American Society Of Anesthesiologists Grade Research Articles

Effects of Preoperative Oral Carbohydrate Loading on Preoperative and Postoperative Comfort in Patients Planned to Undergo Elective Cholecystectomy: A Prospective Randomized Controlled Clinical Trial

Background: Cholecystectomy is a widespread abdominal procedure. A period of 8-hour-fasting for this relatively rapid surgery negatively affects the patients’ comfort. Objectives: The current study aimed to evaluate the effects of the presurgical intake of carbohydrate on patients’ comfort. Materials and Methods: This prospective study was carried out on 42 cholecystectomy patients (with the American Society of Anesthesiologists grade of I-II) divided into two groups. The patients in group 1 underwent laparoscopic cholecystectomy after an 8-hour-fasting period. The subjects in group 2 received a carbohydrate-rich solution with 12.5% dextrose before the surgery (125 g of sugar melted in 1 L of water; 800 and 200 mL 8 and 2 h before the surgery, respectively). Thirst, hunger, and nausea at the 9th preoperative hour and 30 min before the surgery in addition to nausea and vomiting at the 2nd, 8th, and 24th postoperative hours were assessed in both groups. Results: The mean age and body mass index (BMI) values of the patients were 48.38±12.68 years and 29.85±5.20 kg/m², respectively. The mean operational time was 36.5 min (range: 26-114 min). No difference was observed between the two groups in terms of age, BMI, and operational time. The investigation 30 min before cholecystectomy revealed that the rates of hungry and thirsty patients were higher in group 1, compared to those reported for group 2 (P=0.003 and P=0.032). Nevertheless, at the 2nd and 8th postoperative hours, the rate of patients complaining of nausea were higher in group 2 in comparison to that of group 1 (P=0.048 and P=0.014). Conclusions: It is suggested that the intake of carbohydrate-rich fluids up to the preoperative 2nd hour decreased presurgical hunger/thirst. The results of this study are in line with the findings of previous studies. It is believed that the intake of CHO-rich solutions up to 2 h before surgery may provide comfort by decreasing hunger/thirst. Nevertheless, it is necessary to take into account a potential rise in a feeling of nausea among these patients.

Are there predictive tests that determine the difficulty in Laryngeal Mask Airway Insertion?

To determine the predictive tests for difficulty in laryngeal mask airway insertion, and to observe the success rate of insertion in the first attempt. The prospective, observational study was conducted at Bülent Ecevit University Hospital, Turkey, from September 2013 to 2014, and comprised patients of American Society of Anaesthesiologists grade I to IV adult patients who underwent elective surgery under general anaesthesia. The supraglottic airway device was randomly selected for each patient, and the laryngeal mask airway was used as per the decision of an anaesthesiologist who was not part of the study. Patients were divided into three groups according to laryngeal mask airway types as classic group A, i-gel group B and suprema group C. These were inserted by anaesthesia residents with the same seniority when bispectral index value reached 40-60. Data was noted and analysed using SPSS 24. Of the 120 patients, 40(33.33%) were in cLMA, 38(31.66%) in i-gel, and 42(35%) in sLMA. There was no significant difference among the groups in terms of demographics (p>0.05). Apart from the height/thyromental distance ratio (p=0.046), no predictive test was statistically significant in identifying the difficulty in laryngeal mask airway insertion (p>0.05). There was no significant difference involving number of attempts, difficulty in insertion, and patient response (p>0.05). Placement success rate at first attempt was similar among the groups (p>0.05). Higher height/thyromental distance ratio values were associated with difficulty in laryngeal mask airway insertion, and first-attempt success rate was similar in all the three laryngeal mask airway types.

An audit of process and outcome for emergency colectomy in England and Wales.

The aim of this work was to describe process and outcome for patients undergoing emergency colectomy for colitis in England and Wales. The National Emergency Laparotomy Audit (NELA) is a national audit including patients undergoing emergency laparotomy and laparoscopic resectional procedures. Data from adult patients under 65years of age who underwent emergency subtotal colectomy or panproctocolectomy for colitis between 2013 and 2016 were analysed. In total 1204 patients were included. Although approximately a third of patients underwent a colectomy within 5days of admission [37% (440/1204)], 32% (383/1204) were admitted for more than 10days prior to surgery. Colorectal surgeons were present at operation in 72% (869/1204) of cases and consultant surgeons attended 94% (1137/1204) of procedures. Laparoscopy was attempted in 32% (390/1204) of operations with wide institutional variation in its use (0-100% of cases). The overall 30-day inpatient mortality was 2.9% (35/1204). On multivariable regression analysis, age>55years [OR 3.59 (1.05-12.21), P=0.041], female gender [OR 2.88 (1.27-6.52), P=0.011] and American Society of Anesthesiologists grade 5 [OR 37.43 (2.72-514.52), P=0.007] were associated with increased mortality. There is a consultant-driven service that is largely delivered by specialist colorectal surgeons. Laparoscopy rates were high although there was wide variation in use across institutions. Preoperative delays were evident, and further work is necessary to determine the underlying reasons for these.

Effects of intravenous clonidine or dexmedetomidine on haemodynamic responses to laryngoscopy and endotracheal intubation and sedation: A randomised double-blind clinical efficacy study

Background: Laryngoscopy and tracheal intubation (LTI) is associated with undesirable haemodynamic (HD) responses. Both clonidine and dexmedetomidine have been tried to attenuate this HD response. The present study was to assess whether single pre-induction dose of intravenous clonidine (2 μg/Kg) or dexmedetomidine (1 μg/Kg) is more efficient to attenuate the HD response to LTI. Methods: Sixty patients belonging to American Society of Anesthesiologists Grade I and II were randomly divided into two groups: group C (clonidine 2 μg/Kg) and Group D (dexmedetomidine 1 μg/Kg). Study drug was given as an infusion over 10 Min before induction of anaesthesia followed by standardised anaesthetic technique. Heart rate (HR) and blood pressure (BP) were studied at baseline, before study drug infusion (BSD), after study drug infusion, before LTI and at 1, 2, 3, 5 and 10 m in after intubation. Sedation score was analysed BSD, after study drug infusion and at the end of surgery Results: This study revealed suppression of HR and BP at all time points in both the groups without any significant difference in suppression of HR between the groups. The magnitude of fall in BP in the clonidine group is more compared to the dexmedetomidine group before LTI and at 3, 5, and 10 min after tracheal intubation. The patients in the dexmedetomidine group were more sedated than in the clonidine group at the end of the study drug infusion. Conclusions: Both clonidine and dexmedetomidine were effective in attenuating HD response to LTI. Dexmedetomidine appears to be superior to clonidine in maintaining stable HD.

Predictor of postoperative dyspnea for Pierre Robin Sequence infants.

The aim of this retrospective study is to determine the predictive factors of postoperative dyspnea in infants with Pierre Robin sequence (PRS). Forty children with PRS, who underwent general anesthesia, were retrospectively analyzed. The patient’s physiological status and anesthesiology data were collected accordingly, demographic characteristics including age, gender, height and weight at surgery, weight gain, preoperative airway status, tracheal intubation route, American Society of Anesthesiologists grading and airway Cormack–Lehane classification. Weight gain, dyspnea before the operation, Cormack–Lehane grade distribution showed a significant difference between patients with and without postoperative dyspnea (p = 0.0175, p = 0.0026, and p = 0.0038, respectively). Incompetent weight gain was identified as a predictor (p = 0.0371) of PRS postoperative dyspnea through the binary logistic regression model. In conclusion, this study established an early alerting model by monitoring the weight gain, dyspnea before the operation, Cormack–Lehane grade as potential combinations to predict the risk of postoperative dyspnea for PRS.

Importance of Routine Laboratory Investigations Before Elective Surgery.

BACKGROUND AND AIMS: Certain routine pre-operative laboratory investigations are performed in all patients before elective surgeries. We conducted this study to assess the value of routine pre-operative tests in the ASA (American Society of Anesthesiologists) Grade I and II adults undergoing elective surgery and their influence in the conduct of anaesthesia together with the costs incurred on unwarranted tests. METHODS: A total of 1271 patients posted for elective surgery under anaesthesia were recruited. Each patient attended the Pre-Anaesthetic Checkup Clinic and underwent clinical evaluation and investigations according to institutional policy. Demographic data and other characteristics were recorded, along with the results of laboratory test, any peri-operative intervention done as a result of abnormality and the cost incurred on tests. RESULTS: Majority of the patients belonged to ASA status I (74%) and underwent moderately invasive surgery (78%). The total number of routine investigations performed was 8015. Of these, 351 (4.37%) tests had abnormal results. Amongst these 333 (4.15%) abnormalities were suspected clinically and peri-operative intervention was only performed in 0.43% of patients. Anemia was the most common abnormal finding. Abnormal blood glucose was detected in 6 patients who were not clinically suspected. Abnormal electrocardiograph (ECG) was found in 54 patients. However, the intervention was required only in 13 patients. No intervention was required because of abnormal findings of the chest X-Ray. In total cost of investigations, only 6.9% was contributed by abnormal investigations and the rest was spent on the normal tests. CONCLUSION: The incidence of tests with abnormal results was very low in our study, and less than 1% of the patients with abnormal tests required changes in their peri-anaesthetic management. No major complications were seen in any patient with normal or abnormal test results. Most of the expenses (93%) were related to the normal test, which did not contribute to the perioperative management, safety and outcome of the patient. Thus, pre-operative investigations should be judiciously advised to avoid inconvenience, surgical delays and escalation of the costs of surgical care.

Incidence and predictive factors of problems after fixation of trochanteric hip fractures with sliding hip screw or intramedullary devices.

Hip fractures are common and disabling injuries, usually managed surgically. The most common type outside the joint capsule are trochanteric fractures, usually fixed with either sliding hip screw or intramedullary nail. Data are available in the National Hip Fracture Database (NHFD) on early failure and other major complications, but late or subtler complications may escape recording. This study sought to quantify such problems after fixation performed at 3different sites and identify their predictors. Patients with a trochanteric fracture treated at 1 of 3 sites were identified from the NHFD over a 3-year period. Any with further, related episodes of care were identified, and reasons recorded, then age- and sex-matched with those with no such episodes. Data was collected on Arbeitsgemeinschaft für Osteosynthesefragen classification, tip-apex distance, American Society of Anesthesiologists (ASA) grade, Abbreviated Mental Test Score and pre-injury mobility. The cohorts were compared, and a binomial logistic regression model used to identify predictors of problems. A total of 4010 patients were entered in the NHFD across 3 sites between January 2013 and December 2015. Of these, 1260 sustained trochanteric fractures and 57 (4.5%) subsequently experienced problems leading to re-presentation. The most common was failure of fixation, occurring in 22 patients (1.7%). The binomial logistic regression model explained 47.6% of the variance in incidence of postoperative problems with ASA grade and tip-apex distance being predictive. The incidence of re-presentation with problems was around of 5%. A failure rate of less than 2% was seen, in keeping with existing data. This study has quantified the incidence of subtler postoperative problems and identified their predictors. The type of implant used was not amongst them and patients with both implants experienced problems. Fixation continues to yield imperfect results, but patient health and robust surgical technique remain important factors in a good outcome.

Safety and feasibility of minimally invasive esophagectomy for elderly esophageal cancer patients.

The number of elderly patients with esophageal cancer has increased in recent years. The use of thoracoscopic esophagectomy has also increased, and its minimal invasiveness is believed to contribute to postoperative outcomes. However, the short- and long-term outcomes in elderly patients remain unclear. This study aimed to elucidate the safety and feasibility of minimally invasive esophagectomy in elderly patients. This retrospective study included 207 patients who underwent radical thoracoscopic esophagectomy for thoracic esophageal squamous cell carcinoma at Kobe University Hospital between 2005 and 2014. Patients were divided into non-elderly (<75years) and elderly (≥75years) groups. A propensity score matching analysis was performed for sex and clinical T and N stage, with a total of 29 matched pairs. General preoperative data, surgical procedures, intraoperative data, postoperative complications, in-hospital death, cancer-specific survival, and overall survival were compared between groups. The elderly group was characterized by lower preoperative serum albumin levels and higher American Society of Anesthesiologists grade. Intraoperative data and postoperative complications did not differ between the groups. The in-hospital death rate was 4% in the elderly group, which did not significantly differ from the non-elderly group. Cancer-specific survival was similar between the two groups. Although overall survival tended to be poor in the elderly group, it was not significantly worse than that of the non-elderly group. In conclusion, the short- and long-term outcomes of minimally invasive esophagectomy in elderly versus non-elderly patients were acceptable. Minimally invasive esophagectomy is a safe and feasible modality for elderly patients with appropriate indications.

Does preoperative dipyridamole-thallium scanning reduce 90-day cardiac complications and 1-year mortality in patients with femoral neck fractures undergoing hemiarthroplasty?

BackgroundThis study aimed to evaluate the effect of dipyridamole-thallium scanning (DTS) on the rates of 90-day cardiac complications and 1-year mortality in patients with a femoral neck fracture treated with hemiarthroplasty.MethodsBetween 2008 and 2015, 844 consecutive patients who underwent cemented or cementless hemiarthroplasty were identified from the database of a single level-one medical center. One-hundred and thirteen patients (13%) underwent DTS prior to surgery, and 731 patients (87%) did not. Patient characteristics, comorbidities, surgical variables, and length of the delay until surgery were recorded. A propensity score-matched cohort was utilized to reduce recruitment bias in a 1:3 ratio of DTS group to control group, and multivariate logistic regression was performed to control confounding variables.ResultsThe incidence of 90-day cardiac complications was 19.5% in the DTS group and 15.6% in the control group (p = 0.343) among 452 patients after propensity score-matching. The 1-year mortality rate (10.6% vs 13.3%, p = 0.462) was similar in the two groups. In the propensity score-matched patients, utilization of DTS was not associated with a reduction in the rate of 90-day cardiac complications (matched cohort, adjusted odds ratio [aOR] = 1.32; 95% confidence interval [CI] 0.75–2.33, p = 0.332) or the 1-year mortality rate (aOR = 0.62; 95% CI 0.27–1.42, p = 0.259). Risk factors for cardiac complications included an American Society of Anesthesiologists grade ≥ 3 (OR 3.19, 95% CI 1.44–7.08, p = 0.004) and pre-existing cardiac comorbidities (OR 5.56, 95% CI 3.35–9.25, p < 0.001). Risk factors for 1-year mortality were a long time to surgery (aOR 1.15, 95% CI 1.06–1.25, p = 0.001), a greater age (aOR 1.05, 95% CI 1.00 to 1.10, p = 0.040), a low body mass index (BMI; aOR 0.89, 95% CI 0.81–0.98, p = 0.015), and the presence of renal disease (aOR 4.43, 95% CI 1.71–11.46, p = 0.002).DiscussionPreoperative DTS was not associated with reductions in the rates of 90-day cardiac complications or 1-year mortality in patients with a femoral neck fracture undergoing hemiarthroplasty. The necessity for DTS should be re-evaluated in elderly patients with femoral neck fractures, given that this increases the length of the delay until surgery.Level of evidencePrognostic level III

Prediction of Postoperative Outcomes Following Hip Fracture Surgery: Independent Validation and Recalibration of the Nottingham Hip Fracture Score

ObjectivesIndependent validation of risk scores after hip fracture is uncommon, particularly for evaluation of outcomes other than death. We aimed to assess the Nottingham Hip Fracture Score (NHFS) for prediction of mortality, physical function, length of stay, and postoperative complications. DesignAnalysis of routinely collected prospective data partly collected by follow-up interviews. Setting and ParticipantsConsecutive hip fracture patients were identified from the Northumbria hip fracture database between 2014 and 2018. Patients were excluded if they were not surgically managed or if scores for predictive variables were missing. MethodsC statistics were calculated to test the discriminant ability of the NHFS, Abbreviated Mental Test Score (AMTS), and American Society of Anesthesiologists (ASA) grade for in-hospital, 30-day, and 120-day mortality; functional independence at discharge, 30 days, and 120 days; length of stay; and postoperative complications. ResultsWe analyzed data from 3208 individuals, mean age 82.6 (standard deviation 8.6). 2192 (70.9%) were female. 194 (6.3%) died during the first 30 days, 1686 (54.5%) were discharged to their own home, 211 (6.8%) had no mobility at 120 days, 141 (4.6%) experienced a postoperative complication. The median length of stay was 18 days (interquartile range 8-28). For mortality, C statistics for the NHFS ranged from 0.68 to 0.69, similar to ASA and AMTS. For postoperative mobility, the C statistics for the NHFS ranged from 0.74 to 0.83, similar to AMTS (0.61-0.82) and better than the ASA grade (0.68-0.71). Length of stay was significantly correlated with each score (P < .001 by Jonckheere-Terpstra test); NHFS and AMTS showed inverted U-shaped relationships with length of stay. For postoperative complications, C statistics for NHFS (0.54-0.59) were similar to ASA grade (0.53-0.61) and AMTS (0.50-0.58). Conclusions and ImplicationsThe NHFS performed consistently well in predicting functional outcomes, moderately in predicting mortality, but less well in predicting length of stay and complications. There remains room for improvement by adding further predictors such as measures of physical performance in future analyses.

Health-related quality-of-life improvement with lumbar fusion in patients with lower-extremity arthritis.

Lumbar fusion can lead to significant improvements in patient-reported outcomes (PROs) in patients with degenerative conditions. It is unknown whether the presence of hip or knee arthritis confounds the responses of patients to low-back-specific PROs. This study examined PROs with lumbar fusion in patients with concomitant lower-extremity arthritis. The purpose of the current study was to examine whether patients with significant lower-extremity arthritis who undergo lumbar fusion achieve similar improvements in low-back-specific PROs compared to patients without lower-extremity arthritis. Patients were identified from a prospectively enrolled multicenter registry of patients undergoing lumbar fusion surgery for degenerative conditions. Two hundred thirty patients identified with lumbar fusion and who also had concomitant lower-extremity arthritis were propensity matched to 233 patients who did not have lower-extremity arthritis based on age, BMI, sex, smoking status, American Society of Anesthesiologists grade, number of levels fused, and surgical approach. One-year improvement in PROs, numeric rating scales (0-10) for back and leg pain, and the Oswestry Disability Index and EuroQol-5D scores were compared for patients with and without lower-extremity arthritis. Baseline demographics and preoperative outcome measures did not differ between the two propensity-matched groups with 110 cases each. Patients with concomitant lower-extremity arthritis achieved similar improvement in health-related quality-of-life measures to patients without lower-extremity arthritis, with no significant differences between the groups (p > 0.10). The presence of lower-extremity arthritis does not adversely affect the results of lumbar fusion in properly selected patients. Patients with lower-extremity arthritis who undergo lumbar fusion can achieve meaningful improvement in PROs similar to patients without arthritis.

Laparoscopic versus open resection for elderly patients with gastric cancer: a double-center study with propensity score matching method.

The applicability of laparoscopic-assisted radical gastrectomy for elderly patients with gastric cancer is still not well clarified. The aim of this double-center study was to explore the feasibility and effectiveness of laparoscopic-assisted radical gastrectomy on elderly patients with gastric cancer. We prospectively collected data of patients who underwent gastrectomy for cancer in two centers from June 2016 to December 2019. Propensity score matching was performed at a ratio of 1:1 to compare the laparoscopic-assisted radical gastrectomy group and open radical gastrectomy group. Univariate analyses and multivariate logistic regression analyses evaluating the risk factors for total, surgical, and medical complications were performed. A total of 481 patients with gastric cancer met the inclusion criteria and were included in this study. After propensity score analysis, 258 patients were matched each other (laparoscopic-assisted radical gastrectomy (LAG) group, n = 129; open radical gastrectomy (OG) group, n = 129). LAG group had lower rate of surgical complications (P = 0.009), lower rate of severe complications (P = 0.046), shorter postoperative hospital stay (P = 0.001), and lower readmission rate (P = 0.039). Multivariate analyses revealed that anemia, Charlson comorbidity index, and combined resection were independent risk factors in the LAG group, whereas body mass index and American Society of Anesthesiology grade in the OG group. Laparoscopic-assisted radical gastrectomy was relative safe even effective in elderly gastric cancer patients. We should pay attention to the different risk factors when performing different surgical procedures for gastric cancer in elderly patients.

Variation in timely surgery for hip fracture by day and time of presentation: a nationwide prospective cohort study from the National Hip Fracture Database for England, Wales and Northern Ireland

Background and ObjectiveSeveral studies report poorer quality healthcare for patients presenting at weekends. Our objective was to examine how timely surgery for patients with hip fracture varies with day and...

COMPARING THE EFFECTS OF BUPIVACAINE AND ROPIVACAINE INSTILLATION FOR POST OPERATIVE ANALGESIA IN PATIENTS UNDERGOING LUMBER SPINE SURGERY: A PROSPECTIVE RANDOMISED DOUBLE BLIND STUDY

As it is a comparative study of Bupivacaine and Ropivacaine therefore Ropivacaine is a long-acting amide local anaesthetic with a potentially improved safety profile when compared to bupivacaine . Ropivacaine is less lipophilic than bupivacaine and is less likely to penetrate large myelinated motor fibres, resulting in a relatively reduced motor blockade.&#x0D; Subject and Methods: 90 patients, who belongs to American society of Anesthesiologist grade I &amp; II of age 18-65 years randomized into three groups (n=30). All three groups received propofol bolus 0.75mg/kg IV followed by IV infusion at 0.025 mg/kg/min. group A received Nalbuphine 50 μg/kg IV bolus, group B fentanyl 1.5 μg/kg IV bolus and group C received Dexmedetomidine infusion 1 μg/kg given over 10 min as bolus followed by 0.1 mg/kg/hr IV infusion for maintenance. Ramsay sedation score and Visual analogue scale measured for sedation and analgesia respectively at 10 minute interval for 1st hour of surgery then every 30 minutes upto the end of surgery. Desired RSS was defined 3-5. Intraoperative hemodynamic variables viz. Heart Rate (HR), Respiratory Rate (RR), Mean Arterial Pressure (MAP) and SPO2 were recorded every 10 min till the end of surgery. Recovery was assessed using Modified Aldrete Score in the recovery room. Time to achieve Aldrete recovery score of 10 was recorded. Patient satisfaction score and Surgeon satisfaction score were noted using a 7-point Likert verbal rating scale.&#x0D; Results: The groups were comparable with respect to demographic parameters. Ramsay sedation was significantly higher in Dexmedetomidine group (P&lt;0.05) than Nalbuphine and fentalyl group, while Visual analogue score was comparable in all three study groups (p&gt;0.05). Heart rate and Mean arterial pressure both significantly decreased in Dexmedetomidine group from the baseline during study period (p&lt;0.05). Respiratory rate and SPO2 were comparable in all three groups. In this study MAP was never &lt;60 mmhg, SPO2 was never &lt;94% and Respiratory rate was never &lt;12 bpm. Time to achieve modified alderate score in Dexmedetomidine (0.93±2.33 min) was significantly least as compare to Nalbuphine (1.80±2.65) &amp; Fentanyl group (3.50±4.76) (p=0.016). Patient satisfaction score in Dexmedetomidine was significantly higher (6.53±0.44) (p=0.005). Surgeon satisfaction score in Dexmedetomidine was also significantly higher (6.73±0.52) (p=0.000). Two patients in Dexmedetomidine group had episode of bradycardia which was managed with injection Atropine 0.6 mg effectively Conclusion: From these observations and analyses of the present study, it can be inferred that:&#x0D; ❖ Sedation in Dexmedetomidine was acceptable when used for MAC for middle ear surgeries.&#x0D; ❖ Visual analogue score was similar in all three study groups.&#x0D; ❖ Heart rate &amp; Mean arterial pressure in Dexmedetomidine was lower than baseline value.&#x0D; ❖ Changes in Respiratory rate and SPO2 were similar in all three study groups.&#x0D; ❖ Time to achieve Modified alderate score of 10 in group Dexmedetomidine was least, suggesting quicker recovery from anesthesia.&#x0D; ❖ Patient and surgeon satisfaction score in Dexmedetomidine was significantly higher.&#x0D; Keywords: Dexmedetomidine, Nalbuphine, Bupivacaine, Ropivacaine

The effect of surgical approach in total hip replacement on outcomes: an analysis of 723,904 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

BackgroundTotal hip replacement (THR) is clinically and cost-effective. The surgical approach employed influences the outcome; however, there is little generalisable and robust evidence to guide practice.MethodsA total of 723,904 primary THRs captured in the National Joint Registry, linked to hospital inpatient, mortality and patient-reported outcome measures (PROMs) data with up to 13.75 years follow-up, were analysed. There were seven surgical approach groups: conventional posterior, lateral, anterior and trans-trochanteric groups and minimally invasive posterior, lateral and anterior. Survival methods were used to compare revision rates and 90-day mortality. Groups were compared using Cox proportional hazards and Flexible Parametric Survival Modelling (FPM). Confounders included age at surgery, sex, risk group (indications additional to osteoarthritis), American Society of Anesthesiologists grade, THR fixation, thromboprophylaxis, anaesthetic, body mass index (BMI) and deprivation. PROMs were analysed with regression modelling or non-parametric methods.ResultsUnadjusted analysis showed a higher revision risk than the referent conventional posterior for the conventional lateral, minimally invasive lateral, minimally invasive anterior and trans-trochanteric groups. This persisted with all adjusted FPM and adjusted Cox models, except in the Cox model including BMI where the higher revision rate only persisted for the conventional lateral approach (hazard rate ratio (HRR) 1.12 [95% CI 1.06,1.17] P < 0·001) and trans-trochanteric approaches (HRR 1.48 [95% CI 1.14,1.91] P = 0.003). PROMs demonstrated statistically, but not clinically, significant differences. Self-reported complications were more frequent with the conventional lateral approach, and the risk of 90-day mortality was higher (HRR 1.15 [95%CI 1.01–1.30] P = 0.029).ConclusionsLateral approaches for THR are associated with worse outcomes, including more deaths and revisions, than the posterior approach. We recommend the posterior approach should be considered the current standard approach for THR. Large well-designed studies are needed to assess any potential benefits from using minimally invasive posterior approaches and the conventional anterior approach.

Supine versus semi-Fowler\u2019s positions for tracheal extubation in abdominal surgery-a randomized clinical trial

BackgroundTracheal extubation is commonly performed in the supine position. However, in patients undergoing abdominal surgery, the supine position increases abdominal wall tension, especially during coughing and deep breathing, which may aggravate pain and lead to abdominal wound dehiscence. The semi-Fowler’s position may reduce abdominal wall tension, but its safety and comfort in tracheal extubation have not been reported. We aimed to evaluate the safety and comfort of different extubation positions in patients undergoing abdominal surgery.MethodsWe enrolled 141 patients with an American Society of Anesthesiologists grade of I-III who underwent abdominal surgery. All patients were anesthetized with propofol, fentanyl, cisatracurium, and sevoflurane. After surgery, all patients were transferred to the post-anesthesia care unit (PACU). Patients were then randomly put into the semi-Fowler’s (n = 70) or supine (n = 71) position while 100% oxygen was administered. The endotracheal tube was removed after the patients opened their eyes and regained consciousness. Vital signs, coughing, and pain and comfort scores before and/or after extubation were recorded until the patients left the PACU.ResultsIn comparison with the supine position, the semi-Fowler’s position significantly decreased the wound pain scores at all intervals after extubation (3.51 ± 2.50 vs. 4.58 ± 2.26, 2.23 ± 1.68 vs. 3.11 ± 2.00, 1.81 ± 1.32 vs. 2.59 ± 1.88, P = 0.009, 0.005 and 0.005, respectively), reduced severe coughing (8[11.43%] vs. 21[29.58%], P = 0.008) and bucking after extubation (3[4.29%] vs. 18[25.35%], P < 0.001), and improved the comfort scores 5 min after extubation (6.11 ± 2.30 vs. 5.17 ± 1.78, P = 0.007) and when leaving from post-anesthesia care unit (7.17 ± 2.27 vs. 6.44 ± 1.79, P = 0.034). The incidences of vomiting, emergence agitation, and respiratory complications were of no significant difference.ConclusionTracheal extubation in the semi-Fowler’s position is associated with less coughing, sputum suction, and pain, and more comfort, without specific adverse effects when compared to the conventional supine position.Trial registrationChinese Clinical Trial Registry, ChiCTR1900025566. Registered on 1st September 2019.

Sexual Dysfunction: Prevalence and Prognosis in Patients Operated for Degenerative Lumbar Spondylolisthesis.

There is a paucity of investigation on the impact of spondylolisthesis surgery on back pain-related sexual inactivity. To investigate predictors of improved sex life postoperatively by utilizing the prospective Quality Outcomes Database (QOD) registry. A total of 218 patients who underwent surgery for grade 1 degenerative lumbar spondylolisthesis were included who were sexually active. Sex life was assessed by Oswestry Disability Index item 8 at baseline and 24-mo follow-up. Mean age was 58.0±11.0 yr, and 108 (49.5%) patients were women. At baseline, 178 patients (81.7%) had sex life impairment. At 24 mo, 130 patients (73.0% of the 178 impaired) had an improved sex life. Those with improved sex lives noted higher satisfaction with surgery (84.5% vs 64.6% would undergo surgery again, P=.002). In multivariate analyses, lower body mass index (BMI) was associated with improved sex life (OR=1.14; 95% CI [1.05-1.20]; P<.001). In the younger patients (age < 57 yr), lower BMI remained the sole significant predictor of improvement (OR=1.12; 95% CI [1.03-1.23]; P=.01). In the older patients (age ≥ 57 yr)-in addition to lower BMI (OR=1.12; 95% CI [1.02-1.27]; P=.02)-lower American Society of Anesthesiologists (ASA) grades (1 or 2) (OR=3.7; 95% CI [1.2-12.0]; P=.02) and ≥4 yr of college education (OR=3.9; 95% CI [1.2-15.1]; P=.03) were predictive of improvement. Over 80% of patients who present for surgery for degenerative lumbar spondylolisthesis report a negative effect of the disease on sex life. However, most patients (73%) report improvement postoperatively. Sex life improvement was associated with greater satisfaction with surgery. Lower BMI was predictive of improved sex life. In older patients-in addition to lower BMI-lower ASA grade and higher education were predictive of improvement.

Drivers for nonhome discharge in a consecutive series of 1502 patients undergoing 1- or 2-level lumbar fusion.

Unexpected nonhome discharge causes additional costs in the current reimbursement models, especially to the payor. Nonhome discharge is also related to longer length of hospital stay and therefore higher healthcare costs to society. With increasing demand for spine surgery, it is important to minimize costs by streamlining discharges and reducing length of hospital stay. Identifying factors associated with nonhome discharge can be useful for early intervention for discharge planning. The authors aimed to identify the drivers of nonhome discharge in patients undergoing 1- or 2-level instrumented lumbar fusion. The electronic medical records from a single-center hospital administrative database were analyzed for consecutive patients who underwent 1- to 2-level instrumented lumbar fusion for degenerative lumbar conditions during the period from 2016 to 2018. Discharge disposition was determined as home or nonhome. A logistic regression analysis was used to determine associations between nonhome discharge and age, sex, body mass index (BMI), race, American Society of Anesthesiologists grade, smoking status, marital status, insurance type, residence in an underserved zip code, and operative factors. A total of 1502 patients were included. The majority (81%) were discharged home. Factors associated with a nonhome discharge were older age, higher BMI, living in an underserved zip code, not being married, being on government insurance, and having more levels fused. Patients discharged to a nonhome facility had longer lengths of hospital stay (5.6 vs 3.0 days, p < 0.001) and significantly increased hospital costs ($21,204 vs $17,518, p < 0.001). Increased age, greater BMI, residence in an underserved zip code, not being married, and government insurance are drivers for discharge to a nonhome facility after a 1- to 2-level instrumented lumbar fusion. Early identification and intervention for these patients, even before admission, may decrease the length of hospital stay and medical costs.

Time to surgery and transfer-associated mortality for hip fractures in Western Australia.

Transfer time for patients with fractured hips is a significant problem in Australia. Current guidelines support operative management of hip fractures within 48 h with delays to surgery resulting in worse outcomes. The aim of study is to evaluate transfer times and delays and their effect on outcomes. A total of 506 hip fractures undergoing surgical management were reviewed between 2017 and 2018 at a tertiary metropolitan hospital. We examined age, time to surgery, transfer time, delay to surgery, American Society of Anesthesiologists grading and 30-day and 1-year mortality. We directly compared outcomes between patients presenting initially to the tertiary hospital and those who were referred from a peripheral site requiring inter-hospital transfer. The mean time to surgery was 24.4 h. Ninety-five percent of patients received their emergency surgery within 48 h with inter-hospital transfer patients delayed on average only by 12.08 h when compared to primary presenters. Patients who received their surgery in more than 48 h had worse mortality outcomes. Inter-hospital transfer, regardless of time to surgery, was associated with increased mortality. Increased time to surgery was associated with increased mortality rates. Transfer delays from a peripheral hospital had a significant bearing on time to surgery. Transfer, regardless of time to surgery, is associated with increased mortality. Early transfer to a referral hospital or bypass of the peripheral hospital is recommended.

Analysis of risk factors of severe postoperative complications in elderly patients with colorectal cancer aged over 80 years

Objective: To investigate the risk factors of severe postoperative complications in elderly patients with colorectal cancer aged over 80 years old. Methods: A retrospective case-control study was conducted to collect and analyze the clinicopathological data of patients (≥80 years old) who underwent radical colorectal cancer surgery at department of Colorectal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College from January 2010 to December 2018. A total of 269 patients were included in the study, including 160 males and 109 females. The average age was 83 (80-94) years. Among them, the pathological TNM stage was 16 in stage I, 76 in stage II, 167 in stage III, and 10 in stage IV. According to Clavien-Dindo classification, the postoperative complications of grade III and above were defined as serious complications. To analyze the relationship between the patient's clinical data, such as general information, the surgeon's experience (whether to complete more than 500 radical colorectal cancer surgery), intraoperative conditions and the occurrence of severe complications. Univariate analysis was conducted with the chi-squared test. Multivariate logistic regression analysis was used for statistically significant variables in univariate analysis. Results: Of the 269 patients, 34 (12.6%) had severe complications after surgery. The incidence of postoperative complications ranged from high to low, respectively, for pulmonary infection (8/269,3.0%), intestinal obstruction (8/269, 3.0%) and anastomotic leakage (7/269, 2.6%). One patient died of pulmonary embolism and one patient died of multiple organ failure, with a perioperative mortality rate of 0.7% (2/269). On univariate analysis, the occurrence of severe postoperative complications was associated with age (χ(2)=8.181, P=0.004), American society of anesthesiologists grade (χ(2)=7.945, P=0.005), preoperative albumin level (χ(2)=9.088, P=0.003), operation experience (χ(2)=9.395, P=0.002). Multivariable logistic regression analysis showed that age ≥85 years old (OR=4.415, 95% CI: 1.702-11.453, P=0.080), preoperative albumin <35 g/L (OR=2.544, 95%CI: 1.083-5.974, P=0.032), and less-experieced group (OR=2.475, 95% CI:1.082-5.661, P=0.032) was independent risk factor for severe postoperative complications. The incidence of serious postoperative complications was similar in patients undergoing laparoscopy and laparotomy [10.1% (17/169) vs. 17.0% (17/100), χ(2)=2.741, P=0.098]. Conclusion: Adequate preoperative evaluation, appropriate perioperative nutritional support and experienced specialists are the key factors to ensure the successful perioperative period of elderly patients with colorectal cancer aged over 80 years old. In addition, more attention should be paid to the elderly patients aged ≥85 years.