Marlene Fischer

BACKGROUND: Patients’ perception of their health outcomes after surgery has become increasingly important in perioperative medicine. This study aimed to evaluate whether emergence delirium in the postanesthesia care unit (PACU) has a relevant impact on self-reported quality of recovery on the first postoperative day. METHODS: This prospective observational cohort study was conducted in a German tertiary care university hospital. Patients ≥60 years, scheduled for elective noncardiac surgery were included. Patients were screened for the presence of delirium signs 30 minutes after arrival in the PACU using the 3-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM). Self-reported quality of recovery after surgery was assessed with the German version of the Quality of Recovery-15 questionnaire (QoR-15GE), which patients completed preoperatively and on the first postoperative day. The association between emergence delirium and self-reported quality of recovery was analyzed using a linear multivariable regression model taking into account covariates with a potential impact on recovery after surgery. RESULTS: A total of 428 patients were tested for emergence delirium. Of these, 397 were assessed for self-reported quality of recovery on the first postoperative day. The incidence of emergence delirium was 32.9% (141/428). Patients with emergence delirium showed a greater decline in QoR-15GE sum scores from pre- to postoperative (difference between preoperative and postoperative QoR-15GE sum scores [ΔQoR-15GE]), with a mean difference (± standard deviation [SD]) of 32.8 ± 25.3, compared to 21.6 ± 26.6 in patients without emergence delirium. The between-group difference was 11.2 points (95% confidence interval [CI], 5.5–16.8; P < .001). After adjusting for potentially confounding covariates, the negative impact of emergence delirium on ΔQoR-15GE (adjusted effect 10.11 [95% CI, 4.99–15.23]; P < .001) remained significant. CONCLUSIONS: In a heterogeneous cohort of elderly patients who underwent elective noncardiac surgery, we found a significant negative impact of emergence delirium on self-reported quality of recovery on the first postoperative day. Our findings suggest that the presence of delirium symptoms in the PACU may be an important determinant of patient comfort after surgery.

Purpose: The Quality of Recovery-15 questionnaire (QoR-15) has been developed to assess patient-reported recovery 24 h after non-cardiac surgery. This prospective cohort study sought to analyze patient-reported recovery throughout day five after open radical retropubic prostatectomy (ORP) and robot-assisted radical retropubic prostatectomy (RARP). Methods: Between June 2022 and February 2023 adult patients, who were scheduled for elective radical prostatectomy, completed the German version of the QoR-15 (QoR-15GE) preoperatively to establish a baseline value. Between postoperative day one and day five, patients completed the QoR-15GE daily until the day of discharge. Results: A total of 523 patients completed the questionnaires. On postoperative day one QoR-15GE scores were significantly lower after RARP compared with ORP (ORP: 113 ± 22 vs. RARP: 107 ± 24; p = 0.006) with a higher decline in postoperative QoR-15GE scores in RARP compared with ORP patients (ORP: 27 ± 20 vs. RARP: 32 ± 23; p = 0.006). The multivariable analysis confirmed an influence of surgical technique (Estimate: 4.39; 95% CI [0.27; 8.50], p = 0.037) on postoperative quality of recovery after adjusting for clinically relevant variables. Irrespective of surgical technique, we observed a consistent increase in QoR-15GE scores with similar recovery scores on postoperative days three, four, and five. Conclusion: Patients who undergo RARP experience poorer postoperative recovery at postoperative days one and two compared to those undergoing ORP. However, recovery scores align from postoperative day three, indicating a similar level of patient-reported recovery before hospital discharge. These findings suggest that the QoR-15GE may be appropriate for serial assessments.

Purpose: Cerebrovascular autoregulation (CVA) is a homoeostatic regulatory function to maintain constant cerebral blood flow (CBF) despite changes in systemic blood pressure. The CVA-based optimal mean arterial pressure (MAPopt) refers to the MAP level at which the CVA mechanism reaches its lowest degree of pressure passiveness, allowing for optimal autoregulation. This study aimed to determine MAPopt by analyzing existing CVA data from patients undergoing non-cardiac surgery. Methods: This single-center investigation is a secondary analysis of prospectively recorded CVA data of patients undergoing oncologic prostate surgery. Intraoperative CVA was assessed using the cerebral oxygenation index (COx) derived from the simultaneous measurement of MAP and regional cerebral oxygen saturation (rSO₂). Patient-specific MAPopt values were calculated using a second-order polynomial formula, in which the MAP related to the lowest COx was considered to be the intraoperative MAPopt. Results: A total of 180 patients were enrolled into the study. The average age was 63 years, 83.9% of patients had no or mild systemic disease. MAPopt determination was feasible in 128 patients, while 52 patients exhibited no U-shaped correlation between MAP and COx. The average intraoperative MAPopt was 81.7 mmHg ranging from 60.2 to 101.4 mmHg. The mean duration of intraoperative CVA measurement was 178 min. Conclusion: This study demonstrates a wide range of individual intraoperative MAPopt values and underscores that CVA-based MAPopt during non-cardiac surgery may differ from commonly accepted intraoperative MAP thresholds in clinical practice (ie 65 mmHg).

Objectives: Nirmatrelvir/ritonavir is recommended for high-risk patients with coronavirus disease 2019 (COVID-19) to reduce disease progression and mortality. Ritonavir significantly increases the bioavailability of nirmatrelvir and is the most potent irreversible cytochrome P 450 3A4 inhibitor in clinical use, resulting in a substantial risk for drug–drug interactions (DDI). We aimed to analyze the incidence of potential DDI (pDDI) in critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Methods: This is a retrospective single-center study in a quaternary care center in Northern Germany. We reviewed electronic health records for demographic characteristics, comorbid conditions, and medication history. The pre-existing comedication was screened for pDDI with nirmatrelvir/ritonavir using publicly available databases. Binary logistic regression was used to identify patient characteristics associated with pDDI. Key findings: Of 500 critically ill patients with SARS-CoV-2 infection, 362 (72.4%) received pre-existing comedication. A total of 241/500 patients (48.2%) had a medication history prone to pDDI. Antidiabetics, lipid-lowering drugs, and anticoagulants were among the most frequently used agents with a pDDI. Higher age (OR 1.043; 1.028–1.058; P < .01) and the number of comorbidities (OR 1.229; 1.119–1.350; P < .01) were significantly associated with pDDI. Conclusions: The very patient population that may benefit most from treatment with nirmatrelvir/ritonavir also has the greatest risk of pDDI. Polypharmacy is frequently present in these patients and a conscientious check of the comedication is mandatory before a treatment with nirmatrelvir/ritonavir can be initiated.

Background: Energy expenditure (EE) in patients with aneurysmal subarachnoid hemorrhage (SAH) may differ from other intracranial pathologies, such as intracerebral hemorrhage (ICH) or traumatic brain injury (TBI), due to an activation of the sympathetic nervous system. Indirect calorimetry (IC) is recommended, but is not always available. We study EE, catabolism, and metabolic stress in patients with SAH, TBI, ICH, and sepsis as controls. Methods: A prospective observational study was conducted in the intensive care units of the University Medical Center Hamburg-Eppendorf, Germany. IC was used to measure EE on days 2–3, 5–7, and 10–15 post-admission. Urinary catecholamines, metabolites, and urine urea were also measured. Statistical analysis included t-tests, Chi-square tests, and generalized mixed models. Results: We included 110 patients—43 SAH patients (13 with the surgical securing of the aneurysm and 30 with coil embolization of the aneurysm), 22 TBI patients, 23 ICH patients, and 22 controls. The generalized linear mixed model analysis for groups and timepoints including age, height, and weight as covariates revealed a significantly lower EE at timepoint 1 for ICH versus SAH—interventional (p = 0.003) and versus the control (p = 0.004), as well as at timepoint 2 for ICH versus SAH—interventional (p = 0.002) and versus SAH—surgical (p = 0.013) with a lower EE in ICH patients. No significant differences between groups were found for EE at the other timepoints, or concerning urine urea and measurements of catecholamines in urine. Conclusions: In patients with SAH, ICH, and TBI, no meaningful differences in EE were detected compared to septic critically ill patients, except for a lower EE in ICH patients in the early phase.

Background: This study aimed to investigate the associations between dyscapnia, ventilatory variables, and mortality. We hypothesized that the association between mechanical power or ventilatory ratio and survival is mediated by dyscapnia. Methods: Patients with moderate or severe acute respiratory distress syndrome (ARDS), who received mechanical ventilation within the first 48 h after admission to the intensive care unit for at least 48 h, were included in this retrospective single-center study. Values of arterial carbon dioxide (PaCO₂) were categorized into “hypercapnia” (PaCO₂≥ 50 mm Hg), “normocapnia” (PaCO₂ 36-49 mmHg), and “hypocapnia” (PaCO₂≤ 35 mm Hg). We used path analyses to assess the associations between ventilatory variables (mechanical power and ventilatory ratio) and mortality, where hypocapnia or hypercapnia were included as mediating variables. Results: Between December 2017 and April 2021, 435 patients were included. While there was a significant association between mechanical power and hypercapnia (B_EM= 0.24 [95% CI: 0.15; 0.34], P < .01), there was no significant association between mechanical power or hypercapnia and ICU mortality. The association between mechanical power and intensive care unit (ICU) mortality was fully mediated by hypocapnia (B_EM= −0.10 [95% CI: −0.19; 0.00], P = .05; B_MO= 0.38 [95% CI: 0.13; 0.63], P < .01). Ventilatory ratio was significantly associated with hypercapnia (B = 0.23 [95% CI: 0.14; 0.32], P < .01). There was no significant association between ventilatory ratio, hypercapnia, and mortality. There was a significant effect of ventilatory ratio on mortality, which was fully mediated by hypocapnia (B_EM= −0.14 [95% CI: −0.24; −0.05], P < .01; B_MO= 0.37 [95% CI: 0.12; 0.62], P < .01). Conclusion: In mechanically ventilated patients with moderate or severe ARDS, the association between mechanical power and mortality was fully mediated by hypocapnia. Likewise, there was a mediating effect of hypocapnia on the association between ventilatory ratio and ICU mortality. Our results indicate that the debate on dyscapnia and outcome after ARDS should consider the impact of ventilatory variables.