OBJECTIVE: Intraoperative hypoglycemia is presumed to be rare, but generalizable multicentre incidence and risk factor data for adult patients are lacking. We used a multicentre registry to characterize adults with intraoperative hypoglycemia and hypothesized that intraoperative insulin administration would be associated with hypoglycemia.
METHODS: We conducted a cross-sectional retrospective multicentre cohort study. We searched the Multicenter Perioperative Outcomes Group registry to identify adult patients with intraoperative hypoglycemia (glucose < 3.3 mmol·L-1 [< 60 mg·dL-1]) from 1 January 2015 to 31 December 2019. We evaluated characteristics of patients with intraoperative glucose measurements and with intraoperative hypoglycemia.
RESULTS: Of 516,045 patients with intraoperative glucose measurements, 3,900 (0.76%) had intraoperative hypoglycemia. Diabetes mellitus and chronic kidney disease were more common in the cohort with intraoperative hypoglycemia. The odds of intraoperative hypoglycemia were higher for the youngest age category (18-30 yr) compared with the odds for every age category above 40 yr (odds ratio [OR], 1.57-3.18; P < 0.001), and were higher for underweight or normal weight patients compared with patients with obesity (OR, 1.48-2.53; P < 0.001). Parenteral nutrition was associated with lower odds of hypoglycemia (OR, 0.23; 95% confidence interval [CI], 0.11 to 0.47; P < 0.001). Intraoperative insulin use was not associated with hypoglycemia (OR, 0.996; 95% CI, 0.91 to 1.09; P = 0.93).
CONCLUSIONS: In this large cross-sectional retrospective multicentre cohort study, intraoperative hypoglycemia was a rare event. Intraoperative insulin use was not associated with hypoglycemia.
RéSUMé: OBJECTIF: L’hypoglycémie peropératoire est présumée rare, mais il n’existe pas de données généralisables sur l’incidence multicentrique et les facteurs de risque chez la patientèle adulte. Nous avons utilisé un registre multicentrique pour caractériser les personnes adultes atteintes d’hypoglycémie peropératoire et émis l’hypothèse que l’administration peropératoire d’insuline serait associée à l’hypoglycémie. MéTHODE: Nous avons réalisé une étude de cohorte multicentrique rétrospective transversale. Nous avons effectué des recherches dans le registre du Multicenter Perioperative Outcomes Group afin d’identifier les patient·es adultes atteint·es d’hypoglycémie peropératoire (glucose < 3,3 mmol· L−1 [< 60 mg·dL−1]) du 1er janvier 2015 au 31 décembre 2019. Nous avons évalué les caractéristiques des patient·es présentant des mesures de glucose et une hypoglycémie peropératoires. RéSULTATS: Sur 516 045 patient·es ayant des mesures de glucose peropératoires, 3900 (0,76 %) ont présenté une hypoglycémie peropératoire. Le diabète sucré et l’insuffisance rénale chronique étaient plus fréquents dans la cohorte présentant une hypoglycémie peropératoire. Les risques d’hypoglycémie peropératoire étaient plus élevés pour la catégorie d’âge la plus jeune (18-30 ans) par rapport aux catégories d’âge au-dessus de 40 ans (rapport des cotes [RC], 1,57-3,18; P < 0,001), et étaient plus élevés chez les patient·es de poids insuffisant ou de poids normal par rapport aux patient·es obèses (RC, 1,48-2,53; P < 0,001). La nutrition parentérale était associée à une probabilité plus faible d’hypoglycémie (RC, 0,23; intervalle de confiance [IC] à 95 %, 0,11 à 0,47; P < 0,001). L’utilisation peropératoire d’insuline n’était pas associée à l’hypoglycémie (RC, 0,996; IC 95 %, 0,91 à 1,09; P = 0,93). CONCLUSION: Dans cette vaste étude de cohorte multicentrique rétrospective transversale, l’hypoglycémie peropératoire était un événement rare. L’utilisation peropératoire d’insuline n’était pas associée à l’hypoglycémie.

BACKGROUND: Venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, is a common and potentially fatal post-surgery complication. Research has shown that 50% of VTE causes are intraoperative, with the risk of occurrence highest during and immediately post-surgery. Therefore, strategies for early assessment and prevention should be established.
OBJECTIVE: To identify optimal equipment selection, compression protocols, and strategies for complication prevention and management during intraoperative intermittent pneumatic compression (IPC), this study aims to synthesize the best available evidence. The objective is to inform accurate risk assessment and facilitate early mechanical prophylaxis against venous thrombosis.
METHODS: The Practical Application to Clinical Evidence model proposed by the Joanna Briggs Institute was utilized. Indicators were identified using the available best evidence from January 2023 to October 2023, and a baseline review was conducted. Negative factors were identified based on clinical evidence-based practice. The implementation rates of different indicators before (n = 372) and after (n = 405) evidence-based practice, the incidence rates of intraoperative IPC-related adverse events and VTE, and the risk of venous thrombosis before (n = 50) and after (n = 50) practice were identified and compared. Furthermore, medical staff\'s knowledge of best practices for intraoperative IPC was assessed through pre- and post-intervention surveys involving 109 operating room personnel.
RESULTS: All review indicators significantly improved (P < 0.01) after the evidence-based practice, and 9 reached 100%. Two intraoperative venous thrombosis events occurred before the evidence-based practice, with an incidence rate of 0.53%; no intraoperative venous thrombosis event occurred after the evidence-based practice, with no significant difference (X2 = 2.171, P = 0.141 > 0.05). However, there were significant differences in intraoperative venous blood hemodynamics before and after the practice (P < 0.05). Moreover, 9 IPC-related adverse events, including 4 cases of skin pressure, 3 cases of skin allergy, and 2 cases of lower limb circulation disorders, were reported before the evidence-based practice, with an incidence rate of 2.4%. Notably, no intraoperative IPC-associated adverse events occurred after the evidence-based practice(X2 = 9.913, P < 0.01). Meanwhile, the score of comprehension of the standard utilization of IPC for preventing venous thrombosis by medical staff in the operating room was 93.34 ± 3.64 after the evidence-based practice, which was higher than that (67.55 ± 5.45) before the evidence-based practice. Overall, the clinical practice was significantly improved the evidence-based practice.
CONCLUSIONS: Applying intraoperative IPC utilization standards based on the best evidence in clinical practice effectively reduces the intraoperative IPC-associated adverse event rate and the risks of intraoperative venous thrombosis. It also improves the execution rates and compliance with mechanical prevention standards in the operating room by medical staff. Future research should prioritize the development and refinement of best clinical practices for intraoperative venous thrombosis prevention, with a particular emphasis on the integration of mechanical prophylaxis strategies.

Introduction With the use of advanced instruments and techniques, the reported incidence of bile duct injury is low; however, the actual frequency might be slightly higher than reported. Most surgeons might encounter bile duct injury or bile duct-related complications in their early training days. Nevertheless, with newer techniques and technologies, cases of bile duct injuries have been mostly observed in open cholecystectomy. The predominant cause of injury is the misinterpretation of the anatomy of the bile duct, cystic duct, or aberrant right sectoral hepatic duct. Laparoscopic cholecystectomy is currently the gold standard of therapy for cholecystitis. Materials and methods The study was conducted in the Department of General Surgery at the Indira Gandhi Institute of Medical Sciences in Patna, after obtaining clearance from the ethics committee. The duration of the study was one year. Results A total of 50 patients were enrolled in the study, whose ages ranged from 20 to 55 years. They were predominantly female. The mean operative time was 68.5 ± 8.7 minutes. There were no cases of conversion to an open procedure, bile duct injury, or biliary stricture. Conclusion The injection of methylene blue into the gallbladder fundus during laparoscopic cholecystectomy is a practical, affordable, and simple procedure that does not require any special equipment or radiation exposure for the improved delineation of the gallbladder and biliary system. The use of intraoperative methylene blue could be a low-cost and simple alternative for safe laparoscopic cholecystectomy.

BACKGROUND: The aim of this study was to analyze the causes and characteristics of IOL explantation within the first year after primary implantation.
METHODS: In this retrospective, cross sectional database study, a database consisting of over 2500 IOL explants sent from 199 national and international doctors over the past 10 years was analyzed. All IOLs explanted within the first year after implantation were included in this analysis. Explants with insufficient information as well as phakic and Add-on IOLs were excluded. Main outcome measures were the reason for explantation, the time between implantation and explantation, as well as IOLs\' and patients\' characteristics. Additionally, the explanted IOLs were microscopically and histologically analyzed, as required.
RESULTS: Of all explanted IOLs from the database, 1.9% (n = 50) were explanted within the first year after implantation. The most frequent reasons for early IOL explantation were IOL dislocation (32%), visual intolerance (26%), opacification (20%), and intraoperative complications (16%). The time between implantation and explantation was the shortest in cases with intraoperative complications (1.5 ± 3.1 days), followed by IOL dislocation (90.9 ± 103.9 days), visual intolerance (98.3 ± 86.5 days), opacifications (253.5 ± 124.0 days) and other indications (249.7 ± 124.0 days). Calcification of hydrophilic IOLs was the main type of opacification (80%). Notably, seven IOLs required immediate intraoperative exchange due to an intraoperative crack in the optic or a torn off haptic.
CONCLUSIONS: Indications for early IOL explantation were IOL dislocation, visual intolerance, opacification, and intraoperative complications. Especially intraoperative damages to the IOL and early calcification show a potential for improvement of affected IOLs and implantation systems.

BACKGROUND: In the perioperative setting, the most accurate way to continuously measure arterial blood pressure (ABP) is using an arterial catheter. Surrogate methods such as finger cuff have been developed to allow non-invasive measurements and are increasingly used, but need further evaluation. The aim of this study is to evaluate the accuracy and clinical concordance between two devices for the measurement of ABP during neuroradiological procedure.
METHODS: This is a prospective, monocentric, observational study. All consecutive patients undergoing a neuroradiological procedure were eligible. Patients who needed arterial catheter for blood pressure measurement were included. During neuroradiological procedure, ABP (systolic, mean and diatolic blood pressure) was measured with two different technologies: radial artery catheter and Nexfin. Bland-Altman and error grid analyses were performed to evaluate the accuracy and clinical concordance between devices.
RESULTS: From March 2022 to November 2022, we included 50 patients, mostly ASA 3 (60%) and required a cerebral embolization (94%) under general anaesthesia (96%). Error grid analysis showed that 99% of non-invasive ABP measures obtained with the Nexfin were located in the risk zone A or B. However, 65.7% of hypertension events and 41% of hypotensive events were respectively not detected by Nexfin. Compared to the artery catheter, a significant relationship was found for SAP (r2 = 0.78) and MAP (r2 = 0.80) with the Nexfin (p < 0.001). Bias and limits of agreement (LOA) were respectively 9.6 mmHg (- 15.6 to 34.8 mmHg) and - 0.8 mmHg (- 17.2 to 15.6 mmHg), for SAP and MAP.
CONCLUSIONS: Nexfin is not strictly interchangeable with artery catheter for ABP measuring. Further studies are needed to define its clinical use during neuroradiological procedure.
BACKGROUND: Clinicaltrials.gov, registration number: NCT05283824.

UNASSIGNED: Hypothermia is characterized by a drop in core body temperature of less than 36°C. It occurs frequently throughout the operating period and affects surgical patient outcomes differently in terms of morbidity and mortality. Because of coagulopathy, metabolic acidosis, multiple organ failure, hemodynamic instability, and infections, a core temperature below 34°C is strongly associated with mortality.
UNASSIGNED: This study aimed to assess the magnitude and associated factors of intraoperative hypothermia in pediatric patients undergoing elective surgery at the Ayder Comprehensive Specialized Hospital.
UNASSIGNED: A prospective observational cross-sectional study was conducted on 399 pediatric patients undergoing elective surgery at Ayder Comprehensive Specialized Hospital in Tigray, Ethiopia, from 1 May 2023, to 30 July 2023. Participants in the study were selected by a systematic random sampling technique. The data collection procedure was chart review and intraoperative temperature measurement, and the collected data were analyzed by SPSS version 23. The independent variables were analyzed using binary and multi-logistic regression. The odds ratio, 95% CI, and p value of less than 0.05 were considered statistical significance.
UNASSIGNED: The magnitude of intraoperative hypothermia was 52.9%. Neonate and infant [adjusted odds ratio (AOR): 6, 95% CI: 3.7, 9.8], (AOR=4.5, 95% CI: 2.9, 7) respectively, volume of fluid administered greater than half-liter [AOR: 4.37, (95% CI, 3, 6.4)], patients who underwent surgery during the morning [AOR: 5.3, (95% CI: 3.8, 7.4)], and duration of surgery and anesthesia greater than 120 minutes [AOR: 2.7, (95% CI, 1.8, 4)] and (AOR=3.4, 95% CI, 2.4, 4.9], respectively, were factors significantly associated with intraoperative hypothermia.
UNASSIGNED: This study revealed a high magnitude of intraoperative hypothermia among pediatric patients. Being neonates and infants, having a cold volume of IV fluid administered greater than half a liter, entering surgery during the morning, the duration of surgery, and the anesthesia time were significantly associated with intraoperative hypothermia. The authors would like to advise anesthetists to use warm intravenous fluids, calculate IV fluids, and maintain room temperature.

Achieving clear resection margins at the time of lumpectomy is essential for optimal patient outcomes. Margin status is traditionally determined by pathologic evaluation of the specimen and often is difficult or impossible for the surgeon to definitively know at the time of surgery, resulting in the need for re-operation to obtain clear surgical margins. Numerous techniques have been investigated to enhance the accuracy of intraoperative margin and are reviewed in this manuscript.

UNASSIGNED: Postoperative nausea and vomiting (PONV) occurs in up to 30% of patients and its pathophysiology and mechanisms have not been completely described. Hypotension and a decrease in cardiac output are suspected to induce nausea. The hypothesis that intraoperative hypotension might influence the incidence of PONV was investigated.
UNASSIGNED: The study was conducted as a retrospective large single center cohort study. The incidence of PONV was investigated until discharge from post anesthesia care unit (PACU). Surgical patients with general anesthesia during a 2-year period between 2018 and 2019 at a university hospital in Germany were included. Groups were defined based on the lowest documented mean arterial pressure (MAP) with group H50: MAP <50mmHg; group H60: MAP <60mmHg; group H70: MAP <70mmHg, and group H0: no MAP <70mmHg. Decreases of MAP in the different groups were related to PONV. Propensity-score matching was carried out to control for overlapping risk factors.
UNASSIGNED: In the 2-year period 18.674 patients fit the inclusion criteria. The overall incidence of PONV was 11%. Patients with hypotension had a significantly increased incidence of PONV (H0 vs. H50: 11.0% vs.17.4%, Risk Ratio (RR): 1.285 (99%CI: 1.102-1.498), p < 0.001; H0 vs. H60: 10.4% vs. 13.5%, RR: 1.1852 (99%CI: 1.0665-1.3172), p < 0.001; H0 vs. H70: 9.4% vs. 11.2%, RR: 1.1236 (99%CI: 1.013 - 1.2454); p = 0.0027).
UNASSIGNED: The study demonstrates an association between intraoperative hypotension and early PONV. A more severe decrease of MAP had a pronounced effect.

BACKGROUND: Endovascular aortic repair (EVAR) requires extensive preoperative, intraoperative, and postoperative imaging for planning, surveillance, and detection of endo-leaks. There have been manyadvancements in imaging modalities to achieve this purpose. This review discussed different imaging modalities used at different stages of treatment of complex EVAR.
METHODS: We conducted a literature review of all the imaging modalities utilized in EVAR by searching various databases.
RESULTS: Preoperative techniques include analysis of images obtained via modified central line using analysis software and intravascular ultrasound. Fusion imaging (FI), carbon dioxide (CO2) angiography, intravascular ultrasound, and Fiber Optic RealShape (FORS) technology have been crucial in obtaining real-time imaging for the detection of endo-leaks during operative procedures. Conventional imaging modalities like computed tomography (CT) angiography (CTA) and magnetic resonance (MR) angiography are still employed for postoperative surveillance along with computational fluid dynamics and contrast-enhanced ultrasound (CEUS). The advancements in artificial intelligence (AI) have been the breakthrough in developing robust imaging applications.
CONCLUSIONS: This review explains the advantages, disadvantages, and side-effect profile of the abovementioned imaging modalities.

Background and Objectives: Large language models (LLMs) are emerging as valuable tools in plastic surgery, potentially reducing surgeons\' cognitive loads and improving patients\' outcomes. This study aimed to assess and compare the current state of the two most common and readily available LLMs, Open AI\'s ChatGPT-4 and Google\'s Gemini Pro (1.0 Pro), in providing intraoperative decision support in plastic and reconstructive surgery procedures. Materials and Methods: We presented each LLM with 32 independent intraoperative scenarios spanning 5 procedures. We utilized a 5-point and a 3-point Likert scale for medical accuracy and relevance, respectively. We determined the readability of the responses using the Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) score. Additionally, we measured the models\' response time. We compared the performance using the Mann-Whitney U test and Student\'s t-test. Results: ChatGPT-4 significantly outperformed Gemini in providing accurate (3.59 ± 0.84 vs. 3.13 ± 0.83, p-value = 0.022) and relevant (2.28 ± 0.77 vs. 1.88 ± 0.83, p-value = 0.032) responses. Alternatively, Gemini provided more concise and readable responses, with an average FKGL (12.80 ± 1.56) significantly lower than ChatGPT-4\'s (15.00 ± 1.89) (p < 0.0001). However, there was no difference in the FRE scores (p = 0.174). Moreover, Gemini\'s average response time was significantly faster (8.15 ± 1.42 s) than ChatGPT\'-4\'s (13.70 ± 2.87 s) (p < 0.0001). Conclusions: Although ChatGPT-4 provided more accurate and relevant responses, both models demonstrated potential as intraoperative tools. Nevertheless, their performance inconsistency across the different procedures underscores the need for further training and optimization to ensure their reliability as intraoperative decision-support tools.