Search

Background: The SpO2/FiO2 is a useful oxygenation parameter with prognostic capacity in patients with ARDS. We investigated the prognostic capacity of SpO2/FiO2 for mortality in patients with ARDS due to COVID–19. Methods: This was a post-hoc analysis of a national multicenter cohort study in invasively ventilated patients with ARDS due to COVID–19. The primary endpoint was 28–day mortality. Results: In 869 invasively ventilated patients, 28–day mortality was 30.1%. The SpO2/FiO2 on day 1 had no prognostic value. The SpO2/FiO2 on day 2 and day 3 had prognostic capacity for death, with the best cut-offs being 179 and 199, respectively. Both SpO2/FiO2 on day 2 (OR, 0.66 [95%–CI 0.46–0.96]) and on day 3 (OR, 0.70 [95%–CI 0.51–0.96]) were associated with 28–day mortality in a model corrected for age, pH, lactate levels and kidney dysfunction (AUROC 0.78 [0.76–0.79]). The measured PaO2/FiO2 and the PaO2/FiO2 calculated from SpO2/FiO2 were strongly correlated (Spearman's r = 0.79). Conclusions: In this cohort of patients with ARDS due to COVID–19, the SpO2/FiO2 on day 2 and day 3 are independently associated with and have prognostic capacity for 28–day mortality. The SpO2/FiO2 is a useful metric for risk stratification in invasively ventilated COVID–19 patients.

During pneumoperitoneum, intra-abdominal pressure (IAP) is usually kept at 12–14 mmHg. There is no clinical benefit in IAP increments if they do not increase intra-abdominal volume IAV. We aimed to estimate IAV (DIAV) and respiratory driving pressure changes (DP RS) in relation to changes in IAP (DIAP). We carried out a patient-level meta-analysis of 204 adult patients with available data on IAV and DP RS during pneumoperitoneum from three trials assessing the effect of IAP on postoperative recovery and airway pressure during laparoscopic surgery under general anesthesia. The primary endpoint was DIAV, and the secondary endpoint was DP RS. The endpoints’ response to DIAP was modeled using mixed multivariable Bayesian regression to estimate which mathematical function best fitted it. IAP values on the pressure–volume (PV) curve where the endpoint rate of change according to IAP decreased were identified. Abdomino-thoracic transmission (ATT) rate, that is, the rate DP RS change to DIAP was also estimated. The best-fitting function was sigmoid logistic and linear for IAV and DP RS response, respectively. Increments in IAV reached a plateau at 6.0 [95%CI 5.9–6.2] L. DIAV for each DIAP decreased at IAP ranging from 9.8 [95%CI 9.7–9.9] to 12.2 [12.0–12.3] mmHg. ATT rate was 0.65 [95%CI 0.62–0.68]. One mmHg of IAP raised DP RS 0.88 cmH 2O. During pneumoperitoneum, IAP has a nonlinear relationship with IAV and a linear one with DP RS. IAP should be set below the point where IAV gains diminish. NEW & NOTEWORTHY We found that intra-abdominal volume changes related to intra-abdominal pressure increase reached a plateau with diminishing gains in commonly used pneumoperitoneum pressure ranges. We also found a linear relationship between intra-abdominal pressure and respiratory driving pressure, a known marker of postoperative pulmonary complications.

BACKGROUND: High intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery. METHODS: The three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Pre-specified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed. RESULTS: Complete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75-1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26-0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60-2.17). CONCLUSIONS: High PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION: NCT03937375 (Clinicaltrials.gov).

It remains uncertain whether individualization of pneumoperitoneum pressures during laparoscopic surgery improves postoperative recovery. This study compared an individualized pneumoperitoneum pressure (IPP) strategy with a standard pneumoperitoneum pressure (SPP) strategy with respect to postoperative recovery after laparoscopic colorectal surgery.This was a multicentre RCT. The IPP strategy comprised modified patient positioning, deep neuromuscular blockade, and abdominal wall prestretching targeting the lowest intra-abdominal pressure (IAP) that maintained acceptable workspace. The SPP strategy comprised patient positioning according to the surgeon's preference, moderate neuromuscular blockade and a fixed IAP of 12 mmHg. The primary endpoint was physiological postoperative recovery, assessed by means of the Postoperative Quality of Recovery Scale. Secondary endpoints included recovery in other domains and overall recovery, the occurrence of intraoperative and postoperative complications, duration of hospital stay, and plasma markers of inflammation up to postoperative day 3.Of 166 patients, 85 received an IPP strategy and 81 an SPP strategy. The IPP strategy was associated with a higher probability of physiological recovery (odds ratio (OR) 2·77, 95 per cent c.i. 1·19 to 6·40, P = 0·017; risk ratio (RR) 1·82, 1·79 to 1·87, P = 0·049). The IPP strategy was also associated with a higher probability of emotional (P = 0·013) and overall (P = 0·011) recovery. Intraoperative adverse events were less frequent with the IPP strategy (P 0·001) and the plasma neutrophil-lymphocyte ratio was lower (P = 0·029). Other endpoints were not affected.In this cohort of patients undergoing laparoscopic colorectal surgery, an IPP strategy was associated with faster recovery, fewer intraoperative complications and less inflammation than an SPP strategy. Registration number: NCT02773173 ( http://www.clinicaltrials.gov).No se sabe con certeza si individualizar las presiones del neumoperitoneo durante la cirugía laparoscópica mejora la recuperación postoperatoria. Comparamos una estrategia con individualización de la presión del neumoperitoneo (individualised pneumoperitoneum pressure, IPP) frente a una estrategia con presión estándar del neumoperitoneo (standard pneumoperitoneum pressure, SPP) respecto a la recuperación postoperatoria tras cirugía colorrectal laparoscópica. MÉTODOS: Ensayo clínico aleatorizado multicéntrico. La estrategia IPP consistió en una modificación de la posición, bloqueo neuromuscular profundo, y una distensión de la pared abdominal conseguida con la presión intraabdominal (intra-abdominal pressure, IAP) más baja en la que el espacio quirúrgico operativo siguiera siendo aceptable. La estrategia SPP consistió en una posición de acuerdo con la preferencia del cirujano, bloqueo neuromuscular moderado, e IAP fija de 12 mm Hg. El resultado primario fue la recuperación fisiológica postoperatoria, evaluada mediante la escala de calidad en la recuperación postoperatoria (Postoperative Quality of Recovery Scale, PQRS). Los resultados secundarios incluyeron la recuperación en otros dominios y la recuperación global, la aparición de complicaciones intraoperatorias y postoperatorias, duración de la estancia hospitalaria, y los valores de los marcadores inflamatorios séricos durante tres días postoperatorios.De un total de 166 pacientes, 85 recibieron una estrategia IPP y 81 una estrategia SPP. La estrategia IPP se asoció con una elevada probabilidad de recuperación fisiológica (razón de oportunidades, odds ratio OR, 2,8 (i.c. del 95% 1,2-6,4); P = 0,017, razón de riesgo, 1,8 (i.c. del 95% 1,7-1,9), P = 0,05)). La estrategia IPP también se asoció con una elevada probabilidad de recuperación emotiva (P = 0,013) y global (P = 0,011). Los eventos adversos intraoperatorios fueron menos frecuentes con la estrategia IPP (P0,001) y la tasa neutrófilo-linfocito fue más baja (P = 0,029). No se observaron cambios en otras variables. CONCLUSIÓN: En esta cohorte de pacientes sometidos a cirugía colorrectal laparoscópica, una estrategia IPP se asoció con una recuperación más rápida, menos complicaciones intraoperatorias y menos inflamación en comparación con una estrategia SPP.

Background Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure. Methods Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. “Targeted PEEP” (2 cm H2O above intraabdominal pressure) was compared with “standard PEEP” (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure. Results Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels. Conclusions Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Contains fulltext : 286720.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To study the effects of intra-abdominal pressure on the quality of recovery and innate cytokine production capacity after laparoscopic colorectal surgery within the enhanced recovery after surgery program. BACKGROUND: There is increasing evidence for the safety and advantages of low-pressure pneumoperitoneum facilitated by deep neuromuscular blockade (NMB). Nonetheless, there is a weak understanding of the relationship between clinical outcomes, surgical injury, postoperative immune dysfunction, and infectious complications. METHODS: Randomized controlled trial of 178 patients treated at standard-pressure pneumoperitoneum (12 mm Hg) with moderate NMB (train-of-four 1-2) or low pressure (8 mm Hg) facilitated by deep NMB (posttetanic count 1-2). The primary outcome was the quality of recovery (Quality of Recovery 40 questionnaire) on a postoperative day 1 (POD1). The primary outcome of the immune substudy (n=100) was ex vivo tumor necrosis factor α production capacity upon endotoxin stimulation on POD1. RESULTS: Quality of Recovery 40 score on POD1 was significantly higher at 167 versus 159 [mean difference (MD): 8.3 points; 95% confidence interval (CI): 2.5, 14.1; P =0.005] and the decline in cytokine production capacity was significantly less for tumor necrosis factor α and interleukin-6 (MD: -172 pg/mL; 95% CI: -316, -27; P =0.021 and MD: -1282 pg/mL; 95% CI: -2505, -59; P =0.040, respectively) for patients operated at low pressure. Low pressure was associated with reduced surgical site hypoxia and inflammation markers and circulating damage-associated molecular patterns, with a less impaired early postoperative ex vivo cytokine production capacity. At low pressure, patients reported lower acute pain scores and developed significantly less 30-day infectious complications. CONCLUSIONS: Low intra-abdominal pressure during laparoscopic colorectal surgery is safe, improves the postoperative quality of recovery and preserves innate immune homeostasis, and forms a valuable addition to future enhanced recovery after surgery programs.

Purpose of Review Antagonists of mu-opioid receptor role in cancer progression remains to be elucidated. The objective of this review was to summarize the available evidence on antagonists of mu-opioid receptor effect on tumor progression and prognosis in different types of cancers and an evaluation of the available findings on their mechanism of action. Recent Findings We have found studies related to methylnaltrexone (MNTX) and naltrexone (NTX) usage in cancer outcomes-related setting. We found consistent preclinical evidence of a potential action of MNTX and NTX on cancer growth and spread mediated mainly by effect on the opioid growth factor receptor (OGFr) axis, which results in depressed cell replication. However, clinical results are scarce and limited to poor-quality evidence. Summary Further high-quality studies are warranted to study antagonists of mu-opioid receptor role as a therapeutic option in different types of cancer, especially in patients where the classical treatment causes unacceptable side effects.

BackgroundOpioid receptors are expressed not only by neural cells in the central nervous system, but also by many solid tumor cancer cells. Whether perioperative opioids given for analgesia after tumor resection surgery might inadvertently activate tumor cells, promoting recurrence or metastasis, remains controversial. We analysed large public gene repositories of solid tumors to investigate differences in opioid receptor expression between normal and tumor tissues and their association with long–term oncologic outcomes.MethodsWe investigated the normalized gene expression of µ, κ, δ opioid receptors (MOR, KOR, DOR), Opioid Growth Factor (OGFR), and Toll-Like 4 (TLR4) receptors in normal and tumor samples from twelve solid tumor types. We carried out mixed multivariable logistic and Cox regression analysis on whether there was an association between these receptors’ gene expression and the tissue where found, i.e., tumor or normal tissue. We also evaluated the association between tumor opioid receptor gene expression and patient disease–free interval (DFI) and overall survival (OS).ResultsWe retrieved 8,780 tissue samples, 5,852 from tumor and 2,928 from normal tissue, of which 2,252 were from the Genotype Tissue Expression Project (GTEx) and 672 from the Cancer Genome Atlas (TCGA) repository. The Odds Ratio (OR) [95%CI] for gene expression of the specific opioid receptors in the examined tumors varied: MOR: 0.74 [0.63–0.87], KOR: 1.27 [1.17–1.37], DOR: 1.66 [1.48–1.87], TLR4: 0.29 [0.26–0.32], OGFR: 2.39 [2.05–2.78]. After controlling all confounding variables, including age and cancer stage, there was no association between tumor opioid receptor expression and long–term oncologic outcomes.ConclusionOpioid receptor gene expression varies between different solid tumor types. There was no association between tumor opioid receptor expression and recurrence. Understanding the significance of opioid receptor expression on tumor cells remains elusive.

Background: There is scant information about intensity of ventilation and mortality in COVID–19 patients with ARDS. Aim: To investigate the association between exposure to different levels of driving pressure (ΔP) and mechanical power (MP) with mortality in these patients Methods: Multicenter observational study in 734 COVID–19 patients with ARDS. ΔP and MP were calculated at fixed time points during the first 4 calendar days of ventilation using granular ventilation data. The primary endpoint was 28–day mortality. To assess the effects of time–varying exposure, Bayesian joint models adjusted for confounders were used. Results: In the first 28 days, 214 (29.2%) patients died. A significant increase in the hazard of death was associated with each increment in ΔP (HR 1.04 [95%–CrI 1.01–1.07]; P = 0.010) and in MP (HR 1.12 [95%–CrI 1.01–1.36]; P = 0.018). Cumulative exposure to higher levels of ΔP or MP were both associated with higher risk for 28–day mortality (Figure 1). Conclusions: Cumulative exposure to higher intensities of ventilation in COVID–19 patients with ARDS is associated with increased risk of 28–day mortality. Limiting exposure to high ΔP or MP has the potential to improve survival in these patients.

OBJECTIVE To study the effect of postoperative complications (POC) on overall survival (OS) and disease-free survival (DFS) after surgical resection of colorectal liver metastases (CRLM). SUMMARY BACKGROUND DATA Morbidity rates after liver resection can reach 45%. The negative impact of POC on oncologic outcomes has been reported in various types of cancer, especially colorectal. However, data on the consequences of POC after CRLM resection on long-term survival are scarce. METHODS Eligible studies examining the association between POC after CRLM resection and OS/DFS were sought using the PubMed and Web of Science databases. A random-effects model was used to calculate pooled effect estimate for OS and DFS hazard ratios (HR), estimating between-study variance with restricted maximum likelihood estimator with Hartung-Knapp adjustment. Subgroup analysis was used to control the effect of POC on OS and DFS for: 1) Method used to define postoperative complications, 2) Exclusion of early postoperative death from survival analysis, 3) Method of data extraction used, and 4) Tumor and treatment characteristics. RESULTS Forty-one studies were deemed eligible, including 12,817 patients. POC patients had a significant risk of reduced OS compared with no POC group (HR 1.43 [95% CI: 1.3, 1.57], P < 0.0001). POC had also a negative impact on DFS. The HR for reduced DFS was 1.38 [95% CI 1.27, 1.49], P < 0.0001. The negative impact of POC on survival and recurrence was confirmed in subgroup analysis. CONCLUSIONS Our findings evidence the negative impact of POC on survival and recurrence after CRLM resection.

Background—The incidence of colorectal cancer is increasing among elderly people, where postoperative complications are frequent. Methods—We evaluated postoperative physical and quality of life changes in elderly patients undergoing laparoscopic surgery for colorectal cancer. A prospective cohort study was performed in 31 colorectal cancer patients ≥60 years who were scheduled for laparoscopic surgery due to colorectal cancer. Outcomes were measured one month preoperative (T1), three days postoperative (T2) and one month postoperative (T3). Results—The largest early postoperative (from T1 to T2) declines were observed for isometric knee extension strength (33.1%), 30 s Chair Stand Test (27.9%) and handgrip strength (16.9%). Significant reductions in quality of life measured with the QLQ-C30 summary score and the EQ 5D index score were found between T1–T3 and T1–T2, respectively. Conclusions—A decline in isometric knee extension strength, 30 s Chair Stand Test, handgrip strength and quality of life is evident in elderly patients in the days following laparoscopic surgery for colorectal cancer. Preoperative values are recovered one month after surgery for all the outcomes, except for isometric knee extension, which should receive especial attention.

Background The SpO2/FiO2 is a useful oxygenation parameter with prognostic capacity in patients with ARDS. We investigated the prognostic capacity of SpO2/FiO2 for mortality in patients with ARDS due to COVID–19. Methods This was a post-hoc analysis of a national multicenter cohort study in invasively ventilated patients with ARDS due to COVID–19. The primary endpoint was 28–day mortality. Results In 869 invasively ventilated patients, 28–day mortality was 30.1%. The SpO2/FiO2 on day 1 had no prognostic value. The SpO2/FiO2 on day 2 and day 3 had prognostic capacity for death, with the best cut-offs being 179 and 199, respectively. Both SpO2/FiO2 on day 2 (OR, 0.66 [95%–CI 0.46–0.96]) and on day 3 (OR, 0.70 [95%–CI 0.51–0.96]) were associated with 28–day mortality in a model corrected for age, pH, lactate levels and kidney dysfunction (AUROC 0.78 [0.76–0.79]). The measured PaO2/FiO2 and the PaO2/FiO2 calculated from SpO2/FiO2 were strongly correlated (Spearman's r = 0.79). Conclusions In this cohort of patients with ARDS due to COVID–19, the SpO2/FiO2 on day 2 and day 3 are independently associated with and have prognostic capacity for 28–day mortality. The SpO2/FiO2 is a useful metric for risk stratification in invasively ventilated COVID–19 patients.

Background: Patients with coronavirus disease 2019 (COVID-19) may need hospitalization for supplemental oxygen, and some need intensive care unit (ICU) admission for escalation of care. Practice of adjunctive and supportive treatments remain uncertain and may vary widely between countries, within countries between hospitals, and possibly even within ICUs. We aim to investigate practice of adjunctive and supportive treatments, and their associations with outcome, in critically ill COVID-19 patients.Methods: The 'PRactice of Adjunctive Treatments in Intensive Care Unit Patients with Coronavirus Disease 2019' (PRoAcT-COVID) study is a national, observational study to be undertaken in a large set of ICUs in The Netherlands. The PRoAcT-COVID includes consecutive ICU patients, admitted because of COVID-19 to one of the participating ICUs during a 3-month period. Daily follow-up lasts 28 days. The primary endpoint is a combination of adjunctive treatments, including types of oxygen support, ventilation, rescue therapies for hypoxemia refractory to supplementary oxygen or during invasive ventilation, other adjunctive and supportive treatments, and experimental therapies. We will also collect tracheostomy rate, duration of invasive ventilation and ventilator-free days and alive at day 28 (VFD-28), ICU and hospital length of stay, and the mortality rates in the ICU, hospital and at day 90.Discussion: The PRoAcT-COVID study is an observational study combining high density treatment data with relevant clinical outcomes. Information on treatment practices, and their associations with outcomes in COVID-19 patients in highly and urgently needed. The results of the PRoAcT-COVID study will be rapidly available, and circulated through online presentations, such as webinars and electronic conferences, and publications in peer-reviewed journals-findings will also be presented at a dedicated website. At request, and after agreement of the PRoAcT-COVID steering committee, source data will be made available through local, regional and national anonymized datasets.Trial registration: The PRoAcT-COVID study is registered at clinicaltrials.gov (study identifier NCT04719182).

BACKGROUND: The roles of high-flow nasal cannula (HFNC) and CPAP in coronavirus disease 2019 (COVID-19) are controversial. The objective of the study was to evaluate the impact of the application of a noninvasive respiratory support algorithm on clinical outcomes in subjects with COVID-19 and with acute respiratory failure. METHODS: We performed a single-center prospective observational study of subjects with respiratory failure from COVID-19 managed with HFNC and with CPAP plus HFNC (combined therapy). The main outcome was the intubation rate, which defined failure of therapy. We also analyzed the role of the ROX index ([ S pO 2 / F IO 2 ]/breathing frequency) to predict the need for intubation. RESULTS: From June to December 2020, 113 subjects with COVID-19 respiratory failure were admitted to our respiratory intermediate care unit. HFNC was applied in 65 subjects (57.52%) and combined therapy in 48 subjects (42.47%). A total of 83 subjects (73.45%) were successfully treated with noninvasive respiratory support. The intubation rate was 26.54%, and the overall mortality rate was 14.15%. The mortality rate in subjects who were intubated was 55.2%. An ROX index of 6.28 at 12 h predicted noninvasive respiratory support failure, with 97.6% sensitivity and 51.8% specificity. CONCLUSIONS: Data from our cohort managed in a respiratory intermediate care unit showed that combined noninvasive respiratory support was feasible, with favorable outcomes. Further prospective studies are required.

Background: It is uncertain whether associations between driving pressure (ΔP) during and occurrence of pulmonary complications after abdominal surgery depend on the surgical approach. Our primary objective was to test the time–weighted average ΔP (ΔPTW) association with postoperative pulmonary complications and our secondary objective was to test the association between ΔPTW and intraoperative Adverse Events. Methods: We realized a posthoc retrospective propensity score weighted cohort analysis of the ‘Local ASsessment of Ventilatory management during General Anesthesia for Surgery’ (LAS VEGAS) study including patients undergoing abdominal surgery from the study database including data from 146 hospitals across 29 countries. The primary endpoint was a composite of postoperative pulmonary complications. The secondary endpoint was the occurrence of intraoperative adverse events. Results: The analysis included 1,128 and 906 patients undergoing open or closed abdominal surgery repsectively. Absolute postoperative pulmonary complications rate was 5%. While driving pressure was lower in open abdominal surgery patients, time-weighted driving pressure was not different between groups. The association of ΔPTW with occurrence of postoperative pulmonary complications was significant in both groups, with a higher risk ratio in closed than in open abdominal surgery patients (1.11 [95%CI 1.10 to 1.20], PTW marginal effect estimation showed increased probability of pulmonary complication in both groups with a steeper increase in closed surgery patients at ΔPTW above 20 cmH2O∙hour-1. The association of ΔPTW with occurrence of intraoperative adverse events was also significant in both groups, with higher odds ratio in closed surgery (1.13 [95%CI 1.12 to 1.14]; PConclusions: Our results show how driving pressure represents a marker for pulmonary complications and adverse events in abdominal surgery regardless of surgical approach.Trial registration: LAS VEGAS was registered at clinicaltrials.gov (trial identifier NCT01601223).

BACKGROUND: Postoperative pulmonary complications (PPCs) negatively affect morbidity, healthcare costs and postsurgical survival. Preoperative and intraoperative peripheral oxyhemoglobin saturation (SpO2) levels are independent risk factors for postoperative pulmonary complications (PPCs). The air-test assesses the value of SpO2 while breathing room-air. We aimed at building a clinical score that includes the air-test for predicting the risk for PPCs. METHODS: This is a development and validation study in patients -randomly divided into two cohorts- from a large randomized clinical trial (iPROVE) that enrolled 964 intermediate-to-high risk patients scheduled for abdominal surgery. Arterial oxygenation was assessed on room-air in the preoperative period (preoperative air-test) and 3h after admission to the postoperative care unit (postoperative air-test). The air-test was defined as positive or negative if SpO2 was ≤96% or >96%, respectively. Positive air-tests were stratified into weak (93-96%) or strong (75%. CONCLUSIONS: The simple, non-invasive and inexpensive bedside air-test score, evaluating pre- and postoperatively SpO2 measured on room-air, helps to predict the risk for PPCs.

Background In intermediate-to-high-risk patients, major abdominal surgery is associated with a high incidence of postoperative complications, mainly pulmonary. Neuromuscular blocking drugs have been suggested as a contributing factor, but this remains unproven. Objective To define the relationship of neuromuscular blockade management (reversal) with postoperative pulmonary complications (PPCs). Design The individualised PeRioperative Open-lung approach Versus standard protectivE ventilation in abdominal surgery study was a prospective, multicentre, four-arm, randomised controlled trial. This is a secondary analysis of the data. Setting Twenty-one teaching hospitals in Spain. The study was conducted between 2 January 2015, and 18 May 2016. Patients Age more than 18 years with an intermediate-to-high risk for PPCs, scheduled for major abdominal surgery lasting more than 2 h. Exclusion criteria included pregnancy or breastfeeding, and moderate-to-severe organ diseases. Interventions The mode of reversal of neuromuscular blockade determined two patient groups: pharmacological reversal versus spontaneous recovery. Main outcome measures The primary outcome was a composite of PPCs during the first 30 postoperative days. The association between categorical variables and PPCs within 30 days was studied. Univariate and multivariable logistic regression modelling and propensity score analyses were performed. Results From the 923 patients included, 596 (64.6%) presented with PPCs within 30 days after surgery. Patients who developed these complications were older with a higher BMI, a lower pre-operative SpO2, a higher ASA physical status score and a higher incidence of arterial hypertension, diabetes mellitus or chronic obstructive pulmonary disease. Pharmacological neuromuscular blockade reversal was associated with a lower incidence of PPCs (odds ratio 0.62, 95% CI 0.47 to 0.82). Conclusion Spontaneous recovery of neuromuscular blockade was an independent risk factor for PPCs in patients with intermediate-to-high risk, undergoing abdominal surgery. We suggest this factor should be included in future studies on PPCs. Trial registration clinicaltrials.gov identifier: NCT02158923.

Aim: To summarize the literature on the long-term impact of perioperative opioids in colorectal cancer. Materials & methods: Combined results from two searching strategies in PubMed/MEDLINE (1950–2018), based on a PICO approach; P: Opioid influence on cancer-related long-term outcome in patient undergoing colorectal surgery; I: Opioid drugs administered in the perioperative period; C: Correlation between dose and/or type of opioid with long-term oncologic outcome; O: Disease-free survival and/or overall survival (OS). Results: Thirteen articles fulfilled the predetermined inclusion criteria. Due to the heterogeneity of the different studies, a quantitative meta-analysis to sum the evidence was deemed unfeasible. Conclusion: Our review indicates that there is no conclusive evidence to avoid the use of opioids with the goal of reducing the risk of recurrence in colorectal cancer.

Preclinical evidence has shown increased expression of mu opioid receptor 1 (MOR-1) in colorectal cancer although its association with disease-free and overall survival (DFS and OS) has not been investigated. We hypothesized that MOR-1 was overexpressed in tumor samples compared to normal tissue and this was associated with decreased DFS and OS. We carried out a retrospective study assessing the association of MOR-1 tumor expression with long-term outcomes by immunohistochemistry in normal and tumor samples from 174 colorectal cancer patients. The primary endpoint was five years of DFS. Secondary endpoints were five years of OS, the difference in MOR-1 expression between normal and tumor tissue and the occurrence of postoperative complications. Multivariable Cox regression showed no significant association between MOR-1 expression and DFS (HR 0.791, 95% CI 0.603&ndash, 1.039, p = 0.092). MOR-1 expression was higher in tumor tissue compared to non-tumor tissue. No associations were found between MOR-1 expression and OS or postoperative complications. These findings suggest that although MOR-1 is over-expressed in colorectal cancer samples there is no association to increased risk of recurrence or mortality. Future studies are warranted to elucidate the role of cancer stage, genetic polymorphism, and quantitative assessment of MOR-1 over-expression on long-term outcomes in colorectal cancer.

Background It has been estimated that 20% of the general population will suffer shoulder pain throughout their lives, with a prevalence that can reach up to 50%. The suprascapular nerve (SSN) provides sensation for the posterior and superior regions of the glenohumeral joint, whereas the anterior and inferior zones and the skin are innervated mostly by the axillary nerve. Pulsed radiofrequency on the SSN has been proposed as a therapeutic option in chronic shoulder pain. Axillary nerve block has been proposed in the context of surgical analgesia as an adjuvant to SSN block. Interventions Ultrasound (US)-guided techniques target the nerve selectively, minimizing patients’ and physicians’ exposure to harmful radiation while increasing success rates by better needle placement. We perform both US-guided techniques with the patient in a lateral decubitus position with the affected shoulder on the upper side. Objective The aim of this report is to describe the adaptation of a US-guided technique that targets both the suprascapular and axillary nerves for the treatment of painful shoulder syndrome. The simultaneous pulsed radiofrequency on the suprascapular and axillary nerves for the treatment of the chronic condition of shoulder pain has been scarcely studied, with very few references in the literature. Conclusions By adapting an approach developed in acute pain management, we can safely deliver pulsed radiofrequency to the suprascapular and axillary nerves for the treatment of shoulder pain.

BACKGROUND: Tracheal intubation failure in patients with difficult airway is still not uncommon. While videolaryngoscopes such as the Glidescope offer better glottic vision due to an acute-angled blade, this advantage does not always lead to an increased success rate because successful insertion of the tube through the vocal cords may be the limiting factor. We hypothesize that combined use of Glidescope and fiberscope used only as a dynamic guide facilitates tracheal intubation compared to a conventional Glidescope technique with a preshaped nondynamic stylet. METHODS: One hundred sixty adult patients with predicted difficult airway were randomly assigned to a conventional Glidescope (standard Glidescope group) or a combined Glidescope + fiberscope group intubation. In the Glidescope + fiberscope group under direct vision from the Glidescope, tracheal intubation was performed using the fiberscope as a guide without using fiberoptic vision, while in the standard Glidescope group, a conventional stylet-guided intubation technique was performed. We evaluated the rate of tracheal intubation success at first attempt as the primary end point (Fisher exact test). The difference between groups in airway injury, time to successful intubation, and the need for an alternative technique was also evaluated. RESULTS: First-attempt intubation success was higher in the Glidescope + fiberscope group than in the standard Glidescope group (91% vs 67%; P = .0012; fragility index, 8; absolute risk reduction, 24% [95% CI, 12%-36%]). Median time to successful tracheal intubation was shorter in the Glidescope + fiberscope group (50 vs 64 seconds; P = .035). Airway injury rate was lower in the Glidescope + fiberscope group than in the standard Glidescope group (1% vs 11%; P = .035; fragility index, 1; absolute risk reduction, 10% [95% CI, 3%-18%]). Alternative rescue technique requirements to achieve tracheal intubation were higher in the standard Glidescope group (24% vs 4%; P < .001; fragility index, 7). CONCLUSIONS: The use of a dynamic, flexible guide during a Glidescope laryngoscopy in patients with a predicted difficult airway compared to a standard intubation technique improves first-attempt intubation success, decreases the incidence of airway injury and time to successful intubation, as well as the need of an alternative technique to succeed.

Background and objectivesIn the context of opioid-sparing perioperative management, there is still little evidence from randomized controlled trials regarding the effectiveness of interfascial thoracic blocks. This study hypothesizes that receiving a serratus plane block reduces opioid requirements, pain scores, and rescue medication needs.MethodsThis double-blind, randomized controlled study was conducted on 60 adult females undergoing oncologic breast surgery. After general anesthesia, patients were randomly allocated to either conventional analgesia (control group, n=30) or single-injection serratus block with L-bupivacaine 0.25% 30mL (study group, n=30). First 24-hour total morphine consumption (primary outcome), pain scores at 1, 3, 6, 12, and 24 hours, time-to-first opioid rescue analgesia, and adverse effects were recorded.ResultsMedian 24 hours’ opioid dose was greater in the control group (median difference 9 mg (95% CI 4 to 14.5 mg); pConclusionsInterfascial serratus plane block reduces opioid requirements and is associated with better pain scores and lower and later rescue analgesia needs in the first 24 hours, compared with conventional intravenous analgesia, in breast surgery.Trial registration numberNCT02905149.

Background The effects of individualised perioperative lung-protective ventilation (based on the open-lung approach [OLA]) on postoperative complications is unknown. We aimed to investigate the effects of intraoperative and postoperative ventilatory management in patients scheduled for abdominal surgery, compared with standard protective ventilation. Methods We did this prospective, multicentre, randomised controlled trial in 21 teaching hospitals in Spain. We enrolled patients who were aged 18 years or older, were scheduled to have abdominal surgery with an expected time of longer than 2 h, had intermediate-to-high-risk of developing postoperative pulmonary complications, and who had a body-mass index less than 35 kg/m(2). Patients were randomly assigned (1: 1: 1: 1) online to receive one of four lung-protective ventilation strategies using low tidal volume plus positive end-expiratory pressure (PEEP): open-lung approach (OLA)-iCPAP (individualised intraoperative ventilation [individualised PEEP after a lung recruitment manoeuvre] plus individualised postoperative continuous positive airway pressure [CPAP]), OLA-CPAP (intraoperative individualised ventilation plus postoperative CPAP), STD-CPAP (standard intraoperative ventilation plus postoperative CPAP), or STD-O-2 (standard intraoperative ventilation plus standard postoperative oxygen therapy). Patients were masked to treatment allocation. Investigators were not masked in the operating and postoperative rooms; after 24 h, data were given to a second investigator who was masked to allocations. The primary outcome was a composite of pulmonary and systemic complications during the first 7 postoperative days. We did the primary analysis using the modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02158923. Findings Between Jan 2, 2015, and May 18, 2016, we enrolled 1012 eligible patients. Data were available for 967 patients, whom we included in the final analysis. Risk of pulmonary and systemic complications did not differ for patients in OLA-iCPAP (110 [46%] of 241, relative risk 0.89 [95% CI 0.74-1.07; p=0.25]), OLA-CPAP (111 [47%] of 238, 0.91 [0.76-1.09; p=0.35]), or STD-CPAP groups (118 [48%] of 244, 0.95 [0.80-1.14; p=0.65]) when compared with patients in the STD-O-2 group (125 [51%] of 244). Intraoperatively, PEEP was increased in 69 (14%) of patients in the standard perioperative ventilation groups because of hypoxaemia, and no patients from either of the OLA groups required rescue manoeuvres. Interpretation In patients who have major abdominal surgery, the different perioperative open lung approaches tested in this study did not reduce the risk of postoperative complications when compared with standard lung-protective mechanical ventilation.

During neuromuscular monitoring, repeated electrical stimulation evokes muscle responses of increasing magnitude ('staircase phenomenon', SP). We aimed to evaluate whether SP affects time course and twitches' values of an acceleromyographic assessed neuromuscular block with or without previous tetanic stimulation. Fifty adult patients were randomized to receive a 50Hz tetanic stimulus (S group) or not (C group) before monitor calibration. After 20min of TOF ratio (TOFr) stimulation rocuronium was administered. Onset time of block (primary endpoint), recovery of T1 to 25%, TOFr to 0.9, and recovery index were compared. We also compared T1 and TOFr at baseline, post-stimulation, and during recovery from block. Moreover the correlation between T1 at maximum recovery and (a) baseline T1 and (b) post-stimulation T1 along with T1/TOFr ratio during recovery were evaluated. After stimulation median T1 increased (32%) in group C and decreased (16%) in group S (P=0.0001). Onset time (Median [IQR] in seconds) was 90 (29-77) vs. 75 (28-60) in C and S group (P=0.002). Time [Mean (SD) in minutes] to normalized TOFr 0.9 were 70.13 (14.9) vs. 62.1 (21.2) in C and S groups (P=0.204). TOFr showed no differences between groups at any time point. T1 at maximum recovery showed a stronger correlation with post-stabilization T1 compared to baseline. (rho=0.80 and rho=0.85, for C and S groups.) Standard calibration does not ensure twitch baseline stabilization and prolongs onset time of neuromuscular block. TOF ratio is not influenced by SP.

The fragility index (FI), the number of events the statistical significance a result depends on, and the number of patients lost to follow-up are important parameters for interpreting randomised clinical trial results. We evaluated these two parameters in randomised controlled trials in anaesthesiology. For this, we performed a systematic search of the medical literature, seeking articles reporting on anaesthesiology trials with a statistically significant difference in the primary outcome and published in the top five general medicine journals, or the top 15 anaesthesiology journals. We restricted the analysis to trials reporting clinically important primary outcome measures. The search identified 139 articles, 35 published in general medicine journals and 104 in anaesthesiology journals. The median (inter-quartile range) sample size was 150 (70-300) patients. The FI was 4 (2-17) and 3 (2-7), and the number of patients lost to follow-up was 0 (0-18) and 0 (0-6) patients in trials published in general medicine and anaesthesiology journals, respectively. The number of patients lost to follow-up exceeded the FI in 41 and 27% in trials in general medicine journals and anaesthesiology journals, respectively. The FI positively correlated with sample size and number of primary outcome events, and negatively correlated with the reported P-values. The results of this systematic review suggest that statistically significant differences in randomised controlled anaesthesiology trials are regularly fragile, implying that the primary outcome status of patients lost to follow-up could possibly have changed the reported effect.