Metabolic changes, hypothalamo-pituitary-adrenal axis and oxidative stress after short-term starvation in healthy pregnant women

Aim: To compare metabolic effects and oxidative stress in pregnant and non-pregnant women after 12h of fasting. Methods: Twenty-six healthy women with uncomplicated singleton pregnancies between the 24th and 28th gestational week were recruited. After an overnight fast, venous blood samples and urine samples were tested for metabolic parameters characteristic for starvation, cortisol and oxidative stress products. Healthy non-pregnant women matched by age, body mass index and length of fasting comprised the control group. Results: The metabolic parameters β-hydroxybutyrate and free fatty acids in blood and ketones in urine showed no differences in pregnant and non-pregnant women. However, the oxidative stress parameters, 8,12-iso-iPF2α-VI, isoprostanes and malondialdehyde were significantly higher in pregnant subjects, as was cortisol. Conclusion: Healthy pregnant women are exposed to oxidative stress and activation of the hypothalamo-pituitary-adrenal axis, but not to metabolic changes resembling starvation during short fasting periods in comparison to non-pregnant healthy wome

Cost-Effectiveness of Propofol (Diprivan) Versus Inhalational Anesthetics to Maintain General Anesthesia in Noncardiac Surgery in the United States.

Abstract Objectives It is not known whether using propofol total intravenous anaesthesia (TIVA) to reduce incidence of postoperative nausea and vomiting (PONV) is cost-effective. We assessed the economic impact of propofol TIVA versus inhalational anesthesia in adult patients for ambulatory and inpatient procedures relevant to the US healthcare system. Methods Two models simulate individual patient pathways through inpatient and ambulatory surgery with propofol TIVA or inhalational anesthesia with economic inputs from studies on adult surgical US patients. Efficacy inputs were obtained from a meta-analysis of randomized controlled trials. Probabilistic and deterministic sensitivity analyses assessed the robustness of the model estimates. Results Lower PONV rate, shorter stay in the post-anesthesia care unit, and reduced need for rescue antiemetics offset the higher costs for anesthetics, analgesics, and muscle relaxants with propofol TIVA and reduced cost by 11.41 ± 10.73 USD per patient in the inpatient model and 11.25 ± 9.81 USD in the ambulatory patient model. Sensitivity analyses demonstrated strong robustness of the results. Conclusions Maintenance of general anesthesia with propofol was cost-saving compared to inhalational anesthesia in both inpatient and ambulatory surgical settings in the United States. These economic results support current guideline recommendations, which endorse propofol TIVA to reduce PONV risk and enhance postoperative recovery

Predicting the onset of delirium on hourly basis in an intensive care unit following cardiac surgery

Delirium, affecting up to 52% of cardiac surgery patients, can have serious long-term effects on patients by damaging cognitive ability and causing subsequent functional decline. This study reports on the development and evaluation of predictive models aimed at identifying the likely onset of delirium on an hourly basis in intensive care unit following cardiac surgery. Most models achieved a mean AUC > 0.900 across all lead times. A support vector machine achieved the highest performance across all lead times of AUC = 0.941 and Sensitivity = 0.907, and BARTm, where missing values were replaced with missForest imputation, achieved the highest Specificity of 0.892. Being able to predict delirium hours in advance gives clinicians the ability to intervene and optimize treatments for patients who are at risk and avert potentially serious and life-threatening consequences

Development and validation of a digital biomarker predicting acute kidney injury following cardiac surgery on an hourly basis

Objectives To develop and validate a digital biomarker for predicting the onset of acute kidney injury (AKI) on an hourly basis up to 24 hours in advance in the intensive care unit after cardiac surgery. Methods The study analyzed data from 6056 adult patients undergoing coronary artery bypass graft (CABG) and/or valve surgery between 1st April 2012 and 31st December 2018 (development phase, training, and testing) and 3572 patients between 1st January 2019 and 30th June 2022 (validation phase). The study utilized two dynamic predictive modeling approaches, namely logistic regression and bootstrap aggregated regression trees machine (BARTm), to predict AKI. The mean area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV) across all lead times before the occurrence of AKI were reported. The clinical practicality was assessed using calibration. Results Of all included patients, 8.45% and 16.66% had AKI in the development and validation phases, respectively. When applied to testing data, AKI was predicted with the mean AUC of 0.850 and 0.802 by BARTm and logistic regression, respectively. When applied to validation data, BARTm and LR resulted in a mean AUC of 0.844 and 0.786, respectively. Conclusions This study demonstrated the successful prediction of AKI on an hourly basis up to 24 hours in advance. The digital biomarkers developed and validated in this study have the potential to assist clinicians in optimizing treatment and implementing preventive strategies for patients at risk of developing AKI after cardiac surgery in the ICU

Decision support in cardiac surgery : early exploration of requirements with cardiac anesthetists and surgeons

Successful implementation of clinical decision support tools is rare, the key barrier being the lack of user involvement during development. Following the idea, development, exploration, assessment, long-term follow-up (IDEAL) framework, this study aims to provide early insights into the current challenges, clinical processes, and priorities when developing new decision support tools in cardiac surgery. Using a qualitative approach, semi-structured interviews were conducted with cardiac anesthetists and surgeons from three Scottish cardiac centers. Thematic analysis identified adverse postoperative outcomes, ageing cardiac patient population and changing surgical procedures to be the main challenges in cardiac surgery. Existing risk prediction tools were largely not used due to a perceived lack of utility and validation. This study underscores the need to shift focus towards predicting postoperative complications, instead of mortality. It emphasizes the importance of early collaboration with clinical experts and stakeholders in developing decision support systems that are fit for purpose. By identifying the priorities of cardiac clinicians, the study lays the groundwork for developing clinically meaningful prediction models

Definition and classification of postoperative complications after cardiac surgery : a pilot Delphi study

Background: Postoperative complications following cardiac surgery are common and represent a serious burden to health services and society. However, there is a lack of consensus among experts on what events should be considered as a ‘complication’ and how to assess their 'severity'. Objective: This study aimed to consult domain experts to pilot a development of a definition and classification system for complications following cardiac surgery with the goal to allow the progression of standardized clinical processes and systems in cardiac surgery. Methods: We conducted a Delphi study, which is a well-established method to reach expert consensus on complex topics. Two rounds of surveys were sent out to domain experts, including cardiac surgeons and anesthetists, to define and classify postoperative complications following cardiac surgery. The responses to open-ended questions were analyzed using a thematic analysis framework. Results: In total, N=71 and N=37 experts’ opinion were included in the analysis in Round 1 and Round 2 of the study, respectively. Cardiac anesthetists and cardiac critical care specialists took part of the study. Cardiac surgeons did not participate. Experts agreed that a classification of postoperative complications for cardiac surgery is useful, and a consensus was reached for the generic definition of a postoperative complication in cardiac surgery. Consensus was also reached on classification of complications according to the following 4 levels: “Mild”, “Moderate”, “Severe” and “Death”, and consensus was also reached on a definition of “Mild” and “Severe” categories of complications. Conclusions: Domain experts agreed on the definition and classification of complications in cardiac surgery for "Mild" and "Severe" complications. The standardization of complication identification, recording and reporting in cardiac surgery should help the development of quality benchmarks, clinical audit, care quality assessment, resources planning, risk management, communication, and research

No Success without Effort: Follow-Up at Six Years after Implementing a Benchmarking and Feedback Concept for Postoperative Pain after Total Hip Arthroplasty

Background: Total hip arthroplasty (THA) is still ranked among the operations with the highest postoperative pain scores. Uncontrolled postsurgical pain leads to prolongated hospital stays, causes more frequent adverse reactions and can induce chronical pain syndromes. In 2014, we implemented a standardized, multidisciplinary pain management concept with continuous benchmarking at our tertiary referral center by using the “Quality Improvement in Postoperative Pain Management” (QUIPS) program with excellent results over a period of two years. The initial study ended in 2016 and we aimed to evaluate if it was possible to obtain the excellent short-term results over a period of six years without any extra effort within the daily clinical routine. Materials and Methods: In a retrospective study design, we compared postoperative pain, side effects and functional outcome after primary THA for 2015 and 2021, using validated questionnaires from the QUIPS project. In contrast to the implementation of the pain management concept in 2014, the weekly meetings of the multidisciplinary health care team and special education for nurses were stopped in 2021. Data assessment was performed by an independent pain nurse who was not involved in pain management. Results: Altogether, 491 patients received primary THA in 2015 and 2021 at our tertiary referral center. Collected data revealed significantly worse maximum and activity-related pain (both p < 0.001) in combination with significantly higher opioid consumption in comparison to implementation in 2015. Though the patients reported to be less involved in pain management (p < 0.001), the worse pain scores were not reflected by patient satisfaction which remained high. While the participation rate in this benchmarking program dropped, we still fell behind in terms of maximum and activity-related pain in comparison to 24 clinics. Conclusion: Significantly worse pain scores in combination with higher opioid usage and a lower hospital participation rate resemble a reduced awareness in postoperative pain management. The significantly lower patient participation in pain management is in line with the worse pain scores and indirectly highlights the need for special education in pain management. The fact patient satisfaction appeared to remain high and did not differ significantly from 2015, as well as the fact we still achieved an acceptable ranking in comparison to other clinics, highlight the value of the implemented multidisciplinary pain management concept

The impact of primary total hip and knee replacement on frailty: an observational prospective analysis

Background Osteoarthritis is a prevalent condition in frail older adults that requires hip or knee replacement in many patients. The aim of the study was to determine the impact of hip and knee arthroplasty on frailty. Methods In this prospective short-term study, we used data from 101 participants of the ongoing Special Orthopaedic Geriatrics (SOG) trial, funded by the German Federal Joint Committee (GBA). Frailty, measured by Fried’s Physical Frailty Phenotype (PFP), was assessed preoperatively, 7 days postoperatively, 4–6 weeks and 3 months after hip and knee arthroplasty. ANOVA with repeated measures and post-hoc tests for the subgroups were used for the statistical analysis. Results Of the 101 participants, 50 were pre-frail (1–2 PFP criteria) and 51 were frail (≥ 3 PFP criteria) preoperatively. In the pre-frail group, the PFP score decreased from 1.56 ± 0.50 (median 2) preoperatively to 0.53 ± 0.73 (median 0) 3 months after surgery (p < 0.001). The PFP score in the frail cohort decreased from 3.39 ± 1.45 (median 3) preoperatively to 1.27 ± 1.14 (median 1) 3 months postoperatively (p < 0.001). While the PFP score of the pre-frail participants increased 7 days after surgery, the PFP score of the frail group decreased significantly. Conclusion Pre-frail individuals often regain robustness and patients with frailty are no longer assessed as frail after surgery. Joint replacement is an effective intervention to improve frailty in hip and knee osteoarthritis. Trial registration This study is part of the Special Orthopaedic Geriatrics (SOG) trial, German Clinical Trials Register DRKS00024102. Registered on 19 January 2021