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Poorly controlled acute postsurgical pain is associated with delayed recovery, chronic postsurgical pain (CPSP), chronic opioid use and impaired functioning in daily activities. The aim was to determine the effectiveness of a transitional pain service (TPS) to improve quality of recovery for patients at risk of CPSP. We hypothesized that a TPS improves the quality of recovery in patients at risk of CPSP. Single-center, pragmatic, randomized, superiority trial. Tertiary hospital in the Netherlands. Assessed for eligibility if ≥18 years of age, undergoing elective surgery, and had an increased risk of developing CPSP. After being stratified for sex, 176 patients were included. Patients were randomized to receive TPS or standard of care (SOC). TPS was a multidisciplinary intervention providing a patient-tailored perioperative pain management plan, throughout all phases of surgery. The primary outcome was the difference in quality of recovery on the third postoperative day, measured by the Quality of Recovery (QoR)-15 questionnaire. Secondary outcomes include the between group differences in opioid consumption. The primary outcome was available in 169 (96.0%) patients. No difference between groups was found in QoR-15 on the third postoperative day (mean difference 2.0, 95% CI -5.5 to 9.4, p = 0.607). A decrease in opioid usage (compared to baseline) was observed in chronic opioid users, the median [IQR] reduction in total daily oral morphine milligram equivalents (MME) for TPS was −30 [−60, 0] at three and − 29.3 [−65.6, 0] at six months, whereas SOC had a median reduction of 0 [−56, 0] at three, and 0 [−60, 7.5] at six months. TPS did not significantly affect short-term quality of recovery but might improve long-term outcomes, such as the incidence of chronic pain, opioid consumption, and functioning in daily life. However, sample size in the present study was too small to provide solid evidence for this positive signal. • The Transitional Pain Service (TPS) could optimize perioperative pain management. • RCTs investigating the effectiveness of a TPS have not been conducted yet. • In this RCT which included 176 patients, TPS did not improve quality of recovery. • TPS might improve long-term outcomes such as opioid consumption. • Limited support for positive long-term outcomes due to the small sample size. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, a significant proportion of moderate-to-deep sedation is performed by sedation practitioners under the indirect supervision of an anaesthesiologist but there are limited safety data available.Objective: To estimate the rate of sedation-related adverse events and patient relevant outcomes (PRO).Design: This was a prospective national observational study. Data were collected with a modified adverse event reporting tool from the International Sedation Task Force of the World Society of Intravenous Anaesthesia.Setting: A total of 24 hospitals in the Netherlands where moderate-to-deep sedation was performed by sedation practitioners from the 1 February 2015 to 1 March 2016.Patients: Consecutive adults undergoing moderate-to-deep sedation for gastrointestinal, pulmonary and cardiac procedures.Intervention: Observation: Analysis included descriptive statistics and a multivariate logistic regression model for an association between adverse events and PRO.Main Outcome Measures: The primary outcome was the rate of unfavourable PRO (admission to ICU, permanent neurological deficit, pulmonary aspiration or death). Secondary outcome was the rate of moderate-to-good PRO (unplanned hospital admission or escalation of care). Composite outcome was the sum of all primary and secondary outcomes.Results: A total of 11 869 patients with a median age of 64 years [interquartile range 51 to 72] were included. ASA physical score distribution was: first, 19.1%; second, 57.6%; third, 21.6%; fourth, 1.2%. Minimal adverse events occurred in 1517 (12.8%), minor adverse events in 113 (1.0%) and major adverse events in 80 instances (0.7%).Primary Outcome: Five (0.04%) unfavourable PRO were observed; four patients needing admission to the intensive care unit; and one died. Secondary outcome: 12 (0.1%) moderate-to-good PRO were observed. Moderate and major adverse events were associated with the composite outcome [3.7 (95% confidence interval 1.1 to 11.9) and 40.6 (95% confidence interval 11.0 to 150.4)], but not minimal or minor adverse events.Conclusion: Moderate-to-deep sedation performed by trained sedation practitioners has a very low rate of unfavourable outcome. [ABSTRACT FROM AUTHOR]

The article focuses on a study which examined the relation between hypoglycemia and intensive care unit mortality. The study included 5,961 patients who were admitted at the intensive care unit of Onze Lieve Vrouwe Gasthuis Hospital in Amsterdam, the Netherlands. It found that the incidence of death rate in patients with hypoglycemia was 40 per 1,000 intensive care unit days. Study authors concluded that hypoglycemia is related to intensive care unit mortality.

Management of pain after foot and ankle surgery remains a concern for patients and healthcare professionals. This study determined the effectiveness of ambulatory continuous popliteal sciatic nerve blockade, compared to standard of care, on overall benefit of analgesia score (OBAS) in patients undergoing foot or ankle surgery. We hypothesized that usage of ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care. Single center, randomized, non-inferiority trial. Tertiary hospital in the Netherlands. Patients were enrolled if ≥18 years and scheduled for elective inpatient foot or ankle surgery. Patients were randomized to ambulatory continuous popliteal sciatic nerve blockade or standard of care. The primary outcome was the difference in OBAS, which includes pain, side effects of analgesics, and patient satisfaction, measured daily from the first to the third day after surgery. A non-inferiority margin of 2 was set as the upper limit for the 90% confidence interval of the difference in OBAS score. Mixed-effects modeling was employed to analyze differences in OBAS scores over time. Secondary outcome was the difference in opioid consumption. Patients were randomized to standard of care (n = 22), or ambulatory continuous popliteal sciatic nerve blockade (n = 22). Analyzing the first three postoperative days, the OBAS was significantly lower over time in the ambulatory continuous popliteal sciatic nerve blockade group compared to standard of care, demonstrating non-inferiority (−1.9 points, 90% CI -3.1 to −0.7). During the first five postoperative days, patients with ambulatory continuous popliteal sciatic nerve blockade consumed significantly fewer opioids over time compared to standard of care (−8.7 oral morphine milligram equivalents; 95% CI -16.1 to −1.4). Ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care with single shot popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia. • Ambulatory nerve blocks are safe and feasible in foot and ankle surgery. • Ambulatory nerve blockade is non-inferior on overall benefit of analgesia. • Reduced opioid consumption makes this a promising option for foot or ankle surgery. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most complex gastrointestinal endoscopic procedures. Currently, it is still unclear which sedation regimen best facilitates an ERCP. The N-methyl-D-aspartate receptor antagonist esketamine has anaesthetic, analgesic and sympathomimetic properties and is known to cause less cardiorespiratory depression than other sedatives. It could therefore be an ideal adjunct to propofol for deep sedation., Objective: To assess the effectiveness of esketamine versus alfentanil as an adjunct to propofol target-controlled infusion (TCI) for deep sedation during ambulant ERCP., Design: A randomised controlled multicentre study., Setting: Endoscopic intervention suite at an academic and general hospital in the Netherlands., Participants: Adult, American Society of Anesthesiologists Physical Status I to III patients scheduled to undergo ERCP., Intervention: Consecutive patients were randomly assigned to receive sedation for an ERCP with propofol TCI and alfentanil (group A) or with propofol TCI and esketamine (group E)., Main Outcome Measures: The primary outcome was effectiveness of the sedation regimen expressed as the total dose of propofol - as a surrogate parameter - necessary to perform ERCP in a satisfactory manner for endoscopist and patients. Secondary outcomes were recovery time, patients' and endoscopists' satisfaction with sedation, side effects (e.g. psychotomimetic effects, nausea and vomiting) and the number of respiratory and cardiovascular adverse events., Results: Data from 162 patients were analysed. The total dose of propofol required was significantly lower in group E (n=83) (8.3 mg kg h) than in group A (n=79) (10.5 mg kg h) (P < 0.001). There were no significant differences in recovery time, patients' and endoscopists' satisfaction, side effects, psychotomimetic effects and the number of sedation-related adverse events., Conclusion: Low-dose esketamine reduces the total amount of propofol necessary for sedation during ERCP in American Society of Anesthesiologists I and II patients without affecting recovery time, satisfaction of patients and endoscopists, side effects and respiratory or cardiovascular adverse events, when compared with alfentanil., Trial Registration: The Netherlands Trial Register (NTR5486).

Objective: To investigate the relation between perioperative hyperglycemia and complications after pancreatoduodenectomy., Background: Perioperative hyperglycemia is associated with complications after various types of surgery. This relation was never investigated for pancreatoduodenectomy., Methods: In a consecutive series of 330 patients undergoing pancreatoduodenectomy, glucose values were collected from the hospital information system during 3 periods: pre-, intra-, and early postoperative. The average glucose value per period was calculated for each patient and divided in duals according to the median group value. Odds ratios for complications were calculated for the upper versus lower dual, adjusted for age, sex, American Society of Anesthesiologists Classification, body mass index, diabetes mellitus, intraoperative blood transfusion, duration of surgery, intraoperative insulin administration, and octreotide use. The same procedures were carried out to assess the consequences of increased glucose variability, expressed by the standard deviation., Results: Average glucose values were 135 (preoperative), 133 (intraoperative) and 142 mg/dL (early postoperative). Pre- and intraoperative glucose values were not associated with postoperative complications. Early postoperative hyperglycemia (≥140 mg/dL) was significantly associated with complications [odds ratio (OR) 2.9, 95% confidence interval (CI), 1.7-4.9]. Overall, high glucose variability was not significantly associated with postoperative complications, but early postoperative patients who had both high glucose values and high variability had an OR for complications of 3.6 (95% CI, 1.9-6.8) compared to the lower glucose dual., Conclusions: Early postoperative hyperglycemia is associated with postoperative complications after pancreatoduodenectomy. High glucose variability may enhance this risk. Future research must demonstrate whether strict glucose control in the early postoperative period prevents complications after pancreatoduodenectomy.

Objective: Mounting evidence suggests a role for glucose variability in predicting intensive care unit (ICU) mortality. We investigated the association between glucose variability and intensive care unit and in-hospital deaths across several ranges of mean glucose., Design: Retrospective cohort study., Setting: An 18-bed medical/surgical ICU in a teaching hospital., Patients: All patients admitted to the ICU from January 2004 through December 2007., Interventions: None., Measurements and Main Results: Two measures of variability, mean absolute glucose change per hour and sd, were calculated as measures of glucose variability from 5728 patients and were related to ICU and in-hospital death using logistic regression analysis. Mortality rates and adjusted odds ratios for ICU death per mean absolute glucose change per hour quartile across quartiles of mean glucose were calculated. Patients were treated with a computerized insulin algorithm (target glucose 72-126 mg/dL). Mean age was 65 +/- 13 yrs, 34% were female, and 6.3% of patients died in the ICU. The odds ratios for ICU death were higher for quartiles of mean absolute glucose change per hour compared with quartiles of mean glucose or sd. The highest odds ratio for ICU death was found in patients with the highest mean absolute glucose change per hour in the upper glucose quartile: odds ratio 12.4 (95% confidence interval, 3.2-47.9; p < .001). Mortality rates were lowest in the lowest mean absolute glucose change per hour quartiles., Conclusions: High glucose variability is firmly associated with ICU and in-hospital death. High glucose variability combined with high mean glucose values is associated with highest ICU mortality. In patients treated with strict glycemic control, low glucose variability seemed protective, even when mean glucose levels remained elevated.

Background: The long-term prognosis of endocarditis is described primarily in relation to clinical outcome measures-for example, such complications as cerebrovascular accident, cardiac failure, need for cardiac surgery, relapse rate, and mortality. To our knowledge, to date, no studies have examined the health-related quality of life and the prevalence of long-term persistence of physical symptoms for survivors of left-sided native valve endocarditis., Methods: We conducted a prospective follow-up study of patients treated for left-sided native valve endocarditis from 1 November 2000 through 31 October 2003 in 23 hospitals in the Netherlands. Of 86 patients eligible to participate, 55 completed questionnaires administered 3 m and 12 m after discharge; an additional 12 patients completed questionnaires 12 m after discharge only, making a total of 67 patients in our study. Persistence of symptoms and employment status were recorded. The health-related quality of life was measured by using the Dutch version of the Medical Outcomes Study Short Form 36-item health survey and the Posttraumatic Stress Disorder questionnaire., Results: Three months after the end of antimicrobial treatment, 41 (75%) of 55 patients still had physical symptoms. Twelve months after the end of antimicrobial treatment, 36 (54%) of 67 patients still had physical symptoms. Before the episode of endocarditis, 30 (81%) of 37 patients aged < or =60 years were employed and working. At 3 m follow-up, 16 (52%) of 31 patients returned to work, and at 12 m follow-up, 24 (65%) of 37 patients were working. One year after discharge, the health-related quality of life was impaired in 5 of 8 dimensions, compared with age-adjusted standard values, and 7 (11%) of 64 patients suffered from posttraumatic stress disorder., Conclusions: A year after discharge, most survivors of left-sided native valve endocarditis still had persisting symptoms and a seriously diminished quality of life, and 11% of patients suffered from posttraumatic stress disorder.