Ultrasound-Guided Transmuscular Quadratus Lumbar Block Reduces Opioid Consumption after Laparoscopic Partial Nephrectomy

Objectives Transmuscular quadratus lumborum block(TQLB)may provide postoperative analgesia in patients undergoing intraperitoneal surgeries.The purpose of this study was to examine the potential efficacy of TQLB among patients undergoing retroperitoneal procedures,such as the laparoscopic partial nephrectomy(LPN).Methods This prospective,randomized,controlled study was conducted from August 2017 to November 2018 at Peking Union Medical College Hospital(Beijing,China).Patients who were scheduled for a LPN,aged 18・70 years old with an ASA physical status score of I-II were randomly assigned to receive either TQLB with 0.6 ml/kg of 0.5%ropivacaine plus general anesthesia(TQLB group)or general anesthesia alone(control group).Patient-controlled intravenous analgesia with morphine was initiated immediately upon surgery completion.The primary outcome was the cumulative consumption of morphine within 8 h after surgery.The secondary outcome included postoperative consump廿ons of morphine at other time points,pain score at rest and during activity,postoperative nausa and vomitting(PONV),and recovery related parameters.Results Totally 30 patients per group were recruited in the study.The 8 h consumption of morphine was lower in theTQLB group than in the control group(median,0.023 mg/kg vs.0.068 mg/kg,U=207.5,P<0.001).No significant differences were observed in postoperative pain scores between the two groups.Patients in the TQLB group had fewer episodes of PONV(20%vs.47%,χ2=4.&P=0.028)in the first 24 h after surgery and higher scores for quality of recovery(mean,13&6 vs.131.9,t=-2.164,P=0.035)120 h after surgery than the controls.Conclusions TQLB resulted in an opioid-sparing effect during the early postoperative period following LPN,as well as a lower incidence of PONV and improved quality of recovery.

Expert Recommendations for Tracheal Intubation in Critically Ill Patients with Noval Coronavirus Disease 2019

Coronavirus Disease 2019(COVID-19),caused by a novel coronavirus(SARS-Co V-2),is a highly contagious disease.It firstly appeared in Wuhan,Hubei province of China in December 2019.During the next two months,it moved rapidly throughout China.Most of the infected patients have mild symptoms including fever,fatigue and cough,but in severe cases,patients can progress rapidly and develop into acute respiratory distress syndrome,septic shock,metabolic acidosis and coagulopathy.The new coronavirus was reported to spread via droplets,contact and natural aerosols from human to human.Therefore,aerosol-producing procedures such as endotracheal intubation may put the anesthesiologists at high risk of nosocomial infections.In fact,SARSCo V-2 infection of anesthesiologists after endotracheal intubation for confirmed COVID-19 patients have been reported in hospitals in Wuhan.The expert panel of airway management in Chinese Society of Anaesthesiology has deliberated and drafted this recommendation,by which we hope to guide the performance of endotracheal intubation by frontline anesthesiologists and critical care physicians.During the airway management,enhanced droplet/airborne personal protective equitment(PPE)should be applied to the health care providers.A good airway assessment before airway intervention is of vital importance.For patients with normal airway,awake intubation should be avoided,and modified rapid sequence induction is strongly recommended.Sufficient muscle relaxant should be assured before intubation.For patients with difficult airway,good preparation of airway devices and detailed intubation plans should be made.

Ultrasound-Guided Continuous Thoracic Paravertebral Block Improves Patientʼs Quality of Recovery After Open Hepatectomy: A Randomized, Double-Blind, Placebo-Controlled Trial

Background Ultrasound-guided continuous thoracic paravertebral block can provide pain-relieving and opioid-sparing effects in patients receiving open hepatectomy.We hypothesize that these effects may improve the quality of recovery(QoR)after open hepatectomy.Methods Seventy-six patients undergoing open hepatectomy were randomized to receive a continuous thoracic paravertebral block with ropivacaine(CTPVB group)or normal saline(control group).All patients received patient-controlled intravenous analgesia with morphine postoperatively for 48 hours.The primary outcome was the global Chinese 15-item Quality of Recovery score on postoperative day 7,which was statistically analyzed using Student’s t-test.Results Thirty-six patients in the CTPVB group and 37 in the control group completed the study.Compared to the control group,the CTPVB group had significantly increased global Chinese 15-item Quality of Recovery scores(133.14±12.97 vs.122.62±14.89,P=0.002)on postoperative day 7.Postoperative pain scores and cumulative morphine consumption were significantly lower for up to 8 and 48 hours(P<0.05;P=0.002),respectively,in the CTPVB group.Conclusion Perioperative CTPVB markably promotes patient’s QoR after open hepatectomy with a profound analgesic effect in the early postoperative period.

Infection Prevention Strategy in Operating Room during Coronavirus Disease 2019(COVID-19)Outbreak

A novel coronavirus that emerged in late 2019 rapidly spread around the world.Most severe cases need endotracheal intubation and mechanical ventilation,and some mild cases may need emergent surgery under general anesthesia.The novel coronavirus was reported to transmit via droplets,contact and natural aerosols from human to human.Therefore,aerosol-producing procedures such as endotracheal intubation and airway suction may put the healthcare providers at high risk of nosocomial infection.Based on recently published articles,this review provides detailed feasible recommendations for primary anesthesiologists on infection prevention in operating room during COVID-19 outbreak.

Risk Factors for Anesthesia-Related Airway Patient Safety Incidents:A Single-Center Retrospective Case-Control Analysis from 2009 to 2022

Objective Airway-related patient safety incident(PSI)has always been the top concern of anesthesiologists because this type of incidents could severely threaten patient safety if not treated immediately and properly.This study intends to reveal the composition,prognosis,and to identify risk factors for airway related incidents reported by anesthesiologists.Methods All airway related PSIs reported by anesthesiologists in a Chinese academic hospital between September 2009 and May 2022 were collected from the PSI reporting system.Patients with airway incidents reported were matched 1:1 with controls based on sex and type of surgery.Univariable and multivariable analysis were performed to find risk factors associated with airway incident occurrence,and to evaluate influence of airway PSIs on patient prognosis.Results Among 1,038 PSIs voluntarily reported by anesthesiologists during the study period,281 cases(27.1%)were airway-related incidents,with an overall reporting incidence of 4.74 per 10,000 among 592,884 anesthesia care episodes.Only ASA physical status was found to be significant independent predictor of these airway PSIs(P=0.020).Patients with airway PSIs reported had longer extubation time(0.72±1.56 d vs.0.16±0.77 d,95%CI:0.29 to 0.82,P<0.001),longer ICU length of stay(LOS)(1.63±5.71 d vs.0.19±0.84 d,95%CI:0.57 to 2.32,P=0.001),longer post operative LOS(10.56±13.09 d vs.7.59±10.76 d,95%CI:0.41 to 5.53,P=0.023),and longer total in-hospital LOS(14.99±15.18 d vs.11.62±11.88 d,95%CI:0.46 to 6.27,P=0.024).Conclusions This single-center retrospective case-control study describes the composition of airway-related PSIs reported by anesthesiologists within thirteen years.Airway incidents might influence patient prognosis by elongating extubation time and LOS.Airway PSI data were worth analyzing to improve patient safety.

Evaluation of Burnout Among Anesthesiologists Working in Tibet, China: Altitude and Attitude

Objective Burnout is a triad of emotional exhaustion,depersonalization,and reduced personal accomplishment resulting from job stress.Although with distinct regional and cultural characteristics,burnout among anesthesiologists in the Tibet has not been described.This study aimed to explore the prevalence of burnout among anesthesiologists in Tibet and its associated factors.Methods A cross-sectional survey was conducted in Tibet,China,with an anonymous questionnaire.Socialdemographic characteristics,work status,three dimensions of burnout assessed by the Maslach Burnout Inventory-Human Service Survey were collected and analyzed.Results A total of 133 individuals from 17 hospitals completed the survey from March to June 2018.The prevalence of moderate-to high-level of emotional exhaustion,depersonalization,and burnout in personal accomplishment was 65.4%(95%CI,57.0%-72.9%),66.9%(95%CI,58.5%-74.3%),and 83.5%(95%CI,76.2%-88.8%),respectively.An annual caseload≥500,frequent overtime work and fair to poor sleep quality were significantly associated with a higher level of emotional exhaustion(P<0.001,P=0.001,and P<0.0001,respectively).5-9 years in anesthesiology experience was significantly associated with a high level of emotional exhaustion and depersonalization(P=0.002 and P=0.003,respectively).Conclusions More than half of anesthesiologists working in Tibet experience a moderate-to high-level of burnout in at least one dimensional scale.Anesthesiologists having 5-9 years of experience are more prone to emotional exhaustion and depersonalization.Efforts to decrease burnout through reducing the working load and raising the social recognition of anesthesiologists in Tibet should be considered.

Assessing Empathy in Anesthesia Residents with the Chinese Version of the Consultation and Relational Empathy: A Pilot Standardized Patient Program

Objectives To validate the reliability of the Chinese version of the Consultation and Relational Empathy(CARE)in physician-standardized patient(SP)encounter.We also tried to examine the agreement between video-based ratings and in-room ratings,as well as the agreement between the faculty ratings and SP ratings.Methods The CARE was translated into Chinese.Forty-eight anesthesia residents were recruited to make preoperative interview in SP-counter.Performance of each resident was graded by in-room raters,video raters and SP raters.Consistency between different raters was examined.Results The Chinese-CARE measure demonstrated high scale reliability with a Cronbach's alpha value of 0.95 and high consistency in the in-room ratings in intraclass correlation(coefficient=0.888,P<0.001).Despite a good consistency in intraclass correlation,video ratings were significantly higher than in-room ratings(39.6±7.1 vs.24.0±10.0,P<0.001),and Wilcoxon signed-rank test indicated that the pass/fail rate was significantly higher based on video ratings than based on in-room ratings(45/48 vs.22/48,P<0.001).SP ratings had a moderate consistency with in-room faculty ratings(coefficient=0..568,P<0.001),and there was no significant difference between the pass/fail rates based on the in-room ratings and SP ratings(22/48vs.28/48,P=0.12).Conclusions The Chinese-CARE measure is reliable in the assessment of empathy during preoperative anesthesia interview.In-room and video ratings are not equivalent,while SP may provide a feasible alternative for the faculty rater in the assessment of communication skills with an appropriate measure.

Possible Risk Factors for Severe Complications Occurring after Primary Total Knee Arthroplasty

Objective Total knee arthroplasty is one of the most common orthopedic surgeries.Readmission due to severe complications after total knee arthroplasty is a grave concern to surgeons.In this study,we evaluated the risk factors for severe complications after primary total knee arthroplasty.Methods We retrospectively collected clinical data of 2,974 patients who underwent primary total knee arthroplasty from July 2013 to June 2019 in our hospital.Postoperative complication≥gradeⅢwas defined as severe complication according to Clavien-Dindo classification system.Binary logistic regression was used to identify the predictive risk factors for severe complications.Results The complication rate after primary total knee arthroplasty was 6.8%and severe complication rate was 2.5%.Male(OR=2.178,95%CI:1.324-3.585,P=0.002),individuals above 75 years old(OR=1.936,95%CI:1.155-3.244,P=0.012),arrhythmia(OR=2.913,95%CI:1.350-6.285,P=0.006)and cerebrovascular disease(OR=2.804,95%CI:1.432-5.489,P=0.003)were predictive risk factors for severe complications after primary total knee arthroplasty.Conclusion Advanced age,male,arrhythmia,and cerebrovascular disease might be patients-related risk factors for postoperative severe complications after primary total knee arthroplasty.Special attention should be paid to patients with risk factors.

Phrenic Nerve Injury Is a Differential Diagnosis of Hypoxemia after Video-Assisted Thoracoscopic Thymectomy:2 Cases Report and Literature Review

Hypoxemia after general anesthesia is not uncommon.For patients after thoracotomy,the differential diagnosis is usually difficult.Surgical,anesthetic,and patient-associated factors may contribute to postoperative hypoxemia.We described two patients who underwent videassisted thoracoscopic thymectomy and developed hypoxemia immediately after extubation.Phrenic nerve injury was suspected in both patients.One case recovered spontaneously without intervention.The second case who had been demonstrated as bilateral phrenic nerve injury after the operation was continuously on ventilator after physical therapy and respiratory training for 2 months.

Network prediction of surgical complication clusters:a prospective multicenter cohort study

Complicated relationships exist in both occurrence and progression of surgical complications,which are difficult to account for using a separate quantitative method such as prediction or grading.Data of 51,030 surgical inpatients were collected from four academic/teaching hospitals in a prospective cohort study in China.The relationship between preoperative factors,22 common complications,and death was analyzed.With input from 54 senior clinicians and following a Bayesian network approach,a complication grading,cluster-visualization,and prediction(GCP)system was designed to model pathways between grades of complication and preoperative risk factor clusters.In the GCP system,there were 11 nodes representing six grades of complication and five preoperative risk factor clusters,and 32 arcs representing a direct association.Several critical targets were pinpointed on the pathway.Malnourished status was a fundamental cause widely associated(7/32 arcs)with other risk factor clusters and complications.American Society of Anesthesiologists(ASA)score≥3 was directly dependent on all other risk factor clusters and influenced all severe complications.Grade III complications(mainly pneumonia)were directly dependent on4/5 risk factor clusters and affected all other grades of complication.Irrespective of grade,complication occurrence was more likely to increase the risk of other grades of complication than risk factor clusters.

Construction of meloxicam and bupivacaine co-delivery nanosystem based on the pathophysiological environment of surgical injuries for enhanced postoperative analgesia

Besides peripheral nerve injury,the acute inflammation is one of the pathological features of tissues after surgery,which exacerbates the postoperative pain,especially in the first 48 h after the surgery.Multimodal analgesia(MMA),such as the combination of non-steroidal anti-inflammatory drugs(NSAIDs)with local anesthetics,has shown enhanced potency compared with the usage of local anesthetics alone.However,rare formulations can provide long-term analgesia at a single dose.Herein,bupivacaine(BUP,a local anesthetic)loading poly(lactic-co-glycolic acid)(PLGA)nanoparticles(NPB)were coated with meloxicam(MLX,an NSAID)loading lipid bilayer(LPM),forming a core–shell nanosystem(NPB@LPM)to provide enhanced and long-term analgesia to treat postoperative pain.MLX was encapsulated in the lipid shell,which enabled high dose MLX to be released in the first 48 h after surgery to reduce the acute inflammation induced pain.BUP was encapsulated in the PLGA core to provide a long-term release for the nerve block.This nanosystem provided a 7-day(whole recovery cycle)effective analgesia in the Brennan’s plantar incision rat model.The tissue reactions of NPB@LPM are benign.This work will provide feasible strategies on designing drug delivery systems for postoperative pain management.

Effect of intra-operative hyperglycemia and insulin treatment on post-operative neutrophil counts:a retrospective observational study

To the Editor:Peri-operative hyperglycemia in patients with or without diabetes is associated with a higher incidence of post-operative complications.[1]In China,more than 130 million people have been diagnosed with diabetes,and more than one-third of the total population has prediabetes.Hyperglycemia in hospitalized patients is common,and the peri-operative hyperglycemia rate varies from 30%to 40%in different studies.[2]Controlling perioperative blood glucose is conducive to a better outcome of surgery and this has become a broad consensus;the awareness of a need for blood glucose control is continuously increasing among surgeons.It has been reported that the immune cell composition following hyperglycemia differs in both diabetic and non-diabetic patients,as compared to other patients.[3]To study the impact of intra-operative blood glucose management,an observational study was performed on intra-operative hyperglycemia patients to compare the outcomes of patients who received insulin treatment and those who did not.

Expert consensus on difficult airway assessment

Background:Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room(OR)and non-operation room sites.There are no guidelines or expert consensus focused on the assessment of the difficult airway before,so this expert consensus is developed to provide guidance for airway assessment,making this process more standardized and accurate to reduce airway-related complications and improve safety.Methods:Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology(CSA)met to discuss the first draft and then this was sent to 15 international experts for review,comment,and approval.The Grading of Recommendations,Assessment,Development and Evaluation(GRADE)is used to determine the level of evidence and grade the strength of recommendations.The recommendations were revised through a three-round Delphi survey from experts.Results:This expert consensus provides a comprehensive approach to airway assessment based on the medical history,physical examination,comprehensive scores,imaging,and new developments including transnasal endoscopy,virtual laryngoscopy,and 3D printing.In addition,this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway.Conclusions:This consensus applies to anesthesiologists,critical care,and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.

The brain,another potential target organ,needs early protection from SARS-CoV-2 neuroinvasion

With the outbreak and rapid spread of the novel coronavirus disease(COVID-19)around the world,humans are engaged in a life-and-death battle with the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2),formerly known as 2019-Novel Coronavirus(2019-nCoV).

Perioperative management for parturients with pulmonary hypertension:experience with 30 consecutive cases

Pregnancy with pulmonary hypertension is considered to be associated with increased maternal and neonatal mortality.We retrospectively reviewed all parturients with pulmonary hypertension who registered at our hospital between 1999 and December 2008.We collected information about patient characteristics,including maternal age,gravida and para,pulmonary hypertension category,New York Heart Association(NYHA)functional class,pulmonary artery pressure,mode of delivery and type of anesthesia,use of anticoagulation and advanced therapy(nitric oxide,prostacyclin analogus,bosentan or sildenafil).The overall maternal mortality was 16.7%in puerperium,and there were four fetal/neonatal deaths(13%).Logistic regression could not identify any factors,including modes of anesthesia,mode of delivery,and categories and severity of pulmonary hypertension,that were significant predictors of mortality.Maternal mortality in parturients with pulmonary hypertension is high and women with pulmonary hypertension who become pregnant warrant a multidisciplinary approach.

The adverse impact,assessment and management of sarcopenia in liver transplantation candidates and recipi

Sarcopenia is one of the common complications for cirrhotic patients on the waiting list of liver transplantation(LT),which has proven to be the best therapy for end-stage liver disease(ESLD).Some severe complications,including ascites,variceal bleeding,coagulation disorders and hepatic encephalopathy,were carefully managed by clinical physicians.Comparing with these complications,sarcopenia does not affect the mortality during hospitalization that much,even though it might have negative effects on patients’long-term quality of life(QOL)or even survival.