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STUDY OBJECTIVE: Semaglutide is a long-acting glucagon-like peptide-1 receptor agonist used for management of type 2 diabetes and/or obesity. To test the hypothesis that perioperative semaglutide use is associated with delayed gastric emptying and increased residual gastric content (RGC) despite adequate preoperative fasting, we compared the RGC of patients who had and had not taken semaglutide prior to elective esophagogastroduodenoscopy. The primary outcome was the presence of increased RGC. DESIGN: Single-center retrospective electronic chart review. SETTING: Tertiary hospital. PATIENTS: Patients undergoing esophagogastroduodenoscopy under deep sedation/general anesthesia between July/2021-March/2022. INTERVENTIONS: Patients were divided into two (SG = semaglutide, NSG = non-semaglutide) groups, according to whether they had received semaglutide within 30 days prior to the esophagogastroduodenoscopy. MEASUREMENTS: Increased RGC was defined as any amount of solid content, or > 0.8 mL/Kg (measured from the aspiration/suction canister) of fluid content. MAIN RESULTS: Of the 886 esophagogastroduodenoscopies performed, 404 (33 in the SG and 371 in the NSG) were included in the final analysis. Increased RGC was observed in 27 (6.7%) patients, being 8 (24.2%) in the SG and 19 (5.1%) in the NSG (p < 0.001). Semaglutide use [5.15 (95%CI 1.92-12.92)] and the presence of preoperative digestive symptoms (nausea/vomiting, dyspepsia, abdominal distension) [3.56 (95%CI 2.2-5.78)] were associated with increased RGC in the propensity weighted analysis. Conversely, a protective [0.25 (95%CI 0.16-0.39)] effect against increased RGC was observed in patients undergoing esophagogastroduodenoscopy combined with colonoscopy. In the SG, the mean time of preoperative semaglutide interruption in patients with and without increased RGC was 10.5 ± 5.5 and 10.2 ± 5.6 days, respectively (p = 0.54). There was no relationship between semaglutide use and the amount/volume of RGC found on esophagogastroduodenoscopy (p = 0.99). Only one case (in the SG) of pulmonary aspiration was reported. CONCLUSIONS: Semaglutide was associated with increased RGC in patients undergoing elective esophagogastroduodenoscopy. Digestive symptoms prior to esophagogastroduodenoscopy were also predictive of increased RGC.

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Abstract Introduction and objectives Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids. Methods Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR). Results Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03-0.28]), and (P2) (PR = 0.42%; 95% CI [0.20-0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20-29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22-8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p< 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p< 0.05). Conclusion MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.

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COVID-19-related in-hospital mortality has been reported at 30.7-47.3% in Brazil, however studies assessing exclusively private hospitals are lacking. This is important because of significant differences existing between the Brazilian private and public healthcare systems. We aimed to determine the COVID-19-related in-hospital mortality and associated risk factors in a Brazilian private network from March/2020 to March/2021. Data were extracted from institutional database and analyzed using Cox regression model. Length of hospitalization and death-related factors were modeled based on available independent variables. In total, 38,937 COVID-19 patients were hospitalized of whom 3058 (7.8%) died. Admission to the intensive care unit occurred in 62.5% of cases, and 11.5% and 3.8% required mechanical ventilation (MV) and renal replacement therapy (RRT), respectively. In the adjusted model, age ≥ 61 years-old, comorbidities, and the need for MV and/or RRT were significantly associated with increased mortality (p < 0.05). Obesity and hypertension were associated with the need for MV and RRT (p < 0.05).

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OBJECTIVES: The American Society of Anesthesiologists Physical Status (ASA-PS) is a grading system routinely adopted worldwide by physicians to classify patients' overall health status. Concerns have been raised surrounding the subjectiveness of this system, potentially leading to poor inter-rater agreement/reliability. We hypothesized that physicians are overconfident when assigning ASA-PS scores and that presenting them with the ASA-PS definitions/examples would improve accuracy. We therefore evaluated participants' accuracy and self-reported confidence on the ASA-PS Classification System (1) while assigning ASA-PS according to their baseline knowledge/judgment; and (2) after a single exposure to the ASA-PS definitions/examples. DESIGN: Prospective before-and-after web-based study. PARTICIPANTS: 272 anesthesiologists and 114 non-anesthesiologists. INTERVENTIONS: Participants voluntarily answered a web-based questionnaire consisting of 10 hypothetical cases. They were asked to assign an ASA-PS score and rate their perceived self-confidence level (20-100%) on the accuracy of their assigned score for each case both (1) before and (2) after reviewing the ASA-PS definitions/examples. The correct ASA-PS for each hypothetical case was determined by consensus among investigators. MEASUREMENTS: Participants' accuracy, self-reported confidence, and calibration of confidence on the application of ASA-PS Classification System. Agreement between measures was tested using kappa coefficient. RESULTS: Anesthesiologists had better accuracy than non-anesthesiologists both on initial [6(5-7) vs. 4(3-5) out of 10; p < 0.001] as well as subsequent [7(6-8) vs. 6(4-7); p < 0.001] ASA-PS score assignments. Participants' self-reported confidence was greater than their accuracy for assigned ASA-PS scores (p < 0.001). ASA-PS agreement between anesthesiologists and non-anesthesiologists was poor (κ < 0.20). Participants' accuracy for hypothetical cases of ASA-PS I, II, and III involving adult patients was overall greater than for ASA-PS IV, V, and III (the latter involving a neonate) for both anesthesiologists and non-anesthesiologists (p < 0.001). CONCLUSIONS: Physicians tend to disagree and be overconfident when assigning ASA-PS scores. A brief consultation of the ASA-PS definitions/examples improves the accuracy for both anesthesiologists and non-anesthesiologists.

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INTRODUCTION AND OBJECTIVES: Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids. METHODS: Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR). RESULTS: Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03-0.28]), and (P2) (PR = 0.42%; 95% CI [0.20-0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20-29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22-8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p < 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p < 0.05). CONCLUSION: MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.

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BACKGROUND: Venous thromboembolism (VTE) is a major cause of perioperative morbimortality. Despite significant efforts to advance evidence-based practice, prevention rates remain inadequate in many centres. OBJECTIVE: To evaluate the effectiveness of different strategies aimed at improving adherence to adequate VTE prophylaxis in surgical patients at high risk of VTE. METHOD: Before and after intervention study conducted at a tertiary hospital. Adherence to adequate VTE prophylaxis was compared according to three strategies consecutively implemented from January 2019 to December 2020. A dedicated hospitalist physician alone (strategy A) or in conjunction with a nurse (strategy B) overlooked the postoperative period to ensure adherence and correct inadequacies. Finally, a multidisciplinary team approach (strategy C) focused on promoting adequate VTE prophylaxis across multiple stages of care-from the operating room (ie, preoperative team-based checklist) to collaboration with clinical pharmacists in the postoperative period-was implemented. RESULTS: We analysed 2074 surgical patients: 783 from January to June 2019 (strategy A), 669 from July 2019 to May 2020 (strategy B), and 622 from June to December 2020 (strategy C). VTE prophylaxis adherence rates for strategies (A), (B) and (C) were (median (25th-75th percentile)) 43.29% (31.82-51.69), 50% (42.57-55.80) and 92.31% (91.38-93.51), respectively (p<0.001; C>A=B). There was a significant reduction in non-compliance on all analysed criteria (risk stratification (A (25.5%), B (22%), C (6%)), medical documentation (A (68%), B (55.2%) C (9%)) and medical prescription (A (51.85%), B (48%), C (6.10%)) after implementation of strategy C (p<0.05). Additionally, a significant increase in compliance with adequate dosage, dosing interval and scheduling of the prophylactic regimen was observed. CONCLUSION: Perioperative VTE prophylaxis strategies that relied exclusively on physicians and/or nurses were associated with suboptimal execution and prevention. A multidisciplinary team-based approach that covers multiple stages of patient care significantly increased adherence to adequate VTE prophylaxis in surgical patients at high risk of developing perioperative VTE.

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Background: Orotracheal intubation (OTI) can result in aerosolisation leading to an increased risk of infection for healthcare providers, a key concern during the COVID-19 pandemic. Objective: This study aimed to evaluate the OTI time and success rate of two aerosol-mitigating strategies under direct laryngoscopy and videolaryngoscopy performed by anaesthesiologists, intensive care physicians and emergency physicians who were voluntarily recruited for OTI in an airway simulation model. Methodology: The outcomes were successful OTI, degree of airway visualisation and time required for OTI. Not using a stylet during OTI reduced the success rate among non-anaesthesiologists and increased the time required for intubation, regardless of the laryngoscopy device used. Results: Success rates were similar among physicians from different specialties during OTI using videolaryngoscopy with a stylet. The time required for successful OTI by intensive care and emergency physicians using videolaryngoscopy with a stylet was longer compared with anaesthesiologists using the same technique. Videolaryngoscopy increased the time required for OTI among intensive care physicians compared with direct laryngoscopy. The aerosol-mitigating strategy under direct laryngoscopy with stylet did not increase the time required for intubation, nor did it interfere with OTI success, regardless of the specialty of the performing physician. Conclusions: The use of a stylet within the endotracheal tube, especially for non-anaesthesiologists, had an impact on OTI success rates and decreased procedural time.

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Abstract Background Postoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half-life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil-based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil-based total intravenous anesthesia. Methods Forty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil-based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient-controlled analgesia pump. Self-reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery. Results The mean difference between the sufentanil and control groups regarding morphine consumption in the post-anesthetic care unit and at 12, 24 and 48 h after surgery were -7.2 mg (95%CI: -12.5 to -2.1, p < 0.001), -3.9 mg (95%CI: -11.9 to 4.7, p = 0.26), -0.6 mg (95%CI: (-12.7 to 12.7, p = 0.80), and -1.8 mg (95%CI: (-11.6 to 15.6, p = 0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point. Conclusion Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.

Resumo Justificativa A dor pós-operatória é uma grande preocupação quando o remifentanil é usado para anestesia intravenosa total devido à sua meia-vida ultracurta. Os opioides de ação mais longa, como o sufentanil, têm sido usados durante a indução de anestesia intravenosa total à base de remifentanil como um meio de superar essa deficiência. Porém, a eficácia e segurança de tal estratégia ainda precisam de evidências advindas de ensaios clínicos randômicos. Portanto, objetivamos avaliar a eficácia analgésica e a segurança pós-operatória de uma dose única de sufentanil administrada durante a indução de anestesia intravenosa total à base de remifentanil. Métodos Quarenta pacientes eletivamente agendados para cirurgia abdominal aberta foram randomizados para receber anestesia intravenosa total à base de remifentanil, com ou sem uma dose única de sufentanil, após a indução da anestesia. Avaliamos o consumo de morfina no pós-operatório, administrado através de uma bomba de analgesia controlada pelo paciente. Os escores de dor autorrelatados e a ocorrência de náusea, vômito, prurido, agitação, sonolência e depressão respiratória também foram avaliados até dois dias após a cirurgia. Resultados A diferença média entre os grupos sufentanil e controle em relação ao consumo de morfina em sala de recuperação pós-anestesia e após 12, 24 e 48 horas da cirurgia foi de -7,2 mg (IC 95%: -12,5 a -2,1, p < 0,001), -3,9 mg (IC 95%: -11,9 a 4,7, p = 0,26), -0,6 mg (IC 95%: (-12,7 a 12,7, p = 0,80) e -1,8 mg (IC 95%: -11,6 para 15,6, p = 0,94), respectivamente. Não houve diferença significativa tanto nos escores de dor autorrelatados, quanto na incidência de eventos adversos entre os grupos. Conclusão Nossos achados sugerem que a administração de sufentanil durante a indução de anestesia intravenosa total à base de remifentanil está associada à redução do consumo de opioides no pós-operatório imediato.

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BACKGROUND: Postoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half-life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil-based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil-based total intravenous anesthesia. METHODS: Forty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil-based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient-controlled analgesia pump. Self-reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery. RESULTS: The mean difference between the sufentanil and control groups regarding morphine consumption in the post-anesthetic care unit and at 12, 24 and 48h after surgery were -7.2mg (95%CI: -12.5 to -2.1, p<0.001), -3.9mg (95%CI: -11.9 to 4.7, p=0.26), -0.6mg (95%CI: (-12.7 to 12.7, p=0.80), and -1.8mg (95%CI: (-11.6 to 15.6, p=0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point. CONCLUSION: Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.

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Abstract Background and objectives: Focused Cardiac Ultrasound (FoCUS) has proven instrumental in guiding anesthesiologists' clinical decision-making process. Training residents to perform and interpret FoCUS is both feasible and effective. However, the degree of knowledge retention after FoCUS training remains a subject of debate. We sought to provide a description of our 4-week FoCUS curriculum, and to assess the knowledge retention among anesthesia residents at 6 months after FoCUS rotation. Methods: A prospective analysis involving eleven senior anesthesia residents was carried out. At end of FoCUS Rotation (EOR) participants completed a questionnaire (evaluating the number of scans completed and residents' self-rated knowledge and comfort level with FoCUS), and a multiple-choice FoCUS exam comprised of written- and video-based questions. Six months later, participants completed a follow-up questionnaire and a similar exam. Self-rated knowledge and exam scores were compared at EOR and after 6 months. Spearman correlations were conducted to test the relationship between number of scans completed and exam scores, perceived knowledge and exam scores, and number of scans and perceived knowledge. Results: Mean exam scores (out of 50) were 44.1 at EOR and 43 at the 6-month follow-up. Residents had significantly higher perceived knowledge (out of 10) at EOR (8.0) than at the 6-month follow-up (5.5), p = 0.003. At the EOR, all trainees felt comfortable using FoCUS, and at 6 months 10/11 still felt comfortable. All the trainees had used FoCUS in their clinical practice after EOR, and the most cited reason for not using FoCUS more frequently was the lack of perceived clinical need. A strong and statistically significant (rho = 0.804, p = 0.005) correlation between number of scans completed during the FoCUS rotation and 6-month follow-up perceived knowledge was observed. Conclusion: Four weeks of intensive FoCUS training results in adequate knowledge acquisition and 6-month knowledge retention.

Resumo Justificativa e objetivos: A ultrassonografia cardíaca no local de atendimento (USCLA) provou ser importante para orientar o processo de tomada de decisão clínica dos anestesiologistas. Treinar os residentes para fazer e interpretar uma USCLA é viável e eficaz. No entanto, o grau de retenção do conhecimento após o treinamento permanece um assunto de debate. Procuramos fornecer uma descrição do currículo de quatro semanas do treinamento de USCLA e avaliar a retenção do conhecimento entre os residentes de anestesia seis meses após a rotação em USCLA. Métodos: Uma análise prospectiva foi realizada com 11 residentes seniores de anestesia. Ao final da rotação em USCLA, os participantes preencheram um questionário (avaliando o número de exames ultrassonográficos concluídos, o conhecimento adquirido e o nível de conforto dos residentes com a USCLA) e fizeram um exame de múltipla escolha para USCLA, composto por perguntas escritas e baseadas em vídeo. Seis meses depois, os participantes preencheram um questionário de acompanhamento e um exame similar. A autoavaliação do conhecimento e os escores do exame foram comparados no final da rotação e após seis meses. Correlações de Spearman foram usadas para testar a relação entre o número de exames concluídos e os escores dos exames, o conhecimento percebido, os escores dos exames, o número de exames e o conhecimento percebido. Resultados: Os escores médios dos exames (50) foram: 44,1 no final da rotação e 43 após seis meses. Os residentes tiveram conhecimento percebido significativamente maior (10) no final da rotação (8,0) que após seis meses (5,5), p = 0,003. No final da rotação, todos os residentes se sentiram confortáveis usando o aparelho de USCLA e, aos seis meses, 10/11 ainda se sentiam confortáveis. Todos os residentes haviam usado o USCLA em sua prática clínica após o final da rotação e a razão mais citada para não usar o USCLA com mais frequência foi a falta de necessidade clínica percebida. Uma correlação forte e estatisticamente significativa (rho = 0,804, p = 0,005) foi observada entre o número de exames realizados durante a rotação em USCLA e o conhecimento percebido em seis meses de seguimento. Conclusão: Quatro semanas de treinamento intensivo de USCLA resultaram em aquisição e retenção adequadas do conhecimento por seis meses.

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