Elective Surgery Patients Research Articles

Trends and Prediction of Surgical Site Infection After Elective Spine Surgery: An Analysis of the American College of Surgeons National Surgical Quality Improvement Project Database.

Background: Surgical site infection (SSI) is an infrequent but costly complication after elective spine surgery. Identification of important temporal changes and predictive factors may inform targeted prevention efforts. Patients and Methods: A retrospective study of elective spine surgery patients was performed using the National Surgical Quality Improvement Programs (NSQIP) database from 2011 and 2019. Temporal changes in SSI and related factors were examined descriptively. Recursive partitioning and bootstrap forest techniques were used to inform the development of predictive models for SSI. Results: A total of 6,038 (1.66%) of 363,754 patients had an SSI recorded. Peri-operative transfusion and preoperative anemia decreased over the nine-year period, however, obesity and diabetes mellitus increased, whereas the SSI rate remained essentially unchanged. A full model including 15 variables had an area under the curve (AUC) of 0.693 (95% confidence interval [CI], 0.686-0.700) whereas a reduced model with just nine variables had an AUC of 0.690 (95% CI, 0.683-0.697). Adjusted odd ratios (aOR) greater than two were noted for only three variables; a posterior approach (aOR, 2.32; 95% CI, 2.14-2.50), body mass index (BMI) >40 kg/m2 (aOR, 2.63; 95% CI, 2.39-2.90), and surgical duration longer than 350 minutes (aOR, 2.39; 95% CI, 2.14-2.67). Remaining retained variables included albumin <3.5 g/dL, inpatient procedure, peri-operative transfusion, diabetes mellitus (both insulin/non-insulin), anemia, and smoking. Conclusions: Surgical site infection rate remained unchanged over a nine-year period despite the lower rates of allogeneic blood transfusion. Class 3 obesity, long operative times, and a posterior approach mainly for thoracic/lumbar spine procedures seemed more pragmatic, but their predictive performance was only modest in our prediction models for SSI.

Case mix-based changes in health status: A prospective study of elective surgery patients in Vancouver, Canada.

Hospital activity is often measured using diagnosis-related groups, or case mix groups, but this information does not represent important aspects of patients' health outcomes. This study reports on case mix-based changes in health status of elective (planned) surgery patients in Vancouver, Canada. We used a prospectively recruited cohort of consecutive patients scheduled for planned inpatient or outpatient surgery in six acute care hospitals in Vancouver. All participants completed the EQ-5D(5L) preoperatively and 6months postoperatively, collected from October 2015 to September 2020 and linked with hospital discharge data. The main outcome was whether patients' self-reported health status improved among different inpatient and outpatient case mix groups. The study included 1665 participants with completed EQ-5D(5L) preoperatively and postoperatively, representing a 44.8% participation rate across eight inpatient and outpatient surgical case mix categories. All case mix categories were associated with a statistically significant gain in health status (p < .01 or lower) as measured by the utility value and visual analogue scale score. Foot and ankle surgery patients had the lowest preoperative health status (mean utility value: 0.6103), while bariatric surgery patients reported the largest improvements in health status (mean gain in utility value: 0.1515). This study provides evidence that it was feasible to compare patient-reported outcomes across case mix categories of surgical patients in a consistent manner across a system of hospitals in one province in Canada. Reporting changes in health status of operative case mix categories identifies characteristics of patients more likely to experience significant gains in health.

Hundred Pediatric Cases Treated for Chiari Type II Malformation with Hydrocephalus and Myelomeningocele.

Background Chiari malformation type II (CM-II) may not always present as an asymptomatic disorder but prove to be difficult in managing. This is especially true for neonates who show the worst prognosis. There is confounding data over whether shunting or craniocervical junction (CVJ) decompression should be employed. This retrospective analysis summarizes the results of 100 patients diagnosed and treated for CM-II along with hydrocephalus and myelomeningocele. Methods We reviewed all the children who were diagnosed and surgically treated for CM-II at the Moscow Regional Hospital. Surgical timing was decided on the clinical conditions of each patient. Urgent surgery in the more compromised patients (usually infants) and elective surgery for patients with less severe conditions was performed. All patients first underwent CVJ decompression. Results The retrospective review yielded 100 patients operated on for CM-II with concomitant hydrocephalus and myelomeningocele. The average herniation was 11.2 ± 5.1 mm. However, herniation level did not correlate with clinical findings. Concomitant syringomyelia was observed in 60% of patients. More severe spinal deformity was observed in patients with widespread syringomyelia ( p = 0.04). In children of the younger age group, cerebellar symptoms and bulbar disorders were more frequently observed ( p = 0.03), and cephalic syndrome was noted much less frequently ( p = 0.005). The severity of scoliotic deformity correlated with the prevalence of syringomyelia ( p = 0.03). Satisfactory results were significantly more often observed in patients of the older age group ( p = 0.02). Patients with unsatisfactory results at the time of treatment were significantly younger ( p = 0.02). Conclusion If CM-II is asymptomatic, then no specific treatment is prescribed. If the patient develops pain in the occiput and neck, then pain relievers are prescribed. If a patient has neurological disorders or concomitant syringomyelia, hydrocephalus or myelomeningocele, surgical intervention is indicated. The operation is also performed if the pain syndrome cannot be overcome within the framework of conservative therapy.

Perceptions and Attitudes of Patients and Health Care Stakeholders on Implementing a Telehealth Service for Preoperative Evaluation: A Qualitative Analysis.

Studies suggest that preoperative evaluation can be effectively conducted through telehealth. As the COVID-19 pandemic has accelerated digital transformation, we hypothesize that a new telehealth model of care may be feasibly implemented for preoperative evaluation at our institution. This qualitative study seeks to evaluate the attitudes and perception of elective surgery patients and health care providers toward telehealth conducted for preanesthesia evaluation. At a tertiary women's hospital in Asia, health care providers and elective surgery patients were recruited by convenience and snowball sampling to undergo one-on-one semistructured interviews regarding a new telehealth model of care for preanesthesia evaluation, under-pinned by the Normalization Process Theory. Data were analyzed, coded, and consolidated into themes using the framework analysis method by a team of four researchers from diverse backgrounds. Twenty-five interviews were conducted among 10 patients and 15 health care participants. Ninety-five codes were identified, consolidated into four themes that connect to guide the implementation of a new telehealth pathway for preoperative care, mapped to the Normalization Process Theory. The themes pertain to advantages of telehealth workflow (coherence), requisites for new telehealth workflow (coherence, collective action), barriers to implementation (cognitive participation, collective action), and enablers of implementation (cognitive participation, collective action). All participants were receptive to telehealth, but health care participants expressed concern about the impact of additional tasks on current clinical workload. Training in videoconferencing was deemed essential by both patients and health care providers. The study has provided insights into levels of coherence and cognitive participation among patients and health care providers. The telehealth workflow should be redesigned, considering systems' constraints and stakeholders' needs. Greater buy-in is needed to gain health care providers' commitment for collective action. Clinicaltrials.gov identifier: NCT05781789.

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.

Cardiovascular assessment in Noncardiovascular surgery: what evidences say?

Annually more than 300 million patients (about 5% of the world population) undergo major surgery worldwide. Nearly 85% of major operations are noncardiac surgical procedures. Proper preoperative evaluation is important to reduce cardiovascular morbidity and mortality in patients undergoing noncardiac surgery. Cardiac risk is determined by two main factors: patient-related risk and surgical risk. Timing of surgery (Immediate, Urgent, time-sensitive, elective), type of surgical approach ( laparoscopy, vascular and endovascular procedure, open surgeries) , risk of surgery ( Low, intermediate, high surgical risk) determine surgical risk. Patient-related risk is assessed by patient’s age, the presence of cardiovascular risk factors (e.g. smoking, hypertension, diabetes, dyslipidaemia,) or established cardiovascular disease, and comorbidities (heart failure, arrhythmia etc.).In emergency surgery preoperative evaluation is limited as saving life is more important. In elective surgery patient related risk factors, comorbidity, associated cardiovascular diseases, timing and risk of surgery , functional capacity determine further preoperative evaluation with necessary investigations like ECG, Echo, laboratory investigations, biomarkers, stress test, coronary angiogram etc. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 179

Preoperative slow-wave sleep is associated with postoperative delirium after heart valve surgery: A prospective pilot study.

Postoperative delirium (POD) is a very common neurological complication after valve surgery. Some studies have shown that preoperative sleep disorder is associated with POD, but the correlation between preoperative slow wave sleep (SWS) and POD remains unclear. Therefore, this study aims to identify the correlation between preoperative slow wave sleep and postoperative delirium in patients with heart valve disease. This was a prospective, observational study of elective valve surgery patients admitted to the Heart Medical Center between November 2021 and July 2022. Polysomnography (PSG) was used to monitor sleep architecture from 9:30 p.m. for 1 night before surgery to 6:30 a.m. on the day of surgery. Patients were assessed for postoperative delirium from postoperative day 1 to extubation or day 5 by using the Richmond Agitation/Sedation Scale (RASS) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). A total of 60 elective valve surgery patients were enrolled in this study. Prolonged N1 (11.44%) and N2 (58.62%) sleep, decreased N3 sleep (8.75%) and REM sleep (18.24%) within normal limits were the overall sleep architecture. Compared with patients without POD, patients with POD had less slow wave sleep 1 night before surgery (5.77% vs 10.88%, p < 0.001). After adjusting for confounding factors, slow wave sleep (OR: 0.647, 95% CI 0.493-0.851, p = 0.002) was found to be a protective factor for postoperative delirium. The preoperative SWS is a predictive factor of the POD in patients undergoing valve surgery. But further studies with larger sample sizes are still needed to elucidate the relationship between preoperative slow wave sleep and postoperative delirium.

Effect of the machine learning-derived Hypotension Prediction Index (HPI) combined with diagnostic guidance versus standard care on depth and duration of intraoperative and postoperative hypotension in elective cardiac surgery patients: HYPE-2 – study protocol of a randomised clinical trial

IntroductionHypotension is common during cardiac surgery and often persists postoperatively in the intensive care unit (ICU). Still, treatment is mainly reactive, causing a delay in its management. The Hypotension Prediction...

Time requirements for perioperative glucose management using fully closed-loop versus standard insulin therapy: A proof-of-concept time-motion study.

To compare the time required for perioperative glucose management using fully automated closed-loop versus standard insulin therapy. We performed a time-motion study to quantify the time requirements for perioperative glucose management with fully closed-loop (FCL) and standard insulin therapy applied to theoretical scenarios. Following an analysis of workflows in different periods of perioperative care in elective surgery patients receiving FCL or standard insulin therapy upon hospital admission (pre- and intra-operatively, at the intermediate care unit and general wards), the time of process-specific tasks was measured by shadowing hospital staff. Each task was measured 20 times and its average duration in combination with its frequency according to guidelines was used to calculate the cumulative staff time required for blood glucose management. Cumulative time was calculated for theoretical scenarios consisting of elective minor and major abdominal surgeries (pancreatic surgery and sleeve gastrectomy, respectively) to account for the different care settings and lengths of stay. The FCL insulin therapy reduced the time required for perioperative glucose management compared to standard insulin therapy, across all assessed care periods and for both perioperative pathways (range 2.1-4.5). For a major abdominal surgery, total time required was 248.5 min using FCL versus 753.9 min using standard insulin therapy. For a minor abdominal surgery, total time required was 68.6 min and 133.2 min for FCL and standard insulin therapy, respectively. The use of fully automated closed-loop insulin delivery for inpatient glucose management has the potential to alleviate the workload of diabetes management in an environment with adequately trained staff.

Cardiac surgery during the COVID-19 pandemic.

The COVID-19 pandemic had several specific as well as general implications on cardiac surgery. Acute respiratory distress made extracorporeal oxygenation necessary in asignificant number of patients and accordingly many patients were treated in anesthesiological and even more in cardiac surgical intensive care units, which left only alimited number of beds in the intensive care units available for elective surgery cases. Moreover, the necessary availability of intensive care beds for severely diseased COVID-19 patients in general posed afurther limit, as did the relevant number of diseased personnel. Specific emergency plans were developed for many heart surgery units, limiting the number of elective cases. Increasing waiting lists were of course stressful for numerous elective-surgery patients and the decreased number of heart operations also meant afinancial burden for many units.

Efficacy of Intraperitoneal 0.2% Ropivacaine With Dexmedetomidine Versus 0.2% Ropivacaine With Ketamine in Laparoscopic Surgeries: A Randomized Controlled Trial.

Effective pain management modalities are the armamentarium for enhanced recovery in laparoscopic surgeries. Intraperitoneal instillation of local anaesthetics with adjuvants is advantageous in minimizing pain. So, we designed this study with the aim to compare the analgesic effectiveness of intraperitoneal ropivacaine with adjuvants like dexmedetomidine versus ketamine for postoperative analgesia. The objective of this study is to assess the total duration of analgesia and total rescue analgesic dose requirements in the first 24 hours postoperatively. A total of 105 consenting patients for elective laparoscopic surgeries were enrolled and divided into three groups by computer-generated randomization as follows: Group 1: 30 ml of 0.2% ropivacaine with ketamine 0.5 mg/kg diluted to 1 ml; Group 2: 30 ml of 0.2% ropivacaine with dexmedetomidine 0.5 mcg/kg diluted to 1 ml; Group 3: 30 ml of 0.2% ropivacaine with 1 ml of normal saline. The postoperative visual analogue scale (VAS) score, total duration of analgesia, and total analgesic dose were calculated and compared among the three groups. The postoperative analgesic duration after intraperitoneal instillation of Group 2 was longer as compared to Group 1. The total analgesic requirement was lower in Group 2 as compared to Group 1, and the p-value was significant (p ≤ 0.001) for both parameters. Demographic parameters and VAS scores among the three groups were not statistically significant. We conclude that intraperitoneal instillation of local anaesthetics with adjuvants is effective for postoperative analgesia in laparoscopic surgeries, and ropivacaine 0.2% with dexmedetomidine 0.5 mcg/kg is more effective when compared to ropivacaine 0.2% with ketamine 0.5 mg/kg.

Pain Self-Efficacy (PSEQ) score of

BACKGROUND CONTEXTPain self-efficacy, or the belief that one can carry out activities despite pain, has been shown to be associated with back and neck pain severity. However, the literature correlating psychosocial factors to opioid use, barriers to proper opioid use, and Patient-Reported Outcome Measurement Information System (PROMIS) scores is sparse. PURPOSEThe primary aim of this study was to determine whether pain self-efficacy is associated with daily opioid use in patients presenting for spine surgery. The secondary aim was to determine whether there exists a threshold self-efficacy score that is predictive of daily preoperative opioid use and subsequently to correlate this threshold score with opioid beliefs, disability, resilience, patient activation, and PROMIS scores. PATIENT SAMPLEFive hundred seventy-eight elective spine surgery patients (286 females; mean age of 55 years) from a single institution were included in this study. STUDY DESIGN/SETTINGRetrospective review of prospectively collected data. OUTCOME MEASURESPROMIS scores, daily opioid use, opioid beliefs, disability, patient activation, resilience. METHODSElective spine surgery patients at a single institution completed questionnaires preoperatively. Pain self-efficacy was measured by the Pain Self-Efficacy Questionnaire (PSEQ). Threshold linear regression with Bayesian information criteria was utilized to identify the optimal threshold associated with daily opioid use. Multivariable analysis controlled for age, sex, education, income, and Oswestry Disability Index (ODI) and PROMIS-29, version 2 scores. RESULTSOf 578 patients, 100 (17.3%) reported daily opioid use. Threshold regression identified a PSEQ cutoff score of <22 as predictive of daily opioid use. On multivariable logistic regression, patients with a PSEQ score <22 had two times greater odds of being daily opioid users than those with a score ≥22. Further, PSEQ <22 was associated with lower patient activation; increased leg and back pain; higher ODI; higher PROMIS pain, fatigue, depression, and sleep scores; and lower PROMIS physical function and social satisfaction scores (p<.05 for all). CONCLUSIONSIn patients presenting for elective spine surgery, a PSEQ score of <22 is associated with twice the odds of reporting daily opioid use. Further, this threshold is associated with greater pain, disability, fatigue, and depression. A PSEQ score <22 can identify patients at high risk for daily opioid use and can guide targeted rehabilitation to optimize postoperative quality of life.

Caprini assessment utilization and impact on patient safety in gynecologic surgery.

Postoperative venous thromboembolism (VTE) can potentially be associated with significant morbidity, mortality, and healthcare costs. The aim of this study was to determine the utilization of Caprini guideline indicated VTE in elective gynecologic surgery patients and its impact on postoperative VTE and bleeding complications. This was a retrospective cohort study of elective gynecologic surgical procedures performed between January 1, 2016, and May 31, 2021. Two study cohorts were generated: (1) those who received and (2) those who did not receive VTE prophylaxis based on Caprini score risk stratification. Outcome measures were then compared between the study cohorts and included the development of a VTE up to 90-days postoperatively. Secondary outcome measures included postoperative bleeding events. A total of 5471 patients met inclusion criteria and the incidence of VTE up to 90days postoperatively was 1.04%. Overall, 29.6% of gynecologic surgery patients received Caprini score-based guideline VTE prophylaxis. 39.2% of patients that met high-risk VTE criteria (Caprini > 5) received appropriate Caprini score-based prophylaxis. In multivariate regression analysis, the American Society of Anesthesiologists (ASA) score (OR 2.37, CI 1.27-4.45, p < 0.0001) and Caprini score (OR 1.13, CI 1.03-1.24, p = 0.008) predicted postoperatively VTE occurrence. Increasing Charlson comorbidity score (OR 1.39, CI 1.31-1.47, P < 0.001) ASA score (OR 1.36, CI 1.19-1.55, P < 0.001) and Caprini score (OR 1.10, CI 1.08-1.13, P < 0.001) were associated with increased odds of receiving appropriate inpatient VTE prophylaxis. While the overall incidence of VTE was low in this cohort, enhanced adherence to risk-based practice guidelines may provide more patient benefit than harm to postoperative gynecologic patients.

Perioperative Insulin Regimens in Patients With Insulin-Treated Type 2 Diabetes Mellitus Hospitalized for a Short Time for Minor Eye Surgery.

Elective surgery in patients with insulin-treated type 2 diabetes mellitus (T2D) and the admission period in the hospital, comprise a distinctive and challenging situation for physicians, nurses, as well as for the patients themselves. There is a lack of widely accepted evidence-based and standardized approach of care in regard to perioperative management of patients with insulin-treated T2D. The main purpose of this proof-of-concept study was to investigate whether a standardized insulin and meal regimen on the day of surgery leads to a better management of diabetes in terms of blood glucose (BG) levels. Two different insulin and meal regimens-group A with half of insulin dose given with a standardized postoperative meal and group B with a custom preoperative breakfast and full insulin dose-were compared with Group C with routine care (no meal and no insulin injection on the day of surgery). Each group consisted of 12 to 15 patients. BG measurements were performed pre- and immediately postoperatively, before meals and at bedtime. Both standardized and well-defined insulin and meal regimens resulted in better average BG levels in the perioperative period, especially in the morning after the surgery. In this study, we observed that a standardized perioperative insulin regimen efficiently lowered postoperative BG levels. Providing a custom breakfast and a full insulin dose resulted in lower postoperative BG levels. These approaches were not associated with an increase in hypoglycemic events. Physicians and nursing staff gave positive feedback to the structured and well-defined approaches.

Clonidine premedication was better in preventing hemodynamic response changes post laryngoscopy and endotracheal intubation compared to fentanyl premedication

Background: Airway control under general anesthesia can be performed using laryngoscopy and endotracheal intubation. Laryngoscopy and endotracheal intubation produce mechanical and chemical stimuli that increase sympatho-adrenergic activity, causing an increased hemodynamic response. Various pharmacological and non-pharmacological methods have been used to reduce the response of hemodynamic changes in laryngoscopy and endotracheal intubation, such as fentanyl and clonidine. This study aimed to compare the effectiveness of fentanyl and clonidine in reducing hemodynamic response changes after laryngoscopy and endotracheal intubation. Methods: A double-blind randomized clinical trial was conducted on 48 elective surgery patients in the Surgical Installation of Dr. Kariadi General Hospital and Diponegoro National Hospital Semarang who were planned for laryngoscopy and endotracheal intubation procedures. Subjects were randomized and divided into 2 groups. Group 1 was administered with 2 µg/kgBW intravenous fentanyl premedication and group II was administered with 1 µg/kgBW intravenous clonidine premedication 5 minutes before the laryngoscopy and endotracheal intubation procedure. At baseline and at 1, 3, and 5 minutes after laryngoscopy and endotracheal intubation, the systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded simultaneously. Results: Both fentanyl and clonidine could maintain SBP, DBP, MAP, and HR within normal range. However, clonidine premedication seemed to be better in preventing hemodynamic response changes post-laryngoscopy and endotracheal intubation compared to fentanyl premedication. Clonidine premedication showed lower SBP, DBP, and MAP, but not HR, at the 1st and 3rd-minute post laryngoscopy and endotracheal intubation in comparison with fentanyl premedication (p&lt;0.05). Conclusion: If confirmed by further findings, clonidine premedication may be preferable to prevent hemodynamic changes after laryngoscopy and endotracheal intubation.

Surgical site infections are independently associated with the development of postoperative acute-on-chronic liver failure in liver cirrhosis.

Acute-on-chronic liver failure (ACLF) is associated with organ failure and high short-term mortality. Bacterial infections and surgery have been reported as major precipitants for ACLF. However, detailed characterization of postoperative infections after elective surgery in patients with liver cirrhosis and their impact on the development of ACLF have not been investigated yet. A total of 235 patients with cirrhosis without ACLF and proven bacterial infections undergoing elective surgery were included. The primary end point was the development of ACLF within 28 days after surgery, and secondary end points were infection development within 28 days and 3-month ACLF-related mortality. Cox regression analysis was used for identification of risk factors associated with ACLF development, infection development, and mortality. A total of 86 patients (37%) developed ACLF within 28 days after surgery. Patients with new postoperative infections had significantly higher rates of associated ACLF episodes within 28 days (51% vs. 24%, p < 0.001) and higher 3-month mortality ( p < 0.05) than patients without postoperative infections. New infections after surgery [HR: 2.43 (1.59-3.71), p < 0.001] and organ/space surgical site infections [HR: 2.46 (1.26-4.80), p = 0.01] in particular were independent risk factors associated with ACLF development 28 days after surgery. Extensive procedures were associated with the development of new postoperative infection episodes within 28 days. Infections treated with initial appropriate empirical antibiotic strategies showed significantly improved survival. This study characterizes and identifies bacterial infections in general and organ/space surgical site infection in particular as precipitating events for the development of ACLF after elective surgery in patients with cirrhosis. Postoperative ACLF combined with infections leads to higher postoperative short-term mortality than each condition separately, especially in extensive procedures. Interdisciplinary care, early identification of postoperative ACLF and infections, and adequate, broad, and early treatment strategies are needed to improve postoperative outcome.

Comparison of 4.5% Versus 8% Sevoflurane for Inhalational Induction in Adults

Background: Inhalational induction is a frequently used anesthetic technique in pediatric patients. However, it is less frequently used in adult patients undergoing surgery. General anesthesia can be induced either by intravenous injection or inhalation of anesthetic drugs. There are no established guidelines about the usage of 4.5% vs 8% sevoflurane for inhalation induction in adults undergoing elective day care surgery. Aim: To compare mean time to loss of eyelash reflex using 4.5% vs 8% sevoflurane for inhalational induction in adult patients undergoing elective day care surgery. Methodology: This randomized controlled trial was conducted in the department of anesthesia, Mayo Hospital Lahoreover a period of six months from June 2018 to December 2018. A total of 60 patients were enrolled in the study. We included adult patients aged 18-60 years of either gender and ASA status I &amp; II undergoing elective day care surgery. While, patients having history of adverse reaction to inhalational agents and those who were on chronic sedatives, antipsychotic treatment were excluded. Demographic data of age and gender were obtained along with their body weight, height and BMI. They were randomly divided into two study groups using lottery method. After routine pre-op check and attaching standard anesthesia monitoring, patients in group-A and group-B were given 4.5% sevoflurane &amp; 8% sevoflurane respectively at a fresh gas flow of 8 L/min of oxygen and they were instructed to take deep breaths while inhaling gas with help of face mask. Results: The mean age in 4.5% sevoflurane group was 42.27±11.83 years while in 8% sevoflurane group it was 45.43±12.76 years. In 4.5% sevoflurane group there were 12(40%) male and 18(60%) female cases while in 8% sevoflurane group there were 11(36.67%) male and 19(63.33%) female cases. The mean time to loss of eyelash reflex in 4.5% sevoflurane group was 88.57±6.71 seconds and in 8% sevoflurane group the mean time to loss eyelashes reflex was 67.87±5.90 seconds. The mean time to loss eyelashes reflex was statistically less in 8% sevoflurane group, with p-value 0.001. Conclusion: We concluded that mean time to loss eyelashes reflex was considerably lesser with8% sevoflurane when compared with 4.5% sevoflurane for inhalational induction in adult patients for elective day care surgery. Keywords: Inhalational induction, sevoflurane, eyelash reflex, day care surgery.

Prediction of Male Coronary Artery Bypass Grafting Outcomes Using Body Surface Area Weighted Left Ventricular End-diastolic Diameter: Multicenter Retrospective Cohort Study

The presence of a high left ventricular end-diastolic diameter (LVEDD) has been linked to a less favorable outcome in patients undergoing coronary artery bypass grafting (CABG) procedures. However, by taking into consideration the reference of left ventricular size and volume measurements relative to the patient's body surface area (BSA), it has been suggested that the accuracy of the predicting outcomes may be improved. We propose that BSA weighted LVEDD (bLVEDD) is a more accurate predictor of outcomes in patients undergoing CABG compared to simply using LVEDD alone. This study was a comprehensive retrospective cohort study that was conducted across multiple medical centers. The inclusion criteria for this study were patients who were admitted for treatment between October 2016 and May 2021. Only elective surgery patients were included in the study, while those undergoing emergency surgery were not considered. All participants in the study received standard care, and their clinical data were collected through the institutional registry in accordance with the guidelines set forth by the Society of Thoracic Surgeons National Adult Cardiac Database. bLVEDD was defined as LVEDD divided by BSA. The primary outcome was in-hospital all-cause mortality (30 days), and the secondary outcomes were postoperative severe adverse events, including use of extracorporeal membrane oxygenation, multiorgan failure, use of intra-aortic balloon pump, postoperative stroke, and postoperative myocardial infarction. In total, 9474 patients from 5 centers under the Chinese Cardiac Surgery Registry were eligible for analysis. We found that a high LVEDD was a negative factor for male patients' mortality (odds ratio 1.44, P<.001) and secondary outcomes. For female patients, LVEDD was associated with secondary outcomes but did not reach statistical differences for morality. bLVEDD showed a strong association with postsurgery mortality (odds ratio 2.70, P<.001), and secondary outcomes changed in parallel with bLVEDD in male patients. However, bLVEDD did not reach statistical differences when fitting either mortality or severer outcomes in female patients. In male patients, the categorical bLVEDD showed high power to predict mortality (area under the curve [AUC] 0.71, P<.001) while BSA (AUC 0.62) and LVEDD (AUC 0.64) both contributed to the risk of mortality but were not as significant as bLVEDD (P<.001). bLVEDD is an important predictor for male mortality in CABG, removing the bias of BSA and showing a strong capability to accurately predict mortality outcomes. ClinicalTrials.gov NCT02400125; https://clinicaltrials.gov/ct2/show/NCT02400125.

Viruses in the Respiratory Tract in Elective Cardiac Surgery Patients

Objectives: Acute respiratory distress syndrome after cardiac surgery is a severe complication that is associated with high morbidity and mortality. The presence of viruses in the respiratory tract is postulated to be one of multiple factors attributing to development of Acute Respiratory Distress Syndrome (ARDS), but studies report conflicting results. Since this possible risk factor can potentially be influenced by screening or vaccination, we aimed to further investigate the role of viruses in the development of ARDS after cardiac surgery. Methods: We conducted an explorative prospective cohort study in 49 randomly chosen asymptomatic adult elective cardiac surgery patients. On four different time points, non-fiberscopic mini-broncho alveolar lavages (miniBAL) were collected and analysed with multiplex PCR testing for 11 types of respiratory viruses. Results and Conclusions: Various (merely low pathogenic) respiratory viruses were detected in 12% of our study population. Respiratory viruses were present both within and out of the influenza-like-illness- season. 19 (39%) of all patients developed acute respiratory distress syndrome. No relationship of viral presence with major pulmonary outcomes (PaO2/FiO2 ratio, development of acute respiratory distress syndrome or mechanical ventilation time) could be demonstrated, though events were too few to allow multivariate analyses. Conclusion: Asymptomatic elective cardiac surgery patients do carry respiratory viruses, though not associated with development of respiratory complications. Further research is warranted, in particular research into the (more pathogenic) diverse subtypes of the respiratory viruses, the relevance of virus load (cycle threshold-values) and even into the diagnostic method (throat swab versus deeper material).

Atrial dysrhythmias are independent predictors of serious complications and 30-day mortality after elective bariatric surgery: a retrospective study of 731,981 patients.

The objectives of this study were to characterize the prevalence of atrial dysrhythmias for elective bariatric surgery patients and to explore their impact on postoperative outcomes. Data was extracted from the North American Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to2019. All primary Roux-en-Y gastric bypass and sleeve gastrectomy procedures were included. Patients with atrial dysrhythmias (ADs) were identified as patients coded as receiving preoperative therapeutic anticoagulation without a prior history of deep vein thrombosis, venous thromboembolism, pulmonary embolism, or other conditions requiring anticoagulation. Multivariable logistic regression analysis was used to determine the impact of preoperative ADs on postoperative complications and 30-day mortality. We evaluated 731,981 patients, of whom 13,591 (1.9%) had preoperative ADs. Patients with ADs were more likely to be older, have a higher body mass index, and be male. Metabolic co-morbidities also were more common in those with ADs, as demonstrated by the higher rates of medication use and insulin-dependent diabetes, hypertension, dyslipidemia, and sleep apnea. After adjusting for co-morbidities using multivariable logistic regression, AD was the single greatest independent predictor of serious complications and 30-day mortality. ADs were observed in approximately 2% of MBSAQIP patients. ADs are among the greatest independent predictors of serious complications and mortality, suggesting that these patients are associated with a higher perioperative risk profile warranting further optimization.