Alparslan Turan

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Background: Mechanical power—the energy transferred to the respiratory system per unit time—has been proposed as an overall indicator of ventilator-related harm. The authors therefore tested in this post hoc analysis of trial data whether intraoperative mechanical power normalized to predicted bodyweight is associated with impaired oxygenation in the postanesthesia care unit (PACU) or in the ward, postoperative pulmonary complications (PPCs), and length of postoperative hospital stay (LoS). Methods: The original trial randomly assigned patients having orthopedic surgery to sequential factorial clusters of intraoperative ventilation with tidal volumes of 6 versus 10 ml/kg predicted bodyweight and a positive end-expiratory pressure of 5 versus 8 cm H ₂ O, providing a wide range of exposure to mechanical power. The authors calculated the time-weighted mechanical power normalized to the predicted bodyweight for each patient included in the underlying trial and evaluated its association with the time-weighted average oxygen saturation measured by pulse oximetry/fraction of inspired oxygen ratio (SF-TWA) during the first hour of PACU stay, SF-TWA in the ward, PPCs, and LoS using a multivariable linear mixed model. They accounted for repeated surgeries and adjusted for demographic and intraoperative characteristics. Results: The authors included 2,860 surgeries performed in 2,582 patients. Patients had a mean ± SD age of 63 ± 14 yr, were 53% female and 83% White; had a mean ± SD body mass index of 31 ± 7 kg/m ² ; and were mainly American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status III (72%). Mean ± SD mechanical power normalized to the predicted bodyweight was 0.20 ± 0.06 J/min/kg, and mean ± SD SF-TWA in PACU was 353 ± 41. A 0.1 J/min/kg increment in mechanical power normalized to the predicted bodyweight was associated with a reduction in SF-TWA in PACU by −11 (95% CI, −14 to −8; P < 0.001), a reduction in SF-TWA in wards by −8 (95% CI, −11 to −5; P < 0.001), and 55% higher odds of PPCs (odds ratio, 1.55; 95% CI, 1.05 to 2.27; P = 0.026). Mechanical power normalized to the predicted bodyweight was unrelated to LoS (odds ratio, 1.01; 95% CI, 0.97 to 1.05; P = 0.68). Models including peak or driving pressures explained nearly the same amount of variance in postoperative oxygenation (marginal R ² , 0.207) as the model including mechanical power normalized to the predicted bodyweight (marginal R ² , 0.210). Conclusions: Higher intraoperative mechanical power was associated with impaired postoperative oxygenation and pulmonary complications in patients undergoing orthopedic surgery. Driving pressure had a comparable strength of association with postoperative oxygenation.

Background: Enhanced Recovery After Surgery pathways recommend transversus abdominis plane (TAP) blocks, but their efficacy is controversial and limited by the duration of local anesthetics. Liposomal bupivacaine is commonly used in single-injection TAP blocks to extend analgesia, although its effectiveness remains unclear. Therefore, two coprimary hypotheses were tested: first, that opioid consumption during the initial 24 postoperative hours is higher with saline than plain bupivacaine or liposomal bupivacaine; and second, that opioid consumption between 24 to 48 h after surgery is comparable or greater with saline or plain bupivacaine than with liposomal bupivacaine. Methods: Patients having major abdominal surgery ( e.g. , colorectal, gynecological, hernia repairs) were enrolled and randomly assigned 1:1:1 to bilateral four-quadrant TAP blocks with liposomal bupivacaine (40 ml plain bupivacaine 0.25% with 20 ml liposomal bupivacaine and 20 ml saline), plain bupivacaine (50 ml plain bupivacaine 0.5% with 30 ml normal saline), and placebo (80 ml normal saline). Patient-controlled intravenous opioids were used as needed. Patients, clinicians who adjusted opioid analgesia, ward nurses who evaluated pain scores, and study investigators who evaluated local anesthetic effects were blinded to treatment groups. Results: In the modified intention-to-treat cohort of 261 patients, opioid requirements during the first 24 h were median [interquartile range] 26 [18, 48] milligram morphine equivalents (MME) for liposomal bupivacaine (n = 89), 33 [13, 75] MME for plain bupivacaine (n = 84), and 31 [17, 53] MME for placebo (n = 88). The estimated ratio of geometric means was 0.86 (97.7% CI, 0.60 to 1.24; P = 0.355) between liposomal bupivacaine and placebo groups, and 0.91 (97.7% CI, 0.63 to 1.32; P = 0.578) between plain bupivacaine and placebo groups. Opioid requirements between 24 and 48 h were also comparable across groups. Secondary outcomes, including time to sensation return, pain scores, and opioid requirements from 48 to 72 h, were similar across all groups, with no significant differences observed. Conclusions: Single-shot, four-quadrant TAP blocks performed with liposomal bupivacaine, plain bupivacaine, or normal saline before incision for various open and laparoscopic abdominal procedures resulted in similar postoperative opioid consumption and pain scores at 24, 48, and 72 h. Absence of early benefit suggests that routine preincision, single-shot TAP blocks in this mixed surgical population provide little analgesia.

Purpose Tranexamic acid (TXA) is a synthetic antifibrinolytic agent widely used in a diverse range of hemorrhagic scenarios. Despite documented superior safety profile, increasing reports have emerged describing anaphylactic reactions to TXA. We reviewed reported cases of anaphylactic reactions to TXA and summarize their clinical characteristics, diagnosis and treatment protocols. Methods PubMed, Embase, Web of Science were searched with the terms “tranexamic acid”, “antifibrinoly*”, “anaphylaxis”, “anaphylactic”, “anaphylactoid”, “allergy” and “hypersensitivity” to identify relevant case reports. Data were extracted and analyzed. Results Our review identified 15 cases of TXA-induced anaphylaxis. Patients were 2 to 80 years old, with 60.0% adults. The most common symptoms were hypotension, hypoxia and rash in an equal 66.7%, followed by tachycardia in 60.0%. TXA was confirmed as the culprit allergen in 73.3% of cases through allergological workup. Major treatments consisted of corticosteroids (80.0%), epinephrine (73.3%) and antihistamine (60.0%). While most patients recovered, 1 patient experienced recurrent anaphylaxis and 1 patient died. Conclusions Anaphylaxis to TXA is a rare drug adverse reaction with varying manifestations. Prompt recognition and appropriate treatment are critical in facilitating optimal outcomes.

Background: Postoperative delirium is a common and serious complication after noncardiac surgery. A possible precipitating factor may be perioperative hemodynamic changes, with subsequent changes in brain perfusion. This study aims to investigate whether intraoperative hypotension, perioperative average blood pressure, or blood pressure variability are associated with postoperative delirium. Methods: The authors conducted a retrospective cohort study analyzing adult noncardiac surgery patients from a single academic center between 2018 and 2022. The primary exposure was intraoperative hypotension, defined as area under the curve of intraoperative mean arterial pressure (MAP) less than 65 mmHg. Secondary exposures were intraoperative and postoperative time-weighted average of MAP. The outcome was the incidence of postoperative delirium, assessed twice daily using the brief Confusion Assessment Method and Confusion Assessment Method for Intensive Care Unit. Results: The authors included 38,940 noncardiac surgeries. The incidence of postoperative delirium was 6.56%. In the primary analysis, the authors found no significant association between the intraoperative area under the curve of MAP less than 65 mmHg and postoperative delirium (odds ratio [OR], 1.000; 95% CI, 0.999 to 1.000; P = 0.17). In the secondary analyses, association with intraoperative time-weighted average MAP was linear, where increasing MAP was associated with lower delirium risk (OR, 0.993; 95% CI, 0.990 to 0.996; P < 0.001). Postoperatively, the authors identified one change point for time-weighted average MAP at 88 mmHg—where increasing increments of MAP were associated with lower risk of delirium when MAP was less than 88 mmHg (OR, 0.995; 95% CI, 0.992 to 0.998; P < 0.001), but higher risk of delirium when MAP was 88 mmHg or greater (OR, 1.022; 95% CI, 1.019 to 1.027; P < 0.001). Conclusions: Intraoperative hypotension and intraoperative average blood pressure were not associated with postoperative delirium. Postoperative higher average blood pressures demonstrated a statistically significant association with delirium; however, this finding lacks clinical relevance.

Validation and Translation of the 3D-CAM to Turkish in Surgical Intensive Care Patients - Turkish Journal of Anaesthesiology and Reanimation

Background: Patients with chronic kidney disease who require maintenance dialysis suffer excess morbidity and mortality for reasons that are not clearly elucidated. There are few targets for intervention to improve their outcomes. The authors hypothesized that perioperative hypotension is more common in patients receiving dialysis. Methodology: A retrospective cohort study was conducted of adult patients who had inpatient noncardiac surgery lasting greater than 2 h with general anesthesia between January 2012 and December 2021 at the Cleveland Clinic (Cleveland, Ohio). Using International Classification of Diseases codes and dialysis documentation in the electronic medical record, was derived age, American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status, surgery type, and propensity score (predicting dialysis dependence) matched groups of patients (1) with dialysis-dependent chronic kidney disease, (2) with nondialysis chronic kidney disease, and (3) without kidney disease. The primary outcomes were total area under the curve of mean arterial pressure (MAP) less than 65 mmHg during the surgery and postoperative MAP less than 70 mmHg during 48 h after surgery. Results: Three 1:1:1 matched groups of 1,886 patients (total, 5,658 patients) from an overall cohort of 123,761 were derived. Cases with dialysis-dependent kidney disease had a greater intraoperative area under the curve of MAP less than 65 mmHg (difference in medians, 18.4 mmHg-min 98.75% CI, 11.3 to 25.6; P < 0.001) when compared to patients who had nondialysis kidney disease and when compared to patients without kidney disease (difference in medians, 15.5 mmHg-min; 98.75% CI, 6.6 to 24.4; P < 0.001). Patients receiving preoperative dialysis were also more likely to have postoperative MAP less than 70 mmHg compared to patients with nondialysis kidney disease (rate ratio, 1.52; 98.75% CI, 1.48 to 1.57; P < 0.0001) and compared to patients without kidney disease (rate ratio, 1.43; 98.75% CI, 1.38 to 1.47; P < 0.0001). Conclusions: Perioperative hypotension is more severe and common among patients who undergo chronic maintenance dialysis compared to similar patients without dialysis dependence. The management of hemodynamics in this population comes with unique considerations that warrant further systematic evaluation.