American Society Of Anesthesiologists Grade Research Articles

Balanced opioid-free anesthesia with lidocaine and esketamine versus balanced anesthesia with sufentanil for gynecological endoscopic surgery: a randomized controlled trial

In this randomized controlled trial, 74 patients scheduled for gynecological laparoscopic surgery (American Society of Anesthesiologists grade I/II) were enrolled and randomly divided into two study groups: (i) Group C (control), received sufentanil (0.3 μg/kg) and saline, followed by sufentanil (0.1 μg/kg∙h) and saline; and (ii) Group F (OFA), received esketamine (0.15 mg/kg) and lidocaine (2 mg/kg), followed by esketamine (0.1 mg/kg∙h) and lidocaine (1.5 mg/kg∙h). The primary outcome was the 48-h time-weighted average (TWA) of postoperative pain scores. Secondary outcomes included time to extubation, adverse effects, and postoperative sedation score, pain scores at different time points, analgesic consumption at 48 h, and gastrointestinal functional recovery. The 48-h TWAs of pain scores were 1.32 (0.78) (95% CI 1.06–1.58) and 1.09 (0.70) (95% CI 0.87–1.33) for Groups F and C, respectively. The estimated difference between Groups F and C was − 0.23 (95% CI − 0.58 − 0.12; P = 0.195). No differences were found in any of the secondary outcomes and no severe adverse effects were observed in either group. Balanced OFA with lidocaine and esketamine achieved similar effects to balanced anesthesia with sufentanil in patients undergoing elective gynecological laparoscopic surgery, without severe adverse effects.Clinical Trial Registration: ChiCTR2300067951, www.chictr.org.cn 01 February, 2023.

INFLUENCE OF OBESITY ON FUNCTIONAL OUTCOMES AND REVISION RATES FOLLOWING REVISION TOTAL KNEE ARTHROPLASTY

BackgroundObesity has been linked with increased rates of knee osteoarthritis. Limited information is available on the survival and functional outcome results of rTKR in the obese patients. This registry-based study aimed to identify whether BMI is an independent risk factor for poorer functional outcomes and /or implant survival in rTKA.MethodsNew Zealand Joint Registry (NZJR) data of patients who underwent rTKA from 1st January 2010 to January 2023 was performed. Demographics, American Society of Anesthesiologists (ASA), BMI, Operative time, indications for revision and components revised of the patients undergoing rTKA was collected. Oxford knee score (OKS) at 6 months and rates of second revision (re- revision) were stratified based on standardised BMI categories.ResultsOf the 2687 revisions, functional outcome scores were available for 1261 patients. Oxford knee scores following rTKA are significantly inferior in higher BMI patients (36.5 vs 31.5 p<0.001). This held true when adjusted for age (35.7 vs 30.9 p<0.001).Tibial component loosening was a more common indication for revision in patients with BMI >40 (31.1% vs 21% for BMI <25), whereas periprosthetic femoral fracture was significantly more commonly seen in patients with BMI <25.Re-revision rates displayed no significant differences between any pairs of BMI groups (2.18/100 component years) and adjusting for age and sex did not alter this (p= 0.462). Indications for re-revision were also not different between BMI categories.Over 50% of the rTKA patients were obese. Significantly more obese patients were ASA grade 3,4 and more were <75 years. Operative time was longer in the obese patients (p<0.001).ConclusionsAlthough overall re-revision rates are similar between all BMI categories, the functional outcomes favour those with lower BMI. Patients with higher BMI are younger, more comorbid and carry potentially higher perioperative risks. The registry data provides valuable information when providing counsel to patients undergoing rTKA and lends further support to optimising patients prior to pTKA.

Hip Reconstruction In Situ with Screws and Cement (HiRISC) construct to treat large acetabular bone defects.

Large bone defects resulting from osteolysis, fractures, osteomyelitis, or metastases pose significant challenges in acetabular reconstruction for total hip arthroplasty. This study aimed to evaluate the survival and radiological outcomes of an acetabular reconstruction technique in patients at high risk of reconstruction failure (i.e. periprosthetic joint infection (PJI), poor bone stock, immunosuppressed patients), referred to as Hip Reconstruction In Situ with Screws and Cement (HiRISC). This involves a polyethylene liner embedded in cement-filled bone defects reinforced with screws and/or plates for enhanced fixation. A retrospective chart review of 59 consecutive acetabular reconstructions was performed by four surgeons in a single institution from 18 October 2018 to 5 January 2023. Cases were classified based on the Paprosky classification, excluding type 1 cases (n = 26) and including types 2 or 3 for analysis (n = 33). Radiological loosening was evaluated by an orthopaedic surgeon who was not the operating surgeon, by comparing the immediate postoperative radiographs with the ones at latest follow-up. Mean follow-up was 557 days (SD 441; 31 to 1,707). Out of the 33 cases analyzed, six (18.2%) constructs required revision, with four revisions due to uncontrolled infection, one for dislocation, and one for aseptic loosening. Among the 27 non-revised constructs, only one showed wider radiolucencies compared to immediate postoperative radiographs, indicating potential loosening. Patients who underwent revision (n = 6) were significantly younger and had a higher BMI compared to those with non-revised constructs (p = 0.016 and p = 0.026, respectively). Sex, race, ethnicity, American Society of Anesthesiologists grade, infection status (patients with postoperative PJI diagnosis (septic) vs patients without such diagnosis (aseptic)), and mean follow-up did not significantly differ between revised and non-revised groups. The HiRISC technique may serve as a feasible short-term (about one to two years) alternative in patients with large acetabular defects, particularly in cases of PJI. Longer follow-up is necessary to establish the long-term survival of this technique.

The outcome of revision total hip arthroplasty for instability.

Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocation. The aim of this study was to assess the risk for recurrent dislocation after revision THA for instability. Between 2009 and 2019, 163 patients underwent revision THA for instability at Stanford University Medical Center. Of these, 33 (20.2%) required re-revision due to recurrent dislocation. Cox proportional hazard models, with death and re-revision surgery for periprosthetic infection as competing events, were used to analyze the risk factors, including the size and alignment of the components. Paired t-tests or Wilcoxon signed-rank tests were used to assess the outcome using the Veterans RAND 12 (VR-12) physical and VR-12 mental scores, the Harris Hip Score (HHS) pain and function, and the Hip disability and Osteoarthritis Outcome score for Joint Replacement (HOOS, JR). The median follow-up was 3.1 years (interquartile range 2.0 to 5.1). The one-year cumulative incidence of recurrent dislocation after revision was 8.7%, which increased to 18.8% at five years and 31.9% at ten years postoperatively. In multivariable analysis, a high American Society of Anesthesiologists (ASA) grade (hazard ratio (HR) 2.72 (95% confidence interval (CI) 1.13 to 6.60)), BMI between 25 and 30 kg/m2 (HR 4.31 (95% CI 1.52 to 12.27)), the use of specialized liners (HR 5.39 (95% CI 1.97 to 14.79) to 10.55 (95% CI 2.27 to 49.15)), lumbopelvic stiffness (HR 6.03 (95% CI 1.80 to 20.23)), and postoperative abductor weakness (HR 7.48 (95% CI 2.34 to 23.91)) were significant risk factors for recurrent dislocation. Increasing the size of the acetabular component by > 1 mm significantly decreased the risk of dislocation (HR 0.89 (95% CI 0.82 to 0.96)). The VR-12 physical and HHS (pain and function) scores improved significantly at mid term. Patients requiring revision THA for instability are at risk of recurrent dislocation. Higher ASA grades, being overweight, a previous lumbopelvic fusion, the use of specialized liners, and postoperative abductor weakness are significant risk factors.

A comparison of clinical outcomes between narrow and broad dynamic compression plate for femur fractures

Purpose: To review the short term performance 4.5/5.0mm Wise-Lock Narrow Dynamic Compression Plate with LC under cuts and 4.5/5.0mm Wise-Lock Broad Dynamic Compression Plate with LC under cuts for femur fractures in terms of postoperative complications and failure rates. Methods: The total number of 46 patients, 24 to 55 years’ age group, who underwent internal fixation with wise-lock narrow and broad dynamic compression plate for femur fractures were reviewed. These implants were manufactured at Auxein Medical Private Limited Sonipat (India). The wise-lock narrow dynamic compression plates were implanted to 24 patients (18 Male and 05 Female) and broad dynamic compression plates were implanted to 22 patients (15 Male and 08 Female). These plates were made up of SS 316L and Ti6Al4V alloy respectively. Clinical and radiological follow-ups were conducted at the end of 30 days, 90 days, 180 days, 270 days and 365 days after surgery to examine the bone union, non-union & other related complications. During the one year of follow-up by the surgeon the patient's health status was analysed by the American society of anesthesiologists grade and the visual analogue score (VAS) was also determined. Results: Patients were followed up for one year. Out of 24 patients who were treated with wise-lock narrow dynamic compression plate, stainless steel, 04 patients (03 males & 01 female) were faced the complications of pain. However, out of 22 patients who were treated with broad dynamic compression plate, titanium, 02 patients (02 males) developed complications of pain. No biomechanical issue related to screw loosening, corrosion, bending, or other factors was not detected in 46 patients. Conclusions: Femur plate fixation is feasible for the treatment of femur fracture. The clinical outcomes and prognosis of patients are dependent on the accuracy of intraoperative reduction and surgical expertise.

A study of hemodynamic effects, postoperative recovery, and safety of esketamine (right handed) during flexible bronchoscopy under general anesthesia

Objective Flexible bronchoscopy during general anesthesia has become an indispensable tool. Anesthetics are widely utilized in flexible bronchoscopy (FB). This study delved into the application value of a subanesthetic dose of esketamine (ES) (right handed) in flexible bronchoscopy during general anesthesia. Methods A sample of 160 patients who underwent flexible bronchoscopy during general anesthesia were selected as study subjects and were equally divided into the control and ES groups, with clinical baseline data (age, sex, body mass index, American Society of Anesthesiologists grading) collected. Hemodynamic parameters (mean artery pressure, heart rate, pulse blood oxygen saturation) at different time points, the onset time of anesthesia, surgery time, analgesia maintenance time, anesthesia awakening time, and perioperative adverse reactions were recorded. Visual analogue scale (VAS), Mini-Mental State Examination (MMSE), and quality of recovery-40 (QoR-40) scales were utilized for assessing post-surgery satisfaction, cognitive function, and post-surgery early recovery quality. Results The hemodynamics were stable at each time point, but patients in the ES group were more stable than those in the control group. Patients in the ES group exhibited faster onset and awakening time of anesthesia, longer duration of analgesia, and lower total incidence of adverse reactions versus the control group. The patients’ QoR-40 total scores in the ES group were improved versus the control group at 1 day after surgery. Conclusion Compared with fentanyl, the use of ES (right handed) in flexible bronchoscopy during general anesthesia produces more stable hemodynamics, faster onset and recovery time of anesthesia, longer duration of analgesia, lower incidence of adverse reactions, and improved early postoperative recovery quality in patients.

Short-term outcomes after liver resection with vascular reconstruction: Results from a study with the National Clinical Database of Japan.

Although curative resection with vascular reconstruction improves the prognosis of blood-invading locally advanced hepatobiliary tumors, the mortality and morbidity of the procedure remains unclear. This study aimed to clarify the risk factors associated with mortality and morbidity in patients undergoing liver resection with vascular reconstruction. This retrospective observational study included 1215 patients undergoing hepatectomy of more than one section with vascular reconstruction, except for left lateral sectionectomy registered in the National Clinical Database (NCD) between 2015 and 2019. The rates of surgical mortality and relevant clinical factors were evaluated. Among the four types of vascular reconstruction, portal venous reconstruction was frequently performed in 724 patients (59.6% of the enrolled patients). Surgical mortality was 8.1%. Patients with hepatic artery reconstruction had the highest surgical mortality rate of 15.8%. In other types of reconstruction, surgical mortality was 9.1% in the portal vein, 5.2% in inferior vena cava, and 4.9% in hepatic vein. Factors significantly associated with surgical mortality include age, sex (male), preoperative comorbidity (American Society of Anesthesiologists grade >3, respiratory distress, diabetes, preoperative pneumonia, weight loss, and obstructive jaundice), poorer liver functional reserve (indocyanine green retention rate at 15 min and prothrombin time/international normalized ratio >1.1) and accompanying biliary reconstruction. The NCD revealed the detailed status of liver resection combined with vascular reconstruction in Japan. Based on the results of this analysis, understanding the factors that influence the outcome and postoperative course of each procedure will provide patients with accurate information and opportunities to improve future outcomes.

Development and validation of a prediction model for postoperative pneumonia in patients who received spinal surgery: A retrospective study

ObjectivesTo develop and validate a risk prediction model by identifying the preoperative factors associated with an increased risk of pneumonia after spinal surgery. MethodsThis study included patients with spinal disease from two hospitals between January 2021 and June 2023. The patients were divided into the training and validation sets, which were categorized as postoperative pneumonia (POP) or non-POP, respectively. This study identified the independent risk variables for POP using a multivariate logistic regression analysis. A nomogram prediction model was developed and validated using risk factors, receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) to assess predictive performance. ResultsFollowing exclusion, 2223 patients from Changzheng Hospital were enrolled in the training set and 357 patients from the No. 905 Hospital of PLA Navy were enrolled in the validation set. Univariate and multivariate logistic regression analyses revealed that operation time, American Society of Anesthesiologists (ASA) grade, smoking, non-wearing of medical masks, lack of preoperative respiratory training, chronic obstructive pulmonary disease (COPD), underlying diseases, and spinal section were risk factors for POP development in patients with spinal diseases. The area under the ROC curve of the training set was 0.950, whereas that of the validation set was 0.879. The model calibration curves demonstrated good agreement, and the DCA indicated a high expected net benefit value. ConclusionThe POP risk prediction model has high accuracy and efficiency in predicting POP in patients with spinal diseases. POP development is influenced by factors such as operation length, ASA grade, smoking, non-wearing of medical masks, lack of preoperative respiratory training, COPD, underlying diseases, and lumbar surgery.

Safety of tranexamic acid in surgically treated isolated spine trauma.

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, effectively reduces blood loss by inhibiting plasmin-induced fibrin breakdown. This is the first study in the United Kingdom to investigate the effectiveness of TXA in the surgical management of isolated spine trauma. To assess the safety of TXA in isolated spine trauma. The primary and secondary outcomes are to assess the rate of thromboembolic events and to evaluate blood loss and the incidence of blood transfusion, respectively. This prospective observational study included patients aged ≥ 17 years with isolated spine trauma requiring surgical intervention over a 6-month period at two major trauma centers in the United Kingdom. We identified 67 patients: 26 (39%) and 41 (61%) received and did not receive TXA, respectively. Both groups were matched in terms of age, gender, American Society of Anesthesiologists grade, and mechanism of injury. A higher proportion of patients who received TXA had a subaxial cervical spine injury classification or thoracolumbar injury classification score > 4 (74% vs 56%). All patients in the TXA group underwent an open approach with a mean of 5 spinal levels involved and an average operative time of 203 min, compared with 24 patients (58%) in the non-TXA group who underwent an open approach with an average of 3 spinal levels involved and a mean operative time of 159 min. Among patients who received TXA, blood loss was < 150 and 150-300 mL in 8 (31%) and 15 (58%) patients, respectively. There were no cases of thromboembolic events in any patient who received TXA. Our study demonstrated that TXA is safe for isolated spine trauma. It is challenging to determine whether TXA effectively reduces blood loss because most surgeons prefer TXA for open or multilevel cases. Further, larger studies are necessary to explore the rate, dosage, and mode of administration of TXA.

Evaluation of comorbidity scoring systems in patients undergoing knee arthroplasty.

Ageing populations are increasing the demand for knee arthroplasty. Concurrently, the prevalence of medical comorbidities are rising too. The Self-Administered Comorbidity Questionnaire was developed to provide a patient's assessment of their own comorbidities whereas the American Society of Anesthesiologists grades and the Charlson Comorbidity Index utilise clinical evaluation to objectively measure perioperative morbidity and mortality risk. The primary aim of this study was to compare Self-Administered Comorbidity Questionnaire scores with American Society of Anesthesiologists grades and Charlson Comorbidity Index scores. The secondary aim was to compare Self-Administered Comorbidity Questionnaire scores with knee outcome scores. A single centre observational cohort study of patients with knee osteoarthritis undergoing elective knee arthroplasty. Preoperative evaluation included Self-Administered Comorbidity Questionnaire scores, American Society of Anesthesiologists grades, Charlson Comorbidity Index scores and validated patient-reported outcome measures specific to knee surgery. A total of 141 patients were included in this study. Self-Administered Comorbidity Questionnaire scores were directly correlated with American Society of Anesthesiologists grade (rho = 0.37, p < 0.001) and Charlson Comorbidity Index scores (rho = 0.19, p = 0.047). Individual American Society of Anesthesiologists grades had significantly different Self-Administered Comorbidity Questionnaire scores (p = 0.001). Self-Administered Comorbidity Questionnaire scores were specifically associated with hypertension, ischaemic heart disease, chronic obstructive pulmonary disease and the total number of comorbidities, but American Society of Anesthesiologists and Charlson Comorbidity Index scores were associated with more comorbidities. Overall, Self-Administered Comorbidity Questionnaire scores were inversely correlated with patient-reported outcome measure scores. Self-Administered Comorbidity Questionnaire scores are associated with increasing comorbidity in patients with symptomatic knee osteoarthritis; however, American Society of Anesthesiologists grades and Charlson Comorbidity Index scores had stronger and more abundant associations with comorbidities and patient-reported outcome measure scores. Self-Administered Comorbidity Questionnaires may complement but not replace current objective assessments of comorbidity when evaluating perioperative risk for knee arthroplasty.

A prospective randomized comparative study of analgesic effect of dexmedetomidine versus dexamethasone as an adjuvant to 0.75% ropivacaine in ultrasound-guided interscalene block

Abstract Background: Ultrasound (USG)-guided interscalene block (ISB) provides excellent anesthesia and analgesia for humerus surgery. Various adjuvants have been used to improve the quality of block and duration of analgesia. Aim: The aim of the study was to compare the efficacy of dexmedetomidine (DXM) and dexamethasone (DXA) as an adjuvant to 0.75% ropivacaine for interscalene brachial plexus block among patients undergoing humerus surgery. Settings and Design: The study design was a prospective randomized comparative study at a tertiary care teaching hospital. Materials and Methods: After ethical approval and CTRI registration, 52 patients of 18–60 years of age, American Society of Anesthesiology Grade I–II, scheduled for proximal and mid-shaft humerus surgery were randomly allocated in Groups A and B. Group A (n=26) received Ropivacaine 0.75% (20 ml) along with DXM 0.5 µg/ Kg and 2 ml saline (total 22 ml) and Group B (n=26) received Ropivacaine 075% along with DXA 8 mg (total 22 ml). ISB was performed with an in-plane technique using a linear probe. Duration of analgesia, block characteristics (onset, complete sensory, and motor block), and complications were recorded and compared for 24 h. Statistical Analysis: Data were statistically analyzed with Social Science Statistics. Student’s unpaired t-test and Chi-square tests were used, and all statistical tests were examined with P ≤ 0.05 level of significance. Results: The duration of analgesia in Group B was significantly longer than Group A (13 h 12 min ± 2 h 33 min–8 h 48 min ± 1 h 52 min, P &lt; 0.00001). The groups were comparable regarding block characteristics, baseline demographics, and intraoperative hemodynamic parameters. Conclusion: DXA as an adjuvant to ropivacaine provides analgesia for longer duration compared to DXM in USG-guided ISB.

Comparison of nalbuphine and morphine as intrathecal adjuvant to 0.5% bupivacaine for post-operative analgesia in lower abdominal surgeries – A randomized and control study

Background: The use of a higher volume of 0.5% bupivacaine, however, is associated with hemodynamic instability. Adjuvants such as morphine and other opioids are added in with the local anesthetic to reduce this adverse effect and extend the duration of sensory block, hence extending the length of analgesia. However, opiates are associated with a high risk of respiratory depression and other side effects. Nalbuphine has been used to counteract these adverse effects. Thus, we decided to compare the analgesic effect of intrathecal (IT) nalbuphine with IT morphine. Aims and Objectives: The aim of the study was to compare IT morphine with nalbuphine as adjuvant to a spinal anesthetic agent. The primary objective was to compare between the time of onset of sensory and motor blockade and the post-operative analgesic duration between the two adjuvants, while hemodynamic variables and side effects were studied as secondary variables. Materials and Methods: This randomized controlled study was conducted after Ethical Committee approval for a period of 1 year on 100 patients who fulfilled the inclusion criteria. They were randomized into two groups to receive sub-arachnoid block: Group A: 3 mL of 0.5% Hyperbaric Bupivacaine and 0.2 mg morphine and Group B:3 mL of 0.5% Hyperbaric Bupivacaine and 0.5 mg nalbuphine. The following parameters were monitored – Height, Weight, blood pressure, American Society of Anesthesiologists grading, time of onset, maximum duration and regression of Motor and sensory blocks, and total duration of analgesia. Results: The onset of sensory blockade was comparable in both groups while the onset of motor blockade was significantly longer in the morphine group (P≤0.001). The duration of analgesia in the morphine group was longer as compared to nalbuphine group and was statistically significant (P&lt;0.05). The incidence of side effects was 26% in the morphine group and 6% in the nalbuphine group, which was statistically significant (P&lt;0.05). Fourteen patients in the morphine group had pruritus and four patients in the nalbuphine group experienced nausea. Conclusion: IT nalbuphine with 0.5% bupivacaine produces rapid onset of anesthesia and early post-operative analgesia with minimal side effects, but the total analgesic duration was more with IT morphine.

Effect of Esketamine on Postoperative Delirium in Patients Undergoing Cardiac Valve Replacement with Cardiopulmonary Bypass: A Randomized Controlled Trial.

The aim of this study was to investigate the effects of esketamine on the risk of postoperative delirium (POD) in adults undergoing on-pump cardiac valve surgery. In this randomized, triple-blind, controlled trial, 116 adult patients with an American Society of Anesthesiologists (ASA) grade Ⅱ or Ⅲ and a New York Heart Association (NYHA) grade Ⅱ or Ⅲ who underwent cardiac valve surgery with cardiopulmonary bypass were included. Esketamine (0.25 mg/kg) or normal saline was administered intravenously before anesthesia induction. The primary outcome was POD, defined as a positive delirium assessment according to the 3-minute confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) on a twice-daily basis for 7 days after surgery. Delirium duration and the delirium subtype were also recorded. The cognitive status of patients was measured according to the Mini-Mental State Examination at baseline, discharge, 30 days postoperatively and 3 months postoperatively. A total of 112 patients (mean age, 52 years; 53.6% female) were enrolled; 56 were assigned to receive esketamine, and 56 were assigned to receive placebo. POD occurred in 13 (23.2%) patients in the esketamine group and in 25 (44.6%) patients in the placebo group (relative risk [RR], 0.52, 95% confidence interval [CI], 0.28-0.91; P = .018). Thirteen patients (23.2%) in the esketamine group and 24 (42.9%) patients in the placebo group had multiple episodes of delirium (RR, 0.54, 95% CI, 0.28-0.92), and 13 (23.2%) vs 22 (39.3%) patients exhibited the hyperactive subtype. A single dose of esketamine (0.25 mg/kg) injected intravenously before anesthesia induction reduced the incidence of delirium in relatively young patients with ASA grade Ⅱ or Ⅲ who underwent on-pump cardiac surgery.

Perioperative Adjunctive Esketamine for Postpartum Depression Among Women Undergoing Elective Cesarean Delivery

Postpartum depression (PPD) is one of the most common mental health conditions during the perinatal and postpartum periods, which can have adverse effects on both mother and infant. To investigate the efficacy of perioperative adjunctive esketamine administration after cesarean deliveries in the prevention of PPD. A single-center, double-blind, placebo-controlled, randomized clinical trial was conducted from January 1, 2022, to January 1, 2023, at Fujian Provincial Hospital among 298 women aged 18 to 40 years, with an American Society of Anesthesiologists grade I to III classification and singleton full-term pregnancies who were scheduled for elective cesarean deliveries. Primary analyses were performed on a modified intention-to-treat basis. Patients were randomly assigned to the esketamine (n = 148) and control (n = 150) groups. Those in the esketamine group received a single intravenous injection of 0.25 mg/kg of esketamine immediately after fetal delivery, followed by 50 mg of esketamine as an adjuvant in patient-controlled intravenous analgesia for 48 hours after surgery. Saline was given to the control group of patients. The primary outcome was assessments of PPD symptoms by using the Edinburgh Postnatal Depression Scale (EPDS) at postpartum day 7. Positive screening for PPD was defined as a score of 10 or more points on the EPDS. In addition, the EPDS was analyzed as a continuous variable to evaluate depressive symptoms. Secondary outcomes included the Numeric Rating Scale (NRS) of postoperative pain, along with safety evaluations including adverse events and clinical assessments at postpartum days 14, 28, and 42. A total of 298 pregnant women were included, with 150 in the control group (median age, 31.0 years [IQR, 29.0-34.0 years]) and 148 in the esketamine group (median age, 31.0 years [IQR, 28.0-34.0 years]). The prevalence of depression symptoms was significantly lower among patients given esketamine compared with controls (23.0% [34 of 148] vs 35.3% [53 of 150]; odds ratio, 0.55; 95% CI, 0.33-0.91; P = .02) on postpartum day 7. In addition, the esketamine group also showed a significantly lower change in EPDS scores (difference of least-squares means [SE], -1.17 [0.44]; 95% CI, -2.04 to -0.31; effect size, 0.74; P = .008). However, there were no differences between the groups in the incidence of positive screening results for PPD or in changes from the baseline EPDS scores at postpartum days 14, 28, and 42. There were no differences in NRS scores at rest and on movement except on movement at 72 hours postoperatively, when scores were significantly lower in the esketamine group (median, 3.0 [IQR, 2.0-3.0] vs 3.0 [IQR, 3.0-3.5]; median difference, 0 [95% CI, 0-0]; P = .03). These results suggest that intravenous administration of esketamine during the perioperative period of elective cesarean delivery can improve depression symptoms during the early postpartum period. However, this antidepression effect may not be universally applicable to patients with low EPDS scores. Chinese Clinical Trial Registry Identifier: ChiCTR2100054199.

Influence of the type of stem and its fixation on revision and immediate postoperative mortality in elective total hip arthroplasty.

Despite higher rates of revision after total hip arthroplasty (THA) being reported for uncemented stems in patients aged > 75 years, they are frequently used in this age group. Increased mortality after cemented fixation is often used as a justification, but recent data do not confirm this association. The aim of this study was to investigate the influence of the design of the stem and the type of fixation on the rate of revision and immediate postoperative mortality, focusing on the age and sex of the patients. A total of 333,144 patients with primary osteoarthritis (OA) of the hip who underwent elective THA between November 2012 and September 2022, using uncemented acetabular components without reconstruction shells, from the German arthroplasty registry were included in the study. The revision rates three years postoperatively for four types of stem (uncemented, uncemented with collar, uncemented short, and cemented) were compared within four age groups: < 60 years (Young), between 61 and 70 years (Mid-I), between 71 and 80 years (Mid-II), and aged > 80 years (Old). A noninferiority analysis was performed on the most frequently used designs of stem. The design of the stem was found to have no significant influence on the rate of revision for either sex in the Young group. Uncemented collared stems had a significantly lower rate of revision compared with the other types of stem for females in the Mid-I group. There was a significantly higher rate of revision for uncemented stems in females in the Mid-II group compared with all other types of stem, while in males the rate for uncemented stems was only significantly higher than the rate for cemented stems. Cemented stems had a significantly lower revision rate compared with uncemented and short stems for both sexes in the Old cohort, as did females with collared stems. The rate of immediate postoperative mortality was similar for all types of stem in the Old age group, as were the American Society of Anesthesiologists grades. In patients aged > 80 years, uncemented and short stems had significantly higher revision rates compared with cemented and collared stems, especially in females. The design of the stem and type of fixation have to be analyzed in more detail than only considering cemented and uncemented fixation, in order to further improve the success of THA.

Factors associated with decreased length of stay following robotic arm-assisted and conventional total hip arthroplasty.

Postoperative length of stay (LOS) and discharge dispositions following arthroplasty can be used as surrogate measurements for improvements in patients' pathways and costs. With the increasing use of robotic technology in arthroplasty, it is important to assess its impact on LOS. The aim of this study was to identify factors associated with decreased LOS following robotic arm-assisted total hip arthroplasty (RO THA) compared with the conventional technique (CO THA). This large-scale, single-institution study included 1,607 patients of any age who underwent 1,732 primary THAs for any indication between May 2019 and January 2023. The data which were collected included the demographics of the patients, LOS, type of anaesthetic, the need for treatment in a post-anaesthesia care unit (PACU), readmission within 30 days, and discharge disposition. Univariate and multivariate logistic regression models were used to identify factors and the characteristics of patients which were associated with delayed discharge. The multivariate model identified that age, female sex, admission into a PACU, American Society of Anesthesiologists grade > II, and CO THA were associated with a significantly higher risk of a LOS of > two days. The median LOS was 54 hours (interquartile range (IQR) 34 to 78) in the RO THA group compared with 60 hours (IQR 51 to 100) in the CO THA group (p < 0.001). The discharge dispositions were comparable between the two groups. A higher proportion of patients undergoing CO THA required PACU admission postoperatively, although without reaching statistical significance (7.2% vs 5.2%, p = 0.238). We found that among other baseline characteristics and comorbidities, RO THA was associated with a significantly shorter LOS, with no difference in discharge destination. With the increasing demand for THA, these findings suggest that robotic assistance in THA could reduce costs. However, randomized controlled trials are required to investigate the cost-effectiveness of this technology.

Should high-risk patients seek out care from high-volume surgeons?

Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons. Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period. Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group. The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes.

The Effect of American Society of Anesthesiologists Score and Operative Time on Surgical Site Infection Rates in Major Abdominal Surgeries.

The objective of this study was to evaluate the influence of two crucial variables, the American Society of Anesthesiologists (ASA) score and operative time, on the occurrence of surgical site infections (SSIs) in the context of major abdominal surgical procedures. A cross-sectional research study involved patients undergoing various gastrointestinal surgical procedures. Surgical details, procedure duration, and ASA score were meticulously documented. Patients were observed for surgical site infections (SSIs) during their inpatient stay until discharge. Following their discharge, patients were monitored in the outpatient department for a minimum of 30 days post-surgery, and those who underwent mesh procedures were observed for one year. In the overall study population, surgical site infections were identified in 42 cases, constituting 6.7%. There was a significant association between ASA grade and the incidence of surgical site infections (p=0.001), indicating a higher prevalence of infections in cases with elevated ASA grades. Furthermore, a statistically significant association exists between the average duration of surgery and the occurrence of surgical site infections (p=0.001). The meansurgery duration for cases with infections is reported as 206.33 min, with a standard deviation of 103.73, while for cases without infections, the mean duration is 99.72 min, with a standard deviation of 79.71. In the multivariate analysis, it was found that an ASA score of 3 or higher and operative time exceeding 90 min were identified as independent factors for predicting the likelihood of surgical site infections. The significant associations identified between the American Society of Anesthesiologists (ASA) grade, average surgery duration, and SSIs underscore the importance of comprehensive preoperative assessment and procedural management in infection prevention.

Incidence, risk factors and impact of anemia after elective neurosurgery: A retrospective cohort study

ObjectivesAnemia after surgery is common and is associated with adverse clinical outcomes. Understanding the incidence and risk factors for postoperative anemia is important to reduce anemia-related complications and blood transfusion. There is lack of data regarding postoperative anemia and its contributing factors in neurosurgery. This study evaluates the incidence and risk factors of postoperative anemia, and its impact on clinical outcomes. MethodsThis was a single centre, retrospective study of patients who underwent elective neurosurgery over seven months. Data regarding age, gender, body mass index, American Society of Anesthesiologists (ASA) physical status, diagnosis, surgery, preoperative hemoglobin, surgery duration, intraoperative blood loss and red blood cell (RBC) transfusion, dose of tranexamic acid, intraoperative fluid balance, years of surgeon’s experience, postoperative hemoglobin, postoperative RBC transfusion, Glasgow Coma Scale (GCS) score at hospital discharge, and duration of postoperative intensive care unit and hospital stay were collected. Logistic regression was used to identify predictors of postoperative anemia. ResultsThe incidence of postoperative anemia was 11.3% (116/1025). On univariate analysis; age, preoperative hemoglobin, surgery duration, gender, ASA grade, surgery type, and surgeon’s experience were associated with postoperative anemia. Lower preoperative hemoglobin (p<0.001) and non-tumor surgery (p<0.001) were predictive of postoperative anemia on multivariate analysis. Postoperative anemia resulted in increased RBC transfusion (p<0.001) and lower GCS score at discharge (p=0.012). ConclusionsAtleast one in ten patients undergoing elective neurosurgery develop postoperative anemia. Lower preoperative hemoglobin and non-tumor surgery predict anemia. Anemia results in increased RBC transfusion and lower discharge GCS score.

The relationship between extent of mobilisation within the first postoperative day and 30-day mortality after hip fracture surgery

Objective To determine the association between the extent of mobilisation within the first postoperative day and 30-day mortality after hip fracture. Design Cohort study Setting Acute orthopaedic hospital ward Participants Consecutive sample of 701 patients, 65 years of age or older, 80% from own home, 49% with a trochanteric fracture, and 61% with an American Society of Anesthesiology grade > 2. Intervention n/a Main measures Cumulated ambulation score (CAS) (0-6 points) on the first postoperative day and 30-day postoperative mortality. A CAS = 0 reflects no functional mobility (bedridden), while a CAS = 6 reflects independent out-of-bed-transfer, chair-stand, and indoor walking status. Results Overall, 86% of patients were mobilised to standing or seated in chair (CAS ≥ 1) on the first postoperative day. A CAS of 0, 1–3, and 4–6 was observed for 97 (14%), 519 (74%), and 85 (12%) patients, respectively. Overall, 61 (8.7%) patients died within 30 days with the highest mortality (23.7%, n = 23) seen for those not mobilised (CAS = 0). Only one patient (1.2%) with a CAS of 4–6 points died. Cox regression analysis adjusted for age, sex, residential status, pre-fracture CAS, fracture type, and American Society of Anesthesiology grade, showed that a one-unit increase in CAS was associated with a 38% lower risk of 30-day mortality (Hazard Ratio = 0.63, 95%Confidence Interval, 0.50–0.78). Conclusion Mobility on the first postoperative day was associated with 30-day postoperative mortality, with a lower risk observed for those completing greater mobility. National registries may consider extending collection of mobility on the first postoperative day from a binary indicator to the CAS which captures the extent of mobility achieved.