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Purpose: Providing perioperative care for children who express anxiety or react with negative anxiety-associated consequences can be a challenge. The use of premedication is established as an important intervention for young children before surgery, yet research into care providers’ experiences of premedication is limited. The aim of this study was to explore perioperative staff’s experiences of premedication for preschool-age children.

Design: A descriptive inductive qualitative study was performed based on focus group discussions.

Methods: A purposive sample of a team from the operating department with experience in anesthetizing and caring for children in the perioperative period was interviewed in small focus groups: five preoperative and postoperative care nurses, five nurse anesthetists, and five anesthesiologists. The transcribed text was categorized using qualitative content analysis.

Findings: The content analysis revealed three themes: a matter of time, do not wake the sleeping bear, and on responsive tiptoes.

Conclusions: Care providers must adapt their work to the child’s emotional state of mind and needs, allowing time for the child to trust and accept the premedication and for the premedication to reach its peak effect. Premedication provides light sleep preoperatively, which requires careful treatment of the child to avoid emotional reactions, and the postoperative path is most peaceful when the premedication supports a long duration of sedation. Our findings highlight the need for safety precautions and a permissive and flexible organization with the goal of achieving a smooth and safe journey for the child in the perioperative path.

BACKGROUND: In 2022, the European Society of Cardiology updated guidelines for preoperative evaluation. The aims of this study were to quantify: (1) the impact of the updated recommendations on the yield of pathological findings compared with the previous guidelines published in 2014; (2) the impact of preoperative B-type natriuretic peptide (NT-proBNP) use for risk estimation on the yield of pathological findings; and (3) the association between 2022 guideline adherence and outcomes.

METHODS: This was a secondary analysis of MET-REPAIR, an international, prospective observational cohort study (NCT03016936). Primary endpoints were reduced ejection fraction (EF<40%), stress-induced ischaemia, and major adverse cardiovascular events (MACE). The explanatory variables were class of recommendations for transthoracic echocardiography (TTE), stress imaging, and guideline adherence. We conducted second-order Monte Carlo simulations and multivariable regression.

RESULTS: In total, 15,529 patients (39% female, median age 72 [inter-quartile range: 67-78] yr) were included. The 2022 update changed the recommendation for preoperative TTE in 39.7% patients, and for preoperative stress imaging in 12.9% patients. The update resulted in missing 1 EF <40% every 3 fewer conducted TTE, and in 4 additional stress imaging per 1 additionally detected ischaemia events. For cardiac stress testing, four more investigations were performed for every 1 additionally detected ischaemia episodes. Use of NT-proBNP did not improve the yield of pathological findings. Multivariable regression analysis failed to find an association between adherence to the updated guidelines and MACE.

CONCLUSIONS: The 2022 update for preoperative cardiac testing resulted in a relevant increase in tests receiving a stronger recommendation. The updated recommendations for TTE did not improve the yield of pathological cardiac testing.

Purpose: Sedative premedication in children may negatively impact their cardiorespiratory status during the perioperative course, and no clear consensus exists on the optimal premedication treatment for pediatric patients. The objective was to compare the perioperative cardiorespiratory responses to sedation using three different sedative premedication regimens in preschool children scheduled for surgery with total intravenous anesthesia.

Design: A single-center randomized controlled trial.

Methods: This is a planned secondary analysis of a study conducted at a 200-bed tertiary referral hospital. Ninety children participated in the study. They were aged 2–6 years and scheduled for ear, nose, and throat surgery with propofol/remifentanil anesthesia. Participants were randomly assigned to receive oral midazolam 0.5 mg/kg-1 (MID), oral clonidine 4 mcg/kg–1 (CLO), or intranasal dexmedetomidine 2 mcg/kg-1 (DEX). The main outcome measures were the sedation level, based on the Ramsay Sedation Scale (RSS), and cardiorespiratory status, monitored during the perioperative period.

Findings: The final cohort had 83 children (MID, n=27; CLO, n=26; DEX, n=30), with similar intergroup patient characteristics. RSS scores were lower in the MID group than in the CLO and DEX groups before induction and within 30 min postsurgery (P<0.001 and P=0.006, respectively). A negative correlation existed between the RSS and heart rate (HR) (r=-0.570, P<0.001). Before anesthesia induction, the respiratory rate was lowest in the DEX group (MID 21.5±1.7 min–1, CLO 20.6±2.6 min–1, DEX 20.2±1.7 min–1; P=0.042). The HR was lower in the CLO and DEX groups than in the MID group (MID, 102.8±10.0 min–1; CLO, 87.4±9.6 min–1; DEX, 87.6±7.9 min–1; P<0.001). The HR was lower immediately after induction (P=0.009) and intraoperatively (P=0.025) in the CLO and DEX groups than in the MID group.

Conclusions: When used as premedication before propofol/remifentanil anesthesia, clonidine and dexmedetomidine provided deeper preoperative sedation compared to midazolam. From a clinical perspective, all three study drugs provided essentially stable cardiovascular and respiratory conditions during the entire perioperative period.

BACKGROUND: Approximately 25% of ambulatory surgery patients experience post-discharge nausea and vomiting (PDNV). We aimed to investigate whether palonosetron, a long-acting anti-emetic, decreases the incidence of PDNV in high-risk patients.

METHODS: In this prospective, randomised, double-blind, placebo-controlled trial, 170 male and female patients undergoing ambulatory surgery under general anaesthesia, with a high predicted risk for PDNV, were randomised to receive either palonosetron 75 μg i.v. (n=84) or normal saline (n=86) before discharge. During the first 3 postoperative days (PODs), we measured outcomes using a patient questionanaire. The primary outcome was the incidence of a complete response (no nausea, vomiting, or use of rescue medication) until POD 2. Secondary outcomes included the incidence of PDNV each day until POD 3.

RESULTS: The incidence of a complete response until POD 2 was 48% (n=32) in the palonosetron group and 36% (n=25) in the placebo group (odds ratio 1.69 [95% confidence interval: 0.85-3.37]; P=0.131). No significant difference in the incidence of PDNV was observed between the two groups on the day of surgery (47% vs 56%; P=0.31). Significant differences in the incidence of PDNV were found on POD 1 (18% vs 34%; P=0.033) and POD 2 (9% vs 27%; P=0.007). No differences were observed on POD 3 (15% vs 13%; P=0.700).

CONCLUSIONS: Compared with placebo, palonosetron did not reduce the overall incidence of PDNV up to POD 2. The lower incidence of PDNV on POD 1 and POD 2 in the palonosetron group requires further investigation.

Background: Preoperative anxiety in pediatric patients can worsen postoperative outcomes and delay discharge. Drugs aimed at reducing preoperative anxiety and facilitating postoperative recovery are available; however, their effects on postoperative recovery from propofol-remifentanil anesthesia have not been studied in preschool-aged children. Thus, we aimed to investigate the effects of three sedative premedications on postoperative recovery from total intravenous anesthesia in children aged 2–6 years.

Methods: In this prespecified secondary analysis of a double-blinded randomized trial, 90 children scheduled for ear, nose, and throat surgery were randomized (1:1:1) to receive sedative premedication: oral midazolam 0.5 mg/kg, oral clonidine 4 μg/kg, or intranasal dexmedetomidine 2 μg/kg. Using validated instruments, outcome measures including time for readiness to discharge from the postoperative care unit, postoperative sedation, emergence delirium, anxiety, pain, and nausea/vomiting were measured.

Results: After excluding eight children due to drug refusal or deviation from the protocol, 82 children were included in this study. No differences were found between the groups in terms of median time [interquartile range] to readiness for discharge (midazolam, 90 min [48]; clonidine, 80 min [46]; dexmedetomidine 100.5 min [42]). Compared to the midazolam group, logistic regression with a mixed model and repeated measures approach found no differences in sedation, less emergence delirium, and less pain in the dexmedetomidine group, and less anxiety in both clonidine and dexmedetomidine groups.

Conclusions: No statistical difference was observed in the postoperative recovery times between the premedication regimens. Compared with midazolam, dexmedetomidine was favorable in reducing both emergence delirium and pain in the postoperative care unit, and both clonidine and dexmedetomidine reduced anxiety in the postoperative care unit. Our results indicated that premedication with α₂-agonists had a better recovery profile than short-acting benzodiazepines; although the overall recovery time in the postoperative care unit was not affected.

BACKGROUND: Guidelines endorse self-reported functional capacity for preoperative cardiovascular assessment, although evidence for its predictive value is inconsistent. We hypothesised that self-reported effort tolerance improves prediction of major adverse cardiovascular events (MACEs) after noncardiac surgery.

METHODS: This is an international prospective cohort study (June 2017 to April 2020) in patients undergoing elective noncardiac surgery at elevated cardiovascular risk. Exposures were (i) questionnaire-estimated effort tolerance in metabolic equivalents (METs), (ii) number of floors climbed without resting, (iii) self-perceived cardiopulmonary fitness compared with peers, and (iv) level of regularly performed physical activity. The primary endpoint was in-hospital MACE consisting of cardiovascular mortality, non-fatal cardiac arrest, acute myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care or resulting in a prolongation of stay on ICU/intermediate care (≥24 h). Mixed-effects logistic regression models were calculated.

RESULTS: In this study, 274 (1.8%) of 15 406 patients experienced MACE. Loss of follow-up was 2%. All self-reported functional capacity measures were independently associated with MACE but did not improve discrimination (area under the curve of receiver operating characteristic [ROC AUC]) over an internal clinical risk model (ROC AUC_baseline 0.74 [0.71-0.77], ROC AUC_{baseline+4METs} 0.74 [0.71-0.77], ROC AUC_{baseline+floors climbed} 0.75 [0.71-0.78], AUC_{baseline+fitnessvspeers} 0.74 [0.71-0.77], and AUC_{baseline+physical activity} 0.75 [0.72-0.78]).

CONCLUSIONS: Assessment of self-reported functional capacity expressed in METs or using the other measures assessed here did not improve prognostic accuracy compared with clinical risk factors. Caution is needed in the use of self-reported functional capacity to guide clinical decisions resulting from risk assessment in patients undergoing noncardiac surgery.

CLINICAL TRIAL REGISTRATION: NCT03016936.

Background: Left ventricular (LV) diastolic dysfunction is an acknowledged peri-operative risk factor that should be identified before surgery. This study aimed to evaluate a simplified echocardiographic method using e’ and E/e’ for identification and grading of diastolic dysfunction pre-operatively.

Methods: Ninety six ambulatory surgical patients were consecutively included to this prospective observational study. Pre-operative transthoracic echocardiography was conducted prior to surgery, and diagnosis of LV diastolic dysfunction was established by comprehensive and simplified assessment, and the results were compared. The accuracy of e’-velocities in order to discriminate patients with diastolic dysfunction was established by calculating accuracy, efficiency, positive (PPV) and negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC).

Results: Comprehensive assessment established diastolic dysfunction in 77% (74/96) of patients. Of these, 22/74 was categorized as mild dysfunction, 43/74 as moderate dysfunction and 9/74 as severe dysfunction. Using the simplified method with e’ and E/e’, diastolic dysfunction was established in 70.8% (68/96) of patients. Of these, 8/68 was categorized as mild dysfunction, 36/68 as moderate dysfunction and 24/68 as severe dysfunction. To discriminate diastolic dysfunction of any grade, e’-velocities (mean < 9 cm s− 1) had an AUROC of 0.901 (95%CI 0.840–0.962), with a PPV of 55.2%, a NPV of 90.9% and a test efficiency of 0.78.

Conclusions: The results of this study indicate that a simplified approach with tissue Doppler e’-velocities may be used to rule out patients with diastolic dysfunction pre-operatively, but together with E/e’ ratio the severity of diastolic dysfunction may be overestimated.

Background: The overall risk of post-operative nausea and vomiting (PONV) after general anaesthesia is reportedly 20%–40%. The first episode of PONV may occur early in the post-anaesthesia care unit (PACU) or later at the ward or after discharge at home in an ambulatory setting. This study aimed to investigate and describe the risk of early PONV in a PACU, and we hypothesised that patients and perioperative factors were associated with early PONV.

Methods: This single-centre retrospective observational study was conducted in a Swedish county hospital from January to June 2017 and included adult patients who underwent surgical procedures under general anaesthesia. Perioperative data were obtained by reviewing the local registry for surgical procedures, medical records and anaesthesia and post-operative charts. Early PONV was defined as PONV occurring up to 4 hours post-operatively at the PACU. Any notification in the medical records, perioperative charts or the registry regarding nausea, vomiting or PONV treatment was regarded as PONV. Univariate and multivariate analyses were performed for factors associated with early PONV.

Results: A total of 2030 patients were included in the study, of which 9.6% (n = 194) experienced early PONV. Factors associated with a high risk of early PONV were suboptimal PONV prophylaxis, need for opioids, female sex, body mass index >35 kg m−2 and major surgery and anaesthesia time ≥60 minutes.

Conclusion: We found that every 10th patient under general anaesthesia experienced early PONV. Suboptimal PONV prophylaxis and previously acknowledged risk factors for PONV were associated with early PONV.