BACKGROUND: Postoperative delirium (POD) is a frequent and serious complication after surgery. Parameters of the electroencephalogram (EEG), such as the Bispectral Index and the occurrence of burst suppression, have been...BACKGROUND: Postoperative delirium (POD) is a frequent and serious complication after surgery. Parameters of the electroencephalogram (EEG), such as the Bispectral Index and the occurrence of burst suppression, have been associated with POD. We analyzed the predictive properties of periodic and aperiodic parameters of the EEG power spectrum. METHODS: In a secondary post-hoc analysis of a prospective observational study, patients with an age of at least 60 years undergoing major cardiac or non-cardiac surgery were analyzed. The frontal intraoperative raw EEG was recorded by a BIS monitor and offline analyzed with the FOOOF toolbox, revealing the periodic and aperiodic parameters of the power spectrum. Patients were screened for POD and divided in a 2:1 ratio into a training and a validation cohort. Predictors of POD were identified by uni- and multivariable logistic regression. RESULTS: Thirty-two out of the 120 training group patients developed POD. These showed a significantly longer median duration of surgery (286 [interquartile range {IQR} 236-391] vs 223 [127-331] min, P = .005), lower median BIS (40.4 [IQR 38.1-43.4] vs 42.7 [39.5-46.0], P = .038), and a higher mean aperiodic exponent (2.09 ± 0.19 vs 1.99 ± 0.17, P = .017). Duration of surgery (odds ratio [OR] = 1.01; 95% confidence interval [CI], 1.00-1.01, P = .005), peak center frequency (OR = 0.79; CI, 0.62-0.97, P = .039) and aperiodic exponent (OR = 23.2; CI, 2.1-318.2, P = .013) were predictors of POD according to univariable logistic regression. At a cutoff of 1.967, the aperiodic exponent had a sensitivity of 0.813 and a specificity of 0.478 for the prediction of POD. A low duration of time spent in burst suppression was observed in both patients with POD (67 [6-363] s) and without POD (173 [4-641] s, P = .30), and cumulative burst suppression time was not a predictor of POD. In a stepwise regression model, age, duration of surgery, peak power, and the aperiodic exponent were associated with POD (AUROC = 0.80 (CI, 0.71-0.89, P < .001). The predictive model was confirmed in the validation group (n = 60) with an AUROC = 0.77 (CI, 0.65-0.90, P = .001). CONCLUSIONS: A higher aperiodic exponent, for example, a less complex EEG signal, is associated with a greater POD risk, especially in combination with known POD predictors such as age and duration of surgery.
BACKGROUND: Dexmedetomidine for procedural sedation during ophthalmic surgery is popular, in part due to high levels of patient satisfaction and analgesia, and low intraocular pressure and respiratory depression, compare...BACKGROUND: Dexmedetomidine for procedural sedation during ophthalmic surgery is popular, in part due to high levels of patient satisfaction and analgesia, and low intraocular pressure and respiratory depression, compared to alternative medications. However, longer recovery times were reported when dexmedetomidine was used for cataract or vitreoretinal surgery. Because of these reports, a concern was raised by our hospital's retinal surgeons and administrators that dexmedetomidine might be delaying discharge home from the postanesthesia care unit. Therefore, we performed a retrospective analysis of discharge times of all patients undergoing vitreoretinal surgery under regional anesthesia and sedation at our high-volume ophthalmology specialty hospital. METHODS: Data from all cases involving vitreoretinal surgery in adults performed with sedation were extracted from the hospital's electronic health record system. Discharge times were calculated from the end of surgery (eye dressings applied) until discharge home from the phase II postanesthesia care unit. Using general linear models, discharge times were compared between patients who received dexmedetomidine or other medications for sedation between fiscal year (July 1 to June 30) 2020 and fiscal year 2024. The modeling controlled for interactions between sedation group and year, and included the anesthesia clinician administering the sedation as a fixed effect. RESULTS: The fraction of cases during which dexmedetomidine was used for sedation during vitreoretinal surgery increased progressively from <0.7% in 2019 to 91.3% by 2023. Among the 6180 cases with dexmedetomidine, the mean (standard deviation ) dose of dexmedetomidine, normalized for body weight and the interval from entering the operating room to the end of surgery, was 0.24 (0.20) µg/kg/h. Intermittent bolus doses were administered without infusion in 96.3% of cases. The mean discharge time among the dexmedetomidine cases did not differ significantly from the 2274 cases without dexmedetomidine (-2.04 minutes; 95% confidence interval, -5.71 to 1.65 minutes; P = .28). CONCLUSIONS: A low-dose, bolus dexmedetomidine technique did not prolong the time to home discharge when administered for sedation during vitreoretinal surgery. Managerial concerns about such use prolonging discharge times following vitreoretinal surgery are unwarranted.
BACKGROUND: In an era of fast-track surgery and enhanced recovery protocols, postoperative urinary retention (POUR) remains a common barrier to same-day discharge, contributing to prolonged PACU stays, patient discomfort...BACKGROUND: In an era of fast-track surgery and enhanced recovery protocols, postoperative urinary retention (POUR) remains a common barrier to same-day discharge, contributing to prolonged PACU stays, patient discomfort, and unplanned admissions. Although sugammadex has been associated with a reduced incidence of POUR, no prospective, randomized studies have compared neostigmine and sugammadex for neuromuscular blockade reversal in laparoscopic cholecystectomy. The objective of this study was to determine the incidence of postoperative urinary retention after the reversal of rocuronium-induced neuromuscular blockade with neostigmine versus sugammadex in patients undergoing laparoscopic cholecystectomy. METHODS: A total of 235 patients undergoing laparoscopic cholecystectomy were enrolled. Anesthesia was induced with rocuronium 0.6 mg/kg (ideal body weight, IBW) to facilitate intubation, and moderate neuromuscular blockade was maintained intraoperatively with 0.15 mg/kg (IBW) doses. At the end of surgery, patients received either sugammadex 2 mg/kg (total body weight, TBW) or neostigmine 50 to 70 µg/kg (IBW) with glycopyrrolate 8 to 10 µg/kg (IBW) for reversal. Bladder volumes were assessed via ultrasound before and after attempted voiding. Postoperative urinary retention (POUR) was defined as (1) inability to void with bladder volume ≥ 300 mL, (2) post-void residual ≥ 200 mL, or (3) need for catheterization. The incidence of POUR was recorded as the primary end point. RESULTS: The incidence of POUR was significantly lower with sugammadex compared with neostigmine, difference of 12.8% (95% CI of the difference 4% to 22%, P < .001). There were no major adverse events in either group. CONCLUSIONS: In patients undergoing laparoscopic cholecystectomy, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significant reduction in postoperative urinary retention when compared to reversal with neostigmine, without any major adverse effects.
High-flow nasal oxygen (HFNO) generates positive airway pressure, raising concerns about gastric insufflation and aspiration risk. Although most studies report minimal or no gastric distension, some suggest significant c...High-flow nasal oxygen (HFNO) generates positive airway pressure, raising concerns about gastric insufflation and aspiration risk. Although most studies report minimal or no gastric distension, some suggest significant changes. This systematic review and meta-analysis applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to evaluate the effect of HFNO on gastric insufflation and related markers across clinical settings. We searched Medline, Embase, Emcare, and CINAHL through August 2025 for studies reporting qualitative or quantitative markers of gastric insufflation during HFNO use, including comet-tail artifacts, antral cross-sectional area, and gastric volume. Eligible designs included randomized trials, observational and volunteer studies, and case reports. Methodological quality was evaluated using the Mixed Methods Appraisal Tool, and certainty of evidence was rated with GRADE. Meta-analysis was performed for outcomes reported in two or more studies. Six randomized trials, five observational studies, two volunteer studies, one case series, and two case reports were included. Observational studies primarily assessed outcomes before and after HFNO intervention. Pooled analysis of four randomized controlled trials (RCTs; n = 375) showed HFNO significantly reduced gastric insufflation compared with face-mask ventilation during elective peri-intubation (risk ratios [RR] = 0.32; 95% confidence interval [CI], 0.19-0.52; P < .00001; I2 = 0%), rated moderate-certainty. For antral cross-sectional area, pooled analysis of three RCTs (n = 318) found no significant difference between HFNO and face-mask ventilation (MD -0.33 cm2; 95% CI, -0.72 to 0.05; P = .09; I2 = 74%), rated moderate-certainty. Observational studies assessing pre- and post-HFNO changes showed no significant increase in antral cross-sectional area (MD 0.08 cm2; 95% CI, -0.29 to 0.45; P = .67; I2 = 0%) and no significant change in gastric liquid volume (MD -0.01 ml/kg; 95% CI, -0.07 to 0.06; P = .80; I2 = 0%), both rated low certainty. Nonpooled data suggested possible increases in critically ill patients, but the evidence was of very low certainty. A single study assessing microaspiration found HFNO reduced gastroesophageal reflux and prevented microaspiration compared with face-mask ventilation. No clinically significant aspiration events were reported across studies. Moderate-certainty evidence supports HFNO as safe regarding gastric insufflation and antral cross-sectional area in most elective and procedural contexts. Low-certainty evidence suggests no increase in gastric volume. Caution is warranted due to limited, low-to-very-low-certainty evidence at higher flow rates and among critically ill patients. Larger multicenter trials and robust observational studies are necessary to confirm safety in these settings.
BACKGROUND: The Society for Obstetric Anesthesia and Perinatology (SOAP) recommends monitoring for respiratory depression after cesarean delivery according to intrathecal morphine (ITM) dose. The aim of the study was to...BACKGROUND: The Society for Obstetric Anesthesia and Perinatology (SOAP) recommends monitoring for respiratory depression after cesarean delivery according to intrathecal morphine (ITM) dose. The aim of the study was to compare respiratory metrics after ITM administration, to determine evidence for the SOAP recommendations. METHODS: Prospective observational cohort study design. Following institutional review board approval, women undergoing non-emergency cesarean delivery with spinal anesthesia in a single center were enrolled. Women were offered 50 µg, 150 µg or transversus abdominis plane (TAP) block without ITM, for postoperative analgesia. Respiratory monitoring, continuous acoustic respiratory rate (RR) and pulse oximetry oxygen saturation (SpO 2 ) monitor Masimo Radius-7, was used after surgery up to 12 hours postoperatively. The primary outcome was bradypnea, number of women with RR ≤ 8 breaths per minute according to dose. RESULTS: Among 80 recruits, 33 (41%) chose 50 µg, 46 (57%) chose 150 µg, and one chose TAP block. Bradypnea events were detected 564 times among 27 (81.8%) women receiving 50 µg and 529 times among 40 (87.0%) women receiving 150 µg. Median [interquartile range (IQR)] duration of bradypnea per patient was 1.58 [1.15-2.42] in 50 µg group and 1.09 [0.83-1.70] in 150 µg group, P < .001. The event rate of bradypnea was 1.89 (95% confidence intervals [CIs], 1.73-2.05) events per person-hour among women receiving 50 µg versus 1.23 (95% CI, 1.12-1.34) events per person-hour among women receiving 150 µg, P = .624. Most, 62% of bradypnea occurred by 6 hours, and 86% of events by 12 hours. Apnea and hypoxemia event rates were similar, but hypoxemia duration was significantly prolonged after 150 µg, median 48 [IQR, 36-90] versus 56 sec [IQR, 40-106]; P = .001. Nursing assessments done per institutional protocol did not identify any respiratory events. No woman required oxygen or naloxone administration. CONCLUSION: We found no statistically significant differences in RR comparing 50 and 150 µg ITM, using continuous monitoring. Although the 150 µg group experienced a higher incidence of hypoxemia events, these were not clinically significant.