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Adults undergoing cardiac surgery with cardiopulmonary bypass received either an intravenous balanced mixture of amino acids or placebo for up to 3 days. Amino acids reduced the occurrence of acute kidney injury.

To investigate whether a single dosage of esketamine injection in the anesthesia period could improve postoperative negative emotions and early cognitive function in patients undergoing non-cardiac thoracic surgery. A prospective single center double blinded randomized placebo-controlled trial. Perioperative period; operating room, post anesthesia care unit and hospital ward. 129 adult patients that underwent elective non-cardiac thoracic surgery under general anesthesia. During the operation, pharmacologic prevention of postoperative negative emotion and early cognitive disorder with 0.2 mg/kg (Low esketamine group) and 0.5 mg/kg esketamine (High esketamine group) vs. placebo. Emotion and early cognitive performance were assessed on the day before surgery (POD-1), postoperative day 1 (POD1) and day 3 (POD3) using HADS-A, HADS-D, Pain Visual Analogue Scale (VAS), Confusion Assessment Method (CAM), Mini-Mental State Examination (MMSE), and serum biomarkers (S100β, BDNF, IL-6, acetylcholine, and norepinephrine). The high esketamine group showed significantly lower HADS-A and HADS-D scores than control group on POD1 and POD3. No significant differences were observed between the low esketamine group and the control group. The esketamine-treated groups showed lower pain VAS scores than the control group at 2 h and on the first day after operation. There were no significant differences among the three groups in CAM and MMSE scores. However, the high esketamine group had lower S100β and IL-6 levels, and higher BDNF levels postoperatively, while serum acetylcholine and norepinephrine were not significantly different. A single intraoperative injection of 0.5 mg/kg esketamine can alleviate postoperative anxiety, depression, and pain to some extent. Although cognitive function behavioral evaluation did not show obvious benefits, it can also reduce the production of pro-inflammatory and brain injury-related factors while promoting the generation of brain-derived neurotrophic factor. Registration Trial registry: http://www.chictr.org.cn/; Identifier: ChiCTR2100047067. •Intraoperative injection of 0.5 mg/kg of esketamine relieves postoperative anxiety, depression, and pain in thoracic surgery.•0.5 mg/kg of esketamine reduces inflamation, brain injury factors, and boosts BDNF.•0.2 mg/kg esketamine somewhat relieves post-op pain, not anxiety or depression.•Esketamine used in this study did not show an obvious benefit on postoperative cognitive assessment.

This trial examines the effect of delirium preventive measures on the incidence of postoperative cognitive dysfunction in older adults. In a randomised approach, a delirium prevention and a standard care group were compared regarding manifestation of postoperative cognitive dysfunction at seven days, three and twelve months postoperatively (primary outcome). To correct for practice effects and age-depended cognitive decline, a control group of age-matched healthy subjects was included. The trial was conducted at the University Medical Centre Hamburg between 2014 and 2018, data assessment took place in the Anaesthesia Outpatient Clinic and on the surgical ward. A total of 609 patients ≥60 years scheduled for cardiovascular surgery were enrolled, allocated treatment was received by 284 patients in the delirium prevention and 274 patients in the standard care group. The intervention consisted of a delirium prevention bundle including reorientation measures, sleeping aids and early mobilisation. Measurements: Cognitive functions were assessed via neuropsychological testing of attention, executive functions including word fluency, and verbal memory utilizing a computerised test of attentional performance, the trail making test, the digit span subtest from the Wechsler Adult Intelligence Scale-IV, the verbal learning and memory test, and the Regensburg Word Fluency Test. Assessments were performed preoperatively and at three time points postoperatively (one week, three months and 12 months). Postoperative cognitive dysfunction was defined as a clinically meaningful decline in at least two out of nine chosen test parameters compared to the preoperative level (reliable change index ≤ − 1.96). The rates of postoperative cognitive dysfunction were 25.9% (delirium prevention group, n = 284) vs. 28.1% (standard care group, n = 274) [X2(1,n = 433) = 0.245;p = 0.621] at postoperative day seven and declined to 7.8% vs. 6.8% [X2(1,n = 219) = 0.081;p = 0.775] and 1.3% vs. 5.6% (p = 0.215, Fisher's exact test) at three and 12 months following surgery, respectively. The postoperative delirium rates did not differ between the two groups (delirium prevention group: 13.4% vs. standard care group: 17.3%). Attentional performance was impaired shortly after surgery, whereas verbal delayed recall was most frequently affected over the whole postoperative period. These findings suggest that an intervention combining specific measures extracted from established postoperative delirium prevention programs did not reduce the rate of postoperative cognitive dysfunction in older adults. •Delirium prevention measures do not prevent postoperative cognitive dysfunction•Pattern of postoperative cognitive dysfunction is highly individual•Most patients recover from postoperative cognitive dysfunction within one year

In a randomized trial, the routine use of cerebral embolic protection during TAVI did not reduce the incidence of stroke within 72 hours or before discharge from the hospital (if discharge occurred sooner).

BackgroundThe effect of two lung ventilation (TLV) with carbon dioxide artificial pneumothorax on cerebral desaturation and postoperative neurocognitive changes in elderly patients undergoing elective minimally invasive esophagectomy (MIE) is unclear.ObjectivesThe first aim of this study was to compare the effect of TLV and one lung ventilation (OLV) on cerebral desaturation. The second aim was to assess changes in early postoperative cognitive outcomes of two ventilation methods.MethodsThis prospective, randomized, controlled trial enrolled patients 65 and older scheduled for MIE. Patients were randomly assigned (1:1) to TLV group or OLV group. The primary outcome was the incidence of cerebral desaturation events (CDE). Secondary outcomes were the cumulative area under the curve of desaturation for decreases in regional cerebral oxygen saturation (rSO2) values below 20% relative to the baseline value (AUC.20) and the incidence of delayed neurocognitive recovery.ResultsFifty-six patients were recruited between November 2019 and August 2020. TLV group had a lower incidence of CDE than OLV group [3 (10.71%) vs. 13 (48.14%), P = 0.002]. TLV group had a lower AUC.20 [0 (0–35.86) % min vs. 0 (0–0) % min, P = 0.007], and the incidence of delayed neurocognitive recovery [2 (7.4%) vs. 11 (40.7%), P = 0.009] than OLV group. Predictors of delayed neurocognitive recovery on postoperative day 7 were age (OR 1.676, 95% CI 1.122 to 2.505, P = 0.006) and AUC.20 (OR 1.059, 95% CI 1.025 to 1.094, P < 0.001).ConclusionCompared to OLV, TLV had a lower incidence of CDE and delayed neurocognitive recovery in elderly patients undergoing MIE. The method of TLV combined with carbon dioxide artificial pneumothorax may be an option for these elderly patients.Chinese Clinical Trial Registry (identifier: ChiCTR1900027454).

AbstractObjectivesTo evaluate the clinical effectiveness and safety of a perioperative algorithm for cardiac output-guided haemodynamic therapy in patients undergoing major gastrointestinal surgery.DesignMulticentre randomised controlled trial.SettingSurgical services of 55 hospitals worldwide.Participants2498 adults aged ≥65 years with an American Society of Anesthesiologists physical status classification of II or greater and undergoing major elective gastrointestinal surgery, recruited between January 2017 and September 2022.InterventionsParticipants were assigned to minimally invasive cardiac output-guided intravenous fluid therapy with low dose inotrope infusion during and four hours after surgery, or to usual care without cardiac output monitoring.Main outcome measuresThe primary outcome was postoperative infection within 30 days of randomisation. Safety outcomes were acute cardiac events within 24 hours and 30 days. Secondary outcomes were acute kidney injury within 30 days and mortality within 180 days.ResultsIn 2498 patients (mean age 74 (standard deviation 6) years, 57% women), the primary outcome occurred in 289/1247 (23.2%) intervention patients and 283/1247 (22.7%) usual care patients (adjusted odds ratio 1.03 (95% confidence interval 0.84 to 1.25); P=0.81). Acute cardiac events within 24 hours occurred in 38/1250 (3.0%) intervention patients and 21/1247 (1.7%) usual care patients (adjusted odds ratio 1.82 (1.06 to 3.13); P=0.03). This difference was primarily due to an increased incidence of arrhythmias among intervention patients. Acute cardiac events within 30 days occurred in 85/1249 (6.8%) intervention patients and 79/1247 (6.3%) usual care patients (adjusted odds ratio 1.06 (0.77 to 1.47); P=0.71). Other secondary outcomes did not differ.ConclusionsThis clinical effectiveness trial in patients undergoing major elective gastrointestinal surgery did not provide evidence that cardiac output-guided intravenous fluid therapy with low dose inotrope infusion could reduce the incidence of postoperative infections. The intervention was associated with an increased incidence of acute cardiac events within 24 hours, in particular tachyarrhythmias. Based on these findings, the routine use of this treatment approach in unselected patients is not recommended.Trial registrationISRCTN Registry ISRCTN39653756.

Early recognition and management of postoperative complications, before they become clinically relevant, can improve postoperative outcomes for patients, especially for high-risk procedures such as pancreatic resection. We did an open-label, nationwide, stepped-wedge cluster-randomised trial that included all patients having pancreatic resection during a 22-month period in the Netherlands. In this trial design, all 17 centres that did pancreatic surgery were randomly allocated for the timing of the crossover from usual care (the control group) to treatment given in accordance with a multimodal, multidisciplinary algorithm for the early recognition and minimally invasive management of postoperative complications (the intervention group). Randomisation was done by an independent statistician using a computer-generated scheme, stratified to ensure that low–medium-volume centres alternated with high-volume centres. Patients and investigators were not masked to treatment. A smartphone app was designed that incorporated the algorithm and included the daily evaluation of clinical and biochemical markers. The algorithm determined when to do abdominal CT, radiological drainage, start antibiotic treatment, and remove abdominal drains. After crossover, clinicians were trained in how to use the algorithm during a 4-week wash-in period; analyses comparing outcomes between the control group and the intervention group included all patients other than those having pancreatic resection during this wash-in period. The primary outcome was a composite of bleeding that required invasive intervention, organ failure, and 90-day mortality, and was assessed by a masked adjudication committee. This trial was registered in the Netherlands Trial Register, NL6671. From Jan 8, 2018, to Nov 9, 2019, all 1805 patients who had pancreatic resection in the Netherlands were eligible for and included in this study. 57 patients who underwent resection during the wash-in phase were excluded from the primary analysis. 1748 patients (885 receiving usual care and 863 receiving algorithm-centred care) were included. The primary outcome occurred in fewer patients in the algorithm-centred care group than in the usual care group (73 [8%] of 863 patients vs 124 [14%] of 885 patients; adjusted risk ratio [RR] 0·48, 95% CI 0·38–0·61; p<0·0001). Among patients treated according to the algorithm, compared with patients who received usual care there was a decrease in bleeding that required intervention (47 [5%] patients vs 51 [6%] patients; RR 0·65, 0·42–0·99; p=0·046), organ failure (39 [5%] patients vs 92 [10%] patients; 0·35, 0·20–0·60; p=0·0001), and 90-day mortality (23 [3%] patients vs 44 [5%] patients; 0·42, 0·19–0·92; p=0·029). The algorithm for the early recognition and minimally invasive management of complications after pancreatic resection considerably improved clinical outcomes compared with usual care. This difference included an approximate 50% reduction in mortality at 90 days. The Dutch Cancer Society and UMC Utrecht.

BackgroundLung cancer surgery is associated with a high incidence of postoperative pulmonary complications (PPCs). We evaluated whether enhanced recovery after surgery plus pulmonary rehabilitation was superior over enhanced recovery after surgery alone in reducing the incidence of postoperative PPCs and length of hospital stay.MethodsIn this pragmatic multicentre, randomised controlled, parallel-group clinical trial, eligible patients scheduled for video-assisted lung cancer surgery were randomly assigned (1:1) to either a newly developed programme that integrated preoperative and postoperative pulmonary rehabilitation components into a generic thoracic enhanced recovery after surgery pathway, or routine thoracic enhanced recovery after surgery. Primary outcome was the overall occurrence of PPCs within 2 weeks after surgery. Secondary outcomes were the occurrence of specific complications, time to removal of chest drain, and length of hospital stay (LOS).ResultsOf 428 patients scheduled for lung cancer surgery, 374 were randomised with 187 allocated to the experimental programme and 187 to control. Incidence of PPCs at 14 Days was 18.7% (35/187) in the experimental group and 33.2% (62/187) in the control group (intention-to-treat, unadjusted HR 0.524, 95% CI 0.347 to 0.792, p=0.002). Particularly, significant risk reduction was observed regarding pleural effusion, pneumonia and atelectasis. Time to removal of chest drain and LOS were not significantly reduced in the experimental group.ConclusionsAdding pulmonary rehabilitation to enhanced recovery after surgery appears to be effective in reducing the incidence of PPCs, but not LOS. Standard integration of pulmonary rehabilitation into thoracic enhanced recovery after surgery is a promising approach to PPC prophylaxis.Trial registration numberChiCTR1900024646.

A randomized trial evaluating spinal as compared with general anesthesia for hip-fracture surgery in adults 50 years of age or older did not show superiority of spinal anesthesia with respect to a composite of death or an inability to walk unassisted at 60 days. Postoperative delirium occurred in similar percentages of patients in the two groups.

Enhanced recovery after surgery (ERAS) protocols have been proven to improve outcomes but have not been widely used in neurosurgery. The purpose of this study was to design a multidisciplinary enhanced recovery after elective craniotomy protocol and to evaluate its clinical efficacy and safety after implementation. A prospective randomized controlled trial. The setting is at an operating room, a post-anesthesia care unit, and a hospital ward. This randomized controlled trial (RCT) prospectively analyzed 151 patients who underwent elective craniotomy between January 2019 and June 2020. The neurosurgical ERAS group was cared for with evidence-based systematic optimization approaches, while the control group received routine care. The primary outcomes were the postoperative length of stay (LOS) and hospitalization costs. The secondary outcomes included 30-day readmission rates, postoperative complications, postoperative pain scores, length of intensive care unit (ICU) stay, duration of the drainage tube, time to oral intake, time to ambulation, and postoperative functional recovery status. After ERAS protocol implementation, the median postoperative LOS (4 days to 3 days, difference [95% confidence interval, CI], 2 [1 to 2], P < 0.0001) and hospitalization costs (6266 USD to 5880 USD, difference [95% CI], 427.0 [234.8 to 633.6], P < 0.0001) decreased. Compared to routine perioperative care, the ERAS protocol reduced the incidence of postoperative nausea and vomiting (PONV) (28.0% to 9.2%, adjusted odds ratio [OR] 0.3, 95% CI 0.1–0.7, P = 0.003), shortened urinary catheter removal time by 24 h (64.0% to 83.0%, adjusted OR 2.9, 95% CI 1.3–6.5, P = 0.031), improved ambulation on postoperative day 1 (POD 1) (30.7% to 75.0%, adjusted OR 7.5, 95% CI 3.6–15.8, P < 0.0001), shortened the time to oral intake (15 h to 13 h, difference [95% CI], 3 [1 to 4], P < 0.001), and improved perioperative pain management. Implementation of an enhanced recovery after elective craniotomy protocol had significant benefits over conventional perioperative management. It was associated with a significant reduction in postoperative length of stay, medical cost, and postoperative complications. •Implementation of the ERAS protocol in patients undergoing elective craniotomy reduce postoperative length of stay and hospitalization costs.•The application of multimodal analgesic approaches reduce moderate and severe postoperative pain, and shorten the pain duration in craniotomy.•Patients who received the ERAS protocol achieved a low incidence of PONV and early postoperative functional recovery.•Our study complements the gap in clinical research on the application of the ERAS protocol in neurosurgical anesthesia.