Daily Anesthesiology Research Analysis

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, nutritional therapy is mandatory for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: a) Integration of nutrition into the overall management of the patient, b) avoidance of long periods of preoperative fasting c) re-establishment of oral feeding as early as possible after surgery d) start of nutritional therapy early, as soon as a nutritional risk becomes apparent e) metabolic control e.g. of blood glucose, f) reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function, g) minimized time on paralytic agents in the postoperative period, and h) early mobilization to facilitate protein synthesis and muscle function. The guideline presents 44 recommendations for clinical practice in patients undergoing elective and non-elective surgery, including new recommendations for frailty assessment, sarcopenia diagnosis, and prehabilitation. As in the former ESPEN practical guideline, the recommendations were additonally presented in decision-making flowcharts.

IMPORTANCE: Robot-assisted surgery (RAS) is increasingly used for abdominal procedures; however, postoperative pulmonary complications (PPCs) are more frequent in patients undergoing RAS compared with patients undergoing conventional laparoscopic surgery (CLS). OBJECTIVE: To compare the incidence of PPCs after CLS and RAS and to determine which patient-, surgery-, and anesthesia-related factors are associated with PPCs. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used the Laparoscopic and Robot-Assisted Surgery (LapRAS) database, a pooled dataset containing individual patient data of 2 worldwide prospective cohort studies: the Local Assessment of Ventilatory Management During General Anaesthesia for Surgery (LAS VEGAS) study and the Assessment of Ventilatory Management During General Anesthesia for Robotic Surgery and Its Effects on Postoperative Pulmonary Complications (AVATaR) study. Data were collected from adult patients requiring intraoperative ventilation during general anesthesia for CLS or RAS surgical procedures from 163 centers and 31 countries in the Americas, Europe, the Middle East, and North Africa from January 2013 to March 2019. Data were analyzed from December 2023 to October 2024. EXPOSURES: Type of surgical approach (CLS vs RAS), duration of intraoperative ventilation, and intensity of mechanical ventilation, assessed using the 4 times the driving pressure (DP) plus respiratory rate (RR) estimator (4DP + RR). MAIN OUTCOME AND MEASURES: The primary outcome was occurrence of 1 or more PPCs in the first 5 postoperative days. Mixed-effects logistic regression assessed associations with PPCs; mediation and matched cohort analyses served as sensitivity analyses. RESULTS: A total of 2738 patients (median [IQR] age, 56 [41-66] years; 1456 female [53.1%]) were included. PPCs occurred in 172 of 903 patients (19.0%) in the RAS group and 174 of 1835 patients (9.5%) in the CLS group (P < .001). Duration of intraoperative ventilation was longer in RAS compared with CLS (median [IQR] duration, 219 [180-270] vs 95 [68-145] minutes; P < .001) and the intensity of mechanical ventilation was higher (median [IQR] intensity, 84 [69-100] vs 72 [60-87] 4DP + RR; P < .001). PPCs were independently associated only with duration of ventilation (adjusted odds ratio [aOR], 1.49; 95% CI, 1.33-1.66; P < .001), not with the surgical approach (ie, RAS vs CLS; aOR, 1.35; 95% CI, 0.72-2.54; P = .35) nor the intensity of ventilation as measured by 4DP + RR (aOR, 1.01; 95% CI, 1.01-1.01; P = .21). A post hoc analysis showed a more pronounced association of intensity of ventilation in surgical procedures of shorter duration. CONCLUSIONS AND RELEVANCE: In this cohort study, patients who received RAS vs CLS had a higher incidence of PPCs and received longer and more intense mechanical ventilation; however, only the duration of ventilation rather than intensity of ventilation or type of surgical approach (ie, RAS vs CLS) was independently associated with the occurrence of PPCs, indicating that the longer duration of ventilation in RAS underlies the higher incidence of PPCs observed in those who undergo this type of surgery.

INTRODUCTION: Safe vascular access is integral to anaesthetic and critical care practice. However, despite technological and procedural advances, it remains a frequent source of adverse events and patient harm. Ensuring a safe and effective approach to the selection, insertion and care of vascular access devices should be a priority for all practitioners. METHODS: This updated consensus statement builds upon previous iterations of safe vascular access guidelines. An expert, multidisciplinary, multi-society working party agreed on major themes and conducted a review of literature and best practice to build a comprehensive body of work. This was followed by a two-round Delphi process to agree on specific recommendations and to inform these concise guidelines. RESULTS: We agreed successfully 15 recommendations encompassing operational, training and clinical issues with an emphasis on a holistic approach to vascular access and long-term vessel health. These recommendations were divided into six major themes, covering: process (vascular access teams and responsiveness key performance indicators); device selection; insertion, including the use of safety standards, ultrasound, catheter tip position and vein/catheter ratios; the management of anticoagulation therapy, catheter-related thrombosis and coagulopathies; specific patient groups, including patients requiring renal replacement therapy, following mastectomy and axillary lymph node resection and the use of peripheral vasoconstrictors; and training in advanced vascular access. DISCUSSION: It is hoped that these guidelines, together with the larger body of work, will improve the care of patients who require vascular access, embed a more holistic approach to vascular access and lifetime vein preservation, and support staff and hospitals with vascular access service development. Putting tubes into veins (called vascular access or putting a ‘drip’ in) is very important for giving people medicine during surgery or when they are very sick. But even with new tools and better ways of doing it, problems still happen and patients can get hurt. Doctors and nurses need to be very careful when choosing, putting in and looking after these tubes. A group of experts from different medical backgrounds worked together to update the rules for doing this safely. They looked at the best ways to do it by reading lots of information and research. Then they voted on the best ideas to make a clear and simple list of suggestions. They came up with 15 important tips that talk about how to safely choose, place and take care of these tubes. These tips are split into six main parts, including: how teams should work and how fast they should help; how to choose the right kind of tube; how to safely put the tube in, using things like ultrasound; how to take care of patients who have blood problems or are on special medicines; special care for patients who have had kidney treatment or breast surgery; and training doctors and nurses to do this better. These new rules are meant to help patients stay safer when they need tubes in their veins. They also help hospitals do a better job and teach staff how to protect veins for future us.