- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT06256354
Effects of Intraoperative Targeted Temperature Management on Incidence of Postoperative Delirium and Long-term Survival
Effects of Intraoperative Targeted Temperature Management on Incidence of Postoperative Delirium and Long-term Survival in Older Patients Having Major Cancer Surgery: A Multicenter Randomized Trial
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Perioperative hypothermia results from anesthetic-impaired thermoregulatory responses combined with cool operating rooms and exposed body cavities. Core temperatures <35.5°C increases perioperative blood loss, delays post anesthetic recovery, and increases surgical wound infections.
Despite guideline recommendations, compliance with intraoperative temperature monitoring and management remains poor. In a national survey published in 2017, intraoperative hypothermia (core temperature <36.0°C) occurred in 44% of patients having elective surgery with general anesthesia. According to a survey of anesthesiologists in six Asia-Pacific countries (Singapore, Malaysia, Philippines, Thailand, India, and South Korea), only 67% of respondents measured temperature intraoperatively during general anesthesia, and only 44% report intraoperative active warming and warming was ineffective in more than half of their patients. Perioperative hypothermia thus remains common.
The 5,056-patient PROTECT trial showed that myocardial injury, surgical site infections, and blood loss were similar in patients randomized to intraoperative core temperatures of 35.5 or 37°C. However, there are other important complications that may be caused by intraoperative hypothermia including delirium, cancer recurrence, shivering, and thermal discomfort.
Perioperative neurocognitive disorders (NCDs), especially postoperative delirium and postoperative cognitive dysfunction (POCD), are significant challenges to older patients scheduled for surgery. Delirium is a syndrome of acutely occurring and fluctuating changes in attention, level of consciousness, and cognitive function. Postoperative cognitive dysfunction refers to cognitive decline (including the ability of study, memory, action, and judgement) detected from 30 days to 12 months after surgery.
In patients aged 60 years or above, the incidence of postoperative delirium is about 12-24%. The incidence of POCD is about 7-12% at 3-month follow-up and is associated with delirium, although the relationship is probably not causal. Delirium and POCD are associated with worse perioperative outcomes including prolonged hospitalization, increased complications, and high mortality, and worse long-term outcomes including shortened overall survival, as well as increased dementia and lowered life quality.
Postoperative delirium and POCD are multifactorial. Predisposing factors include advanced age, lower educational level, cognitive impairment, comorbidities (e.g., cerebrovascular disease, diabetes, and kidney disease), alcohol abuse, and malnutrition. Precipitating factors include deep anesthesia, opioid use, benzodiazepines, intraoperative blood loss/blood transfusion, and severe pain. Hypothermia may also increase the risk of delirium.
Hypothermia provokes both autonomic and behavioral protective responses. The first autonomic response is arterio-venous shunt constriction. Thermoregulatory vasoconstriction occurs many times a day in a typical hospital environment. It is highly effective, but does not usually disturb people and is generally considered to be of little consequence. Shivering is the other primary autonomic thermoregulatory defense against cold and has a triggering threshold about 1°C below the core temperature that triggers vasoconstriction. Unlike vasoconstriction, shivering is uncomfortable for patients. Furthermore, it is accompanied by a tripling of catecholamine concentrations, hypertension, and tachycardia. Behavioral thermoregulatory defenses are mediated by thermal comfort, and provoke voluntary defensive measures such as putting on a sweater, open windows, etc. Behavioral defenses include air conditioning and building shelters and are thus far stronger than autonomic responses. Thermal comfort matters to patients and is thus worth evaluating.
Despite advances in surgery and oncology, postoperative survival decreases about 10% per year, mainly due to cancer recurrence. The development of cancer recurrence mainly depends on the balance between the invasive ability of residual cancer cells and the anti-cancer immune function. Perioperative hypothermia increases stress responses and provokes immune suppression.
The investigators therefore propose to determine whether intraoperative targeted temperature management decreases the incidence of delirium, improves thermal comfort, reduces postoperative shivering, and improves long-term survival in older patients recovering from major cancer surgery. Specifically, the investigators will test the primary short-term hypothesis that perioperative normothermia (core temperature near 36.8°C) reduces delirium over the initial 4 postoperative days. Secondary short-term hypotheses are that perioperative normothermia improves thermal comfort, reduces shivering, and reduces delayed neurocognitive recovery. The primary long-term hypothesis is that perioperative normothermia improves progression-free survival.
Study Type
Enrollment (Estimated)
Phase
- Not Applicable
Contacts and Locations
Study Contact
- Name: Dong-Xin Wang, MD, PhD
- Phone Number: 8610 83572784
- Email: wangdongxin@hotmail.com
Study Contact Backup
- Name: Xin-quan Liang, MD
- Phone Number: +8615210846532
- Email: liangxinquan09@163.com
Study Locations
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Anhui
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Chizhou, Anhui, China, 247099
- The Pepple's Hospital of Chizhou
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Contact:
- Ming-sheng Bao
- Phone Number: +86 15339668345
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Beijing
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Beijing, Beijing, China, 100730
- Peking Union Medical College Hospital
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Contact:
- Li-jian Pei
- Phone Number: 8610-65296114
- Email: hazelbeijing@vip.163.com
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Beijing, Beijing, China, 100007
- Dongzhimen Hospital Beijing University of Chinese Medicine
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Contact:
- Guo-kai Liu
- Phone Number: 8610-80816655
- Email: liuguokaidoc@163.com
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Beijing, Beijing, China, 100055
- Guang'anmen Hospital China Academy of Chinese Medical Sciences
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Contact:
- Xi-chen Dong
- Phone Number: +86 13810248772
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Beijing, Beijing, China, 100091
- Xiyuan Hospital of CACMS(China Academy of Chinese Medical Sciences
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Contact:
- Xiu-mei Gao
- Phone Number: +86 13810208575
- Email: 2592153818@qq.com
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Chongqing
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Chongqing, Chongqing, China
- The First Affiliated Hospital of Chongqing Medical University
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Contact:
- Su Min
- Phone Number: +86 13508302749
- Email: ms89011068@163.com
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Guangdong
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Shenzhen, Guangdong, China, 518034
- Peking University Shenzhen Hospital
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Contact:
- Tao Luo
- Phone Number: +86 13510820779
- Email: 496855048@qq.com
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Hebei
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Shijia Zhuang, Hebei, China, 050011
- The Fourth Hospital of Hebei Medical University (Hebei Tumor Hospital)
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Contact:
- Chao Li
- Email: jysylc@163.com
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Henan
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Zhengzhou, Henan, China, 450052
- The First Affiliated Hospital of Zhengzhou University
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Contact:
- Jian-jun Yang
- Phone Number: +86 13357739238
- Email: yjyangjj@126.com
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Zhengzhou, Henan, China, 463599
- Henan Provincial People's Hospital
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Contact:
- Jia-qiang Yang
- Phone Number: +86 13937121360
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Jiangsu
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Jiangyin, Jiangsu, China, 214400
- Jiangyin People's Hospital
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Contact:
- Jian-qing Chen
- Phone Number: +86 18921233188
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Nanjing, Jiangsu, China, 210029
- Jiangsu Province Hospital
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Contact:
- Cun-ming Liu
- Phone Number: +86 13951890866
- Email: cunmingliu@njmu.edu.cn
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Wuxi, Jiangsu, China, 214023
- The People's Hospital of Wuxi
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Contact:
- Xin Zhang
- Phone Number: +86 13818832760
- Email: xinzhang3@njmu.edu.cn
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Shandong
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Jinan, Shandong, China, 250013
- The First Affiliated Hospital Of Shandong First Medical University
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Contact:
- Jian-bo Wu
- Phone Number: +86 13805319310
- Email: jianbowu@sdu.edu.cn
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Liaocheng, Shandong, China, 252000
- The Pepple's Hospital of Liaocheng
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Contact:
- Chong-wang Zhang
- Phone Number: +86 13346256809
- Email: zwzhang68@sina.com
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Shanxi
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Xi'an, Shanxi, China, 710032
- Xijing Hospital, Fourth Military Medical University
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Contact:
- Zhi-Hong Lu, MD
- Phone Number: +86 13891975018
- Email: deerlu23@163.com
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Sichuan
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Chendu, Sichuan, China, 610072
- Sichuan Provincial People's Hospital
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Contact:
- Qian Lei
- Phone Number: +86 17744339891
- Email: leiqianggh@163.com
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Chendu, Sichuan, China, 610500
- The First Affiliated Hospital of Chengdu Medical College
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Contact:
- Ping-liang Yang
- Phone Number: +86 18140064602
- Email: pingliangyang@163.com
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Chengdu, Sichuan, China, 610042
- Sichuan Cancer hospital
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Contact:
- Yang Zou
- Phone Number: +86 18908178799
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Chengdu, Sichuan, China, 610041
- Chengdu Seventh People's Hospital
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Contact:
- Hui Zhong
- Phone Number: +86 18280318565
- Email: qyymzsszx@163.com
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
- Older Adult
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Age ≥65 years.
- Planned potentially curative initial cancer surgery with an expected duration of 2 hours or longer under general anesthesia.
Exclusion Criteria:
- Preoperative fever (oral temperature ≥38℃).
- Known or suspected preoperative infection.
- Previous history of schizophrenia, epilepsy, Parkinson disease, myasthenia gravis, or delirium.
- Unable to communicate due to severe dementia, language barrier, or coma.
- Critically ill (Left ventricular ejection fraction <30%, Child-Pugh grades C, requirement of renal replacement therapy, American Society of Anesthesiologists physical status>IV, or expected survival <24 hours).
- Scheduled surgery for breast cancer, intracranial tumors, or rare cancers.
- Planned to undergo therapeutic hypothermia.
- Body mass index >30 kg/m2.
- Have participated in this study previously.
- Any other conditions that are considered unsuitable for study participation.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Prevention
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Single
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Placebo Comparator: Routine thermal management
Patients assigned to routine thermal management will not be pre-warmed and ambient intraoperative temperature will be maintained near 20°C per routine.
Only transfused blood will be warmed.
An upper- or lower-body forced-air cover will be positioned over an appropriate non-operative site but will not initially be activated.
Should core temperature decrease to 35.5°C, the warmer will be activated as necessary to prevent core temperature from decreasing further.
The target nasopharyngeal temperature is 35.5°C.
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Patients assigned to routine thermal management will not be pre-warmed and ambient intraoperative temperature will be maintained near 20°C per routine.
Only transfused blood will be warmed.
An upper- or lower-body forced-air cover will be positioned over an appropriate non-operative site but will not initially be activated.
Should core temperature decrease to 35.5°C, the warmer will be activated as necessary to prevent core temperature from decreasing further.
The target nasopharyngeal temperature is 35.5°C.
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Experimental: Target temperature management
Pre-warming is performed with a full-body forced-air cover and electrically heated blanket for about 30 minutes before induction of anesthesia.
The warmer will initially be set to "high" which corresponds to about 43°C.
It will be subsequently adjusted to make patients feel warm, but not uncomfortably so.
Patients will be warmed during surgery using two forced-air covers or combining forced-air covers with electric heating blanket when clinically practical.
All intravenous fluids will be warmed to body temperature.
There is no need to control ambient temperature since ambient temperature has little effect on core temperature in patients warmed with forced air.
The target nasopharyngeal temperature is 36.8°C.
|
Pre-warming is performed with a full-body forced-air cover and electrically heated blanket for about 30 minutes before induction of anesthesia.
The warmer will initially be set to "high" which corresponds to about 43°C.
It will be subsequently adjusted to make patients feel warm, but not uncomfortably so.
Patients will be warmed during surgery using two forced-air covers or combining forced-air covers with electric heating blanket when clinically practical.
All intravenous fluids will be warmed to body temperature.
There is no need to control ambient temperature since ambient temperature has little effect on core temperature in patients warmed with forced air.
The target nasopharyngeal temperature is 36.8℃.
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Progression-free survival after surgery
Time Frame: Up to 2 years after surgery of the last enrolled patient.
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Time interval from index surgery to cancer recurrence/metastasis/progression or all-cause death, whichever comes first.
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Up to 2 years after surgery of the last enrolled patient.
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Incidence of delirium within 4 days after surgery
Time Frame: During the first four days after surgery.
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Occurrence of delirium during the first four postoperative days is assessed with the 3D-Confusion Assessment Method or Confusion Assessment Method for the Intensive Care Unit (for intubated patients) twice daily (8-10 am and 6-8 pm).
Immediately before assessing delirium, sedation or agitation is assessed with the Richmond Agitation-Sedation Scale (RASS; scores range from -5 [unarousable] to +4 [combative] and 0 indicates alert and calm).
Deeply sedated or unarousable patients (RASS -4 or -5) is recorded as comatose and not assessed for delirium.
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During the first four days after surgery.
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Postoperative thermal comfort
Time Frame: Up to 30 minutes after arriving PACU/ICU or after extubation.
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Postoperative thermal comfort is evaluated with the Numerical Rating Scale (NRS; an 11-point scale where 0=intense cold, 5=thermal comfort, and 10=intense warm).
For patients who are extubated in the operation room, evaluation is conducted at 5 and 30 minutes after arriving post-anesthesia care unit (PACU)/intensive care unit (ICU).
For patients who are admitted to PACU/ICU with endotracheal intubation, evaluation is conducted at 5 and 30 minutes after extubation.
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Up to 30 minutes after arriving PACU/ICU or after extubation.
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Postoperative shivering intensity
Time Frame: Up to 30 minutes after arriving PACU/ICU or after extubation.
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Postoperative shivering intensity is evaluated with a four-point scale (0=no shivering, 1=intermittent, mild shivering, 2=moderate shivering, and 3=persistent, intense shivering).
For patients who are extubated in the operation room, evaluation is conducted at 5 and 30 minutes after arriving post-anesthesia care unit (PACU)/intensive care unit (ICU).
For patients who are admitted to PACU/ICU with endotracheal intubation, evaluation is conducted at 5 and 30 minutes after extubation.
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Up to 30 minutes after arriving PACU/ICU or after extubation.
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Incidence of delayed neurocognitive recovery
Time Frame: At 30 days after surgery.
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Cognitive function will be assessed with the Telephone Montreal Cognitive Assessment (T-MoCA; scores range from 0 to 22, with higher score indicating better function) before surgery and at 30 days after surgery.
A T-MoCA score reduction of 1 standard deviation (SD) or more from baseline will be considered the occurrence of delayed neurocognitive recovery.
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At 30 days after surgery.
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Incidence of postoperative neurocognitive disorders
Time Frame: At 6 months and 12 months after surgery.
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Cognitive function will be assessed with the Telephone Montreal Cognitive Assessment (T-MoCA; scores range from 0 to 22, with higher score indicating better function) before surgery and at 6 months and 12 months after surgery.
A T-MoCA score reduction of 1 standard deviation (SD) or more from baseline will be considered as the occurrence of postoperative neurocognitive disorders.
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At 6 months and 12 months after surgery.
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Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Incidence of emergence delirium
Time Frame: Up to 30 minutes after arriving PACU/ICU or after extubation.
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Patients are firstly be evaluated with the Richmond Agitation-Sedation Scale (RASS; scores range from -5 [unarousable] to +4 [combative] and 0 indicates alert and calm).
Patients will then be evaluated with the Confusion Assessment Method for the Intensive Care Unit.
For patients who are extubated in the operation room, evaluation is conducted at 5 and 30 minutes after arriving post-anesthesia care unit (PACU)/intensive care unit (ICU).
For patients who are admitted to PACU/ICU with endotracheal intubation, evaluation is conducted at 5 and 30 minutes after extubation.
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Up to 30 minutes after arriving PACU/ICU or after extubation.
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Length of stay in post-anesthesia care unit (PACU)
Time Frame: Up to 24 hours after surgery.
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Length of stay in post-anesthesia care unit (PACU)
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Up to 24 hours after surgery.
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Change of blood hemoglobin in the first postoperative day
Time Frame: Up to 24 hours after surgery.
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Blood hemoglobin in the first postoperative day minus preoperative value.
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Up to 24 hours after surgery.
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Quality of recovery in the first postoperative day
Time Frame: Up to 24 hours after surgery.
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Quality of recovery is assessed with the Quality of Recovery-15 questionaire in the first postoperative day.
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Up to 24 hours after surgery.
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Proportion of patients requiring blood transfusion
Time Frame: Up to 4 days after surgery.
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Proportion of patients who required blood transfusion during the first 4 days after surgery.
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Up to 4 days after surgery.
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Length of stay in hospital after surgery
Time Frame: Up to 30 days after surgery.
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Length of stay in hospital after surgery.
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Up to 30 days after surgery.
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Incidence of surgical site infections with 30 days after surgery
Time Frame: Up to 30 days after surgery.
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The surgical site infection includes superficial, deep, and organ-space surgical site infections.
The definitions were modified from "Guideline for prevention of surgical site infection, 1999" (https://stacks.cdc.gov/view/cdc/7160).
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Up to 30 days after surgery.
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Incidence of non-delirium major complications within 30 days after surgery.
Time Frame: Up to 30 days after surgery
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Non-delirium major complications are defined as new-onset medical events other than delirium that are deemed harmful and require therapeutic intervention, that is grade II or higher on the Clavien-Dindo classification.
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Up to 30 days after surgery
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All-cause 30-day mortality
Time Frame: Up to 30 days after surgery.
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All-cause 30-day mortality
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Up to 30 days after surgery.
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Overall survival after surgery
Time Frame: Up to 2 years after surgery of the last enrolled patient.
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Time interval from index surgery to all-cause death.
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Up to 2 years after surgery of the last enrolled patient.
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Cancer-specific survival after surgery
Time Frame: Up to 2 years after surgery of the last enrolled patient.
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Time interval from index surgery to cancer-specific death, with deaths from other causes being censored at the time of death.
Cancer-specific death is defined as death fully attributable to the cancer for which the index surgery is performed and usually involves cancer recurrence/metastasis/progression after exclusion of other causes such as stroke and myocardial infarction.
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Up to 2 years after surgery of the last enrolled patient.
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Event-free survival after surgery
Time Frame: Up to 2 years after surgery of the last enrolled patient.
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Time interval from index surgery to cancer recurrence/metastasis/progression, new-onset cancer, new-onset serious illness (requiring hospitalization), or all-cause death, whichever comes first.
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Up to 2 years after surgery of the last enrolled patient.
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Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Principal Investigator: Dong-Xin Wang, MD, PhD, Peking University first hospital
Publications and helpful links
General Publications
- Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010 Jul 28;304(4):443-51. doi: 10.1001/jama.2010.1013.
- Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, Dancey J, Arbuck S, Gwyther S, Mooney M, Rubinstein L, Shankar L, Dodd L, Kaplan R, Lacombe D, Verweij J. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009 Jan;45(2):228-47. doi: 10.1016/j.ejca.2008.10.026.
- Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology. 2008 Jan;108(1):71-7. doi: 10.1097/01.anes.0000296719.73450.52.
- Kim JY, Shinn H, Oh YJ, Hong YW, Kwak HJ, Kwak YL. The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump coronary artery bypass surgery. Eur J Cardiothorac Surg. 2006 Mar;29(3):343-7. doi: 10.1016/j.ejcts.2005.12.020. Epub 2006 Jan 24.
- Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR Jr. Preoperative combined with intraoperative skin-surface warming avoids hypothermia caused by general anesthesia and surgery. J Clin Anesth. 2003 Mar;15(2):119-25. doi: 10.1016/s0952-8180(02)00512-3.
- Sessler DI, Schroeder M, Merrifield B, Matsukawa T, Cheng C. Optimal duration and temperature of prewarming. Anesthesiology. 1995 Mar;82(3):674-81. doi: 10.1097/00000542-199503000-00009.
- Katayama H, Kurokawa Y, Nakamura K, Ito H, Kanemitsu Y, Masuda N, Tsubosa Y, Satoh T, Yokomizo A, Fukuda H, Sasako M. Extended Clavien-Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria. Surg Today. 2016 Jun;46(6):668-85. doi: 10.1007/s00595-015-1236-x. Epub 2015 Aug 20.
- Wang M, Singh A, Qureshi H, Leone A, Mascha EJ, Sessler DI. Optimal Depth for Nasopharyngeal Temperature Probe Positioning. Anesth Analg. 2016 May;122(5):1434-8. doi: 10.1213/ANE.0000000000001213.
- Sessler DI. Long-term consequences of anesthetic management. Anesthesiology. 2009 Jul;111(1):1-4. doi: 10.1097/ALN.0b013e3181a913e1. No abstract available.
- Zhang DF, Su X, Meng ZT, Li HL, Wang DX, Xue-Ying Li, Maze M, Ma D. Impact of Dexmedetomidine on Long-term Outcomes After Noncardiac Surgery in Elderly: 3-Year Follow-up of a Randomized Controlled Trial. Ann Surg. 2019 Aug;270(2):356-363. doi: 10.1097/SLA.0000000000002801.
- Sessler DI. Temperature monitoring and perioperative thermoregulation. Anesthesiology. 2008 Aug;109(2):318-38. doi: 10.1097/ALN.0b013e31817f6d76.
- Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999 Apr;20(4):250-78; quiz 279-80. doi: 10.1086/501620. No abstract available.
- Mehlen P, Puisieux A. Metastasis: a question of life or death. Nat Rev Cancer. 2006 Jun;6(6):449-58. doi: 10.1038/nrc1886.
- Gleason LJ, Schmitt EM, Kosar CM, Tabloski P, Saczynski JS, Robinson T, Cooper Z, Rogers SO Jr, Jones RN, Marcantonio ER, Inouye SK. Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults. JAMA Surg. 2015 Dec;150(12):1134-40. doi: 10.1001/jamasurg.2015.2606.
- Beilin B, Shavit Y, Razumovsky J, Wolloch Y, Zeidel A, Bessler H. Effects of mild perioperative hypothermia on cellular immune responses. Anesthesiology. 1998 Nov;89(5):1133-40. doi: 10.1097/00000542-199811000-00013.
- Silva AR, Regueira P, Albuquerque E, Baldeiras I, Cardoso AL, Santana I, Cerejeira J. Estimates of Geriatric Delirium Frequency in Noncardiac Surgeries and Its Evaluation Across the Years: A Systematic Review and Meta-analysis. J Am Med Dir Assoc. 2021 Mar;22(3):613-620.e9. doi: 10.1016/j.jamda.2020.08.017. Epub 2020 Oct 1.
- Berian JR, Zhou L, Russell MM, Hornor MA, Cohen ME, Finlayson E, Ko CY, Rosenthal RA, Robinson TN. Postoperative Delirium as a Target for Surgical Quality Improvement. Ann Surg. 2018 Jul;268(1):93-99. doi: 10.1097/SLA.0000000000002436.
- Sun Z, Honar H, Sessler DI, Dalton JE, Yang D, Panjasawatwong K, Deroee AF, Salmasi V, Saager L, Kurz A. Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed with forced air. Anesthesiology. 2015 Feb;122(2):276-85. doi: 10.1097/ALN.0000000000000551.
- Kurz A, Sessler DI, Narzt E, Bekar A, Lenhardt R, Huemer G, Lackner F. Postoperative hemodynamic and thermoregulatory consequences of intraoperative core hypothermia. J Clin Anesth. 1995 Aug;7(5):359-66. doi: 10.1016/0952-8180(95)00028-g.
- Matsukawa T, Sessler DI, Christensen R, Ozaki M, Schroeder M. Heat flow and distribution during epidural anesthesia. Anesthesiology. 1995 Nov;83(5):961-7. doi: 10.1097/00000542-199511000-00008.
- Matsukawa T, Sessler DI, Sessler AM, Schroeder M, Ozaki M, Kurz A, Cheng C. Heat flow and distribution during induction of general anesthesia. Anesthesiology. 1995 Mar;82(3):662-73. doi: 10.1097/00000542-199503000-00008.
- Camus Y, Delva E, Sessler DI, Lienhart A. Pre-induction skin-surface warming minimizes intraoperative core hypothermia. J Clin Anesth. 1995 Aug;7(5):384-8. doi: 10.1016/0952-8180(95)00051-i.
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- Kurz A, Go JC, Sessler DI, Kaer K, Larson MD, Bjorksten AR. Alfentanil slightly increases the sweating threshold and markedly reduces the vasoconstriction and shivering thresholds. Anesthesiology. 1995 Aug;83(2):293-9. doi: 10.1097/00000542-199508000-00009.
- Reynolds L, Beckmann J, Kurz A. Perioperative complications of hypothermia. Best Pract Res Clin Anaesthesiol. 2008 Dec;22(4):645-57. doi: 10.1016/j.bpa.2008.07.005.
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- Du YT, Li YW, Zhao BJ, Guo XY, Feng Y, Zuo MZ, Fu C, Zhou WJ, Li HJ, Liu YF, Cheng T, Mu DL, Zeng Y, Liu PF, Li Y, An HY, Zhu SN, Li XY, Li HJ, Wu YF, Wang DX, Sessler DI; Peking University Clinical Research Program Study Group. Long-term Survival after Combined Epidural-General Anesthesia or General Anesthesia Alone: Follow-up of a Randomized Trial. Anesthesiology. 2021 Aug 1;135(2):233-245. doi: 10.1097/ALN.0000000000003835.
- Kong H, Xu LM, Wang DX. Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment. CNS Neurosci Ther. 2022 Aug;28(8):1147-1167. doi: 10.1111/cns.13873. Epub 2022 Jun 1.
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- 2023-545
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Studies a U.S. FDA-regulated drug product
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