaxis using any regimen or on-demand treatment, entered the model. Outcomes included joint and non-joint bleeds, quality-adjusted life-years, total direct costs, and the incremental cost-effectiveness ratio. Costs were expressed in US dollars and inflated to January 2023 prices. Discount rates of 3% were used. One-way probabilistic and scenario analyses were conducted. The willingness-to-pay threshold was assumed at $150,000 per quality-adjusted life-year. Efanesoctocog alfa was more effective and less costly (also referred to as 'dominant') versus factor VIII extended half-life therapies, with a lower lifetime number of joint (undiscounted 34.00 vs 140.65) and non-joint (undiscounted 13.33 vs 55.99) bleeds, higher quality-adjusted life-years (24.00 vs 22.92), and lower total costs ($30,716,640 vs $32,953,485). A broad range of scenario analyses and probabilistic sensitivity analyses resulted in 100% of simulations being cost effective. Dosing level and drug costs had the largest impact on results in the deterministic sensitivity analyses. Our analysis suggests that efanesoctocog alfa was dominant versus prophylaxis with standard and elevated factor VIII extended half-life dosing regimens. Efanesoctocog alfa was associated with better joint health and, hence, contributed to fewer bleeds, lower costs, and higher quality-adjusted life-years.

Introduction: The role of the surgical multidisciplinary team (MDT), particularly surgical resident doctors and nurses, extends far beyond the confines of the operating theatre. The peri-operative ward environment presents unique clinical and communication challenges that demand a distinct skillset to manage complications in unpredictable, high-pressure situations. Formal team training in peri-operative complication management can lead to increased confidence among healthcare professionals, improved team cohesiveness, and positively impact on patient care [1]. Despite this, structured training for MDT members in managing such scenarios is limited. Simulation-based education provides a safe, reflective environment for healthcare professionals to develop these skills without compromising patient safety [2]. Recognising a gap in peri-operative simulation training for surgical MDTs, we developed a targeted programme to address this need. Methods: A structured simulation-based teaching programme was implemented at Newham University Hospital, within Barts Health NHS Trust. The programme was designed for the surgical MDT, with particular focus on resident doctors and nursing staff. Scenarios were based on the CCriSP (Care of the Critically Ill Surgical Patient) framework and aligned with the surgical portfolio’s learning outcomes. Scenarios focused on common peri-operative challenges, including clinical deterioration, communication breakdowns, and ethical dilemmas. Participants completed pre- and post-session confidence surveys using Likert scales, analysed using a paired T-test. Qualitative feedback was collected anonymously via an online feedback form. Results: Thirteen MDT members (12 surgical residents and 1 student nurse) participated in the simulation sessions. Of these, four submitted feedback forms. Preliminary analysis showed a statistically significant increase in self-reported confidence in managing peri-operative scenarios, rising from 50% pre-session to 95% post-session (p=0.0182). All respondents found the sessions and debriefs beneficial to their learning, and 75% expressed interest in receiving post-session summaries. Logistical barriers, especially concurrent clinical commitments, limited attendance during working hours. The small number of nursing participants also highlighted the need for broader MDT engagement. Discussion: Initial findings suggest that simulation is an effective educational method for improving confidence and preparedness in managing peri-operative complications among surgical MDT members. Despite the small sample of formal feedback, positive trends and qualitative responses indicate this model fills a critical gap in surgical education. Barriers to attendance and limited nursing involvement prompted plans to transition to in-situ simulation delivery within clinical areas. This shift aims to increase realism, reduce simulation artefact, and facilitate greater MDT participation. Ongoing evaluation will support iterative improvements and inform integration into broader surgical education frameworks. Ethics Statement: As the submitting author, I can confirm that all relevant ethical standards of research and dissemination have been met. Additionally, I can confirm that the necessary ethical approval has been obtained, where applicable

BackgroundThis study aimed to evaluate the efficacy and safety of ultrasound-guided lumbar plexus block (LPB) combined with transmuscular quadratus lumborum block (TQLB) at the L3 level using the Shamrock approach for total hip arthroplasty.MethodsEighty-four patients were enrolled and randomly assigned into three groups at a 1:1:1 ratio: P group (LPB at L3 level), TP group (T12 paravertebral block combined with LPB at L3 and L4 levels) or PQ group (LPB combined with TQLB at L3 level). The primary outcome was the effective rate of sensory block, assessed via the cutaneous sensory block area. The secondary outcomes included postoperative pain intensity, intraoperative sufentanil consumption, incidence of hypotension, procedure time of block and complications.ResultsThe PQ group achieved a significantly higher effective rate of 67.6% compared to the P group, which was at 7.1% (p < 0.001), though lower than the TP group (89.3%, p = 0.051). The PQ group demonstrated significantly lower postoperative visual analogue scales (VAS) during movement compared to the P group (PACU: p = 0.009; 6 h: p = 0.046; 24 h: p = 0.006). However, no significant differences were observed between the PQ and TP groups under any condition (rest or movement). Sufentanil consumption remained comparable across the three groups. Notably, the PQ group experienced a lower frequency of intraoperative hypotension compared to the TP group (p = 0.028). Regarding procedure time, the PQ group exhibited a significantly lower mean value compared to the TP group, but it was higher than that in the P group (p < 0.001). Furthermore, no clinical signs of local anaesthetic systemic toxicity, nerve injury, haematoma or epidural block were observed in any of the groups.ConclusionsThe combined technique may provide effective block with fewer technical challenges and hypotension risks compared to multi-level LPB, making it a feasible alternative for perioperative pain management in total hip arthroplasty.Trial registrationClinicalTrials.gov, NCT04266236. Registered on 10 February 2020. ClinicalTrials.gov PRS: Record Summary NCT04266236.

This study aimed to implement and evaluate an enhanced recovery after surgery pathway for pediatric patients undergoing the Nuss procedure. The enhanced recovery after surgery pathway was implemented in 2024, and this protocol included preoperative education and counseling, a perioperative multimodal pain management protocol, a perioperative staged rehabilitation exercise program, and predischarge education. Data were collected prospectively for patients in the ERAS pathway and retrospectively for previous patients. Length of stay (LOS) and activity of daily living (the Barthel Index) were the main outcomes of this study, and the pain scores and time to first ambulation postoperatively were the secondary outcomes. A total of 86 patients were included in this study, with 43 patients in each group. There was no significant difference in age, sex, or the Haller index between the two groups. The average LOS decreased from 7.74 days to 6.84 days with ERAS. Patients in the ERAS group had improved Barthel indices, particularly on the day of discharge, and significantly lower pain scores from POD0 to POD3. The time to first ambulation was also shorter in the ERAS group. An enhanced recovery after surgery procedure implemented for the Nuss procedure can reduce the length of stay and early pain score. Alterations in the pathway may lead to the achievement of the desired goals of better self-care ability in daily living. Not applicable.

Introduction: Rectus Sheath Block (RSB) is a ‘Plan A’ regional anaesthesia technique used for perioperative pain management in abdominal surgeries [1]. Anaesthetists must perform these blocks proficiently, yet limited training opportunities reduce confidence and procedural uptake. Simulation training offers a solution, but existing models are often costly or lack anatomical realism. This study aims to develop and evaluate a cost-effective, anatomically representative, and reusable RSB training model. Methods: This prospective quality improvement project was registered with University Hospitals Sussex NHS Foundation Trust. A portable anterior abdominal wall model was constructed in a 1L storage container using ADAMgel, a low-cost, ultrasound-compatible material, alongside commercially available components such as chia seeds and latex exercise band [2]. The prototype was refined based on expert feedback. Anaesthetists from two hospitals evaluated the model by performing ultrasound scanning and needle insertions, on the 22/01/2025 and 07/02/2025 respectively. Feedback was then collected via an online questionnaire assessing ease of use, anatomical realism, needling practice, and overall usefulness on a 5-point Likert scale. Free-text responses provided additional insights. Quantitative data were analysed using descriptive statistics in Microsoft Excel, while qualitative data underwent thematic analysis. Results: Twelve anaesthetists (10 trainees, 2 consultants) evaluated the model. The majority (83%) found it easy to use (Likert score 4 or 5), and the same proportion considered it anatomically realistic. However, the most frequent suggestion was improving anatomical accuracy, particularly by varying the thickness of the transversus abdominis, internal oblique, and external oblique muscles. The model was especially valued as a medium to practice needling, with 92% rating it 4 or 5. This idea was further reflected in the free-text feedback where the realistic tactile response and reusable nature of the model were identified as key strengths. Discussion: This study demonstrates that a low-cost, reusable RSB training model can be effectively constructed using ADAMgel and other commercially available materials. The model was well received, particularly for its suitability for needling practice and realistic tactile feedback. Future improvements will focus on enhancing anatomical accuracy and enabling local anaesthetic injection to create a more lifelike experience. By providing an accessible training tool, this model has the potential to improve trainee confidence and proficiency, supporting regional anaesthesia training. Ethics Statement: As the submitting author, I can confirm that all relevant ethical standards of research and dissemination have been met. Additionally, I can confirm that the necessary ethical approval has been obtained, where applicabley.

Introduction: Right ventricular failure (RVF) is a common complication following left ventricular assist device (LVAD) implantation, resulting in significant morbidity and mortality. However, accurate prediction of RVF after LVAD remains limited, highlighting a critical need to improve patient selection and identify those who may benefit from enhanced right ventricular (RV) support. Hypothesis: We hypothesized that patients with genetic cardiomyopathies exhibit global myocardial dysfunction, including RV impairment and are at higher risk of RVF following LVAD implantation. Methods: We conducted a single-center retrospective study of consecutive adult patients who underwent LVAD implantation from January 1, 2018, to June 30, 2024. Clinical and genetic data were collected from the electronic medical record. Post-LVAD outcomes were classified using the 2021 INTERMACS Adverse Event Definitions, with early RVF defined as occurring within 30 days of implantation. Results: Among 136 LVAD recipients (87% male, 65% non-White, mean age 58 ± 14.4 years), most had non-ischemic cardiomyopathy (NICM, 68%) and received HeartMate 3 devices (82%) as destination therapy (63%). No significant differences in post-LVAD outcomes were observed between NICM and ischemic cardiomyopathy (ICM) groups. Genetic testing was performed in 48 patients (35%), revealing pathogenic/likely pathogenic (P/LP) variants in 9 (19%), variants of uncertain significance (VUS) in 26 (54%), and negative results in 13 (27%). Baseline RV function by echocardiography and invasive hemodynamics did not differ by genetic test results. Furthermore, genetic test results were not associated with significant differences in post-LVAD outcomes, including survival, driveline infection, pump thrombosis, stroke, and gastrointestinal bleeding. However, patients with P/LP variants had a significantly higher incidence of early RVF compared to those with VUS or negative results (89% vs. 38% vs. 15%, p&lt;0.01). Among only HeartMate 3 recipients, early RVF remained significantly more common in those with P/LP variants (75% vs. 30% vs. 8.3%, p=0.035). Conclusion: Presence of clinically actionable genetic (P/LP) variants were significantly associated with a higher incidence of early RVF post-LVAD. There were no differences in outcomes when stratified by cardiomyopathy etiology. These findings suggest that genetic testing may help identify patients who are at higher risk of early RVF post-LVAD and inform perioperative management strategies.

Introduction: As the global elderly population grows, so does the incidence of acute coronary syndrome (ACS) requiring urgent intervention. Emergency coronary artery bypass grafting (CABG) may offer a survival benefit, but concerns remain about its feasibility and safety in critically ill elderly patients with multiple comorbidities. Description of Case: This single-surgeon case series includes eight patients &gt;65 years old who underwent emergency CABG for ACS between September 2023 and September 2024. Comorbidities included diabetes, hypertension, CKD, COPD, and previous stroke. All patients were critically ill, requiring combinations of inotropes, intra-aortic balloon pump (IABP), and mechanical ventilation. Ejection fractions ranged from 20–45%, and EuroSCOREs ranged from 10.86 to 30.45. Standard cardiopulmonary bypass with moderate hypothermia and a single aortic cross-clamp was used. Postoperatively, complications included transient ischemic attacks, dialysis-requiring renal dysfunction, atrial fibrillation, and infections. All patients survived; extubation times ranged from 7 to 70 hours, and hospital stays from 5 to 12 days. Discussion: This case series examines outcomes of CABG in elderly patients, emphasizing that despite multiple comorbidities, through physiological assessment, CABG can safely be performed in critically ill patients Although the LVEF was low and multiple comorbidities like diabetes and chronic kidney disease, signify the importance of a comprehensive assessment of physiology beyond standard biomarkers is necessary to determine readiness for surgery. Ventilation times variations highlighted the consequences of pulmonary and hematological challenges encountered in these patients. Recent advances in surgical techniques and perioperative care have improved outcomes, and most patients showed enhanced quality of life and physical function within a year post-surgery. Conclusion: Emergency CABG can be a lifesaving therapy in critically ill elderly ACS patients. With careful perioperative management, advanced age and comorbidity burden should not preclude surgical intervention.

Introduction: Heart failure (HF) is one of the leading causes of hospitalization and mortality in the United States. Heart transplantation (HT) remains the definitive treatment for end-stage HF, sometimes preceded by left ventricular assist device (LVAD) implantation as a bridge to transplant. However, national data on inpatient outcomes for HT recipients with and without LVAD bridging remain limited. Methods: We analyzed the Nationwide Readmissions Database (NRD) from 2016–2019 to identify adult patients who underwent HT and were discharged between January and November of each year. Patients with missing data on event time or length of stay were excluded. Survey-weighted procedures were applied to account for the complex sampling design. We compared inpatient outcomes between patients who received LVAD implantation during the same index hospitalization and those who did not. Data were analyzed using SAS 9.4. Results: We identified 11,351 weighted adult patients who underwent HT from January to November 2016–2019. Of these, 2% (n=233) received LVAD during the same index hospitalization. LVAD recipients were younger (mean age: 50.7 vs. 53.3 years) and less likely to be female (23% vs. 27%) compared to non-LVAD patients. They also had higher rates of comorbidities, including acute encephalopathy (35% vs. 15%), advanced chronic kidney disease (19% vs. 9%), and cardiac cachexia (42% vs. 21%) (all p &lt; 0.001). LVAD recipients required more intensive inpatient interventions, such as percutaneous coronary intervention (1.7% vs. 0.6%), coronary artery bypass grafting (3.4% vs. 0.2%), intra-aortic balloon pump (27% vs. 19%), extracorporeal membrane oxygenation (28% vs. 9%), and peripheral VAD (63% vs. 4%) (all p &lt; 0.001). These patients experienced longer hospital stays (mean: 85 vs. 38 days) and higher inpatient mortality (15% vs. 5%, p &lt; 0.0007), as well as greater 30-day readmission mortality (1.3% vs. 0.2%, p = 0.01). Multivariable analysis identified acute encephalopathy, coagulopathy, and cardiac cachexia as independent predictors of inpatient mortality after adjusting for age, sex, kidney disease, and LVAD bridging. Conclusion: Heart transplant recipients requiring LVAD implantation during the same hospitalization experience significantly worse inpatient outcomes, including higher mortality and resource utilization. Early identification and risk stratification of these patients may help guide perioperative management and improve outcomes.

Aims: The aim of this systematic review with meta-analysis is to evaluate the mainly cardiovascular complications of the TAVI procedure in DM patients, addressing specifically the myocardial infarction and other injuries. Methods: The search of this systematic review and meta-analysis was conducted in PubMed, Cochrane and Embase to verify and identify relevant original trials and observational studies, fulfilling all of the regulations established by PRISMA guideline. The inclusion criteria used were studies that approached the complications of TAVI in DM patients and studies that used major cardiovascular events and complications as the main outcome. Furthermore, the forest plots analyzed the risk ratio of myocardial infarction, stroke, renal injury and other complications in patients with and without DM, using the R software (version 4.2.3, R Foundation for Statistical Computing, Vienna, Austria) under the random-effects model to estimate pooled outcomes and heterogeneity. Results: In outcomes related to Post-TAVI complications, a total of 5 studies were included in the bleeding outcome, involving 166,406 patients, with 60,311 in the DM group and 106,095 in the NDM group. This showed a pooled Risk Ratio of 0.98 [95% CI (0.83 to 1.17)]. Four studies were included in myocardial infarction outcome, involving 14,916 patients, with 4,536 in the DM group and 10,380 in the NDM group. The pooled Risk Ratio (RR) calculated using a random-effects model was 1.50 [95% CI (0.80 to 2.81)]. A total of 5 studies were included in renal injury outcome, involving 155,518 patients, with 56,925 in the DM group and 98,593 in the NDM group. The pooled Risk Ratio (RR) calculated using a random-effects model was 1.46 [95% CI (1.41 to 1.51)]. A total of 5 studies were included in stroke outcome, involving 166,156 patients, with 60,236 in the DM group and 105,920 in the NDM group. The pooled Risk Ratio (RR) calculated using a random-effects model was 0.91 [95% CI (0.83 to 0.99)]. Conclusion: This meta-analysis indicates that post-TAVI complications differ between diabetic and non-diabetic patients. While the risk of bleeding and stroke was comparable, diabetes was associated with a higher risk of renal injury and a potential increase in myocardial infarction. These findings emphasize the need for targeted perioperative management in diabetic patients undergoing TAVI.

Septic peritonitis (SP) is a complex, life-threatening disease, driven by peritoneal inflammation and microbial contamination, requiring timely and dynamic perioperative management. The aim of this review was to synthesize current knowledge on the perioperative management of SP in dogs and cats. Evidence-based strategies for initial stabilization include fluid resuscitation with balanced crystalloids, asopressors, and antimicrobial therapy targeting polymicrobial infections. Anesthetic management should prioritize hemodynamic stability and a multimodal approach to analgesia. Postoperative management should include early enteral nutrition (which is associated with increased survival) and monitoring and treatment of coagulation derangements. Patients should be closely monitored for recurrent SP after surgery, which is associated with high mortality. Evidence for risk factors of dehiscence such as hypoalbuminemia and interoperative hypotension is inconsistently found in studies. Other potential complications include hospital acquired infection and intra-abdominal hypertension. There is significant variation in the treatment approach for small animals with SP, likely due to gaps in evidence. Reported survival rates vary widely between studies due to diverse and inconsistent study populations, highlighting the need for further research to optimize care in veterinary patients.

Background: Wrong-route administration of intravenous (IV) medications into the epidural space is a rare but potentially harmful event in anesthetic practice. Although various agents have been inadvertently injected via the epidural route, there have been no previous reports involving sugammadex or ramosetron.Case: We report the accidental epidural injection of sugammadex (200 mg) and ramosetron (0.3 mg) in a 69-year-old female under general anesthesia with thoracic epidural analgesia. Errors were recognized within 5 min. As the patient exhibited no immediate adverse effects, emergence from anesthesia proceeded with IV sugammadex administration. Six hours later, the patient developed mild right triceps weakness and bilateral C8 dermatomal tingling, which improved on postoperative day two. The patient was discharged without any neurological sequelae.Conclusions: Although the outcome was benign, this incident underscores the potential risks of wrong-route drug delivery and highlights the need for vigilance and preventive strategies in perioperative medication management.

Post-endoscopic submucosal dissection electrocoagulation syndrome (PEECS) is a critical complication following endoscopic resection of gastric gastrointestinal stromal tumors (gGISTs). However, validated tools for predicting PEECS risk remain limited. This study aimed to develop and validate a scoring system to stratify PEECS risk in patients undergoing endoscopic submucosal dissection (ESD). A multicenter retrospective analysis included 618 patients with gGISTs treated with ESD between January 2011 and December 2024. Cohorts were stratified into a training cohort (TC, N = 346), an internal validation cohort (IVC, N = 148), and an external validation cohort (EVC, N = 124). Univariate and multivariate logistic regression analyses identified independent risk factors, which were weighted by regression coefficients to construct a scoring system. Performance metrics, including area under the curve (AUC), sensitivity, specificity, and predictive values, were evaluated across cohorts. PEECS occurred in 89 cases (14.4%). Multivariate analysis confirmed that circumferential tumor location, severe intraoperative bleeding, and prolonged procedure time as independent predictors. The scoring system assigned points as follows: anterior wall location (2 points), occurrence of severe intraoperative bleeding (3 points), and procedure time ≥ 60min (1 point). The scoring system demonstrated robust discrimination, with AUCs of 0.838 (IVC) and 0.842 (EVC), and high negative predictive values (NPV: 95.6% and 92.1%, respectively). PEECS incidence escalated with risk strata: low-risk (score 0-1: 4.8% TC, 4.4% IVC, 5.5% EVC), intermediate-risk (score 2-3: 21.6% TC, 21.6% IVC, 25.0% EVC), and high-risk (score 4-6: 92.3% TC, 100.0% IVC/EVC). This innovative scoring system, integrating tumor location, intraoperative bleeding, and procedure duration, provides a practical tool for predicting PEECS risk. Its robust validation across cohorts underscores its potential utility in guiding perioperative management and improving patient outcomes. Clinicians may use this tool to identify high-risk patients and implement preventive strategies proactively.

Blood pressure control during microsurgical clipping of intracranial aneurysms is challenging, as high blood pressure increases the risk of rupture, while hypotension may impair cerebral perfusion. The impact of intraoperative hypotension on postoperative cerebral infarction remains unclear. This study aims to identify independent risk factors and quantify the association between intraoperative hypotension and postoperative cerebral infarction. We conducted a retrospective case-control study of patients undergoing intracranial aneurysm clipping. The primary outcome was postoperative cerebral infarction, identified using routine computed tomography scans. Multivariate logistic regression analysis was performed to determine independent risk factors and assess the relationship between intraoperative hypotension parameters and postoperative cerebral infarction. Restricted cubic spline (RCS) models were used to quantify the relationship between intraoperative blood pressure and postoperative cerebral infarction. Among 689 patients, 83 (12.05%) experienced postoperative cerebral infarction. Multivariate regression analysis identified aneurysm size (odds ratio [OR] = 2.353, 95%CI: 1.327-4.173, P = 0.003), duration of intraoperative hypotension (OR = 1.021, 95%CI: 1.001-1.042, P = 0.045), and maximum diastolic blood pressure (OR = 0.717, 95%CI: 0.525-0.981, P = 0.038) as significant risk factors for postoperative cerebral infarction. RCS plots demonstrated an increased risk of postoperative cerebral infarction with prolonged hypotension durations and greater cumulative exposure to hypotension. The high incidence of cerebral infarction following intracranial aneurysm clipping underscores the need for careful perioperative management. Aneurysm size and intraoperative hypotension burden are independent risk factors for cerebral infarction. Strategies to minimize intraoperative hypotension during microsurgical clipping may help reduce postoperative infarction rates and improve patient outcomes. Clinical trial number: Not applicable.

Perioperative hyperglycemia in people with diabetes is associated with increased morbidity, mortality, and health care costs. Despite guideline recommendations to institute interventions to reduce hyperglycemia, standardized protocols that integrate into clinical workflows are lacking. In this article, we evaluate the efficacy of a digitally embedded, glycemic management protocol in people with diabetes undergoing surgery. We conducted a retrospective analysis of a quality improvement study conducted at a tertiary-care academic hospital. Adults with diabetes undergoing noncardiac surgery with more than two hours of procedure time were included. A multidisciplinary protocol was implemented guiding insulin administration and glucose monitoring across preoperative, intraoperative, and post-anesthesia care unit (PACU) phases. People undergoing surgery during one year before protocol implementation were compared with those in the year after. The primary outcome was the proportion of intraoperative glucose readings within 70 to 180 mg/dL. Secondary outcomes included glucose control in other perioperative phases, hypoglycemia incidence, and 30-day postoperative complications. Among 1254 adults (634 pre-intervention, 620 post-intervention), the mean proportion of intraoperative glucose values in the target range of 70 to 180 mg/dL showed a modest yet statistically significant improvement after protocol implementation (0.65 vs 0.72, P = .021). We found a reduced risk of hypoglycemia in the preoperative phase (3.7% vs 1.3%, P = .007) and no increased risk of hypoglycemia in the intraoperative or PACU phases. An increase in glucose monitoring and intravenous insulin use was noted across all phases of care (P < .001). Implementation of a digitally embedded perioperative glycemic management protocol improved glucose monitoring and intraoperative glucose control without increasing hypoglycemia. These findings support the safe and effective use of the protocol across surgical specialties and case urgencies, supporting the value of integrating decision support tools into clinical workflows.