General Surgical Population Research Articles

National outcomes of cardiac surgery in patients receiving kidney replacement therapy.

Studies estimating risks following cardiac surgery for patients receiving kidney replacement therapy have been limited by the size and generalizability of those cohorts. This study used data linked between registries to estimate short-term postoperative outcomes for large patient cohorts receiving kidney replacement therapy at the time of surgery. This population-based observational cohort study included adult patients who had undergone cardiac surgery in Australia between 2010 and 2019. Patient data were linked with a kidney replacement therapy registry to accurately identify cohorts and extract relevant data. Multivariable logistic regression estimated risk of operative (30-day) mortality and other postoperative outcomes for long-term dialysis and functioning kidney transplant cohorts compared with each other and the general cardiac surgical population. Of 114,496 surgeries, 1,241 were for patients receiving long-term dialysis and 298 for those with a kidney transplant. The mortality rate was highest for valve-with-coronary artery bypass grafting for dialysis (18.78 per 100 surgeries (95% CI 13.37,25.25) and transplant patients (14.00 [5.82,26.74]). Dialysis patients had higher adjusted odds of mortality (odds ratio [OR] 4.17 [95% CI 3.31,5.25]) and all other measured outcomes than the general population. Kidney transplant recipients had similarly elevated odds of mortality (OR 3.52 [95% CI 2.16,5.72]). Despite the younger age of dialysis and transplant cohorts at surgery, operative mortality rates were higher, and for valve-with-coronary artery bypass grafting were 3.7- to 5-fold those of the general population. Dialysis patients were a high risk for cardiac surgery, and the prognosis for kidney transplant recipients was similarly poor.

Excessive use of preoperative blood type and antibody screening: A retrospective observational study conducted in a hospital in Norway.

This study aimed to identify the blood transfusion rates for several surgical procedures in a single district general hospital and assess the value of preoperative blood type and antibody screen across all relevant surgical procedures. We hypothesized that there was an overuse of blood type and antibody screen in our general surgical population. A database containing transfusions of patients who underwent elective- or emergency surgery from January 2015 to September 2020 was matched to a database of preoperative type-and-screen performed in the same period. Registered procedures where the incidence of transfusion is deemed low were excluded. The included procedures were assessed for the intraoperative usefulness of type- and-screen testing. In the included 68.892 surgeries, 36.134 (52.0%) blood samples were preoperatively tested for the blood type and screened for antibodies according to the hospital's routine. Overall 3.517 (5.1%) of surgeries had patients that received a transfusion in the perioperative period and 1.2% (n = 850) during the surgery. Most surgeries had a very low incidence of transfusion. Despite this, type-and-screen tests were widely used. This suggests the need for a more focused pre-surgery type-and-screen approach, and a more data driven approach to local guidelines in collaboration with surgical specialties.

The performance of a post-induction fentanyl-test in predicting postoperative respiratory adverse events in children after adenotonsillectomy.

Postoperative respiratory adverse events (PRAE) occurred more frequently in children having adenotonsillectomy than the general surgical population, and can require escalation of care. This study aims to assess the usefulness of post-induction fentanyl-test to predict PRAE in children with obstructive sleep apnea (OSA) after adenotonsillectomy. Two hundred and forty patients with OSA undergoing adenotonsillectomy were included in this study. The oxygen saturation during sleep was monitored the night before adenotonsillectomy. Fentanyl-test was conducted under spontaneous breath after anesthesia induction with sevoflurane. Fentanyl-induced reduction in respiratory rate (FRR) was defined as the percentage of reduction in respiratory rate after 1 mcg/kg fentanyl administration. PRAE in the post-anesthesia care unit (PACU) included both respiratory complications and medical interventions. Receiver operating characteristic (ROC) analysis was used to assess the usefulness of fentanyl-test in predicting PRAE. Of the 240 children undergoing elective adenotonsillectomy, 38 children (16%) experienced PRAE in PACU. The areas under ROC curve for FRR and Nadir SpO2 were 0.756 and 0.692, respectively. FRR greater than 53% best predicted PRAE in PACU, with a sensitivity of 68% and a specificity of 72%. Patients with FRR > 53% exhibited a significantly longer duration of desaturation requiring supplementary oxygen than those with FRR ≦ 53% (p < 0.001). We suggest that post-induction fentanyl-test is a feasible evaluation for children undergoing adenotonsillectomy to predict early PRAE, especially for those who have not undergone polysomnography. Registry: ClinicalTrials.gov; Name: Effects of Individualized Opioid Analgesia Versus Conventional Opioid Analgesia After Adenotonsillectomy in Children; URL: https://clinicaltrials.gov/study/NCT04527393; Identifier: NCT04527393.

#242 Incidence of postoperative acute kidney injury is twice as high in men than women following radical colorectal surgery—key findings from PROSACC

Abstract Background and Aims Acute kidney injury (AKI) affects approximately 8% of the general surgical population. Additionally, AKI increases the risk for morbidity and mortality by 8- and 3-fold respectively. It was earlier believed that women had a greater risk for postoperative AKI. However, recent literature indicates that the incidence of AKI is actually higher in hospitalized men than women (2.2 odds ratio). Hence the male sex is currently discussed to be a risk factor for AKI. We therefore hypothesized that the incidence of postoperative AKI will be higher amongst men than women after radical colorectal surgery. Method We conducted a post hoc analysis (PROSACC: Propofol or Sevoflurane Anesthesia in Colon Cancer, NCT05585866) on the database from the CAN-study (Cancer and Anesthesia: Survival After Radical Surgery, NCT01975064). The CAN-study included cancer patients undergoing radical surgery at several sites in China, Croatia, Poland, and Sweden. Patients included in PROSACC were those undergoing colorectal surgery at any predefined site. Primary outcome was incidence of AKI by changes in plasma creatinine, secondary outcome was AKI in association to gender (women/men). The KDIGO criteria was used for classifying AKI on postoperative days 1-3 and 4-10. Database management and statistical analysis was performed by Uppsala Research Centre. Men vs women AKI outcome at day 1-3 and 4-10 was statistically compared with the Pearson's chi-square test. Results A total of 3254 patients (n = 1900 men; n = 1354 women) were included in the analysis with their preoperative plasma creatinine. Demographics showed that of the women, 39% had hypertension, 12% had diabetes and 2% had pre-existing kidney disease. In comparison, amongst the men, 24% had hypertension, 9% had diabetes and 1% pre-existing kidney disease. Postoperative plasma creatinine values were obtainable from the database in 2741 patients (n = 1578 men; n = 1163 women) on postoperative day 1-3. One hundred and ninety patients (7%) of this group had developed AKI. Separated by gender, 6% of the women (n = 72) and 8% of the men (n = 118) had established AKI according to KDIGO (p = 0.190). Plasma creatinine values were obtainable in 986 patients (n = 582 men; n = 404 women) on postoperative day 4-10 whereas 87 patients (9%) in this group had developed AKI. Separated by gender, 6% of the women (n = 23) but 11% of the men (n = 64) had established AKI at this timepoint (p = 0.004). Conclusion With this post hoc analysis of a global, multicentre, randomized controlled trial we conclude that the incidence of postoperative AKI is twice as high in men compared with women after 4-10 postoperative days following radical colorectal surgery. Since the women had higher rate of pronounced preoperative risk factors yet still had lower incidence of AKI, this study aligns with the conclusion that the male sex is a risk factor for postoperative AKI.

Incidence of postoperative acute kidney injury is twice as high in men than women following radical colorectal surgery — key findings from PROSACC, a posthoc analysis of a global, multicenter, randomized controlled trial

Acute kidney injury (AKI) affects approximately 8% of the general surgical population. Additionally, AKI increases the risk for morbidity and mortality by 8- and 3-fold respectively. It was earlier believed that women had a greater risk for postoperative AKI. However, recent literature indicates that the incidence of AKI is actually higher in hospitalized men than women (2.2 odds ratio). Hence the male sex is currently discussed to be a risk factor for AKI. We therefore hypothesized that the incidence of postoperative AKI will be higher amongst men than women after radical colorectal surgery. We conducted a posthoc analysis (PROSACC: Propofol or Sevoflurane Anesthesia in Colon Cancer, NCT05585866) on the database from the CAN-study (Cancer and Anesthesia: Survival After Radical Surgery, NCT01975064). The CAN-study included cancer patients undergoing radical surgery at several sites in China, Croatia, Poland, and Sweden. Patients included in PROSACC were those undergoing colorectal surgery at any predefined site. Primary outcome was incidence of AKI by changes in plasma creatinine, secondary outcome was AKI in association to gender (women/men). The KDIGO criteria was used for classifying AKI on postoperative days 1-3 and 4-10. Database management and statistical analysis was performed by Uppsala Research Centre. Men vs women AKI outcome at day 1-3 and 4-10 was statistically compared with the Pearson’s chi-square test. A total of 3254 patients (n=1900 men; n=1354 women) were included in the analysis with their preoperative plasma creatinine. Demographics showed that of the women, 39% had hypertension, 12% had diabetes and 2% had preexisting kidney disease. In comparison, amongst the men, 24% had hypertension, 9% had diabetes and 1% preexisting kidney disease. Postoperative plasma creatinine values were obtainable from the database in 2741 patients (n=1578 men; n=1163 women) on postoperative day 1-3. One hundred and ninety patients (7%) of this group had developed AKI. Separated by gender, 6% of the women (n=72) and 8% of the men (n=118) had established AKI according to KDIGO (p=0.190). Plasma creatinine values were obtainable in 986 patients (n=582 men; n=404 women) on postoperative day 4-10 whereas 87 patients (9%) in this group had developed AKI. Separated by gender, 6% of the women (n=23) but 11% of the men (n=64) had established AKI at this timepoint (p=0.004). With this posthoc analysis of a global, multicenter, randomized controlled trial we conclude that the incidence of postoperative AKI is twice as high in men compared with women after 4-10 postoperative days following radical colorectal surgery. Since the women had higher rate of pronounced preoperative risk factors yet still had lower incidence of AKI, this study aligns with the conclusion that the male sex is a risk factor for postoperative AKI. Funded by the Swedish Research Council (2014–02569 and 2014–07606). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Analysis of Social Determinants of Health in the Pediatric General Surgical Population of a Northeastern Urban Health System

BackgroundSocial determinants of health (SDOH) have been identified as factors that influence patient health outcomes. These are well described in adult and pediatric general populations, however, there is a paucity of data for surgical patients. This study compares the prevalence of health-related social needs (HRSN) among pediatric surgery and general pediatric patients. MethodsWe retrospectively assessed electronic health record data to identify patients who completed a standardized HRSN screener within our health system and underwent surgery by a pediatric surgeon between January 2019 and December 2021. We compared this population to non-surgical pediatric patients during this time. Bivariate and multivariate logistic regressions were conducted to estimate the likelihood of having 1 or more HRSN given a patient's surgery status. Logistic and linear regressions were conducted to estimate healthcare utilization in pediatric surgery patients given their HRSN status. Results33,989 general pediatric and pediatric surgery patients (age <21 years) were screened for HRSNs, and 2112 operations were performed during the study period. 343 (20%) of the surgical patients operated on by pediatric surgeons were screened for HRSNs. Surgical patients were more likely to be younger, Latinx, Spanish-speaking, and non-commercially insured (p < 0.0001). Surgical patients were 50% more likely to report one or more HRSN, when adjusting for demographic characteristics (aOR 1.50, 95% CI 1.16, 1.94). ConclusionPediatric surgery patients are more likely to report HRSNs compared to the general pediatric population. Surgical patients may represent an at-risk group, and universal HRSN screening and support should be considered to improve outcomes. Level of EvidenceLevel III.

Incidence of sodium–glucose cotransporter-2 inhibitor-associated perioperative ketoacidosis in surgical patients: a prospective cohort study

PurposeSodium-glucose cotransporter 2 inhibitors (SGLT2is) are commonly prescribed anti-diabetic medications with various beneficial effects; however, they have also been associated with ketoacidosis. The aim of this study was to determine the incidence of SGLT2i-associated perioperative ketoacidosis (SAPKA) in surgical patients.MethodsWe conducted a multicenter, prospective cohort study across 16 centers in Japan, enrolling surgical patients with diabetes who were prescribed SGLT2is between January 2021 and August 2022. Patients were monitored until the third postoperative day to screen for SAPKA, defined as urine ketone positivity with a blood pH of < 7.30 and HCO3 level ≤ 18.0 mEq/L, excluding cases of respiratory acidosis.ResultsIn total, 759 of the 762 evaluated patients were included in the final analysis. Among these, three patients (0.40%) had urine ketones with a blood pH of < 7.30; however, blood gas analysis revealed respiratory acidosis in all three, and none of them was considered to have SAPKA. The estimated incidence of SGLT2i-associated postoperative ketoacidosis was 0% (95% confidence interval, 0%–0.4%).ConclusionsThe observed incidence of SAPKA in our general surgical population was lower than expected. However, given that the study was observational in nature, interpretation of study results warrants careful considerations for biases.

Assessing the Quality of Postoperative Recovery: A Guide for Making Adjustments in Anesthesia Delivery

PurposeThe purpose of this project was to develop a plan and then implement a process for improving anesthesia delivery at a surgery center in the Southeast United States over a 2-month period. DesignThe design of the project was based on utilization of the instrument QoR-15 (Quality of recovery - 15 item questionnaire). This tool is a valid and reliable instrument for the measurement of postoperative outcomes. The QoR-15 includes 15 questions that can each be scored on a 10-point scale. MethodsMethods included a literature search, collecting pre-assessment data, making phone calls to patients utilizing QoR-15 tool, analyzing data, presenting findings to stakeholders, creating a plan of future anesthesia care adjustments. FindingsThe results revealed the following outcome data: a total of 183 postoperative phone calls were successfully performed. The calls were completed on the first postoperative day during the months of July and August 2021. There were 459 total cases during this 2-month period with 113 successful patient contacts (24.6 % successful contact rate). Mean scores of the QoR-15 data for the total population were above 9 for all 15 items. The data was then analyzed according to surgical specialty. The category of moderate pain scores in patients from the General and Ophthalmology surgical specialties were 7.9 and 7.8 respectively. General surgery patients also had one of the highest scores in severe pain with a mean of 8.7. ConclusionsIn conclusion, the leadership team at the ASC received a formal presentation of the results and recommendations for future adjustments that could be potentially implemented in anesthesia care. The benefits of regional anesthesia were suggested to help achieve better patient pain outcomes in both the General and Ophthalmologic surgical populations.

Preoperativna procena rizika u pedijatrijskoj anesteziji

In general pediatric surgical population, the incidence of perioperative 30-day mortality is low. A child's physical status at the time of elective surgery and the presence of comorbidities can notably impact the perioperative risk. In order to provide quality care, preoperative evaluation should be undertaken in a timely and thorough manner. In preoperative period, it is highly important to be able to identify the patients who are at a higher risk, with the premise that early identification of these patients will allow for additional care to be provided, thereby minimizing possible complications. The main objectives of adequate preoperative assessment are to evaluate patients' readiness for the procedure, optimize patients' health status before surgery, reduce surgical morbidity, and help patients regain their usual functions postoperatively. Routine prescription of additional tests in children should be replaced by selective and rational prescriptions, based on the patients' history and performed clinical evaluation. Surgical and anesthetic complications can have adverse effects on patients' health, and they have also been proven to be associated with increased inpatient and postoperative costs. Each member of the surgical team plays a vital role in the safe care of pediatric patients. Well known risk factors for critical events in the perioperative period in pediatric population are as follows: ASA physical status, age, emergency surgery, and the existence of an underlying disease. This review highlights potential risks encountered in children and directs preoperative assessment towards selecting essential tests based on identified individual risk factors.

Pharmacological interventions for reducing the incidence of myoclonus in patients receiving etomidate for induction of general anesthesia: an umbrella review.

The objective of this umbrella review was to examine various pharmacologic interventions for their potential to reduce etomidate-induced myoclonus. A secondary objective was to compare the relative effectiveness of those medications in reducing the incidence of myoclonus when etomidate is utilized for the induction of general anesthesia. Etomidate is the drug of choice when inducing general anesthesia in hemodynamically unstable patients. However, its use is limited among the general surgical population due to its ability to cause adrenal suppression, vomiting, and myoclonus. Myoclonus can lead to damage of muscle fibers, myalgias, and patient discomfort, and can also be detrimental in patients with low cardiac reserve. Several systematic reviews have reported on the effectiveness of various intravenous medications in reducing mild, moderate, and severe myoclonus; however, a more thorough examination of their influence was lacking. This review included systematic reviews and meta-analyses of randomized controlled trials involving the use of pharmacologic interventions to reduce etomidate-induced myoclonus. Reviews in English and conducted after 1965 were considered for inclusion. A comprehensive search of 11 databases was conducted to identify published and unpublished reviews up to March 2022. Critical appraisal was conducted by 2 independent reviewers using the standardized JBI appraisal tool. Quantitative findings were summarized according to the dose, timing of administration, and relative risk using a data matrix, and were synthesized in tabular format with supporting narrative text. Results were organized by severity of myoclonus (overall, mild, moderate, and severe) and by type of intervention. Eight systematic reviews were included in this umbrella review, which included 48 relevant studies, after removal of duplicates (3909 participants included in the primary studies). Five of the systematic reviews examined the effectiveness of various types of opioids in the prevention of myoclonus, and 3 systematic reviews examined the effectiveness of non-opioid interventions, such as lidocaine, midazolam, and dexmedetomidine. Seven reviews searched at least 4 databases for pertinent studies and specifically indicated that blinded reviewers appraised the articles. All reviews used a published and validated appraisal instrument. The overall quality of all included reviews was judged to be moderate to high. The absolute risk reduction indicating the effectiveness of the prophylactic medications ranged from 47% to 81% for mild, 52% to 92% for moderate, and 61% to 96% for severe myoclonus. Opioids demonstrated the most consistent and substantial effect on the reduction in myoclonus. All pharmacologic interventions identified in this review demonstrated a statistically significant reduction in the incidence of myoclonus. Future studies and reviews should focus on elucidating the particular dose range and timing that is most effective. Anesthesia providers should consider a pre-treatment dose of one of the medications described in this umbrella review as a means to reduce myoclonus and the untoward effects of that condition.

INTRA-ABDOMINAL HYPERTENSION AND INCREASED SERUM PROCALCITONIN LEVELS ARE IMPORTANT PROGNOSTIC MARKERS IN CRITICALLY ILL SURGICAL PATIENT’S OUTCOME: A PROSPECTIVE OBSERVATIONAL STUDY

Objective: The objective of the study is to determine the clinical value of procalcitonin (PCT) levels and in recognizing surgical complications, morbidity and mortality in a heterogeneous group of general surgical patient population admitted in casualty ward and intensive care unit (ICU). Methods: A prospective, observational study was conducted on 100 patients by purposive sampling for blood and ascites in the peritoneal cavity, bowel distension and edema, high-volume resuscitation and massive transfusion, damage control surgery in traumatic patients, excessive tension after abdominal closure, post-operative ileus, circumferential abdominal eschar in burn patients, and hemodilution with severe sepsis were enrolled within 24 h of admission to the ICU or casualty ward in the Department of General Surgery, J.L.N. Medical College and Hospital, Ajmer, from August 2021 to December 2022. Results: The mean age of the overall patient population for the study is 52.29 years and it ranges between 16 years and 84 years. 79% of the patients presented with intra-abdominal hypertension (IAH), and mean serum PCT level in the IAH group is 4.47±7.49 which is higher than that in the non- IAH group (p&lt;0.05). The mean serum PCT levels among the group having peritonitis as the cause of sepsis is 5.69 ng/mL and having pneumonitis as the cause of sepsis is 6.74 ng/mL (p=0.033). Conclusion: Serum PCT, a new serum biomarker for infection and inflammation, that has been found to be more sensitive and specific for the same, is also an indicator for patient mortality and morbidity, and also correlates with patient’s length of hospital stay can be said to have an important role in prediction of critically ill surgical patient’s outcome.

Preoperative Intravenous Iron Reduces the Need for Blood Transfusion in Colorectal Cancer Surgery

Approximately 30% to 60% of the general surgical population is commonly affected by preoperative anemia*. This form of anemia is associated with an increased risk of postoperative morbidity, prolonged hospital stay, and impaired recovery.[1] Hence, planning potentially high-blood-loss surgery, especially patients with preoperative anemia, requires proper advance planning to allow time for adequate identification, assessment, and management to avoid adverse events.

Frequency and Characteristics of Postoperative Neuropathy in Individuals on Gender-Affirming Hormone Therapy Undergoing Gender Affirmation Surgery: A Retrospective Cohort Study.

Introduction Gender affirmation surgery includes procedures of the face, larynx, chest, reproductive system, external genitalia, and adipose tissue performed to ameliorate incongruence between gender identity and phenotype. The annual number of gender affirmation surgeries performed in the United States has increased significantly. There have been no investigations into the frequency of peripheral neuropathy after gender affirmation surgery, which is an important topic, given transgender individuals are at increased risk for delaying necessary medical care. After appreciating a number of cases of postoperative neuropathy in our clinical practice, we hypothesized that gender affirmation surgery is a high-risk procedure for postoperative neuropathy. Methods We conducted a one-year, monocentric, retrospective cohort study utilizing clinical data of individuals on gender-affirming hormone therapy undergoing gender-affirmation surgery under general anesthesia. The study included transgender women, assigned male at birth, receiving antiandrogen, progesterone, or estrogen therapy (target range plasma estradiol concentration 90-200 pg/ml) and transgender men, assigned female at birth, receiving antiestrogen or testosterone therapy (target range plasma testosterone concentration 320-1000 ng/dl). The primary objective was to estimate the incidence of postoperative peripheral neuropathy, defined as new numbness, paresthesia, neuropathic pain, or muscle weakness occurring in a peripheral innervation territory. Secondary objectives were to summarize the clinical presentation of neuropathy and investigate for associations between procedure characteristics and neuropathy. Results We identified nine cases of postoperative peripheral nerve injury in 232 consecutive gender affirmation procedures establishing an incidence of 3.9%. All injuries were associated with surgery longer than six hours and were characterized by sensory deficits including numbness 89% (8/9) and tingling 56% (5/9), which were diagnosed by postoperative day one. Conclusions Our results suggest that gender affirmation surgery is a high-risk procedure for postoperative neuropathy, with an incidence similar to other high-risk procedures, and an incidence that is higher than the general surgical population. However, given this has not been previously reported and our study includes a heterogenous population from a single institution, our results should be considered hypothesis generating. Additional studies that include multiple institutions are needed to confirm our findings and identify modifiable risk factors for postoperative neuropathy.

Prolonged Ileus after Colorectal Surgery, a Systematic Review.

The development of prolonged post-operative ileus (POI) remains a significant problem in the general surgical patient population. The aetiology of ileus is poorly understood and management options/preventative measures are currently extremely limited. The pathophysiology leading to a post-operative ileus is relatively poorly understood, and there is no validated method to estimate ileus occurrence or duration. Ileus in the post-operative period commonly occurs following major colorectal surgery and leads to painful abdominal distension, vomiting, nutritional deficit, pneumonia, prolonged hospital stays and susceptibility to hospital-acquired infection. An increased hospital stay, the burden of treatment costs and the burden on the health system highlight the importance of future research on finding definitions, preventions and predictions of ileus. A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing the rate of ileus on various treatments for prolonged post-operative ileus following colorectal surgery. A confidence evaluation in a meta-analysis were performed using CINeMA. Direct and indirect comparisons of all interventions were simultaneously carried out using a network meta-analysis. The level of certainty was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. The method of assessing the risk of bias, the quality assessment, used the Cochrane Risk of Bias 2 tool (RoB2). Among the seven included studies, the majority suffered from considerable within-study bias, affecting the confidence rates of study findings. Heterogeneity and incoherence made the pairwise meta-analysis and ranking of interventions unfeasible. Indirect comparisons were considered unreliable due to this incoherence. This systematic review, with a confidence evaluation in the network meta-analysis, determined that there is a knowledge gap in the field of study on prolonged ileus following digestive surgery. The current evidence suffers from heterogeneity and incoherence more than imprecision. There is a gap in the data on ileus occurrence in interventional trials for digestive surgery. This could inform clinicians and trialists to better appraise the current literature and plan future trials.

A Single-Center Retrospective Review of Patients with Suspected Malignant Hyperthermia Susceptibility.

Purpose The diagnosis of malignant hyperthermia susceptibility (MHS) has significant implications for the perioperative period that may persist for generations. Anesthetic medication options are reduced, anesthetic workstations require preparation to reduce exposure to inhaled volatile anesthetics, and patients may be excluded from surgery at ambulatory centers. In this study, we sought to better characterize the etiology of MHS diagnoses in our health system and the downstream effects of this diagnosis on anesthetic care. Methods We retrospectively reviewed the electronic medical records of 55 patients with a documented concern for MHS who received care at University of Florida (UF) Health between 2014 and 2020. We characterized the etiology of the patient's MHS diagnosis, whether this diagnosis was supported by formal genetic or muscle contracture testing, and the details of the recorded anesthetics that were delivered to these patients. Results The 55 patients with suspected MHS were evenly split between those with a family history of malignant hyperthermia (MH) (28/55) and those with a concern for MHS in their personal medical history (27/55). Of the 28 patients with a family history of MH, 16 reported that the affected family member was a first-degree relative, and two of these 16 reported that the affected family member had undergone confirmatory muscle contracture testing. Of the 27 patients with a personal history suspicious for MHS, two had undergone confirmatory genetic testing, and two patients had anesthetic records available for review where intraoperative MH was suspected and treated with dantrolene. An additional four patients were told of a concern about MHS due to another underlying diagnosis. No patients with a personal history suspicious of MHS had undergone confirmatory muscle contracture testing. These 55 patients underwent 87 anesthetics, and exclusively non-triggering anesthetic techniques were utilized in nearly all cases. In pediatric patients, some perioperative challenges were identified, related to the avoidance of mask inhalational induction. Only six of these 87 anesthetics occurred at our ambulatory surgery centers, a proportion (6.9%) lower than that of the general surgical population at UF Health (20.0%). Conclusions Among patients suspected to be MH susceptible in our health system over a six-year period, a minority (8/55) were supported by clear records of a prior MH event, confirmatory genetic or muscle contracture testing, or an underlying diagnosis closely linked to MH. The vast majority had limited documentation supporting their MH risk but continued to be treated with non-triggering anesthetics and were less likely to have surgery at an ambulatory surgery center than our overall surgical population. Among pediatric patients, some anesthetic challenges related to delivering non-triggering anesthetics were identified. Improving the documentation of index cases of MH and increasing referrals to clinical geneticists and genetic testing may be a viable route to decreasing the proportion of suspected MHS patients with a poorly characterized risk profile.

Anesthetic Management of Patients with Dilated Cardiomyopathy Undergoing Noncardiac Surgery.

Dilated cardiomyopathy (DCM), a primary myocardial disease, is characterized by dilation of the left or both ventricles and systolic dysfunction with or without congestive heart failure. DCM per se is a well-recognized risk factor for sudden cardiac death and poor surgical outcomes following noncardiac surgery. Surgical trauma/stress represents unique challenges for DCM patient management. Unfortunately, there is a big knowledge gap in managing DCM patients undergoing non-cardiac surgery. Therefore, the aim of our review is to provide basic facts and current advances in DCM, as well as a practical guideline to perioperative care providers, for the management of surgical patients with DCM, who are quite rare compared with the general surgical population. This review summarizes recent advances in the medical management of DCM as well as perioperative assessment and management strategies for DCM patients undergoing noncardiac surgery. Optimal surgical outcomes depend on multiple-disciplinary care to minimize perioperative cardiovascular disturbances.

Association of Postoperative Delirium With Incident Dementia and Graft Outcomes Among Kidney Transplant Recipients.

Kidney transplant (KT) recipients have numerous risk factors for delirium, including those shared with the general surgical population (eg, age and major surgery) and transplant-specific factors (eg, neurotoxic immunosuppression medications). Evidence has linked delirium to long-term dementia risk in older adults undergoing major surgery. We sought to characterize dementia risk associated with post-KT delirium. Using the United States Renal Data System datasets, we identified 35 800 adult first-time KT recipients ≥55 y. We evaluated risk factors for delirium using logistic regression. We evaluated the association between delirium and incident dementia (overall and by subtype: Alzheimer's, vascular, and other/mixed-type), graft loss, and death using Fine and Gray's subhazards models and Cox regression. During the KT hospitalization, 0.9% of recipients were diagnosed with delirium. Delirium risk factors included age (OR = 1.40, 95% CI, 1.28-1.52) and diabetes (OR = 1.38, 95% CI, 1.10-1.73). Delirium was associated with higher risk of death-censored graft loss (aHR = 1.52, 95% CI, 1.12-2.05) and all-cause mortality (aHR = 1.53, 95% CI, 1.25-1.89) at 5 y post-KT. Delirium was also associated with higher risk of dementia (adjusted subhazard ratio [aSHR] = 4.59, 95% CI, 3.48-6.06), particularly vascular dementia (aSHR = 2.51, 95% CI, 1.01-6.25) and other/mixed-type dementia (aSHR = 5.58, 95% CI, 4.24-7.62) subtypes. The risk of all-type dementia associated with delirium was higher for younger recipients aged between 55 and 64 y ( Pinteraction = 0.01). Delirium is a strong risk factor for subsequent diagnosis of dementia among KT recipients, particularly those aged between 55 and 64 y at the time of transplant. Patients experiencing posttransplant delirium might benefit from early interventions to enhance cognitive health and surveillance for cognitive impairment to enable early referral for dementia care.

A retrospective validation of ROTEM algorithms for detecting hyperfibrinolysis demonstrates poor agreement for prediction of in-hospital mortality and transfusion requirement in a general, non-cardiac, surgical population

IntroductionHyperfibrinolysis diagnosed on Rotational Thromboelastography (ROTEM) is associated with increased transfusion requirements and mortality in trauma. The diagnosis and significance of hyperfibrinolysis in a mixed, non-cardiac, general surgical population has not been investigated. We aimed to measure agreement between four ROTEM algorithms for diagnosing hyperfibrinolysis and transfusion requirements and mortality in general surgical patients. These algorithms mostly incorporate measures of early or late clot amplitude reduction on the Extrinsic Clotting Pathway Test with Tissue Factor (EXTEM) channel. MethodFour hospital administrative data sets were linked from 2019 to 2022. Adults >18 years were included if a ROTEM was performed during their surgery (intraoperative period) or within 24-h of the surgery completion (postoperative period). The four hyperfibrinolysis criteria were applied to the ROTEM data and assessed for their agreement, intraoperative and postoperative transfusion requirements and in-patient mortality. ResultsWe linked 933 ROTEMs to 558 patient-procedures. One algorithm identified hyperfibrinolysis on only three patients so was excluded. Agreement between the remaining three was slight (Cohens Kappa 0.18 (p < 0.001)) with hyperfibrinolysis diagnosed between 22 and 69 % of the procedures. The association between hyperfibrinolysis diagnosis and intraoperative or postoperative transfusion requirement was inconsistent between the criteria. However, an algorithm put forward by Goerling et al. was more often associated with transfusion requirement and inpatient mortality. DiscussionThe poor agreement between criteria suggests that some ROTEM criteria may not transfer directly to general surgical patients. Future research should focus on optimising hyperfibrinolysis cut-off values to update algorithms for bleeding general surgical patients.

Exploring I-FABP, endothelin-1 and L-lactate as biomarkers of acute intestinal necrosis: a case-control study

Objective Acute intestinal necrosis (AIN) is a disease with devastating high mortality. AIN due to obstructed arterial blood flow has a blurred clinical presentation. Timely diagnosis is paramount, and a blood-based biomarker is warranted to increase patient survival. We aimed to assess intestinal fatty acid binding protein (I-FABP) and endothelin-1 as diagnostic biomarkers for AIN. To our knowledge, this is the first study exploring endothelin-1 in AIN patients from a general surgical population. Design We conducted a single-centre nested case–control study comparing acutely admitted AIN patients to age- and sex-matched non-AIN patients during 2015–2016. I-FABP and endothelin-1 were analysed using an enzyme-linked immunosorbent assay. L-lactate levels were also measured in all patients. Cut-offs were estimated using receiver operator characteristic curves, and the diagnostic performance was estimated using the area under the receiver operator characteristic curve (AUC). Results We identified 43 AIN patients and included 225 matched control patients. Median levels of I-FABP, endothelin-1 and L-lactate were 3550 (IQR: 1746–9235) pg/ml, 3.91 (IQR: 3.33–5.19) pg/ml and 0.92 (IQR: 0.74–1.45) mM in AIN patients and 1731 (IQR: 1124–2848) pg/ml, 2.94 (IQR: 2.32–3.82) pg/ml and 0.85 (IQR: 0.64-1.21) mM in control patients, respectively. The diagnostic performances of endothelin-1 and of I-FABP + endothelin-1 combined were moderate. Endothelin-1 alone revealed an AUC of 0.74 (0.67; 0.82). The sensitivity and specificity of endothelin-1 were 0.81 and 0.64, respectively. Conclusion I-FABP and endothelin-1 are promising biomarkers for AIN, with moderate diagnostic performance compared with the commonly used biomarker L-lactate. Preregistration ClinicalTrials.gov: NCT05665946.

Difficult Tracheal Intubation and Airway Outcomes after Radiation for Nasopharyngeal Carcinoma.

The aim of the study was to characterize the incidence and management of difficult tracheal intubations (DTIs) in nasopharyngeal carcinoma (NPC) after primary radiation therapy (RT). The study was a retrospective review of airway assessment and outcomes in post-RT NPC patients. Primary analysis was performed on patients who underwent post-RT procedures, who were split into non-DTI and DTI groups. Patients were classified as DTI if they (i) required >1 attempt to intubate, (ii) failed to be intubated, or (iii) experienced complications attributed to airway management. Secondary analysis was performed between patients who underwent post-RT procedures (procedure group) and those who did not (control group). One-hundred and fifty patients were included, and 71.3% underwent post-RT procedures, with no differences in characteristics between the procedure and control groups. One-hundred and fifty procedures were identified, and 28.0% were categorized as DTI. There was no difference in patient characteristics or airway assessment measures between DTI and non-DTI groups. Regression analysis revealed concurrent cervical mobility restriction, and trismus increased DTI incidence by 7.1-fold (p = 0.011). Being non-White was an independent predictor of DTI. The incidence of high-grade intraoperative laryngoscopic view was lower in the non-DTI compared to the DTI group (20.4% vs. 64.3%, p < 0.0001). Failure to intubate occurred in 2.0% of cases, and 6.0% cases had perioperative complications. Based on preoperative assessment, sensitivity of predicting DTI was 54.8% and specificity was 63.9%. NPC patients frequently undergo post-RT procedures requiring complex airway management. Rates of DTI and failed intubation are significantly higher than those in the general surgical population, and the ability to predict DTI with standard preoperative airway measures is poor. 4 Laryngoscope, 134:120-126, 2024.