The health status, health needs and demands as well as the concept of health itself have changes dramatically in the last one hundred years, the organizational and institutional evolutions of health system took place accordingly. To adapt the changes of health system, medical education has experienced three generations of major reform in the last century: the science-based curricula, problem-based instruction, system-based and competence-oriented education. At the same time the organization of medical education evolved from academic medicine to academic health center to academic health system. This article briefly describes the process of this evolution and presents author’s personal views on academic health system.
Cardiac surgery has always been one of the major specialties in the development of “fast track surgery”. Enhanced recovery after surgery (ERAS) has become a widespread topic in perioperative medicine over the past 20 years, and it results in substantial improvements in clinical outcomes and cost savings. This frontier concept has also been increasingly applied and promoted in cardiac surgery. However, compared with other surgical fields, current studies regarding cardiac surgery are still limited in quantity, scale and universality of application. Therefore, this review focuses on current concept and progress of ERAS in adult patients undergoing cardiac surgery with cardiopulmonary bypass, aiming to provide guidance for the establishment of a better framework.
ObjectiveTo explore the incidence and influencing factors of moderate-to-poor quality of recovery (QoR) in patients undergoing minimally invasive esophagectomy (MIE). MethodsA secondary analysis was conducted based on data from a randomized controlled study on the effects of different anesthesia methods on postoperative pulmonary complications after MIE. Patients who underwent elective MIE at West China Hospital of Sichuan University from May 2019 to December 2021 were included. The QoR-15 scale was used to assess the QoR 30 days postoperatively, and logistic regression analysis was performed to identify factors affecting moderate-to-poor QoR (defined as a QoR-15 score≤121). ResultsA total of 541 patients were included, including 426 males and 115 females, with an average age of (63.0±8.3) years. At 30 days postoperatively, the numbers of patients with excellent, good, moderate, and poor QoR were 101 (18.7%), 273 (50.5%), 147 (27.2%), and 20 (3.7%), respectively. Multivariate logistic regression analysis indicated that preoperative pain [OR=1.527, 95%CI (1.032, 2.258), P=0.034] and a nutrition risk screening-2002 score≥3 [OR=1.617, 95%CI (1.069, 2.447), P=0.023] were influencing factors for moderate-to-poor QoR 30 days postoperatively. ConclusionAbout 30.9% of patients undergoing MIE have a moderate-to-poor QoR 30 days postoperatively. Improving preoperative pain management and nutritional status may enhance postoperative QoR.
Objective To evaluate the association between intraoperative fluid management and prolonged postoperative ileus (PPOI) after colorectal surgery. Methods We reviewed the data of 980 patients who underwent elective colorectal surgery in West China Hospital of Sichuan University between July and December 2016. The primary outcome was PPOI. The association of intraoperative fluid volume and fluid balance with PPOI were analyzed. Results Nine hundred and eighty patients undergoing elective colorectal surgery were included, and the incidence of PPOI was 31.1% (305/980). Compared with non-PPOI patients, patients with PPOI had longer postoperative hospital stay and increased total hospital cost (P<0.05). Multivariate logistic regression analysis did not find intraoperative fluid volume and fluid balance were associated with PPOI in patients undergoing colorectal surgery (P>0.05). Conclusions There is no clinically relevant association between intraoperative fluid management and PPOI in adult patients underwent colorectal surgery. However, the occurrence of PPOI may prolong postoperative hospital stay and increase hospitalization cost.
[Abstract]The number of lung transplantation is gradually increasing worldwide, which brings new challenges to the multi-disciplinary team of lung transplantation. The prognosis of lung transplant recipients is seriously affected by the pathophysiological state of specific lung diseases and perioperative risk factors. It is of great significance for these patients to optimize perioperative management according to these factors. Recently, several expert consensus have been published regarding anesthesia management of lung transplantation. Based on the current evidence and clinical practice of West China Hospital, this review summarizes the key points of anesthesia management for lung transplant recipients to guide anesthesiologists' clinical practice.
ObjectiveTo evaluate the correlation between positive end-expiratory pressure (PEEP) level and postoperative pulmonary complications (PPCs) in patients undergoing thoracoscopic lung surgery. MethodsThe clinical data of patients who underwent elective thoracoscopic lung surgery at West China Hospital of Sichuan University from January 2022 to June 2023 were retrospectively analyzed. Patients were divided into 2 groups according to intraoperative PEEP levels: a PEEP 5 cm H2O group and a PEEP 10 cm H2O group. The incidence of PPCs in the two groups after matching was compared using a nearest neighbor matching method with a ratio of 1∶1, setting the clamp value as 0.02. ResultsA total of 538 patients were screened, and after propensity score-matching, a total of 229 pairs (458 patients) were matched, with an average age of 53.9 years and 69.4% (318/458) females. A total of 118 (25.8%) patients had PPCs during hospitalization after surgery, including 60 (26.2%) patients in the PEEP 5 cm H2O group and 58 (25.3%) patients in the PEEP 10 cm H2O group, with no statistically significant difference between the two groups [OR=0.997, 95%CI (0.495, 1.926), P=0.915]. Multivariate logistic regression analysis showed that PEEP was not an independent risk factor for PPCs [OR=0.920, 95%CI (0.587, 1.441), P=0.715]. ConclusionFor patients undergoing thoracoscopic lung surgery, intraoperative PEEP (5 cm H2O or 10 cm H2O) is not associated with the risk of PPCs during hospitalization after surgery, which needs to be further verified by prospective, large-sample randomized controlled studies.
Lidocaine is an amide local anaesthetic. In recent years, clinical evidence shows that perioperative intravenous lidocaine injection plays an active role in anti-inflammation, analgesia, anti-tumor and organ protection. Postoperative pain is severe in patients after thoracic surgery, and the incidence of pulmonary complications and cognitive impairment is high. These adverse reactions and complications are closely related to the inflammatory reaction after thoracic surgery. Intravenous infusion of lidocaine may have some effects on alleviating these adverse reactions and complications. Thus, this article reviews the current status of intravenous lidocaine injection in thoracic surgery and explores the related mechanisms to optimize the management of anaesthesia during the perioperative period of thoracic surgery.
ObjectiveTo investigate the association between preoperative systemic immune-inflammation index (SII) and early allograft dysfunction (EAD) in liver transplant recipients. MethodsThe patients underwent liver transplantation who met the inclusion and exclusion criteria in the West China Hospital of Sichuan University from January 2015 to December 2019 were collected. The postoperative EAD was analyzed. The generalized propensity score weighting (GPSW) were used to balance the confounding factors affecting the occurrence of EAD. ResultsA total of 390 patients who met the inclusion and exclusion criteria were enrolled in this study, 93 cases of EAD occurred, the incidence of EAD was 23.8%. The recipient’s model for endstage liver disease score and Child-Pugh grade, the donor’s body mass index, age, and graft weight, and the intraoperative cold ischemia time, liver transplantation time, intraoperative blood loss, total infusion, red blood cell transfusion, autologous blood reinfusion, fresh frozen plasma transfusion, concentrated platelet transfusion, total red blood cell and autologous blood transfusions were balanced by GPSW, then the overall mean correlation coefficient of the 14 covariables and SII decreased from 0.049 to 0.039, and each covariable reached the standard of less than 0.1. The binary logistic regression analysis based on GPSW showed that there was no significant association between SII and EAD (P=0.371). ConclusionFrom preliminary result of this study, it is not found that preoperative SII of liver transplantation patients is related to occurrence of postoperative EAD.
ObjectiveTo investigate the current status of routine practice and perspective of anesthesiologists regarding ventilation strategies during cardiac surgery, and to analyze whether there is a gap between the clinical application and theoretical understanding of lung-protective ventilation (LPV) strategies. MethodsWe conducted a multi-institutional cross-sectional survey of anesthesiologists working at high-volume (>1000 cardiac procedures each year) Chinese hospitals. The electronic questionnaire was designed and distributed from September 2021 to February 2022. ResultsA total of 323 replies were collected and 297 (92.0%) replies were valid. Among the respondents, 84.8% (252/297) performed the combination of low tidal volume (VT), positive end-expiratory pressure (PEEP) and alveolar recruitment maneuver (ARM) during non-CPB period. The vast majority of respondents (90.6%, 269/297) ventilated patients with the VT of 6-8 mL/kg. 92.3% (274/297) of respondents applied PEEP, among those 57.9% (172/297) set a PEEP level <5 cm H2O. Most of the respondents (67.3%, 200/297) performed intraoperative ARM, and manual ARM was used by 86.2% (256/297) of anesthesiologists. During CPB, 89.9% (267/297) of respondents withdrew mechanical ventilation, and 29.6% (88/297) performed ARM. ConclusionThis national survey in China showed that the majority of anesthesiologists adopted LPV strategy with the combination of low VT, PEEP and ARM during cardiac surgery. Except VT, the intraoperative ventilator settings varied widely from one anesthesiologist to another. Meanwhile, there is a gap between the clinical practice and theoretical understanding of LPV.
Objective To investigate the relationship between morphologic macular changes and visual outcome in eyes with persistent submacular fluid (SMF) after surgery for macula-off rhegmatogenous retinal detachment (RRD) and the relevant factors of persistent submacular fluid. Methods Sixty-three consecutive patients (63 eyes) who underwent successful surgery for macula-off RRD were enrolled in this retrospective study. The patients were divided into three groups according to duration of SMF: no SMF group, short-term group (duration of SMF less than three months) and long-term group (duration of SMF more than three months). The follow-up ranged from six to 12 months. The morphologic macular changes, height of SMF and thickness of the outer nuclear layer (ONL) one month after surgery were assessed by spectral domain-optical coherence tomography (SD-OCT). The relationship between morphologic macular changes and logarithm of the minimum angle of resolution (logMAR) visual acuity and the relevant factors of persistent SMF were evaluated. Results Forty-five of 63 eyes (71.42%) presented morphologic changes after surgery. SMF was detected in 32 eyes (50.79%), which included 21 patients that had long-term course of SMF. Irregular thickness of the photoreceptor outer segments (OS) was observed in 23 eyes; disrupted inner segment/outer segment (IS/OS) junction was noted in 21 eyes, and disrupted external limiting membrane (ELM) was noted in 14 eyes. Irregular thickness of OS in long-term group was significantly higher than that in short-term group (chi;2=5.788, P=0.035). The proportion of IS/OS disruption and ELM discontinuation in long-term group was also higher than those in short-term group, but there was no statistically significant difference (chi;2=0.744, 0.375; P=0.472, 0.403). The postoperative visual acuity correlated positively with preoperative visual acuity and the time of retinal detachment (r=0.611, -0.374; P=0.007, 0.037). There was a significant difference of postoperative logMAR visual acuity (U=28.640, P=0.049) among no SMF group (0.27plusmn;0.26), short-term group (0.42plusmn;0.31) and long-term group (0.53plusmn;0.41). The postoperative visual acuity was insignificantly associated with irregular OS and IS/OS disruption (r=0.331, 0.320; P=0.073, 0.102). The irregular OS correlated positively with IS/OS disruption (r=0.388, P=0.027). The postoperative visual acuity in eyes with disrupted both IS/OS and ELM significantly decreased (U=29.920, P=0.036). The surgery manner (r=0.477, P＜0.001), time of preoperative retinal detachment (r=0.354, P=0.047) and SMF height one month after surgery (r=0.375, P=0.039) were factors influencing persistent SMF. Conclusions The incidence of postoperative photoreceptor lesion was increased with time of persistent SMF. Disruption of both IS/OS and ELM after surgery means a poorer vision outcome. Duration of preoperative macular detachment, type of surgery and SMF heights one month after surgery were important factors for persistent SMF.