BIS-guided anesthesia reduced anesthetic exposure and decreased the risk of POCD at 3 months after surgery. For every 1000 elderly patients undergoing major surgery, anesthetic delivery titrated to a range of BIS between 40 and 60 would prevent 23 patients from POCD and 83 patients from delirium.

; for the Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) Study Investigators IMPORTANCE Unrecognized obstructive sleep apnea increases cardiovascular risks in the general population, but whether obstructive sleep apnea poses a similar risk in the perioperative period remains uncertain. OBJECTIVES To determine the association between obstructive sleep apnea and 30-day risk of cardiovascular complications after major noncardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study involving adult at-risk patients without prior diagnosis of sleep apnea and undergoing major noncardiac surgery from 8 hospitals in 5 countries between January 2012 and July 2017, with follow-up until August 2017. Postoperative monitoring included nocturnal pulse oximetry and measurement of cardiac troponin concentrations. EXPOSURES Obstructive sleep apnea was classified as mild (respiratory event index [REI] 5-14.9 events/h), moderate (REI 15-30), and severe (REI >30), based on preoperative portable sleep monitoring. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, and stroke within 30 days of surgery. Proportional-hazards analysis was used to determine the association between obstructive sleep apnea and postoperative cardiovascular complications. RESULTS Among a total of 1364 patients recruited for the study, 1218 patients (mean age, 67 [SD, 9] years; 40.2% women) were included in the analyses. At 30 days after surgery, rates of the primary outcome were 30.1% (41/136) for patients with severe OSA, 22.1% (52/235) for patients with moderate OSA, 19.0% (86/452) for patients with mild OSA, and 14.2% (56/395) for patients with no OSA. OSA was associated with higher risk for the primary outcome

BACKGROUND: Obstructive sleep apnea (OSA) has been found to be associated with difficult airway, although there is a paucity of prospective studies investigating thresholds of OSA severity with difficult airway outcomes. The aim of this study was to examine the association between OSA and difficult intubation or difficult mask ventilation. We also explored the utility of the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender (STOP-Bang) score for difficult airway prediction. METHODS: The Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) trial was an international prospective cohort study of surgical patients 45 years or older with one or more cardiac risk factor presenting for noncardiac surgery, with planned secondary analyses of difficult airway outcomes. Multivariable logistic regression analyses tested associations between OSA severity and predictors of difficult airway with difficult intubation or difficult mask ventilation. Overall, 869 patients without prior diagnosis of OSA were screened for OSA risk with the STOP-Bang tool, underwent preoperative sleep study, and had routine perioperative care, including general anesthesia with tracheal intubation. The primary outcome analyzed was difficult intubation, and the secondary outcome was difficult mask ventilation. RESULTS: Based on the sleep studies, 287 (33%), 324 (37%), 169 (20%), and 89 (10%) of the 869 patients had no, mild, moderate, and severe OSA, respectively. One hundred and seventy-two (20%) had a STOP-Bang score of 0–2 (low risk), 483 (55%) had a STOP-Bang score of 3–4 (intermediate risk), and 214 (25%) had a STOP-Bang score 5–8 (high risk). The incidence of difficult intubation was 6.7% (58 of 869), and difficult mask ventilation was 3.7% (32 of 869). Multivariable logistic regression demonstrated that moderate OSA (odds ratio [OR] = 3.26 [95% confidence interval {CI}, 1.37-8.38], adjusted P = .010) and severe OSA (OR = 4.05 [95% CI, 1.51-11.36], adjusted P = .006) but not mild OSA were independently associated with difficult intubation compared to patients without OSA. Relative to scores of 0–2, STOP-Bang scores of 3–4 and 5–8 were associated with increased odds of difficult intubation (OR = 3.01 [95% CI, 1.13-10.40, adjusted P = .046] and 4.38 [95% CI, 1.46-16.36, adjusted P = .014]), respectively. OSA was not associated with difficult mask ventilation, and only increasing neck circumference was found to be associated (adjusted P = .002). CONCLUSIONS: Moderate and severe OSA were associated with difficult intubation, and increasing neck circumference was associated with difficult mask ventilation. A higher STOP-Bang score of 3 or more may be associated with difficult intubation versus STOP-Bang score of 0–2. Anesthesiologists should be vigilant for difficult intubation when managing patients suspected or diagnosed with OSA.

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Background The purpose of this study was to evaluate the association between single-nucleotide polymorphisms and chronic postsurgical pain. Methods Using GoldenGate genotyping assays, we genotyped 638 polymorphisms within 54 pain-related genes in 1,152 surgical patients who were enrolled in our Persistent Pain after Surgery Study. Patients were contacted by phone to determine whether they had chronic postsurgical pain at 12 months. Polymorphisms identified were validated in a matched cohort of 103 patients with chronic postsurgical pain and 103 patients who were pain free. The functions of targeted polymorphisms were tested in an experimental plantar incisional nociception model using knock-in mice. Results At 12 months after surgery, 246 (21.4%) patients reported chronic postsurgical pain. Forty-two polymorphisms were found to be associated with chronic postsurgical pain, 19 decreased the risk of pain, and 23 increased the risk of pain. Patients carrying allele A of rs6265 polymorphism in brain-derived neurotrophic factor (BDNF) had a lower risk of chronic postsurgical pain in the discovery and validation cohorts, with an adjusted odds ratio (95% CI) of 0.62 (0.43 to 0.90) and 0.57 (0.39 to 0.85), respectively. Age less than 65 yr, male sex, and prior history of pain syndrome were associated with an increased risk of pain. Genetic polymorphisms had higher population attributable risk (7.36 to 11.7%) compared with clinical risk factors (2.90 to 5.93%). Importantly, rs6265 is a substitution of valine by methionine at amino acid residue 66 (Val66Met) and was associated with less mechanical allodynia in BDNFMet/Met mice compared with BDNFVal/Val group after plantar incision. Conclusions This study demonstrated that genetic variant of BDNF rs6265G>A is associated with decreased risk of chronic postsurgical pain.

Crew resource management (CRM) was introduced to enhance patient safety and reduce medical errors through multidisciplinary learning experience. This study investigates the impact of locally adopted simulation-based CRM training on participants’ perceptions and knowledge. A 32-item web-based questionnaire was administered pre course, 1 month, and 1 year post course to assess changes in perceptions and knowledge. Another 12-item paper-based questionnaire was administered immediately post course to assess reactions. Among 712 participants analyzed, 165 were operating room staff. The majority agreed that the training is useful and relevant in daily practice. All participants showed significant improvements in perception and knowledge 1 month post course; however, these improvements declined 1 year post course. The CRM course is associated with satisfactory reaction (Kirkpatrick level 1) and improvement in attitude and knowledge (level 2) toward patient safety. However, the effect may be short-lived and regular refresher courses should be mandatory to sustain momentum of ongoing change.

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diversities in mass-casualty incident and disaster preparedness and training curricula. Methods: Extensive literature review, quantitative data analysis of the feedback of 50 trainees (medical professionals (55%), paramedics (25%), social scientists (20%)) in two phases, before and after their participation in the simulation exercises; and qualitative analysis of 2 focus group discussions composed by facilitators and 7 expert external evaluators. Results: Expressed concerns and challenges before the simulation exercises were afterwards, characterized as acquired skills and knowledge (increased awareness regarding disaster preparedness, enhancement of non-technical skills such as decision-making, communication, conflict resolution, teamwork and coordination among stakeholders, improvement of technical skills such as identification of critically patients and triage). Furthermore, all parties involved in the study recognized the following innovating elements: -the involvement of public medical professionals, and civil protection officers and their direct interaction with the trainees, -the active contribution of trainees in the simulation scenarios design (ie roles allocation independently their professional background) -the use of fully functional public spaces as training locations for the simulation exercises (hospitals, airport, port, hotels).Overall, participants described feeling more prepared and confident for disaster response compared to prior the training. Conclusion: Learning by doing, facilitating cross-sectoral and transdisciplinary collaboration, transposing real events into educational processes, enabling actual challenges, are proposed as a remedy to the apparent disconnect between theory and methodology used in disaster preparedness drilling. Institute, Virtual Reality (VR) aeromedical incident films were produced, which will be displayed using 360 degree goggles and a dome-shaped projection platform. To enhance fidelity of the simulation, sound effects and a mock-up cockpit will be produced. The hybrid training will be established by requiring the participants to carry out first aid and resuscitation procedures on mannequins. A self-administered questionnaire will be distributed to participants for process evaluation.Results: Regular trainings will be conducted throughout two years, reaching a total of 50 participants. The first training is on December 3, 2016. Results of the process evaluation will be ready after data collection and analysis. Conclusion: It is anticipated that the use of VR in search and rescue training will add a more realistic aspect to this area of training, and allow for consistency in trainings and for the ease of evaluation, yet keeping the training in a safe environment and at a low-cost.