Although cardiac output (CO) by pulmonary artery catheterization (PAC) has been an important guideline in clinical management for more than four decades, some studies have questioned the clinical efficacy of CO in certain patient populations. Further, the use of CO by PAC has been linked to numerous complications including dysrhythmia, infection, rupture of pulmonary artery, injury to adjacent arteries, embolization, pulmonary infarction, cardiac valvular damage, pericardial effusion, and intracardiac catheter knotting. The use of PAC has been steadily declining over the past two decades. Minimally invasive and noninvasive CO monitoring have been studied in the past two decades with some evidence of efficacy. Several different devices based on pulse contour analysis are available currently, including the uncalibrated FloTrac/Vigileo system and the calibrated PiCCO and LiDCO systems. The pressure-recording analytical method (PRAM) system requires only an arterial line and is commercially available as the MostCare system. Transesophageal echocardiography (TEE) can measure CO by non-Doppler- or Doppler-based methods. The partial CO2 rebreathing technique, another method to measure CO, is marketed by Novametrix Medical Systems as the NICO system. Thoracic electrical bioimpedance (TEB) and electric bioreactance (EB) are totally noninvasive CO monitoring. Nexfin HD and the newer ClearSight systems are examples of noninvasive CO monitoring devices currently being marketed by Edwards Lifesciences. The developing focus in CO monitoring devices appears to be shifting to tissue perfusion and microcirculatory flow and aimed more at markers that indicate the effectiveness of circulatory and microcirculatory resuscitations.

Study Objective The aim of this study is to evaluate whether adding the item of “apple body type” to the STOP-BANG questionnaire enhances diagnostic performance of the questionnaire for detecting obstructive sleep apnea (OSA). Design Cross-sectional study Setting Sleep center setting Patients Two hundred and eight subjects who were referred for an evaluation of possible OSA at Tulane Comprehensive Sleep Center. The exclusion criteria were age < 18 years old, incomplete or absent questionnaire, incomplete body type identification, polysomnography (PSG) refusal, and pregnant women. Interventions STOP-BANG items and body type data were collected on the initial clinic visit. An overnight PSG was performed on every participant. Measurements Descriptive analyses of the demographic data and PSG variables were performed. The predictive parameters of STOP and STOP-BANG without and with body type score (STOP-Apple and STOPBANG-Apple) were compared. Main results The STOP questionnaire’s sensitivity/specificity/positive likelihood ratio (+LR) (cut-off = 2) was 96%/11%/1.1, respectively whereas the STOP-Apple questionnaire (cut-off = 3) was 88%/39%/1.5. The STOP-BANG’s sensitivity/specificity/+LR (cut-off = 3) was 96%/19%/1.2, respectively whereas the STOP-BANG-Apple questionnaire (cut-off = 4) was 90%/39%/1.5. The area under the Receiver Operating Characteristic (ROC) curve of STOP-Apple was comparable to the STOP-BANG (P = 0.25). The addition of the apple body type item to the STOP-BANG questionnaire in participants with a score ≥ 3 led to increased specificity (67.4%), increased the odds ratio of having OSA of 2.5 (95% CI, 1.2–5.3) and odds ratio of having moderate-severe OSA of 4.7 (95% CI, 2.5–8.7). Conclusion In the sleep center setting, adding the body type item to the STOP-BANG questionnaire improves not only clinical prediction for PSG confirmed OSA but also predicts moderate to severe of OSA.

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.

Purpose Thoracic paravertebral block (TPVB) is a recommended regional analgesia during video-assisted thoracoscopic surgery (VATS). However, single-injection TPVB does not last long enough to provide sufficient acute postoperative pain relief. Continuous TPVB through a catheter is technically challenging and often unreliable. Intravenous dexamethasone extends the analgesic duration with some peripheral nerve blocks. However, data on the effect of intravenous dexamethasone on pain relief with TPVB are limited. This study aimed to assess the analgesic efficacy of intravenous dexamethasone in patients who received TPVB for VATS. Patients and Methods In this multicenter prospective randomized controlled trial, we recruited patients aged between 18 and 80 years with the American Society of Anesthesiologists of physical status class 1–3 and underwent elective VATS. Patients under general anesthesia randomly received 8 mg of intravenous dexamethasone (group D) or normal saline (group C). Ultrasound-guided TPVB (USG-TPVB) was performed at the T4–T5 and T6-T7 spaces. Multimodal analgesia was achieved via paracetamol, tramadol and intravenous morphine for both study groups. The primary outcome was time for the first analgesic requirement. Postoperative pain in terms of numeric rating score (NRS), total morphine consumption and postoperative nausea and vomiting (PONV) were assessed. Results After excluding one patient, 59 patients were analyzed. There were no intergroup differences in baseline characteristics. The time to first analgesic requirement was longer in group D (305 [240, 510] minutes) than in group C (270 [180, 300] minutes) ( P value = 0.02). The NRS at rest and on movement was lower in group D than in group C at 12 hours but did not differ at other time points. Postoperative morphine consumption was significantly lower in group D than in group C at 6,12,24 and 48 hours. Incidences of PONV were comparable between the groups. Conclusion Intravenous dexamethasone, used as an adjunct to a single-injection USG-TPVB prolonged analgesic duration, had an opioid-sparing effect and provided better postoperative pain relief after VATS.

Background Continuous peripheral nerve catheters (CPNCs) have been used for postoperative pain relief. A common problem encountered with CPNCs is pericatheter leakage, which can lead to dressing adhesive failure. Frequent dressing changes increase the risk of catheter dislodgement and infections. Adhesive glue is effective in securing the peripheral nerve catheter and decreasing leakage around the catheter insertion site. This study aimed to evaluate the incidence of pericatheter leakage with fixation using 2-octyl cyanoacrylate glue (Dermabond®) as compared to sterile strips. Methods Thirty patients undergoing unilateral total knee arthroplasty (TKA) with continuous femoral nerve catheter for postoperative analgesia were randomized into the catheter fixation with 2-octyl cyanoacrylate glue (Dermabond®) group or the sterile strip group. The primary outcome was the incidence of pericatheter leakage. Secondary outcomes included the frequent of catheter displacement, the difficulty of catheter removal, pain score and patient satisfaction. Results The incidence of pericatheter leakage at 24 and 48 h was 0% versus 93 and 0% versus 100% in the Dermabond® and sterile strip groups, respectively (P < 0.001). The incidence of displacement at 24 and 48 h was 6.7% versus 93.3 and 6.7% versus 100% in the Dermabond® and sterile strip, respectively (P < 0.001). There was no difference in numeric rating scale, difficulty of catheter removal, or satisfaction scores between groups. Conclusions Catheter fixation with 2-octyl cyanoacrylate glue (Dermabond®) decreased the incidence of pericatheter leakage, as well as catheter displacement, over 48 h as compared to sterile strip fixation. Trial registration This trial was registered on Thai clinical trial registry: TCTR20200228002, registered 24 February 2020- Retrospectively registered.

Background Undiagnosed obstructive sleep apnea (OSA) is associated with adverse perioperative outcomes. The STOP-Bang questionnaire is a validated screening tool for OSA. However, its precision may vary among different populations. This study determined the association between high-risk OSA based on the modified STOP-Bang questionnaire and perioperative adverse events. Methods This cross-sectional study included patients undergoing elective surgery from December 2018 to February 2019. The modified STOP-Bang questionnaire includes a history of Snoring, daytime Tiredness, Observed apnea, high blood Pressure, Body mass index > 30 kg/m2, Age > 50, Neck circumference > 40 cm, and male Gender. High risk for OSA was considered as a score ≥ 3. Results Overall, 400 patients were included, and 18.3% of patients experienced perioperative adverse events. On the basis of modified STOP-Bang, the incidence of perioperative adverse events was 23.2 and 13.8% in patients with high risk and low risk (P-value 0.016) (Original STOP-Bang: high risk 22.5% vs. low risk 14.7%, P-value 0.043). Neither modified nor original STOP-Bang was associated with perioperative adverse events (adjusted OR 1.91 (95% CI 0.99–3.66), P-value 0.055) vs. 1.69 (95%CI, 0.89–3.21), P-value 0.106). Modified STOP-Bang ≥3 could predict the incidence of difficult ventilation, laryngoscopic view ≥3, need for oxygen therapy during discharge from postanesthetic care unit and ICU admission. Conclusions Neither modified nor original STOP-Bang was significantly associated with perioperative adverse events. However, a modified STOP-Bang ≥3 can help identify patients at risk of difficult airway, need for oxygen therapy, and ICU admission. Trial registrations This study was registered on Thai Clinical Trials Registry, identifier TCTR20181129001, registered 23 November 2018 (Prospectively registered).

Background The Obstetric Quality of Recovery score (ObsQoR-10) is a questionnaire used to assess recovery after cesarean delivery. However, the original ObsQoR-10 is in English and was mainly validated in the Western population. We therefore evaluated the reliability, validity, and responsiveness of the ObsQoR-10-Thai in patients undergoing elective cesarean delivery. Methods The original ObsQoR-10 was translated into Thai, and psychometric validation was performed to evaluate the quality of post-cesarean recovery. The ObsQoR-10-Thai, activities of daily living checklist, and 100-mm visual analog scale of global health (VAS-GH) questionnaires were administered to the study participants before and 24 and 48-h postpartum. Validity, reliability, responsiveness, and feasibility of the ObsQoR-10-Thai were assessed. Results We included 110 patients undergoing elective cesarean delivery. The mean ObsQoR-10-Thai score at baseline and 24 and 48-h postpartum was 83.35 ± 11.15, 56.75 ± 11.6, and 70.96 ± 13.65, respectively. The ObsQoR-10-Thai score differed significantly between the two groups divided based on the VAS-GH (≥ 70 vs. < 70): 75.58 ± 13.81 and 52.56 ± 10.61, respectively (P < 0.001). The convergent validity between the ObsQoR-10-Thai and VAS-GH was good (r = 0.60, P < 0.001). The ObsQoR-10-Thai displayed good internal consistency (Cronbach’s alpha = 0.87), split-half reliability (0.92), and test–retest reliability (0.99, 95% CI: 0.98–0.99). The median time to complete the questionnaire was 2 (IQR, 1–6) min. Conclusions Our findings indicate that the ObsQoR-10-Thai is valid and has good reliability, with a high degree of responsiveness in terms of assessment of recovery after elective cesarean delivery. Trial registration This study was registered on the Thai Clinical Trials Registry, identifier TCTR20210204001, registered on 04/02/2021 (Prospectively registration).

Purpose Unplanned overnight admission (UOA) is an important indicator for quality of care with ambulatory knee arthroscopic surgery (AKAS). However, few studies have explored the factors related to the UOA and how to predict UOA after AKAS. This study aimed to evaluate the effectiveness of a standardized peri-operative protocol for the AKAS and identify whether a correlation exists between the peri-operative surgical factors and UOA in the patients undergoing AKAS. We hypothesized that more surgical invasiveness and prolong tourniquet time increase the risk of UOA after AKAS. Method A prospective cohort study was conducted between October 2017 and March 2021. All 184 patients operated on standard AKAS protocol. The UOA is defined as overnight hospitalization of a patient undergoing AKAS. Demographic and peri-operative data were recorded, and the procedure was categorized based on the surgical invasiveness based on less invasive (intra-articular soft tissue surgery) (n = 65) and more complex surgery (involving extra-articular soft tissue surgery or ligamentous reconstruction) (n = 119). The clinical risk factors for UOA were identified and analyzed with multivariate analysis. Results The incidence of UOA in the more complex group (n = 7, 14.3%) was significantly higher than in the less invasive group (n = 3, 4.6%) (p = 0.049). The peri-operative factors significantly associated with UOA were age, more complex surgery, and longer tourniquet time (p < 0.10 all). However, the multivariate analysis revealed that longer tourniquet time was the only significant predictor for UOA (OR = 1.045, 95% CI = 1.022–1.067, p = 0.0001). The optimal cut-off points of tourniquet time for predicting UOA with the highest Youden index in the less invasive and more complex groups were 56 minutes and 107 minutes, respectively. Conclusion The UOA after AKAS is more common in more complex surgery compared to less invasive surgery. This study showed that unplanned admission significantly associated with many factors—as patient factors, surgical invasiveness, and tourniquet time. However, tourniquet time is the only independent predictor for UOA. Therefore, strict perioperative management protocol must be applied in AKAS, and all patients having these risk factors should be prepared for UOA.