Volume 104 · Issue 23 · 2024

Perioperative crisis events refer to unexpected seriously life-threatening when the patient is during or after surgery, and require rapid identification, evaluation, and management by clinical teams to minimize harm. The pediatric anesthesia management during perioperative period is special and challenging for anesthesiologists, requiring professional technical and non-technical skills. The article mainly elaborates on the incidence and risk factors of pediatric anesthesia crisis events during perioperative period and introduces the concept of anesthesia crisis resource management and strategies. The anesthesiologist team needs to adopt a crisis resource management strategy, taking a typical crisis event of malignant hyperthermia as an example, including identification of crisis signs immediately, termination of trigger drugs rapidly, intravenous injection of the special drug dantrolene, physical cooling, and symptomatic support treatment, seeking assistance from other teams actively, recording and feeding back. This study aims to improve the cognitive decision-making ability and teamwork ability of anesthesiologists and their teams, effectively preventing and responding to potential crisis events effectively, and ensuring the safety of pediatric patients during perioperative period.

Brain-computer interface (BCI) constructs the direct communication between human brain and external devices, which has been extensively applied in clinical research of the diagnosis and treatment of nervous system diseases, and plays a crucial role in functional evaluation, communication control, reconstruction, rehabilitation training, and neural regulation. This paper summarizes the different forms of BCI technology, the progress of clinical research on BCI for neurological diseases, and the importance of developing appropriate clinical trial standards and ethical norms. Further emphasis is placed on the interpretation of the scope of BCI clinical research in neurological diseases, the ethical principles of BCI clinical research in neurological diseases, and the key points of BCI clinical research implementation and management summarized in the Chinese expert Consensus on the implementation and management of BCI clinical research in Neurological diseases. Finally, the role and responsibility of clinical neuroscience in BCI clinical trials are put forward, emphasizing interdisciplinary cooperation in clinical research to better promote the clinical transformation of BCI technology.

The development of brain-computer interface (BCI) technology and its preliminary research results show great clinical application prospects. In particular, the application of BCI technologyis a hot research topic in the field of nervous system diseases at present, but the current BCI technology is still in the stage of experimental exploration, needing systematic and standardized clinical research validation. For this purpose, the consensus is led by the Society of Neurosurgery of Chinese Medical Association and Society of Cerebrovascular Surgery of Chinese Stroke Association. Based on the in-depth discussion of multidisciplinary experts and the vote of the Delphi Method, the guidelines and principles are proposed for pre-clinical qualification review, clinical research implementation and management, and long-term effect tracking and evaluation, so as to standardize research ethics and clinical research procedures and further promote the extensive application and in-depth development of BCI technology in the treatment of nervous system diseases.

Neurophysiological monitoring is important for the assessment and prediction of regression in patients with severe neurocritical illnesses due to various etiologies. At present, the popularity of neuroelectrophysiological monitoring technology for severe neurocritical patients in China is not widespread enought, the level of monitoring varies, and there is a lack of relevant consensus and norms. This expert consensus combines the opinions of national experts in neuroelectrophysiology and neurocritical care medicine, and providess 13 expert opinions on neuroelectrophysiology technology and application. Commonly used Neurophysiologic monitoring in the Neuro-Intensive Care Unit (NICU) includes three categories: electroencephalogram, evoked potentials and electromyography. The main applications include assessment of coma level and prognosis prediction, reflection of intracranial pressure level, identification of nonconvulsive status epilepticus, assessment of sedation level, determination of brain death, and monitoring of severe peripheral neuropathy. It is recommended that NICU at all levels apply neurophysiologic monitoring techniques to severe neurocritical patients according to the expert consensus.

Musculoskeletal diseases are conditions that affect bones, joints, tendons, ligaments and muscles. As the main causes of disability among the elderly, these diseases can lead to pain and loss of mobility, which brings a heavy burden to patients and society. The clinical research of musculoskeletal diseases is crucial for clarifying the risk factors, as well as standardizing and innovating diagnosis and treatment methods of such diseases. To further promote the standardization of clinical research in musculoskeletal diseases and meet the needs of current clinical research practice, the committee has formulated an expert consensus for clinical research in these conditions based on the clinical practice in China and the international clinical research methods or guidelines for musculoskeletal diseases. This consensus is intended to promote standardized, scientific clinical research on musculoskeletal diseases.

To evaluate the influence of thromboelastography-guided hemostatic algorithm on allogeneic transfusion requirements during pediatric hemispherectomy.

Clinical data of 38 children who underwent hemispherectomy from January 1, 2011 to October 31, 2023 at Xuanwu Hospital of Capital Medical University were retrospective collected. Patients were divided into study group (n=17) and control group (n=21) according to whether thromboelastography was employed to guide hemostatic algorithm. Demographic data and surgical data were recorded. The primary outcomes were allogeneic transfusion rates, including RBC transfusion rate, plasma transfusion rate, and platelets transfusion rate. The second outcomes were estimated blood loss, postoperative seizures during hospitalization, thromboembolic events, and length of hospital stay.

There were 13 boys and 4 girls with mean age of (5.7±3.3) years old in study group, and 16 boys and 5 girls with mean age of (7.4±3.4) years old in control group. The surgery duration, anesthesia duration and the proportion of prophylactic administration of tranexamic acid in study group were (424.5±98.5) min, (542.8±106.9) min, and 94.1% (16/17), which were higher than (353.1±85.3) min, (445.3±87.9) min, and 47.6% (10/21) in control group (all P<0.05). The rates of intra- and perioperative allogeneic plasma transfusion in study group were 52.9% (9/17) and 64.7% (11/17) respectively, which were lower than 90.5% (19/21) and 95.2% (20/21) in control group (all P<0.05). The ratio of fibrinogen concentrates administration in study group was 58.8% (10/17), which was higher than that in control group [4.8% (1/21), P=0.001]. There were no statistically differences in intra- and perioperative allogeneic RBC transfusion rates between the two groups (all P>0.05). No platelets were transfused in both groups. There were no statistically differences in estimated blood loss, postoperative seizures during hospitalization and the length of hospital stay between the two groups (all P>0.05). No postoperative thromboembolic events were observed.

Thromboelastography-guided hemostatic algorithm can reduce allogeneic plasma transfusion requirements but not RBC transfusion requirements during pediatric hemispherectomy.

To investigate the impact of intraoperative hypothermia on postoperative outcome in neonatal patients undergoing non-cardiac surgery.

The data of 1 008 neonates undergoing non-cardiac surgery in Children′s Hospital, Zhejiang University School of Medicine from January 2020 to October 2022 were retrospectively collected,which included 558 males and 450 females, with a midian age [M (Q₁, Q₃)] of 6 (2, 14) days. Neonates were divided into 4 groups according to whether hypothermia (below 36 ℃) occurred and the lowest body temperature during the surgery: normal temperature group (n=246), mild hypothermia group (the lowest temperature ranged 35.0-35.9 ℃, n=434), moderate hypothermia group (the lowest temperature ranged 34.0-34.9 ℃, n=232) and severe hypothermia group (the lowest temperature<34 ℃, n=96). The primary outcome was the incidence of intraoperative hypothermia. The four groups′ difference of postoperative hospital stay, postoperative mortality within 30 days, postoperative pulmonary complications, postoperative hemorrhage/blood transfusion and acidosis were compared. Multivariate logistic regression was used to analyze the relationship between intraoperative hypothermia and prolonged postoperative hospital stay (>14 d), 30 d-mortality and other complications.

In the 1 008 neonatal patients, 762 (75.6%) cases suffered intraoperative hypothermia, among which the incidence of mild, moderate and severe hypothermia was 43.1% (434/1008), 23.0% (232/1008) and 9.5% (96/1008), respectively. The postoperative hospital stay in normal, mild, moderate and severe hypothermia groups was 9.0 (5.8, 18.0), 12.0 (7.0, 21.0), 17.0 (10.0, 34.5) and 31.5 (12.5, 55.8) days. The mortality rate with 30 days after surgery was 2.9% (7/246), 4.4% (19/434), 6.9% (16/232) and 14.7% (14/96), the incidence of postoperative pulmonary complications was 31.7%(78/246), 39.9%(173/434), 44.8%(104/232) and 67.4%(64/96), the rate of postoperative hemorrhage/blood transfusion was 19.9%(49/246), 32.3%(140/434), 49.1%(114/232) and 79.0%(75/96), and the incidence of acidosis was 26.8%(66/246), 35.7%(155/434), 44.4%(103/232) and 46.3%(44/96), respectively. All differences were statistically significant (all P<0.05). According to the adjusted logistic regression analysis, compared with the normal body temperature group, severe hypothermia was associated with prolonged postoperative hospital stay (OR=1.962, 95%CI: 1.063-3.619) and postoperative pulmonary complications (OR=2.020, 95%CI: 1.149-3.553). The mild, moderate and severe hypothermia group could increase the risk of postoperative blood/transfusion rate (mild: OR=1.690, 95%CI: 1.080-2.644; Moderate: OR=2.382, 95%CI: 1.444-3.927; Severe: OR=8.334, 95%CI: 3.123-8.929). The mild and moderate hypothermia could raise the risk of acidosis (mild: OR=1.458, 95%CI: 1.009-2.107; Moderate: OR=1.949, 95%CI: 1.279-2.972).

Intraoperative hypothermia can prolong the postoperative hospital stay, and increase the risk of postoperative mortality, postoperative pulmonary complications, postoperative hemorrhage/transfusion, and acidosis.

To compare the effects of bronchial intubation and blocker on the outcomes of thoracoscopic surgery in infants and small children.

A total of 387 children, including 210 males and 177 females, aged (17.5±8.3) months, who underwent elective thoracoscopic surgery under general anesthesia in Children′s Hospital Affiliated to Capital Institute of Pediatrics from January 2019 to August 2023 were retrospectively analyzed. The children were divided into bronchial intubation group and bronchial blocker group according to the intraoperative single-lung ventilation mode. After matching the age factor using the propensity score matching with nearest neighbor matching method, 258 cases were finally included in the bronchial intubation group, and 129 cases were included in the bronchial blocker group. The primary outcome was the incidence of postoperative pulmonary complications in two groups. The secondary outcomes included the incidence of intraoperative hypoxemia, postoperative oxygenation index, postoperative extubation time, the length of postoperative hospitalization and the total medical expenses during hospitalization between the two groups.

The incidence of postoperative pulmonary complications in the bronchial intubation group and bronchial blocker group was 15.5% (40/258) and 12.4% (16/129), the incidence of intraoperative hypoxemia was 20.2% (52/258) and 16.3% (21/129), the postoperative oxygen indexes were 306 (269, 323) and 311 (274, 336) mmHg (1 mmHg=0.133 kPa), the extubation time was (9.2±4.5) and (8.9±4.2) min, the length of postoperative hospitalization was (5.5±0.6) and (5.5±0.5) days and the total medical expenses were (34±6) and (35±6) thousand yuan, with no statistically significant differences between the two groups (all P>0.05).

Both bronchial intubation and blocker can be used for one lung ventilation in thoracoscopic surgery for infants and small children, without affecting the postoperative outcomes.

To investigate the clinical and genetic mutation characteristics of patients with primary hemophagocytic lymphohistiocytosis (HLH) and their impact on prognosis.

Sixty-three primary HLH patients with complete medical records admitted and diagnosed at Beijing Friendship Hospital of Capital Medical University from January 2013 to December 2022 were selected. The patients′ clinical and laboratory features, genetic and rapid immunological indicator characteristics, treatment outcomes and prognosis were retrospectively analyzed. Follow-up was up to June 30, 2023, with a median follow-up time [M (Q₁, Q₃)] of 47 (21, 76) months. Overall survival was analyzed using Kaplan-Meier survival curve, and prognostic factors were analyzed using Cox proportional hazards regression model.

Sixty-three primary HLH patients included 35 males and 28 females, with a median age [M (Q₁, Q₃)] of 17 (7, 27) years. Clinical manifestations at the initial diagnosis mainly included fever (93.7%, 59/63), splenomegaly (87.3%, 55/63), hemophagocytosis (65.1%, 41/63), hepatomegaly (52.4%, 33/63) and central nervous system (CNS) involvement (38.1%, 24/63). A total of 39 patients (61.9%) were diagnosed with EB virus (EBV) infection at initial diagnosis.PRF1 and UNC13D gene mutations were the most common mutations, and the highest frequency mutation site in the PRF1 gene was c.1349C>T, and that of UNC13D gene was c.2588G>A. A total of 76.2% (48/63) of patients had reduced activity of natural killer (NK) cells. Cytotoxic cell degranulation function was impaired or absent in 52.7% (29/55) of patients, of which 79.2% (19/24) of patients with primary HLH with defects in degranulation-related genes had impaired degranulation function. The 1-year and 3-year overall survival rates were 74.8% and 66.7%, respectively. Cox multivariate analysis suggested that peripheral blood EBV≥10 000 copies/ml (HR=3.523, 95%CI: 1.418-8.757, P=0.007) was the risk factor for prognosis.

The main clinical manifestations of primary HLH patients at the initial diagnosis include fever, splenomegaly, hemophagocytosis, hepatomegaly, and CNS involvement. PRF1 and UNC13D are the most commonly mutated genes. High copy number EBV infection in peripheral blood is the risk factor for prognosis.

To establish and validate a prediction model for early-stage epithelial ovarian cancer based on least absolute shrinkage and selection operator (LASSO) regression.

A total of 509 cases ovarian mass patients who underwent surgical treatment in Tianjin Medical General Hospital from January 2018 to March 2023 were retrospectively analyzed. The patients were randomly divided into modeling group [n=356, M(Q₁,Q₃) for age were 43 (31, 61) years] and internal validation group [n=153, age 42 (31, 60) years] by 7∶3 ratio. In addition, 86 patients [age 44 (33, 61) years] who underwent surgical treatment for ovarian mass in Tianjin Medical University General Hospital from April to November 2023 were collected as external validation group. The variables were screened by LASSO regression. The nomogram model was established and plotted by multivariate logistic regression. Internal and external validation were then conducted. The model performance and clinical applicability were evaluated using receiver operating characteristic (ROC) curve, calibration curve and decision curve.

Five variables including age (OR=1.040,95%CI:1.000-1.050,P=0.002), carbohydrate antigen 125 (CA125) (OR=1.001, 95%CI: 1.000-1.010, P=0.017), human epididymis protein 4 (HE4) (OR=1.020, 95%CI: 1.000-1.030, P=0.002), carbohydrate antigen 199 (CA199) (OR=1.001, 95%CI:1.000-1.020, P=0.023) and lactate dehydrogenase (LDH) (OR=1.020, 95%CI: 1.010-1.022, P=0.001) were screened as risk factors for early-stage epithelial ovarian cancer. The nomogram model was constructed based on these above five risk factors to predict early-stage epithelial ovarian cancer. ROC curves showed the area under curve (AUC) were 0.915(95%CI:0.910-0.932)for modeling group, 0.891(95%CI:0.874-0.905) for internal validation group, and 0.924(95%CI:0.907-0.942) for external verification. The calibration curves and clinical decision curves showed the model exhibited good consistency and clinical practicability.

The nomogram model built includes age, CA125, HE4, CA199, and LDH. It can effectively predict early-stage epithelial ovarian cancer and has strong clinical practicability.

To investigate the efficacy and safety of intravenous thrombolysis with Tenecteplase (TNK) in patients with post-awakening branch atheromatous disease (BAD).

A retrospective collection was conducted on 178 patients with post-awakening BAD admitted to the Stroke Centre of Zhengzhou People′s Hospital from January 2017 to June 2023, who had a mismatch in DWI/FLAIR on magnetic resonance imaging. The patients were divided into thrombolysis group (60 patients) and control group (118 patients) according to whether or not they were applied to intravenous thrombolysis by TNK. Propensity score matching (PSM) was used to pair and balance the confounding factors at 1∶1 between the two groups, and the 90-d long-term prognosis of the patients was assessed using the modified Rankin Scale (mRS) and the Barthel Index (BI). The National Institutes of Health Stroke Scale (NIHSS) score was used to compare the early neurological changes between the two groups.The differences in clinical outcomes were compared between the two groups.

Fifty-two pairs of patients, 65 males and 39 females, aged (60±9) years, were successfully matched by PSM. The thrombolysis group had lower NIHSS score than that of the control group at 24 h, 7 d, 14 d after treatment or at discharge [3(2, 5) vs 4(3, 7), 3(2, 5) vs 4(3, 5), and 2(1, 4) vs 3(2, 4)], and shorter hospital stay than that of the control group [9(7, 12) d vs 11(9, 13) d], and at the same time, the thrombolysis group was less likely to experience early neurological deterioration (END) [9.6% (5/52) vs 28.9% (15/52)], and the proportion of 90 d mRS≤1, mRS≤2, and BI scores were higher than those in the control group [63.5% (33/52) vs 30.8% (16/52), 82.7% (43/52) vs 59.6% (31/52), and (91±8) points vs (82±8) points ], all differences were statistically significant (P<0.05). The percentage of mRS≥4 points was higher in the control group than that in the thrombolysis group [23.1% (12/52) vs 7.7% (4/52)]. One case of intracranial haemorrhage occurred in the thrombolysis group, and 1 case in the control group died of pulmonary infection within 90 d of follow-up, with a case-fatality rate of 1.9% (1/52).

In the patients with post-awakening BAD screened by MRI, TNK intravenous thrombolysis can significantly reduce the risk of END, improving long-term prognosis and has a high safety.

To investigate the impact of gallbladder cholesterolosis on the morphology of gallstones.

The patients with gallstone who underwent cholecystectomy at the Gallstone Disease Center of East Hospital Affiliated to Tongjin University from December 2020 to October 2021 were retrospectively included. The patients were divided into the case group (sludge-like) and the control group (non-sludge-like stone), based on gallstone morphology. Clinical baseline characteristics between the two groups were compared. The related factors influencing gallstone morphology were analyzed using multivariate logistic regression analysis.

A total of 110 patients were included, with 30 cases in the case group (13 males, 17 females), aged 26-73 (54±14) years, 80 cases in the control group (24 males, 56 females), aged 18-75 (45±13) years. The age of the case group was higher than that of the control group (P=0.003). The occurrence rate of occult pancreaticobiliary reflux (OPBR) was higher in the case group compared to the control group [33.3% (10/30) vs 13.8% (11/80), P=0.020]; the occurrence rate of gallbladder cholesterolosis was lower in the case group compared to the control group [30.0% (9/30) vs 73.8% (59/80), P<0.001]. The results of multivariate logistic regression analysis showed that gallbladder cholesterolosis (OR=0.19, 95%CI: 0.07-0.49, P=0.001) was a significant factor associated with sludge-like stones.

Gallbladder cholesterolosis can cause the formation of different forms of cholecystolithiasis, and promote the occurrence and development of "solid stones".

This article reports a 34-year-old young female patient who went to Peking Union Medical College Hospital on August 1, 2022 due to "pus and blood stool for more than 1 year". The patient was diagnosed with "inflammatory bowel disease" in another hospital, and the symptoms recurred after short-term mesalazine treatment. The patient's abdominopelvic enhanced CT examination showed thickening of rectosigmoidal colon wall; Under colonoscopy, multiple polypoid protuberances were seen, covered with white coating, and normal mucosa was seen between lesions; Biopsy pathology of the lesion showed ulcer on the mucosal surface, epithelial cell proliferation, epithelial cell necrosis and shedding, and rectal recess twist; Laboratory inflammation indicators were normal; Combined with the patient's medical history of laborious defecation and manual assisted defecation, the diagnosis of "solitary rectal ulcer syndrome (SRUS)" was suspected. Six months after giving the patient defecation guidance, lactulose laxative and mesalazine enema treatment (2 g/time, 1 time/night), the purulent and bloody stool and abdominal pain disappeared, and the original B ulcer and polypoid protuberance disappeared after re-examination of colonoscopy. Follow-up until December 2023, during which the patient had 1 to 2 stool times/d, and other related symptoms did not recur, and was diagnosed as SRUS.

The child was a male, 5 months old. On May 29, 2022, he came to Yuying Children's Hospital of the Second Affiliated Hospital of Wenzhou Medical University for treatment because "there was no opening in the anus for more than 1 h after birth". He was diagnosed with congenital anal atresia with rectourethral fistula, hypospadias, and left cryptorchidism. He underwent "sigmoid colostomy" under tracheal intubation under general anesthesia. X-linked Opitz G/BBB syndrome was diagnosed by genetic testing. On 25 November 2022, he was readmitted to the hospital due to "5 months after sigmoidostomy, requiring anoplasty" and underwent "posterior sagittal approach transsacroperineal anoplasty" under general anesthesia. The surgery lasted for 3 h, and severe laryngeal stridor with oxygen saturation (SpO₂) progressive decline, subglottic stenosis visible under visual laryngoscope, symptoms improved after endotracheal intubation, and transferred to intensive care unit for treatment. Severe laryngeal stridor with SpO after removal of tracheal tube on the 3rd postoperative day₂Unable to maintain, endotracheal intubation again. After consultation in ENT department, subglottic edema was considered, and comprehensive treatment such as intravenous anti-inflammatory treatment with dexamethasone was given. The tracheal tube was removed on the 10th day after operation, and the tracheal tube was transferred to the general ward on the 13th day, and the hospital was discharged one week later. On 23-Mar-2023, the "sigmoidostomy reinstatement" was performed under tracheal intubation under general anesthesia. Considering that the child had a history of subglottic edema, he was admitted to ICU with a tube for monitoring and treatment after operation (the protocol is the same as above). He was transferred to the general ward on April 5th and discharged 3 days later, with a good prognosis.

With the prolonged survival of cancer patients, the number of patients requiring surgery after neoadjuvant chemotherapy is also increasing. However, the adverse reactions of neoadjuvant chemotherapy can cause damage to patients' related organs, resulting in an increased risk of perioperative complications. At the same time, the poor nutritional status of patients after chemotherapy decreases the patient's tolerance to anesthesia surgery, seriously affects the patient's rapid recovery and increases the patient's burden. This article reviews the effects of preoperative neoadjuvant chemotherapy on the body, including cardiotoxicity, pulmonary toxicity, hepatotoxicity, nephrotoxicity, neurotoxicity and malnutrition; It also discussed its influence on the evaluation and management of preoperative anesthesia and intraoperative anesthesia management, aiming at reducing postoperative complications of patients receiving neoadjuvant chemotherapy, promoting early recovery of patients, and providing a theoretical basis for anesthesiologists to formulate anesthesia protocols for patients receiving neoadjuvant chemotherapy.