Sprung, J

Objective Reference values of regional cerebral oxygen saturation (rScO 2 ) in preterm neonates across gestational age (GA) groups remain undefined. This study aimed to establish rScO 2 references for neonates born before 32 weeks of gestation. Design A prospective observational cohort study. Setting Large tertiary neonatal referral centre in Croatia. Patients Preterm neonates without major comorbidities born between 2018 and 2022 with normal cranial ultrasound findings. Interventions rScO 2 was assessed with near-infrared spectroscopy (NIRS) using neonatal sensors. Main outcome measures The primary analysis provided rScO 2 reference ranges for the entire preterm neonatal cohort, followed by stratified analyses based on GA: extremely preterm , <28.0 weeks; very preterm , 28.0–30.0 weeks; and very preterm , 30.1–32.0 weeks. Quantile regression was used to estimate the selected rScO 2 percentiles (5th, 10th, 50th, 90th and 95th) from 6 to 72 hours after birth. Results 114 neonates with median (IQR) GA of 29.9 (29.1–31.5) weeks were included: 22% were EP <28w , 29% were VP 28–30w and 49% were VP >30–32w . The median rScO 2 was 75.6% at 6 hours, 79.5% over the first 24 hours and exceeding 80% in the subsequent 48 hours. When analysed separately, notable differences emerged across prematurity categories, with the highest median rScO 2 observed in the VP >30–32w group. Supplementary analyses, comparing rScO 2 values across the three GA groups, revealed significant differences at 48 and 72 hours. The majority of the estimated rScO 2 fifth percentiles between 6 and 72 hours were in the range ≥60%, with a single lowest estimate of 56.3% at 6 hours in the EP <28w group. Thus, for all subgroups, the estimated fifth percentile of rScO 2 was above the brain hypoxic threshold. Conclusions The use of age-appropriate neonatal NIRS sensors provided the rScO 2 reference values for very and extremely preterm neonates without major comorbidities 6–72 hours after birth.

Objective: Postoperative nausea and vomiting (PONV) is a frequent adverse event after bariatric surgery and is associated with patient dissatisfaction and increased health care burden. Aggressive multimodal antiemetic prophylaxis and the use of propofol infusion during anesthesia are associated with the reduction of PONV. In this study, we examined the use of rescue antiemetics following bariatric surgery performed with 3 different anesthetic strategies designed to reduce PONV: (1) primary volatile (VOL) anesthetic and propofol (PROP) infusion (VOL+PROP), (2) volatile anesthetic with propofol and dexmedetomidine (DEX) infusions (VOL+PROP+DEX), or (3) opioid-sparing total intravenous anesthesia (PROP+DEX). Methods: In this retrospective observational study, we included patients undergoing bariatric surgery from 2018-2022 who received 1 of 3 anesthetics: (1) VOL+PROP, (2) VOL+PROP+DEX, or (3) opioid-sparing PROP+DEX without a VOL. Inverse probability of treatment weighting analysis determined the association between the need for rescue-antiemetics in the postanesthesia care unit (PACU) and following PACU discharge. Results: Three hundred thirty-two patients received VOL+PROP, 354 VOL+PROP+DEX, and 166 PROP+DEX, and all received prophylactic antiemetics during surgery. After surgery, the PROP+DEX patients received fewer rescue antiemetics in the PACU compared with VOL+PROP (11% vs. 24%, P=0.002), and VOL+PROP+DEX fewer compared with VOL+PROP (16% vs. 24%, P=0.023). This differential antinausea effect was limited to PACU stay only. Rescue antiemetic use increased across all anesthetic management groups following PACU discharge until midnight on the day of surgery (ranging from 38% to 46% across groups, P=0.71) and through the first postoperative day (ranging from 47% to 57% across groups, P=0.20). Conclusions: The benefit associated with anesthetic strategies designed to reduce PONV was present but did not persist past PACU discharge. This finding suggests that aggressive perioperative multimodal antiemetic prophylaxis combined with anesthetic strategies designed to prevent PONV after bariatric surgery have only a short-lived effect, thus health care staff in hospital wards may expect to encounter high rates of PONV in these patients. There is a need for the development of novel antinausea treatments to reduce the rate of this frequent postoperative complication.

AbstractBackgroundHospitalization in older age is associated with accelerated cognitive decline, typically preceded by neuropathologic changes. We assess the association between indication for hospitalization and brain neurodegeneration.MethodsIncluded were participants from the Mayo Clinic Study of Aging, a population-based longitudinal study, with ≥1 brain imaging available in those older than 60 years of age between 2004 and 2017. Primary analyses used linear mixed-effects models to assess association of hospitalization with changes in longitudinal trajectory of cortical thinning, amyloid accumulation, and white matter hyperintensities (WMH). Additional analyses were performed with imaging outcomes dichotomized (normal vs abnormal) using Cox proportional hazards regression.ResultsOf 2 480 participants, 1 966 had no hospitalization and 514 had ≥1 admission. Hospitalization was associated with accelerated cortical thinning (annual slope change −0.003 mm [95% confidence interval (CI) −0.005 to −0.001], p = .002), but not amyloid accumulation (0.003 [95% CI −0.001 to 0.006], p = .107), or WMH increase (0.011 cm3 [95% CI −0.001 to 0.023], p = .062). Interaction analyses assessing whether trajectory changes are dependent on admission type (medical vs surgical) found interactions for all outcomes. While surgical hospitalizations were not, medical hospitalizations were associated with accelerated cortical thinning (−0.004 mm [95% CI −0.008 to −0.001, p = .014); amyloid accumulation (0.010, [95% CI 0.002 to 0.017, p = .011), and WMH increase (0.035 cm3 [95% CI 0.012 to 0.058, p = .006). Hospitalization was not associated with developing abnormal cortical thinning (p = .407), amyloid accumulation (p = .596), or WMH/infarctions score (p = .565).ConclusionsMedical hospitalizations were associated with accelerated cortical thinning, amyloid accumulation, and WMH increases. These changes were modest and did not translate to increased risk for crossing the abnormality threshold.

Abstract Background We describe the clinical course of medical and surgical patients who received naloxone on general hospital wards for suspected opioid-induced respiratory depression (OIRD). Methods From May 2018 through October 2020, patients who received naloxone on hospital wards were identified and their records reviewed for incidence and clinical course. Results There were 86,030 medical and 106,807 surgical admissions. Naloxone was administered to 99 (incidence 11.5 [95% confidence interval 9.4–14.0] per 10,000 admissions) medical and 63 (5.9 [95% confidence interval 4.5–7.5]) surgical patients (P &lt; 0.001). Median oral morphine equivalents administered within 24 hours before naloxone were 32 [15, 64] and 60 [32, 88] mg for medical and surgical patients, respectively (P = 0.002). The rapid response team was activated in 69 (69.7%) vs 42 (66.7%) and critical care transfers in 51 (51.5%) vs 30 (47.6%) medical and surgical patients respectively. The number of in-hospital deaths was 21 (21.2%) vs two (3.2%) and the number of discharges to hospice 12 (12.1%) vs one (1.6%) for medical and surgical patients, respectively (P = 0.001). Naloxone did not reverse OIRD in 38 (23%) patients, and these patients had more transfers to the intensive care unit and a higher 30-day mortality rate. Conclusion Medical inpatients are more likely to suffer OIRD than are surgical inpatients despite lower opioid doses. Definitive OIRD was confirmed in 77% of patients because of immediate naloxone response, whereas 23% of patients did not respond, and this subset was more likely to need a higher level of care and had a higher 30-day mortality rate. Careful monitoring of mental and respiratory variables is necessary when opiates are used in hospital.

Abstract Background Hospitalization can impair physical and functional status of older adults, but it is unclear whether these deficits are transient or chronic. This study determined the association between hospitalization of older adults and changes in long-term longitudinal trajectories of 2 measures of physical and functional status: gait speed (GS) and instrumental activities of daily living measured with Functional Activities Questionnaire (FAQ). Method Linear mixed-effects models assessed the association between hospitalization (nonelective vs elective, and surgical vs medical) and outcomes of GS and FAQ score in participants (older than 60 years) enrolled in the Mayo Clinic Study of Aging who had longitudinal assessments. Results Of 4902 participants, 1879 had ≥1 hospital admission. Median GS at enrollment was 1.1 m/s. The slope of the annual decline in GS before hospitalization was −0.015 m/s. The parameter estimate (95% CI) for additional annual change in GS trajectory after hospitalization was −0.009 (−0.011 to −0.006) m/s, p &lt; .001. The accelerated GS decline was greater for medical versus surgical hospitalizations (−0.010 vs −0.003 m/s, p = .005), and nonelective versus elective hospitalizations (−0.011 vs −0.006 m/s, p = .067). The odds of a worsening FAQ score increased on average by 4% per year. Following hospitalization, odds of FAQ score worsening further increased (multiplicative annual increase in odds ratio per year [95% CI] following hospitalization was 1.05 [1.03, 1.07], p &lt; .001). Conclusions Hospitalization of older adults is associated with accelerated long-term decline in GS and functional limitations, especially after nonelective admissions and those for medical indications. However, for most well-functioning participants, these changes have little clinical significance.

IMPORTANCE Hospitalizations are associated with cognitive decline in older adults. OBJECTIVE To determine the association between hospitalization characteristics and the trajectory of cognitive function in older adults. DESIGN Population‐based longitudinal study of cognitive aging. SETTING Olmsted Medical Center and Mayo Clinic, the only centers in Olmsted County, Minnesota, with hospitalization capacity. PARTICIPANTS Individuals without dementia at baseline, with consecutive cognitive assessments from 2004 through 2017, and at least one visit after the age of 60. MEASUREMENTS The primary outcome was longitudinal changes in global cognitive z ‐score. Secondary outcomes were changes in four cognitive domains: memory, attention/executive function, language, and visuospatial skills. Hospitalization characteristics analyzed included elective versus nonelective, medical versus surgical, critical care versus no critical care admission, and long versus short duration admissions. RESULTS Of 4,587 participants, 1,622 had 1 and more hospital admission. Before hospitalization, the average slope of the global z ‐score was −0.031 units/year. After hospitalization, the rate of annual global z ‐score accelerated by −0.051 (95% CI = −0.057, −0.045) units, P < .001, resulting in an estimated annual slope after the first hospitalization of −0.082. The accelerated decline was found in all four cognitive domains (memory, visuospatial, language, and executive, all P < .001). The acceleration of the decline in global z ‐score following hospitalization was greater for medical compared to surgical hospitalizations (slope change following hospitalization = −0.064 vs −0.034 for medical vs surgical, P < .001), and nonelective compared to elective admissions (slope change following hospitalization = −0.075 vs −0.037 for nonelective vs elective, P < .001). The acceleration of cognitive decline was not different for hospitalization with intensive care unit admission versus not. CONCLUSIONS Hospitalization of older adults is associated with accelerated decline of global and domain‐specific cognitive domains, with the rate of decline dependent upon type of admission. The clinical impact of this accelerated decline will depend on the individual's baseline cognitive reserve and expected longevity.

Abstract Background Surgery for catecholamine-producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected. Methods Twenty-one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α-receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality. Results Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α-receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex-sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α-receptor blockade and 0·9 per cent (3 of 343) among patients without α-receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non-pretreated patients. Conclusion There is substantial variability in the perioperative management of catecholamine-producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.

Abstract Abstract Background: Pulmonary hypertension (PH) is a significant preoperative risk factor. We aimed to determine predictors of perioperative morbidity and mortality after noncardiac surgery for patients with precapillary PH. Methods: We conducted a retrospective cohort study of adults with pulmonary hypertension having surgery at a single large medical referral center. The PH and surgical databases were reviewed from 2010 to 2017. Patients were excluded if PH was attributable to left-sided heart disease or they had undergone cardiac or transplant operations. To assess whether PH-specific diagnostic or cardiopulmonary testing parameters were predictive of perioperative complications, analyses were performed using generalized estimating equations. Results: Of 196 patients with PH undergoing noncardiac operations, 53 (27%) experienced 1 or more complications, including 5 deaths (3%) within 30 days. After adjustment for age and PH type, there were more complications in those undergoing moderate-to-high vs low-risk procedures (odds ratio [OR], 4.17 [95% CI, 2.07 to 8.40]; P<0.001). After adjustment for age, surgical risk, and PH type, the risk for complications was higher for patients with worse functional status (OR, 2.39 [95% CI, 1.19 to 4.78]; P=0.01 for class 3/4 vs class 1/2) and elevated serum N-terminal fragment of the prohormone brain natriuretic peptide (NT-proBNP) (OR, 2.28 [95% CI, 1.05 to 4.96]; P=0.04 for ≥300 vs. <300 pg/mL). From an analysis that included covariates for age, surgical risk, and functional status, elevated serum NT-proBNP levels remained associated with increased risk (OR, 2.23 [95% CI, 1.05 to 4.76]; P=0.04). Conclusions: Patients with PH undergoing noncardiac surgery with general anesthesia have a high frequency of perioperative complications. Specific clinical (functional status), diagnostic (serum NT-proBNP), and intraoperative factors (higher-risk surgery) are predictive of worse outcomes.