Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity > 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

Comparison of anesthetic efficacy and adverse effects associated with peribulbar injection of ropivacaine performed with and without ultrasound guidance in dogs

Objective-To compare the anesthetic efficacy and adverse effects associated with peribulbar injection of ropivacaine (1% solution) performed with and without ultrasound guidance (UG) in dogs.Animals-15 dogs without ophthalmologic abnormalities.Procedures-Each dog was sedated and anesthetized. A peribulbar injection of ropivacaine (1% solution; 0.3 mL/kg) was performed with UG in 1 eye and without UG in the contralateral eye (control). For each eye, the intraocular pressure (IOP) immediately after eye centralization and number of punctures were recorded; ophthalmic complications, postinjection corneal sensitivity (determined by Cochet-Bonnet esthesiometry), durations of the sensory and motor blockades (the latter determined as the interval to restoration of the vestibuloocular reflex, pupillary light reflex, and conjugate eye movement), and blockade quality were assessed in both eyes following anesthetic recovery.Results-Needle placement was fully visualized in 8 of the 15 eyes injected with UG. For eyes injected with or without UG, there was no difference with regard to the number of punctures, postinjection corneal sensitivity, and sensory or motor blockade duration and quality; however, restoration of conjugate eye movement occurred later in control eyes. For eyes injected with UG, mean IOP was 18.6 mm Hg, compared with 23.3 mm Hg for control eyes. Incidence of subconjunctival hemorrhage was higher for control eyes; severity of chemosis and hyperemia varied over time within both groups of eyes.Conclusion and Clinical Relevance-In dogs, peribulbar injection of ropivacaine with UG is feasible in dogs and provides effective sensory and motor blockades similar to those achieved with conventional techniques.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Cardiovascular effects of a continuous rate infusion of lidocaine in calves anesthetized with xylazine, midazolam, ketamine and isoflurane

Objective To assess the cardiovascular changes of a continuous rate infusion of lidocaine in calves anesthetized with xylazine, midazolam, ketamine and isoflurane during mechanical ventilation.Study designProspective, randomized, cross-over, experimental trial.AnimalsA total of eight, healthy, male Holstein calves, aged 10 +/- 1months and weighing 114 +/- 11kg were included in the study.MethodsCalves were administered xylazine followed by ketamine and midazolam, orotracheal intubation and maintenance on isoflurane (1.3%) using mechanical ventilation. Forty minutes after induction, lidocaine (2mgkg(-1) bolus) or an equivalent volume of saline (0.9%) was administered IV followed by a continuous rate infusion (100 mu gkg(-1)minute(-1)) of lidocaine (treatment L) or saline (treatment C). Heart rate (HR), systolic, diastolic and mean arterial pressures (SAP, DAP and MAP), central venous pressure (CVP), mean pulmonary arterial pressure (mPAP), pulmonary arterial occlusion pressure (PAOP), cardiac output, end-tidal carbon dioxide (Pe ' CO2) and core temperature (CT) were recorded before lidocaine or saline administration (Baseline) and at 20-minute intervals (T20-T80). Plasma concentrations of lidocaine were measured in treatment L.ResultsThe HR was significantly lower in treatment L compared with treatment C. There was no difference between the treatments with regards to SAP, DAP, MAP and SVRI. CI was significantly lower at T60 in treatment L when compared with treatment C. PAOP and CVP increased significantly at all times compared with Baseline in treatment L. There was no significant difference between times within each treatment and between treatments with regards to other measured variables. Plasma concentrations of lidocaine ranged from 1.85 to 2.06 mu gmL(-1) during the CRI.Conclusion and clinical relevanceAt the studied rate, lidocaine causes a decrease in heart rate which is unlikely to be of clinical significance in healthy animals, but could be a concern in compromised animals.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Ultrasound-assisted periconal ocular blockade in rabbits

ObjectiveThis study aimed to evaluate the benefit and specifically the feasibility of using ultrasound in ophthalmologic periconal block, and the occurrence of complications.Study designProspective experimental study.AnimalsTen healthy New Zealand White rabbits (6-8months of age), weighing 2.0-3.5kg.MethodsRabbits were anesthetized by intramuscular injection of acepromazine (1mgkg(-1)), ketamine (30mgkg(-1)) and xylazine (3mgkg(-1)). Ultrasound-assisted periconal block with lidocaine was performed on 18 eyes. Intraocular pressure was measured by applanation tonometry whereas corneal sensitivity was assessed using an esthesiometer, before and after each periconal anesthesia.ResultsIn all 18 eyes, it was possible to adequately visualize the needle shaft within the periconal space, as well as muscular cone, optic nerve and local anesthetic solution spread. Lidocaine 2% without epinephrine (0.790.19mL) was injected into the periconal space. There was no statistical difference between the intraocular pressure (meanSD) measured before (10.9 +/- 2.9mmHg) and after (11.9 +/- 3.8mmHg) the periconal anesthesia (p=0.38). The effectiveness of the ultrasound-assisted technique was shown according to the values for corneal sensitivity, assessed before and after periconal anesthesia (p<0.0001). Complications were not observed in this study.ConclusionsEye ultrasonography allowed visualization of all anatomic structures necessary to perform a periconal block, as well as the needle insertion and anesthetic spread in real time. Further studies are required to prove the real potential of ultrasound for reducing the incidence of complications associated with ophthalmic blocks, especially when anatomic disorders of the eye could potentially increase the risk.Clinical relevanceUltrasonography is a painless, noninvasive tool that may improve safety of ophthalmic regional blocks, potentially by reducing the prevalence of globe perforation or penetration of the optic nerve associated with the needle-based techniques

Tumescent local anesthesia with ropivacaine in different concentrations in bitches undergoing mastectomy: plasma concentration and post-operative analgesia

Objective To compare two concentrations of ropivacaine administered for tumescent local anesthesia (TLA) in dogs undergoing mastectomy.Study design Prospective randomized clinical study. Animals Seventeen bitches of various breeds, aged 12 +/- 2 years and weighing 10 +/- 6.5 kg requiring total unilateral or bilateral mastectomy.Methods Dogs were premedicated with acepromazine (0.04 mg kg(-1)) and morphine (0.4 mg kg(-1)) intramuscularly. Anesthesia was induced with propofol (2.5 mg kg(-1)) and midazolam (0.2 mg kg(-1)) intravenously, followed by intubation and maintenance with isoflurane and TLA. Dogs were randomly allocated to receive TLA either with 0.1% ropivacaine (group G1) or with 0.05% ropivacaine (group G05). TLA was performed by insertion of a multihole needle under the skin and infusion of ropivacaine and lactated Ringer's solution at a fixed volume of 15 mL kg(-1). Ropivacaine concentrations in arterial blood were measured by high-performance liquid chromatography. Post-operative pain was assessed using two scales (University of Melbourne pain scale and a modified composite measure pain scale) and von Frey filaments, 4 hours after TLA and at 1 hour intervals until sensitivity was regained. A score above 30% of the maximum possible score was considered a positive indicator of pain.Results Peak plasma concentrations of ropivacaine were measured 240 minutes after TLA in G1. Low concentrations were measured in G05 for 60 minutes, with subsequent increase. Analgesic rescue and return of sensitivity occurred at 7 +/- 2.3 and 7 +/- 1.9 hours (mean +/- SD) after TLA for G1 and G05, respectively.Conclusions and clinical relevance Tumescent local anesthesia with ropivacaine provided satisfactory post-operative analgesia that lasted for several hours, with no difference in duration between the concentrations. No serious side effects were attributed to TLA. Results indicated that 0.05% ropivacaine provided adequate analgesia for mastectomy, however, more studies are required to support this conclusion.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP