Elective Surgery Patients Research Articles

Small bowel duplication cyst in the pediatric population—when to operate?

IntroductionAimThe aim of the study is to determine the optimal timing for surgery in patients with small bowel duplications.MethodsA retrospective cohort study, including all patients younger than 18 years who were diagnosed with small bowel duplications from 2013 until 2024 in a single tertiary medical center, was performed. Patients’ demographics, duplication size and location, pathological results, and clinical outcomes were collected.ResultsSixteen patients (nine boys, seven girls) underwent laparoscopic-assisted resection of small bowel duplication at an average age of 3 years. A prenatal diagnosis was made in 11 patients, 10 (91%) of whom underwent elective surgery at a median age of 1.3 years. Overall, six patients required semi-elective or urgent surgery due to bowel obstruction, abdominal discomfort, or symptomatic anemia, with most (83%) lacking prenatal evaluation. Elective surgery patients had significantly smaller duplications (13 cm3 vs. 135 cm3). Post-operative recovery was satisfactory in all patients, with an average hospital stay of 6 days.ConclusionIn conclusion, asymptomatic, small duplication cysts in the small bowel of pediatric patients can be managed expectantly and can be operated after the first year of age. This approach is safe and allows for laparoscopic exploration in older infants, yielding satisfactory outcomes.

Cryospray reduces pain during venous cannulation in elective surgery patients: a randomized placebo-controlled study

BackgroundVenous cannulation is widely used in healthcare systems, and for many patients, it is painful and distressing. We hypothesized that the rapid onset of cryospray use would reduce pain from venous cannulation compared to the use of a placebo spray.MethodsThe trial was a prospective randomized placebo-controlled trial including 130 adult patients scheduled for elective surgery. Patients were randomized to receive either cryospray or placebo before venous cannulation. The primary outcome was patient-reported pain from vein puncture.ResultsThere were no differences in the baseline variables between the two groups with respect to age, sex, height, weight or ASA class. Patients in the cryospray group indicated more pain or discomfort with the application of the spray (0 (0-2.5)) than with the application of the placebo spray (0 (0–0)) (P < 0.005), as measured by the Numeric Rating Scale (NRS). Patients in the placebo group reported more pain with vein puncture than did those in the cryospray group (1 (0–3) vs. 3 [2, 3, 4–5], P < 0.005). When asked if the patient would have the same spray in case of canulation again, 57 patients from the cryospray group reported yes compared to 34 patients in the control group (P < 0.005).ConclusionsThis randomized study found that cryospray significantly reduced pain during venous cannulation without increasing procedure difficulty. Patients reported lower pain scores and a greater preference for cryospray in future procedures, supporting its use as an effective pain relief method in elective surgery.Trial registrationClinicalTrials. gov Identifier: NCT04865783 (28-04-2021).

Association between length of hospital stay before and after surgery and nutritional risk according to NRE-2017 - A secondary analysis of a cohort study.

Aim: to evaluate the predictive ability of the Nutritional Risk Emergency - 2017 (NRE) to predict prolonged length of stay, ICU admission intra-mortality and readmission, severe postoperative complications. Methods: a prospective cohort was conducted with surgical patients admitted in a public tertiary hospital. The NRE-2017 tool was applied for detecting malnutrition risk in hospitalized patients. Surgical complications were assessed by Clavien-Dindo. Patients were followed during hospitalization to identify length of stay as well as stay after surgery in the Intensive Care Unit (ICU). Regression analysis was performed to assess the association between risk of malnutrition and clinical outcomes. Results: we included 162 elective surgery patients; 79 patients were identified with nutritional risk using the NRE-2017 (≥ 1.5) tool and 83 without nutritional risk. Patients with nutritional risk were at higher risk of prolonged hospitalization [18 (10-36) days vs. 13 (7-23 days); p: 0.006] and ICU hospitalization [6 (2-14 days vs. 3.5 (1-7 days; p: 0.020]. There was an association between surgical complications and nutritional risk independently, but the significance was lost when adjusting the analysis. There was no association with mortality and readmission in this sample of patients. Conclusion: the NRE-2017 tool was associated with hospital stay in those patients at nutritional risk, however there was no association with mortality and readmission.

Comparison of resected lymph nodes and additional factors in colorectal cancer patients undergoing emergency versus elective surgery

Aims: Controversy persists regarding the number of lymph nodes (LNs) that should be removed during surgery for accurate colorectal carcinoma (CRC) staging and its impact on prognosis. The effects of other prognostic factors on survival, such as the metastatic LN to resected LN (LNR) ratio and the type of surgical approach, were retrospectively examined. Methods: A total of 325 patients who underwent emergency or elective surgery for CRC between March 1st, 2019, and December 31st, 2022, were included in the study. Age, sex, tumor location, stage, number of resected LNs, number of metastatic LNs, presence of distant metastases, distance of the tumor from the surgical margins, need for ostomy opening, development of postoperative complications, and level of tumor markers at diagnosis were recorded for patient records. Results: The data of 142 (43.7%) emergency surgery patients and 183 (56.3%) elective surgery patients were compared. It was revealed that there was a positive relationship between the removal of at least 22 LNs during surgery and survival (p = 0.036). Factors such as age, a high LNR, emergency surgery, advanced stage of CRC, and not receiving adjuvant chemotherapy were significant predictors of increased mortality (age: hazard ratio (HR): 1.03, 95% CI: 1.01–1.05, p &lt; 0.001; LNR: HR: 4.74, 95% CI: 1.69–13.3, p = 0.003; emergency surgery: HR: 2.33, 95% CI: 1.51–3.59, p &lt; 0.001; advanced stage: HR: 3.24, 95% CI: 1.81–5.79, p &lt; 0.001; adjuvant chemotherapy: HR: 4.93, 95% CI: 2.94–8.25, p &lt; 0.001) in the patients with CRC. Conclusion: Patients with CRC, who had fewer LN dissections, perforation-related peritonitis, advanced disease, were not receiving adjuvant chemotherapy, and emergency surgery, had a worse prognosis.

Effect of a Machine Learning-Derived Early Warning Tool With Treatment Protocol on Hypotension During Cardiac Surgery and ICU Stay: The Hypotension Prediction 2 (HYPE-2) Randomized Clinical Trial.

Cardiac surgery is associated with perioperative complications, some of which might be attributable to hypotension. The Hypotension Prediction Index (HPI), a machine-learning-derived early warning tool for hypotension, has only been evaluated in noncardiac surgery. We investigated whether using HPI with diagnostic guidance reduced hypotension during cardiac surgery and in the ICU. Randomized clinical trial conducted between May 2021 and February 2023. Single-center study conducted in an academic hospital in the Netherlands. Adults undergoing elective on-pump coronary artery bypass grafting, with or without single heart valve surgery, were enrolled if a mean arterial pressure (MAP) greater than or equal to 65 mm Hg was targeted during the surgical off-pump phases and ICU stay. After eligibility assessment, 142 of 162 patients approached gave informed consent for participation. Patients randomized 1:1 received either diagnostic guidance in addition to standard care if HPI reached greater than or equal to 75 (n = 72) or standard care alone (n = 70). The primary outcome was the severity of hypotension, measured as time-weighted average (TWA) of MAP less than 65 mm Hg. Secondary outcomes encompassed hypertension severity and intervention disparities. Of 142 patients randomized, 130 were included in the primary analysis. The HPI group showed 63% reduction in median TWA of hypotension compared with the standard care group, with a median of differences of -0.40 mm Hg (95% CI, -0.65 to -0.27; p < 0.001). In the HPI group, patients spent a median 28 minutes (95% CI, 17-44 min) less in hypotension, with a measurement duration of 322 minutes in the HPI group and 333 minutes in the standard care group. No significant differences were observed in hypertension severity, treatment choice, or fluid, vasopressors, and inotrope amounts. Using HPI combined with diagnostic guidance on top of standard care significantly decreased hypotension severity in elective cardiac surgery patients compared with standard care.

OGC O01 - Stomach Cancer Elective Surgery Morbidity and Mortality at 90-Days (HOLD Study): A Prospective, International Collaborative Cohort Study

Abstract Background Data on multinational 90-day mortality and morbidity rates after surgery for gastric cancer is limited in the literature. This study aimed to understand the 90-day mortality and morbidity outcomes according to GASTRODATA Registry for elective gastric cancer surgery patients and identify risk factors. Method We conducted an international prospective study on ≥18 years patients undergoing elective surgery for gastric cancer with curative intent from 01 April 2022 to 30 September 2022. Known metastatic disease, concurrent secondary cancers, gastrointestinal stromal tumour (GIST) and Siewert type I/II oesophagogastric junction malignancies were excluded. Univariate and multivariate logistic regression was used to identify variables associated to 90-day outcome. Results 380 collaborators from 47 countries submitted data on 1538 patients. Mean age was 64.2 years and 58.5% were males. 90-day morbidity rate was 38.2% (n=587) and mortality rate was 2.9% (n=45). Pre-operative higher CCI or ASA score, pre-operative weight loss &amp;gt;10%, and surgical determinants such as type of gastric resection, positive specimen margin, number of harvested lymph nodes, longer surgery duration and post operative pathological IV staging (p value&amp;lt;0.05) were identified as predictors of postoperative severe complications and mortality. Conclusion Elective gastric cancer surgery has a 90-day morbidity of 38.2% and 90-day mortality of 2.9%, globally. This study identified several factors associated with higher morbidity and exemplified the importance of a unified language on surgical morbidity, pre-habilitation and ongoing audits to enhance patient outcomes.

A causal model for predicting the impact of pharmacotherapy on colorectal surgery outcomes.

Evidence-based principles in enhanced recovery programs (ERPs) demonstrate substantial improvement in patient outcomes. Determining which latent variables predict composite outcomes could refine ERP pharmacotherapy recommendations. Using R, pharmacotherapy data were modeled from an existing dataset of adult elective colorectal surgery patients. Primary composite outcome was absence of surgical site infection, venous thromboembolism, postoperative nausea and vomiting, and other in-hospital postoperative complications (POCs). Secondary composite outcome included no postdischarge POCs, hospital length of stay ≤3days, and no readmission at 7- or 30-days. Variables with greater odds of predicting both positive primary and secondary composite outcomes included prehospital oral iron and oral antibiotic use, postoperative sugammadex and neostigmine use, postoperative morphine milligram equivalents (MME)≤50, and IV fluid stop by postoperative day 2. Preoperative scopolamine patch (OR=0.29 and CI=-0.19-0.77) and perioperative gabapentin (OR=0.46 and CI=0.06-0.83) had lesser odds for both primary and secondary composite outcomes. Ketamine nonanesthetic bolus, ondansetron IV use, and in-hospital enoxaparin use had paradoxical lesser primary but greater odds for secondary composite outcomes. Prehospital oral laxative use (OR=0.61 and CI=0.18-1.04) and postoperative dual IV antibiotics (OR=0.52 and CI=0.10-0.94) had lesser odds for primary, but not secondary, outcome. To improve the odds for positive composite outcomes, oral iron and antibiotics, sugammadex and neostigmine, lower MME, and early IV fluid cessation could be considered essential core items, whereas postoperative dual IV antibiotics and epidural anesthesia might be avoided. Additional research needs to clarify the impacts of in-hospital enoxaparin, ketamine nonanesthetic bolus, and ondansetron use on composite patient outcomes.

Preoperative Anemia and Iron Deficiency in Elective Gastrointestinal Cancer Surgery Patients.

Preoperative anemia can impact postoperative outcomes, but its importance in gastrointestinal cancer patients, and significance of anemia etiology remains unclear. We aimed to characterize the frequency and impact of preoperative anemia, and iron-deficiency anemia (IDA), on perioperative outcomes. We performed a retrospective cohort study of adult patients undergoing elective gastrointestinal cancer surgery. The primary outcome was the incidence of perioperative RBC transfusion. Secondary outcomes included 90-day postoperative major morbidity, ICU admission, and 90-day hospital readmission. Multivariable analyses were performed to assess the association between preoperative anemia and IDA and outcomes. Preoperative anemia was present in 55.5% of patients (n = 15 414), and 58.3% of anemic patients were iron deficient. Preoperative anemia was independently associated with increased risk of RBC transfusion (RR 2.88, 95% CI 2.60-3.20), and secondary outcomes. For every preoperative hemoglobin decrease of 1 g/dL, the adjusted risk of perioperative RBC transfusion increased by 40% (RR 1.39, 95% CI 1.37-1.42). Preoperative anemia is prevalent, and an independent risk factor for adverse postoperative outcomes. Decreases in preoperative hemoglobin levels elevate the risk of transfusion and adverse outcomes, supporting further study to optimize management of treatable causes of preoperative anemia including IDA.

The Impact of Bhramari Pranayama and Om Chanting on Post-operative Wound Healing: A Focus on the Nitric Oxide Pathway.

Introduction Wound healingis a complex process influenced by various physiological and psychological factors. Stress, in particular, has been shown to impair wound healing by affecting the immune response and slowing the repair process. Yoga-based relaxation techniques, such as bhramari pranayama and Om chanting, have demonstrated the potential to reduce stress and improve overall well-being. Material and methods This comprehensive study is a prospective comparative interventional study with a sample size of 268 elective surgery patients. In addition to standard treatment, patientswere taughtyoga, and various parameters were measured to ensure a thorough evaluation of the impact of these techniques on stress levels and wound healing. Result The intervention groups demonstrated significant improvements in wound healing and stress reduction compared to the control group, with the combination of bhramari pranayama and Om chanting showing the most substantial effects. Post-intervention heart rate variability (HRV)low-frequency/high-frequency (LF/HF) ratios decreased to a median of 3.25 (SD 0.14) in the combination group, compared to 4.39 (SD 0.13) in the control group (p<0.001). Endothelial nitric oxide synthase (eNOS) levels increased to 3.49 ng/mL (SD 0.12) from 1.02 ng/mL (SD 0.24) in the control group (p < 0.001). Post-intervention, HRV LF/HF ratios decreased to a median of 3.25 (SD 0.14) in the combination group compared to 4.39 (SD 0.13) in the control group (p<0.001). eNOS levels increased to 3.49 ng/mL (SD 0.12) from 1.02 ng/mL (SD 0.24) in the control group (p < 0.001). Additionally, 36% of participants in the combination group achieved Grade 0 wound healing, compared to 16% in the control group (p<0.001). These findings indicate that yoga interventions effectively enhance post-operative recovery. Conclusion This study is pertinent due to the growing interest in integrating complementary and alternative medicine (CAM) with conventional medical practices to enhance patient outcomes. The intersection of yoga-based practices and wound healing presents a novel approach to post-operative care.

Prevalence of Obesity in Abdominal Surgery Patients at a Tertiary Care Hospital: A Cross-Sectional Study.

Background Obesity significantly impacts surgical outcomes, increasing the risk of postoperative complications, especially in abdominal surgery. Objective To determine the prevalence of obesity among patients undergoing abdominal surgery and to explore its association with postoperative complications. Methodology A cross-sectional study was conducted from January 2022 to December 2023. There were 428 adult patients in total, either for emergency or elective abdominal surgery. A BMI of ≥30 kg/m² was used by the World Health Organization to define obesity. We gathered and examined data on postoperative complications, surgical outcomes, comorbidities, and demographics. Chi-square and t-tests were used to assess the prevalence of obesity and its relationship to complications; a p-value of less than 0.05 was deemed statistically significant. Results Among 428 patients, 151 (35.28%) were obese. Obese patients had significantly higher rates of wound infections, with 36 (23.84%) compared to 28 (10.11%) non-obese patients (p = 0.001). Venous thromboembolism occurred in 18 (11.92%) obese patients versus nine (3.25%) non-obese patients (p = 0.002). Respiratory complications were more frequent in obese patients, with 27 (17.88%) compared to 31 (11.19%) non-obese patients (p = 0.045). Prolonged hospital stays (>7 days) were reported in 52 (34.44%) obese patients versus 39 (14.08%) non-obese patients (p < 0.001). Additionally, obesity was associated with longer surgery durations (124.35 ± 35.82 minutes in obese patientsversus 108.65 ± 29.44 minutes in non-obese patients, p = 0.003) and extended recovery times (11.58 ± 5.67 days versus 8.73 ± 4.25 days, p = 0.002). Conclusion Patients having abdominal surgery are often obese, which is linked to an increased risk of complications and lengthier recovery times.

Post-Neutralisation Activated Clotting Time and Postoperative Transfusions in Cardiac Surgery Outcome.

To assess the impact of post-protamine neutralisation activated clotting time (ACT) values on postoperative outcomes including chest drain output, transfusion requirements, and CICU stay, in patients undergoing cardiac surgery. Observational comparative study. Place and Duration of the Study: Department of Anaesthesiology, The Aga Khan University Hospital, Karachi, Pakistan, from February to August 2023. Ethical approval was obtained to collect data from elective cardiac surgery patients' charts. A sequential sampling approach analysed the baseline and post-protamine neutralisation ACT values, categorising patients into two groups. Group A maintained ACT within 10% of baseline, while Group B deviated. The outcomes measured included transfusion needs, chest drain output, additional protamine, cardiac intensive care unit (CICU) stay, and postoperative reopening. Statistical analysis included mean, median, frequency, t-test / Mann-Whitney U test, and Chi-square test. The study comprised 101 patients (39 in Group A, 62 in Group B), with similar baseline health. No significant differences were found in tranexamic acid use, CICU stay, chest drain output, or transfusion rates between the groups (p >0.05). Maintaining ACT within 10% of baseline post-protamine neutralisation results in similar intraoperative and postoperative outcomes, suggesting potential benefits in avoiding the aggressive protamine therapy and ensuring haemostasis in cardiac surgery. Coronary Artery bypass grafting, Cardiopulmonary bypass, Activated clotting time (ACT), Heparin, Postoperative bleeding, Blood transfusions.

Post-Neutralisation Activated Clotting Time and Postoperative Transfusions in Cardiac Surgery Outcome.

To assess the impact of post-protamine neutralisation activated clotting time (ACT) values on postoperative outcomes including chest drain output, transfusion requirements, and CICU stay, in patients undergoing cardiac surgery. Observational comparative study. Place and Duration of the Study: Department of Anaesthesiology, The Aga Khan University Hospital, Karachi, Pakistan, from February to August 2023. Ethical approval was obtained to collect data from elective cardiac surgery patients' charts. A sequential sampling approach analysed the baseline and post-protamine neutralisation ACT values, categorising patients into two groups. Group A maintained ACT within 10% of baseline, while Group B deviated. The outcomes measured included transfusion needs, chest drain output, additional protamine, cardiac intensive care unit (CICU) stay, and postoperative reopening. Statistical analysis included mean, median, frequency, t-test / Mann-Whitney U test, and Chi-square test. The study comprised 101 patients (39 in Group A, 62 in Group B), with similar baseline health. No significant differences were found in tranexamic acid use, CICU stay, chest drain output, or transfusion rates between the groups (p >0.05). Maintaining ACT within 10% of baseline post-protamine neutralisation results in similar intraoperative and postoperative outcomes, suggesting potential benefits in avoiding the aggressive protamine therapy and ensuring haemostasis in cardiac surgery. Coronary Artery bypass grafting, Cardiopulmonary bypass, Activated clotting time (ACT), Heparin, Postoperative bleeding, Blood transfusions.

Efficacy of a pre-operative anaemia clinic in patients undergoing elective abdominal cancer surgery.

Pre-operative iron deficiency anaemia (IDA) is common in patients undergoing elective major abdominal surgery and is associated with increased risk of perioperative complications. However, widespread implementation of pre-operative anaemia management is lacking. Guidelines recommend investigation of anaemia preferably 4-6 weeks before surgery to allow time for correction. However, this is not always feasible in abdominal cancer surgery with short time to surgery and may be influenced by concomitant chemotherapy. The objective of this study was to assess the efficacy of implementing a pre-operative screening and treatment programme for IDA in elective abdominal cancer surgery patients, with short duration to surgery and concomitant use of chemotherapy. All patients scheduled for elective abdominal cancer surgery with IDA were included. Anaemia was defined according to the World Health Organization-criteria and iron deficiency as a transferrin saturation <0.20. The primary outcome was change in haemoglobin (Hb) between iron infusion and surgery in patients receiving pre-operative intravenous iron infusion. Of 178 diagnosed IDA patients 134 (75%) received intravenous iron, 103 pre-operatively (58%) at median day 17 (interquartile range: 9-27) before surgery while 31 (17%) received post-operative intravenous iron treatment. The pre-operative Hb increased 0.89 g/dL (95% CI: 0.64-1.13, p < .001) compared to a decrease of 0.4 g/dL (95% CI: 0.19-0.58, p < .001) in 75 patients not treated pre-operatively. Patients diagnosed with severe anaemia had the largest pre-operative Hb increase. Iron infusion >2 weeks pre-operatively resulted in a greater Hb increment of 1.13 g/dL (95% CI: 0.81-1.45) compared to iron infusion ≤2 weeks before surgery 0.48 g/dL (95% CI: 0.16-0.81). Hb increased by 0.64 g/dL (95% CI 0.19-1.21) in patients receiving chemotherapy ≤31 days prior to surgery. In patients scheduled for abdominal cancer surgery, including in patients with concomitant chemotherapy, pre-operative IDA management is feasible and results in a significant pre-operative Hb increase compared to patients not treated. On the day of surgery 25% patients treated pre-operatively were no longer anaemic.

An interrater reliability analysis of preoperative mortality risk calculators used for elective high-risk noncardiac surgical patients shows poor to moderate reliability

BackgroundMultiple preoperative calculators are available online to predict preoperative mortality risk for noncardiac surgical patients. However, it is currently unknown how these risk calculators perform across different raters. The current study investigated the interrater reliability of three preoperative mortality risk calculators in an elective high-risk noncardiac surgical patient population to evaluate if these calculators can be safely used for identification of high-risk noncardiac surgical patients for a preoperative multidisciplinary team discussion.MethodsFive anesthesiologists assessed the preoperative mortality risk of 34 high-risk patients using the preoperative score to calculate postoperative mortality risks (POSPOM), the American College of Surgeons surgical risk calculator (SRC), and the surgical outcome risk tool (SORT). In total, 170 calculations per calculator were gathered.ResultsInterrater reliability was poor for SORT (ICC (C.I. 95%) = 0.46 (0.30–0.63)) and moderate for SRC (ICC = 0.65 (0.51–0.78)) and POSPOM (ICC = 0.63 (0.49–0.77). The absolute range of calculated mortality risk was 0.2–72% for POSPOM, 0–36% for SRC, and 0.4–17% for SORT. The coefficient of variation increased in higher risk classes for POSPOM and SORT. The extended Bland–Altman limits of agreement suggested that all raters contributed to the variation in calculated risks.ConclusionThe current results indicate that the preoperative risk calculators POSPOM, SRC, and SORT exhibit poor to moderate interrater reliability. These calculators are not sufficiently accurate for clinical identification and preoperative counseling of high-risk surgical patients. Clinicians should be trained in using mortality risk calculators. Also, clinicians should be cautious when using predicted mortality estimates from these calculators to identify high-risk noncardiac surgical patients for elective surgery.

“Opioid free colorectal surgery: Outcomes of successful non-opiate colorectal surgery in a rural community teaching hospital”

BackgroundOpiates present challenges due to side effects, including prolonged hospitalization and delayed bowel function. Enhanced Recovery After Surgery (ERAS) protocols advocate for multimodal pain management, yet few studies explore entirely non-opiate approaches. Methods134 elective ERAS colorectal surgery patients were reviewed from January 2019 to June 2020 ​at a single institution, with surgery performed by a single surgeon. Endpoints were pain scores, length of stay (LOS), and mortality. ResultsForty patients were included in the non-opiate cohort. Mann Whitney-U test found that postoperatively, non-opiate patients spent significantly less time in moderate or severe pain (p ​< ​.001). There was no significant difference between study groups (non-opiate and opiate) for the no or mild pain categories, LOS, or mortality. Risk factors for opiate use were younger age and prior opiate use. Gender, ASA class, stoma creation, malignancy, and surgical approach were not associated with increased opiates. ConclusionNon-opiate approaches in colorectal surgery are feasible and comparable to opiate regimens in our patient cohort.

Factors influencing hospital stay duration in an elective cardiac surgery cohort

Abstract Cardiac surgery has become more complex in recent years, with increases in patient age, complexity, and associated costs. The use of a multidisciplinary strategy to analyze and standardize patient management offers significant benefits. The development of Enhanced Recovery After Surgery (ERAS) programs has proven useful in various types of surgery, recently including cardiac surgery, yielding good results. One of the primary objectives of ERAS programs is the reduction of the Inpatients' length of stay (LOS), with the subsequent improvement in the patient experience and a reduction in costs. The aim of this study is to analyze preoperative and postoperative factors related to the LOS reduction in a cohort of elective cardiac surgery patients included in the Cardiac ERAS program at our hospital. All patients included in the ERAS program, corresponding to elective cardiac surgery, were included in the analysis. 138 patients were divided into four quartiles based on the inpatient’s LOS. An extensive search was conducted in our quality control database, which contains 470 variables on the factors more strongly associated with LOS. The results were analyzed using Chi-Square test for categorical and the Kruskal-Wallis test for continuous variables, generally of non-normal distribution. The results are summarized in the table. Age, poor mobility, surgery other than coronary bypass, and reoperation were the non-modifiable factors most associated with a prolonged LOS. Lower preoperative hemoglobin and albumin levels were associated with an increase in LOS. A class 3 or 4 NYHA functional class, chronic pulmonary disease, and anticoagulation use were associated with higher LOS. Classic cardiovascular risk factors, such as dyslipidemia, hypertension, and tobacco use, were not associated with differences in hospitalization duration. Postoperative and intraoperative factors associated with higher LOS included extubation in the operating room or within six hours, ICU stay duration, mobilization on postoperative days one and two, time to oral food tolerance and gut motility recovery, hyperglycemia on postoperative day one, the duration of arterial, venous, and urinary catheters, the amount of fluids on postoperative day one and the opioid use in POD 2. The complications most associated with a prolonged duration were any infectious complication, any respiratory complication, reoperation, readmission to intensive care, transfusion after 12 hours or at any time during hospitalization, prolonged postoperative sedation, and any rhythmic complication. Conclusion In our cohort of elective patients for cardiac surgery, factors traditionally addressed by ERAS programs were identified as being associated with a longer inpatient’s length of stay. Pre-operative nutritional and anemia optimization, early extubation and mobilization, and the prevention of respiratory and infectious complications should be targeted to improve hospital stay duration.

Defining Postinduction Hemodynamic Instability With an Automated Classification Model.

Postinduction hypotension (PIH) may be associated with increased morbidity and mortality. In earlier studies, the definition of PIH is solely based on different absolute or relative thresholds. However, the time-course (eg, how fast blood pressure drops during induction) is rarely incorporated, whereas it might represent the hemodynamic instability of a patient. We propose a comprehensive model to distinguish hemodynamically unstable from stable patients by combining blood pressure thresholds with the magnitude and speed of decline. This prospective study included 375 adult elective noncardiac surgery patients. Noninvasive blood pressure was continuously measured between 5 minutes before up to 15 minutes after the first induction agent had been administered. An expert panel rated whether the patient experienced clinically relevant hemodynamic instability or not. Interrater correlation coefficient and intraclass correlation were computed to check for consistency between experts. Next, an automated classification model for clinically relevant hemodynamic instability was developed using mean, maximum, minimum systolic, mean, diastolic arterial blood pressure (SAP, MAP, and DAP, respectively) and their corresponding time course of decline. The model was trained and tested based on the hemodynamic instability labels provided by the experts. In total 78 patients were classified as having experienced hemodynamic instability and 279 as not. The hemodynamically unstable patients were significantly older (7 years, 95% confidence interval (CI), 4-11, P < .001), with a higher prevalence of chronic obstructive pulmonary disease (COPD) (3% higher, 95% CI, 1-8, P = .036). Before induction, hemodynamically unstable patients had a higher SAP (median (first-third quartile): 161 (145-175) mm Hg vs 150 (134-166) mm Hg, P < .001) compared to hemodynamic stable patients. Interrater agreement between experts was 0.92 (95% CI, 0.89-0.94). The random forest classifier model showed excellent performance with an area under the receiver operating curve (AUROC) of 0.96, a sensitivity of 0.84, and specificity of 0.94. Based on the high sensitivity and specificity, the developed model is able to differentiate between clinically relevant hemodynamic instability and hemodynamic stable patients. This classification model will pave the way for future research concerning hemodynamic instability and its prevention.

Improving quantitative neuromuscular monitoring: an education initiative on stimulating electrode placement.

Quantitative neuromuscular monitoring reduces the incidence of residual neuromuscular block, but broad acceptance of monitoring has been elusive despite recommendations for quantitative monitoring for decades. Acceptance of quantitative monitoring may, in part, be related to the quality of the data from monitoring systems. This evaluation explored proper stimulating electrode positioning for electromyographic (EMG) monitoring, the impact of an educational intervention on electrode positioning and anesthesia provider (anesthesiologist, resident, anesthetist) confidence in the monitoring data from the device. In a single-center, observations of EMG electrode placement by anesthesia technicians, in 55 adult elective surgery patients were made by an independent observer. Separately, the anesthesia provider satisfaction with EMG derived data was recorded after reversal of neuromuscular block. An educational intervention then occurred on proper electrode positioning, including prior observations of electrode positioning, and prior anesthesia provider satisfaction with the EMG derived data. After the intervention, stimulating electrode position was observed with an additional 60 patients and anesthesia provider satisfaction with the data was again ascertained. The educational intervention significantly increased the proportion of ideal ulnar nerve groove electrode positioning from 74.5% to 95% (P < 0.003) and ideal wrist crease positioning (distal electrode within 2cm of crease) from 61.8% to 96.7% (P < 0.001). Anesthesia provider confidence with EMG derived information during anesthesia delivery, increased from 67 to 90% after the education (P = 0.005). There was a significant relationship between correct stimulating electrode placement and anesthesia provider confidence in the EMG derived data on neuromuscular block status. An educational intervention to improve EMG electrode positioning proved meaningful. It increased anesthesia provider confidence in the EMG derived data during anesthesia case management.

Effect of low-dose norepinephrine combined with goal-directed fluid therapy on postoperative pulmonary complications in lung surgery: A prospective randomized controlled trial

Study objectivePostoperative pulmonary complications (PPCs), the predominant complications following lung surgery, are closely associated with intraoperative fluid therapy. This study investigates whether continuous low-dose norepinephrine infusion combined with goal-directed fluid therapy (GDFT) reduced the risk of PPCs after lung surgery relative to either GDFT alone or standard fluid treatment. DesignA prospective, randomized controlled trial. SettingThe First Affiliated Hospital of Anhui Medical University, Anhui, China. PatientsThe study included 184 patients undergoing elective thoracoscopic lung resection surgery. InterventionsPatients were randomized into three groups based on different fluid treatment regimens: Group C received standard fluid treatment, Group G received GDFT, and Group N received continuous low-dose norepinephrine infusion combined with GDFT. MeasurementsThe primary outcome was the incidence of PPCs, including respiratory infection, atelectasis, pneumothorax, pleural empyema, respiratory failure, pulmonary embolism and bronchopleural fistula, during the postoperative hospital stay. Secondary outcomes were hemodynamic variables and arterial blood gases. Additional recorded parameters included other postoperative complications such as bleeding, postoperative re-intubation, re-hospitalization within 30 days, and the length of hospital stay. Main resultsGroup N showed a significantly lower PPCs incidence during hospitalization compared to Group C (11.5 % vs 27.9 %; odds ratio, 2.98; 95 % confidence interval, 1.17–8.31; P = 0.023). No significant difference in PPCs was found between Group N and Group G (11.5 % vs 14.5 %; odds ratio, 1.31; 95 % confidence interval, 0.46–3.91; P = 0.616). Additionally, there were no significant differences among the three groups in the components of PPCs. Group N showed higher mean arterial pressure and stroke volume index intraoperatively compared to Group C. ConclusionsContinuous low-dose norepinephrine infusion combined with GDFT reduced PPCs incidence in elective lung surgery patients compared with standard fluid management, but showed no difference compared to GDFT alone. Clinical trial registrationChiCTR2200064081.

Racial-ethnicity group distributions of blood product use in acute trauma care transfusion.

Recent studies suggest Black patients are transfused less often and at lower hemoglobin levels than White patients. In elective surgery, Black and Non-White patients have greater estimated blood loss and transfusion frequency. We asked whether similar transfusion disparities are observable in acute trauma resuscitation. In a single-center retrospective analysis of trauma registry/blood-bank-linked data from a large US trauma center, we identified all acute trauma patients 2011-2022. Our data sources permitted distinction of Race and Ethnicity and therefor binning as Non-White-race/not Hispanic plus any-race/Hispanic or White/not Hispanic. We tallied Injury Severity Scores mild through profound (ISS 1-9, 9-15, 16-25, >25), type (blunt vs. penetrating) and mechanism (firearms, etc.), and associated blood use overall and in the first, first four, and first 24 h, comparing results with chi square, p < .01. Overall, 50,394 (68.41%) acute trauma patients were classified as White and 23,251 (31.7%) as Other than White. White patients were more likely to receive any blood products (17.8% vs. 11.9%), but, for all measures of urgency/quantity, Non-White patients were transfused more often (respectively, first 4 h, 51.9% vs. 42.1%; ≥3u/first hour, 18.5% vs. 11.0%; ≥10u/24 h, 8.1% vs. 3.8%) (all p < .001). White patients were far more likely to have blunt injury than Non-White patients, (77.2% vs. 42.6%), less likely to have penetrating injury (10.1% vs. 14%) and far less likely to be injured by firearms (30.6% vs. 56.9%) (all p < .001). At our center, blood use in acute trauma resuscitation was associated with injury severity and mechanism, not race/ethnicity.