High-risk Surgical Population Research Articles

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.

Cohort profile of BIGPROMISE: a perioperative biobank of a high-risk surgical population

PurposePostoperative complications increase mortality, disability and costs. Advanced understanding of the risk factors for postoperative complications is needed to improve surgical outcomes. This paper discusses the rationale and profile of...

Perioperative use of low dose haloperidol safely reduces episodes of postoperative nausea/vomiting and length of stay following elective minimally invasive bariatric surgery.

While total intravenous anesthesia (TIVA) protocols include Dexamethasone and Ondansetron prophylaxis, bariatric patients continue to be considered at particularly high risk for postoperative nausea/vomiting (PONV). A multimodal approach for prophylaxis is recommended by the Bariatric Enhanced Recovery After Surgery (ERAS) Society however, there remains a lack of consensus on the optimal strategy to manage PONV in these patients. Haloperidol has been shown at low doses to have a therapeutic effect in treatment of refractory nausea and in PONV prophylaxis in other high risk surgical populations. We sought to investigate its efficacy as a prophylactic medication for PONV in the bariatric population andto identify which perioperative strategies were most effective at reducing episodes of PONV. An institutional bariatric database was created by retrospectively reviewing patients undergoing elective minimally invasive bariatric procedures from 2018 to 2022. Demographic data reviewed included age, gender, preoperative body mass index (BMI), ethnicity, and primary language. Primary endpoints included patient reported episodes of PONV, total doses of Ondansetron administered, need for a second antiemetic (rescue medication), complication rate (most commonly readmission within 30days), and length of stay. Fisher's exact test, Mann-Whitney test, and ANOVA were used to evaluate the effect of perioperative management on various endpoints. A total of 475 patients were analyzed with Haloperidol being utilized in 15.8% of all patients. Patients receiving Haloperidol were less likely to require Ondansetron outside of the immediate perioperative period (34.7% vs. 49.8%, p = 0.02), experienced less PONV (41.3% vs. 64.3%, p = 0.01) and also had a decreased median length of stay (27.3 vs. 35.8h, p < 0.0001). Addition of low dose Haloperidol to Bariatric ERAS protocols decreases incidence of PONV and the need for additional antiemetic coverage resulting in a significantly shorter length of stay, increasing the likelihood of safe discharge on postoperative day 1.

Incidence of Post-Anesthesia Complications in the Recovery of Tertiary Care Hospital

Background: The Post- Anesthesia care unit to recover and wakeup after having anesthesia for an operation or procedure. It is a critical care unit where the patient's vital signs are closely observed, pain management begins, and fluids are given. Post-anesthesia complications are common in high-risk surgical populations and are associated with poor short-term and long-term outcomes. Morbidity can be identified using prospective assessment of pathological criteria, or deviations from the ideal postoperative course requiring clinical intervention. Objectives: The aim of this study is to assess the Incidence of post-anesthesia complications in the recovery of tertiary care hospital. Methods: This is an observational study. The study used to be carried out in the admitted patient’s Department of anesthesiology, MH Samorita Hospital &amp; Medical College, Dhaka, Bangladesh. In Bangladesh for the duration of the period from January 2020 to January 2021. The duration of the period from Data was entered in MS Excel and Statistical analysis was done using SPSS trial version. Results: This study shows that the according to age of 100 Patients aged 40 to 69 years. Here according to Age distribution, 18(18.0%) were 20-29 years, 15(15.0%) were 30-39, 48(48.0%) were 40-49, 12(12.0%) were 50-59 years and 7(7.0%) &gt;60 years. And according to gender (76%) males and (24%) females. Conclusion: The especially excessive incidence of issues in healing suggests the significance of using expert personnel and additionally the usage of sufficient monitoring equipment in order to minimize mortality and morbidity of the patients and additionally store on hospital charges.

Predictive Value of Emergency Designation on Outcomes of Moribund Patients

Background: Anesthesiologists are increasingly encountering sicker patients that require potentially life-saving surgical interventions, and assess risk using the American Society of Anesthesiology Physical Status (ASA PS) classification system. Here, we examined long-term mortality along with hospital length of stay (LoS) and discharge disposition for survivors in ASA PS 5 and 5E patients.Methods: Adult surgeries were extracted from New York-Presbyterian Hospital/Weill Cornell Medical Center’s Electronic Medical Record (EMR) for cases between January 1, 2013 and December 31, 2017; outcomes were collected from EMRs and the Social Security Death Index Master File.Results: 194,947 cases were identified. Mortality correlated with increasing ASA PS; the same trend was observed within both emergent and non-emergent sub-populations. Two hundred seventy-six cases were identified as 5/5E. This patient population had a higher rate of mortality at 30 days than at 48 hours (25.9% vs. 13.4%, respectively, p < 0.01); there was no difference between survivor functions at 30 or 90 days (p = 0.63, p = 0.09, respectively). Survivors within the 5 or 5E subpopulations did not have significantly different LoSs. Further, survivors after 90 days typically had a disposition of hospice, long-term facilities, inpatient rehabilitation, or self-discharged.Conclusions: Mortality increases with increases in ASA PS classifications. There is no difference in outcomes for 5 vs 5E at 30- or 90-day postoperatively. Similarly, emergency status did not play a role in LoS. Most 5 or 5E patients are not discharged home but to another facility. These outcomes should be considered during the informed consent process in this high-risk surgical population.

Contemporary Costs Associated With Transcatheter Versus Surgical Aortic Valve Replacement in Medicare Beneficiaries.

In patients with severe aortic stenosis, treatment with transcatheter aortic valve replacement (TAVR) has been shown to be cost-effective in the high-risk surgical population and cost-saving in the intermediate-risk population when compared with surgical aortic valve replacement (SAVR) in early pivotal clinical trials. Whether TAVR is associated with comparable or lower costs when compared with SAVR in contemporary clinical practice is unknown. Using data from the Medicare Dataset Standard Analytic Files 5% Fee for Service database, patients receiving either TAVR or SAVR between 2016 and 2018 were identified. Patients were categorized as low, intermediate, or high mortality risk based on 2 validated indices-the Hospital Frailty Risk Score and the logEuroScore. Health care costs out to 1 year were compared between TAVR and SAVR among the low, intermediate, and high-risk groups, after adjustment for patient demographics. Nine thousand seven hundred forty-six patients were identified (4834 TAVR; 3760 SAVR) and included in the analysis. Patients receiving TAVR were older and more likely to be female. Index hospitalization costs were significantly lower with TAVR compared with SAVR across all risk strata (logEuroScore: low: $61 845 versus $68 986; intermediate: $64 658 versus $76 965; high: $65 594 versus $91 005; P<0.001 for all). Follow-up costs through 1 year were generally lower with TAVR and this difference was more pronounced in the low risk groups (logEuroScore: $9763 versus $14 073; Hospital Frailty Risk Score: $10 116 versus $12 880). Accordingly, cumulative 1-year costs were substantially lower with TAVR compared with SAVR. At 1 year, TAVR is associated with lower health care costs across all risk strata when compared with SAVR in contemporary practice. If long-term data continue to demonstrate similar clinical outcomes and valve durability with TAVR and SAVR, these findings suggest that TAVR may be the preferred treatment strategy for patients with aortic stenosis from an economic standpoint.

Promoting patient engagement during care transitions after surgery using mobile technology: Lessons learned from the MobiMD pilot study

BackgroundPoorly coordinated transitions of care in complex abdominal surgery patients contribute to frequent hospital readmissions and inflated healthcare spending. Mobile health (mHealth) transitional care technologies may reduce surgical readmissions yet remain understudied in high-risk surgical populations. MethodsWe conducted a single-group, prepost study of a mHealth transitional care app in 50 complex surgical patients. Eligible patients were adults undergoing complex abdominal surgery in the divisions of Surgical Oncology and Colorectal Surgery. The main outcome was app engagement, calculated by notification response rate (number of participant-entered datapoints divided by the total number of app-requested datapoints) over the 30-day postoperative period. Secondary outcomes included changes in engagement over time and by individual app feature. ResultsA total of 85% (50/59) of eligible patients enrolled. Most participants were male (58%, n = 29), and mean age was 50 years (range 24–80 years). Overall notification response rate was 28%. Among the 58% of participants (29/50) who engaged with the app at least once after discharge (app users), the average notification response rate was 45%. The mean notification response rate among app users decreased over time from 50% to 32% between weeks 1 and 4 after hospital discharge. Engagement with individual app features ranged from 48–81%, with highest engagement for symptom reports and lowest engagement for wound care instructions. ConclusionmHealth transitional care is feasible in complex surgical patients using only patients’ existing smart devices. Randomized controlled trials are required to determine the impact on hospital readmissions, surgical outcomes, patient satisfaction, and overall resource utilization.

The ARISCAT score is a promising model to predict postoperative pulmonary complications after major emergency abdominal surgery: an external validation in a Danish cohort.

Postoperative pulmonary complications (PPCs) occur in up to 30% of patients undergoing surgery and are a significant contributor to the overall risk of surgery. A preoperative risk prediction tool for postoperative pulmonary complications could succour clinical identification of patients at increased risk and support clinical decision making. This original study aimed to externally validate a risk model for predicting postoperative pulmonary complications (ARISCAT) in a cohort of patients undergoing major emergency abdominal surgery at a Danish University Hospital. ARISCAT was validated prospectively in a cohort of patients undergoing major emergency abdominal surgery between March 2017 and January 2019. Predicted PPCs by ARISCAT were compared with observed PPCs. ARISCAT was validated with calibration, discrimination and accuracy and in adherence to the TRIPOD statement. The study included a total of 585 patients with a median age of 70years. The majority of patients underwent emergency laparotomy without bowel resection. The predicted PPC frequency by ARISCAT was 24.9%, while the observed frequency of PPCs in the cohort was 36.1%. The slope of the calibration plot was 0.9546, the y axis interception was 0.1269 and the plot was well fitted to a linear slope. The Hosmer Lemeshow goodness-of-fit analysis showed good calibration (p > 0.25). ARISCAT showed good discrimination with AUC 0.83 (95% CI 0.79-0.86) on a receiver-operating characteristics curve and the accuracy was also good with a Brier score of 0.19. ARISCAT was a promising tool to predict PPCs in a high-risk surgical population undergoing major emergency abdominal surgery.

Cataract Surgery Considerations for Diabetic Patients.

Given the epidemiology and demographic trends of diabetes mellitus and cataracts, ophthalmologists are likely to encounter patients with both comorbidities at an increasing frequency. Patients with diabetes represent a higher risk population than healthy patients for cataract surgery. In this review, we discuss key risks and risk-mitigation practices when performing cataract surgery on these patients. Patients with diabetes continue to represent a high-risk surgical population: Nagar et al. suggest a dose-dependent relationship may exist between number of intravitreal injections and likelihood of posterior capsular rupture. However, novel treatments are improving outcomes for patients with diabetes. Several studies have reported intracameral phenylephrine/ketorolac may reduce the incidence of post-operative cystoid macular edema while others have discussed the efficacy of pre-treatment and post-treatment with intravitreal bevacizumab on improving cataract surgery outcomes in patients with diabetic retinopathy. Pre-operatively, ophthalmologists should perform an enhanced evaluation, consider timing and lens selection decisions, and complete any appropriate pre-operative treatment. Peri-operatively, surgeons should be aware of pupillary dilation adjustments, combination surgery options, and potential complications. Post-operatively, clinicians should address pseudophakic cystoid macular edema, diabetic macular edema, diabetic retinopathy, and posterior capsular opacification.

MP49-09 IMPACT OF PREEXISTING OPIOID-DEPENDENCE ON MORBIDITY, LENGTH OF STAY, AND INPATIENT COST OF UROLOGIC ONCOLOGIC SURGERY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy IV (MP49)1 Sep 2021MP49-09 IMPACT OF PREEXISTING OPIOID-DEPENDENCE ON MORBIDITY, LENGTH OF STAY, AND INPATIENT COST OF UROLOGIC ONCOLOGIC SURGERY Sohrab Arora, Chandler Bronkema, Buddima Ranasinghe, Hallie Wurst, Jacob Keeley, Akshay Sood, Daniele Modonutti, Giacomo Novara, Mani Menon, Craig Rogers, and Firas Abdollah Sohrab AroraSohrab Arora More articles by this author , Chandler BronkemaChandler Bronkema More articles by this author , Buddima RanasingheBuddima Ranasinghe More articles by this author , Hallie WurstHallie Wurst More articles by this author , Jacob KeeleyJacob Keeley More articles by this author , Akshay SoodAkshay Sood More articles by this author , Daniele ModonuttiDaniele Modonutti More articles by this author , Giacomo NovaraGiacomo Novara More articles by this author , Mani MenonMani Menon More articles by this author , Craig RogersCraig Rogers More articles by this author , and Firas AbdollahFiras Abdollah More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002075.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While recent literature has focused on postoperative opioid use, there are limited data on patients who are already opioid-dependent and need elective surgery. This potentially high-risk surgical population may need tailored perioperative care and represents an area for quality improvement. Our aim was to assess the impact of preexisting opioid-dependence before elective partial/radical nephrectomy, radical prostatectomy, and cystectomy on complications, length of stay, and in-hospital costs. METHODS: We analyzed the National Inpatient Sample from 2003-2014 to study 1,695,152 admissions for elective partial nephrectomy, radical nephrectomy, radical prostatectomy, and cystectomy procedures. Preexisting opioid abuse/dependence was identified using ICD-9 codes. Trends in the prevalence of preexisting opioid dependence in patients undergoing the above surgeries were studied over the study-period. Multivariable analyses evaluated the effect of pre-existing opioid-dependence on major complications, length of stay, and total cost, after adjusting for age, race, comorbidities, insurance, urban/rural location, income, and hospital characteristics. RESULTS: The prevalence of opioid-dependency steadily increased from 7/1000 patients in 2003, to 20/1000 in 2014. Opioid-dependent patients had a significantly higher rate of major complications (20% vs 11%; p<0.001), longer length of stay (4 days [IQR 3-8] vs 2 days [IQR 1-4]; p<0.001), and 47% increased overall cost (adjusted median cost $18,565 [IQR 12,744-28,837] vs $12,596 [IQR 9,324-18,071] in non-opioid dependent, p<0.001). These findings are displayed in the table below. On multivariable analysis, opioid-dependence was independently associated with major complications (odds ratio [OR] 1.45; 95% confidence intervals [CI] 1.05-2.17), length of stay >= 4th quartile (OR 2.02 [95% CI 1.49-2.75]), and total cost >= 4th quartile (OR 2.06 [95% CI 1.49-2.85]). CONCLUSIONS: Preexisting opioid dependence before elective urologic surgery is associated with higher major complication rates, hospital stay, and increased in-hospital costs. This underlies the need to better understand the challenges associated with opioid dependence before surgery, in order to optimize patient care in the perioperative period. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e878-e879 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sohrab Arora More articles by this author Chandler Bronkema More articles by this author Buddima Ranasinghe More articles by this author Hallie Wurst More articles by this author Jacob Keeley More articles by this author Akshay Sood More articles by this author Daniele Modonutti More articles by this author Giacomo Novara More articles by this author Mani Menon More articles by this author Craig Rogers More articles by this author Firas Abdollah More articles by this author Expand All Advertisement Loading ...

Benefits of Transversus Abdominis Plane Block on Postoperative Analgesia after Bariatric Surgery: A Systematic Review and Meta-Analysis

Patients undergoing bariatric surgery present unique analgesic challenges, including poorly controlled pain, increased prevalence of obstructive sleep apnea, and opioid-induced respiratory depression. The transversus abdominis plane (TAP) has been demonstrated to be a safe and effective component of multimodal analgesia for a variety of abdominal surgeries. To determine the benefits of the TAP block on postoperative analgesia and recovery in patients undergoing bariatric surgery. Systematic review and meta-analysis of randomized controlled trials (RCTs) and non-randomized studies. We conducted a comprehensive search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to April 2020 for studies using TAP block in bariatric surgeries and reporting postoperative pain, opioid consumption, and recovery-related outcomes. Primary outcomes included postoperative pain scores, opioid consumption, and recovery-related outcomes (e.g., length of stay, time to ambulation). Outcomes were pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI). Twenty-one studies (15 RCTs [n = 1410] and 6 nonrandomized studies [n = 1959]) were included. Among RCTs, the TAP block group required fewer opioid rescues (RR 0.28; 95% CI 0.18 to 0.42, P < 0.001) (moderate quality); reduced total opioid use over 24 hours (MD -8.33; 95% CI -14.78 to -1.89, P = 0.01); decreased time to ambulation (MD -1.12 hours; 95% CI -1.50 to -0.73, P < 0.001) (high quality); and had significantly lower pain scores at 6 hours (MD -1.52; 95% CI -1.90 to -1.13, P < 0.01) and 12 hours (MD -0.95; 95% CI -1.34 to -0.56, P < 0.001) on a 0-10 pain scale (moderate quality). No difference was observed for nausea and vomiting, or hospital length of stay. Meta-analyzed outcomes from observational studies supported these results, suggesting decreased postoperative pain and opioid consumption. Studies varied with respect to type of surgery and components of comparator multimodal analgesia, likely contributing to heterogeneity. Subgroup analyses by type of comparator group were conducted to address these differences. We were unable to extract data from all trials included due to variability in outcomes reporting, such as non-opioid drugs for postoperative pain management or invalid dosages. Pain-related outcomes may be affected by operative differences leading to variation in visceral pain. Observational studies have their inherent limitations, such as confounding due to lack of participant randomization and intervention blinding, potentially affecting subjective outcomes, such as pain scores, as well as provider-dependent outcomes, such as hospital length of stay. Lastly, there was significant variation of TAP block technique across all studies. TAP block is an effective, safe modality that can be performed under anesthesia. It decreases pain, opioid use, and time to ambulation after bariatric surgeries and should be considered in multimodal analgesia for enhanced recovery in this high-risk surgical population.

ASA classification and surgical severity grading used to identify a high-risk population, a multicenter prospective cohort study in Swedish tertiary hospitals.

Identification of surgical populations at high risk for negative outcomes is needed for clinical and research purposes. We hypothesized that combining two classification systems, ASA (American Society of Anesthesiology physical status) and surgical severity, we could identify a high-risk population before surgery. We aimed to describe postoperative outcomes in a population selected by these two classifications system. Data were collected in a Swedish multicentre, time-interrupted prospective, consecutive cohort study. Eligibility criteria were age ≥18years, ASA ≥3, elective or emergent, major to Xmajor/complex (Specialist Procedure Codes used in United Kingdom), gastrointestinal, urogenital or orthopaedic procedures. Postoperative morbidity was identified by the Postoperative Morbidity Survey on postoperative days 3±1, 7±1, 10+5 and graded for severity by the Clavien-Dindo system. Mortality was assessed at 30, 180 and 360days. Postoperative morbidity was 78/48/47 per cent on postoperative days 3/7/10. Majority of morbidities (67.5 per cent) were graded as >1 by Clavien-Dindo. Any type of postoperative morbidity graded >1 was associated with increased risk for death up to one year. The mortality was 5.7 per cent (61/1063) at 30days, 13.3 per cent (142/1063) at 6months and 19.1 per cent (160/1063) at 12months. Severity classification as major to Xmajor/complex and ASA ≥3 could be used to identify a high-risk surgical population concerning postoperative morbidity and mortality before surgery. Combining the two systems future electronic data extraction is possible of a high-risk population in tertiary hospitals.

Specialised training in paediatric anaesthesia

Paediatric anaesthesia is an upcoming speciality which is gaining wide interest and can be a career choice for the new trainees. The need to develop paediatric anaesthesia as a speciality was realised with the progress in the field of paediatric surgery. The profile of the 'patient' encountered by a paediatric anaesthesiologist spans from an extremely premature neonate on the fringes of survival, to a full-grown adolescent equivalent to an adult. Perioperative morbidity and mortality are 2-3 times higher in infants and neonates compared to adults particularly in middle and low-income countries. The anatomical, physiological, pharmacological variations and presence of congenital cardiac, pulmonary and metabolic diseases in young children make perioperative management challenging. Special expertise and training are required for anaesthetic management of these preverbal children. In India, 3-years DM and 1-year Fellowship courses in paediatric anaesthesia are now available for specialisation. An ideal paediatric anaesthesia training centre should have substantial paediatric and neonatal patient load with exclusive intensive care facility. Paediatric anaesthesiologists, having knowledge of several facets of paediatrics and anaesthesia are capable of coordinating with health care professionals performing procedures outside the operating room. Paediatric anaesthesia, as a career thus offers a great opportunity to enhance quality and safety of anaesthesia in this high-risk surgical population. Persistent coordinated team efforts improve patient outcomes, reduce stress at work and increase job satisfaction.

Enhanced recovery after thoracic surgery: an institutional pre-introduction assessment

Introduction Enhanced Recovery After Surgery (ERAS) is a multimodal, multidisciplinary approach to enhanced patient care for specific surgical populations. ERAS introduction has significantly reduced post-operative morbidity [1,2] and the post-operative length of stay of patients [2]. The aim of our study was to quantify the current standard of care in our institution, prior to the introduction of the Enhanced Recovery After Thoracic Surgery (ERATS) guidelines for this high-risk surgical population. Methods We conducted a retrospective analysis of all thoracic surgeries over a 6-month period. This would allow assessment of the current standard of care prior to the implementation of the ERATS guidelines, which will in turn enable us to assess post-guideline introduction compliance. Patient electronic records were analysed regarding preoperative, perioperative and postoperative care in relation to the 45 enhanced recovery items outlined by the guidelines. Results A total of 66 lung resections were carried out in this timeframe. Equal gender distribution was noted, and average age was 67 years. Mean length of stay was averaged at 8.77 days with 32% requiring ICU admission. 47% of patients developed postoperative complications with an in-hospital mortality of 4.5%. Pre-guideline introduction compliance was as follows: Preoperative compliance – 24.63%, Intraoperative compliance – 54.58% and Postoperative compliance – 51.14%. Discussion ERAS pathways have demonstrated significant benefits in other specialties over the last 15 years and evidence for its use in thoracic surgery is rapidly evolving. With the introduction of a dedicated ERATS protocol in our institution, significant improvements in patient outcomes should be achieved.

Peri-operative oxygen consumption revisited: An observational study in elderly patients undergoing major abdominal surgery.

Monitoring oxygen consumption (VO2) is neither recommended nor included in peri-operative haemodynamic algorithms aiming at optimising oxygen delivery (DO2) in major abdominal surgery. Estimates of peri-operative VO2 changes are uncertain in earlier publications and have limited generalisability in the current high-risk surgical population. In a prospective non-interventional observational study in elderly patients undergoing major abdominal procedures, we investigated the change of VO2 after induction of anaesthesia and secondarily, the further changes during and after surgery in relation to DO2 and estimated oxygen extraction ratio (O2ER) by routine monitoring. VO2 was determined by indirect calorimetry (QuarkRMR) in 20 patients more than 65 years (ASA II to IV), scheduled for elective open upper abdominal surgery with combined epidural and general anaesthesia. Data were collected during 20-minute periods pre-operatively and after anaesthesia induction, with subsequent measurements during surgery and postoperatively. Simultaneously, DO2 was monitored using LiDCOplus. The O2ER was estimated from arterial-central venous oxygen content calculation. Mixed models were used to analyse the peri-operative changes. VO2 decreased after induction of anaesthesia by a mean of 34% (95% CI, 28 to 39). After 2 h of surgery, VO2 was reduced by 24% (95% CI, 20 to 27) compared with the awake baseline measurements. Pre-operative mean DO2 was 440 (95% CI, 396 to 483) ml min m and decreased by a mean of 37% (95% CI, 30 to 43) during anaesthesia. The estimated O2ER did not change intra-operatively 0.24 (95% CI, 0.21 to 0.26) but increased postoperatively to 0.31 (95% CI, 0.27 to 0.36). The changes of VO2 were parallel with changes of DO2 and O2ER in the intra-operative period. General anaesthesia reduced VO2 by approximately a third in elderly patients undergoing major abdominal surgery. Parallel changes of intra-operative VO2 and delivery were demonstrated while oxygen extraction was low. The relevance of these changes needs further assessment in relation to outcomes and haemodynamic interventions. Clinicaltrials.gov NCT03355118.

Opioid Use and Total Joint Replacement

We provide an overview of recent research into the relationship between preoperative opioid use and total joint replacement outcomes. Recent findings indicate that total joint replacement patients with a history of preoperative opioid use experience higher rates of infection, revision, short-term complications, and prolonged postoperative opioid use, along with fewer improvements in pain and function following surgery. These risks are particularly pronounced among chronic opioid users. While the baseline risk profiles of these patients may contribute to higher rates of adverse outcomes, it is also plausible that certain outcomes are directly impacted by opioid use through mechanisms such as opioid-induced hyperalgesia and immunosuppression. There is little available data on the efficacy of interventions that aim to mitigate these risks. Well-designed clinical trials are needed to evaluate the efficacy of targeted perioperative interventions that aim to improve outcomes for this high-risk surgical population. Where such trials are not feasible, additional high-quality observational studies are necessary to further our understanding of the mechanisms underlying the relationships between opioid use and specific adverse outcomes.

Long-Term Opioid Prescriptions After Spine Surgery: A Meta-Analysis of Prevalence and Risk Factors

Opioids are frequently prescribed for back pain, but the prevalence of and risk factors for long-term opioid use after spine surgery were not clearly reported. We conducted a systematic review and meta-analysis to summarize the evidence for long-term opioid use (>90 days) among adults who underwent spine surgery. PubMed, EMBASE, and Cochrane indexing databases were searched until November 9, 2018 for studies reporting the prevalence of and risk factors for long-term opioid use after spine surgery. Separate meta-analyses were conducted for commercial claims databases or registries (claims/registries) and nonclaims observational studies using the random-effects model to estimate the pooled odds ratio (OR). Prevalence meta-analysis was performed in a clinically homogeneous subset of these patients who underwent lumbar spine surgery. Eight claims and 5 nonclaims were meta-analyzed to avoid double-counting participants. The meta-analysis showed that preoperative opioid users (OR, 5.59; 95% confidence interval [CI], 3.37-9.27 vs. OR 4.21; 95% CI, 2.72-6.51) and participants with preexisting depression and/or anxiety (OR, 1.86, 95% CI, 1.43-2.42 and OR, 1.20; 95% CI, 0.83-1.74, respectively) had a statistically significantly higher odds of long-term postoperative opioids, compared with their peers. Males showed lower odds of long-term postoperative opioid use in the claims group (OR, 0.85; 95% CI, 0.79-0.92), but not in the nonclaims group (OR, 0.99; 95% CI, 0.71-1.39). The pooled prevalence of post-lumbar spine surgery long-term opioid use was 63% (95% CI, 50%-74%) in claims and 47% (95% CI, 38%-56%) in nonclaims. Patients undergoing spine surgery represent a high-risk surgical population requiring special attention and targeted interventions, with the strongest evidence for those treated with opioids before surgery and those with psychiatric comorbidities.

Thirty-day readmission rate: A predictor of initial surgical severity or quality of surgical care? A regional hospital analysis.

Unplanned readmission within 30 days is currently being used in high-income countries (HICs) for measuring the quality of surgical care. Surgical site infection (SSI), abdominal complaints and pain are the most common causes for such readmission. The correlation between readmission rates and mortality, increased patient volumes and complexity of surgery remains controversial. To explore the risk factors for unplanned readmission in the surgical population in a low- and middle-income country setting. This is a retrospective review of prospectively collected data of unplanned 30-day readmissions from January 2014 to December 2017 in the Department of General Surgery, Worcester Hospital, South Africa (SA). Basic patient demographics, reasons for readmission, operative urgency and severity, wound class, length of stay and final outcomes were used to compare the inpatient cohort and identify predictors for unplanned readmission. A total of 9 649 patients were admitted to the general surgery department at Worcester Hospital - 2.87% (n=270) were unplanned readmissions within 30 days. The mean age of this cohort was 42 (standard deviation (SD) 22) years, with 61% male patients. SSI (60.37%; n=163), gastrointestinal complications (24.44%; n=66) and blood transfusion (7.03%; n=19) were the most common causes for readmission. Median initial length of stay (LOS) was 4 days; after readmission it was 5 days. Readmissions were responsible for 1 914 additional patient days. Operative Portsmouth-POSSUM (P-POSSUM) (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) score (p&lt;0.001), increase in operative wound classification (p=0.001) and emergency surgical procedures (p=0.001) were significant risk factors for readmission within 30 days. The Department of General Surgery, Worcester Hospital, had a readmission rate comparable with that in HICs. Readmission rate is an indicator of advanced surgical pathology requiring an operative intervention of greater magnitude, often presenting as an emergency. Our results can be used to improve postoperative surveillance and ultimately improve outcomes in high-risk surgical populations. This study provides a benchmark for other regional hospitals in SA and has implications for quality-improvement programmes.

To Clip or Not to Clip: The Use of MitraClip Therapy for Functional Mitral Regurgitation

Percutaneous edge-to-edge repair of the mitral valve with the MitraClip device has been shown to serve as a safe and effective treatment for severe mitral regurgitation in the high-risk surgical population. Although the device originally was designed for the reduction of degenerative mitral regurgitation resulting from primary leaflet abnormalities, numerous studies have included patients with functional mitral regurgitation from annular or ventricular distortion. Two recent landmark studies examined the use of the MitraClip device for functional mitral regurgitation treatment and found drastically opposing results. Data reconciliation by others has suggested only a subset of those with functional mitral regurgitation may benefit from this treatment. Herein 2 seemingly similar cases to illustrate the subtle differences in patient selection that eventually may change the clinical outcome for this procedure are presented.

Extended Care in High-Risk Surgical Patient (EXCARE) Pathway in High-risk Surgical Population

Extended Care in High-Risk Surgical Patient (EXCARE) Pathway in High-risk Surgical Population