This study aimed to investigate the potential effects of intraoperative open-lung strategy (OLS) on pulmonary function and cardiac function in elderly frail patients. 104 frail elderly patients were randomly assigned into non-OLS group [small tidal volume (VT) + 5 cm H2O positive end-expiratory pressure (PEEP)] and OLS group [small VT + stepwise recruitment maneuvers (RM) + individualized PEEP]. Primary outcomes assessed were intraoperative cardiopulmonary function indices and incidence of postoperative pulmonary complications. Secondary outcomes included postoperative myocardial injury markers and recovery outcomes. Eighty-one patients completed the final analysis. The OLS group showed significant improvements in arterial oxygen pressure (PaO2), PaO₂/FiO₂ ratio, and pulmonary dynamic compliance (Cdyn) from the peak of lung recruitment to the end of surgery (T1-T4). The overall incidence of postoperative pulmonary complications (PPCs) also significantly decreased (P<0.05). Compared with the non-OLS group, left ventricular ejection fraction (LVEF), stroke volume (SV), early mitral inflow velocity to early mitral annular velocity ratio (E/E ‘), left ventricular global longitudinal strain (LVGLS), and plane systolic offset of mitral and tricuspid annular plane were significantly decreased at T1 in the OLS group (P<0.05), and recovered at T3. No significant change in the expression of myocardial injury markers between the two groups (P > 0.05). The postoperative recovery outcomes of OLS patients was significantly shortened (P<0.05). The application of OLS can effectively improve intraoperative respiratory mechanics and oxygenation in frail elderly patients, reduce the occurrence of PPCs, and shorten hospital stays of patients, without continuous negative impact on cardiac function. Retrospectively registered; Chinese Clinical Trial Registry, www.chictr.org.cn , number: ChiCTR2200058783; Registered on April 17, 2022.

OBJECTIVE:To evaluate the effect of transnasal humidified rapid insufflation ventilatory exchange (THRIVE) on regional cerebral oxygen saturation (rScO2) during induction of general anesthesia in patients undergoing traumatic brain injury (TBI) emergency surgery. METHODS:A prospective randomized controlled trial was conducted. The TBI emergency general anesthesia patients who underwent intracranial hematoma removal surgery at the Northern Jiangsu People's Hospital from January to July in 2023 were enrolled. The patients were divided into a conventional mask ventilation group and a THRIVE group using a random number table method. The patients in the conventional mask ventilation group were anesthetized and induced to pre oxygenate without positive pressure ventilation in the front mask for 10 minutes, with an oxygen flow rate of 8 L/min and an fraction of inspired oxygen (FiO2) of 1.00. After anesthesia induction for about 90 s, tracheal intubation was performed after the muscle relaxant took effect (patient's jaw muscle was relaxed). The patients in the THRIVE group were pre oxygenated with THRIVE for 10 minutes, with an oxygen flow rate of 30 L/min and a FiO2 of 1.00. During anesthesia induction, the oxygen flow rate was increased to 50 L/min, and anesthesia induction medication was used. The lower jaw of patient was supported with both hands to maintain airway patency, and the patient's mouth was kept closed throughout the process. After the muscle relaxant took effect (the patient's jaw muscle was relaxed), tracheal intubation was performed. At the time of patient entering the operating room, 10 minutes of pre oxygenation, and immediately after successful intubation, rScO2 was measured on the surgical and non-surgical sides. At the same time, ultrasound was used to measure the cross-sectional area (CSA) of the gastric antrum and arterial blood gas analysis was performed. The partial pressure of end-tidal carbon dioxide (PETCO2) during the first mechanical ventilation after successful tracheal intubation, the incidence of hypoxemia [pulse oxygen saturation (SpO2) < 0.95] during tracheal intubation, as well as prognostic indicators such as the length of intensive care unit (ICU) stay, total length of hospital stay, and Glasgow outcome scale (GOS) score at discharge were recorded. RESULTS:During the study period, a total of 70 TBI patients underwent emergency general anesthesia surgery, of which 2 patients died postoperatively, 2 patients were unable to cooperate with closed mouth breathing, and 3 patients had poor ultrasound image acquisition in the gastric antrum, all of whom were excluded. A total of 63 patients were ultimately enrolled, including 32 in the conventional mask ventilation group and 31 in the THRIVE group. There were no statistically significant differences in gender, age, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, Glasgow coma scale (GCS) score, optic nerve sheath diameter (ONSD), baseline vital signs, fasting situation, anesthesia time, surgical time, and intraoperative blood loss between the patients in the two groups, indicating comparability. When entering the operating room, there was no statistically significant difference in rScO2 on the surgical and non-surgical sides, and blood gas analysis indexes arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2) between the patients in the two groups. When pre oxygenated for 10 minutes, both the surgical and non-surgical sides rScO2 levels in the THRIVE group were significantly higher than those in the conventional mask ventilation group (surgical side: 0.709±0.036 vs. 0.636±0.028, non-surgical side: 0.791±0.016 vs. 0.712±0.027, both P < 0.01), and the PaO2 was significantly increased [mmHg (1 mmHg ≈ 0.133 kPa): 450.23±60.99 vs. 264.88±49.33, P < 0.01], PaCO2 was significantly reduced (mmHg: 37.81±3.65 vs. 43.59±3.76, P < 0.01), and the advantage continues tilled immediately after successful intubation. There was no statistically significant difference in CSA at each time point of ultrasound examination between the two groups. Compared with the conventional mask ventilation group, the patients in the THRIVE group showed a significant decrease in PETCO2 during the first mechanical ventilation after successful tracheal intubation (mmHg: 43.10±2.66 vs. 49.22±3.31, P < 0.01), and the incidence of hypoxemia during tracheal intubation was also significantly reduced [0% (0/31) vs. 28.12% (9/32), P < 0.01]. In terms of prognostic indicators, there was no statistically significant difference in the length of ICU stay and total length of hospital stay between the patients in the conventional mask ventilation group and the THRIVE group [length of ICU stay (days): 10 (9, 10) vs. 10 (9, 11), total length of hospital stay (days): 28.00 (26.00, 28.75) vs. 28.00 (27.00, 29.00), both P > 0.05]. However, the proportion of patients in the THRIVE group with a good prognosis at discharge (GOS score > 3) was significantly higher than that in the conventional mask ventilation group [35.5% (11/31) vs. 12.5% (4/32), P < 0.05]. CONCLUSIONS:THRIVE can significantly increase rScO2 during anesthesia induction in TBI emergency surgery patients and improve their neurological function prognosis.

BackgroundTo identify the risk factors for postoperative delirium (POD) after cardiac surgery in frail elderly patients and develop a receiver operating characteristic (ROC) prediction model to confirm the effectiveness.MethodsThis was a prospective observational study, patients were assessed preoperatively according to the frailty index (FI) scale. Cerebral (SctO2) was assessed at different time points using near-infrared spectroscopy (NIRS). On the basis of the occurrence of POD within 7 days after surgery, patients were divided into POD and non-POD groups. Risk factors were analyzed using logistic regression analysis, while their predictive values were evaluated using the receiver operating characteristic curve analysis.ResultsPOD was significantly associated with frailty, lower preoperative MMSE scores, hyperlipidemia, diabetes, cerebrovascular disease, lower hemoglobin level, lower albumin level, longer operation time, longer CPB time, lower SctO2 at T5, and lower SctO2baseline (P < 0.05). SrtO2 and SmtO2 did not differ significantly between groups. FI, preoperative MMSE score, and operation time as independent risk factors (P < 0.05). Significant predictive value was demonstrated in all 3 variables (P < 0.001; respectively). Among them, high sensitivity and specificity were observed with the FI (cut-off value 0.27, sensitivity 75%, specificity 73.5%) and operation time (cut-off value 237.5, sensitivity 62.5%, specificity 78.6%).ConclusionsThe FI, preoperative MMSE score, and operation time were independent risk factors for POD in elderly patients after cardiac surgery, with high predictive value observed with the FI and operation time. Cerebral oxygen saturation was associated with POD but was not an independent risk factor.Clinical Trial RegistrationChinese Clinical Trail Registry, No: chictr2200056038.

目的 调查老年患者无痛胃肠镜检查术后离开恢复室在候诊区滞留时间,筛选滞留时间延长的危险因素.方法 选取行无痛胃肠镜检查的老年患者 1014 例,采用自制调查问卷,收集患者一般资料,术中及麻醉后监测治疗室(PACU)内一般情况.术后 24 h内对患者进行电话随访,调查离室后候诊区滞留情况,根据滞留时间将患者分为延长组和非延长组.采用单因素分析和多因素Logistic回归分析筛选离室后候诊区滞留时间延长的危险因素.结果 222 例(21.9％)老年患者候诊区滞留时间延长.单因素分析显示术前衰弱、下午行胃肠镜检查、术中低氧血症、术后发生低血压及恶心呕吐对老年患者无痛胃肠镜检查离室后候诊区滞留时间有显著影响(P<0.05).多因素Logistic回归分析显示,术前衰弱、下午行胃肠镜检查、术中低氧血症,术后低血压、恶心呕吐是患者离室后候诊区滞留时间延长的危险因素.结论 术前进行衰弱评估,合理安排胃肠镜检查时间,术中常规监测呼气末二氧化碳分压,加强PACU内血压监测并预防术后恶心呕吐发生,有利于缩短老年患者离室后候诊区滞留时间.

肺不张是胸科手术患者术后最常见的肺部并发症 [1]。全身麻醉期间应用肺复张技术或呼气末正压(PEEP)通气可有效减少术中肺不张的发生 [2]，然而其对术后肺复张无明显预防作用。因此，探讨减少或预防术后早期肺不张发生的有效措施具有临床意义。经鼻湿化快速充气交换通气(THRIVE)是指通过鼻导管直接将一定浓度的高流量空-氧混合气体经过加温加湿输送给患者的一种新型氧疗方式 [3]，可产生一定程度的PEEP效应，且正压效应随着流量的增加而增加 [4]。这种新型氧疗方法所产生的持续正压效应，可能对预防胸科手术后早期肺不张具有潜在价值。因此本研究拟评价THRIVE对胸腔镜肺切除术患者术后早期肺不张的影响。

Objective:To compare the safety and efficacy of remimazolam and propofol in sedation for outpatient minor surgery by meta-analysis.Methods:PubMed, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP databases were searched, and the retrieval time was from the establishment of the databases to July 2022. Randomized controlled trial (RCT) that compared the safety and efficacy of remimazolam and propofol for procedural sedation in outpatient minor surgery was included. The remimazolam group used remimazolam as an anesthetic, with or without other analgesics, and the propofol group used a sedation regimen in the same combination. Two researchers selected the trials according to the inclusion and exclusion criteria, extracted data, and evaluated the quality of the included studies according to the quality evaluation criteria provided by the Cochrane System Manual. RevMan 5.3 software was used for meta-analysis.Results:A total of 19 RCT involving 2 633 patients were included, including 1 322 in the remimazolam group and 1 311 in the propofol group. Compared with the propofol group, remimazolam showed significant increases in mean arterial pressure (MAP) [mean difference ( MD) 7.50 [95% confidence interval (CI) 3.77, 11.22], P<0.001], heart rate [ MD 4.37 (95%CI 2.36, 6.38), P<0.001), prolonged drug onset time [ MD 0.19 (95%CI 0.03, 0.35), P=0.020]. Meanwhile, the incidence of hypotension [odds ratio ( OR) 0.23 (95%CI 0.18, 0.29), P<0.001], the incidence of hypoxemia [ OR 0.16 (95%CI 0.07, 0.39), P<0.001], the incidence of injection pain [ OR 0.03 (95%CI 0.01, 0.10), P<0.001], the incidence of respiratory depression [ OR 0.18 (95%CI 0.12, 0.27), P<0.001], the incidence of bradycardia [ OR 0.38 (95%CI 0.24, 0.60), P<0.001], and shortened recovery time after surgery [ MD -0.81 (95%CI -1.56, -0.06), P=0.030] and the time of leaving the chamber [ MD -2.17 (95%CI -3.64, -0.70), P=0.004]. There was no significant difference in sedative effect [ OR 0.68 (95%CI 0.09, 4.96), P=0.700], SpO 2 [ MD 0.45 (95%CI -0.05, 0.94), P=0.080], dizziness [ OR 0.60 (95%CI 0.34, 1.06), P=0.080], nausea and vomiting [ OR 0.83 (95%CI 0.42, 1.62), P=0.580] between the two groups. Conclusions:Remimazolam is a safe and effective sedative drug for outpatient minor surgery, with sedative effect not inferior to propofol, and the incidence of adverse reactions such as hypotension, hypoxemia, injection pain, respiratory depression, and bradycardia is lower. The incidence of postoperative nausea, vomiting and dizziness is similar to that of propofol, and the postoperative recovery is faster, but the onset time after induction is significantly prolonged.

Background:Reflux aspiration is a rare but serious complication during induction of anesthesia. The primary aim of this study is to compare the incidence of reflux and microaspiration in patients undergoing laparoscopic cholecystectomy during induction of general anesthesia using either a facemask or trans-nasal humidified rapid insufflation ventilatory exchange.Methods:We conducted a single-center, randomized, controlled trial. Thirty patients were allocated to either a facemask or a trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) group. Pre-oxygenation for 5 min with a facemask or THRIVE, positive pressure ventilation for 2 min or THRIVE for 2 min after anesthesia induction was followed. Before endotracheal intubation, the secretion above and below the glottis was collected to measure pepsin content and analyze blood gas. The ELISA assay for supra- and subglottic human pepsin content was used to detect the presence of reflux and microaspiration. The primary outcome was the incidence of reflux and microaspiration. Secondary outcomes were apnea time, PaO2 before tracheal intubation, and the end-expiratory carbon dioxide partial pressure.Results:Patients in the THRIVE group had a significantly longer apnea time (379.55 ± 94.12 s) compared to patients in the facemask group (172.96 ± 58.87 s; p < 0.001). There were no differences observed in PaO2 between the groups. A significant difference in gastric insufflation, reflux, and microaspiration was observed between the groups. Gastric insufflation was 6.9% in the THRIVE group vs. 28.57% kPa in the facemask group (p = 0.041); reflux was 10.34% in the THRIVE group vs. 32.14% kPa in the facemask group (p = 0.044); and microaspiration was 0% in the THRIVE group vs. 17.86% kPa in the facemask group (p = 0.023).Conclusion:The application of THRIVE during induction of general anesthesia reduced the incidence of reflux and microaspiration while ensuring oxygenation and prolonged apnea time in laparoscopic cholecystectomy patients. THRIVE may be an optimal way to administer oxygen during the induction of general anesthesia in laparoscopic cholecystectomy patients.Clinical trial registration:Chinese Clinical Trial Registry, No: ChiCTR2100054086, https://www.chictr.org.cn/indexEN.html.

Background To evaluate the ability of tidal volume challenge (V T C)-induced hemodynamic changes to predict fluid responsiveness in patients during one-lung ventilation (OLV). Methods 80 patients scheduled for elective thoracoscopic surgery with OLV were enrolled. The inclusion criteria were: age ≥ 18 years, American Society of Anesthesiologists physical status I-III, normal right ventricular function, normal left ventricular systolic function (ejection fraction ≥55%), and normal or slightly impaired diastolic function. The study protocol was implemented 15 min after starting OLV. Simultaneous recordings were performed for hemodynamic variables of diameter of left ventricular outflow tract, velocity time integral (VTI) of aortic valve, and stroke volume (SV), and ΔSV-V T C, ΔVTI-V T C, and ΔMAP-V T C were calculated at four time points: with V T 5 mL/kg (T1); after V T increased from 5 mL/kg to 8 mL/kg and maintained at this level for 2 min (T2); after V T was adjusted back to 5 mL/kg for 2 min (T3); and after volume expansion (250 mL of 0.9% saline infused over 10–15 min) (T4). Patients were considered as responders to fluid administration if SV increased by ≥10%. Receiver operating characteristic (ROC) curves for percent decrease in SV, VTI, and MAP by V T C were generated to evaluate their ability to discriminate fluid responders from nonresponders. Results Of the 58 patients analyzed, there were 32 responders (55%) and 26 nonresponders (45%). The basic characteristics were comparable between the two groups ( p > 0.05). The area under the curve (AUC) for ΔSV-V T C, ΔVTI-V T C, and ΔMAP-V T C to discriminate responders from nonresponders were 0.81 (95% CI: 0.68–0.90), 0.79 (95% CI: 0.66–0.89), and 0.56 (95% CI: 0.42–0.69). The best threshold for ΔSV-V T C was −16.1% (sensitivity, 78.1%; specificity, 84.6%); the best threshold for ΔVTI-V T C was −14.5% (sensitivity, 78.1%; specificity, 80.8%). Conclusion Tidal volume challenge–induced relative change of stroke volume and velocity time integral can predict fluid responsiveness in patients during one-lung ventilation. Clinical Trial Registration: Chinese Clinical Trial Registry, No: chictr210051310.

Background To evaluate the gastric volume and nature after drinking preoperative oral carbohydrates in patients undergoing laparoscopic cholecystectomy via ultrasonography. Methods One hundred patients who had been scheduled for elective laparoscopic cholecystectomy were enrolled and randomized into the traditional fasting group (Control group, n = 50) and the carbohydrate group (CHO group, n = 50). Patients in the Control group fasted solids and drink from midnight, the day before surgery. Patients in the CHO group drank 800 ml and 400 ml of oral carbohydrates 11 and 3 h before surgery, respectively. At 2 h after oral carbohydrates (T 1 ), all patients underwent an ultrasound examination of residual gastric contents; if the patients had a full stomach, the assessment was performed again 1 h later (T 2 ). A stomach containing solid contents or >1.5 ml/kg of liquid was considered “full”. The primary outcome was full stomach incidences at the above time points. The secondary outcomes included gastric antral CSA in the right lateral decubitus (RLD) and semi-sitting positions, as well as gastric volume (GV), GV per weight (GV/kg), and Perla's grade at T 1 . Results Compared with the Control group, the incidence of entire stomach was significantly high in the CHO group 2 h after oral carbohydrates. At the T 1 time point, 6 patients (13.3%) in the Control group and 14 patients (30.4%) in the CHO group presented with a full stomach [95% confidence interval (CI), (0.96–5.41), P = 0.049]. At T 2 , 3 patients (6.7%) in the Control group and 4 patients (8.7%) in the CHO group had a full stomach, with no marked differences between the two groups [95% CI, (0.31–5.50), P = 0.716]. Compared with the Control group, CSA in the semi-sitting and RLD positions, GV and GV/W were significantly high in the CHO group at T 1 ( P < 0.05). The median (interquartile range) of the Perlas grade was 1 (0–1) in the Control group and 1(1–1.25) in the CHO group ( P = 0.004). Conclusion Cholecystectomy patients experience a 2 h delay in gastric emptying after receiving preoperative carbohydrates. In LC patients, the fasting window for oral carbohydrates before surgery should be adequately prolonged. Clinical Trail registration Chinese Clinical Trail Registry, No: ChiCTR2200055245.