Non-emergency Surgery Research Articles

Computed tomography coronary angiography as an alternative to invasive coronary angiography in preoperative evaluation for mitral surgery.

The aim of this study was to assess the effectiveness of non-invasive coronary computed tomography angiography (CTA) as an alternative to traditional invasive coronary angiography (ICA) for preoperative evaluation of low risk patients with an indication for non-emergent mitral surgery and to assess any difference in adverse outcomes from this strategy. This was a retrospective cohort study from a single center with data collected from July 2014 - June 2020 for 1576 patients undergoing mitral valve surgery of all etiologies - excluding patients requiring coronary artery bypass surgery. We performed a 1:2 propensity score matching for patients evaluated with CT (n=345) to those evaluated with ICA (n=602). The primary outcome was a composite of major adverse events in the immediate postoperative period, including death, stroke, new onset renal failure, post-operative cardiac arrest, need for unplanned coronary artery bypass grafting or percutaneous coronary re-vascularization. The odds ratio was calculated for occurrence of major adverse events in the CT angiography group compared to the catheterization group. The mean age (standard deviation) was 55.62 years (11.54) for the CTA group and 58.22 years (10.11) for the ICA group. In the CTA group 334 (96.8%) and from the ICA group 582 (96.7%) patients underwent mitral valve repair. 13 (3.8%) patients in the CTA group experienced a major adverse event compared to 25 (4.2%) patients in the ICA group. Of these, there were no mortalities in the CTA group but one (0.2%) operative mortality in the ICA group. Four (1.2%) patients in the CTA group had a post-operative stroke compared to three (0.5%) patients in the ICA group. One (0.3%) patient in the CTA group required renal replacement therapy postoperatively compared to 11 (1.8%) in the ICA group. Percutaneous coronary intervention was required in one (0.3%) patient in CTA group and 2 (0.3%) patients in ICA group for a coronary complication of valve surgery despite non-obstructive coronary anatomy being confirmed in both groups pre-operatively. The odds ratio for having a major adverse event when worked up by CTA compared to ICA was 0.904 (0.443, 1.761). There were no increased odds of experiencing a major adverse event for low risk mitral valve patients undergoing preoperative coronary evaluation with CTA compared to ICA. This data has modified our practice pattern where we now offer coronary CTA to all elective patients who are low risk for coronary artery disease.

Slow Down Fluids to Speed Up the Intestine - Exploring Postoperative Ileus in Pediatric Gastrointestinal Surgery.

Postoperative ileus is a known complication of gastrointestinal (GI) surgery. In adult populations, ileus is associated with higher amounts of intraoperative intravenous (IV) fluids. This study examines the relationship between intraoperative IV fluids and postoperative ileus in pediatric patients undergoing GI surgery. The cohort, part of an 18-center prospective trial of the implementation of an enhanced recovery protocol, consists of patients (ages 10-18 years) undergoing non-emergent GI surgery. Statistical analysis compared patients with and without postoperative ileus within 30 days of surgery, stratified by receipt of intraoperative IV fluids. Of 553 patients, 39 (7%) had postoperative ileus. Patients with ileus received a higher mean amount (1453±1219.7mL vs. 1180±838.7mL, p=0.02) of intraoperative IV crystalloid fluid and at a higher rate (9.2mL/kg/h vs. 7.4mL/kg/h, p=0.03) compared to those who did not. Only 4% of patients receiving less than 5mL/kg/h had ileus, 6.3% if receiving 6mL/kg/h to 10mL/kg/h, and 13.6% if receiving >10mL/kg/h. Patients with ileus had a longer length of stay compared to those who did not (11.3±10.7 days, vs. 4.9±6.2 days, p<0.001). There were no statistically significant differences in reason for surgery, type of surgery, American Society of Anesthesiologists (ASA) score, preoperative opioid use, operative technique, or type of anastomosis. Postoperative ileus in pediatric patients undergoing GI surgery is associated with higher amounts and rates of intraoperative IV fluids. Limiting intraoperative fluids is a key target for enhanced recovery protocols in children.

Are current follow-up intervals justified in patients with non-emergent aortic surgeries?

Evidence for different surveillance protocols following aortic treatment is still lacking. Aim of this study was to analyze the clinical relevance of a first follow-up visit after 6 months. Between 01/2018 and 12/2019, 464 patients treated for non-emergent aortic pathologies were retrospectively analysed. Incidence of aortic events during follow-up (ie death, reintervention, endoleaks, anastomotic/new aneurysms, and diameter progression over time) was investigated. A discrete-time non-homogeneous Markov-chain model was used to analyse the data and to arrive at the number of skipped 6-month follow-up visits needed to harm a patient. After 6 months 2 (1.77%) patients had died, 15 (15.31%) patients suffered from aortic events, and a total of 4 (3.67%) patients had undergone reintervention after endovascular surgery, compared to 0 deaths, 2 (0.59%) patients with aortic events and 5 (1.48%) reinterventions after open-surgery. In our Markov Chain Model, after 6 months, 4.75% of patients showed aortic events, received a reintervention, or died. Sixty patients would need to skip their 6-month follow-up visit for one indication for reintervention to go unnoticed. Only 24 would need to skip it for one complication to go by unnoticed. This number is 55 after open surgery and 9 after endovascular. After elective endovascular or open aortic surgery without immediate in-hospital postoperative aortic events, the first follow-up visit after 6 months is important. Extending the first interval to longer time periods might lead to a considerable increase in missed aortic events. The cost and radiation exposure of frequent follow-ups must be balanced against the benefits of early preventative aortic interventions, warranting further research.

Clinical Decision-Making and Process Complications During Anticipated Difficult Airway Management for Elective Surgery.

Difficult airway management (DAM) is a challenging aspect of anesthetic care. Although nearly all DAM episodes result in successful intubation, complications are common and clinical decision-making may be complex. In adults with anticipated DAM scheduled for nonemergent surgery, we prospectively observed clinical decisions made during DAM such as awake/sedated versus anesthetized, choice of initial and subsequent devices, case cancellation/postponement, conversions between awake and anesthetized approaches, and process complications such as multiple intubation/supraglottic airway (SGA) insertion attempts, difficult bag-mask ventilation (BMV), hypoxemia, and cardiovascular destabilization. From 2009 to 2014, we prospectively observed 1295 episodes of anticipated DAM in a convenience sample of 1245 adults scheduled for nonemergent surgery. Trained observers recorded airway management decisions and process complications during DAM. We described clinical decisions made during DAM and outcomes including number of attempts, need for BMV, hypoxemia, and cardiovascular destabilization. No cases were canceled/postponed for airway management failure and all intubations were eventually successful. Of the 1295 episodes of airway management in our study cohort, 166 (13%) were intubated awake. Patients intubated awake had more difficult airway indicators than those intubated anesthetized, their first-pass success rate was 49%, 30% required ≥3 attempts, 4% required a device change, 50% experienced hypoxemia, and 29% experienced cardiovascular destabilization. Among the 1129 patients intubated while anesthetized, first-pass success rate was 64% and 20% required ≥3 attempts, 11% required a device change, hypoxemia occurred in 30%, and cardiovascular destabilization in 20%. One patient (0.08%) was converted from an anesthetized to an awake approach. Patients with a failed anesthetized intubation attempt and difficult BMV between attempts were at high risk for multiple attempts (67%) and hypoxemia (100%). Airway management was successful in all patients and the incidence of process complications was higher than in routine airway management. Despite a high risk of DAM, 87% of patients were intubated anesthetized and conversions between awake and anesthetized approaches were rare. That patients intubated awake had more difficult airway indicators implies that clinicians reserve awake intubation for particularly difficult airways. The high incidence of multiple attempts, hypoxemia, and cardiovascular destabilization in patients intubated awake suggests that awake airway management remains challenging. We found no clear pattern in device choices after a first failed attempt. Patients with a first failed anesthetized intubation attempt and difficult BMV were at particularly high risk for hypoxemia.

An Approach for Combining Clinical Judgment with Machine Learning to Inform Medical Decision Making: Analysis of Nonemergency Surgery Strategies for Acute Appendicitis in Patients with Multiple Long-Term Conditions.

Machine learning (ML) methods can identify complex patterns of treatment effect heterogeneity. However, before ML can help to personalize decision making, transparent approaches must be developed that draw on clinical judgment. We develop an approach that combines clinical judgment with ML to generate appropriate comparative effectiveness evidence for informing decision making. We motivate this approach in evaluating the effectiveness of nonemergency surgery (NES) strategies, such as antibiotic therapy, for people with acute appendicitis who have multiple long-term conditions (MLTCs) compared with emergency surgery (ES). Our 4-stage approach 1) draws on clinical judgment about which patient characteristics and morbidities modify the relative effectiveness of NES; 2) selects additional covariates from a high-dimensional covariate space (P > 500) by applying an ML approach, least absolute shrinkage and selection operator (LASSO), to large-scale administrative data (N = 24,312); 3) generates estimates of comparative effectiveness for relevant subgroups; and 4) presents evidence in a suitable form for decision making. This approach provides useful evidence for clinically relevant subgroups. We found that overall NES strategies led to increases in the mean number of days alive and out-of-hospital compared with ES, but estimates differed across subgroups, ranging from 21.2 (95% confidence interval: 1.8 to 40.5) for patients with chronic heart failure and chronic kidney disease to -10.4 (-29.8 to 9.1) for patients with cancer and hypertension. Our interactive tool for visualizing ML output allows for findings to be customized according to the specific needs of the clinical decision maker. This principled approach of combining clinical judgment with an ML approach can improve trust, relevance, and usefulness of the evidence generated for clinical decision making. Machine learning (ML) methods have many potential applications in medical decision making, but the lack of model interpretability and usability constitutes an important barrier for the wider adoption of ML evidence in practice.We develop a 4-stage approach for integrating clinical judgment into the way an ML approach is used to estimate and report comparative effectiveness.We illustrate the approach in undertaking an evaluation of nonemergency surgery (NES) strategies for acute appendicitis in patients with multiple long-term conditions and find that NES strategies lead to better outcomes compared with emergency surgery and that the effects differ across subgroups.We develop an interactive tool for visualizing the results of this study that allows findings to be customized according to the user's preferences.

Extracorporeal Blood Purification and Acute Kidney Injury in Cardiac Surgery

Cardiac surgery-associated acute kidney injury (CSA-AKI) remains a significant problem following cardiopulmonary bypass (CPB). Various strategies are proposed to attenuate CSA-AKI, including extracorporeal blood purification (EBP), but little is known about the effect of EBP through an acrylonitrile-sodium methallylsulfonate/polyethyleneimine membrane during CPB. To determine whether the use of an EBP device in a nonemergent cardiac surgery population reduces CSA-AKI after CPB. This double-blind, randomized clinical trial was conducted in 2 tertiary hospitals in Spain. Patients 18 years or older undergoing nonemergent cardiac surgery who were at high risk for CSA-AKI were enrolled from June 15, 2016, through November 5, 2021, with follow-up data through February 5, 2022. Of 1156 patients assessed, 343 patients were randomized (1:1) to either receive EBP or standard care. Nonselective EBP device connected to the CPB circuit. The primary outcome was the rate of CSA-AKI in the 7 days after randomization. Among 343 patients randomized (169 to receive EBP and 174 to receive usual care), the mean (SD) age was 69 (9) years and 119 were females. The rate of CSA-AKI was 28.4% (95% CI, 21.7%-35.8%) in the EBP group vs 39.7% (95% CI, 32.3%-47.3%) in the standard care group (P = .03), with an adjusted difference of 10.4% (95% CI, 2.3%-18.5%) using a log-binomial model (P = .01). No significant differences (P > .05) were observed in most of the predefined clinical secondary end points or post hoc exploratory end points. In a sensitivity analysis, EBP was found to be more effective in terms of CSA-AKI reduction in patients with chronic kidney disease, diabetes, hypertension, low left ventricular ejection fraction (<40%), and lower body mass index (<30). No differences were observed between the groups in adverse events tracking. The use of a nonselective EBP device connected to the CPB circuit in a nonemergent population of patients undergoing cardiac surgery was associated with a significant reduction of CSA-AKI in the first 7 days after surgery. ClinicalTrials.gov Identifier: NCT02518087.

Temperature Measurement Timings and the Fever Detection Rate After Gastrointestinal Surgery: Retrospective Cross-Sectional Study.

Postoperative fever frequently indicates surgical complications and is commonly used to evaluate the efficacy of interventions against surgical stress. However, the presence of circadian rhythms in body temperature may compromise the accurate detection of fever. This study aimed to investigate the detection rate of fever under intermittent measurement. We retrospectively reviewed the clinical records of patients who underwent nonemergency gastrointestinal surgery between November 2020 and April 2021. Patients' temperature data were continuously collected every 4 seconds using a wireless axillary thermometer, and fever was defined as a temperature exceeding 38 °C within a day. To simulate intermittent measurement in clinical practice, the body temperature at each hour was selected from the continuously collected temperature dataset. Considering that temperatures are measured multiple times per day, all possible measurement plans using intermittent measurement were composed by combining 1-24 time points from the 24-hour daily cycle. Fever was clinically diagnosed based on the temperature readings at the selected time points per day. The fever detection rates for each plan, with varying measurement times, were listed and ranked. Based on the temperature data continuously collected by the thermometer, fever occurred in 60 (40.8%) of the 147 included patients within 3 days after surgery. Of the measurement plans that included 1-24 measurements daily, the fever detection rates ranged from 3.3% (2/60) to 85% (51/60). The highest detection rates and corresponding timings for measurement plans with 1, 2, 3, and 4 measurements daily were 38.3% (23/60; at 8 PM), 56.7% (34/60; at 3 AM and 7 or 8 PM), 65% (39/60; at 3 AM, 8 PM, and 10 or 11 PM), and 70% (42/60; at 12 AM, 3 AM, 8 PM, and 11 PM), respectively; and the lowest detection rates were 3.3% (2/60), 6.7% (4/60), 6.7% (4/60), and 8.3% (5/60), respectively. Although fever within 3 days after surgery was not correlated with an increased incidence of postoperative complications (5/60, 8.3% vs 6/87, 6.9%; P=.76), it was correlated with a longer hospital stay (median 7, IQR 6-9 days vs median 6, IQR 5-7 days; P<.001). The fever detection rate of the intermittent approach is determined by the timing and frequency of measurement. Measuring at randomly selected time points can miss many fever events after gastrointestinal surgery. However, we can improve the fever detection rate by optimizing the timing and frequency of measurement.

Perioperative interventions to enhance surgical outcomes for older adults with cancer: A systematic review.

219 Background: Older adults with cancer have unique needs, particularly in the perioperative setting, which likely influence surgical outcomes in the geriatric oncology population. Little work has sought to describe available literature investigating perioperative interventions to enhance surgical outcomes for these individuals. Our systematic review sought to describe the literature on perioperative interventions in older adults with cancer undergoing surgery. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a comprehensive search using the Ovid MEDLINE, CINAHL, and Embase databases, searching for literature published from 1/2010-10/2023 (search terms used relevant terminology for geriatric oncology in the perioperative setting). We included randomized controlled trials (RCT) focusing on patient-centered interventions that enrolled adults &gt;60 years old with cancer, excluding studies with pharmacologic, procedural, and radiographic interventions. Results: We included 11 RCTs with 2,177 patients. Patients’ age ranged from 60-95, and median number of patients per study was 147 (range: 44-690). Most studies included patients with colorectal cancer (81.8% [9/11]), all involving non-emergent elective surgeries. Half the studies (54.5% [6/11]) evaluated exercise interventions, and the remaining assessed geriatric assessment-guided interventions (27.2% [3/11]), nutrition optimization (9.1% [1/11]), and patient empowerment (9.1% [1/11]). Primary outcomes were as follows: postoperative complications, quality of life, feasibility of exercise programs, delirium incidence, inspiratory muscle endurance, hospital length of stay, and consistency of nutritional management. All studies had postoperative complications as a primary or secondary outcome. In studies with exercise-based interventions, all but one (83.3% [5/6]) found reduction in postoperative complications, and one showed improvement in quality of life (16.7% [1/6]). Studies focusing on geriatric assessment did not achieve significant differences in outcomes. We found implementation challenges that influenced several studies, including high drop-out rates and intervention fidelity. Conclusions: In this review, we found 11 studies focused on perioperative interventions in older adults with cancer undergoing surgery. Notably, interventions involved exercise, geriatric assessment-guided care, nutrition optimization, and patient empowerment. RCTs to date seem to primarily focus on exercise interventions and geriatric assessment-guided strategies. Although most studies met their primary endpoint, we found heterogeneity in intervention modality and outcome assessment, thus demonstrating a need for ongoing work to address the unique needs of the geriatric oncology population.

Automated line-clearing chest tubes reduce postoperative pain and atrial fibrillation after cardiac surgery

ObjectiveRecent advancements in chest tube technologies have gained interest for their ability to enhance postoperative recovery via reduction of retained blood syndrome after cardiothoracic surgery. The present study investigates the effect of the Centese Thoraguard automated line-clearance chest tube system on postoperative pain and recovery after cardiac surgery. MethodsThis was a single-center retrospective review of 1771 adult patients undergoing nonemergency cardiac surgery between January 2021 and December 2022. Perioperative data were analyzed in 184 patients undergoing surgery with Thoraguard automated clearance chest tubes and 1587 patients with conventional chest tubes. Postoperative outcomes were compared in a propensity-matched cohort of 133 patient pairs with similar preoperative characteristics. ResultsPatients undergoing cardiac surgery with automated clearance chest tubes demonstrated significant reductions in pain scores (0-10) compared with conventional chest tubes on the third postoperative day (5 vs 6, P = .02) and at hospital discharge (0 vs 3, P = .04). Automated clearance chest tubes were associated with a shorter time on the ventilator (5.3 vs 5.8 hours, P < .001). There was a significant reduction in postoperative atrial fibrillation (18.1% vs 30.8%, P = .02) in patients receiving automated clearance chest tubes. There were no significant differences in mortality, myocardial infarction, or stroke between automated line-clearing and conventional chest tubes. ConclusionsThe use of the Thoraguard automated line-clearing chest tube system in routine cardiac surgery was associated with improved postoperative pain control, decreased ventilator duration, and decreased postoperative atrial fibrillation without increased morbidity or mortality.

Impact of non-emergency surgical timing on postoperative recovery quality in mild or asymptomatic SARS-CoV-2 infected patients: a grouped cohort study

ObjectiveTo explore the relationship between the timing of non-emergency surgery in mild or asymptomatic SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infected individuals and the quality of postoperative recovery from the time of confirmed infection to the day of surgery.MethodsWe retrospectively reviewed the medical records of 300 cases of mild or asymptomatic SARS-CoV-2 infected patients undergoing elective general anaesthesia surgery at Yijishan Hospital between January 9, 2023, and February 17, 2023. Based on the time from confirmed SARS-CoV-2 infection to the day of surgery, patients were divided into four groups: ≤2 weeks (Group A), 2–4 weeks (Group B), 4–6 weeks (Group C), and 6–8 weeks (Group D). The primary outcome measures included the Quality of Recovery-15 (QoR-15) scale scores at 3 days, 3 months, and 6 months postoperatively. Secondary outcome measures included postoperative mortality, ICU admission, pulmonary complications, postoperative length of hospital stay, extubation time, and time to leave the PACU.ResultsConcerning the primary outcome measures, the QoR-15 scores at 3 days postoperatively in Group A were significantly lower compared to the other three groups (P < 0.05), while there were no statistically significant differences among the other three groups (P > 0.05). The QoR-15 scores at 3 and 6 months postoperatively showed no statistically significant differences among the four groups (P > 0.05). In terms of secondary outcome measures, Group A had a significantly prolonged hospital stay compared to the other three groups (P < 0.05), while other outcome measures showed no statistically significant differences (P > 0.05).ConclusionThe timing of surgery in mild or asymptomatic SARS-CoV-2 infected patients does not affect long-term recovery quality but does impact short-term recovery quality, especially for elective general anaesthesia surgeries within 2 weeks of confirmed infection. Therefore, it is recommended to wait for a surgical timing of at least greater than 2 weeks to improve short-term recovery quality and enhance patient prognosis.

Right subclavian vein sonoanatomy from the supraclavicular fossa approach in children

Introduction: Although the subclavian vein offers significant advantages over other approaches for ultrasound-guided central venous access, it is not the first choice in the pediatric population, mainly due to its proximity to the pleura and the subclavian artery. Objective: To assess the sonoanatomical characteristics of the subclavian vein and adjacent structures using the supraclavicular approach in a pediatric population. Materials and Methods: Observational, intraoperative, cross-sectional study, between June 2021 and March 2022. The population consisted of ASA I, II and III children taken to non-emergent surgical procedures under general anesthesia. Images were acquired with the patients under general anesthesia, using a high-frequency linear probe to identify the subclavian vein and measure the anatomical landmarks. Results: A total of 67 children were recruited; mean age was 6 years (IQR: 2-12 years), with male sex predominance (61%). Median weight was 22 kg (IQR: 12.2-34 Kg) and median height was 115 cm (IQR: 88-142 cm). Measurements in relation to the vessel showed a mean distance from the skin of 0.70 cm (SD: 0.18 cm), while mean distance from the skin to the pleura was 1.31 cm (SD: 0.28 cm). Mean vein diameter was 0.49 cm (IQR: 0.40-0.63 cm). The mean hypothetical approach angle to the vessel was 22.09 degrees (SD: 4.37 degrees), while the approach angle to the pleura was 39 degrees (SD: 5.31 degrees). No concurrent visualization of the vein and artery was documented in any of the recorded sonoanatomy windows. The tests pointed to an average difference of 0.61 cm in vessel depth in relation to the pleura, and the angle of approach to the vessel was 16.91 degrees smaller when compared with the angle of approach to the pleura (p &lt; 0.001). Conclusions: Using this technique, the supraclavicular approach to the subclavian vein in children is safe and feasible, with an average skin-to-vessel distance of 0.70 cm, minimizing the risk of pleural puncture. Additional studies are required to optimize this technique in the pediatric population.

Prevalence of Aspiration Risk due to a Full Stomach Assessed by Gastric Ultrasonography in Diabetic Patients Undergoing Non-Emergency Surgery

Background: Pulmonary aspiration causes severe complications and high mortality, especially in diabetic patients during the perioperative period. Gastric ultrasonography is able to detect a patient with full stomach that poses high risk of pulmonary aspiration. However, in Thailand, there is no previous prevalence study. Objective: To study the prevalence of aspiration risk resulting from full stomach in diabetic patients during non-emergency surgery and to identify related risk factors using gastric ultrasonography. Materials and Methods: One hundred nineteen diabetic patients were enrolled between July 2021 and January 2022. A preoperative ultrasound examination of gastric content was performed in the right lateral decubitus position. Aspiration risk due to full stomach was defined as having solid contents or fluid volume more than 1.5 mL/kg. The associated risk factors were analyzed using multiple logistic regression models. Results: The prevalence of aspiration risk due to “full stomach” was 18.49% (22 out of 119 patients). Age between 65 and 84 years old (adjusted OR 015, 95% CI 0.04 to 0.54) and blood urea nitrogen (BUN) levels (adjusted OR 1.04, 95% CI 1.00 to 1.08) were statistically significantly associated risk factors (p&lt;0.05). There was no incidence of pulmonary aspiration during the study period. Conclusion: While diabetic patients were advised to follow standard fasting guidelines, the risk of pulmonary aspiration persisted. Implementing an anesthetic plan as though the patient belonged to the “full stomach” group helped ensure the patient’s safety. Additionally, preoperative gastric ultrasound assessment is able to detect “full stomach” condition, thereby, further reducing the incidence of pulmonary aspiration.

Preoperative medication management turnkey order set for nonemergent adult cardiac surgery

ObjectiveThe management of preoperative medications is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Numerous guidelines and expert consensus documents have been published to provide guidance in preoperative medication management. Our objective is to integrate these documents into an evidence-based order set that will facilitate standardized implementation of best practices for preoperative medication management for nonemergent adult cardiac surgery. MethodsSubject matter experts were consulted to translate existing guidelines and peer reviewed literature into a sample turnkey order set for the preoperative management of patients’ medications. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type. ResultsHolding antiplatelet and anticoagulant medications before nonemergent cardiac surgical procedures may reduce the risk of bleeding. Sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 agonists should also be discontinued to prevent acidosis and aspiration, respectively. Specific guidance for frequently used medications are complied within the manuscript, less frequently used medications are listed seperately. ConclusionsDespite strong recommendations from major guidelines and consensus manuscripts, variation exists in preoperative medication orders, with limited availability of succinct implementation tools. This turnkey order set may facilitate standardized comprehensive preoperative medication management before nonemergent cardiac surgery.

Investigating perioperative interventions to enhance surgical outcomes for older adults with cancer: A systematic review.

e13765 Background: Older adults with cancer have unique needs, particularly in perioperative settings, which likely influence surgical outcomes in the geriatric oncology population. Little work has sought to describe available literature investigating perioperative interventions to enhance surgical outcomes for these individuals. We conducted a systematic review to describe the literature on perioperative interventions in older adults with cancer undergoing surgery. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a comprehensive search using the Ovid MEDLINE, CINAHL, and Embase databases, searching for literature published from 1/2010-10/2023 (search terms used relevant terminology for geriatric oncology in the perioperative setting). We included randomized controlled trials that enrolled adults &gt;60 years old with cancer, excluding studies on pharmacologic or procedural interventions. Results: We identified 1,036 studies and 922 abstracts through our initial search. Title and abstract review resulted in 20 manuscripts. After full-text review, 9 were removed as their study design, patient population, or intervention did not align with inclusion criteria. Our final review included 11 studies (90.9% [10/11] were conducted outside of the US and 45.6% [5/11] were published within the past 2 years). Patients’ age ranged from 60-95 and median number of patients per study was 147 (range: 44-690). Studies were primarily on patients with colorectal cancer (81.8% [9/11]), with all involving non-emergent elective surgeries. Most studies (63.6% [7/11]) evaluated exercise interventions, and the remaining assessed geriatric assessment-guided interventions (18.2% [2/11]), nutrition optimization (9.1% [1/11]), or patient empowerment (9.1% [1/11]). Primary outcomes were as follows: postoperative complications (36.4% [4/11]), feasibility of exercise programs (27.3% [3/11]), quality of life (18.2% [2/11]), delirium incidence (9.1% [1/11]), or hospital length of stay (9.1% [1/11]). All studies had postoperative complications as a primary or secondary outcome. Overall, 54.5% (6/11) found a positive primary outcome including: postoperative complications (18.2% [2/11]), implementation of exercise program (18.2% [2/11]), quality of life (9.1% [1/11]), or nutrition (9.1% [1/11]). Conclusions: In this review, we found 11 studies focused on perioperative interventions in older adults with cancer undergoing surgery. Notably, interventions involved exercise, geriatric assessment-guided care, nutrition optimization, and patient empowerment. Although most studies met their primary endpoint, we found heterogeneity in intervention modality and outcome assessment, thus demonstrating further work is required to address the unique perioperative needs of the geriatric oncology population.

Operating Room Extubation for Patients Undergoing Cardiac Surgery: A National Society of Thoracic Surgeons Database Analysis

BackgroundThe utility of operating room extubation (ORE) after cardiac surgery over fast-track extubation (FTE) within 6 hours remains contested. We hypothesized ORE would be associated with equivalent rates of morbidity and mortality, relative to FTE. MethodsPatients undergoing nonemergent cardiac surgery were identified in The Society of Thoracic Surgeons Adult Cardiac Surgery Database between July 2017 and December 2022. Only procedures with The Society of Thoracic Surgeons risk models were included. Risk-adjusted outcomes of ORE and FTE were compared by observed-to-expected ratios with 95% CIs aggregated over all procedure types, and ORE vs FTE adjusted odds ratios (ORs) specific to each procedure type using multivariable logistic regression. Analyzed outcomes were operative mortality, prolonged length of stay, composite reoperation for bleeding and reintubation, and composite morbidity and mortality. ResultsThe study population of 669,099 patients across 1069 hospitals included 36,298 ORE patients in 296 hospitals. Risk-adjusted analyses found that ORE was associated with statistically similar or better results across each of the 4 outcomes and procedure subtypes. Notably, rates of postoperative mortality were significantly lower in ORE patients undergoing coronary artery bypass grafting (OR, 0.54; 95% CI, 0.46-0.65), aortic valve replacement (OR, 0.43; 95% CI, 0.24-0.77), and mitral valve replacement (OR, 0.48; 95% CI, 0.26-0.89). ConclusionsExtubation in the OR was safe and effective in a selected patient population and may be associated with superior outcomes in coronary artery bypass, aortic valve replacement, and mitral valve replacement. These national data appear to confirm institutional experiences regarding the potential benefit of OR extubation. Further refinement of optimal populations may justify randomized investigation.

Outcomes of nonemergency cardiac surgery after overnight operative workload: A statewide experience

ObjectiveCardiac surgeons experience unpredictable overnight operative responsibilities, with variable rest before same-day, first-start scheduled cases. This study evaluated the frequency and associated impact of a surgeon's overnight operative workload on the outcomes of their same-day, first-start operations. MethodsA statewide cardiac surgery quality database was queried for adult cardiac surgical operations between July 1, 2011, and March 1, 2021. Nonemergency, first-start, Society of Thoracic Surgeons predicted risk of mortality operations were stratified by whether or not the surgeon performed an overnight operation that ended after midnight. A generalized mixed effect model was used to evaluate the effect of overnight operations on a Society of Thoracic Surgeons composite outcome (5 major morbidities or operative mortality) of the first-start operation. ResultsOf all first-start operations, 0.4% (239/56,272) had a preceding operation ending after midnight. The Society of Thoracic Surgeons predicted risk of morbidity and mortality was similar for first-start operations whether preceded by an overnight operation or not (overnight operation: 11.3%; no overnight operation: 11.7%, P = .42). Unadjusted rates of the primary outcome were not significantly different after an overnight operation (overnight operation: 13.4%; no overnight operation: 12.3%, P = .59). After adjustment, overnight operations did not significantly impact the risk of major morbidity or mortality for first-start operations (adjusted odds ratio, 1.1, P = .70). ConclusionsFirst-start cardiac operations performed after an overnight operation represent a small subset of all first-start Society of Thoracic Surgeons predicted risk operations. Overnight operations do not significantly influence the risk of major morbidity or mortality of first-start operations, which suggests that surgeons exercise proper judgment in determining appropriate workloads.

First-in-man clinical implantation and acute pacing performance of a novel subxiphoidal pacemaker system.

Intravascular cardiac pacemakers are an established therapy for bradycardic indications. Recently, a new class of leadless pacemakers have mitigated some of the complications related to pacemaker leads. In this study, we evaluate the implantation and performance of a novel extravascular technology that delivers epicardial pacing through a subxiphoidal approach. Fifteen patients undergoing non-emergent open-heart surgery were enrolled. A midline incision was made just below the xiphoid process, and substernal tunneling was used to create a pocket for the device and to access the anterior pericardium over the right ventricle. The test device (Calyan Technologies, Oakdale, MN) was temporarily inserted underneath the ribcage and clipped to the xiphoid process. The sensing and pacing electrode (FlexArm) was positioned on the anterior pericardium. Ventricular sensing and pacing capture thresholds were measured. The test device was successfully implanted in all 15 patients. There were no device or procedure-related adverse events. The first five implanted patients had no pacing capture at maximum stimulation intensity. Design changes were made to the device, including different electrode size and shape, and successful ventricular capture was achieved in 9 of the subsequent 10 patients. In these patients, pacing threshold was 3.8 ± 1.6mA with a pulse width of 0.5 ms. All devices were successfully explanted at the end of the procedure. In a first-in-human experience with a novel extravascular pacemaker, this study demonstrated the feasibility of pericardial ventricular pacing via a subxiphoidal approach. Further chronic studies are required to evaluate the safety and performance of this novel pacing technology.

Influence of elevated liver enzyme level on 30-day mortality rates in patients undergoing nonemergency orthopedic surgery

BackgroundThe effect of elevated preoperative liver enzyme levels on postoperative outcomes is a topic of concern to clinicians. This study explored the association between elevated preoperative liver enzyme levels and surgical outcomes in patients undergoing orthopedic surgery.MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program database, we obtained data on adult patients who received nonemergency orthopedic surgery under general anesthesia between 2011 and 2021.ResultsWe evaluated the data of 477,524 patients, of whom 6.1% (24 197 patients) had elevated preoperative serum glutamic oxaloacetic transaminase (SGOT) levels. An elevated SGOT level was significantly associated with 30-day postoperative mortality (adjusted hazard ratio, 1.62; 95% confidence interval, 1.39 to 1.90). We determined that the mortality rate rose with SGOT levels. The results remained unchanged after propensity score matching.ConclusionElevated preoperative SGOT levels constitute an independent risk factor for 30-day postoperative mortality and are proportionately associated with the risk of 30-day postoperative mortality.

Implementation of a Survey Spine MR Imaging Protocol for Cord Compression in the Emergency Department: Experience at a Level 1 Trauma Center.

Imaging stewardship in the emergency department (ED) is vital in ensuring patients receive optimized care. While suspected cord compression (CC) is a frequent indication for total spine MR imaging in the ED, the incidence of CC is low. Recently, our level 1 trauma center introduced a survey spine MR imaging protocol to evaluate for suspected CC while reducing examination time to avoid imaging overutilization. This study aims to evaluate the time savings, frequency of ordering patterns of the survey, and the symptoms and outcomes of patients undergoing the survey. This retrospective study examined patients who received a survey spine MR imaging in the ED at our institution between 2018 and 2022. All examinations were performed on a 1.5T GE Healthcare scanner by using our institutional CC survey protocol, which includes sagittal T2WI and STIR sequences through the cervical, thoracic, and lumbar spine. Examinations were read by a blinded, board-certified neuroradiologist. A total of 2002 patients received a survey spine MR imaging protocol during the study period. Of these patients, 845 (42.2%, mean age 57 ± 19 years, 45% women) received survey spine MR imaging examinations for the suspicion of CC, and 120 patients (14.2% positivity rate) had radiographic CC. The survey spine MR imaging averaged 5 minutes and 50 seconds (79% faster than routine MR imaging). On multivariate analysis, trauma, back pain, lower extremity weakness, urinary or bowel incontinence, numbness, ataxia, and hyperreflexia were each independently associated with CC. Of the 120 patients with CC, 71 underwent emergent surgery, 20 underwent nonemergent surgery, and 29 were managed medically. The survey spine protocol was positive for CC in 14% of patients in our cohort and acquired at a 79% faster rate compared with routine total spine. Understanding the positivity rate of CC, the clinical symptoms that are most associated with CC, and the subsequent care management for patients presenting with suspected cord compression who received the survey spine MR imaging may better inform the broad adoption and subsequent utilization of survey imaging protocols in emergency settings to increase throughput, improve allocation of resources, and provide efficient care for patients with suspected CC.

Hemodynamic Monitoring In The Cardiac Surgical Patient: Comparison of Three Arterial Catheters

ObjectiveSystemic systolic (SAP) and mean (MAP) arterial pressure monitoring is the cornerstone in hemodynamic management of the cardiac surgical patient and the radial artery is the most common site of catheter placement. The present study compares three different arterial line procedures. It is hypothesized that a 20-G 12.7cm catheter inserted in the radial artery will be equal to 20-G 12.7cm angiocath placed in the brachial artery, and superior to a 20-G 5.0cm angiocath placed in the radial artery. DesignA prospective randomized control was performed. SettingSingle Academic University Hospital ParticipantsAdult patients ≥ 18 years old undergoing non-emergent cardiac surgery utilizing cardiopulmonary bypass. InterventionsAfter approval by the Rhode Island Hospital institutional review board, a randomized prospective control study to evaluate three different peripheral intra-arterial catheter systems was performed: 1) Radial Short (RS). 20-G 5cm catheter, 2) Radial Long (RL): 20-G 12cm catheter, 3) Brachial Long (BL): 20-G 12cm catheter. Measurements&ResultsGradients between central aortic and peripheral catheters (CA-P) were compared and analyzed prior to CPB, and 2 and 10 minutes after separation from CPB. The placement of femoral arterial lines, and administration of vasoactive medications were recorded. After exclusions 67 BL, 61 RL, and 66 RS patients were compared. Prior to CPB CA-P SAP and MAP gradients were not significant among the three groups. Two minutes after CPB the CA-P SAP gradient was significant for the RS group (p=0.005) and insignificant for BL (p=0.47) and RL (p=0.39). Two-group analysis reveal that CA-P SAP gradients are similar between BL and RL (p=0.84), both of which were superior to RS (p=0.02 and p=0.04 resp.). At 10 minutes after CPB, the CA-P SAP gradient for RS remained significant (p=0.004) and similar to the gradient at 2 minutes. The CA-P SAP gradients increased from 2 to 10 minutes for BL (p=0.13) and RL (p=0.06). Two minutes after CPB the CA-P MAP gradients are significant for BL(p=0.003), RL(p< 0.0001), and RS(p< 0.0001) groups. Two-group analysis reveal that the CA-P MAP gradients were lower for the BL group compared to RL (p=0.054) and RS (p< 0.05) groups. Ten minutes after CPB, the CA-P MAP gradients in the RL and RS groups remained significant (p< 0.0001) and both greater than the BL group (p=0.002). A femoral arterial line was placed more frequently in the RS group (8/66=12.1%), than RL group (3/61=4.9%), and the BL group (2/67=3.0%). Vasopressin was administered significantly more frequently in the RS group… ConclusionRegarding CA-P SAP gradients, the RL group performed equally to the BL group, both being superior to RS. Regarding CA-P MAP gradients BL was superior to RL and RS. Clinically, femoral line placement and vasopressin administration was less for the BL and RL groups when compared to the RS group. This study demonstrates the benefits of a long (12.7cm) 20 G angiocath placed in the radial artery.