Adult Elective Surgical Patients Research Articles

Malnutrition risk, outcomes, and costs among older adults undergoing elective surgical procedures: A retrospective cohort study.

We examine here the association between malnutrition risk and adverse health outcomes among older adult patients undergoing elective surgical procedures. We conducted a retrospective study using linked clinical and administrative databases. Malnutrition risk was assessed prior to surgery, defined by unintentional weight loss and decreased food intake. We performed a logistic regression analysis of the primary outcome, a composite adverse outcome measure, including death, bleeding, pneumonia, and other surgical complications. We conducted Fine-Gray proportional hazard regression analysis of hospital length of stay (LOS). We performed a generalized linear regression analysis of in-hospital cost data. All regression analyses controlled for frailty, age, sex, surgical category, and comorbidities. Of a total of 3457 older adult elective surgical patients (65-102 years), 310 (9.0%) screened positive for malnutrition risk. In multivariable regression analyses, malnutrition risk was associated with an increased risk of the composite adverse outcome (odds ratio [OR] = 1.74; 95% CI = 1.25-2.39), higher hospitalization costs (relative cost = 1.84; 95% CI = 1.59-2.13), and a decreased risk of discharge from the hospital (hazard ratio = 0.67; 95% CI = 0.59-0.77) compared with those who screened negative. Older adult patients with malnutrition risk were at an increased risk of adverse surgical outcomes, had longer LOS in the hospital, and incurred higher costs of care. It is important to screen for malnutrition risk and refer older adults for dietetic consults prior to elective surgery.

Assessment of adherence to preoperative fasting guidelines and associated patient discomfort in adult elective surgical patients in public hospitals of Addis Ababa, Ethiopia: a multicenter cross-sectional study

Background: Preoperative fasting is compulsory before anesthesia to lower the risk of pulmonary aspiration. However, it is usually prolonged beyond the recommended time affecting the patient’s comfort and has several deleterious effects. Objective: To assess the adherence to preoperative fasting guidelines and associated patient discomfort in adult elective surgical patients in public hospitals of Addis Ababa, Ethiopia. Materials and methods: A multicenter cross-sectional study was conducted on 422 adult patients who underwent elective surgery at Addis Ababa public hospitals from February 20, to May 10, 2021. The collected data were entered into SPSS, version 24 for analysis. Spearman correlation and independent t test were used to assess the relationship between preoperative fasting time and explanatory variables, as appropriate. P value <0.05 was considered as statistically significant. Results: Majority (97.4%) of patients were instructed to fast from midnight regardless of the food type and schedule. Majority (98.1%) of the participants did not adhere to the preoperative fasting guidelines. The mean preoperative fasting time was 14.26±2.35 hours (range: 8–22 h) for solid foods and 13.89±2.37 hours (range: 8–21 h) for clear fluids. More than half (64%) of the participants felt preoperative discomfort, and factors contributing were thirst, hunger, mouth dryness, lengthy waiting of prior surgery, and tiredness. There was a moderate positive correlation between preoperative fasting time and severity of patient discomfort (P<0.001). There was also a strong positive correlation between total fasting time and the sequence of patient’s schedule (P<0.001). Conclusions: Preoperative fasting for solids and clear liquids was longer than the recommended international fasting guidelines. Preoperative fasting duration had an association with preoperative discomforting factors. Incorrect orders of instructions and changing sequences of schedule challenged the preoperative fasting adherence. Thus, preoperative fasting instructions should be clear, individualized; and health professionals need to communicate when surgery is delayed or changed.

Effectiveness of low-dose ketamine versus lignocaine pre-treatment to prevent propofol injection pain and hemodynamic instability in adult elective surgical patients at Tikur Anbessa specialized hospital, 2022: A prospective observational cohort study

BackgroundPropofol is the most commonly used general anesthesia induction agent. It has injection pain and hemodynamic changes as a major drawback. These side effects are clinically undesirable because they can cause agitation and hinder the smooth induction of anesthesia. Determining the best method to reduce this effect is paramount important. This study aimed to compare the effectiveness of low dose ketamine versus lignocaine pre-treatment to prevent propofol injection pain and hemodynamic changes among study participants. MethodsAn institutional prospective cohort study was conducted on 82 (n1 = n2 = 41) adult elective surgical patients who took general anesthesia induction by propofol at our hospital from 01-Jan-2022 to30 Mar-2022. A systematic random sampling technique was used to select study participants. The pain was scored using a verbal rating scale and mean arterial pressure, heart rate and oxygen saturation was recorded during induction using a questionnaire. An independent samples t-test or chi-square test were used as appropriate. A P-value of < 0.05 was considered as statistically significant. ResultsTwo groups of 41 (LDK = low dose ketamine = Ld = Lignocaine = 41) patients were studied and the incidence of pain after pre-treatment with Low-dose ketamine (4.9%) group was significantly lower than lignocaine (22%) group (p = 0.023). The mean pain score after pre-treatment with low-dose ketamine group was significantly lower than the lignocaine group (p = 0.024). However, there was no statistically significant difference in heart rate, mean arterial pressure, and oxygen saturation (SpO2) between the groups. Conclusion and recommendationPre-treatment with a low dose of ketamine significantly reduces the incidence of propofol injection pain. We recommend its routine use before propofol injection ,and a multi-center more controlled study.

Incidence and associated factors of postoperative hypoxemia among adult elective surgical patients at Dessie Comprehensive Specialized Hospital: An observational study

BackgroundHypoxemia is one of the feared critical events intraoperatively and postoperatively. Undetected postoperative oxygen hypoxemia may lead to pulmonary hypertension, hyperkalemia, respiratory and cardiac failure even brain ischemia, and lastly, it may end up with multiorgan failure. The main purpose of this study was to determine the incidence and associated factors for postoperative hypoxemia among elective surgical patients received anesthesia in Dessie Comprehensive Specialized Hospital. MethodsProspective observational study was conducted in Dessie comprehensive Specialized Hospital from March to June 2021. The study included elective surgical patients. The data was collected with structured questionnaires, and direct measurement of oxygen saturation with pulse oximetry. Statistical analysis was done by using the Statistical Package of Social Science version 23. ResultsA total of 298 patients enrolled with a response rate of 94% in the study. Among the study participants, 167 (56%) were females and 131 (44%) were males. The Mean (±Standard Deviation) age was 37.62 ± 15.75 years. The incidence of hypoxemia was 24.5% (95% of Confidence Interval 19.34, 30.62) among 298 postoperative patients. Associated factors with postoperative hypoxemia were age greater than 55 years, preoperative saturation below 95%, type of anesthesia, postoperative pain score, and postoperative muscular strength, The patient age below 55 years had 84% less likely to develop hypoxemic episodes postoperatively when we compare age above 55-year-old. A patient who received general anesthesia had a chance of developing hypoxia eight times than those who received regional anesthesia. A patient who can keep grip for 15 s had 60% less likely to develop hypoxemia than those who can keep a grip for 15 s postoperatively. ConclusionThis study showed that there was a high incidence of postoperative hypoxemia among elective surgical patients in the study area. The high-risk patients should be identified and postoperative oxygen therapy should be initiated for those high-risk patients.

Assessment of predictors for difficult intubation and laryngoscopy in adult elective surgical patients at Tikur Anbessa Specialized Hospital, Ethiopia: A cross-sectional study

BackgroundGeneral anesthesia is not without morbidity. One of the well-known life-threatening events associated with general anesthesia is difficult airway which can happen during induction of anesthesia while attempting to insert the endotracheal tube with the aid of a laryngoscope. Difficult intubation, inadequate ventilation, and esophageal intubation are the principal causes of death or brain damage related to airway manipulation. ObjectiveThe main objective of this study was to assess the magnitude and predictors for difficult laryngoscopy and intubation among surgical patients who underwent elective surgery under general anesthesia with endotracheal intubation at Tikur Anbessa Specialized Hospital from February 1 to March 30, 2019. Materials &methodAn institutional based cross sectional study was conducted from February 1 to March 30, 2019 on patients who underwent elective surgery under general anesthesia with endotracheal intubation. Data on socio-demographic characteristics, preanesthetic airway assessment and laryngoscopic view were collected. Data were analyzed by SPSS Version 20.0. Chi- square test, binary logistic regression and multivariate analysis were performed. Tables and texts were used to present data. A p value less than 0.05 was considered as statistically significant. ResultsThe magnitude of difficult laryngoscopy, difficult intubation, and failed intubation were 12.2%, 6.1%, and 0.67%, respectively. Upper Lip Bite Test (ULBT) had a higher sensitivity (90.2%) and negative predictive value of 85.3%. Mallampati had a sensitivity of 45.8% and negative predictive value of 86% in predicting difficult laryngoscopy. Mallampati grade, thyromental distance and ratio of height to thyromental distance (HRTMD) have also showed greater sensitivity (69.6%, 58.3% and 47.8%, respectively) when compared to other tests in predicting difficult intubation. Mallampati class, upper lip bite test (ULBT) and inter-incisor distance (IID) are independent predictors for difficult laryngoscopy (p < 0.05). Furthermore, Mallampati class, Thyromental distance and ratio of height to thyromental distance (HRTMD) are identified as independent predictors of difficult intubation (p < 0.001). Conclusionand recommendation: Mallampati class, Thyromental distance and Ratio of height to Thyromental distance (HRTMD) can predict the probability of difficult endotracheal intubation in adult patients. Whereas, Mallampati class and upper lip bite test (ULBT) predicts higher probability for difficult laryngoscopy.

Satisfaction with preoperative education and surgical services among adults elective surgical patients at selected public hospitals in Addis Ababa, Ethiopia.

The purpose of this study was to determine the level of satisfaction with preoperative education and surgical services among adult elective surgical patients at governmental hospitals in Addis Ababa, Ethiopia. Four hundred and twenty-two elective surgical patients at Addis Ababa's governmental hospitals took part in a facility-based cross-sectional study from 8 October to 8 November 2021. Based on past experiments, an instrument for structured data collection was modified and employed. The data were cleaned and sent to Epidata version 4.2 before being exported and analysed in SPSS version 25. Descriptive statistics were used to describe the participant characteristics, and logistic regression, which also included bivariate and multivariate analysis, was used to evaluate the association between the independent and outcome variables. The level of statistical significance was indicated by a p value of 0.05. 84.6% of the participants reported feeling very satisfied with their preoperative education. Preoperative education about surgery (adjusted odds ratios (AOR) = 0.005; 95% confidence interval (CI): (0.000, 0.061)), previous surgery (AOR = 2.7; 95% CI: (2.51, 6.85)), and preoperative anxiety (AOR = 0.013; 95% CI: (0.003, 0.06)) were all significantly associated. About 84% of survey participants reported being satisfied with preoperative education and services. Preoperative patient satisfaction was negatively predicted by preoperative anxiety, prior surgery, and preoperative information about surgery. The decrease of anxiety and enhancement of surgical patient satisfaction may be significantly impacted by proper preoperative education.

Effectiveness of ketofol versus propofol induction on hemodynamic profiles in adult elective surgical patients: A Randomized Controlled Trial

BackgroundMost of the time propofol and ketamine have been used as an induction agent in adult surgical patients but propofol may cause cardiorespiratory depression while ketamine increases heart rate and arterial blood pressure. On the other hand, the clinical effects of propofol and ketamine seem to be complementary. Ketofol is most commonly used for procedural sedation hence exploring its effectiveness for induction will be paramount for the clinical care of surgical patients. ObjectiveThis study aims to compare the hemodynamic changes between ketofol and propofol within 30 min after induction of general anesthesia for elective surgical patients. MethodologyA Double-blind Randomized Controlled Trial was done on 62 patients aged between 18 and 65 years and the American Society of Anesthesiologist class I & II those have been allocated randomly into ketofol and propofol groups. A change in systolic blood pressure, mean arterial pressure, and heart rate within 30mins was followed for both groups. After the normal distribution of data was tested analytic statistics were calculated for variables in the study using Mixed ANOVA, Independent samples T-test, and Mann Whitney U test as appropriate, and for categorical data Chi-square test or fisher's exact test was used for analysis. P-value < 0.05 is considered statistically significant with a power of 90%. ResultsBoth the mean systolic blood pressure and mean arterial pressure were significantly decreased in the propofol group immediately after induction, at 5th minute, 10th minute, and 15th minute compared to the baseline value with a statistically significant value of (p < 0.05).There was a significant increase in mean heart rate in the ketofol group immediately after induction and on the 5th minute after induction compared to the baseline value (p = 0.001 and p = 0.022 respectively). Conclusion and recommendationsWe conclude the administration of ketofol (0.75 mg/kg of ketamine and 1.5 mg/kg of propofol) for induction of general anesthesia has better hemodynamic stability than propofol during the first 30 min after induction. We recommend to researchers to do further randomize controlled trials, with invasive blood pressure measurement and multicenter study.

A multicentre prospective observational study of the prevalence of preoperative anaemia and iron deficiency in adult elective surgical patients in hospitals in Western Cape Province, South Africa.

Preoperative anaemia has been shown to be an independent risk factor for postoperative morbidity and mortality. Iron deficiency is the leading cause of anaemia globally. There are limited data describing the burden of perioperative anaemia and the relative contribution of iron deficiency in South Africa (SA). To determine the prevalence and severity of preoperative anaemia in adults presenting for elective surgery in Western Cape Province, SA, and to investigate the contribution of iron deficiency as a cause of the anaemia. For this purpose, an investigative protocol from a recent consensus statement on the management of perioperative anaemia was applied. We performed a prospective, observational study in adult patients presenting for elective non-cardiac, non-obstetric surgery over a 5-day period at six Western Cape government-funded hospitals. The World Health Organization patient classification was applied, and patients with anaemia were investigated for iron deficiency. The prevalence of preoperative anaemia was 28% (105/375; 95% confidence interval (CI) 23.5 - 32.5); 55/105 patients (52%) had moderate and 11/105 (11%) severe anaemia. Iron deficiency was the cause of anaemia in 37% (32/87; 95% CI 26.6 - 46.9), but only 9% of iron-deficient patients received iron supplementation prior to surgery. Preoperative anaemia was common in this study, and more than half of the affected patients had moderate to severe anaemia. Iron deficiency was responsible for almost 40% of cases. Iron supplementation was under-utilised in the preoperative period as a means of increasing haemoglobin. The introduction of system-wide policies would empower perioperative physicians to mitigate the risk associated with preoperative anaemia in the Western Cape.

Preoperative fasting durations for adult elective surgical patients: Convenient for the professional, but detrimental to the patient? A narrative review.

Preoperative fasting is necessary in reducing the risk of aspiration of stomach contents when undergoing a procedure that requires anaesthesia. There are numerous guidelines based upon evidence-based practice that outline the safe duration of a fast prior to the induction of anaesthesia. Common practice however is to give advice that unnecessarily starves the patient leading to perioperative complications. There is a breadth of literature analysing the fasting durations of various institutions, with a consensus of fasting from midnight being the norm, and side effects of nausea and dehydration being unfortunate by-products of fasting. A review of the literature examines the continued poor compliance of evidenced-based practice.

Prophylactic Cefazolin Dosing and Surgical Site Infections: Does the Dose Matter in Obese Patients?

BackgroundMost surgical prophylaxis guidelines recommend a 3-g cefazolin intravenous dose in patients weighing ≥ 120 kg. However, this recommendation is primarily based on pharmacokinetic studies rather than robust clinical evidence. This study aimed to compare the prevalence of surgical site infections (SSIs) in obese and non-obese patients (body mass index ≥ 30 kg/m2 and < 30 kg/m2), and those weighing ≥ 120 kg and < 120 kg, who received 2- g cefazolin preoperatively.MethodsA retrospective case-control study was conducted in adult elective surgical patients. Patients receiving 2- g cefazolin were grouped as obese and non-obese, and by weight (≥ 120 kg or < 120 kg). The 90-day prevalence of SSI and potential contributing factors were investigated.ResultsWe identified 152 obese (median 134 kg) and 152 non-obese control (median 73 kg) patients. Baseline characteristics were similar between groups, except for an increased prevalence in the obese group of diabetes (35.5% vs 13.2%; p < 0.001) and an American Society of Anaesthesiologists Score of 3 (61.8% vs 17.1%; p < 0.001). While not statistically significant, the prevalence of SSI in the obese group was almost double that in the non-obese group (8.6% vs 4.6%; p = 0.25) and in patients weighing ≥ 120 kg (n = 102) compared to those weighing < 120 kg (n = 202) (9.8% vs 5.0%; p = 0.17).ConclusionThe prevalence of SSI was not significantly increased in obese patients, or those weighing ≥ 120 kg, who received cefazolin 2- g prophylactically; however, trends toward an increase were evident. Large-scale randomised trials are needed to examine whether a 2-g or 3-g cefazolin is adequate to prevent SSI in obese (and ≥ 120 kg) individuals.

Predicting postoperative morbidity in adult elective surgical patients using the Surgical Outcome Risk Tool (SORT)

BackgroundThe Surgical Outcome Risk Tool (SORT) is a risk stratification instrument used to predict perioperative mortality. We wanted to evaluate and refine SORT for better prediction of the risk of postoperative morbidity. MethodsWe analysed prospectively collected data from a single-centre cohort of adult patients undergoing major elective surgery. The data set was split randomly into derivation and validation samples. We used logistic regression to construct a model in the derivation sample to predict postoperative morbidity as defined using the validated Postoperative Morbidity Survey (POMS) assessed at 1 week after surgery. Performance of this ‘SORT-morbidity’ model was then tested in the validation sample and compared against the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM). ResultsThe SORT-morbidity model was constructed using a derivation sample of 1056 patients and validated in a further 527 patients. SORT-morbidity was well calibrated in the validation sample, as assessed using calibration plots and the Hosmer–Lemeshow test (χ2=4.87, P=0.77). It showed acceptable discrimination by receiver operating characteristic curve analysis [area under the receiver operating characteristic curve (AUROC)=0.72, 95% confidence interval: 0.67–0.77]. This compared favourably with POSSUM (AUROC=0.66, 95% confidence interval: 0.60–0.71), whilst being simpler to use. Linear shrinkage factors were estimated, which allow the SORT-morbidity model to predict a range of alternative morbidity outcomes with greater accuracy, including low- and high-grade morbidity, and POMS at later time points. ConclusionsSORT-morbidity can be used before surgery, with clinical judgement, to predict postoperative morbidity risk in major elective surgery.

Graduated Compression Stockings as an Adjunct to Low Dose Low Molecular Weight Heparin in Venous Thromboembolism Prevention in Surgery: A Multicentre Randomised Controlled Trial

The evidence base upon which current global venous thromboembolism (VTE) prevention recommendations have been made is not optimal. The cost of purchasing and applying graduated compression stockings (GCS) in surgical patients is considerable and has been estimated at £63.1 million per year in England alone. The aim was to determine whether low dose low molecular weight heparin (LMWH) alone is non-inferior to a combination of GCS and low dose LMWH for the prevention of VTE. The randomised controlled Graduated compression as an Adjunct to Pharmacoprophylaxis in Surgery (GAPS) Trial (ISRCTN 13911492) will randomise adult elective surgical patients identified as being at moderate and high risk of VTE to receive either the current "standard" combined thromboprophylactic LMWH with GCS mechanical thromboprophylaxis, or thromboprophylactic LMWH pharmacoprophylaxis alone. To show non-inferiority (3.5% non-inferiority margin) for the primary endpoint of all VTE within 90 days, 2236 patients are required. Recruitment will be from seven UK centres. Secondary outcomes include quality of life, compliance with stockings and LMWH, overall mortality, and GCS or LMWH related complications (including bleeding). Recruitment commenced in April 2016 with the seven UK centres coming "on-line" in a staggered fashion. Recruitment will be over a total of 18 months. The GAPS trial is funded by the National Institute for Health Research Health Technology Assessment in the UK (14/140/61).

Systematic review and meta-analysis of enhanced recovery programmes in surgical patients

Enhanced recovery programmes (ERPs) have been developed over the past 10 years to improve patient outcomes and to accelerate recovery after surgery. The existing literature focuses on specific specialties, mainly colorectal surgery. The aim of this review was to investigate whether the effect of ERPs on patient outcomes varies across surgical specialties or with the design of individual programmes. MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials were searched from inception to January 2013 for randomized or quasi-randomized trials comparing ERPs with standard care in adult elective surgical patients. Thirty-eight trials were included in the review, with a total of 5099 participants. Study design and quality was poor. Meta-analyses showed that ERPs reduced the primary length of stay (standardized mean difference -1·14 (95 per cent confidence interval -1·45 to -0·85)) and reduced the risk of all complications within 30 days (risk ratio (RR) 0·71, 95 per cent c.i. 0·60 to 0·86). There was no evidence of a reduction in mortality (RR 0·69, 95 per cent c.i. 0·34 to 1·39), major complications (RR 0·95, 0·69 to 1·31) or readmission rates (RR 0·96, 0·59 to 1·58). The impact of ERPs was similar across specialties and there was no consistent evidence that elements included within ERPs affected patient outcomes. ERPs are effective in reducing length of hospital stay and overall complication rates across surgical specialties. It was not possible to identify individual components that improved outcome. Qualitative synthesis may be more appropriate to investigate the determinants of success.

Preoperative Starvation in Elective General Surgery

Study preoperative fasting times of adult elective surgical patients. Fasting times for food and clear fluids, and the information used by patients to decide when to start fasting were studied. Among 200 patients, median fasting times were 2-4 times the guideline recommendations. Most patients used hospital written instructions but many started fasting substantially earlier than the instructions stipulated. Improved communication with patients could improve fasting times.

A Comparative Study of the Intubating Conditions and Cardiovascular Effects following Succinylcholine and Rocuronium in Adult Elective Surgical Patients

Background: The study was aimed to compare the effect on intubating conditions, onset, clinical duration and cardiovascular effects following administration of Succinylcholine and Rocuronium in Adult Elective Surgical patients. Materials and Methods: In a prospective randomised controlled trial, seventy five adult ASA grade I or II patients of either sex in the age group of 18-65 years undergoing elective surgery under general anaesthesia were given either succinylcholine 1mg/kg (group S), Rocuronium 0.6mg/kg (group R) or Rocuronium 0.9mg/kg (group R) after induction with thiopentone 4-6mg / kg body weight. Results and conclusion: The study revealed a statistically significant difference in onset time between the three groups: fastest in group S (52.8  15 sec) followed by R (102.6  40.8 sec) and R (163.2  58.2 sec) respectively. Intubating conditions were excellent to good in 92% patients in group S, 88% in group R and 100% in group R. Heart rate and mean arterial pressure were increased in all the three groups with persistence in group R+ > R > S.

Preoperative core temperatures in elective surgical patients show an unexpected skewed distribution.

To document the preoperative core temperature of adult elective surgical patients. A prospective audit obtained sublingual temperatures from 446 adult elective surgical patients on arrival in the preoperative holding area. Temperatures ranged from 35.7 degrees C to 37.8 degrees C with a mean of 36.5 degrees C (0.4 SD). The median was 36.4 degrees C and the mode was 36.1 degrees C. There was a skewed distribution with a clustering of values at the lower end of the range. All recordings were within the accepted normothermic range. The asymmetric distribution we observed differs from previously published normothermia data which shows a symmetrical distribution of temperatures. This skewed distribution has not previously been documented and we interpret it as being due to the effect of preoperative cooling factors.