Outcomes Research Consortium

The increasing global burden of liver disease leads to more frequent encounters of anesthesiologists with these high-risk patients. This review summarizes current evidence on perioperative management of patients with liver disease, acute liver failure, and acute-on-chronic liver failure undergoing surgery. The etiology of liver disease is evolving with metabolic dysfunction on the rise creating new perioperative challenges. Patients with liver disease are particularly at risk of cardiovascular events, impaired glucose regulation, and delayed anesthetic recovery. Conventional coagulation assays inadequately reflect bleeding risk in patients with liver disease, whereas viscoelastic-guided coagulation strategies are associated with reduced transfusion requirements. Overall, 90-day mortality is about five-fold higher in patients with liver cirrhosis compared with the general population. Risk scores and clinical assessments are necessary to balance patient- and procedure-related risks during preoperative evaluation. Patients with liver disease undergoing surgery constitute one of the highest-risk surgical populations. Systematic preoperative assessment, individualized anesthetic drug selection, viscoelastic-guided coagulation management, and early multidisciplinary involvement are essential to improve outcomes. High-quality prospective evidence to guide anesthetic practice in patients with liver disease is urgently needed.

The neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory marker predicting cardiovascular mortality (CVM) and all-cause mortality (ACM). To investigate the association between the NLR and CVM and ACM in patients with peritoneal dialysis (PD). We reviewed articles from PubMed, Google Scholar, and Scopus until May 2024 for the association of ACM and CVM in patients with NLR following PD. We used a fixed effects model and I 2 statistics to pool hazard ratio (HR) and measure heterogeneity. Leave-one-out sensitivity analysis assessed the robustness of our study. Multivariate meta-regression (MMR) was utilized to identify influencing confounding factors. Joanna Briggs Institute (JBI) tool was used for quality assessment. Out of 160 articles screened, seven studies from 2011 to 2024 with 4350 patients, a mean age of 49.9 years ± 15 years, and a median follow-up of 4 years were included. We found that higher NLR (> 3) was significantly associated with ACM [adjusted HR (aHR): 1.18, 95%CI: 1.03-1.36, P = 0.016]. However, there was no significant association of NLR (> 3) with CVM (aHR: 1.16, 95%CI: 0.68-1.98, P = 0.59) in patients following PD. Sensitivity analysis showed no variations. JBI tool revealed low bias among the studies. MMR revealed a significant relationship between age and ACM (coefficient: 0.14, P = 0.04). Our meta-analysis identifies a significant association between NLR (> 3) and ACM outcome, which can help prevent deaths in the elderly and optimize resource use. Caution is needed when predicting mortality in this group as age significantly confounds ACM in patients undergoing PD.

Propofol injection pain is common during i.v. induction and is often accompanied by nociceptive behaviours. Whether this pain is subsequently remembered by patients remains poorly characterised. We aimed to estimate the incidence of postoperative day 1 (POD#1) recall of propofol injection pain and to explore unadjusted associations with patient-, procedure-, and technique-related factors in routine clinical practice. We conducted a pilot prospective observational cohort study of adults undergoing low- to intermediate-risk noncardiac surgery with i.v. propofol induction between March and August 2025 at a single tertiary centre. The primary outcome was patient-reported recall of propofol injection pain on POD#1, assessed via structured interview. Secondary outcomes included recalled pain intensity (0-10 numerical rating scale), comparison with i.v. catheter insertion, and associations with observed nociceptive reactions and injection technique (catheter site, gauge, lidocaine use). All regression analyses were univariate, exploratory, and unadjusted. Among 1043 patients with POD#1 data, 102 patients (9.8%; 95% confidence interval, 8.1-11.8%) recalled propofol injection pain. Recall was more frequent in women in univariate analyses. Catheter site, gauge, and lidocaine use showed no unadjusted associations with recall. Nociceptive reactions were frequent but did not differentiate patients with and without recall. Among patients with recall, median pain intensity was 7/10 (interquartile range, 5-9), and 99% rated pain as equal to or worse than i.v. cannulation. Approximately 10% of patients recalled propofol injection pain on POD#1, typically as severe pain. Female sex showed an unadjusted association with recall, whereas injection technique and observed nociceptive reactions did not.

Neonatal life is marked by rapid antigen exposure, necessitating establishment of peripheral immune tolerance via conversion of naive CD4+ T cells into Tregs. We demonstrated heightened capacity for FOXP3 expression and tolerogenic function among cord blood versus adult blood naive CD4+ T cells. Further, this was linked to a distinct cord blood metabolic profile and elevated neonatal expression of the NADase, CD38. Early-life naive CD4+ T cells demonstrated a metabolic preference for glycolysis, which directly facilitated their differentiation trajectory. We revealed an age-dependent gradient in CD38 levels on naive CD4+ T cells and showed that high CD38 expression contributes to the glycolytic state and tolerogenic potential of neonatal CD4+ T cells, effects mediated at least partly via the NAD-dependent deacetylase SIRT1. Thus, the early-life window for peripheral tolerance in humans is critically enabled by the immunometabolic state of the naive CD4+ compartment.

Suzetrigine: A novel nonopioid systemic analgesicO pioids have been the mainstay of postoperative analgesia for decades.However, their side effects and potential complications, such as respiratory depression, postoperative nausea, vomiting, and ileus, have fueled the search for alternative ways to control pain.Thus, the concept of multimodal analgesia was born-a technique using a combination of different analgesic modalities, including acetaminophen, nonsteroidal anti-infl ammatories, N-methyl-D-aspartate receptor antagonists, intravenous lidocaine infusion, local anesthetic infi ltration, regional anesthesia, and peripheral nerve blocks, that can result in maximal pain relief with the minimum necessary dose of opioids to lessen their side effects.This strategy has coincided with the adoption of enhanced recovery after surgery protocols that have helped promote multimodal analgesia to minimize opioid use while permitting a more expedient recovery. 1ecently, suzetrigine, a voltage-gated sodium channel 1.8 (Na V 1.8) blocker, was approved by the US Food and Drug Administration (FDA), leading to interest in possibly adding this nonopioid analgesic to the multimodal analgesic regimen.

Cefazolin is the preferred prophylactic antibiotic for many surgical procedures but is often unnecessarily avoided in patients with reported penicillin and/or cephalosporin allergies. This quality improvement project aimed to increase cefazolin use for preprocedural prophylaxis in these patients. Quasi-experimental quality improvement study Safety net healthcare system in the United States Patients with reported penicillin and/or cephalosporin allergies undergoing procedures requiring antibiotic prophylaxis and anesthesiology services from January 2022 to October 2023 Interventions included the development of allergy management algorithms, educational sessions, electronic medical record updates, and audit and feedback by pharmacists The primary outcomes were changes in proportions of procedures for which cefazolin, clindamycin, and vancomycin were used for preprocedural antibiotic prophylaxis. The secondary outcomes were changes in proportions of procedures in which appropriate dose and timing of preprocedural antibiotic prophylaxis were administered. Data from 3414 patients undergoing various procedures requiring antibiotic prophylaxis and anesthesiology services during the study period were analyzed. The use of cefazolin increased from 30% pre-intervention to 73% post-intervention (p < 0.001), while clindamycin use decreased from 51% to 13% (p < 0.001), and vancomycin use decreased from 5.8% to 3.9% (p = 0.012). Appropriate antibiotic dosing increased from 89% to 93% (p = 0.048), and appropriate timing of preprocedural antibiotics improved from 49% to 74% (p < 0.001). A multi-pronged intervention significantly increased cefazolin use in patients with reported penicillin and/or cephalosporin allergies, leading to optimized antibiotic prophylaxis and reduced use of less effective alternatives.

BackgroundPrior research explored the effect of elevation on deep vein thrombosis (DVT) but primarily examined injuries at elevations <1000 or >4000 feet, excluding elevations in between, and focused on specific subsets of trauma patients. This study aimed to conduct a more detailed analysis of the relationship between elevation and DVT in all trauma admissions.MethodsThis retrospective cohort study at four level I trauma centers included adult trauma patients (October 1, 2022 to October 1, 2023). Injury zip codes were used to define elevation. High-elevation (H-ELV) injuries (≥5000 feet) were compared with low-elevation (L-ELV) injuries (<5000 feet). Elevation was further categorized into 1000-foot increments. An alpha of <0.0001 defined statistical significance.ResultsOf 8620 patients, 49% (4231) had L-ELV injuries and 51% (4389) had H-ELV injuries. Compared to patients with L-ELV injuries, those with H-ELV injuries were significantly older, had lower oxygen saturation and higher heart rate, suffered falls and sports injuries more often, and motor vehicle collisions less often, and had a higher rate of comorbidities, including alcohol use disorder and anticoagulant use. DVTs occurred significantly more often after H-ELV injuries than L-ELV injuries (1.9% vs. 0.5%, p<0.0001). For each 1000-foot increase in elevation, there was a corresponding 0.4% average increase in the rate of DVT (moderate R2=0.6). After adjustment for alcohol use disorder and oxygen saturation, H-ELV injuries were associated with a 3.8-fold increase (95% CI 2.3 to 6.4) in the risk of DVT when compared with L-ELV injuries.ConclusionsEven after adjustment, H-ELV injuries were associated with 3.8 increased odds of developing a DVT compared with L-ELV injuries. There was a significant positive linear association between DVT and injury elevation, with the rate of DVT increasing with increasing elevation. This finding may suggest the need for enhanced screening or tailored DVT prophylaxis methods at higher elevation trauma centers to improve outcomes.Level of evidenceLevel IV.