ASA Physical Status Classification Research Articles

Implementation of nurse administered propofol sedation for same-day discharge pulsed field ablation of atrial fibrillation is safe and has excellent patient reviews

Abstract Background In June 2022, we introduced Pulsed Field Ablation (PFA) for de novo pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Simultaneously, deep sedation with propofol undertaken by trained nurses from the cath lab was introduced. Purpose To evaluate feasibility, safety and patient reported experience for same-day discharge AF ablations performed with PFA on propofol sedation. Methods Patients with an ASA physical status classification of 1 or 2 referred for de novo AF ablation were planned for PFA in propofol sedation. Three nurses with previous experience from the intensive care unit planned and undertook the sedation. In addition, two nurses were trained locally. The initial 200 consecutive patients were included in the observational cohort study after signing consent to participate in follow-up after the procedure. Study data were collected and managed using REDCap electronic data capture tools. In addition to procedure related data, patient-reported quality measures were acquired 30 days after the procedure by an internet based questionnaire including scaling and open questions. Results 96% of the procedures were successfully completed using only propofol while 4% were scheduled for general anesthesia, mainly because of sleep apnea and high BMI. The average procedure time for the first 100 procedures was 57 min (95% CI, 54.1-62.9) and 45 min (95% CI, 42.6-47.4) for the following 100 procedures. Acute PVI was achieved during all procedures. No sedation related adverse effects were observed. One patient experienced pericardial tamponade requiring prolonged hospitalization. 87% were discharged on the same day as planned while 12% remained hospitalized one additional day for reassurance and social reasons. 93% (186/200) completed the questionnaire. 56% of patient only responded "very little" or "not at all" to all questions about adverse symptoms during and after the procedure. For each specific symptom, 80 to 95 % were only experienced "very little" or "not at all" (Fig 1). In general, patients felt safe about the preparation for and handling of the sedation (Fig 2). Conclusions Nurse administered deep sedation with propofol, provides excellent pain relief for PFA procedures, facilitates an efficient workflow and can safely be implemented and administered by nurses from the cath lab. Propofol sedation constitutes an important alternative to general anesthesia that is not widely available.Figure 1Figure 2

Patient Anxiety in Endoscopy: A Comparative Analysis of Single vs. Dual Procedure Effects.

This study aimed to investigate the difference in anxiety levels between patients undergoing gastroscopy only and those subjected to both gastroscopy and colonoscopy. Despite known preoperative anxiety impacts, no prior research has compared these specific patient groups. A total of 150 patients were divided equally into two groups: Group I, undergoing gastroscopy only, and Group II, undergoing gastroscopy and colonoscopy. Inclusion criteria were patients in the age range 18-70 years and having an ASA (American Society of Anesthesiologists) physical status classification of I-III. Exclusion criteria were patients outside the age range, and patients with hearing disorders, psychiatric disorders, dementia, or recent anxiolytic drug use. Anxiety was analysed using the Beck Anxiety Inventory Scale before procedures, without any premedication. Patients in Group II had significantly higher anxiety levels, with particular increases noted in symptoms such as leg weakness and tremors, inability to relax, and fears of adverse events and death. These results highlighted a considerable elevation in anxiety among patients anticipating or undergoing combined endoscopic procedures. The findings revealed that undergoing combined gastroscopy and colonoscopy procedures significantly elevated patient anxiety levels compared to gastroscopy alone. This suggests a critical need for healthcare providers to implement more strong preoperative counselling and anxiety reduction strategies for patients facing multiple procedures. Addressing this increased anxiety could lead to better patient experiences, reduced procedural complications, and improved satisfaction and outcomes.

Need for a paradigm shift? Survival post-pancreatoduodenectomy remains poor despite surgical and oncological advances

Background: Despite advances in surgical techniques and chemotherapy, poor outcomes persist in pancreatic malignancy. This study aimed to investigate clinical outcomes and describe the impact of factors like the closest resection margin on overall survival following open pancreatoduodenectomy at a tertiary referral centre over a ten-year period. Methods: Patients who underwent a pancreaticoduodenectomy at a tertiary hospital in South Australia between 2009-2019 were included in this retrospective study. Patient demographics, systemic treatments, complications, and histological features were analysed for their role in overall survival. Kaplan-Meier survival curves were used to assess patient survival and estimate median survival time. Results: There were 134 open pancreaticoduodenectomy procedures during 2009-2019. Majority of patients were male (54.7%) between 65-75 years of age (41%) with an ASA physical status classification grade of 3 (63.3%). 56.7% of patients experienced a complication with 5 in-hospital deaths recorded and 12 ISPGF grade B or C pancreatic anastomotic leaks (n=5, n=7 respectively). 88% of resected specimens were malignant with an overall 5-year survival of 32%. A resection margin of >2 mm had a significantly improved overall survival compared to 0 mm (p=0.01). There was no survival benefit for a resection margin of <1 mm or 1-2 mm compared 0mm margin (p=0.6 and p=0.2 respectively). 65 patients (54.6%) experienced either local or distal disease recurrence by the end of the study period. Conclusions: There has been no improvement in overall survival post pancreatoduodenectomy for pancreatic malignancy. Further research into the clinical significance of the R status classification is required.

Comparison of Acute Physiology and Chronic Health Evaluation (APACHE) II and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) scoring system in predicting postoperative mortality in patients undergoing emergency laparotomy: A retrospective study.

There is paucity of studies on preoperative risk assessment tools in patients undergoing emergency surgery. The present study evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and American Society of Anesthesiologists (ASA) physical status (PS) classification system in patients undergoing emergency exploratory laparotomy. This retrospective study included 60 adult patients who underwent emergency exploratory laparotomy for perforation peritonitis. The clinical details, ASA PS classification, laboratory investigations and postoperative course of patients were retrieved from their medical records. Based on these details, APACHE II and ACS-NSQIP were calculated for the patients. The study's primary outcome was the accuracy of the preoperative APACHE II, ACS-NSQIP risk calculator and ASA PS class in predicting the postoperative 30-day mortality of patients. The area under the curve (AUC) of APACHE II, ACS-NSQIP score, and ASA PS classification for mortality 30 days after surgery was 0.737, 0.694 and 0.601, respectively. The P value for the Hosmer-Lemeshow (H-L) test of scoring systems was 0.05, 0.25 and 0.05, respectively. AUC for postoperative complications was 0.799 for APACHE II, 0.683 for ACS-NSQIP and 0.601 for ASA PS classification. H-L test of these scoring systems for complications after surgery revealed P values of 0.62, 0.36 and 0.53, respectively. Compared to the ACS-NSQIP and ASA PS classification system, the APACHE II score has a better discriminative ability for postoperative complications and mortality in adult patients undergoing emergency exploratory laparotomy.

International variability in ASA physical status classification in patients undergoing hepato-pancreato-biliary surgery (MILESTONE-2): a survey among surgeons and anesthesiologists

International variability in ASA physical status classification in patients undergoing hepato-pancreato-biliary surgery (MILESTONE-2): a survey among surgeons and anesthesiologists

American society of anesthesiologists physical status classification significantly affects the performances of machine learning models in intraoperative hypotension inference

Study objectiveTo explore how American Society of Anesthesiologists (ASA) physical status classification affects different machine learning models in hypotension prediction and whether the prediction uncertainty could be quantified. DesignObservational Studies SettingUofL health hospital PatientsThis study involved 562 hysterectomy surgeries performed on patients (≥ 18 years) between June 2020 and July 2021. InterventionsNone MeasurementsPreoperative and intraoperative data is collected. Three parametric machine learning models, including Bayesian generalized linear model (BGLM), Bayesian neural network (BNN), a newly proposed BNN with multivariate mixed responses (BNNMR), and one nonparametric model, Gaussian Process (GP), were explored to predict patients' diastolic and systolic blood pressures (continuous responses) and patients' hypotensive event (binary response) for the next five minutes. Data was separated into American Society of Anesthesiologists (ASA) physical status class 1– 4 before being read in by four machine learning models. Statistical analysis and models' constructions are performed in Python. Sensitivity, specificity, and the confidence/credible intervals were used to evaluate the prediction performance of each model for each ASA physical status class. Main resultsASA physical status classes require distinct models to accurately predict intraoperative blood pressures and hypotensive events. Overall, high sensitivity (above 0.85) and low uncertainty can be achieved by all models for ASA class 4 patients. In contrast, models trained without controlling ASA classes yielded lower sensitivity (below 0.5) and larger uncertainty. Particularly, in terms of predicting binary hypotensive event, for ASA physical status class 1, BNNMR yields the highest sensitivity of 1. For classes 2 and 3, BNN has the highest sensitivity of 0.429 and 0.415, respectively. For class 4, BNNMR and GP are tied with the highest sensitivity of 0.857. On the other hand, the sensitivity is just 0.031, 0.429, 0.165 and 0.305 for BNNMR, BNN, GBLM and GP models respectively, when training data is not divided by ASA physical status classes. In terms of predicting systolic blood pressure, the GP regression yields the lowest root mean squared errors (RMSE) of 2.072, 7.539, 9.214 and 0.295 for ASA physical status classes 1, 2, 3 and 4, respectively, but a RMSE of 126.894 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. RMSEs are 2.175, 13.861, 17.560 and 22.426 for classes 1, 2, 3 and 4 respectively for the BGLM. In terms of predicting diastolic blood pressure, the GP regression yields the lowest RMSEs of 2.152, 6.573, 5.371 and 0.831 for ASA physical status classes 1, 2, 3 and 4, respectively; RMSE of 8.084 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. Finally, in terms of the width of the 95% confidence interval of the mean prediction for systolic and diastolic blood pressures, GP regression gives narrower confidence interval with much smaller margin of error across all four ASA physical status classes. ConclusionsDifferent ASA physical status classes present different data distributions, and thus calls for distinct machine learning models to improve prediction accuracy and reduce predictive uncertainty. Uncertainty quantification enabled by Bayesian inference provides valuable information for clinicians as an additional metric to evaluate performance of machine learning models for medical decision making.

Association between body mass and hypotension in dogs under general anaesthesia.

To investigate the association between body mass and hypotension during general anaesthesia in dogs undergoing surgical and diagnostic procedures within a referral hospital. Retrospective evaluation of the anaesthetic records of 1789 dogs was performed. Data on signalment, anaesthetic protocol and physiological variables, including mean arterial pressure, were collected. A multivariable generalised linear model was used to identify associations between explanatory variables, including body mass, and hypotension. In the population studied, increasing body mass (per 10 kg) was significantly associated with decreasing odds of hypotension (odds ratio 0.68; 95% confidence interval: 0.60 to 0.77). Additional variables associated with a decreased odds of hypotension were pre-anaesthetic medication with alpha-2 agonists (odds ratio 0.63; 95% confidence interval 0.48 to 0.82) and increasedbody temperature (per 1°C) during general anaesthesia (odds ratio 0.77; 95% confidence interval 0.67 to 0.88). Brachycephaly (odds ratio 1.72; 95% confidence interval 1.25 to 2.38), ASA physical status classification >3 (odds ratio 2.03; 95% confidence interval 1.16 to 3.56), undergoing a surgical procedure (versus diagnostic) (odds ratio 1.57; 95% confidence interval 1.10 to 2.23) and bradycardia (odds ratio 1.37; 95% confidence interval 1.05 to 1.80) were independently associated with increased odds of hypotension. Dogs of lower body mass and brachycephalic breeds may be at higher risk of hypotension during general anaesthesia or alternatively represent subpopulations in which accurate blood pressure measurement presents a greater challenge. Monitoring blood pressure accurately in these groups requires particular attention and provisions for treating hypotension should be readily accessible.

Prediction of American Society of Anesthesiologists Physical Status Classification from preoperative clinical text narratives using natural language processing

BackgroundElectronic health records (EHR) contain large volumes of unstructured free-form text notes that richly describe a patient’s health and medical comorbidities. It is unclear if perioperative risk stratification can be performed directly from these notes without manual data extraction. We conduct a feasibility study using natural language processing (NLP) to predict the American Society of Anesthesiologists Physical Status Classification (ASA-PS) as a surrogate measure for perioperative risk. We explore prediction performance using four different model types and compare the use of different note sections versus the whole note. We use Shapley values to explain model predictions and analyze disagreement between model and human anesthesiologist predictions.MethodsSingle-center retrospective cohort analysis of EHR notes from patients undergoing procedures with anesthesia care spanning all procedural specialties during a 5 year period who were not assigned ASA VI and also had a preoperative evaluation note filed within 90 days prior to the procedure. NLP models were trained for each combination of 4 models and 8 text snippets from notes. Model performance was compared using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC). Shapley values were used to explain model predictions. Error analysis and model explanation using Shapley values was conducted for the best performing model.ResultsFinal dataset includes 38,566 patients undergoing 61,503 procedures with anesthesia care. Prevalence of ASA-PS was 8.81% for ASA I, 31.4% for ASA II, 43.25% for ASA III, and 16.54% for ASA IV-V. The best performing models were the BioClinicalBERT model on the truncated note task (macro-average AUROC 0.845) and the fastText model on the full note task (macro-average AUROC 0.865). Shapley values reveal human-interpretable model predictions. Error analysis reveals that some original ASA-PS assignments may be incorrect and the model is making a reasonable prediction in these cases.ConclusionsText classification models can accurately predict a patient’s illness severity using only free-form text descriptions of patients without any manual data extraction. They can be an additional patient safety tool in the perioperative setting and reduce manual chart review for medical billing. Shapley feature attributions produce explanations that logically support model predictions and are understandable to clinicians.

Comparison of the effects of pregabalin and famotidine with pregabalin and diphenhydramine on postoperative abdominal pain

ObjectivesPain is one of the most significant problems, and its uncontrolled management can lead to complications such as increased blood pressure, myocardial ischemia, etc. An effective approach to control postoperative pain is preemptive pain management with a combination of drugs prior to surgery. The present study aims to compare the level of postoperative abdominal pain in patients receiving pregabalin and famotidine versus pregabalin and diphenhydramine. Materials and methodsIn this double-blind clinical trial, a total of 34 candidates for abdominal surgery (laparotomy) with ASA physical status classification of 1 or 2 were enrolled from the patients referring to (XXX). They were divided into two groups of 17 (Group A: pregabalin and famotidine, Group B: pregabalin and diphenhydramine). The drugs were administered to the patients 2 h before the surgery. The patients' pain levels were measured using the Visual Analog Scale (VAS) at the recovery stage after complete consciousness and at 6, 12, and 24 h postoperatively. Additionally, the amount of analgesic consumed within the first 24 h after the surgery was recorded and compared between the two groups. ResultsThe average pain intensity score at 6 h postoperatively was (6 ± 0.2) in patients who received pregabalin and diphenhydramine, and (7.1 ± 0.1) in patients who received pregabalin and famotidine (p = 0.002). The average pain intensity score at 12 h postoperatively was (6.1 ± 0.3) in patients who received pregabalin and famotidine, and (5.6 ± 0.2) in patients who received pregabalin and diphenhydramine (p = 0.021). Furthermore, the average pain intensity score at 24 h postoperatively was (5.2 ± 0.2) in patients who received pregabalin and famotidine, and (4.2 ± 0.2) in patients who received pregabalin and diphenhydramine (p = 0.014). The results demonstrated that the pain intensity score decreased in all four measured time intervals in the overall patient population (p < 0.001), and this reduction was significantly different between the two groups (p = 0.002), with the final average pain score being lower in the group receiving pregabalin and diphenhydramine compared to the other group. ConclusionThe results of this study indicate that the use of drugs such as diphenhydramine and pregabalin as preemptive medications can be effective in controlling postoperative abdominal pain and reducing the consumption of analgesics in patients after abdominal surgery.

Comparison of the Efficacy of Continuous Femoral Nerve Block with Epidural Analgesia for Postoperative Pain Relief after Unilateral Total Knee Replacement

Background: By identifying the most effective and safe approach to postoperative pain management, we can enhance patient recovery, improve their quality of life, and optimize healthcare resource utilization. Objective: Comparison of the Efficacy of Continuous Femoral Nerve Block with Epidural Analgesia for Postoperative Pain Relief after Unilateral Total Knee Rep. Method: The study was conducted as a randomized controlled trial at Tertiary Hospital in Dhaka. Sixty patients, consisting of 12 males and 48 females, between the ages of 40 and 90 years, were enrolled in the study. These patients were scheduled to undergo unilateral total knee replacement (TKR) for osteoarthritis and fell under American Society of Anesthesiologists (ASA) physical status classes I and II. The inclusion criteria required patients to weigh between 50 and 99 kg and have the ability to fully understand and respond to the numeric rating scale (NRS). Exclusion criteria comprised patients with ASA physical status class ≥3, those on chronic opiate therapy, individuals with allergies to local anesthetics or equipment materials, or those with neuromuscular disease. Ethical approval was obtained, and the patients were divided into two groups: group A received epidural analgesia, while group B received a femoral nerve block for postoperative pain management. Pain assessments were conducted using the NRS at six, 12, and 24 hours postoperatively, and data were collected for analysis. Results: During the study, in group A (Epidural) and Group B (Femoral nerve block) mean age was 69.45 ± 7.34 and 65.45 ± 7.34 years. Mean Preoperative knee extension between two groups was Group A (Epidural): 9.05 ± 4.38 and Group B (Femoral nerve block): 7.76 ± 4.14. The results showed a significant difference for NRS scoring at six hours and 12 hours. Patients who were in group A and were given Epidural postop for pain management showed better results and lower values for NRS and needed fewer extra boluses for their .....

Mid- to Long-Term Survival of Geriatric Patients with Primary Septic Arthritis of the Shoulder: A Retrospective Study over a Period of 20 Years.

Septic arthritis of the shoulder is an urgent medical emergency that often occurs in elderly patients and is associated with high morbidity and mortality. Retrospectively, 56 patients aged ≥60 years, treated for primary septic monoarthritis of the shoulder at a maximum care hospital between 1 July 2001, and 30 July 2022, were included in this study. The primary aim of the study was analyzing survival rates and different bacteria in these patients. For statistical analysis, Kaplan-Meier curves were used for survival probability and the log-rank test was used to compare a survival probability of 5 years. The mean patient age was 78.7 years and a mean follow-up time of 3011.8 days. The mean survival of the entire study population was 920.3 days or 2.5 years. Significantly impaired 5-year survival was found only with increasing age and higher American Society of Anesthesiologists (ASA) physical status (PS) classification scores. Eight different types of bacteria were detected in the synovial fluid cultures. A total of 42 of 48 overall pathogens was Gram-positive and 6 were Gram-negative bacteria. Staphylococcus aureus was identified as the most frequent variant. We conclude that the mean survival is significantly shortened within the first 5 years with increasing age and ASA PS classification.

Individualised risk scoring in elective colorectal surgery: Why don’t we do it?

Background: National guidelines recommend that all patients having major elective surgery should have a risk estimate communicated to them.1 Several well validated Individualised Risk Scores (IRS) are available to facilitate this.2 Not all patients seem to receive a personalised risk assessment when having elective colorectal surgery. The aim of this study was to investigate the reasons behind this. Methods: An electronic survey was circulated to all general surgeons and anaesthetists (trainees and consultants) at Leeds Teaching Hospitals NHS Trust. Participants had 1 month to respond and received a reminder email at 3 weeks. Ethical approval for this study was gained from the University of Leeds Medical Research Ethics Committee (MREC21-073). Results: There were 43 respondents, 33 of whom assess patients for elective colorectal surgery. Seven were surgeons and 26 were anaesthetists; 80% were consultants. Whereas 66% provide an overall estimate of risk to patients, only 55% use IRSs (Fig. 5). Preferred IRS included SORT, P-POSSUM, ACS NSQIP (Surgical Outcome Risk Tool, Portsmouth - Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity, American College of Surgeons National Surgical Quality Improvement Program, National Emergency Laparotomy Audit) risk calculator, NELA risk calculator and the ASA physical status classification system. Conclusion: Half of respondents do not use IRS. The tools used are heterogeneous and not necessarily validated for this population and context. Clarity is needed regarding which tools to use in this population and what information to present to patients. An improved understanding of clinicians’ perceptions of IRS is required to design appropriate implementation solutions.

Predictive accuracy of cardiac risk indices for cardiovascular complications in patients undergoing noncardiac surgery

Objective: To compare predictive accuracy of the American Society of Anesthesiologists (ASA) score and various cardiac risk indices for perioperative cardiovascular (CV) complications in patients undergoing noncardiac surgery.Materials and methods: We examined 243 patients (148 men and 95 women) aged 45 to 84 (66 [60-71] years) prior to their elective oncological and vascular surgery. We assessed patients using the ASA physical status classification system, Revised Cardiac Risk Index (RCRI), Gupta Myocardial Infarct or Cardiac Arrest (MICA) calculator, and Khoronenko cardiac risk index and analyzed perioperative CV complications.Results: We detected complications in 30 (12.3%) patients, with 3 (1.24%) of them having 2 concomitant CV complications. One death (0.41%) was registered. The MICA risk calculator had the highest predictive value (AUC ROC = 0.753). Risk scores over 0.95% discriminated patients with perioperative CV complications with sensitivity and specificity of 73.3% and 67.45%, respectively.Conclusions: We recommend using the MICA risk calculator to predict perioperative CV complications following elective oncological and vascular surgery.

The incidence of hypotension during general anesthesia: a single-center study at a university hospital

BackgroundAlthough intraoperative hypotension (IOH) has been emerging as a serious concern during general anesthesia, the incidence of IOH has not been demonstrated clearly in the Japanese population.MethodsThis single-center retrospective study investigated the incidence and the characteristics of IOH in non-cardiac surgery at a university hospital. IOH was defined as at least one fall of MAP during general anesthesia, which was categorized into the following groups: mild (65 to < 75 mmHg), moderate (55 to < 65 mmHg), severe (45 to < 55 mmHg), and very severe (< 45 mmHg). The incidence of IOH was calculated as a percentage of the number of events to the total anesthesia cases. Logistic regression analysis was performed to examine factors affecting IOH.ResultsEleven thousand two hundred ten cases out of 13,226 adult patients were included in the analysis. We found moderate to very severe hypotension occurred in 86.3% of the patients for at least 1 to 5 min, and 48.5% experienced severe or very severe hypotension. The results of the logistic regression analysis indicated female gender, vascular surgery, American Society of Anesthesiologists physical status classification (ASA-PS) 4 or 5 in emergency surgery, and the combination with the epidural block (EDB) were significant factors of IOH.ConclusionsIOH during general anesthesia was very frequent in the Japanese population. Female gender, vascular surgery, ASA-PA 4 or 5 in emergency surgery, and the combination with EDB were independent risk factors associated with IOH. However, the association with patient outcomes were not elucidated.

American Society of Anesthesiologists-Physical Status Classification As An Independent Risk Factor of Surgical Site Infection After Infra-Inguinal Arterial Bypass.

The present study aimed to assess whether high-risk American Society of Anesthesiologists (ASA)-Physical Status was an independent risk factor for the development of surgical site infection (SSI) after infra-inguinal lower extremity bypass (LEB). The ASA-Physical Status Classification System assesses the overall physical status preoperatively. ASA-Physical Status is associated with postoperative morbidity and mortality. However, limited data are available on how ASA-Physical Status Class affects the development of SSI after infra-inguinal LEB. Patients who had undergone infra-inguinal LEB from January 1, 2015 to December 31, 2018, for obliterative arteriopathy or popliteal aneurysm at our university hospital were included. SSI risk factors were identified using multivariable logistic regression. The length of hospital stay, major limb events (MALE), major adverse cardiovascular events (MACE), and all-cause mortality were compared for patients with SSI versus those without SSI 3 months and 1- year of follow-up after the index surgery. Among the 267 patients included, 30 (11.2%) developed SSI during the 3-month period and 32 (12%) at 1 year. ASA-Physical Status ≥3 [odds ratio (OR): 3.7, 95% confidence interval CI) 1.5-11.1], emergency surgery (OR: 2.7, 95% CI 1.2-6.0), general anesthesia (OR: 2.8, 95% CI 1.3-6.1), and procedure performed by a junior surgeon (OR: 2.7, 95% CI 1.3-6.0) were independently associated with SSI. At 3 months and 1 year, SSI was significantly associated with MALE (including surgical wound debridement, subsequent thrombectomy, major amputation), length of hospital stay, and all-cause mortality. The ASA-Physical Status should be considered in medical management when an infra-inguinal LEB is considered in frail patients, to prevent surgical complications.

Does American Society of Anesthesiologist classification effect hospital course and postoperative complications following oral and maxillofacial surgical procedures?

The purpose of the present study was to assess the duration of operative time and outcomes related to patients with an increased American Society of Anesthesiologists (ASA) Physical Status classification in the setting of hospital-based maxillofacial surgical procedures. The study was a retrospective multi-institutional cohort study using the American College of Surgeons National Surgical Quality Improvement Program database to enroll patients who underwent maxillofacial procedures between 2012 and 2019. The primary independent variable was ASA Physical Status Classification (I, II, III, IV). Descriptive, univariate, and multiple logistic regression statistics were used to evaluate the relationship between ASA classification, body mass index (BMI), operative time, and perioperative complications. The study cohort was comprised of 1807 patients, with 946 males and 861 females. The ASA Physical Status Classification ranged from class I to IV. On bivariate analysis, patients classified as ASA III (286 [IQR 152-503], P < .001) and ASA IV (412 [IQR 156.5-547.5], P=.003) were associated with longer operative times. The risk of perioperative complications was 2.6% for ASA I patients (n=19), 6.3% for ASA II (n=48; P=.005), 24.5% for ASA III (n=76; P < .001), and 55.0% for ASA IV (n=11; P < .001). On multivariate-adjusted analysis, using ASA I as the reference, ASA III (β +53.2 minutes, 95% CI +28.6 to +77.8, P < .001) and ASA IV (β +81.5 minutes, 95% CI +21.0 to +141.9, P=.008) were variables associated with longer operative time. Increased ASA Physical Status Classification was associated with increased operative time and perioperative complications.

American Society of Anesthesiologists (ASA) physical status system predicts the risk of postoperative Clavien-Dindo complications greater than one at 90days after robot-assisted radical prostatectomy: final results of a tertiary referral center.

To test the hypothesis of an association between the American Society of Anesthesiologists (ASA) physical status classification system and the risk of 90-days postoperative complications after robot-assisted radical prostatectomy (RARP), graded using the Clavien-Dindo classification system (CDS). In a period ranging from January 2013 to October 2020, 1143 patients were evaluated. ASA classification was computed by trained anesthesiologists. Postoperative complications at 90days after RARP were grouped as greater than one (CDS between 2 and 4a) versus up to one (CDS between 0 and 1). The risk association was computed using logistic regression models. According to ASA physical status classification system, patients were distributed as follows: 102 (8.9%) ASA 1, 934 (81.7%) ASA 2, and 107 (9.4%) ASA 3. Overall, 90-days postoperative complications occurred in 277 (24.2%) cases, of which 137 (12%) were graded as CDS 1 vs. 105 (9.2%) CDS 2 vs. 17 (1.5%) CDS 3a vs. 15 (1.3%) CDS 3b vs. 3 (0.3%) CDS 4a. ASA 2 and 3 patient categories were more likely to have 90-days postoperative complications CDS > 1 (12.5% and 16.8%, respectively) compared to ASA 1 patients (4.9%). The risk association was stronger for ASA 3 (odds ratio, [OR]: 4.085; 95%CI: 1.457-11.455; p = 0.007) than for ASA 2 (OR: 2.907; 95%CI: 1.106-7.285; p = 0.023) patient categories. After adjustment for clinical, pathological, and perioperative covariates, including pelvic lymph node dissection (performed vs. not performed), either ASA 2 or 3 categories remained independent predictors of 90-days postoperative complications CDS > 1. The risk of 90-days postoperative complications CDS > 1 after RARP increased as the ASA physical status deteriorated independently by performing or not an extended pelvic lymph node dissection. In the ASA 3 patients category, RARP should be performed at tertiary referral centers to safely manage the risk of postoperative complications.

A propensity score matching study on robot-assisted radical cystectomy for older patients: comparison of intracorporeal ileal conduit and cutaneous ureterostomy

BackgroundRobot-assisted radical cystectomy (RARC) and intracorporeal urinary diversion are less invasive than conventional procedures. However, for older patients, cutaneous ureterostomy (CUS) may be preferred because urinary diversion using the intestine has a high incidence of perioperative complications and is highly invasive. The purpose of this study was to demonstrate the safety and efficacy of intracorporeal ileal conduit (ICIC) compared with CUS in patients aged 75 years or older who underwent RARC.MethodsFrom October 2014 to December 2021, 82 patients aged 75 years or older who underwent RARC at Tokushima University Hospital, Tokushima Prefectural Central Hospital, or Ehime Prefectural Central Hospital were retrospectively reviewed. Of these, 52 and 25 patients who underwent ICIC and CUS, respectively, were included. After adjusting the patients’ characteristics using propensity score-matching, surgical results and prognoses were retrospectively compared. The propensity score was based on age, Eastern Cooperative Oncology Group Performance Status Scale (ECOG-PS), American Society of Anesthesiologists physical status classification (ASA-PS), clinical tumor stage, and neoadjuvant chemotherapy.ResultsThe median age was lower in the ICIC group compared with the CUS group, and the proportion of high-risk cases (ECOG-PS ≥ 2 or ASA-PS ≥ 3) did not differ. The median operation time was longer in the ICIC group, and estimated blood loss was higher, compared with the CUS group. There were no significant differences in the incidence of complications within the first 30 postoperative days, incidence of complications 30–90 days after surgery, 2-year overall survival, 2-year cancer-specific survival, and 2-year recurrence-free survival. The stent-free rate was significantly lower in the CUS group than that in the ICIC group.ConclusionIn older patients, the ICIC group showed non-inferior surgical and oncological outcomes compared with the CUS group. Urinary diversion following RARC in older patients should be carefully selected by considering not only the age but also the general condition (including comorbidities) of the patient.

A novel model forecasting perioperative red blood cell transfusion

We aimed to establish a predictive model assessing perioperative blood transfusion risk using a nomogram. Clinical data for 97,443 surgery patients were abstracted from the DATADRYAD website; approximately 75% of these patients were enrolled in the derivation cohort, while approximately 25% were enrolled in the validation cohort. Multivariate logical regression was used to identify predictive factors for transfusion. Receiver operating characteristic (ROC) curves, calibration plots, and decision curves were used to assess the model performance. In total, 5888 patients received > 1 unit of red blood cells; the total transfusion rate was 6.04%. Eight variables including age, race, American Society of Anesthesiologists' Physical Status Classification (ASA-PS), grade of kidney disease, type of anaesthesia, priority of surgery, surgery risk, and an 18-level variable were included. The nomogram achieved good concordance indices of 0.870 and 0.865 in the derivation and validation cohorts, respectively. The Youden index identified an optimal cut-off predicted probability of 0.163 with a sensitivity of 0.821 and a specificity of 0.744. Decision curve (DCA) showed patients had a standardized net benefit in the range of a 5–60% likelihood of transfusion risk. In conclusion, a nomogram model was established to be used for risk stratification of patients undergoing surgery at risk for blood transfusion. The URLs of web calculators for our model are as follows: http://www.empowerstats.net/pmodel/?m=11633_transfusionpreiction.

204. The ALFA score predicts 30-day mortality after elective anterior lumbar interbody fusion

204. The ALFA score predicts 30-day mortality after elective anterior lumbar interbody fusion