Search

Background Both saline and lactated Ringer’s solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer’s solution than normal saline. Methods The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer’s solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury. Results Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer’s solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer’s versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I–III versus 0, occurred in 6.6% of lactated Ringer’s patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful. Conclusions In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer’s or saline volume replacement. Clinicians can reasonably use either solution intraoperatively. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

INTRODUCTION: Endotracheal intubation is one of the basic procedures performed in emergency medicine in patients with respiratory insufficiency, inability to maintain airway patency, or apnoea. Rapid performance of the procedure and implementation of ventilation are among the basic principles of rescue procedures. The primary aim of the present systematic review and meta-analysis was to compare the VivaSight SL tube-mounted camera with a standard endotracheal single-lumen tube and direct laryngoscope for endotracheal intubation based on randomised controlled trials of simulation or cadaver trials. The analysis was based on the hypothesis that the use of videolaryngoscopy based on VivaSight SL tube increases the effectiveness of endotracheal intubation, reducing the risk of ineffectiveness of the first intubation attempt and the risk of adverse events, such as dental compression. MATERIAL AND METHODS: We searched the MEDLINE, EMBASE, Scopus, Cochrane, and Google Scholar databases for randomised, controlled trials and observational studies from 1985 until October 2019, without language restrictions. Grey literature, clinicaltrials.gov, and reference lists of articles were hand searched. We conducted a meta-analysis with random-effects models to evaluate time to intubation, first-pass success rates, overall success rates, dental compression, and glottic view. RESULTS: The search located 12 eligible studies. The time of intubation using VivaSight was significantly shorter than that of direct laryngoscopy (MD = –11.29 [–13.10, –9.49], p < 0.001). The efficacy of the first intubation attempt was higher for VivaSight than for DL (96.0% vs. 61.7%; RR = 1.62 [1.40, 1.88], p < 0.001). The meta-analysis showed that the total efficacy of VivaSight intubation compared to direct laryngoscopy was statistically significantly higher (100% vs. 88.9%, RR = 1.11 [1.02, 1.20]; p = 0.02). The glottis visibility assessed as Cormack-Lehane grade I or II was better in VivaSight intubation compared to direct laryngoscopy (100% vs. 90.9%, RR = 1.05 [0.99, 1.12]; p = 0.08). CONCLUSIONS: Our meta-analysis suggests that the VivaSight SL provided better glottic visualisation and shorter intubation time, with improved success rates during different simulated intubation scenarios.

INTRODUCTION: The airway management and the implementation of optimal oxygen therapy in trauma patients, especially unconscious ones, is a key element of prehospital management. However, in cases of trauma lung or bronchial rupture, both lungs ventilation may not be advisable. In such cases, intubation with a double-lumen endotracheal tube may be helpful, allowing to provide one-lung ventilation. The aim of the experimental study was to assess the impact of short training in intubation using double-lumen tubes on the effectiveness of intubation performance and one-lung ventilation by paramedics in a simulated trauma patient setting. MATERIAL AND METHODS: This was a prospective, observational, randomized experimental trial. The study involved 30 paramedics. The participants had to perform tracheal intubation using Double Lumen Tube VivaSight-DL (VS-DL; ETView Ltd.; Misgav, Israel) under normal airway conditions. The effectiveness of the first intubation attempt, the time of intubation and the Cormack-Lehane scale were evaluated. RESULTS: The effectiveness of the first attempt at intubation with a double-lumen tube was 90% and the total effectiveness of intubation was 100%. The median time of the procedure was 63 (IQR; 38–72.5) seconds. CONCLUSIONS: In the simulation study, the paramedics were able to intubate using a double tube after a short training.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Arterial pressure is a complex signal that can be characterized by systolic, mean, and diastolic components, along with pulse pressure (difference between systolic and diastolic pressures). The authors separately evaluated the strength of associations among intraoperative pressure components with myocardial and kidney injury after noncardiac surgery. Methods The authors included 23,140 noncardiac surgery patients at Cleveland Clinic who had blood pressure recorded at 1-min intervals from radial arterial catheters. The authors used univariable smoothing and multivariable logistic regression to estimate probabilities of each outcome as function of patients’ lowest pressure for a cumulative 5 min for each component, comparing discriminative ability using C-statistics. The authors further assessed the association between outcomes and both area and minutes under derived thresholds corresponding to the beginning of increased risk for the average patient. Results Out of 23,140 patients analyzed, myocardial injury occurred in 6.1% and acute kidney injury in 8.2%. Based on the lowest patient blood pressure experienced for greater than or equal to 5 min, estimated thresholds below which the odds of myocardial or kidney injury progressively increased (slope P < 0.001) were 90 mmHg for systolic, 65 mmHg for mean, 50 mmHg for diastolic, and 35 mmHg for pulse pressure. Weak discriminative ability was noted between the pressure components, with univariable C-statistics ranging from 0.55 to 0.59. Area under the curve in the highest (deepest) quartile of exposure below the respective thresholds had significantly higher odds of myocardial injury after noncardiac surgery and acute kidney injury compared to no exposure for systolic, mean, and pulse pressure (all P < 0.001), but not diastolic, after adjusting for confounding. Conclusions Systolic, mean, and pulse pressure hypotension were comparable in their strength of association with myocardial and renal injury. In contrast, the relationship with diastolic pressure was poor. Baseline factors were much more strongly associated with myocardial and renal injury than intraoperative blood pressure, but pressure differs in being modifiable.

Chest pain is relatively common postoperatively. Myocardial infarction (MI) is one cause of chest pain after surgery, but chest pain also results from less severe conditions. Because of its potential severity, chest pain usually prompts the activation of Rapid Response Systems (RRS). While chest pain is a cardinal symptom of myocardial ischemia in the non-surgical setting, the significance and relevance of chest pain after noncardiac surgery remains unclear.We conducted a retrospective analysis of noncardiac surgical inpatients for whom postoperative chest pain triggered our multidisciplinary RRS.Surgical wards at Cleveland Clinic, Cleveland, OH.Postsurgical patients after noncardiac surgery in whom the RSS system was activated for chest pain.RRS specified interventions like ECG readings, troponin measurements, transfer to ICU.Our primary outcome was MI. Secondary outcomes included the proportion of patients who had an ECG performed, troponin measurements, echocardiography, cardiac catheterization, and were admitted to the Intensive Care Unit (ICU).5850 surgical patients experienced postoperative chest pain and triggered an RRS activation between 2009 and 2019. A total of 3110 patients had troponin T measured within 6 h after RRS activation, and 538 of them (17%) had elevated troponin, meeting the Fourth Universal Definition criteria for MI. Additionally, 2 patients had ST-segment elevation infarction (STEMI) without troponin measurement. Among the 540 patients with MI, only 19 (3.5%) were diagnosed with a STEMI by ECG, 388 (72%) had echocardiography, 43 patients (8%) had cardiac catheterization, 8 patients (1.5%) required emergent cardiac surgery, and 424 (79%) were admitted to an ICU.Chest pain is a serious clinical sign, often indicating a postoperative myocardial infarction, and therefore should be taken seriously. Troponin screening should be routinely considered in postsurgical patients who report chest pain.

Moderate intraoperative hypothermia promotes myocardial injury, surgical site infections, and blood loss. Whether aggressive warming to a truly normothermic temperature near 37°C improves outcomes remains unknown. We aimed to test the hypothesis that aggressive intraoperative warming reduces major perioperative complications.In this multicentre, parallel group, superiority trial, patients at 12 sites in China and at the Cleveland Clinic in the USA were randomly assigned (1:1) to receive either aggressive warming to a target core temperature of 37°C (aggressively warmed group) or routine thermal management to a target of 35·5°C (routine thermal management group) during non-cardiac surgery. Randomisation was stratified by site, with computer-generated, randomly sized blocks. Eligible patients (aged ≥45 years) had at least one cardiovascular risk factor, were scheduled for inpatient non-cardiac surgery expected to last 2-6 h with general anaesthesia, and were expected to have at least half of the anterior skin surface available for warming. Patients requiring dialysis and those with a body-mass index exceeding 30 kg/mBetween March 27, 2017, and March 16, 2021, 5056 participants were enrolled, of whom 5013 were included in the intention-to-treat population (2507 in the aggressively warmed group and 2506 in the routine thermal management group). Patients assigned to aggressive warming had a mean final intraoperative core temperature of 37·1°C (SD 0·3) whereas the routine thermal management group averaged 35·6°C (SD 0·3). At least one of the primary outcome components (myocardial injury after non-cardiac surgery, cardiac arrest, or mortality) occurred in 246 (9·9%) of 2497 patients in the aggressively warmed group and in 239 (9·6%) of 2490 patients in the routine thermal management group. The common effect relative risk of aggressive versus routine thermal management was an estimated 1·04 (95% CI 0·87-1·24, p=0·69). There were 39 adverse events in patients assigned to aggressive warming (17 of which were serious) and 54 in those assigned to routine thermal management (30 of which were serious). One serious adverse event, in an aggressively warmed patient, was deemed to be possibly related to thermal management.The incidence of a 30-day composite of major cardiovascular outcomes did not differ significantly in patients randomised to 35·5°C and to 37°C. At least over a 1·5°C range from very mild hypothermia to full normothermia, there was no evidence that any substantive outcome varied. Keeping core temperature at least 35·5°C in surgical patients appears sufficient.3M and the Health and Medical Research Fund, Food and Health Bureau, Hong Kong.For the Chinese translation of the abstract see Supplementary Materials section.

BACKGROUND Perioperative bleeding is common in patients undergoing noncardiac surgery. Tranexamic acid is an antifibrinolytic drug that may safely decrease such bleeding. METHODS We conducted a trial involving patients undergoing noncardiac surgery. Patients were randomly assigned to receive tranexamic acid (1-g intravenous bolus) or placebo at the start and end of surgery (reported here) and, with the use of a partial factorial design, a hypotension-avoidance or hypertension-avoidance strategy (not reported here). The primary efficacy outcome was life-threatening bleeding, major bleeding, or bleeding into a critical organ (composite bleeding outcome) at 30 days. The pri- mary safety outcome was myocardial injury after noncardiac surgery, nonhemor- rhagic stroke, peripheral arterial thrombosis, or symptomatic proximal venous thromboembolism (composite cardiovascular outcome) at 30 days. To establish the noninferiority of tranexamic acid to placebo for the composite cardiovascular out- come, the upper boundary of the one-sided 97.5% confidence interval for the hazard ratio had to be below 1.125, and the one-sided P value had to be less than 0.025. RESULTS A total of 9535 patients underwent randomization. A composite bleeding outcome event occurred in 433 of 4757 patients (9.1%) in the tranexamic acid group and in 561 of 4778 patients (11.7%) in the placebo group (hazard ratio, 0.76; 95% confi- dence interval [CI], 0.67 to 0.87; absolute difference, −2.6 percentage points; 95% CI, −3.8 to −1.4; two-sided P

Background: Naloxegol antagonizes peripheral opioid-related side effects without preventing opioid-related analgesia. However, the effect of naloxegol on opioid-induced bladder dysfunction remains unknown. Hypothesis: patients given naloxegol have lower residual bladder urine volume than those given placebo. Methods: 136 patients scheduled for elective hip and knee surgery were randomized to oral naloxegol or placebo given the morning of surgery, and on the first two postoperative mornings. Residual urine volume was measured ultrasonographically within 30 min after voiding once in the morning and once in the afternoon for two postoperative days. Opioid-related Symptom Distress Scale (ORSDS), the need for indwelling urinary catheterization, and quality of recovery (QoR) score were secondary outcomes. Results: 67 were randomized to naloxegol and 64 to placebo. We did not identify a significant effect on urine residual volume, with an estimated ratio of geometric means of 0.9 (0.3, 2.6), p = 0.84. There were no significant differences in ORSDS or QoR. There were 19 (29%) patients assigned to naloxegol who needed indwelling urination catheterization versus 7 (11%) patients in the placebo group, p = 0.012. Conclusions: Our results do not support use of naloxegol for postoperative urinary retention after hip and knee surgery.

Background Specific immunotherapy for patients with honey bee hypersensitivity is commonly applied. Re-challenge with venom is performed to prove protection in individual cases. Case presenation We report a case of near fatal anaphylaxis with asystole for 24 min in a 35-years-old patient with mastocytosis after honey bee sting challenge, despite 5-years of specific immunotherapy. Successful cardio-pulmonary resuscitation was applied for 32 min. Conclusion This intervention demonstrates, that in anaphylaxis with cardio-vascular arrest, prolonged cardio-pulmonary resuscitation for up to 40 min may be appropriate to overcome the half-life of massively released histamine. Failure of specific immunotherapy was possibly due to sensitization to the allergen Api m10, potentially underrepresented in commercial honey bee venom extracts. Molecular analyses may provide additional clues to the potentially unsuccessful outcome of venom specific immunotherapy, especially in high-risk patients such as mastocytosis.

Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.

Obesity, defined by the World Health Organization as body mass index (BMI) ≥ 30.0 kg/mRetrospective cohort study.Operating room.We analyzed electronic records of adults having cardiac and thoracic surgery requiring general anesthesia and endotracheal intubation with DLT at the Cleveland Clinic between 2008 and 2021.BMI, preoperative airway abnormalities and difficult intubation, defined as more than one intubation attempt, was assessed using multivariable logistic regression.Among 8641 analyzed anesthetics requiring DLT, 1459 (17%) were difficult intubations. After adjusting for confounders, each 5 kg/mDifficult intubations with DLT remain common, but BMI is a weak predictor thereof. For example, an increase in BMI from 20 to 40 kg/m

Perioperative myocardial infarction is frequently attributed to type 2 myocardial infarction, a mismatch in myocardial oxygen supply-demand without unstable coronary artery disease. Our aim was to identify characteristics, management, and outcomes of perioperative type 1 versus type 2 myocardial infarction among surgical inpatients.Adults age ≥45 years hospitalized for noncardiac surgery were identified in the United States. Perioperative myocardial infarction were identified using International Classification of Diseases, 10th revision (ICD-10) codes. Clinical characteristics, invasive myocardial infarction management, mortality, and readmissions were assessed by myocardial infarction subtype.Among 4,755,382 surgical hospitalizations, we identified 38,975 perioperative myocardial infarctions (0.82%), with type 2 infarction in 42%. Patients with type 2 myocardial infarction were older, more likely to be women, and less likely to have cardiovascular comorbidities compared with type 1 myocardial infarction. Fewer patients with type 2 myocardial infarction underwent invasive management than type 1 myocardial infarction (6.7% vs 28.8%, P.001). Type 2 myocardial infarction mortality was lower than type 1 myocardial infarction mortality (12.1% vs 17.4%, P.001; adjusted odds ratio [aOR] 0.51, 95% confidence interval [CI] 0.45-0.59). Invasive management of perioperative myocardial infarction was associated with lower mortality in type 1 (aOR 0.56, 95% CI 0.49-0.74) but not type 2 (aOR 1.19, 95% CI 0.77-1.85) myocardial infarction. Among survivors, there was no difference in 90-day hospital readmission between type 2 and type 1 perioperative myocardial infarction (36.5% vs 36.1%, P = .72).Type 2 myocardial infarctions account for approximately 40% of perioperative myocardial infarctions. Patients with type 2 perioperative myocardial infarction are less likely to undergo invasive management and have lower mortality compared with those with type 1 perioperative myocardial infarction.

Background: The ability to perform high-quality cardiopulmonary resuscitation is one of the basic skills for lifeguards. The aim of the study was to assess the influence of chest compression frequency on the quality of the parameters of chest compressions performed by lifeguards. Methods: This prospective observational, randomized, crossover simulation study was performed with 40 lifeguards working in Warsaw, Wroclaw, and Poznan, Poland. The subjects then participated in a target study, in which they were asked to perform 2-min cycles of metronome-guided chest compressions at different rates: 80, 90, 100, 110, 120, 130, 140, and 150 compressions per minute (CPM). Results: The study involved 40 lifeguards. Optimal chest compression score calculated by manikin software was achieved for 110–120 CPM. Chest compression depth achieved 53 (interquartile range [IQR] 52–54) mm, 56 (IQR 54–57) mm, 52.5 (IQR 50–54) mm, 53 (IQR 52–53) mm, 50 (IQR 49–51) mm, 47 (IQR 44–51) mm, 41 (IQR 40–42) mm, 38 (IQR 38–43) mm for 80, 90, 100, 110, 120, 130, 140 and 150 CPM, respectively. The percentage of chest compressions with the correct depth was lower for rates exceeding 120 CPM. Conclusions: The rate of 100–120 CPM, as recommended by international guidelines, is the optimal chest compression rate for cardiopulmonary resuscitation performed by lifeguards. A rate above 120 CPM was associated with a dramatic decrease in chest compression depth and overall chest compression quality. The role of full chest recoil should be emphasized in basic life support training.

Hintergrund Padiatrische Notfallbander (PNB) unterstutzen medizinisches Notfallpersonal bei der Versorgung von padiatrischen Notfallpatienten. Ein kurzlich veroffentlichter digitaler Algorithmus zur langenbasierten Gewichtsschatzung war im Vergleich zu den auf dem Markt erhaltlichen Bandern praziser. Um diesen digitalen Algorithmus klinisch zu testen, wurde ein Prototyp eines elektronischen PNB (ePER) entwickelt. Ziel Das Ziel dieser Studie war es, das ePER mit zwei bekannten papierbasierten, analogen PNB hinsichtlich Zeitbedarf und Prazision in einem padiatrischen Notfallszenario zu vergleichen. Methoden Mitarbeiter der Anasthesieabteilung des Universitats-Kinderspitals Zurich wurden gebeten, in randomisierter Reihenfolge mittels der beiden PNB und des ePER in einem simulierten Notfallszenario an padiatrischen Notfallpuppen die Parameter Gewicht, Defibrillationsenergie, Adrenalindosis und Grose des endotrachealen Tubus zu bestimmen. Jeder Ablauf wurde mit einem digitalen Rekorder aufgezeichnet. Aus diesen Aufzeichnungen wurden die Zeit bis zur Nennung der jeweiligen Parameter und deren Korrektheit ermittelt. Ergebnisse Das Auffinden der definierten Parameter war mit dem ePER schneller als mit den konventionellen PNB (30 s vs. 47 s bzw. 51 s; beide p

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Low 25-hydroxyvitamin D is associated with cardiovascular, renal, and infectious risks. Postsurgical patients are susceptible to similar complications, but whether vitamin D deficiency contributes to postoperative complications remains unclear. We tested whether low preoperative vitamin D is associated with cardiovascular events within 30 days after noncardiac surgery. Methods We evaluated a subset of patients enrolled in the biobank substudy of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) study, who were at least 45 yr with at least an overnight hospitalization. Blood was collected preoperatively, and 25-hydroxyvitamin D was measured in stored samples. The primary outcome was the composite of cardiovascular events (death, myocardial injury, nonfatal cardiac arrest, stroke, congestive heart failure) within 30 postoperative days. Secondary outcomes were kidney injury and infectious complications. Results A total of 3,851 participants were eligible for analysis. Preoperative 25-hydroxyvitamin D concentration was 70 ± 30 nmol/l, and 62% of patients were vitamin D deficient. Overall, 26 (0.7%) patients died, 41 (1.1%) had congestive heart failure or nonfatal cardiac arrest, 540 (14%) had myocardial injury, and 15 (0.4%) had strokes. Preoperative vitamin D concentration was not associated with the primary outcome (average relative effect odds ratio [95% CI]: 0.93 [0.85, 1.01] per 10 nmol/l increase in preoperative vitamin D, P = 0.095). However, it was associated with postoperative infection (average relative effect odds ratio [95% CI]: 0.94 [0.90, 0.98] per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.005) and kidney function (estimated mean change in postoperative estimated glomerular filtration rate [95% CI]: 0.29 [0.11, 0.48] ml min-1 1.73 m-2 per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.004). Conclusions Preoperative vitamin D was not associated with a composite of postoperative 30-day cardiac outcomes. However, there was a significant association between vitamin D deficiency and a composite of infectious complications and decreased kidney function. While renal effects were not clinically meaningful, the effect of vitamin D supplementation on infectious complications requires further study.

Myocardial injury after noncardiac surgery (MINS) differs from myocardial infarction in being defined by troponin elevation apparently from cardiac ischemia with or without signs and symptoms. Such myocardial injury is common, silent, and strongly associated with mortality. MINS is usually asymptomatic and only detected by routine troponin monitoring. There is currently no known safe and effective prophylaxis for perioperative myocardial injury. However, appropriate preoperative screening may help guide proactive postoperative preventative actions. Intraoperative hypotension is associated with myocardial injury, acute kidney injury, and death. Hypotension is common and largely undetected in the postoperative general care floor setting, and independently associated with myocardial injury and mortality. Critical care patients are especially sensitive to hypotension, and the risk appears to be present at blood pressures previously regarded as normal. Tachycardia appears to be less important. Available information suggests that clinicians would be prudent to avoid perioperative hypotension.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is one of the major causes of mortality and mortality affecting the whole world. In the inflammatory process, lectin is elevated and consequently, Galectin-3 expression is increased. This relation has been revealed by studies on coronary diseases. However, studies on the association of Galectin-3 with COPD and even other pulmonary diseases have been limited, although it has been studied and described on cardiologic patients. For this reason, in this study Galectin-3 levels in different stages of COPD patients were investigated and whether Galectin-3 could be a guide clinically. MATERIAL AND METHODS: This is an observational prospective study, approved by local ethic committee (30112015-12), which included three groups of patients, COPD exacerbation, COPD stable and control group, admitted to tertiary healthcare between 01.09.2016 and 01.09.2017. RESULTS: 137 subjects were included in the study. The mean age of patients in the study was 70.6. Galectin- 3 level in the group of COPD (exacerbation and stable) was significantly lower than the control group (p < 0.001). The Galectin-3 level was significantly lower in COPD exacerbation group than groups of stable COPD and control. And also, Galectin-3 level was significantly lower in stable COPD group than the control group (p values: 0.034, 0.001 and 0.013, respectively). The ROC analysis for the Galectin-3 levels between the COPD patients (exacerbation and stable) and the control group is shown in Figure 2 (AUC = 0.784). When the cut-off points of Galectin-3 is selected as 11.4; for this cut-off point, sensitivity is 83% and specificity is 71% for this cut-off point (AUC: 0.79 %95 GA: 0.70–0.86 p < 0.001). CONCLUSIONS: COPD is a disease with high mortality and morbidity and efforts are being made to identify its severity and exacerbations with various biomarkers. In this study, Galectin-3 levels were found to be lower in patients with stable COPD group according to the control group. In addition, galactin-3 levels were found to be lower in COPD exacerbation group according to both Stable COPD group and control group. Although a certain threshold value was found in this study, more studies are needed to determine this threshold value more precisely. However, it is clear that these data are promising.

INTRODUCTION: The ability to protect the airway is one of the basic skills that medical staff should have, especially those working within the Emergency Medical Service or Emergency Department. Endotracheal intubation under medical emergency conditions based on direct laryngoscopy is not effective enough; this effect is additionally reduced in the case of the difficult airway resulting from reduced visibility of the entrance to the glottis due to tongue or epiglottis oedema, trauma, etc. The aim of the study was to compare the intubation time and its effectiveness using two different stylets for difficult airway intubation. MATERIAL AND METHODS: The study involved 37 nurses who participated in training on advanced life support procedures. The experiment was designed as a randomized, cross-over simulation study. During the training, participants were instructed to perform endotracheal intubation using the tested intubation methods and had 20 minutes of practical training during which they were able to intubate with the tested stylets under normal airway. In the study, participants performed endotracheal intubation using a laryngoscope with a Macintosh blade and a difficult airway Bougie stylet (ONTEX, Chennai, India), or the Flexible Tip Bougie (MDSS GmbH, Hannover, Germany), which was designed to allow to guide the distal end of the anteriorly and posteriorly to facilitate entry into the larynx. RESULTS: The effectiveness of the first intubation attempt using a standard Bougie stylet was 37.8%, and that of the new Bougie stylet was 51.4% (p = 0.037). The mean intubation time was 55 s (IQR; 34–65) vs. 37 s (IQR; 25–41) (respectively, p = 0.021). The median ease of intubation was 7 (IQR; 5–9) points for a standard Bougie stylet and 5 (2.5–7) 2 points for a new Bougie stylet (p = 0.018). CONCLUSIONS: In a simulation study, the use of Flextip Bougie by nurses compared to a standard Bougie stylet was associated with higher efficacy and shorter intubation times in difficult airway.

The advent of advanced diagnostic bronchoscopy has shown an increased demand for anesthesiologists to administer anesthesia in the bronchoscopy suite. Procedures such as navigational bronchoscopy, airway stenting and advanced therapeutic procedures often require the presence of an anesthesiologist to manage these more complex patients and procedures. In this review we describe the various bronchoscopic procedures and anesthetic management and complications of these procedures at our institution The Cleveland Clinic, Cleveland Ohio.

Ultrasonography is a diagnostic technique that has been used clinically for 30 years. Due to the increased availability of ultrasound machines as well as the reduction of their size and making them more mobile, ultrasound has found its place in early diagnosis in emergency medicine settings. One of the important, however, an underestimated ultrasound examination is the measurement of the thickness of the optic nerve sheath. The optic nerve is the second cranial nerve, meaning the same sheath surrounds it as the brain. At the moment of intracranial pressure increase, cerebrospinal fluid flows into the subarachnoid space causing an increase in intracranial pressure and thus increasing the diameter of the optic nerve sheath. therefore, ONSD imaging is a quick non-invasive test aimed at detecting and monitoring changes in intracranial pres- sure. Optic nerve sheath ultrasound is a simple, safe and inexpensive bedside diagnostic test. Ophthalmic ultrasound usually uses the frequency between 5 and 10.5 MHz to evaluate the eye and the orbit.

BACKGROUND Neuraxial anesthesia improves components of the Virchow's triad (hypercoagulability, venous stasis, and endothelial injury) which are key pathogenic contributors to venous thrombosis in surgical patients. However, whether neuraxial anesthesia reduces the incidence of venous thromboembolism (VTE) remain unclear. We therefore tested the primary hypothesis that neuraxial anesthesia reduces the incidence of 30-day VTE in adults recovering from orthopedic surgery. Secondarily, we tested the hypotheses that neuraxial anesthesia reduces 30-day readmission, 30-day mortality, and the duration of postoperative hospitalization. METHODS Inpatient orthopedic surgeries from American College of Surgeons National Surgical Quality Improvement Program database (2011-2015) in adults lasting more than 1 hour with either neuraxial or general anesthesia were included. Groups were matched 1:1 by propensity score matching for appropriate confounders. Logistic regression model was used to assess the effect of neuraxial anesthesia on 30-day VTE, 30-day mortality, and readmission, while Cox proportional hazard regression model was used to assess its effect on length of stay. RESULTS Neuraxial anesthesia decreased odds of 30-day VTE (odds ratio 0.85, 95% confidence interval, 0.78-0.95; P = .002) corresponding to number-needed-to-treat of 500. Although there was no difference in 30-day mortality, neuraxial anesthesia reduced 30-day readmission (odds ratio 0.90, 98.3% confidence interval, 0.85-0.95; P < .001) corresponding to number-needed-to-treat of 250 and had a shortened hospitalization (2.87 vs 3.11; P < .001). CONCLUSIONS Neuraxial anesthesia appears to provide only weak VTE prophylaxis, but can be offered as an adjuvant to current thromboprophylaxis in high-risk patients.

To test the hypotheses that in adults having cardiac surgery with cardio-pulmonary bypass, perioperative hypotension increases the risk of delirium and atrial fibrillation during the initial five postoperative days.Sub-analysis of the DECADE multi-center randomized trial.Patients who had cardiac surgery with cardiopulmonary bypass at the Cleveland Clinic.In the underlying trial, patients were randomly assigned 1:1 to dexmedetomidine or normal saline placebo.Intraoperative mean arterial pressures were recorded at 1-min intervals from arterial catheters or at 1-5-min intervals oscillometrically. Postoperative blood pressures were recorded every half-hour or more often. The co-primary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. Delirium was assessed twice daily during the initial 5 postoperative days while patients remained hospitalized with the Confusion Assessment Method for the intensive care unit. Assessments were made by trained research fellows who were blinded to the dexmedetomidine administration.There was no significant association between intraoperative hypotension and delirium, with an adjusted odds ratio of 0.94 (95% CI: 0.81, 1.09; P = 0.419) for a doubling in AUC of mean arterial pressure (MAP)60 mmHg. An increase in intraoperative AUC of MAP60 mmHg was not significantly associated with the odds of atrial fibrillation (adjusted odds ratio = 0.99; 95% CI: 0.87, 1.11; P = 0.819). Postoperative MAP70 mmHg per hour 1.14 (97.5% CI: 1.04,1.26; P = 0.002) and MAP80 mmHg per hour 1.05 (97.5%: 1.01, 1.10; P = 0.010) were significantly associated with atrial fibrillation.In patients having cardiac surgery with cardio-pulmonary bypass, neither intraoperative nor postoperative hypotension were associated with delirium. Postoperative hypotension was associated with atrial fibrillation, although intraoperative hypotension was not.

To test whether patients who experience hypotension in the post-anesthesia care unit or during surgery are most likely to experience hypotension on surgical wards.A prediction study using data from two randomized controlled trials.Operating room, post-anesthesia care unit, and surgical ward.550 adult patients having abdominal surgery with ASA physical status I-IV.Blood pressure measurement per routine intraoperatively, and with continuous non-invasive monitoring postoperatively.The primary predictors were minimum mean arterial pressure (60,65,70 and 80 mmHg) and minimum systolic blood pressure (70,75,80,85 mmHg) in the post-anesthesia care unit. The secondary predictors were intraoperative minimum blood pressures with the same thresholds as the primary ones. Our outcome was ward hypotension defined as mean pressure 70 mmHg or systolic pressure 85 mmHg. A threshold was considered clinically useful if both sensitivity and specificity exceeded 0.75.Minimum mean and systolic pressures in the post-anesthesia care unit similarly predicted ward mean or systolic hypotension, with the areas under the curves near 0.74. The best performing threshold was mean pressure 80 mmHg in the post-anesthesia care unit which had a sensitivity of 0.41 (95% confidence interval [CI], 0.35, 0.47) and specificity of 0.91 (95% CI, 0.87, 0.94) for ward mean pressure 70 mmHg and a sensitivity of 0.44 (95% CI, 0.37, 0.51) and specificity of 0.88 (95% CI, 0.84, 0.91) for ward systolic pressure 85 mmHg. The areas under the curves using intraoperative hypotension to predict ward hypotension were roughly similar at about 0.60, with correspondingly low sensitivity and specificity.Intraoperative hypotension poorly predicted ward hypotension. Pressures in the post-anesthesia care unit were more predictive, but the combination of sensitivity and specificity remained poor. Unless far better predictors are identified, all surgical inpatients should be considered at risk for postoperative hypotension.

Cardiac arrest (CA) is associated with high mortality and poor life quality. Targeted temperature management (TTM) or therapeutic hypothermia is a therapy increasing the survival of adult patients after CA. The study aim was to assess the feasibility of therapeutic hypothermia after pediatric CA. We performed a systematic review and meta-analysis of randomized controlled trials and observational studies evaluating the use of TTM after pediatric CA. The primary outcome was survival to hospital discharge or 30-day survival. Secondary outcomes included a one-year survival rate, survival with a Vineland adaptive behavior scale (VABS-II) score ≥ 70, and occurrence of adverse events. Ten articles (n = 2002 patients) were included, comparing TTM patients (n = 638) with controls (n = 1364). In a fixed-effects meta-analysis, survival to hospital discharge in the TTM group was 49.7%, which was higher than in the non-TTM group (43.5%; odds ratio, OR = 1.22; 95% confidence interval, CI: 1.00, 1.50; p = 0.06). There were no differences in the one-year survival rate or the occurrence of adverse events between the TTM and non-TTM groups. Altogether, the use of TTM was associated with a higher survival to hospital discharge; however, it did not significantly increase the annual survival. Additional high-quality prospective studies are necessary to confer additional TTM benefits.

INTRODUCTION: Despite the introduction of supraglottic devices for ventilation, endotracheal intubation is still a gold standard for airway management in both prehospital and operating theatre conditions. This systematic review and meta-analysis were conducted to investigate the effectiveness and safety of Airtraq vs. Macintosh laryngoscope for endotracheal intubation during general anesthesia. MATERIAL AND METHODS: The current issue of Pubmed, Embase, Cochrane, Web of science, Scopus (from database inception to October 20, 2020) was searched. Randomized controlled trials (RCT) comparing Airtraq and Macintosh laryngoscope were included in this meta-analysis. The primary outcomes were the success rate of first attempt intubation and intubation time. Secondary outcomes were overall intubation success rate, malposition, and adverse events. Review Manager 5.4 software was used to perform the pooled analysis and assess the risk of bias for each eligible RCT. RESULTS: Seventeen studies were included in the review for data extraction. First attempt success rate was 85.6% for ATQ vs. 68.4% for MAC (OR = 3.00; 95% CI: 1.37, 6.60; p = 0.006; I2 = 63%). The use of ATQ and MAC for intubation in cervical spine immobilization was associated with the effectiveness of the first intubation attempt at 98.6% vs. 71.1% (OR = 16.40; 95% CI: 3.55, 78.87; p < 0.001; I2 = 0%). Intubation time with ATQ was shorter than with MAC (MD = -3.19; 95% CI: -9.33, 2.95; p = 0.31; I2 = 97%). The endotracheal intubation during cervical spinal intubation was associated with significantly shorter procedure duration for ATQ than for MAC (MD = -10.30; 95% CI: -18.43, -2.18; p = 0.01; I2 = 74%). The total efficacy of intubation, which for ATQ and MAC varied and was 86.7% vs. 80.6% respectively (OR = 2.88; 95% CI: 1.61, 5.13; p < 0.001; I2 = 0%). CONCLUSIONS: Based on the results of this analysis, we conclude that ATQ can reduce the failed first intubation attempt, especially in cervical manual inline stabilization patients, and reduces the time needed to obtain airway management, but does not provide significant benefits on other adverse events associated with tracheal intubation. Further studies are needed to demonstrate whether severe adverse events are significantly different between the two devices.

Background: Currently, two effective therapeutic options for severe aortic stenosis (AS) are available, one catheter-based [transcatheter aortic valve implantation (TAVI)], the other open surgical approach [surgical aortic valve replacement (SAVR)] The COVID-19 pandemic has limited the availability of medical procedures The purpose of this cross-sectional study was to assess if this pandemic had any impact on the treatment strategy of severe AS in a single cardiac center Methods: This study involved AS patients treated in 3-month periods (February through April) over 3 consecutive years 2018, 2019 [defined as COV(-) group] and 2020 [COV(+)] We assessed if there were any differences regarding patients' clinical profile, applied therapeutic method, procedure complexity and early clinical outcomes Results: In the years 2018 through 2019, approximately 50% of AS patients were treated classically (SAVR) while in 2020 this rate dropped to 34% The preoperative clinical characteristic of TAVI subjects was comparable irrespective of the year Regarding SAVR, more patients in COV(+) underwent urgent and more complex procedures More of them were found in NYHA class III or IV, and had lower left ventricular ejection fraction (LVEF) (51 9%+/-14 4% vs 58 3%+/-8 1%;P=0 021) than in COV(-) individuals During the pandemic, a change in applied therapeutic methods and differences in patients' clinical profile did not have an unfavorable impact on in-hospital mortality (2 0% before vs 3 6% during pandemic) and morbidity Of note, intubation time and in-hospital stay were significantly shorter (P

BACKGROUND Anesthesiologists typically care for patients having a broad range of procedures. Outcomes might be improved when care is provided by caregivers experienced in particular types of surgery. We tested the hypothesis that intraoperative care provided by pairs of anesthesia caregivers having significant experience with a particular type of surgery reduces a composite of in-hospital death and 6 serious complications, including bleeding, cardiac, gastrointestinal, infectious, respiratory, and urinary complications, compared to care provided by pairs of anesthesia caregivers with less experience. METHODS We included patients having surgery lasting at least 30 minutes. Using cluster analysis, attending anesthesiologists, and Certified Registered Nurse Anesthetists (CRNAs) were identified as experienced or inexperienced caregivers for each type of surgery at the case level. We then compared surgeries for which anesthesia was provided by a pair of experienced caregivers versus a pair of inexperienced caregivers on our composite outcome. We estimated the average relative effect (ie, the exponentiated average log odds ratio) of receiving anesthesia from an experienced versus inexperienced caregiver pair across the 7 components of the composite outcome using a generalized estimating equation (GEE) model to adjust for between-component correlation and with inverse propensity score weighing to adjust for potential confounding from a host of variables. RESULTS A total of 8968 patients who received anesthesia care by an experienced pair were compared with 25,361 patients who received care from an inexperienced pair, adjusting for potential confounding. The incidence of composite complications (ie, any component event) was 7.6% (677/8968) for experienced pairs and 12% (2976/25,361) for inexperienced pairs (P < .001). Care by experienced pairs of caregivers was associated with lower odds of the composite outcome with an estimated average relative effect odds ratio across the individual components of 0.61 (95% confidence interval [CI], 0.54-0.71), P < .001. Among the 7 components of the primary outcome, experienced pairs of providers had significantly lower estimated odds of bleeding, infection, and mortality. CONCLUSIONS Anesthesia care by experienced pairs was associated with fewer bleeding complications, fewer infections, shorter hospitalization, and reduced in-hospital mortality.

No abstract available Keywords: COVID-19; Cardiopulmonary resuscitation; Healthcare workers; Infection; Pandemic; Respiratory; Respiratory protection; SARS-CoV-2.

Background Uncontrolled pain after noncardiac surgery activates the sympathetic nervous system, which causes tachycardia, hypertension, and increased cardiac contractility-all of which may increase myocardial oxygen demand. We therefore determined whether time-weighted average pain scores over the initial 72 postoperative hours are associated with myocardial injury after noncardiac surgery (MINS). Methods We conducted a retrospective cohort analysis of adults with routine postoperative troponin monitoring after noncardiac surgery under general, regional, or combined anesthesia at tertiary level centers in Cleveland from January 2012 to December 2015. Time-weighted average pain scores were calculated from all the available pain scores, typically at 4-hour intervals, until a troponin elevation was detected. MINS was defined as peak troponin T concentrations exceeding 0.03 ng/mL within 72 hours after surgery. We used a generalized linear mixed model to assess the association between pain and MINS with 3 hospitals as clusters, adjusting for potential confounders. Results Among 2892 eligible patients, 4.5% had myocardial injury within 72 hours after surgery. Higher time-weighted average pain scores were associated with increased hazard of myocardial injury. The estimated hazard ratio for a 1-unit increase in pain score was 1.12 (95% confidence interval [CI], 1.02-1.22; P = .013), adjusting for confounding variables. Conclusions Among patients undergoing noncardiac surgery, time-weighted average pain scores within 72 hours after surgery were significantly associated with myocardial injury.

Study objective: During a pandemic, medical personnel while in contact with patients with suspected/confirmed COVID-19 should wear full personal protective equipment (PPE) for aerosol-generating procedures to reduce the risk of infection. Most studies of intubation in level C PPE conditions have been relatively small. Our aim is to quantify the available data on success rates in order to provide an evidence-based benchmark to gauge performance in the published literature. Methods: A structured literature search was performed with PubMed, Scopus, Embase, Web of Science, and Cochrane databases. The electronic database search was supplemented by searching Google Scholar and by back-searching the reference lists of identified studies for suitable articles. Data were evaluated and extracted by two independent reviewers on the basis of qualitative and quantitative variables of interest. Q statistic and I2 statistics were used to assess the heterogeneity between the studies. Results : Fifteen randomized controlled trials were included. The use of PPE during intubation as compared with intubation without PPE reduced intubation efficacy (90.0% vs. 97.9%; RR = 0.94; 95%CI: 0.90–0.99; p < 0.001) and increased the procedure time (MD = 7.73; 95%CI: 4.98–10.47; p < 0.001). Direct laryngoscopy compared with video laryngoscopes offered similar intubation success rate (93.6% vs. 92.3%; RR = 0.99; 95%CI: 0.97–1.02; p = 0.66) and shorter intubation time (MD = 63; 95%CI: -0.77–12.03; p = 0.08). However, subgroup analysis showed that intubation with Macintosh blade video laryngoscopes was more effective than that with direct laryngoscopes (98.1% vs. 96.4%; RR = 1.00; 95%CI: 0.97–1.03; p = 0.90). Conclusions: Our meta-analysis suggests that PPE reduces the effectiveness of endotracheal intubation. The use of direct laryngoscopy for intubating patients with suspected/confirmed COVID-19 by an intubator wearing level C PPE is associated with overall intubation time reduction and an increase in intubation success rate compared with video laryngoscopes. However, the findings suggest that Macintosh blade video laryngoscopes during endotracheal intubation with PPE may be an alternative to direct laryngoscopes. Video laryngoscopy can be helpful for less experienced personnel.

Background: The aim of the study was to evaluate various methods of chest compressions in patients with suspected/confirmed SARS-CoV-2 infection conducted by medical students wearing full personal protective equipment (PPE) for aerosol generating procedures (AGP). Methods: This was prospective, randomized, multicenter, single-blinded, crossover simulation trial. Thirty-five medical students after an advanced cardiovascular life support course, which included performing 2-min continuous chest compression scenarios using three methods: (A) manual chest compression (CC), (B) compression with CPRMeter, (C) compression with LifeLine ARM device. During resuscitation they are wearing full personal protective equipment for aerosol generating procedures. Results: The median chest compression depth using manual CC, CPRMeter and LifeLine ARM varied and amounted to 40 (38–45) vs. 45 (40–50) vs. 51 (50–52) mm, respectively (p = 0.002). The median chest compression rate was 109 (IQR; 102–131) compressions per minute (CPM) for manual CC, 107 (105–127) CPM for CPRMeter, and 102 (101–102) CPM for LifeLine ARM (p = 0.027). The percentage of correct chest recoil was the highest for LifeLine ARM — 100% (95–100), 80% (60–90) in CPRMeter group, and the lowest for manual CC — 29% (26–48). Conclusions: According to the results of this simulation trial, automated chest compression devices (ACCD) should be used for chest compression of patients with suspected/confirmed COVID-19. In the absence of ACCD, it seems reasonable to change the cardiopulmonary resuscitation algorithm (in the context of patients with suspected/confirmed COVID-19) by reducing the duration of the cardiopulmonary resuscitation cycle from the current 2-min to 1-min cycles due to a statistically significant reduction in the quality of chest compressions among rescuers wearing PPE AGP.

Background Myocardial injury after noncardiac surgery (MINS) is common, mostly silent, and a strong predictor of postoperative mortality. MINS appears to result from myocardial supply–demand mismatch. Recent data support restrictive perioperative transfusion strategies that can result in low postoperative haemoglobin concentrations. Whether low postoperative haemoglobin is associated with myocardial injury remains unknown. We therefore tested the hypothesis that anaemia is associated with an increased risk of myocardial injury in adults having noncardiac surgery. Methods We conducted a retrospective analysis of adults ≥45 yr old who had routine postoperative troponin T (TnT) monitoring after noncardiac surgery at the Cleverland Clinic (including those enrolled in the PeriOperative ISchemic Evaluation-2 Trial [POISE-2], the Safety of Addition of Nitrous Oxide to General Anaesthesia in At-risk Patients Having Major Non-cardiac Surgery [ENIGMA-II], Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study [VISION], and Anaesthetic Depth and Complications After Major Surgery [BALANCED] trial). Patients with baseline increase in TnT and non-ischaemic aetiologies for TnT increase were excluded. The association between postoperative haemoglobin concentration during the 3 initial postoperative days and the incidence of MINS (fourth-generation TnT ≥0.03 ng ml−1 judged as attributable to ischaemia) was assessed using a time-varying covariate Cox proportional hazards survival analysis. Results Among 6141 patients, 4480 were analysed. The incidence of MINS was 155/4480 (3.5%), ranging from 0/345 (0%) among patients whose lowest postoperative haemoglobin exceeded 13 g dl−1 to 52/611 (8.5%) in patients whose minimum postoperative haemoglobin was Conclusion Lower postoperative haemoglobin values are associated with MINS. Whether this association is modifiable by prevention or treatment of anaemia remains to be determined.

The current pandemic has raised great global public health concern. The disease name was subsequently recommended as COVID-19 by the World Health Organisation (WHO) [1,2]. Meanwhile, 2019-nCoV was renamed SARS-CoV-2 by the International Committee on Taxonomy of Viruses. SARS CoV-2 is considered highly contagious. As of April 1, 2020, more than 883,255 confirmed cases, including more than 44,156 deaths, have been reported worldwide, affecting almost the whole world.

BACKGROUND Two-thirds of the US population is considered obese and about 8% morbidly obese. Obese patients may present a unique challenge to anesthesia clinicians in airway management. Videolaryngoscopes may provide better airway visualization, which theoretically improves intubation success. However, previous work in morbidly obese patients was limited. We therefore tested the primary hypothesis that the use of McGrath video laryngoscope improves visualization of the vocal cords versus Macintosh direct laryngoscopy (Teleflex, Morrisville, NC) in morbidly obese patients. METHODS We enrolled 130 surgical patients, aged 18-99 years, with a body mass index ≥40 kg/m and American Society of Anaesthesiologists (ASA) physical status I-III. Patients were randomly allocated 1:1-stratified for patient's body mass index ≥50 kg/m-to McGrath video laryngoscope versus direct laryngoscopy with a Macintosh blade. The study groups were compared on glottis visualization, defined as improved Cormack and Lehane classification, with proportional odds logistic regression model. RESULTS McGrath video laryngoscope provided significantly better glottis visualization than Macintosh direct laryngoscopy with an estimated odds ratio of 4.6 (95% confidence interval [CI], 2.2-9.8; P < .01). We did not observe any evidence that number of intubation attempts and failed intubations increased or decreased. CONCLUSIONS McGrath video laryngoscope improves glottis visualization versus Macintosh direct laryngoscopy in morbidly obese patients. Large clinical trials are needed to determine whether improved airway visualization with videolaryngoscopy reduces intubation attempts and failures.

BACKGROUND: Evidence of the optimal surgery strategy for early stage metachronous second primary lung cancer (SPLC) has been limited and controversial. This study aims to compare the survival outcomes of different extents of resection and lymph node evaluation in these patients. METHODS: Early stage metachronous SPLC patients, who had received lobectomy for initial primary lung cancer (IPLC) and developed SPLC more than 3 months later, were selected from the Surveillance, Epidemiology, and End Results (SEER) database according to the American College of Chest Physicians (ACCP) guideline. Overall survival (OS) and lung cancer-specific survival (CSS) of different extents of resection and lymph node evaluation were analyzed using Kaplan-Meier method and multivariate Cox regression model. RESULTS: Overall, 1,784 SPLC patients without nodal or distant metastasis were identified. Lobectomy was associated with significantly longer OS (HR: 0.83, 95% CI: 0.71-0.97, 5-year survival: 59.2% vs. 53.3%, P=0.02) and CSS (HR: 0.72, 95% CI: 0.60-0.88, 5-year survival: 71.5% vs. 63.2%, P=0.001) compared with sublobar resection. In addition, examined lymph node number ≥10 demonstrated longer OS (HR: 0.63, 95% CI: 0.50-0.81, 5-year survival: 66.6% vs. 53.9%, P

ULTRASONOGRAPHY is a modern diagnostic tool both in intensive care and emergency medicine. Small, portable and simple ultrasound devices have been introduced due to technological advances. The image quality, size, and weight of portable ultrasound devices are improving. Prehospital point-of-care ultrasonog- raphy may have an impact on the decision making in prioritizing initial treatment. First aid at the scene of the accident and transporting the patient to the hospital is a key element, which in the case of appropriate diagnostics allows you to fight life-threatening injuries. The intention of using ultrasound protocols is to shorten and simplify the ultrasound examination allowing to eliminate or find complications of an injury as soon as possible. The protocols used include elements of ultrasonography and echocardiography of the lung tissue, abdominal cavity, pelvis, large vessels or the eyeball. The intention of the authors of the article was to present to the reader the basic ultrasound protocols applicable to patients in emergency situations.

Background Laboratory testing is a common component of preanesthesia evaluation and is designed to identify medical abnormalities that might otherwise remain undetected. While blood testing might optimally be performed shortly before surgery, it is often done earlier for practical reasons. We tested the hypothesis that longer periods between preoperative laboratory testing and surgery are associated with increased odds of having a composite of 30-day morbidity and mortality. Methods We obtained preoperative data from 2,320,920 patients in the American College of Surgeons National Surgical Quality Improvement Program who were treated between 2005 and 2012. Our analysis was restricted to relatively healthy patients with American Society of Anesthesiology physical status I-II who had elective surgery and normal blood test results (n = 235,010). The primary relationship of interest was the odds of 30-day morbidity and mortality as a function of delay between preoperative testing and surgery. A multivariable logistic regression model was used for the 10 pairwise comparisons among the 5 laboratory timing groups (laboratory blood tests within 1 week of surgery; 1-2 weeks; 2-4 weeks; 1-2 months; and 2-3 months) on 30-day morbidity, adjusting for any imbalanced baseline covariables and type of surgery. Results A total of 4082 patients (1.74%) had at least one of the component morbidities or died within 30-days after surgery. The observed incidence (unadjusted) was 1.7% when the most recent laboratory blood tests measured within 1 week of surgery, 1.7% when it was within 1-2 weeks, 1.8% when it was within 2-4 weeks, 1.7% when it was between 1 and 2 months, and 2.0% for patients with most recent laboratory blood tests measured 2-3 months before surgery. None of the values within 2 months differed significantly: estimated odds ratios for patients within blood tested within 1 week were 1.00 (99.5% confidence interval, 0.89-1.12) as compared to 1-2 weeks, 0.88 (0.77-1.00) for 2-4 weeks, and 0.95 (0.79-1.14) for 1-2 months, respectively. The estimated odds ratio comparing 1-2 weeks to each of 2-4 weeks and 1-2 months were 0.88 (0.76-1.03) and 0.95 (0.78-1.16), respectively. Blood testing 2-3 months before surgery was associated with increased odds of outcome compared to patients whose most recent test was within 1 week (P = .002) and 1-2 weeks of the date of surgery. Conclusions In American Society of Anesthesiologists physical status I and II patients, risk of 30-day morbidity and mortality was not different with blood testing up to 2 months before surgery, suggesting that it is unnecessary to retest patients shortly before surgery.

Standardized clinical pathways are useful tool to reduce variation in clinical management and may improve quality of care. However the evidence supporting a specific clinical pathway for a patient or patient population is often imperfect limiting adoption and efficacy of clinical pathway. Machine intelligence can potentially identify clinical variation and may provide useful insights to create and optimize clinical pathways. In this quality improvement project we analyzed the inpatient care of 1786 patients undergoing colorectal surgery from 2015 to 2016 across multiple Ohio hospitals in the Cleveland Clinic System. Data from four information subsystems was loaded in the Clinical Variation Management (CVM) application (Ayasdi, Inc., Menlo Park, CA). The CVM application uses machine intelligence and topological data analysis methods to identify groups of similar patients based on the treatment received. We defined “favorable performance” as groups with lower direct variable cost, lower length of stay, and lower 30-day readmissions. The software auto-generated 9 distinct groups of patients based on similarity analysis. Overall, favorable performance was seen with ketorolac use, lower intra-operative fluid use (

Background: Optimal preservation of endothelial integrity of the vessels used as aortocoronary grafts is a crucial determinant of long-term clinical success of coronary artery bypass grafting (CABG). The purpose of this study was to evaluate an impact of two common techniques to harvest left internal thoracic artery (LITA) on endothelial integrity. Methods: One hundred twenty consecutive patients (84 males and 36 females) with a mean age of 64.9±8.8 years undergoing CABG were randomized to receive pedicled (group P; n=60) or skeletonized (group S; n=60) LITA grafts. During surgery LITA was harvested by the same experienced cardiac surgeon. The most peripheral surplus segments of LITA were obtained and then analysed histologically under light microscope. Additionally, endothelial expression of CD31, CD34, CD133 and nitric oxide synthase (eNOS) were evaluated by means of immunohistochemistry. Results: In both groups, no cases of major arterial wall damage such as disruption, dissection, thrombosis or subadventitial hematoma were noted on LITA cross sections. Immunohistochemical assessment of protein expression revealed no differences in endothelial expression of CD133, CD34 antigens (markers of regeneration potential) and eNOS (indicating preserved functional integrity) between studied groups. Contrary to them, endothelial immunoreactivity of CD31, a marker of the morphological integrity of the endothelium, was revealed to be stronger in group P. Conclusions: The skeletonized method of LITA harvesting may be associated with worse preservation of morphological integrity of endothelium but without compromising functional integrity and potential for tissue regeneration.

Background: Continuous thoracic epidural analgesia (TEA) is a preferred method of postoperative analgesia in thoracic surgery. Intravenous patient-controlled analgesia (IVPCA) may be an effective alternative. One of the most commonly used opioids in PCA is morphine. It has high antinociceptive efficacy but is associated with many adverse events. Oxycodone can be an alternative. A small number of scientific reports comparing morphine and oxycodone in PCA for the treatment of acute postoperative pain after thoracotomy was the reason to conduct this study. Methods: Prospective, randomised, observational study. In total of 99 patients scheduled for elective thoracotomy were randomized into three study groups. TEA group received continuous TEA as a method of postoperative pain management, morphine (MF) group received morphine IVPCA, and morphine (OXY) group oxycodone IVPCA. For 48 hours’ hemodynamic parameters, level of pain, sedation and the need for rescue analgesia were monitored. After 48 hours’ patients were asked about their satisfaction with pain treatment using Likert scale and assessment of opioid related adverse events via overall benefit of analgesia score (OBAS). Results: The level of pain in visual analogic score (VAS) and Prince Henry Hospital Pain Score (PHHPS) scales was significantly lower in TEA group with no significant difference between groups MF and OXY. Using morphine in PCA was associated with a significantly higher likelihood of need of rescue analgesia. The level of sedation in Ramsay scale was significantly higher in MF compared to OXY and TEA group. There were no significant differences between groups in OBAS scale. TEA group was characterized by the highest degree of patient satisfaction. Conclusions: TEA provided superior anaesthesia compared to PCA in our study group. Use of PCA oxycodone in postoperative pain management after open thoracotomy provides similar nociception control compared to morphine but is associated with less sedation and patients using oxycodone IVPCA require smaller doses of rescue analgesia compared to systemic morphine IVPCA.

Background: Early bystander cardiopulmonary resuscitation (CPR) for cardiac arrest is crucial in the chain of survival. Cardiac arrest in infants is rare, but CPR is also performed in severe bradycardia. European Resuscitation Council and American Heart Association guidelines recommend continuing CPR until the heart muscle is sufficiently oxygenated and regains sufficient contractility and function. The most common and recommended CPR techniques that can be applied in newborns are the two-finger technique and two-thumb technique. Aim: We sought to assess the quality of CPR performed in newborns with the two-finger technique depending on the posi­tion of the rescuer during resuscitation. Methods: This was a prospective, randomised, crossover, simulated study. It involved 93 nurses who were required to perform a two-minute CPR using the two-finger technique in three scenarios: (A) with the newborn lying on the floor; (B) on a table; and (C) with the newborn on the rescuer’s forearm. The Newborn Tory® S2210 manikin was used to simulate a neonatal patient in cardiac arrest. The following parameters were measured: chest compression (CC) depth, CC rate, no-flow time, percentage of full release, ventilation rate, and ventilation volume, as well as the number of effective compressions and effective ventilations. Results: Statistical analysis showed significant differences in CC rates between scenarios A and B (p < 0.001) and between scenarios B and C (p = 0.002). Significant differences were also observed between the median CC depth. The median per­centage of no-flow-fraction was the highest for scenario A (55%), followed by scenario B (48%), and scenario C (46%). There were significant differences between the values of no-flow-fraction between scenarios A and B (p < 0.001), and between scenarios A and C (p < 0.001). The percentage of chest full releases for scenarios A, B, and C amounted to 94%, 1%, and 92%, respectively. Significant differences in the number of effective CCs between scenarios A and B (p < 0.001) as well as B and C (p < 0.001) were revealed. The median ventilation rate was highest for scenario B (13 × min–1), and lowest for scenario A (9 × min–1). The highest tidal volume was obtained in scenario A (27 mL), and the lowest in scenario C (26 mL). The most effective CPR was performed when resuscitation was carried out on the rescuer’s forearm. Conclusions: The quality of CCs in newborns depends on the location of the patient and the rescuer. The optimal form of resuscitation of newborns is resuscitation on the rescuer’s forearm.

Background Whether supplemental intraoperative oxygen reduces surgical site infections remains unclear. Recent recommendations from the World Health Organization and Center for Disease Control to routinely use high inspired oxygen concentrations to reduce infection risk have been widely criticized. We therefore performed a meta-analysis to evaluate the influence of inspired oxygen on infection risk, including a recent large trial. Methods A systematic literature search was performed. Primary analysis included all eligible trials. Sensitivity analyses distinguished studies of colorectal and non-colorectal surgeries, and excluded studies with high risk of bias. Another post-hoc sensitivity analysis excluded studies from one author that appear questionable. Results The primary analysis included 26 trials (N=14,710). The RR [95%CI] for wound infection was 0.81 [0.70, 0.94] in the high vs. low inspired oxygen groups. The effect remained significant in colorectal patients (N=10,469), 0.79 [0.66, 0.96], but not in other patients (N=4,241), 0.86 [0.69, 1.09]. When restricting the analysis to studies with low risk of bias, either by strict inclusion criteria (N=5,047) or by researchers' judgment (N=12,547), no significant benefit remained: 0.84 [0.67, 1.06] and 0.89 [0.76, 1.05], respectively. Conclusions When considering all available data, intraoperative hyperoxia reduced wound infection incidence. However, no significant benefit remained when analysis was restricted to objective- or investigator-identified low-bias studies, although those analyses were not as well-powered. Meta-analysis of the most reliable studies does not suggest that supplemental oxygen substantively reduces wound infection risk, but more research is needed to fully answer this question.

Background Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes. However, it remains unclear for how long smoking cessation is necessary, and even whether a brief preoperative period of abstinence is helpful and well tolerated. Objective We evaluated associations between various periods of preoperative smoking cessation and major morbidity and death. Design Retrospective cohort analysis. Setting Adults who had noncardiac surgery at the Cleveland Clinic Main Campus between May 2007 and December 2013. Patients A total of 37 511 patients whose smoking history was identified from a preoperative Health Quest questionnaire. Of these patients, 26 269 (70%) were former smokers and 11 242 (30%) were current smokers. Of the current smokers, 9482 (84%) were propensity matched with 9482 former smokers (36%). We excluded patients with American Society of Anesthesiologists' physical status exceeding four, patients who did not have general anaesthesia, and patients with missing outcomes and/or covariables. When multiple procedures were performed within the study period, only the first operation for each patient was included in the analysis. Main outcome measures The relationship between smoking cessation and in-hospital morbidity/mortality. Results The incidence of the primary composite of in-hospital morbidity/mortality was 6.9% (656/9482) for all former smokers; the incidence was 7.8% (152/1951) for patients who stopped smoking less than 1 year before surgery, 6.3% (118/1977) for 1 to 5 years, 7.2% (115/1596) for 5 to 10 years and 6.9% (271/3457) for more than 10 years. Conclusion Smoking cessation was associated with reduced in-hospital morbidity and mortality which was independent of cessation interval.

As noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer-providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes.

Cardiac arrest in the operating room and procedural areas has a different spectrum of causes (ie, hypovolemia, gas embolism, and hyperkalemia), and rapid and appropriate evaluation and management of these causes require modification of traditional cardiac arrest algorithms. There is a small but growing body of literature describing the incidence, causes, treatments, and outcomes of circulatory crisis and perioperative cardiac arrest. These events are almost always witnessed, frequently known, and involve rescuer providers with knowledge of the patient and their procedure. In this setting, there can be formulation of a differential diagnosis and a directed intervention that treats the likely underlying cause(s) of the crisis while concurrently managing the crisis itself. Management of cardiac arrest of the perioperative patient is predicated on expert opinion, physiologic rationale, and an understanding of the context in which these events occur. Resuscitation algorithms should consider the evaluation and management of these causes of crisis in the perioperative setting.