Journal of Personalized Medicine

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10 pages, 740 KiB

Open AccessArticle

Evaluation of an Innovative Care Pathway in the Diagnostic and Therapeutic Management of Hepatobiliary and Pancreatic Pathologies: “One-Day Diagnosis”

by Zineb Cherkaoui, Barbara Seeliger, Vanina Faucher, Céline Biermann, Arne Kock and Patrick Pessaux

J. Pers. Med. 2023, 13(1), 12; https://doi.org/10.3390/jpm13010012 - 21 Dec 2022

Cited by 3 | Viewed by 1396

Abstract

“One-Day Diagnosis” (1DD) for hepatobiliary and pancreatic (HBP) diseases is an innovative care pathway that combines, on the same day, surgical consultation, medical imaging, anesthesia, diagnosis announcement, and therapeutic support consultations. The objective was to evaluate the length of the 1DD care pathway [...] Read more.

“One-Day Diagnosis” (1DD) for hepatobiliary and pancreatic (HBP) diseases is an innovative care pathway that combines, on the same day, surgical consultation, medical imaging, anesthesia, diagnosis announcement, and therapeutic support consultations. The objective was to evaluate the length of the 1DD care pathway compared to a conventional one. The prospective “1DD care pathway” arm included 330 consecutive patients (January 2017–April 2019) vs. 152 (November 2014–November 2015) in the retrospective “conventional” one. In the 1DD group, diagnosis was made on the same day in 83% of consultations vs. 68.4% (p = 0.0005). Although there was no difference in overall time to diagnosis, diagnostic and therapeutic management was faster in the 1DD group (1 day vs. 15 days, p < 0.0004). In addition, 77% of patients who benefited from 1DD were very satisfied with their treatment overall. The mean cost of the 1DD consultation was EUR 176.8 +/− 149 (range: 50–546). The median cost of the overall program was similar (EUR 584 vs. EUR 563, p = 0.67). As an organizational innovation, the 1DD for HBP pathologies is a promising care pathway that optimizes diagnostic and therapeutic management, without creating medical overconsumption or additional costs. Given patient satisfaction, this model should be generalized to optimize cancer care by adapting it to the constraints of different healthcare structures. Full article

(This article belongs to the Special Issue Individual Evaluation, Management and Outcome in Perioperative Medicine)

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9 pages, 447 KiB

Open AccessArticle

The Cardiac Power Index during Abdominal Open Aortic Surgery: Intraoperative Insights into the Cardiac Performance—A Retrospective Observational Analysis

by Fulvio Nisi, Enrico Giustiniano, Massimo Meco, Luca Pugliese, Lorenzo Calabrò, Sofia Spano, Umberto Ripani and Maurizio Cecconi

J. Pers. Med. 2022, 12(10), 1705; https://doi.org/10.3390/jpm12101705 - 12 Oct 2022

Cited by 1 | Viewed by 2401

Abstract

Background: The Cardiac Power Index (CPI) measures the rate of energy output generated by the heart and correlates this with in-hospital mortality due to cardiogenic shock. In open aortic surgery, both aortic clamping and unclamping expose the heart to abrupt variations of the [...] Read more.

Background: The Cardiac Power Index (CPI) measures the rate of energy output generated by the heart and correlates this with in-hospital mortality due to cardiogenic shock. In open aortic surgery, both aortic clamping and unclamping expose the heart to abrupt variations of the left ventricle afterload, preload, and contractility, with possible hemodynamic impairment. We investigated how aortic-cross clamping (Ao-XC) and unclamping (Ao-UC) procedures affect the CPI during open aortic surgery. Methods: We retrospectively analyzed our surgical database of 67 patients submitted to open surgical aortic repair at Humanitas Research Hospital, Milan. Patients were monitored by an EV1000-FloTrac System^TM (Edwards Lifescience, Irvine, CA, USA) beyond the standard intra-operative hemodynamic monitoring. The primary outcome was the variation of basal CPI after aortic clamping and unclamping. Secondary outcomes were variations of the cardiac index (CI), mean arterial pressure (MAP), heart rate, and lactate during aortic clamping and after unclamping. The CPI was computed as: (CI × MAP)/451. Results: The CPI changed significantly after aortic unclamping. CPI: basal = 0.39 ± 0.1 W/m², after Ao-XC = 0.39 ± 0.1 W/m², and after Ao-UC = 0.44 ± 0.2 W/m², p < 0.05. The CI changed during both cross-clamping and unclamping (p < 0.0001), whilst the MAP and heart rate did not during any phase of the surgery. Five subjects (8.3%) needed inotropic support after cross-clamping. Their basal CPI was lower than the general population: 0.31 ± 0.11 W/m² vs. 0.39 ± 0.1 W/m². Conclusions: The CPI describes the adaptation of the cardiac function to the changes in preload, contractility, and afterload occurring during aortic cross-clamping and unclamping. It may be used to explore the cardiac performance in real-time and predict cardiac impairment in the intraoperative period in a minimally invasive way, similar to ventriculo-arterial coupling parameters. Full article

(This article belongs to the Special Issue Individual Evaluation, Management and Outcome in Perioperative Medicine)

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12 pages, 581 KiB

Open AccessArticle

Characteristics of Patients with Unrecognized Sleep Apnea Requiring Postoperative Oxygen Therapy

by Edwin Seet, Rida Waseem, Matthew T. V. Chan, Chew Yin Wang, Vanessa Liao, Colin Suen and Frances Chung

J. Pers. Med. 2022, 12(10), 1543; https://doi.org/10.3390/jpm12101543 - 20 Sep 2022

Cited by 4 | Viewed by 1949

Abstract

Surgical patients with obstructive sleep apnea (OSA) have increased risk of perioperative complications. The primary objective is to determine the characteristics of surgical patients with unrecognized OSA requiring oxygen therapy for postoperative hypoxemia. The secondary objective is to investigate the characteristics of patients [...] Read more.

Surgical patients with obstructive sleep apnea (OSA) have increased risk of perioperative complications. The primary objective is to determine the characteristics of surgical patients with unrecognized OSA requiring oxygen therapy for postoperative hypoxemia. The secondary objective is to investigate the characteristics of patients who were responsive to oxygen therapy. This was a post-hoc multicenter study involving patients with cardiovascular risk factors undergoing major non-cardiac surgery. Patients ≥45 years old underwent Type 3 sleep apnea testing and nocturnal oximetry preoperatively. Responders to oxygen therapy were defined as individuals with ≥50% reduction in oxygen desaturation index (ODI) on postoperative night 1 versus preoperative ODI. In total, 624 out of 823 patients with unrecognized OSA required oxygen therapy. These were mostly males, had larger neck circumferences, higher Revised Cardiac Risk Indices, higher STOP-Bang scores, and higher ASA physical status, undergoing intraperitoneal or vascular surgery. Multivariable regression analysis showed that the preoperative longer cumulative time SpO₂ < 90% or CT90% (adjusted p = 0.03), and lower average overnight SpO₂ (adjusted p < 0.001), were independently associated with patients requiring oxygen therapy. Seventy percent of patients were responders to oxygen therapy with ≥50% ODI reduction. Preoperative ODI (19.0 ± 12.9 vs. 14.1 ± 11.4 events/h, p < 0.001), CT90% (42.3 ± 66.2 vs. 31.1 ± 57.0 min, p = 0.038), and CT80% (7.1 ± 22.6 vs. 3.6 ± 8.7 min, p = 0.007) were significantly higher in the responder than the non-responder. Patients with unrecognized OSA requiring postoperative oxygen therapy were males with larger neck circumferences and higher STOP-Bang scores. Those responding to oxygen therapy were likely to have severe OSA and worse preoperative nocturnal hypoxemia. Preoperative overnight oximetry parameters may help in stratifying patients. Full article

(This article belongs to the Special Issue Individual Evaluation, Management and Outcome in Perioperative Medicine)

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11 pages, 1556 KiB

Open AccessArticle

Prediction of Mortality after Burn Surgery in Critically Ill Burn Patients Using Machine Learning Models

by Ji Hyun Park, Yongwon Cho, Donghyeok Shin and Seong-Soo Choi

J. Pers. Med. 2022, 12(8), 1293; https://doi.org/10.3390/jpm12081293 - 6 Aug 2022

Cited by 5 | Viewed by 1913

Abstract

Severe burns may lead to a series of pathophysiological processes that result in death. Machine learning models that demonstrate prognostic performance can be used to build analytical models to predict postoperative mortality. This study aimed to identify machine learning models with the best [...] Read more.

Severe burns may lead to a series of pathophysiological processes that result in death. Machine learning models that demonstrate prognostic performance can be used to build analytical models to predict postoperative mortality. This study aimed to identify machine learning models with the best diagnostic performance for predicting mortality in critically ill burn patients after burn surgery, and then compare them. Clinically important features for predicting mortality in patients after burn surgery were selected using a random forest (RF) regressor. The area under the receiver operating characteristic curve (AUC) and classifier accuracy were evaluated to compare the predictive accuracy of different machine learning algorithms, including RF, adaptive boosting, decision tree, linear support vector machine, and logistic regression. A total of 731 patients met the inclusion and exclusion criteria. The 90-day mortality of the critically ill burn patients after burn surgery was 27.1% (198/731). RF showed the highest AUC (0.922, 95% confidence interval = 0.902–0.942) among the models, with sensitivity and specificity of 66.2% and 93.8%, respectively. The most significant predictors for mortality after burn surgery as per machine learning models were total body surface area burned, red cell distribution width, and age. The RF algorithm showed the best performance for predicting mortality. Full article

(This article belongs to the Special Issue Individual Evaluation, Management and Outcome in Perioperative Medicine)

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10 pages, 831 KiB

Open AccessArticle

Initiation Timing of Continuous Interscalene Brachial Plexus Blocks in Patients Undergoing Shoulder Arthroplasty: A Retrospective Before-and-After Study

by Ha-Jung Kim, Hyojune Kim, Kyoung Hwan Koh, In-Ho Jeon, Hyungtae Kim, Young-Jin Ro and Won Uk Koh

J. Pers. Med. 2022, 12(5), 739; https://doi.org/10.3390/jpm12050739 - 1 May 2022

Cited by 1 | Viewed by 2032

Abstract

A continuous interscalene brachial plexus block (CIBPB) is usually administered before surgery in awake patients. However, the use of CIBPB before surgery could hinder the identification of nerve injuries after total shoulder arthroplasty (TSA). This study aimed to compare the analgesic effects of [...] Read more.

A continuous interscalene brachial plexus block (CIBPB) is usually administered before surgery in awake patients. However, the use of CIBPB before surgery could hinder the identification of nerve injuries after total shoulder arthroplasty (TSA). This study aimed to compare the analgesic effects of preoperatively and postoperatively initiated CIBPBs in patients undergoing TSA. The medical records of patients who underwent TSA between January 2016 and August 2020 were retrospectively reviewed. The following analgesic phases were used: intravenous (IV) patient-controlled analgesia (PCA) phase (IV PCA group, n = 40), preoperative block phase (PreBlock group, n = 44), and postoperative block phase (PostBlock group, n = 33). The postoperative initiation of CIBPB after a neurologic exam provided better analgesia than IV PCA and had no differences with the preoperative initiation of CIBPB, except for the worst pain at the postanesthetic care unit. Opioid consumption was significantly greater in the IV PCA group, but there were no differences between the PreBlock and PostBlock groups on operation day after the transfer to the general ward. The initiation of CIBPB after a patient’s emergence from general anesthesia had comparable analgesic efficacy with preoperative CIBPB but offered the chance of a postoperative neurologic exam. Full article

(This article belongs to the Special Issue Individual Evaluation, Management and Outcome in Perioperative Medicine)

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10 pages, 804 KiB

Open AccessArticle

Effect of Flumazenil on Emergence Agitation after Orthognathic Surgery: A Randomized Controlled Trial

by Young Hyun Koo, Geun Joo Choi, Hyun Kang, Yong Hun Jung, Young Cheol Woo, Young-Jun Choi and Chong Wha Baek

J. Pers. Med. 2022, 12(3), 416; https://doi.org/10.3390/jpm12030416 - 7 Mar 2022

Viewed by 2256

Abstract

Flumazenil, a gamma-aminobutyric acid receptor antagonist, can promote arousal even under general anesthesia without the use of benzodiazepines. We hypothesized that flumazenil could promote arousal and reduce emergence agitation in patients undergoing orthognathic surgery with sevoflurane anesthesia. One hundred and two patients were [...] Read more.

Flumazenil, a gamma-aminobutyric acid receptor antagonist, can promote arousal even under general anesthesia without the use of benzodiazepines. We hypothesized that flumazenil could promote arousal and reduce emergence agitation in patients undergoing orthognathic surgery with sevoflurane anesthesia. One hundred and two patients were randomly allocated to the control or flumazenil group. Saline or flumazenil was administered at the end of the surgery. The incidence of emergence agitation was measured by using Aono’s four-point scale, with scores of 3 and 4 indicating emergence agitation. The primary outcome was the incidence of emergence agitation. Secondary outcomes included duration of emergence agitation and time intervals between the discontinuation of anesthetics, first response, extubation, and post-anesthesia care-unit discharge readiness. The incidence of emergence agitation was 58.3% and 38.9% in the control and flumazenil groups, respectively, but it was not statistically significant. However, the duration of emergence agitation was shorter in the flumazenil group (p = 0.012). There were no significant differences in the time intervals between the discontinuation of anesthetics, first response, and extubation. Although flumazenil did not reduce the incidence of emergence agitation in patients undergoing orthognathic surgery with sevoflurane anesthesia, it can be considered as an option for awakening patients in terms of improving emergence profiles. Full article

(This article belongs to the Special Issue Individual Evaluation, Management and Outcome in Perioperative Medicine)

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Review

Jump to: Research

11 pages, 278 KiB

Open AccessReview

Prevention of Spinal Cord Injury during Thoracoabdominal Aortic Aneurysms Repair: What the Anaesthesiologist Should Know

by Federico Marturano, Fulvio Nisi, Enrico Giustiniano, Francesco Benedetto, Federico Piccioni and Umberto Ripani

J. Pers. Med. 2022, 12(10), 1629; https://doi.org/10.3390/jpm12101629 - 1 Oct 2022

Cited by 5 | Viewed by 3776

Abstract

Thoraco-abdominal aortic repair is a high-risk surgery for both mortality and morbidity. A major complication is paraplegia-paralysis due to spinal cord injury. Modern thoracic and abdominal aortic aneurysm repair techniques involve multiple strategies to reduce the risk of spinal cord ischemia during and [...] Read more.

Thoraco-abdominal aortic repair is a high-risk surgery for both mortality and morbidity. A major complication is paraplegia-paralysis due to spinal cord injury. Modern thoracic and abdominal aortic aneurysm repair techniques involve multiple strategies to reduce the risk of spinal cord ischemia during and after surgery. These include both surgical and anaesthesiologic approaches to optimize spinal cord perfusion by staging the procedure, guaranteeing perfusion of the distal aorta through various techniques (left atrium–left femoral artery by-pass) by pharmacological and monitoring interventions or by maximizing oxygen delivery and inducing spinal cord hypothermia. Lumbar CSF drainage alone or in combination with other techniques remains one of the most used and effective strategies. This narrative review overviews the current techniques to prevent or avoid spinal cord injury during thoracoabdominal aortic aneurysms repair. Full article

(This article belongs to the Special Issue Individual Evaluation, Management and Outcome in Perioperative Medicine)

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15 pages, 1781 KiB

Open AccessReview

Perioperative Magnesium for Postoperative Analgesia: An Umbrella Review of Systematic Reviews and Updated Meta-Analysis of Randomized Controlled Trials

by Geun Joo Choi, Young Il Kim, Young Hyun Koo, Hyoung-Chul Oh and Hyun Kang

J. Pers. Med. 2021, 11(12), 1273; https://doi.org/10.3390/jpm11121273 - 2 Dec 2021

Cited by 12 | Viewed by 3401

Abstract

The purpose of this study was to summarize and evaluate evidence on the effectiveness of perioperative magnesium as an adjuvant for postoperative analgesia. We conducted an umbrella review of the evidence across systematic reviews and meta-analyses of randomized controlled trials (RCTs) on the [...] Read more.

The purpose of this study was to summarize and evaluate evidence on the effectiveness of perioperative magnesium as an adjuvant for postoperative analgesia. We conducted an umbrella review of the evidence across systematic reviews and meta-analyses of randomized controlled trials (RCTs) on the effect of perioperative magnesium on pain after surgical procedures. Two independent investigators retrieved pain-related outcomes and assessed the methodological quality of the evidence of included studies using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) tool, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. In addition, an updated meta-analysis of postoperative pain-related outcomes with a trial sequential analysis (TSA) was conducted. Of the 773 articles initially identified, 17 systematic reviews and meta-analyses of 258 RCTs were included in the current umbrella review. Based on the AMSTAR tool, the overall confidence of the included systematic reviews was deemed critically low to low. Pain score, analgesic consumption, time to first analgesic request, and incidence of analgesic request were examined as pain-related outcomes. According to the GRADE system, the overall quality of evidence ranged from very low to moderate. While the updated meta-analysis showed the beneficial effect of perioperative magnesium on postoperative analgesia, and TSA appeared to suggest sufficient existing evidence, the heterogeneity was substantial for every outcome. Although the majority of included systematic reviews and updated meta-analysis showed a significant improvement in outcomes related to pain after surgery when magnesium was administered during the perioperative period, the evidence reveals a limited confidence in the beneficial effect of perioperative magnesium on postoperative pain. Full article

(This article belongs to the Special Issue Individual Evaluation, Management and Outcome in Perioperative Medicine)

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