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Background Tracheal extubation is commonly performed in the supine position. However, in patients undergoing abdominal surgery, the supine position increases abdominal wall tension, especially during coughing and deep breathing, which may aggravate pain and lead to abdominal wound dehiscence. The semi-Fowler’s position may reduce abdominal wall tension, but its safety and comfort in tracheal extubation have not been reported. We aimed to evaluate the safety and comfort of different extubation positions in patients undergoing abdominal surgery. Methods We enrolled 141 patients with an American Society of Anesthesiologists grade of I-III who underwent abdominal surgery. All patients were anesthetized with propofol, fentanyl, cisatracurium, and sevoflurane. After surgery, all patients were transferred to the post-anesthesia care unit (PACU). Patients were then randomly put into the semi-Fowler’s ( n  = 70) or supine ( n  = 71) position while 100% oxygen was administered. The endotracheal tube was removed after the patients opened their eyes and regained consciousness. Vital signs, coughing, and pain and comfort scores before and/or after extubation were recorded until the patients left the PACU. Results In comparison with the supine position, the semi-Fowler’s position significantly decreased the wound pain scores at all intervals after extubation (3.51 ± 2.50 vs. 4.58 ± 2.26, 2.23 ± 1.68 vs. 3.11 ± 2.00, 1.81 ± 1.32 vs. 2.59 ± 1.88, P  = 0.009, 0.005 and 0.005, respectively), reduced severe coughing (8[11.43%] vs. 21[29.58%], P  = 0.008) and bucking after extubation (3[4.29%] vs. 18[25.35%], P  < 0.001), and improved the comfort scores 5 min after extubation (6.11 ± 2.30 vs. 5.17 ± 1.78, P  = 0.007) and when leaving from post-anesthesia care unit (7.17 ± 2.27 vs. 6.44 ± 1.79, P  = 0.034). The incidences of vomiting, emergence agitation, and respiratory complications were of no significant difference. Conclusion Tracheal extubation in the semi-Fowler’s position is associated with less coughing, sputum suction, and pain, and more comfort, without specific adverse effects when compared to the conventional supine position. Trial registration Chinese Clinical Trial Registry, ChiCTR1900025566 . Registered on 1st September 2019.

Background Current principles of postoperative pain management are primarily based on the types and extent of surgical intervention. This clinical study measured patient’s self-anticipated pain score before surgery, and compared the anticipated scores with the actual pain levels and analgesic requirements after surgery. Methods This prospective observational study recruited consecutive patients who received elective surgery in the E-Da Hospital, Taiwan from June to August 2018. Patients were asked to subjectively rate their highest anticipated pain level (numeric rating scale, NRS 0–10) for the scheduled surgical interventions during their preoperative anesthesia assessment. After the operation, the actual pain intensity (NRS 0–10) experienced by the patient in the post-anesthesia care unit and the total dose of opioids administered during the perioperative period were recorded. Pain scores ≥4 on NRS were regarded as being unacceptable levels for anticipated or postoperative pain that required more aggressive intervention. Results A total of 996 patients were included in the study. Most of the patients (86%) received general anesthesia and 73.9% of them had a history of previous operation. Female anticipated significantly higher overall pain intensities than the male patients (adjusted odd ratio 1.523, 95% confidence interval 1.126–2.061; P  = 0.006). Patients who took regular benzodiazepine at bedtime ( P  = 0.037) and those scheduled to receive more invasive surgical procedures were most likely to anticipate for higher pain intensity at the preoperative period ( P  < 0.05). Higher anticipated pain scores (preoperative NRS ≥ 4) were associated with higher actual postoperative pain levels ( P  = 0.007) in the PACU and higher total equivalent opioid use ( P  < 0.001) for acute pain management during the perioperative period. Conclusion This observational study found that patients who are female, use regular benzodiazepines at bedtime and scheduled for more invasive surgeries anticipate significantly higher surgery-related pain. Therefore, appropriate preoperative counseling for analgesic control and the management of exaggerated pain expectation in these patients is necessary to improve the quality of anesthesia delivered and patient’s satisfaction.

Hann-Shyan Hwang, Hui-Wen Hsu, Ming-Hui Hung Department of Anesthesiology, National Taiwan University Hospital, Taipei, TaiwanCorrespondence: Ming-Hui Hung, Department of Anesthesiology, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100225, Taiwan, Email hung.minghui@gmail.com

Postoperative delirium has the potential to impact individuals of all age groups, with a significant emphasis on the elderly population. Its presence leads to an increase in surgical morbidity and mortality rates, as well as a notable prolongation of hospital stays. However, there is a lack of research regarding the prevalence, risk factors, and implications of postoperative delirium in developing nations like Ethiopia, which affects both patients and healthcare institutions. An observational study was conducted at hospitals in the South Gondar Zone to diagnose postoperative delirium in the Post-Anesthesia Care Unit (PACU) using the Nursing Delirium Screening Scale. Both bivariable and multivariable logistic regression techniques were employed to analyze the association between independent factors and postoperative delirium. The strength of the association was indicated by the odds ratio with a 95% confidence interval (CI). Any p-values below 0.05 were considered statistically significant. The incidence of postoperative delirium was determined to be 41%. In the multivariate logistic regression analysis, several factors were identified as significantly associated with postoperative delirium. These factors include an age of 75 or older (AOR, 11.24; 95% CI, 4.74–26.65), ASA-PS IV (AOR, 3.25; 95% CI, 1.81–5.85), severe functional impairment of activities of daily living (AOR, 3.29; 95% CI, 1.06–10.20), premedication with benzodiazepine (AOR, 4.61; 95% CI, 2.48–8.57), intraoperative estimated blood loss exceeding 1000 ml (AOR, 2.74; 95% CI, 1.50–4.98), and intraoperative ketamine use (AOR, 3.84; 95% CI, 2.21–6.68). Additionally, postoperative delirium was found to significantly prolong the duration of stay in the post-anesthesia care unit (PACU) and the length of hospital stay (p-value < 0.05). Patients aged 75 or older, ASA-PS IV, experiencing severe functional impairment of ADL, patients premedicated with benzodiazepine, patients with intraoperative estimated blood loss exceeding 1000 ml, and intraoperative ketamine use were identified as risk factors for post-operative delirium.

The operating room is a major cost and revenue center for most hospitals. Thus, more effective operating room management and scheduling can provide significant benefits. In many hospitals, the post-anesthesia care unit (PACU), where patients recover after their surgical procedures, is a bottleneck. If the PACU reaches capacity, patients must wait in the operating room until the PACU has available space, leading to delays and possible cancellations for subsequent operating room procedures. We develop a generalizable optimization and machine learning approach to sequence operating room procedures to minimize delays caused by PACU unavailability. Specifically, we use machine learning to estimate the required PACU time for each type of surgical procedure, we develop and solve two integer programming models to schedule procedures in the operating rooms to minimize maximum PACU occupancy, and we use discrete event simulation to compare our optimized schedule to the existing schedule. Using data from Lucile Packard Children’s Hospital Stanford, we show that the scheduling system can significantly reduce operating room delays caused by PACU congestion while still keeping operating room utilization high: simulation of the second half of 2016 shows that our model could have reduced total PACU holds by 76% without decreasing operating room utilization. We are currently working on implementing the scheduling system at the hospital.

Dexmedetomidine, which is commonly used for procedural sedation and as adjunct to general anesthesia for ambulatory procedures, may affect patient discharge from the post-anesthesia care unit (PACU). We hypothesized that intraoperative dexmedetomidine use in ambulatory surgery is associated with delayed discharge from the PACU and that this is modified by surgical duration and anesthesia type. Retrospective cohort study. Academic medical center. 130,854 adult patients undergoing ambulatory surgery between 2008 and 2018. Intraoperative administration of dexmedetomidine. The primary outcome was PACU length of stay. In secondary and exploratory analyses, we examined dose-dependency, effect modification by duration of surgery and anesthesia type, effects of timing of dexmedetomidine administration, and PACU discharge delays. Dexmedetomidine was associated with a prolonged PACU length of stay (adjusted absolute difference [ADadj] 15.0 min; 95%CI 12.7–17.3; p < 0.001). This effect was dose-dependent (p-for-trend < 0.001), magnified in surgeries of less than one hour (ADadj 20.7 min; 95%CI 16.7–24.7; p < 0.001) and in patients undergoing monitored anesthesia care compared to general anesthesia (ADadj 16.8 min; 95%CI 14.1–19.6; p < 0.001). The effect was more pronounced if dexmedetomidine was administered within the last 60 min of surgery (ADadj 18.7 min; 95%CI 15.7–21.7; p < 0.001). Dexmedetomidine was associated with discharge delays due to cardiovascular complications (ORadj 2.27; 95%CI 1.59–3.24; p < 0.001) and over-sedation (ORadj 1.28; 95%CI 1.11–1.48; p < 0.001). In patients who received dexmedetomidine (n = 2901), the use of bolus doses only versus the combination of bolus and infusions, magnified the effects on PACU length of stay (ADadj 29.5 min per μg/kg; 95%CI 17.3–41.8 versus 18.1 min per μg/kg; 95%CI 11.4–24.8; p < 0.001). The intraoperative administration of dexmedetomidine was dose-dependently associated with a prolonged PACU length of stay. Clinicians should judiciously titrate dexmedetomidine, especially when using this long-acting drug for monitored anesthesia care for shorter procedures. •Dexmedetomidine dose-dependently increases PACU length of stay.•The effect was magnified with monitored anesthesia care, and in patients undergoing procedures of shorter duration.•A dexmedetomidine bolus administered towards the end of surgery carries a magnified risk of prolonged PACU length of stay.•PACU discharge delays can in part be explained by over-sedation and cardiovascular complications.

Postoperative thirst affects 70% of surgical patients, causing discomfort and potential complications, especially in orthopedic patients. Current relief strategies remain suboptimal. This trial evaluated the efficacy and safety of mini-mint ice cubes (1 cm³, 20% mint) for early postoperative thirst relief. 282 patients were randomized to three groups: mini-mint ice cubes, room temperature water or absolute fasting. Primary outcome was thirst intensity at PACU discharge, measured by Numerical Rating Scale. Secondary outcomes included PACU stay, oropharyngeal discomfort, satisfaction, 24-hour postoperative quality of recovery (QoR-15), postoperative nausea and vomiting (PONV), delirium and adverse events. Mini-mint group had lower thirst (median [IQR]: 3 [1–5]) vs. water (4 [2–5], median difference: -1, 95% CI: -2 to 0; P  = 0.004); vs. absolute fasting (7 [5–9], median difference: -4, 95% CI: -5 to -3; P  < 0.001), shorter PACU stay (35 [30–43] min) vs. water (40 [33–45] min, P  = 0.014); vs. absolute fasting (40 [35–55] min, P  < 0.001), less oropharyngeal discomfort (12.9% vs. absolute fasting 27.2%, P  = 0.015), higher satisfaction (4 [4–5]) vs. water (4 [4–5], P  = 0.003) and absolute fasting (3 [2–4], P  < 0.001), higher QoR-15 (124 [119–130]) vs. water (119 [114–125], P  < 0.001) and absolute fasting (117 [111–123], P  < 0.001). PONV, delirium, and hypoxemia showed no intergroup differences; cough occurred only in the water group (6.4%). Mini-mint ice cubes safely and effectively alleviate early postoperative thirst in orthopedic patients under general anesthesia, conferring clinically meaningful benefits compared to absolute fasting. Compared to room temperature water, the improvement is modest with uncertain clinical relevance. Clinical trial registration number: ClinicalTrials.gov (ChiCTR2400089335, 6/9/2024).

Purpose: Lung ultrasound is widely accepted as a reliable, noninvasive tool for evaluating lung status at the bedside. We assessed the impact of perioperative variables on atelectasis and lung aeration using lung ultrasound, and their correlation with postoperative oxygenation in patients undergoing general anesthesia. Methods: This prospective observational study evaluated 93 consecutive patients scheduled to undergo elective non-cardiothoracic surgery under general anesthesia. Lung ultrasound was performed 5 min after admission to the post-anesthesia care unit (PACU). Twelve pulmonary quadrants were selected for each ultrasound examination. The lung ultrasound scores and atelectasis status were calculated. The oxygenation assessment was obtained by arterial blood gas analysis before discharge from the PACU. Results: Thirty-two patients (34%) had atelectasis in at least one of the 12 evaluated segments, whereas 12 patients (13%) had atelectasis in at least three segments. The proportion of B-lines (≥ 3) and atelectasis in the inferolateral and posterior regions was significantly higher than in other regions. Patients with lung ultrasound scores ≥ 5 had a higher body mass index and lower PaO2 before discharge from the PACU than those with scores < 5. Patients with atelectasis had higher body mass indices and lung ultrasound scores. The presence of ≥ 2 regions of atelectasis was associated with lower PaO2. Using multivariate analysis, body mass index, intraoperative body position, and sex independently correlated with lung ultrasound scores. Age and lung ultrasound scores independently correlated with hypoxemia. Conclusion: Lung ultrasound enables early postoperative evaluation of atelectasis and lung aeration, which are closely associated with postoperative oxygenation.Trial registrationThe study protocol was approved by the Institutional Review Board of the Fudan University Shanghai Cancer Center (No.220,825,810; date of approval: August 5, 2022) and registered on Chinese Clinical Trial Registry (number: ChiCTR2200062761).

To investigate post-procedural recovery as well as peri-procedural respiratory and hemodynamic safety parameters with prolonged use of high-frequency jet ventilation (HFJV) versus conventional ventilation in patients undergoing catheter ablation for atrial fibrillation. Hospital registry study. Tertiary academic teaching hospital in New England. 1822 patients aged 18 years and older undergoing catheter ablation between January 2013 and June 2020. HFJV versus conventional mechanical ventilation. The primary outcome was post-anesthesia care unit (PACU) length of stay. In secondary analyses we assessed the effect of HFJV on intra-procedural hypoxemia, defined as the occurrence of peripheral hemoglobin oxygen saturation (SpO2) <90%, post-procedural respiratory complications (PRC) as well as intra-procedural hypocarbia and hypotension. Multivariable negative binomial and logistic regression analyses, adjusted for patient and procedural characteristics, were applied. 1157 patients (63%) received HFJV for a median (interquartile range [IQR]) duration of 307 (253–360) minutes. The median (IQR) length of stay in the PACU was 244 (172–370) minutes in patients who underwent ablation with conventional mechanical ventilation and 226 (163–361) minutes in patients receiving HFJV. In adjusted analyses, patients undergoing HFJV had a longer PACU length of stay (adjusted absolute difference: 37.7 min; 95% confidence interval [CI] 9.7–65.8; p = 0.008). There was a higher risk of intra-procedural hypocarbia (adjusted odds ratio [ORadj] 5.90; 95%CI 2.63–13.23; p < 0.001) and hypotension (ORadj 1.88; 95%CI 1.31–2.72; p = 0.001) in patients undergoing HFJV. No association was found between the use of HFJV and intra-procedural hypoxemia or PRC (p = 0.51, and p = 0.97, respectively). After confounder adjustment, HFJV for catheter ablation procedures for treatment of atrial fibrillation was associated with a longer length of stay in the PACU. It was further associated with an increased risk of intra-procedural abnormalities including abnormal carbon dioxide homeostasis, as well as intra-procedural arterial hypotension. [Display omitted] •High-Frequency Jet Ventilation (HFJV) is associated with intra-procedural catheter stability and reduced disease recurrence.•Limited evidence exists on the peri-procedural safety of prolonged HFJV.•HFJV was associated with an extended recovery time by about 38 min longer stay in the post-anesthesia care unit.•Patients receiving HFJV were at higher risk of intraoperative hypocarbia and hypotension.

Background Inadvertent perioperative hypothermia is an unintentional drop in core body temperature to less than 36 °C perioperatively and is associated with many negative outcomes such as infection, a prolonged stay in a recovery room, and decreased patient comfort. Objective To determine the incidence of postoperative hypothermia and to identify the associated factors with postoperative hypothermia in patients undergoing head, neck, breast, general, urology, and vascular surgery. The incidences of pre- and intraoperative hypothermia were examined as the intermediate outcomes. Materials and methods A retrospective chart review was conducted in adult patients undergoing surgery at a university hospital in a developing country for two months (October to November 2019). Temperatures below 36 °C were defined as hypothermia. Univariate and multivariate analyses were used to identify factors associated with postoperative hypothermia. Results A total of 742 patients were analyzed, the incidence of postoperative hypothermia was 11.9% (95% CI 9.7%-14.3%), and preoperative hypothermia was 0.4% (95% CI 0.08%-1.2%). Of the 117 patients with intraoperative core temperature monitoring, the incidence of intraoperative hypothermia was 73.5% (95% CI 58.8–90.8%), and hypothermia occurred most commonly after anesthesia induction. Associated factors of postoperative hypothermia were ASA physical status III-IV (OR = 1.78, 95%CI 1.08–2.93, p  = 0.023) and preoperative hypothermia (OR = 17.99, 95%CI = 1.57-206.89, p  = 0.020). Patients with postoperative hypothermia had a significantly longer stay in the PACU (100 min vs. 90 min, p  = 0.047) and a lower temperature when discharged from PACU (36.2 °C vs. 36.5 °C, p  < 0.001) than those without hypothermia. Conclusion This study confirms that perioperative hypothermia remains a common problem, especially in the intraoperative and postoperative periods. High ASA physical status and preoperative hypothermia were associated factors of postoperative hypothermia. In order to minimize the incidence of perioperative hypothermia and enhance patient outcomes, appropriate temperature management should be emphasized in patients at high risk. Registration Clinical Trials.gov (NCT04307095) (13/03/2020).