Perioperative medicine: Journals & articles

Abstract
Background: The prevalence of postoperative pain is notably high among the elderly population, which poses significant challenges for their postoperative recovery. In this study, we aimed to identify preoperative predictors for acute and chronic postoperative pain in patients undergoing lumbar spinal surgery through a longitudinal investigation.

Methods: We recruited 75 patients (mean age 68.29 ± 5.60 years) and collected their resting-state electroencephalography (EEG) data two hours before the surgery. The aperiodic and periodic signal components were extracted from the resting-state EEG using the Fitting Oscillations and One-Over-F algorithm. We also collected the preoperative pain ratings, demographic information and the Hospital Anxiety and Depression Scale from all patients. The postoperative pain ratings were collected ten times from Day 1 to Week 12 after surgery.

Results: We observed a high incidence of postoperative acute and chronic pain among older patients. Preoperative pain and peak alpha frequency in resting-state EEG were the primary predictors of acute postoperative pain. Although age is a significant predictor of chronic postoperative pain, its predictive performance is poor.

Conclusions: Overall, our study provides valuable insights into the complex pattern of preoperative EEG features, preoperative pain and age in predicting postoperative pain at different stages. Our findings highlight the significance of exploring preoperative features to identify patients who are at a higher risk of developing severe postoperative pain, which can aid in the development of more personalized and effective pain management strategies.

Significance: The heightened occurrence of postoperative pain among the elderly presents formidable obstacles to their recuperation. This study delves into identifying preoperative factors influencing acute and chronic postoperative pain. Our findings indicate that preoperative pain and peak alpha frequency are crucial predictors of acute postoperative pain. However, the predictive performance for chronic postoperative pain is limited, although age was a significant predictor of chronic postoperative pain. These insights contribute to the identification of patients at elevated risk for severe acute and chronic postoperative pain, offering valuable guidance for pre-surgical risk assessment.

Abstract
Background: Perioperative handoffs are known to present unique challenges to safe and effective patient care. Numerous national accrediting bodies have called for standardized, structured handoff processes. Handoff mnemonics provide a memory aid and standardized structure, as well as promote a shared mental model. We set out to identify perioperative handoff intervention studies that included a handoff mnemonic; critically assess process and patient outcome improvements that support specific mnemonics; and propose future recommendations.

Methods: We conducted a systematic review of the English language perioperative handoff intervention literature designed to identify handoff mnemonic interventions. A comprehensive protocol was developed and registered (CRD42022363615). Searches were conducted using PubMed, Scopus, ERIC (EBSCO), Education Full Text (EBSCO), EMBASE (Elsevier), and Cochrane (January 1, 2010 to May 31, 2022). Pairs of trained reviewers were involved in all phases of the search and extraction process.

Results: Thirty-seven articles with 23 unique mnemonics met the inclusion criteria. Most articles were published after 2015 (29/37; 78%). Situation, Background, Assessment, Recommendation (SBAR), and SBAR variants were used in over half of all studies (22/37; 59%), with 45% (10/22) reporting at least 1 statistically significant process improvement. Seventy percent of handoff mnemonics (26/37) were expanded into lists or checklists. Fifty-seven percent of studies (21/37) reported using an interdisciplinary/interprofessional team to develop the intervention. In 49% of all studies (18/37) at least 1 measurement tool was either previously published or the authors conducting some form of measurement tool validation. Forty-one percent of process measurement tools (11/27) had some form of validation. Although most studies used training/education as an implementation strategy (36/37; 97%), descriptions tended to be brief with few details and no study used interprofessional education. Twenty-seven percent of the identified studies (10/37) measured perception alone and 11% (4/37) measured patient outcomes.

Conclusions: While the evidence supporting one handoff mnemonic over others is weak, SBAR/SBAR variants have been studied more often in the perioperative environment demonstrating some process improvements. A key finding is that 70% of included studies converted their handoff mnemonic to a list or checklist. Finally, given the essential nature of effective handoffs to perioperative patient safety, it is crucial that handoff interventions are well developed, implemented, and evaluated. We propose 8 recommendations for future perioperative handoff mnemonic clinical interventions and research.

Abstract
The Complex Decision Pathway (CDP) is a novel perioperative shared decision-making pathway that was established in the Bay of Plenty, New Zealand in 2018. Unique features of the pathway include the use of a structured communication tool to facilitate a goals-of-care conversation in addition to medical assessment, and the use of a tikanga Māori framework for Māori patients. From May 2019 until May 2022, 81 patients attending the CDP clinic were recruited to a prospective study of their demographics, health status and experience at the time of presentation, along with outcomes and opinions over the subsequent 12 months. Participants were mostly elderly and frail with multiple comorbidities, and just over half of participants chose to undergo surgery. Participants who chose, or were recommended, not to undergo surgery were older, more comorbid and had worse outcomes over the subsequent 12 months. Qualitative data suggested an overall positive patient experience of the pathway, and an economic analysis demonstrated its cost-effectiveness. Overall, the data presented here suggested that the CDP assisted in risk-stratifying patients into operative and non-operative groups, provided a positive patient experience, and was a cost-effective intervention.

Abstract in English, French
Purpose: We sought to assess the feasibility and estimate the effects on outcomes of a multimodal prehabilitation service implemented as an ancillary surgical service.

Methods: We conducted a pragmatic, nonrandomized feasibility study of surgical prehabilitation. Patients were eligible if they were ≥ 18 yr of age, fluent in English, and referred by a health professional for prehabilitation. Participants received an individualized program of preoperative exercise, nutrition, psychological, and/or smoking cessation support. The primary outcome was operational feasibility, including referral volume, enrolment rate, prehabilitation window, engagement, completion rate, and safety. Secondary outcomes included surgical complications, length of hospital stay, readmission, quality of life, and physical and mental health. Qualitative data related to intervention feasibility and acceptability. We compared intervention participants with patients who were referred for, but declined, prehabilitation.

Results: One hundred and sixteen patients were referred for prehabilitation. The mean age of referred patients was 71 yr and 55% were male. Over 90% of referrals were from surgical oncology, and the most common indication for referral was frailty (46%). Of the 116 referred patients, 83 consented to participate in the study. Patient-reported and objectively measured outcomes improved by a clinically important margin from baseline to presurgery, and returned to presurgery levels by 90 days postoperatively. Qualitative findings suggest that the prehabilitation intervention was well received.

Conclusion: Multimodal surgical prehabilitation is feasible as an integrated clinical service and may be effective for improving physical and psychological outcomes. Further evaluations of clinically integrated prehabilitation programs in Canada are needed to confirm these findings.

Abstract
Background: Postoperative pain following video-assisted thoracoscopic surgery (VATS) remains a significant challenge. While epidural analgesia is still the gold standard, other types of regional analgesia are gaining popularity because of perceived less risk of complications. The efficacy of systemic opioids as an alternative to epidural analgesia has not been thoroughly explored. This systematic review and meta-analysis aims to evaluate and compare the efficacy of systemic opioids versus epidural analgesia in managing postoperative pain after VATS.

Methods: We will conduct a systematic review and meta-analysis in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) checklist. A comprehensive search will be conducted in MEDLINE, EMBASE, and the Cochrane Library supplemented with Scopus citation searches, search for gray literature using Google Scholar and a search for ongoing studies. We will include studies based on the PICO methodology without restrictions regarding study type. Two independent reviewers will screen studies, extract data, and assess study quality using the Cochrane Risk of Bias tools. The primary outcomes will be postoperative pain intensity at rest and during activity at 24, 48, and 72 h. Secondary outcomes will include use of "rescue" opioids, hospital length of stay, and adverse events. If feasible, a meta-analysis will be done, otherwise we will perform a descriptive analysis.

Results: The results will provide a comparative analysis of the effectiveness of systemic opioids versus epidural analgesia in managing postoperative pain in VATS patients. Data synthesis will include pooled estimates for pain scores, opioid consumption, and adverse events, possibly with subgroup and sensitivity analyses conducted to explore heterogeneity across studies.

Conclusions: This systematic review will offer valuable insights into the optimal pain management strategy for patients undergoing VATS. The findings may guide clinical practice in selecting the most effective and safe analgesic approach, improving postoperative recovery, and patient outcomes.

Abstract
Background: Postoperative pain management is a challenge after robot-assisted cystectomy (RAC). Methadone has a long duration of action, and we therefore hypothesized that a single dose of intraoperative methadone would reduce postoperative opioid requirements and pain intensity in bladder cancer patients undergoing RAC.

Methods: We conducted a blinded randomized controlled clinical trial from July 2020 to August 2023. Patients scheduled to undergo RAC because of bladder cancer were randomized to receive intraoperative methadone (0.15 mg/kg-1) or morphine (0.15 mg kg-1) 1 h before endotracheal extubation. The primary outcome was opioid requirements after 24 h. Secondary outcomes were opioid requirements after 3 h, pain intensity at rest and during coughing, postoperative nausea and vomiting (PONV), sedation, hypoxemia, hypoventilation, time spent in the post-anesthetic care unit, and patient satisfaction.

Results: A total of 114 patients were randomized. Data from 99 patients (14 females, 85 males; mean age 69.8 ± 8.9 years) were available for analysis; 52 received methadone and 47 received morphine. Opioid consumption was similar between the methadone group and morphine group at 3 h (median, mg, 45 (IQR 30 to 75) vs. 45 (IQR 15 to 82.5) p = .97) and at 24 h (median, mg, 125 (IQR 75 to 198.5) versus 105 (IQR 72 to 157.5), p = .29). Pain intensity was significantly lower in the morphine group at 48 h compared with the methadone group. Patient satisfaction at 24 h was increased in the methadone group compared with the morphine group (median, (IQR), NRS; 9 (IQR 7 to 10) versus 7 (IQR 4 to 9), p = .020). There were no differences between treatment groups in terms of time spent in the post-anesthetic care unit and the occurrence of opioid-related side effects.

Conclusion: A single dose of intraoperative methadone does not reduce postoperative opioid requirements compared with a single dose of morphine in bladder cancer patients undergoing RAC.

Abstract
Objectives: Perioperative blood pressure control is crucial to ensure organ perfusion and avoid adverse events. However, no consensus on blood pressure targets is available. This study was designed to gain insights into current European perioperative hypertension management practices.

Design: Survey research.

Setting: Online survey.

Participants: The survey was administered to members of the European Association of Cardiothoracic Anaesthesiology and Intensive Care and distributed through the organization's social media.

Interventions: A 22-item questionnaire on the approach to perioperative hypertension control and its pharmacological management.

Measurements and main results: The study included surveys completed between July 1 and October 30, 2023. In total, 339 participants completed the questionnaire; 70% were anesthesiologists, 17% were intensive care physicians, and 12% were cardiac surgeons.

Major findings: More than 50% of respondents declared dealing with perioperative hypertension in 20% to 50% of their surgeries, and most target the 120 to 140 mmHg systolic blood pressure (SBP) range during surgery. Respondents mostly rely on α-adrenoreceptor antagonists (29%), nitrates (23%), and calcium channel blockers (15%) to manage perioperative hypertension. Titratable control was the most appreciated attribute of intravenous antihypertensives. Antihypertensive treatment failure occurred in less than 20% of surgeries, and the highest risk of hypotensive episodes was perceived by participants to be when using nitroglycerin and nitroprusside.

Conclusions: Perioperative SBP targets above 140 mmHg are uncommon among respondents, who predominantly target SBP values between 120 and 140 mmHg. The choice of intravenous antihypertensives is based on their manageability and user experience, and titratable control is the most appreciated characteristic.

Abstract
In this Pro-Con commentary article, we discuss whether anesthesiologists should be responsible for treating preoperative anemia. This debate was proposed based on the article published in this issue of Anesthesia & Analgesia by Warner et al, which is an advisory on managing preoperative anemia endorsed by both the Society of Cardiovascular Anesthesiologists and the Society for Advancement of Patient Blood Management. All evidence suggests that anemia is not just an innocent "bystander" which can be solved by transfusion. In fact, both anemia and transfusion are independently associated with adverse outcomes, so why not avoid both? It just makes sense that patients show up for surgery with enough red blood cells to avoid needing transfusion with someone else's. Even if we agree that preoperative anemia is worth treating before surgery, the question remains who should be responsible for doing so, and therein lies the reason for this Pro-Con debate. Should it be the responsibility of the anesthesiologist, or not? Let the readers decide.

Abstract
Background: Whether regional anesthesia impacts the development of chronic postsurgical pain is currently debateable, and few studies have evaluated an effect on prolonged opioid use. We sought to systematically review the effect of regional anesthesia for adults undergoing noncardiac elective surgery on these outcomes.

Methods: A systematic search was conducted in MEDLINE, EMBASE, CENTRAL, and CINHAL for randomized controlled trials (from inception to April 2022) of adult patients undergoing elective noncardiac surgeries that evaluated any regional technique and included one of our primary outcomes: (1) prolonged opioid use after surgery (continued opioid use ≥2 months postsurgery) and (2) chronic postsurgical pain (pain ≥3 months postsurgery). We conducted a random-effects meta-analysis on the specified outcomes and used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to rate the quality of evidence.

Results: Thirty-seven studies were included in the review. Pooled estimates indicated that regional anesthesia had a significant effect on reducing prolonged opioid use (relative risk [RR] 0.48, 95% CI, 0.24-0.96, P = .04, I2 0%, 5 trials, n = 348 patients, GRADE low quality). Pooled estimates for chronic pain also indicated a significant effect favoring regional anesthesia at 3 (RR, 0.74, 95% CI, 0.59-0.93, P = .01, I2 77%, 15 trials, n = 1489 patients, GRADE moderate quality) and 6 months (RR, 0.72, 95% CI, 0.61-0.85, P < .001, I2 54%, 19 trials, n = 3457 patients, GRADE moderate quality) after surgery. No effect was found in the pooled analysis at 12 months postsurgery (RR, 0.44, 95% CI, 0.16-1.17, P = .10).

Conclusions: The results of this study suggest that regional anesthesia potentially reduces chronic postsurgical pain up to 6 months after surgery. Our findings also suggest a potential decrease in the development of persistent opioid use.

Abstract
Purpose: The use of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) by patients undergoing surgery and procedures requiring anesthesia has become a topic of significant concern for perioperative providers because of the potential increased risk of aspiration resulting from the medication's effect of delaying gastric emptying. There is currently a lack of high-quality data regarding the safety of GLP-1 RAs in patients undergoing surgery, which has led to variations in practice.

Source: We performed an internet search of society-endorsed statements and guidelines related to perioperative management of GLP-1 RAs, focusing on the top 20 countries with the largest anesthesiology societies determined by membership data from the World Federation of Societies of Anesthesiologists. We excluded articles and websites that were not in English.

Principal findings: Our search revealed endorsed statements from fourteen major anesthesiology, endocrinology, and gastroenterology societies. There was considerable variation between societies in the recommendations and guidance for withholding these medications before surgery, the duration of withholding, assessment of the need for avoiding deep sedation or general anesthesia, use of rapid sequence intubation, need for prolonged fasting periods and clear fluid before a nil per os period, recognition of signs and symptoms for aspiration risk, the management of glucose in the perioperative period, and the use of point-of-care ultrasound for risk assessment.

Conclusion: Society-endorsed statements and guidelines provide varying recommendations on the perioperative management of GLP-1 RAs. The insights gained from this comparative analysis may help guide clinical practice, develop institutional practice guidelines, and direct future research efforts.

Abstract
Background: The etiology of anemia has tremendous overlap with the disease states responsible for cognitive decline. We used data from a perioperative database of older adults undergoing elective surgery with anesthesia to (1) examine relationships among preoperative anemia blood markers, preoperative screeners of cognitive function, and chronic disease status; and (2) examine the relationship of these factors with operative outcomes. The primary goal of this study was to investigate the association between preoperative anemia blood markers and cognition measured by a preoperative cognitive screener. Secondary goals were to (1) examine the relationship between preoperative anemia blood markers and chronic disease states (ie, American Society of Anesthesiologists [ASA] and frailty), and (2) investigate the relationship of preoperative anemia blood markers and cognition with operative outcomes (ie, discharge disposition, 1-year mortality, number of surgical complications, length of hospital stay, and length of intensive care unit [ICU] stay).

Methods: Data were collected at the University of Florida Health Shands Presurgical Center and the Perioperative Cognitive Anesthesia Network clinic within the electronic medical record. Patients 65 years of age or older were included if they had a preoperative hemoglobin (Hgb) value and a preoperative screening. Nonparametric methods were used for bivariate analysis. Logistic regression was used for the simultaneous examination of variables associated with nonhome discharge and 1-year mortality. Primary outcomes were discharge disposition and 1-year mortality. Secondary outcomes were number of surgical complications and length of hospital and ICU stay.

Results: Of 14,795 patients cognitively assessed, 8643 met the inclusion criteria. Of these, 26.7% were anemic, with 16.8%, 9.5%, and 0.4% having mild, moderate, and severe anemia, respectively. The Spearman correlation coefficient [95% confidence interval, CI] between the Hgb level and the clock drawing time (CDT) was -.15 [-.17 to -.13] (P < .0001) indicating that a lower Hgb level was associated with cognitive vulnerability. Hgb was also negatively correlated with the ASA physical status classification, patient Fried Frailty Index, and hospital and ICU length of stay. In the multivariable model, age, surgical service, ASA and Fried Frailty Index significantly predicted nonhome discharge. Furthermore, age, surgical service, ASA, Fried Frailty Index, and Hgb independently predicted death within 1 year of surgery. The odds of death, adjusted for ASA, Fried Frailty, and covariates, were 2.7 times higher for those in the mild anemic group compared to those who were not anemic (odds ratio [OR], 2.7, 95% CI, [2.1-3.5]). The odds of death, adjusted for ASA, Fried Frailty, and covariates, were 3.6 times higher for those in the moderate/severe anemic group compared to those who were not anemic (OR, 3.6, 95% CI, [2.7-4.9]).

Conclusions: In this first medicine study, we established relationships among anemia, preoperative markers of frailty and cognition, and chronic disease states in a large cohort of older patients undergoing elective surgery in a large tertiary medical center. We found that anemia, cognitive vulnerability, and chronic health disease states predicted death within 1 year of surgery, and that these preoperative factors negatively contribute to surgical outcomes such as time in the ICU, length of hospital stay, nonhome discharge, and 1-year mortality. The World Health Organization (WHO) and many academic medical societies have urged the adoption of patient blood management (PBM) disciplines, yet anemia is not routinely optimized as a preoperative risk factor. Given the well-defined association between preoperative anemia and postoperative morbidity and mortality, performing elective surgery on an untreated anemic patient should be considered substandard care. With established safe and effective treatment regimens, iron deficiency anemia is a modifiable preoperative risk factor that should be addressed before elective surgery.

Abstract
The increasing prevalence of diabetes mellitus has been accompanied by a rapid expansion in wearable continuous glucose monitoring (CGM) devices and insulin pumps. Systems combining these components in a "closed loop," where interstitial glucose measurement guides automated insulin delivery (AID, or closed loop) based on sophisticated algorithms, are increasingly common. While these devices' efficacy in achieving near-normoglycemia is contributing to increasing usage among patients with diabetes, the management of these patients in operative and procedural environments remains understudied with limited published guidance available, particularly regarding AID systems. With their growing prevalence, practical management advice is needed for their utilization, or for the rational temporary substitution of alternative diabetes monitoring and treatments, during surgical care. CGM devices monitor interstitial glucose in real time; however, there are potential limitations to use and accuracy in the perioperative period, and, at the present time, their use should not replace regular point-of-care glucose monitoring. Avoiding perioperative removal of CGMs when possible is important, as removal of these prescribed devices can result in prolonged interruptions in CGM-informed treatments during and after procedures, particularly AID system use. Standalone insulin pumps provide continuous subcutaneous insulin delivery without automated adjustments for glucose concentrations and can be continued during some procedures. The safe intraoperative use of AID devices in their hybrid closed-loop mode (AID mode) requires the CGM component of the system to continue to communicate valid blood glucose data, and thus introduces the additional need to ensure this portion of the system is functioning appropriately to enable intraprocedural use. AID devices revert to non-AID insulin therapy modes when paired CGMs are disconnected or when the closed-loop mode is intentionally disabled. For patients using insulin pumps, we describe procedural factors that may compromise CGM, insulin pump, and AID use, necessitating a proactive transition to an alternative insulin regimen. Procedure duration and invasiveness is an important factor as longer procedures increase the risk of stress hyperglycemia, tissue malperfusion, and device malfunction. Whether insulin pumps should be continued through procedures, or substituted by alternative insulin delivery methods, is a complex decision that requires all parties to understand potential risks and contingency plans relating to patient and procedural factors. Currently available CGMs and insulin pumps are reviewed, and practical recommendations for safe glycemic management during the phases of perioperative care are provided.

_Despite advancements in surgical and anesthesia techniques, acute and persistent postoperative pain are still a common challenge. Postoperative pain has direct effects on individual patient care and outcome, as well as putting strain on limited health care resources. Several prediction methods for postoperative pain have been described. One such method is the assessment of pain during peripheral venous cannulation (VCP). It is not known if different approaches to anesthesia and analgesia, depending on the evaluation of risk for postoperative pain, can improve outcome. The aim of this study is to evaluate if individualized anesthesia and analgesia can affect postoperative pain and recovery after surgery, in patients stratified by VCP.Methods_ Adult patients scheduled for laparoscopic surgery undergo pain-sensitivity stratification using VCP on the day of surgery. Patients scoring VCP ≥2.0 on the visual analogue scale (pain-sensitive) are randomized to multimodal anaesthesia and analgesia with opioids or standard of care. Patients scoring VCP ≤1.9 (pain-tolerant) are randomized to opioid-free anaesthesia or standard of care. The primary outcome is acute postoperative pain measured with numeric rating scale in the postoperative care unit. Secondary outcomes include analysis of pain after 24 h, persistent postoperative pain and quality of recovery.Discussion_ Individualized perioperative pain management has the potential to improve patient care. This study will examine the impact of different anesthesia and analgesia regimes, in patients with differing pain sensitivity, on postoperative pain_

Abstract in English, French
Background: Online video sharing platforms like YouTube (Google LLC, San Bruno, CA, USA) have become a substantial source of health information. We sought to conduct a systematic review of studies assessing the overall quality of perioperative anesthesia videos on YouTube.

Methods: We searched Embase, MEDLINE, and Ovid for articles published from database inception to 1 May 2023. We included primary studies evaluating YouTube videos as a source of information regarding perioperative anesthesia. We excluded studies not published in English and studies assessing acute or chronic pain. Studies were screened and data were extracted in duplicate by two reviewers. We appraised the quality of studies according to the social media framework published in the literature. We used descriptive statistics to report the results using mean, standard deviation, range, and n/total N (%).

Results: Among 8,908 citations, we identified 14 studies that examined 796 videos with 59.7 hr of content and 47.5 million views. Among the 14 studies that evaluated the video content quality, 17 different quality assessment tools were used, only three of which were externally validated (Global Quality Score, modified DISCERN score, and JAMA score). Per global assessment rating of video quality, 11/13 (85%) studies concluded the overall video quality as poor.

Conclusions: Overall, the educational content quality of YouTube videos evaluated in the literature accessible as an educational resource regarding perioperative anesthesia was poor. While these videos are in demand, their impact on patient and trainee education remains unclear. A standardized methodology for evaluating online videos is merited to improve future reporting. A peer-reviewed approach to online open-access videos is needed to support patient and trainee education in anesthesia.

Abstract
Background: Postdischarge primary care follow-up is associated with lower readmission rates after medical hospitalizations. However, the effect of primary care utilization on readmission has not been studied in surgical patients.

Methods: Retrospective cohort study of Medicare beneficiaries aged 65 and older undergoing major inpatient diagnostic or therapeutic procedures (n = 3,552,906) from 2017 through 2018, examining the association between postdischarge primary care visits within 14 days of discharge (primary exposure), and Annual Wellness Visits in the year prior (secondary exposure), with 30-day unplanned readmission (primary outcome), emergency department visits, and mortality (secondary outcomes).

Results: Overall, 9.5% (n = 336,837) had postdischarge visits within 14 days, 2.9% (n = 104,571) had Annual Wellness Visits in the year preceding the procedure, 9.5% (n = 336,401) were readmitted, 9% (n = 319,054) had emergency department visits, and 0.6% (n = 22,103) of the cohort died within 30 days. Our fully adjusted propensity-matched proportional hazards Cox regression analysis showed that postdischarge visits were associated with a 5% lower risk of readmission (hazard ratio [HR], 0.95, 95% confidence interval [CI], 0.93-0.97), 43% higher risk of emergency department use (HR, 1.43, 95% CI, 1.40-1.46) and no difference in mortality risk (HR, 0.98, 95% CI, 0.90-1.06), compared with not having a visit within 14 days of discharge. In a separate set of regression models, Annual Wellness Visits were associated with a 9% lower risk of readmission (HR, 0.91, 95% CI, 0.88-0.95), 45% higher risk of emergency department utilization (HR, 1.45, 95% CI, 1.40-1.49) and an 18% lower mortality risk (HR, 0.82, 95% CI, 0.75-0.89) compared with no Annual Wellness Visit in the year before the procedure.

Conclusions: Both postdischarge visits and the Medicare Annual Wellness Visit appear to be extremely underutilized among the older surgical population. In those patients who do utilize primary care, compared with propensity-matched patients who do not, our study suggests primary care use is associated with modestly lower readmission rates. Prospective studies are needed to determine whether targeted primary care involvement can reduce readmission.

Abstract
Background: Methadone is used as a perioperative analgesic in the management of postoperative pain. Despite positive outcomes from randomized trials favoring methadone, concerns about its safety persist, particularly regarding respiratory depression (RD) and excessive sedation. In this study, we compared the incidence of naloxone administration between patients administered intraoperative methadone and those administered intraoperative morphine as a measure of severe RD. Time spent at the postanesthesia care unit (PACU) was used as a proxy variable for excessive sedation.

Methods: This was a retrospective cohort study including all patients aged ≥18 years who underwent surgery between March 2019 and March 2023 at Aarhus University Hospital, Denmark. We assessed the association between intraoperative administration of either methadone or morphine and postoperative naloxone administration within the first 24 hours using logistic regression (primary outcome). An analogous linear regression model was used for the secondary outcome of time spent in the PACU after surgery. Patients were weighted using propensity scores to adjust for potential confounding variables.

Results: A total of 14,522 patients were included in the analysis. Among the 2437 patients who received intraoperative methadone, 15 (0.62%) patients received naloxone within the first 24 hours after surgery compared to 68 of 12,0885 (0.56%) who received intraoperative morphine. No statistical difference was observed in the odds of naloxone administration between patients administered methadone or morphine (adjusted odds ratio 95% confidence interval [CI], 1.21 [0.40-2.02]). Patients who were administered intraoperative methadone had a mean PACU length of stay (LOS) of 334 minutes (standard deviation [SD], 382) compared to 195 minutes (SD, 228) for those administered intraoperative morphine. The adjusted PACU LOS of patients administered intraoperative methadone was 26% longer compared to those administered intraoperative morphine (adjusted ratio of the geometric means 95% CI, 1.26 [1.22-1.31]).

Conclusions: The incidence of naloxone administration to treat severe RD was low. No difference was observed in the odds of naloxone administration to treat severe RD between patients administered intraoperative methadone or intraoperative morphine. Intraoperative methadone was associated with longer stays at the PACU; however, this result should be interpreted with care. Our findings suggest that intraoperative methadone has a safety profile comparable to that of morphine with regard to severe RD.

Abstract
Background: The amount of same-day surgery has increased markedly worldwide in recent decades, but there remains limited evidence on chronic postsurgical pain in this setting.

Methods: We assessed pain 90 days after ambulatory surgery in an international, multicentre prospective cohort study of patients ≥45 years old with comorbidities or ≥65 years old. Pain was assessed using the Brief Pain Inventory. Chronic postsurgical pain was defined as a change ≥1 in self-rated average pain at the surgical site between baseline and 90 days, and moderate to severe chronic postsurgical pain as a score ≥4 in self-rated average pain at the surgical site at 90 days. Risk factors for chronic postsurgical pain were identified using multivariable logistic regression.

Results: Between November 2021 and January 2023, a total of 2054 participants were included, and chronic postsurgical pain occurred in 12% of participants, of whom 93.1% had new chronic pain at the surgical site (i.e., participants without pain prior to surgery). Moderate to severe chronic postsurgical pain occurred in 9% of overall participants. Factors associated with chronic postsurgical pain were: active smoking (OR 1.82; 95% CI 1.20 to 2.76), orthopaedic surgery (OR 4.7; 95% CI 2.24 to 9.7), plastic surgery (OR 4.3; 95% CI 1.97 to 9.2), breast surgery (OR 2.74; 95% CI 1.29 to 5.8), vascular surgery (OR 2.71; 95% CI 1.09 to 6.7), and ethnicity (i.e., Hispanic/Latino ethnicity OR 3.41; 95% CI 1.68 to 6.9 and First Nations/Native persons OR 4.0; 95% CI 1.05 to 15.4).

Conclusions: Persistent postsurgical pain after same-day surgery is common, usually moderate to severe in nature, and occurs mostly in patients without chronic pain prior to surgery.

Abstract
Purpose: Acetaminophen is the most common drug used to treat acute pain in the pediatric population, given its wide safety margin, low cost, and multiple routes for administration. We sought to determine the most efficacious route of acetaminophen administration for postoperative acute pain relief in the pediatric surgical population.

Methods: We conducted a systematic review of randomized controlled trials (RCTs) that included children aged between 30 days and 17 yr who underwent any type of surgical procedure and that evaluated the analgesic efficacy of different routes of administration of acetaminophen for the treatment of postoperative pain. We searched MEDLINE, CENTRAL, Embase, CINAHL, LILACs, and Google Scholar databases for trials published from inception to 16 April 2023. We assessed the risk of bias in the included studies using the Cochrane Risk of Bias 1.0 tool. We performed a frequentist network meta-analysis using a random-effects model. Our primary outcome was postoperative pain using validated pain scales.

Results: We screened 2,344 studies and included 14 trials with 829 participants in the analysis. We conducted a network meta-analysis for the period from zero to two hours, including six trials with 496 participants. There was no evidence of differences between intravenous vs rectal routes of administration of acetaminophen (difference in means, -0.28; 95% confidence interval [CI], -0.62 to 0.06; very low certainty of the evidence) and intravenous vs oral acetaminophen (difference in means, -0.60; 95% CI, -1.20 to 0.01; low certainty of the evidence). For the comparison of oral vs rectal routes, we found evidence favouring the oral route (difference in means, -0.88; 95% CI, -1.44 to -0.31; low certainty of the evidence). Few trials reported secondary outcomes of interest; when comparing the oral and rectal routes in the incidence of nausea and vomiting, there was no evidence of differences (relative risk, 1.20; 95% CI, 0.81 to 1.78).

Conclusion: The available evidence on the effect of the administration route of acetaminophen on postoperative pain in children is very uncertain. The outcomes of postoperative pain control and postoperative vomiting may differ very little between the oral and rectal route. Better designed and executed RCTs are required to address this important clinical question.

Abstract
Annually, about 300 million surgeries lead to significant intraoperative adverse events (iAEs), impacting patients and surgeons. Their full extent is underestimated due to flawed assessment and reporting methods. Inconsistent adoption of new grading systems and a lack of standardization, along with litigation concerns, contribute to underreporting. Only half of relevant journals provide guidelines on reporting these events, with a lack of standards in surgical literature. To address these issues, the Intraoperative Complications Assessment and Reporting with Universal Standard (ICARUS) Global Surgical Collaboration was established in 2022. The initiative involves conducting global surveys and a Delphi consensus to understand the barriers for poor reporting of iAEs, validate shared criteria for reporting, define iAEs according to surgical procedures, evaluate the existing grading systems' reliability, and identify strategies for enhancing the collection, reporting, and management of iAEs. Invitation to participate are extended to all the surgical specialties, interventional cardiology, interventional radiology, OR Staffs and anesthesiology. This effort represents an essential step towards improved patient safety and the well-being of healthcare professionals in the surgical field.

Abstract in English, French
Purpose: Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined.

Clinical features: This clinical report reviews the principles underlying strain analysis and describes its main clinical uses pertinent to the field of anesthesiology and perioperative medicine. Strain for assessment of left and right ventricular function as well as atrial strain is described. We also discuss the potential role of strain to aid in perioperative risk stratification, surgical patient selection in cardiac surgery, and guidance of anesthetic monitor choice and clinical decision-making in the perioperative period.

Conclusion: Echocardiographic strain analysis is a powerful tool that allows seeing what conventional 2D imaging sometimes fails to reveal. It often provides pathophysiologic insight into various cardiac diseases at an early stage. Strain analysis is readily feasible and reproducible thanks to the use of highly automated software platforms. This technique shows promising potential to become a valuable tool in the arsenal of the anesthesiologist-echocardiographer and aid in perioperative risk-stratification and clinical decision-making.

Abstract
Background: Ineffective collaboration can increase adverse events in the operating theatre. When professionals work collaboratively, they are more likely to improve patient safety and outcomes.

Aim: To identify interprofessional collaboration interventions involving operating theatre teams and describe their effect on facilitating communication, teamwork, and safety.

Methods: A scoping review of four databases. Results were analysed by identifying interventions and mapping their related outcomes.

Results: Twenty studies evaluated single or multi-faceted interventions. Despite low-quality study designs (no randomised controlled trials), four interventions (eg: briefings, checklists, team training, debriefing) improved communication and teamwork, and enhanced safety outcomes. Only one study, using team training, reported that organisational level interventions (eg: Standard Operating Procedures, Lean quality improvement management system) improved teamwork and safety outcomes.

Conclusion: Several studies reported interventions enhanced interprofessional collaboration within operating theatre teams. Although findings were in favour of improved communication and teamwork, more rigorous research is required.

Abstract
Background: Despite being a commonly performed surgical procedure, pain management for appendicectomy is often neglected because of insufficient evidence on the most effective treatment options.

Objective: To provide evidence-based recommendations by assessing the available literature for optimal pain management after appendicectomy.

Design and data sources: This systematic review-based guideline was conducted according to the PROSPECT methodology. Relevant randomised controlled trials, systematic reviews and meta-analyses in the English language from January 1999 to October 2022 were retrieved from MEDLINE, Embase and Cochrane Databases using PRISMA search protocols.

Eligibility criteria: We included studies on adults and children. If articles reported combined data from different surgeries, they had to include specific information about appendicectomies. Studies needed to measure pain intensity using a visual analogue scale (VAS) or a numerical rating scale (NRS). Studies that did not report the precise appendicectomy technique were excluded.

Results: Out of 1388 studies, 94 met the inclusion criteria. Based on evidence and consensus, the PROSPECT members agreed that basic analgesics [paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs)] should be administered perioperatively for open and laparoscopic appendicectomies. A laparoscopic approach is preferred because of lower pain scores. Additional recommendations for laparoscopic appendicectomies include a three-port laparoscopic approach and the instillation of intraperitoneal local anaesthetic. For open appendicectomy, a preoperative unilateral transverse abdominis plane (TAP) block is recommended. If not possible, preincisional infiltration with local anaesthetics is an alternative. Opioids should only be used as rescue analgesia. Limited evidence exists for TAP block in laparoscopic appendicectomy, analgesic adjuvants for TAP block, continuous wound infiltration after open appendicectomy and preoperative ketamine and dexamethasone. Recommendations apply to children and adults.

Conclusion: This review identified an optimal analgesic regimen for open and laparoscopic appendicectomy. Further randomised controlled trials should evaluate the use of regional analgesia and wound infiltrations with adequate baseline analgesia, especially during the recommended conventional three-port approach.

Registration: The protocol for this study was registered with the PROSPERO database (Registration No. CRD42023387994).

Abstract
Purpose: Improvement in delivery of perioperative care depends on the ability to measure outcomes that can direct meaningful changes in practice. We sought to identify and provide an overview of perioperative quality indicators specific to the practice of anesthesia in noncardiac surgery.

Source: We conducted an umbrella review (a systematic review of systematic reviews) according to Joanna Briggs Institute methodology. We included systematic reviews examining perioperative indicators in patients ≥ 18 yr of age undergoing noncardiac surgery. Our primary outcome was any quality indicator specific to anesthesia. Indicators were classified by the Donabedian system and perioperative phase of care. The quality of systematic reviews was assessed using AMSTAR 2 criteria. Level of evidence of quality indicators was stratified by the Oxford Centre for Evidence-Based Medicine Classification.

Principal findings: Our search returned 1,475 studies. After removing duplicates and screening of abstracts and full texts, 23 systematic reviews encompassing 3,164 primary studies met our inclusion criteria. There were 330 unique quality indicators. Process indicators were most common (n = 169), followed by outcome (n = 114) and structure indicators (n = 47). Few identified indicators were supported by high-level evidence (45/330, 14%). Level 1 evidence supported indicators of antibiotic prophylaxis (1a), venous thromboembolism prophylaxis (1a), postoperative nausea/vomiting prophylaxis (1b), maintenance of normothermia (1a), and goal-directed fluid therapy (1b).

Conclusion: This umbrella review highlights the scarcity of perioperative quality indicators that are supported by high quality evidence. Future development of quality indicators and recommendations for outcome measurement should focus on metrics that are supported by level 1 evidence. Potential targets for evidence-based quality-improvement programs in anesthesia are identified herein.

Abstract
Purpose: Preoperative anemia is associated with poor postoperative outcomes. Older patients have limited physiologic reserves, which renders them vulnerable to the stress of major abdominal surgery. We aimed to determine if the severity of preoperative anemia is associated with early postoperative morbidity among older patients undergoing major abdominal surgery.

Methods: Ethics approval was obtained from SingHealth Centralized Institutional Review Board. This is a prospective observational study conducted in the preoperative anesthesia clinic of a tertiary Singapore hospital from 2017 to 2021. Patient demographic data, comorbidities, and intraoperative details were collected. Outcome measures included blood transfusions, complications according to the Postoperative Morbidity Survey, days alive and out of hospital (DaOH), length of hospital stay, and mortality.

Results: A total of 469 patients were analyzed, 37.5% of whom had preoperative anemia (serum hemoglobin of < 13 g·dL-1 in males and < 12 g·dL-1 in females). Anemia was significantly associated with older age, a higher age-adjusted Comprehensive Complication Index score, a higher incidence of diabetes mellitus, and a higher proportion of patients with an American Society of Anesthesiologists Physical Status of III or IV. The severity of anemia was associated with the presence of early postoperative morbidity at day 5, increased blood transfusions, longer length of hospital stay, and fewer DaOH at 30 days and six months.

Conclusion: Anemia is significantly associated with poorer postoperative outcomes in the older population. The impact of anemia on postoperative outcomes could be further evaluated with quality of life indicators, patient-reported outcome measures, and health economic tools.

Abstract
Background: International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes.

Methods: This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records.

Main results: A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year.

Conclusions: This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.

Abstract
In November of 2022, the Anesthesia Patient Safety Foundation held a Consensus Conference on Hemodynamic Instability with invited experts. The objective was to review the science and use expert consensus to produce best practice recommendations to address the issue of perioperative hemodynamic instability. After expert presentations, a modified Delphi process using discussions, voting, and feedback resulted in 17 recommendations regarding advancing the perioperative care of the patient at risk of, or with, hemodynamic instability. There were 17 high-level recommendations. These recommendations related to the following 7 domains: Current Knowledge (5 statements); Preventing Hemodynamic Instability-Related Harm During All Phases of Care (4 statements); Data-Driven Quality Improvement (3 statements); Informing Patients (2 statements); The Importance of Technology (1 statement); Launch a National Campaign (1 statement); and Advancing the Science (1 statement). A summary of the recommendations is presented in Table 1 .

Abstract
Background: Qualitative data on the opinions of anaesthesiologists regarding the impact of peri-operative night-time working conditions on patient safety are lacking.

Objectives: This study aimed to achieve in-depth understanding of anaesthesiologists' perceptions regarding the impact of night-time working conditions on peri-operative patient safety and actions that may be undertaken to mitigate perceived risks.

Design: Qualitative analysis of responses to two open-ended questions.

Setting: Online platform questionnaire promoted by the European Society of Anaesthesiology and Intensive Care (ESAIC).

Participants: The survey sample consisted of an international cohort of anaesthesiologists.

Main outcome measures: We identified and classified recurrent themes in the responses to questions addressing perceptions regarding (Q1) peri-operative night-time working conditions, which may affect patient safety and (Q2) potential solutions.

Results: We analysed 2112 and 2113 responses to Q1 and Q2, respectively. The most frequently reported themes in relation to Q1 were a perceived reduction in professional performance accompanied by concerns regarding the possible consequences of work with fatigue (27%), and poor working conditions at night-time (35%). The most frequently proposed solutions in response to Q2 were a reduction of working hours and avoidance of 24-h shifts (21%), an increase in human resources (14%) and performance of only urgent or emergency surgeries at night (14%).

Conclusion: Overall, the surveyed anaesthesiologists believe that workload-to-staff imbalance and excessive working hours were potential bases for increased peri-operative risk for their patients, partly because of fatigue-related medical errors during night-time work. The performance of nonemergency elective surgical cases at night and lack of facilities were among the reported issues and potential targets for improvement measures. Further studies should investigate whether countermeasures can improve patient safety as well as the quality of life of anaesthesia professionals. Regulations to improve homogeneity, safety, and quality of anaesthesia practice at night seem to be urgently needed.

Abstract
Objective: Randomized controlled trials indicate regional anesthesia (RA) improves postoperative outcomes with reduced pain and opioid consumption. Therefore, we hypothesized children who received RA, regardless of technique, would have reduced pain/opioid use in routine practice.

Methods: Using a retrospective cohort, we assessed the association of RA with perioperative outcomes in everyday practice at our academic pediatric hospital. Patients ≤18 years undergoing orthopedic, urologic, or general surgeries with and without RA from 5/2014 to 9/2021 were categorized as single-shot, catheter-based, or no-block. Outcomes included: intraoperative opioid exposure and dose, pre-incision anesthesia time, post anesthesia care unit (PACU) opioid exposure and dose, PACU antiemetic/antipruritic administration, PACU/inpatient pain scores, PACU/inpatient lengths of stay, and cumulative opioid exposure. Regression models estimated the adjusted association of RA with outcomes, controlling for multiple variables.

Results: 11,292 procedures with 3,160 RAs were included. Compared to no-block group, single-shot and catheter-based blocks were associated with opioid-free intraoperative anesthesia and opioid-free PACU stays. Post-PACU (i.e. while inpatient), single-shot blocks were not associated with improved pain scores or reduced opioid use. Catheter-based blocks were associated with reduced PACU and inpatient opioid use until 24 hours post-op, no difference of opioid use from 24 to 36 hours, and higher probability of use from 36 to 72 hours. RA was not associated with reduced cumulative opioid consumption.

Discussion: Despite adjustment for confounders, the association of RA with pediatric pain/opioid use outcomes was mixed. Further investigation is necessary to maximize the benefits of RA.

Abstract
There is general agreement that acute pain management is an important component of perioperative medicine. However, there is no consensus on the best model of care for perioperative pain management, mainly because evidence is missing in many aspects. Comparing the similarities and differences between countries might reveal some insights into different organisational models and how they work. Here, we performed a narrative review to describe and compare the structures, processes and outcomes of perioperative pain management in the healthcare systems of four European countries using Donabedian's framework as a guide. Our comparison revealed many similarities, differences and gaps. Different structures of acute pain services in the four countries with no common definition and standards of care were found. Protocols have been implemented in all countries and guidelines in some. If outcome is assessed, it is mainly pain intensity, and many patients experiencing more intense pain than others have common risk factors (e.g. preoperative pain, preoperative opioid intake, female sex and young age). Outcome assessment beyond pain intensity (such as pain-related physical function, which is important for early rehabilitation and recovery) is currently not well implemented. Developing common quality indicators, a European guideline for perioperative pain management (e.g. for patients at high risk for experiencing severe pain and other outcome parameters) and common criteria for acute pain services might pave the way forward for improving acute pain management in Europe. Finally, the education of general and specialist staff should be aligned in Europe, for example, by using the curricula of European Pain Federation (EFIC).

Abstract
Background: Chronic pain is a recognized complication of surgery, and it has been hypothesized that regional anesthesia might reduce the risk of development of chronic pain after upper extremity surgery.

Methods: A systematic literature review was performed to assess whether in patients undergoing elective upper extremity surgery (P), regional anesthesia (I), compared to general anesthesia (C), would result in lower long-term (>3 months) postoperative pain intensity (O). We included randomized and nonrandomized controlled trials (RCTs). Our primary outcome was numerical rating score or visual analogue scale for pain, at >3 months postoperatively. The Embase, Medline ALL, Web of Science Core Collections, Cochrane Central Register of Controlled Trials, and Google Scholar databases were searched for all reports assessing pain at >3 months after upper extremity surgery under general versus regional anesthesia. Secondary outcomes were: opioid prescription filling, complex regional pain syndrome (CRPS) incidence, the Mayo Wrist Score (MWS), and scores on the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Quality (or certainty) of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Risk-of-bias was assessed using the Cochrane tool for randomized trials (RoB 2.0) and nonrandomized trials (ROBINS-I).

Results: This review included 14 studies, comprising 7 RCTs and 7 nonrandomized studies. Six of the 7 studies (4 RCTs, N = 273; 2 nonrandomized studies, N = 305) using a pain score, our primary outcome, report comparable long-term postoperative pain scores after regional and general anesthesia. Six of the 7 studies using our secondary outcomes report comparable long-term outcomes in terms of opioid prescription filling (2 retrospective cohort studies [RCSs], N = 89,256), CRPS incidence (1 RCT, N = 301), MWS (1 RCT and 1 RCS, N = 215), and DASH score (1 RCT, N = 36). Comparable outcomes were reported in all 7 RCTs (N = 778) and in 5 of the 7 nonrandomized studies, comprising 5 RCSs (N = 89,608). Two prospective observational studies (POSTs), comprising 279 patients, report a statistically significant difference in outcomes, with less pain and better DASH scores after brachial plexus anesthesia. All 14 studies provided moderate to very low certainty evidence, and there was a serious risk of bias due to confounding bias in 5 of the 7 nonrandomized studies (N = 631).

Conclusions: The results of this review indicate that upper extremity regional anesthesia, compared to general anesthesia, is unlikely to change pain intensity at >3 months postoperatively.

Abstract
Value-based care and quality improvement are related concepts used to measure and improve clinical care. Value-based care represents the relationship between the incremental gain in outcome for patients and cost efficiency. It is achieved by identifying outcomes that are important to patients, codesigning solutions using multidisciplinary teams, measuring both outcomes and costs to drive further improvements, and developing partnerships across the health system. Quality improvement is focused on process improvement and compliance with best practice, and often uses "Plan-Do-Study-Act" cycles to identify, test, and implement change. Validated, standardized core outcome sets for perioperative neuroscience are currently lacking, but neuroanesthesiologists can consider using traditional clinical indicators, patient-reported outcomes measures, and perioperative core outcome measures. Several examples of bundled care solutions have been successfully implemented in perioperative neuroscience to increase value; for example, enhanced recovery for spine surgery, delirium reduction pathways, and same-day discharge craniotomy. This review proposes potential individual- and system-based solutions to address barriers to value-based care and quality improvement in perioperative neuroscience.

Abstract
Concerns regarding the perioperative management of acute psychostimulant intoxication have been recognized for decades, but novel and diverse substances in this class continue to be developed. Despite the similarities in mechanisms of action among psychostimulants, each subclass within this broad category has unique receptor specificity and different mechanisms that play a role in patient clinical presentation. These issues present challenges to anesthesia providers when caring for patients with either acute or chronic exposure to psychostimulants during the perioperative period. Challenges result from both physiological and psychological effects that influence the action of the primary anesthetic agent, adjuvant anesthetics, and analgesics used for perioperative management of pain. The epidemiology, pharmacology, and perioperative implications of psychostimulant use are presented for amphetamines and similar acting nonamphetamines, cocaine, and, finally, the mixed-action drugs known as entactogens that share stimulant and psychedelic properties. This information is then used as the foundation for safe and effective perioperative management of patients exposed to psychostimulants.

Abstract
Perioperative cardiac arrest (POCA) is a catastrophic complication that requires immediate recognition and correction of the underlying cause to improve patient outcomes. While the hypoxia, hypovolemia, hydrogen ions (acidosis), hypo-/hyperkalemia, and hypothermia (Hs) and toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary), and thrombosis (coronary) (Ts) mnemonic is a valuable tool for rapid differential diagnosis, it does not cover all possible causes leading to POCA. To address this limitation, we propose using the preload-contractility-afterload-rate and rhythm (PCARR) construct to categorize POCA, which is comprehensive, systemic, and physiologically logical. We provide evidence for each component in the PCARR construct and emphasize that it complements the Hs and Ts mnemonic rather than replacing it. Furthermore, we discuss the significance of utilizing monitored variables such as electrocardiography, pulse oxygen saturation, end-tidal carbon dioxide, and blood pressure to identify clues to the underlying cause of POCA. To aid in investigating POCA causes, we suggest the Anesthetic care, Surgery, Echocardiography, Relevant Check and History (A-SERCH) list of actions. We recommend combining the Hs and Ts mnemonic, the PCARR construct, monitoring, and the A-SERCH list of actions in a rational manner to investigate POCA causes. These proposals require real-world testing to assess their feasibility.

Abstract
Purpose of review: This study indicates that there are differences between hospitals in detection, as well as in adequate management of postsurgical complications, a phenomenon that is described as 'failure-to-rescue'.In this review, recent initiatives to reduce failure-to-rescue in the perioperative period are described.

Recent findings: Use of cognitive aids, emergency manuals, family participation as well as remote monitoring systems are measures to reduce failure-to-rescue situations. Postoperative visit of an anaesthesiologist on the ward was not shown to improve outcome, but there is still room for improvement of postoperative care.

Summary: Improving the complete emergency chain, including monitoring, recognition and response in the afferent limb, as well as diagnostic and treatment in the efferent limb, should lead to reduced failure-to-rescue situations in the perioperative period.

Abstract
Purpose of the review: Highlight sources of low-value care (LVC) during the perioperative period help understanding the decision making behind its persistence, the barriers for change, and the potential implementation strategies to reduce it.

Recent findings: The behavioural economics science spread of use through aligned strategies or nudge units offer an opportunity to improve success in the LVC reduction.

Summary: LVC, such as unneeded surgeries, or preanaesthesia tests for low-risk surgeries in low-risk patients, is a relevant source of waste and preventable harm, most especially in the perioperative period. Despite the international focus on it, initial efforts to reduce it in the last decade have not clearly shown a sustainable improvement. Understanding the shared decision-making process and the barriers to be expected when tackling LVC is the first step to build the change. Applying a structured strategy based on the behavioural science principles may be the path to increasing high value care in an effective an efficient way. It is time to foster nudge units at different healthcare system levels.

Abstract
Patients with type 1 diabetes mellitus (T1D) require insulin administration at all times to maintain euglycemia and metabolic stability. Insulin administration in the perioperative period is complicated by fasting requirements and perioperative stressors that can change the patient's insulin needs. In addition, many anesthesia providers are not familiar with insulin dosing strategies and technology, such as insulin pumps and continuous glucose monitors (CGMs), that are commonly used by patients with T1D. Errors in perioperative insulin administration can lead to hypoglycemia, hyperglycemia, and diabetic ketoacidosis. This article reviews common errors of associated with the perioperative management of patients with T1D, including failure to assess and coordinate patient care preoperatively; failure to understand diabetes management and technology; failure to monitor blood glucose and recognize dysglycemia; and failure to appropriately administer basal insulin.

Abstract
Purpose: Diversion of controlled substances in the perioperative setting is an ongoing challenge, with consequences for patients, anesthesiologists, perioperative staff, and health care facilities alike. Perioperative environments are at high risk for diversion, since controlled substances are frequently handled in these settings, with varying levels of oversight. In this narrative review, we summarize strategies for preventing diversion of controlled substances in perioperative settings (i.e., operating rooms, endoscopy suites, and postanesthesia recovery units).

Source: We performed a targeted literature search in PubMed MEDLINE, Embase, Scopus, Web of Science, the Cochrane Register of Controlled trials, and the Cochrane Database of Systematic Reviews, as well as a manual search for additional references. We used terminology related to drug diversion, drug abuse, anesthesiologists, pharmacists, physicians, operating room personnel, and controlled substances.

Principal findings: Many strategies have been described for preventing diversion in perioperative settings, and these are broadly categorized into: education, distribution, auditing, or provider screening. Some of these approaches may be time- and resource-intensive. There is limited evidence to inform anesthesia departments' choice of which strategies to adopt.

Conclusion: Although awareness of perioperative controlled substance diversion has been improving, there are too few data to suggest an optimal approach. Anesthesia departments will need to work collaboratively with hospital pharmacies and actively select strategies that are reasonable given local resources.

Abstract in English
Purpose: Preoperative exercise could improve postoperative outcomes for people with frailty; however, little is known about how to predict older people's adherence to exercise before surgery (i.e., prehabilitation) programs. Our objective was to derive and validate a model to predict prehabilitation adherence in older adults living with frailty before cancer surgery.

Methods: This was a nested prospective cohort study of older adults with frailty having cancer surgery who participated in a randomized controlled trial of home-based prehabilitation compared with standard perioperative care. We constructed a multivariable ordinary least squares linear regression model to predict adherence. Covariates were selected a priori based on clinical expertise and systematic review. Optimism was estimated through internal validation using bootstrap resampling.

Results: The derivation cohort consisted of 95 participants in the intervention arm of the trial. Percent adherence ranged from 0% to 100%, with a mean (standard deviation) of 61 (34)%. Previous physical activity and age were the only predictors significant at the 5% level.

Conclusion: A prespecified multivariable model may help to explain a modest degree of variation in prehabilitation adherence in older people with frailty. While this model is an important step toward personalizing prehabilitation support, this study was limited by a small sample size and future research is needed to better understand personalized prediction of prehabilitation adherence in older people with frailty.

Abstract
Purpose: We sought to evaluate 1) patient- and anesthesiologist-reported rates of postoperative delirium (POD) risk discussion during preoperative meetings, 2) patients' and anesthesiologists' ratings of the importance of POD, and 3) predictors of patient-reported discussion of POD risk during preoperative meetings.

Methods: In this multicentre two-part cross-sectional survey study, patients ≥ 65 yr scheduled to undergo elective noncardiac surgery completed a five-minute survey after preoperative anesthesia consultation. Patients were asked about their perception of POD importance, and whether they discussed or were assessed for POD risk. Anesthesiologists were surveyed using self-administered surveys circulated via institutional email lists. Anesthesiologists were asked about the frequency of POD risk assessment and discussion in older adults, tools used, and perception of POD-screening barriers.

Results: Four hundred and twelve (of 510 approached) patients (50% male; mean age, 73 yr) and 267 anesthesiologists (of 1,205 invited via e-mail) participated in this study conducted in five Canadian hospitals. Postoperative delirium screening and discussion was reported by 88/412 (22%) patients and 229/267 (86%) anesthesiologists. Postoperative delirium was rated as "somewhat-extremely" important by 64% of patients. A previous history of delirium, higher education, the number of daily medications, and longer surgical duration were associated with POD discussion. On average, anesthesiologists rated the importance of POD at 8/10, and 42% ranked "patient risk factors" as the top reason prompting discussion.

Conclusion: The combined evaluation of patients' and anesthesiologists' perspectives provides valuable information on preoperative POD screening and risk assessment, and highlights areas for improvement in the current practice. Most factors we identified to be associated with higher odds of POD discussion are recognized risk factors of POD.

Abstract
There is an increase in outpatient procedures and this trend will continue in the future. For hemorrhoidectomy, it is the standard of treatment in many health care systems. Perioperative management including adequate pain control is of paramount importance to ensure successful ambulatory surgery. This study investigates the role and effect of morphine compared to short-acting opiates applied before, during, or after proctological interventions and with focus on hemorrhoidectomy. A retrospective analysis of a prospective database was conducted comparing two populations. The control cohort received morphine (Yes-Mô) intra- and postoperatively, while the intervention group did not receive morphine (No-Mô) between January 2018 and January 2020. Both cohorts were balanced by propensity score matching. The outcomes were postoperative pain measured by numeric ratings scale (NRS) one hour postoperatively, pain 24 h postoperatively, success rate of outpatient management, and complication rate including postoperative nausea and vomiting as well as urinary retention. The intervention population comprised 54 patients and the control group contained 79 patients. One hour after surgery, patients in No-Mô reported lower NRS (1.44 ± 1.41) compared to Yes-Mô (2.48 ± 2.30) (p = 0.029). However, there was no difference in NRS 24 h postoperatively (No-Mô: 1.61 ± 1.41 vs Yes-Mô: 1.63 ± 1.72; p = 0.738). 100% of No-Mô was managed as outpatients while only 50% of Yes-Mô was dismissed on the day of the operation (p = < 0.001). There was no difference in postoperative complications (including postoperative nausea and vomiting (PONV) and urinary retention) between the two groups (PONV No-Mô 7.4% vs Yes-Mô 5.6%, p = 1.0 and urinary retention No-Mô 3.7% vs Yes-Mô 7.4%, p = 0.679). No-Mô received an oral morphine equivalent of 227.25 ± 140.35 mg intraoperatively and 11.02 ± 18.02 mg postoperatively. Yes-Mô received 263.17 ± 153.60 mg intraoperatively and 15.97 ± 14.17 mg postoperatively. The difference in received morphine equivalent between the groups was not significant after matching for the intraoperative (p = 0.212) and postoperative (p = 0.119) received equivalent. Omission of perioperative morphine is a viable but yet not understood method for reducing postoperative pain. Omission of morphine leads to a lower use of total morphine equivalent to attain satisfactory analgesia. The reduction of the overall opiate load and using opiates with a very short half-life potentially leads to a reduction of side effects like sedation. This in turn promotes discharge of the patient on the day of surgery. Omission of morphine is safe and does not increase postoperative complications.

Abstract
Background: Worldwide, there is an increasing trend of performing more complex operations in a day care setting, usually driven by economic considerations. Provision of appropriate pain relief is still inadequate in this setting. Poor pain control and adverse effects of opioids provided for pain control are common reasons for readmission, with human and economic consequences. The aim of this review was to develop evidence-based protocol for pain management of day surgery in a resource limited setting.

Method: After formulating the key questions, scope, and eligibility criteria for the articles to be included, advanced search strategy of electronic sources from data bases and websites was conducted. Screening of literatures was conducted with proper appraisal checklist. This review was reported in accordance with preferred reporting items for systematic reviews and meta-analysis (PRISMA) 2020 statement.

Results: A total of 333 articles were identified from data bases and websites using an electronic search. 45 articles were removed for duplication and 87 studies were excluded after reviewing titles and abstracts. At the screening stage, 73 articles were retrieved and evaluated for eligibility. Finally, 40 studies met the eligibility criteria and were included in this systematic review.

Conclusion: Day surgery encourages patients to mobilize soon after surgery and empowers them to manage their own pain. Thus, preoperative patient education and high-quality perioperative pain management are paramount. With increasing healthcare demands for more day-case procedures, multi-modal analgesic techniques in the perioperative period with good extension of analgesia into the postoperative discharge period are essential.

Abstract
Tobacco smoking is associated with a substantially increased risk of postoperative complications. The peri-operative period offers a unique opportunity to support patients to stop tobacco smoking, avoid complications and improve long-term health. This systematic review provides an up-to-date summary of the evidence for tobacco cessation interventions in surgical patients. We conducted a systematic search of randomised controlled trials of tobacco cessation interventions in the peri-operative period. Quantitative synthesis of the abstinence outcomes data was by random-effects meta-analysis. The primary outcome of the meta-analysis was abstinence at the time of surgery, and the secondary outcome was abstinence at 12 months. Thirty-eight studies are included in the review (7310 randomised participants) and 26 studies are included in the meta-analysis (5969 randomised participants). Studies were pooled for subgroup analysis in two ways: by the timing of intervention delivery within the peri-operative period and by the intensity of the intervention protocol. We judged the quality of evidence as moderate, reflecting the degree of heterogeneity and the high risk of bias. Overall, peri-operative tobacco cessation interventions increased successful abstinence both at the time of surgery, risk ratio (95%CI) 1.48 (1.20-1.83), number needed to treat 7; and 12 months after surgery, risk ratio (95%CI) 1.62 (1.29-2.03), number needed to treat 9. More work is needed to inform the design and optimal delivery of interventions that are acceptable to patients and that can be incorporated into contemporary elective and urgent surgical pathways. Future trials should use standardised outcome measures.

Abstract
Objectives: The quality of postoperative pain management is often poor. A 'bundle', a small set of evidence-based interventions, is associated with improved outcomes in different settings. We assessed whether staff caring for surgical patients could implement a 'Perioperative Pain Management Bundle' and whether this would be associated with improved multi-dimensional pain-related Patient-Reported-Outcomes (PROs).

Methods: PAIN OUT, a perioperative pain registry, offers tools for auditing pain-related PROs and obtaining information about perioperative pain management during the first 24 hours after surgery. Staff from 10 hospitals in Serbia used this methodology to collect data at baseline. They then implemented the 'perioperative pain management bundle' into the clinical routine and collected another round of data. The bundle consists of four treatment elements: (1) a full daily dose of 1-2 non-opioid analgesics (e.g. paracetamol, NSAIDs); (2) at least one type of local/regional anesthesia; (3) pain assessment by staff; (4) offering patients information about pain management. The primary endpoint was a multi-dimensional pain composite score (PCS), evaluating pain intensity, interference and side-effects: It was compared between patients who received the full bundlevs.not.

Results: Implementation of the complete bundle was associated with a significant reduction in the PCS (P<0.001, small-medium effect size [ES]). When each treatment element was evaluated independently, non-opioid analgesics were associated with a higher PCS (i.e. poorer outcome; negligible ES); the other elements were associated with a lower PCS (all negligible-small ES). Individual PROs were consistently better in patients receiving the full bundle compared to 0-3 elements. The PCS was not associated with surgical discipline.

Discussion: We report findings from using a bundle approach for perioperative pain management in patients undergoing mixed surgical procedures. Future work will seek strategies to improve the effect.

Abstract
Objective: Adverse events in the perioperative environment, a potential risk to patients, may be mitigated by nurturing staff adaptability and resiliency. An activity called "One Safe Act" (OSA) was developed to capture and highlight proactive safety behaviors that staff use in their daily practice to promote safe patient care.

Methods: One Safe Act is conducted in-person in the perioperative environment by a facilitator. The facilitator gathers an ad hoc group of perioperative staff in the work unit. The activity is run as follows: staff introductions, purpose/instructions of the activity, participants self-reflect about their OSA (proactive safety behavior) and record it as free text in an online survey tool, the group debriefs with each person sharing their OSA, and the activity is concluded by summarizing behavioral themes. Each participant completed an attitudinal assessment to understand changes in safety culture perception.

Results: From December 2020 to July 2021, a total of 140 perioperative staff participated (21%, 140/657) over 28 OSA sessions with 136 (97%, 140/136) completing the attitudinal assessment. A total of 82% (112/136), 88% (120/136), and 90% (122/136) agreed that this activity would change their practices related to patient safety, improve their work unit's ability to deliver safe care, and demonstrated their colleagues' commitment to patient safety, respectively.

Conclusions: The OSA activity is participatory and collaborative to build shared, new knowledge, and community practices focused on proactive safety behaviors. The OSA activity achieved this goal with a near universal acceptance of the activity in promoting an intent to change personal practice and increasing engagement and commitment to safety culture.

Abstract
Purpose: Nurses routinely assess respiration of hospitalized children; however, respiratory rate measurements are technically difficult due to rapid and small chest wall movements. The aim of this study is to reveal the respiratory status of small children undergoing minor surgery with load cells placed under the bed legs, and to test the hypothesis that respiratory rate (primary variable) is slower immediately after arrival to the ward and recovers in 2 h.

Methods: Continuous recordings of the load cell signals were performed and stable respiratory waves within the 10 discriminative perioperative timepoints were used for respiratory rate measurements. Apnea frequencies were calculated at pre and postoperative nights and 2 h immediately after returning to the ward after surgery.

Results: Continuous recordings of the load cell signals were successfully performed in 18 children (13 to 119 months). Respiratory waves were appraisable for more than 70% of nighttime period and 40% of immediate postoperative period. There were no statistically significant differences of respiratory rate in any timepoint comparisons (p = 0.448), thereby not supporting the study hypothesis. Respiratory rates changed more than 5 breaths per minute postoperatively in 5 out of 18 children (28%) while doses of fentanyl alone did not explain the changes. Apnea frequencies significantly decreased 2 h immediately after returning to the ward and during the operative night compared to the preoperative night.

Conclusion: Respiratory signal extracted from load cell sensors under the bed legs successfully revealed various postoperative respiratory pattern change in small children undergoing minor surgery.

Clinical trail registration: UMIN (University Hospital Information Network) Clinical Registry: UMIN000045579 ( https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000052039 ).

Keywords: Apnea; Bed sensor; Children; Monitoring; Postoperative; Recovery; Respiration; Respiratory rate.

Abstract
Current guidelines support the use of continuous glucose monitoring devices and insulin pumps in minor surgical procedures for pediatric patients with type 1 diabetes mellitus. However, there are few reported cases of using hybrid closed loop technology in the perioperative period. This retrospective case series presents seven pediatric patients with type 1 diabetes who underwent eight surgical procedures with maintenance of hybrid closed loop systems. This paper also provides considerations for future use of hybrid closed loop systems perioperatively.

Abstract
Purpose: Patients with mastocytosis have an increased risk of anaphylaxis during surgical procedures with general anesthesia. Therefore, we reviewed the anesthesia course of a large cohort of patients with mastocytosis.

Methods: We retrospectively reviewed adult and pediatric patients with mastocytosis who underwent surgical procedures with general anesthesia at Mayo Clinic from January 1, 2000, through June 30, 2021. We also included any procedures with general anesthesia that occurred during the 3-year period preceding mastocytosis diagnosis and designated the patients who underwent these procedures as having an unknown diagnosis at the time of their surgical procedure. We analyzed whether patients received chronic antimediator treatment for mastocytosis and/or prophylactic medications before the procedures. We also determined whether medications indicative of mastocytosis-related adverse events were intraoperatively administered.

Keywords: cardiac surgery; inhaled iloprost; inhaled prostacyclins; pulmonary hypertension.

Keywords: acute pain; chronic kidney failure pain management; continuous catheter analgesia; erector spinae plane (esp) blockade; opioid-free analgesia; perioperative analgesia; regional anaesthesiology; transplant

Learning Objectives:
By reading this article, you should be able to:

• Describe the clinical assessment of fluid status and fluid responsiveness in children.
• Explain the clinical reasoning for the type and amount of i.v. fluids given to children during surgery.
• Detail the reasons and benefits for promoting clear oral fluid intake in children before surgery.

This open access journal focuses on sharing information interactively for educators in perioperative medicine.

Published four times per year, the objective of this online journal is to serve as a multidisciplinary, peer-reviewed source of information related to the administrative, economic, operational, safety, and quality aspects of the ambulatory and in-patient operating room and interventional procedural processes. As the official journal of the Society of Perioperative Assessment and Quality Improvement (SPAQI), the journal will provide high-quality information and research findings on operational and system-based approaches to ensure safe, coordinated, and high-value periprocedural care. With the current focus on value in health care it is essential that there is a venue for researchers to publish articles on quality improvement process initiatives, process flow modeling, information management, efficient design, cost improvement, use of novel technologies, and management.

This journal's audience includes all groups who participate in the planning, execution, and monitoring of the periprocedural process such as medical specialists (surgeons, anaesthesiologists, hospitalists), nurses, administrators, pharmacists, systems and process engineers, and other health care providers.

Regional Anesthesia & Pain Medicine, the official publication of the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine), is a monthly journal that publishes peer-reviewed scientific and clinical studies to advance the understanding and clinical application of regional techniques for surgical anesthesia and postoperative analgesia. Coverage includes intraoperative regional techniques, perioperative pain, chronic pain, obstetric anesthesia, paediatric anesthesia, outcome studies, and complications.

Incorporated into Journal of Critical Care.