Anaesthesia in septic patients: good preparation and making the right choice?

Septic patients may require anaesthesia for surgery or to facilitate endotracheal intubation for respiratory failure. These patients frequently start with a deranged haemodynamic state, including vasodilation with hypotension, and cardiomyopathy, making induction of anaesthesia a potentially hazardous task. Anaesthetic agents are well known to decrease contractility and to cause vasodilation - in part from direct effect of the drugs, and in part due to the state of anaesthesia, that causes reduced sympathetic tone. Before induction, the physician should understand the haemodynamic state (especially using echocardiography), should restore cardiovascular reserve with inotropes and vasopressors, and should induce anaesthesia with the smallest dose of the safest drug. In the previous issue of Critical Care, Zausig and colleagues show that propofol may not be the safest choice of induction agent in septic patients

The Effect of a Hyperdynamic Circulation on Tissue Doppler Values: A Simulation in Young Adults during Exercise

Left ventricular tissue Doppler imaging (TDI) velocities are used to monitor systolic and diastolic function, but it is not known how these may change in a hyperdynamic circulation, as often occurs in anesthesia and critical care medicine. Twenty-six healthy young volunteers were recruited and left ventricular systolic and diastolic tissue Doppler velocities measured at rest, light exercise, strenuous exercise, and recovery (10 minutes after exercise). At rest, TDI velocities significantly decreased from base to apex (P < .001). Within basal, mid, and apical sections, systolic and diastolic peak velocities differed between segments (P < .05), except for systolic middle (P = .094) and late diastolic apical velocities (P = .257). Basal septal velocities differed from basal lateral, for systolic (P = .041) but not diastolic peak values. Inferobasal radial values differed from basal lateral values for both systolic and diastolic velocities (P < .05). Both systolic and diastolic TDI velocities increased significantly in all segments in a proportionate manner with a hyperdynamic circulation

SAfety and feasibility of EArly resistance training after median sternotomy : the SAFE-ARMS study

Objective: The purpose of this study was to determine the safety and feasibility of subacute upper limb resistance exercise on sternal micromotion and pain and the reliability of sternal ultrasound assessment following cardiac surgery via median sternotomy. Methods: This experimental study used a pretest-posttest design to investigate the effects of upper limb resistance exercise on the sternum in patients following their first cardiac surgery via median sternotomy. Six bilateral upper limb machine-based exercises were commenced at a base resistance of 20 lb (9 kg) and progressed for each participant. Sternal micromotion was assessed using ultrasound at the mid and lower sternum at 2, 8, and 14 weeks postsurgery. Intrarater and interrater reliability was calculated using intraclass correlation coefficients (ICCs). Participant-reported pain was recorded at rest and with each exercise using a visual analogue scale. Results: Sixteen adults (n = 15 males; 71.3 [SD = 6.2] years of age) consented to participate. Twelve participants completed the study, 2 withdrew prior to the 8-week assessment, and 2 assessments were not completed at 14 weeks due to assessor unavailability. The highest median micromotion at the sternal edges was observed during the bicep curl (median = 1.33 mm; range = -0.8 to 2.0 mm) in the lateral direction and the shoulder pulldown (median = 0.65 mm; range = -0.8 to 1.6 mm) in the anterior-posterior direction. Furthermore, participants reported no increase in pain when performing any of the 6 upper limb exercises. Interrater reliability was moderate to good for both lateral-posterior (ICC = 0.73; 95% CI = 0.58 to 0.83) and anterior-posterior micromotion (ICC = 0.83; 95% CI = 0.73 to 0.89) of the sternal edges. Conclusion: Bilateral upper limb resistance exercises performed on cam-based machines do not result in sternal micromotion exceeding 2.0 mm or an increase in participant-reported pain. Impact: Upper limb resistance training commenced as early as 2 weeks following cardiac surgery via median sternotomy and performed within the safe limits of pain and sternal micromotion appears to be safe and may accelerate postoperative recovery rather than muscular deconditioning. © 2022 The Author(s). Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved

Predictors of patient satisfaction with anaesthesia and surgery care: a cohort study using the Postoperative Quality of Recovery Scale

Context Previous research has shown that most patients are satisfied with their anaesthetic care. For those who are not the causes may be multifactorial including dissatisfaction with surgical outcomes. Objectives We aimed to identify whether quality of recovery after anaesthesia and surgery measured in multiple domains affects patient satisfaction. Design Sub-group analysis of previously published observational cohort study of quality of recovery after surgery (using the Postoperative Quality of Recovery Scale) was used to identify predictors of incomplete satisfaction 3 days after surgery. Setting Multicentre perioperative surgery. Patients Patients !6 years old, undergoing a variety of operation types and all receiving general anaesthesia. Observations Of 701 patients, 573 completed the satisfaction question on day 3. Satisfaction was rated by a single fivepoint rating question. Patients were divided into two groups: 477 (83%) were completely satisfied and 96 (17%) were not completely satisfied. Multivariable logistic regression analysis was performed on preoperative and patient characteristics and recovery in five domains as follows: physiological, nociceptive (pain and nausea), emotive (anxiety and depression), activities of daily living and cognition. Recovery was defined as return to baseline values or better for all questions within each domain. Results Incomplete satisfaction was predicted by persistent pain or nausea at day 3 [OR 8.2 (95% CI 2.5 to 27), P &lt; 0.01] and incomplete satisfaction at day 1 [OR 28 (95% CI 10 to 77), P &lt; 0.01]. Paradoxically, incomplete satisfaction was less likely to occur if pain or nausea was present 15 min after surgery [OR 0.34 (95% CI 0.11 to 0.99), P &lt; 0.05] or at day 1 [OR 0.30 (95% CI 0.10 to 0.91), P ¼ 0.03]. Incomplete recovery in the other domains did not influence satisfaction. Conclusion Of the recovery domains measured using the Postoperative Quality of Recovery Scale, only nociception (pain or nausea) contributed to incomplete satisfaction. Eur J Anaesthesiol 2012; 29:000-00

Validation of the Portuguese Version of the Postoperative Quality Recovery Scale (PostopQRS)

Introduction: The Postoperative Quality Recovery Scale is a brief instrument of six domains designed to assess quality of recovery from early to long term after surgery. This study aims to validate the Portuguese version of the Postoperative Quality Recovery Scale. Material and Methods: In this observational study 101 adult patients undergoing elective surgery completed the Postoperative Quality Recovery Scale at 15 minutes and 40 minutes, one and three days after surgery. Three constructs were assessed for validity: increased recovery over time; effect of gender and recovery association with muscle strength. Reliability, responsiveness, feasibility and acceptability were also assessed. Results: Construct validity was shown by increased recovery over time; worse recovery for female patients in emotive, nociceptive, activities of daily living and overall recovery; improved muscle strength in recovered patients. Internal consistency for activities of daily living was acceptable at all-time points (Cronbach’s α value of 0.772 or higher), indicating scale reliability. The scale was able to detect differences in postoperative quality of recovery between the neuromuscular blockade reversal agents, neostigmine and sugammadex, indicating scale responsiveness. The time to conduct the Portuguese version at baseline was 95 - 581 seconds (median 319 seconds) and it was reduced with subsequent assessments. The proportion of patients completing all scale items was 87%, 75%, 65% and 94% for the four time periods evaluated, indicating scale feasibility and acceptability. Discussion: This study shows that the Portuguese version of the Postoperative Quality Recovery Scale, demonstrates construct validity, reliability, responsiveness, feasibility and acceptability. Conclusions: This study allowed validation of the Portuguese version of the Postoperative Quality Recovery Scale

Surgery for rheumatic heart disease in the Northern Territory, Australia, 1997-2016: what have we gained?

Background: Between 1964 and 1996, the 10-year survival of patients having valve replacement surgery for rheumatic heart disease (RHD) in the Northern Territory, Australia, was 68%. As medical care has evolved since then, this study aimed to determine whether there has been a corresponding improvement in survival. Methods: A retrospective study of Aboriginal patients with RHD in the Northern Territory, Australia, having their first valve surgery between 1997 and 2016. Survival was examined using Kaplan-Meier and Cox regression analysis. Findings: The cohort included 281 adults and 61 children. The median (IQR) age at first surgery was 31 (18-42) years; 173/342 (51%) had a valve replacement, 113/342 (33%) had a valve repair and 56/342 (16%) had a commissurotomy. There were 93/342 (27%) deaths during a median (IQR) follow-up of 8 (4-12) years. The overall 10-year survival was 70% (95% CI: 64% to 76%). It was 62% (95% CI: 53% to 70%) in those having valve replacement. There were 204/281 (73%) adults with at least 1 preoperative comorbidity. Preoperative comorbidity was associated with earlier death, the risk of death increasing with each comorbidity (HR: 1.3 (95% CI: 1.2 to 1.5), p50 mm Hg before surgery (HR 1.9 (95% CI: 1.2 to 3.1) p=0.007) were independently associated with death. Interpretation: Survival after valve replacement for RHD in this region of Australia has not improved. Although the patients were young, many had multiple comorbidities, which influenced long-term outcomes. The increasing prevalence of complex comorbidity in the region is a barrier to achieving optimal health outcomes

Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery.

BACKGROUND The effect of a restrictive versus liberal red-cell transfusion strategy on clinical outcomes in patients undergoing cardiac surgery remains unclear. METHODS In this multicenter, open-label, noninferiority trial, we randomly assigned 5243 adults undergoing cardiac surgery who had a European System for Cardiac Operative Risk Evaluation (EuroSCORE) I of 6 or more (on a scale from 0 to 47, with higher scores indicating a higher risk of death after cardiac surgery) to a restrictive red-cell transfusion threshold (transfuse if hemoglobin level was <7.5 g per deciliter, starting from induction of anesthesia) or a liberal red-cell transfusion threshold (transfuse if hemoglobin level was <9.5 g per deciliter in the operating room or intensive care unit [ICU] or was <8.5 g per deciliter in the non-ICU ward). The primary composite outcome was death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or by day 28, whichever came first. Secondary outcomes included red-cell transfusion and other clinical outcomes. RESULTS The primary outcome occurred in 11.4% of the patients in the restrictive-threshold group, as compared with 12.5% of those in the liberal-threshold group (absolute risk difference, -1.11 percentage points; 95% confidence interval [CI], -2.93 to 0.72; odds ratio, 0.90; 95% CI, 0.76 to 1.07; P<0.001 for noninferiority). Mortality was 3.0% in the restrictive-threshold group and 3.6% in the liberal-threshold group (odds ratio, 0.85; 95% CI, 0.62 to 1.16). Red-cell transfusion occurred in 52.3% of the patients in the restrictive-threshold group, as compared with 72.6% of those in the liberal-threshold group (odds ratio, 0.41; 95% CI, 0.37 to 0.47). There were no significant between-group differences with regard to the other secondary outcomes. CONCLUSIONS In patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive strategy regarding red-cell transfusion was noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis, with less blood transfused. (Funded by the Canadian Institutes of Health Research and others; TRICS III ClinicalTrials.gov number, NCT02042898 .)