Daily Anesthesiology Research Analysis

IMPORTANCE: Prehabilitation programs are increasingly recognized for their potential to improve surgical outcomes. However, their efficacy remains debated, largely due to a lack of pathophysiologically driven implementation and limited personalization. OBJECTIVE: To determine the impact of personalized vs standard prehabilitation on preoperative physical, cognitive, and immune function and postoperative outcomes. DESIGN, SETTING, AND PARTICIPANTS: In this prospective, single-blinded, randomized interventional trial conducted from June 2020 to September 2022 in a single academic medical center, 58 patients undergoing major elective surgery were randomized to standard (n = 30) or personalized prehabilitation (n = 28) using block randomization. Those with contraindication to exercise, an American Society of Anesthesiologists score 4 or higher, in palliative care, less than 14 days between screening and surgery were excluded. Data were analyzed from April 2023 to May 2025. INTERVENTION: The personalized group received 2 weekly one-on-one remote coaching sessions tailored to individual progress in 4 domains (physical activity, nutrition, cognitive training, and mindfulness), whereas the standard group followed a paper-based program, including the same domains, without individualized support. MAIN OUTCOMES AND MEASURES: Primary clinical outcomes included cognitive assessments and physical performance measures, including the wall squat test, timed-up-and-go test, and 6-minute walk test (6MWT). The primary immunological outcomes included major innate and adaptive immune cell frequencies and intracellular signaling responses measured using a 47-plex mass cytometry immunoassay. RESULTS: Of 58 patients (median [IQR] age, 57 [45-67] years; 31 [57%] female) enrolled, 54 completed the study (n = 27 per group). The personalized group exhibited significant improvements in physical measures (eg, median [IQR] 6MWT: 496 [340-619] minutes before prehab versus 546 [350-728] minutes after; P = .03) and fewer moderate-to-severe postoperative complications (4 vs 11 Clavien-Dindo grade >1; P = .04). Multivariable modeling identified profound and cell-type specific immune alterations postprehabilitation compared to baseline (area under the receiver operating characteristic curve [AUROC], 0.88; 0.79-0.97; P < .001; leave-one-out cross-validation), including dampened phosphorylated protein kinase R-like endoplasmic reticulum kinase 1/2 signaling in classical monocytes and myeloid-derived suppressor cells after interleukin 2, 4, and 6 stimulation, and reduced phosphorylated cyclic adenosine monophosphate response-element binding protein signaling in Th1 cells. In contrast, the standard group showed only moderate clinical improvements and no immune changes (AUROC = 0.63; 95% CI, 0.48-0.78; P = .12). CONCLUSIONS AND RELEVANCE: In this study, personalized prehabilitation significantly altered the immunome before surgery, dampening inflammatory signaling responses previously implicated in the pathophysiology of key surgical outcomes, including surgical site infections and postoperative neurocognitive decline. These changes were accompanied by improved physical and cognitive function before surgery and decreased postoperative complications. These findings support the use of personalized prehabilitation and provide an avenue for biologically driven monitoring of prehabilitation efficacy, and individual tailoring of programs to optimize surgical readiness and recovery. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04498208.

BACKGROUND: The external oblique intercostal (EOI) plane block has been proposed as an innovative regional anesthetic technique for upper abdominal surgery by recent case reports. This randomized controlled study evaluated whether ultrasound-guided EOI plane block improves analgesia compared with patient-controlled intravenous analgesia (PCIA) alone in patients undergoing open hepatectomy. METHODS: Between July 24, 2023 and May 29, 2024, 70 adult patients scheduled for elective open hepatectomy at Zhongshan Hospital, Fudan University, were randomly assigned (1:1) to receive an EOI plane block with ropivacaine 0.375% (30 ml) or the equivalent 0.9% normal saline, in addition to PCIA. The primary outcome was opioid consumption in intravenous (IV) morphine equivalents within 24 h postoperatively. Secondary outcomes included opioid consumption at 1, 8, 12, 36, and 48 h postoperatively; visual analogue scale (VAS) pain scores at rest and during coughing at 12, 24, and 48 h postoperatively; intraoperative opioid use; time to first postoperative rescue analgesia; pruritus; nausea or vomiting; EOI-related complications; QoR-15 at 24 and 48 h; length of hospital stay, and chronic pain at 3 months. RESULTS: The EOI group showed significantly lower opioid consumption in IV morphine equivalents at 24 h postoperatively (mean difference=-2.91, P=0.019), with greater reduction at 36 h (-4.66 mg), and 48 h (-6.06 mg, both P<0.001) postoperatively. The EOI group also required less intraoperative fentanyl, reported lower resting VAS pain scores, and had a longer time to first postoperative rescue analgesia. No significant between-group differences were observed in coughing pain scores, QoR-15, length of stay, or chronic pain. No complications related to EOI were detected. CONCLUSIONS: Preoperative EOI plane block reduced intraoperative and postoperative opioid consumption and improve pain control after open hepatectomy compared to PCIA alone without block-related complications.

BACKGROUND: Postoperative delirium (POD) is a common complication. Pain and sleep disturbances may contribute to the development of postoperative delirium, while transcutaneous electrical acupoint stimulation (TEAS) can alleviate these symptoms. This study investigated the effect of preoperative TEAS on POD prevention in older patients undergoing orthopedic surgery. METHODS: A total of 608 patients were randomly assigned to either an intervention group (TEAS group) or a placebo group (control group). The TEAS group received stimulation at bilateral Hegu-Neiguan and Zusanli-Taichong acupoints for three consecutive days prior to surgery. POD was assessed twice daily using the Confusion Assessment Method from postoperative day 1 through day 5. Sleep disturbances were evaluated using the Athens Insomnia Scale (AIS), and pain was measured using the visual analog scale (VAS) on preoperative 3 days. Serum levels of interleukin-6 (IL-6), C-reactive protein (CRP), and S100β protein were quantified on postoperative days 1 and 3. In addition, cognitive function was evaluated on postoperative day 7 using the Montreal Cognitive Assessment (MoCA). RESULTS: The incidence of POD was significantly lower in the TEAS group compared to the control group (6.08% vs. 17.57%, CONCLUSION: Preoperative application of TEAS was associated with a reduced incidence of POD in older adults undergoing orthopedic surgery. The intervention may also contribute to improvements in preoperative sleep quality and pain reduction, as well as attenuation of postoperative inflammatory responses. CLINICAL TRIAL REGISTRATION: The trial was prospectively registered with the Chinese Clinical Trial Registry (Registration No. ChiCTR-INR-17012951; October 12, 2017).