Adverse Perioperative Outcomes Research Articles

Cefazolin Alone Versus Cefazolin With Tobramycin or Gentamicin as Intraoperative Antibiotic Prophylaxis for Total Joint Arthroplasty.

Prosthetic joint infection is a serious complication of total knee arthroplasty (TKA) and total hip arthroplasty (THA). While cefazolin is the standard prophylactic antibiotic, some groups have considered adding aminoglycosides (gentamycin or tobramycin) to this regimen. Adult primary THA and TKA patients were identified from 2010-2021 Q1 PearlDiver M151 database. Inclusion criteria were activity in the database ≥ 90 days postoperative and no infectious, neoplastic, or traumatic diagnoses within 90 days preoperative. Intraoperative antibiotic prophylaxis regimens were determined using Current Procedural Terminology J codes. For both THA and TKA, 2 subcohorts were created: (1) Patients who received cefazolin alone and (2) cefazolin and tobramycin or gentamicin. Differences in 90-day postoperative adverse outcomes were assessed with multivariable logistic regression controlling for age, sex, and Elixhauser Comorbidity Index. Five-year implant survival was assessed using Kaplan-Meier analysis and log-rank tests. For THA, 32,882 patients were identified, prophylactic cefazolin alone was given to 30,527 (92.8%), and cefazolin+ gentamicin/tobramycin was given to 2355 (7.2%). For TKA, 119,611 patients were identified, prophylactic cefazolin alone was given to 110,469 (92.4%), and cefazolin+ gentamicin/tobramycin was given to 9142 (7.6%). Overall SSI rate for THA was 1.1% and for TKA 0.8%. For both THA and TKA, antibiotic subgroups were clinically similar with regard to age, sex, and Elixhauser Comorbidity Index. On univariable and multivariable analysis, no 90-day outcomes varied significantly. Five-year implant survivals were not significantly different. For THA and TKA, cefazolin alone vs cefazolin+ gentamicin/tobramycin were not found to have differences in rates of perioperative adverse outcomes (including SSI/prosthetic joint infection) or 5-year revision rates.

Evaluation of Modified Frailty Index-5 as a Predictor of 60-day Perioperative Morbidity and Mortality in Geriatric Patients Presenting for Orthopaedic Surgery: A Prospective Cohort Study

Introduction: Frailty indices predicting perioperative adverse outcomes have been used predominantly in retrospective studies for prediction of surgical adverse outcomes. Aim: To evaluate the modified 5-item Frailty Index (mFI-5) as a predictor of anaesthetic and surgical complications up to 60 days in geriatric patients presenting for orthopaedic surgery. Materials and Methods: The prospective cohort study was conducted at Lokmanya Tilak Municipal General Hospital, Mumbai, Maharashtra, India, from December 2019 to December 2020. Details of participants and caregivers, mFI-5 scores and surgical details of 62 patients aged >65 years undergoing orthopaedic surgeries were studied. The mFI-5 score was calculated based on the presence of five co-morbidities: Congestive Heart Failure (CHF), Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD) or pneumonia, functional health status and hypertension, as defined in NSQIP database. Complications of perioperative bleeding and inotropic support, along with others mentioned in the National Surgical Quality Improvement Program (NSQIP) database, were noted up to 60 days, with milestones of 48 hours, seven days and 30 days. The data were analysed for association between mFI-5 and complications by applying t-test, Chi-square test and multivariate analysis using the Statistical Package for the Social Sciences (SPSS) 20.0 version. Results: Mean age was 71.44±6.70 years, with 26 patients having an mFI-5 >3 (mean 2.33±0.96). Forty-five patients had at least one complication (mean 2.39±2.59). Mortality was observed in three out of 26 patients with an mFI-5 >3 (11.54%), while one in 36 patients (2.78%) died with mFI-5<3. No association with mortality was observed with either unit increase in mFI-5 scores or mFI5>3. Complications included use of blood and blood products, inotropes and postoperative ventilation in the first 48 hours (mean 0.73±0.75), respiratory complications and blood and blood product transfusions in the 48 hours to seven days period (mean 0.65±1.13), Surgical Site Infections (SSIs) and reoperations between 8-30 days (mean 0.74±1.41) and renal insufficiency and death in the 30-60 days period (mean 0.27±0.61). Age (p-value=0.315), gender (p-value=0.635), scheduling (p-value=0.530), site (p-value=0.077) and nature of surgery (p-value=0.172) were not statistically significant, while mFI scores ≥3 (p-value <0.001), American Society of Anaesthesiologists (ASA) grades (p-value=0.016), surgical duration (p-value=0.012), CHF (p-value=0.003) and DM (p-value=0.002) were statistically significant. Conclusion: Patients aged >65 years with mFI-5 scores ≥3, having CHF, DM, ASA grades >2, undergoing orthopaedic surgeries of duration up to three hours, had statistically significant chance of developing postoperative complications, other than death, up to 60 days. A randomised controlled trial with mFI-5 cut-off of ≥3 and longer follow-up periods would yield better results.

Perioperative outcomes in patients with symptomatic versus asymptomatic previous COVID-19 infection undergoing neurosurgical treatment (post–COVID-19 study)

Abstract Background and Aims: The long-term effects of coronavirus disease 2019 (COVID-19) infection (long-COVID) are being increasingly recognized. The long-COVID effects are more likely in individuals who were symptomatic than asymptomatic during their previous COVID-19 infection. The data on perioperative outcomes of patients undergoing elective neurosurgery long after their recovery from COVID-19 infection is lacking. The primary objective of this study was to compare the perioperative outcomes after elective neurosurgery between patients who were symptomatic and those who were asymptomatic during their previous COVID-19 infection. The secondary objectives were to compare the earlier COVID-19 characteristics and the perioperative pulmonary profile during current surgery between these groups. Material and Methods: This prospective observational study was performed in adult patients undergoing elective neurosurgery with history of previous COVID-19 infection. Data was collected regarding previous COVID-19 infection (symptoms, hospitalization, treatment, complications, etc.) and current perioperative characteristics (pulmonary profile, perioperative complications, hospital stay, mortality, etc.). Results: A total of 50 patients were recruited during the study period, of which 35 (73%) patients were symptomatic during previous COVID-19 infection (two patients were excluded). The mean duration between current surgery and previous COVID-19 infection was 7 months. Patients symptomatic during earlier COVID-19 infection were females, older, and had a lower oxygen level during current surgery. There was no difference between symptomatic and asymptomatic groups in adverse perioperative outcomes such as desaturation, pulmonary or extrapulmonary complications, or non-extubation. Conclusion: The perioperative outcomes of patients undergoing elective neurosurgery with previous mild to moderate symptomatic COVID-19 infection may not be different from those of patients with asymptomatic COVID-19 infection.

The impact of obstructive sleep apnoea on post-operative outcomes.

Unrecognised obstructive sleep apnoea (OSA) has been associated with adverse cardiorespiratory perioperative outcomes. However, with changing anaesthetic and perioperative management, there is ongoing uncertainty about the importance of OSA as a risk factor for post-operative complications. A cohort study involving subjects undergoing elective surgery was conducted. OSA was diagnosed with a limited channel sleep monitor. In subjects undergoing routine perioperative care, complications were identified based on the assessment of the attending clinical team. The primary outcome was a composite end-point of cardiorespiratory outcomes comprising myocardial infarction, atrial fibrillation, other arrhythmias, bradycardia, need for inotropic support, unplanned intensive care unit admission, pneumonia or respiratory failure. Four hundred seventy-two subjects were recruited, with 356 being included in the analyses; 281 (79%) had OSA and 66 (19%) had severe OSA. Subjects with OSA did not have a significantly higher incidence of complications (5.7%) compared to those without (2.7%, adjusted relative risk 1.89 (0.23-15.67)). Additionally, complications were not increased in those with severe OSA. Unrecognised OSA was not associated with an increase in clinically evident cardiorespiratory complications in this cohort. The lower complication rates compared with earlier studies suggest that increased use of less invasive surgical techniques, improved pain management and increased awareness of OSA have had an impact in reducing postoperative complications in this group. Further research is needed to clarify the impact of severe OSA on post-operative outcomes in different surgical cohorts with varying risk profiles in order to develop optimal perioperative pathways.

Patients With Diabetes on Sodium-Glucose Cotransporter-2 Inhibitors Undergoing Total Knee Arthroplasty Are at Increased Odds for a Number of Postoperative Adverse Events But Reduced Risk of Transfusion.

Diabetes mellitus (DM) is a common comorbidity in total knee arthroplasty (TKA) patients, which has been associated with multiple complications. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are one class of medications recently approved to better manage DM. This study investigates the correlation of SGLT2i use on postoperative complications and revision rates for diabetic patients undergoing TKA. The M157 PearlDiver database was used to identify DM patients undergoing primary TKA. Those prescribed SGLT2i were identified and matched in 1:4 ratio with control DM patients based on age, sex, obesity diagnosis, and Elixhauser comorbidity index. Ninety-day adverse events and 5-year rates of revision were abstracted and compared by multivariable regression, controlling for age, sex, Elixhauser comorbidity index, long-term insulin use, obesity, metformin use, and active tobacco use. A total of 164,474 TKA patients with DM were identified, of which SGLT2i were prescribed for 9,246 (5.6%). On multivariable analysis, SGLT2i use in DM patients was independently associated with higher odds of aggregated adverse events driven by myocardial infarction (odds ratio [OR] 2.40), sepsis (OR 1.81), urinary tract infection (OR 2.10), pneumonia (OR 1.87), and acute kidney injury (OR 1.33) but had lower odds of transfusion (OR 0.31) (P < 0.0001 for each). On multivariable analysis, 5-year survival to revision TKA were not markedly different between the matched cohorts. SGLT2i are being increasingly prescribed for DM patients undergoing TKA. Although they are associated with increased risk of multiple 90-day perioperative adverse outcomes, they are also associated with reduced incidence of blood transfusion. These results may guide surgical decision making and counseling for patients taking this group of medications and align with some prior studies related to glucagon-like protein-1 agonists.

Perioperative and frailty outcomes after total knee arthroplasty: a retrospective cohort study.

Total knee arthroplasty (TKA) is a common procedure with an increasing demand, especially among the elderly. Frailty is known to be associated with adverse perioperative outcomes in the older population. In this article, we aimed to understand the associations of preoperative frailty status and comorbid conditions in relation to their clinical and healthcare outcomes after TKA, and to describe the perioperative factors leading to improvement in a patient's frailty status after TKA. This is a retrospective cohort study, and the outcomes were assessed over 2 years. Frailty is defined by the Clinical Frailty Score. A total of 96 patient records were assessed, of which 13 (13.5%) patients were robust and 83 (86.5%) patients were prefrail or frail. Two years after TKA, the number of robust patients increased to 58 (61.7%) patients, showing a reversal of frailty in 48.2% of patients. Total knee arthroplasty in prefrail and frail patients is a safe procedure that leads to improvement of frailty status, with an increase in the proportion of patients becoming robust within 2 years after the operation.

Algorithm for Managing Patients Hospitalized in the Surgical Wards Due to COVID-19-Related Acute Abdominal Pathology

AIM OF THE STUDY. Was to improve the outcomes of treatment of patients with COVID-19-related acute abdominal pathology by developing and implementing an algorithm for the diagnosis and treatment of those patients.MATERIAL AND METHODS. The study involved 200 patients who were randomized into two groups. This research was retrospective, based on the analysis of the medical histories of patients hospitalized with clinical manifestations of acute abdominal pathology that developed against the background of COVID-19. All medical histories in emergency departments and centers of the Republic of Uzbekistan were analyzed in the period from the beginning of the declaration of the pandemic (March 2020) to July 2022 inclusive.RESULTS. In the context of an infectious disease pandemic (COVID–19 as an example), it is very important to develop an algorithm for managing patients with acute surgical pathology. This algorithm should include a diagnostic component with the purpose of timely diagnosis of acute surgical pathology and hospitalization in the surgical department. The next step is to identify patients with a high risk of perioperative complications and adverse outcomes. The final component of the algorithm is the correction of possible risk factors for adverse outcomes.CONCLUSION. The duration of hospitalization of patients who underwent surgery for acute abdominal pathology was significantly longer during the pandemic compared to that of in the post-pandemic period (10.35±7.01 vs. 5.83±3.85 days, p&lt;0.001), which may be due to both changes in the structure of the pathology and a larger number of complicated forms. The application of the developed algorithm will optimize the management of patients with COVID-19-related acute surgical pathology, guarantee rapid decision-making while minimizing the risk of infection, reduce the risk of complications and adverse outcomes.

Propensity score matching analysis of early vs. delayed surgery for intertrochanteric fracture in older patients: a retrospective multicenter cohort study of 7414 patients with a mean 4-year follow up

BackgroundThe widespread acceptance of early surgery as a treatment for acute intertrochanteric fracture (ITF) has been accompanied by ongoing controversy due to conflicting conclusions presented in previous studies. This study aims to compare the occurrence of perioperative complications and mortality, as well as functional outcomes in older patients with ITF who underwent either early or delayed surgery.MethodsA retrospective multicenter cohort study involving 7414 patients with ITF between Jan. 2017 and Dec. 2021 was conducted. After predefined participants selection inclusion and exclusion criteria, 2323 surgically treated ITF patients were included and analyzed utilizing propensity score matching (PSM) method. Their demographics, injury-related data, surgery-related data, and perioperative adverse outcomes during hospitalization were collected and compared between the early or delayed surgery groups by PSM with a 1:4 ratio. All participants received a minimum of two-year follow-up and perioperative outcomes, functional outcomes, and survival analyses were conducted and compared.ResultsAfter adjustment for potential confounders, there were no significant difference in surgery duration, intraoperative blood loss, transfusion rate, mortality rates, functional outcomes, and perioperative complications rates including severe complications, cardiac complications, pulmonary complications, and neurological complications regardless of whether the patient was treated with early or delayed surgery (all P > 0.05). Although length of hospital stay (mean, 11.5 versus 14.4 days, P < 0.001), total hospital costs (mean, 39305 versus 42048 yuan, P < 0.001), and minor complications rates including hematological complications (31.7% versus 41.2%, P = 0.007) and nutritional/metabolic complications (59.3% versus 66.4%, P = 0.039) were lower in the early surgery group, our result indicated patients with early surgery were more inclined to receive more blood transfusion (mean, 2.8 versus 2.2 units, P = 0.004).ConclusionsOur findings suggest that a 48-hour delay in surgical intervention for older patients with an ITF does not result in a higher mortality rate, worse functional outcomes, and increased incidence of major perioperative complications when compared to early surgery. While expedited surgery is undoubtedly necessary for suitable patients, a reasonable preoperative delay of 48 h may be justified and safe for those with severe conditions, rather than strictly adhering to the current guidelines.

The association of perioperative serum uric acid variation with in-hospital adverse outcomes in coronary artery bypass grafting patients.

Previous studies proposed the predictive value of baseline serum uric acid (SUA) in the prognosis of coronary artery bypass grafting (CABG) patients. The association of perioperative SUA variation with in-hospital adverse outcomes in CABG patients is unknown. A total of 2,453 patients were included in the study and were divided into four groups (G1-G4) according to perioperative SUA variation (ΔSUA) (G1, ΔSUA ≤ -90 μmol/L; G2, -90 μmol/L < ΔSUA < 0; G3, 0 ≤ ΔSUA < 30 μmol/L; G4, 30 μmol/L ≤ ΔSUA.) The basic characteristics and incidence of adverse outcomes were compared between the groups in the overall population and the subgroups. Multivariate logistic regression was performed to explore the association between perioperative SUA increases and adverse outcomes, and receiver operating characteristic analysis was used to obtain the cutoff value of SUA increases. The patients had a mean age of 60.9 years and the majority were males (76.7%). In the group with the most significant increase in SUA (G4), incidences of in-hospital all-cause death and fatal arrhythmia were higher than in other groups in the overall population and the subgroups. Multivariate logistic regression showed that an increase in the SUA level of ≥30 µmol/L was significantly associated with in-hospital all-cause death and fatal arrhythmia, independent of the baseline SUA level and renal function. This association was significant in most subgroups for in-hospital fatal arrhythmia and in the ≥60 years, myocardial infarction, and female subgroups for in-hospital all-cause death. The cutoff values of SUA increases in the overall population were 54.5 µmol/L for in-hospital all-cause death and 42.6 µmol/L for in-hospital fatal arrhythmia. The perioperative SUA increase significantly correlated with a higher incidence of in-hospital all-cause death and fatal arrhythmia in CABG patients, independent of the baseline SUA level and renal function. Perioperative SUA variation may provide complementary information in the identification of patients potentially at risk.

The Effect of Teleprehabilitation on Adverse Events After Elective Cardiac Surgery: A Randomized Controlled Trial

Patients scheduled for cardiac surgery and procedures often present with modifiable risk factors for adverse perioperative outcomes. Prehabilitation has shown potential to enhance mental and physical fitness; however, its effect on clinical cardiovascular endpoints in this population has not been studied. The current trial was designed to evaluate the effect of a personalized multimodal teleprehabilitation on the incidence of composite endpoint on major adverse cardiovascular events in patients scheduled for elective cardiac surgery. In a multicenter randomized controlled trial, 394 patients awaiting elective cardiac surgery and procedures were enrolled. Of these, 197 patients were randomized to an online multimodal personalized teleprehabilitation program through shared decision-making by a multidisciplinary team, and 197 were assigned to a control group. The primary outcome was major adverse cardiovascular events (ie, cardiovascular death, myocardial infarction, stroke, hospitalization for heart failure or other life-threatening cardiac events, and earlier or repeated intervention), as measured from the randomization until 1-year postoperatively. All events were adjudicated by a blinded event committee. Secondary outcomes included length of hospital stay, postoperative complications, quality of life, adherence to the program, and effect on the incidence of modifiable risk factors. Sensitivity analyses of the primary outcome were conducted adjusting for baseline characteristics to evaluate the consistency of treatment effects. From randomization until 1 year postoperatively, the primary endpoint occurred in 33 patients (16.8%) in theteleprehabilitation group and 50 patients (25.5%) in the control group (difference 8.8%; 95%CI: 0.7%-16.8%; P=0.032). This difference was primarily driven by a reduction in hospitalizations, and the sensitivity analyses showed that treatment effect was mainly in the patients undergoing a cardiac surgery rather than transcatheter procedures with adjusted OR of 0.54 (95%CI: 0.30-0.96; P = 0.035). Teleprehabilitation also reduced the incidence of active smokers, elevated pulmonary risk scores, and elevated depression scores. There was no significant difference in postoperative length of hospital stay, occurrence of postoperative complications, physical fitness, incidence of obesity, or malnutrition. Multimodal personalized teleprehabilitation resulted in a clinically relevant and statistically significant reduction of the primary endpoint in patients undergoing cardiac surgery. (Digital Cardiac Counseling Trial:DCC Trial [DCC]; NCT04393636).

Frailty: A Familiar Challenge or an Unknown Question for Anesthesiologist – Results of an Indian Survey

Abstract Background: Frailty is a public health issue, and with increased life expectancy, more elderly patients are coming for surgical interventions. It is a multidimensional condition, characterized by loss of functional reserve which leads to adverse perioperative outcomes. This novel survey in the Indian scenario not only identifies the knowledge and orientation of the Indian anesthesiologists but also their day-to-day practice of frailty assessment. Methods: This 22-question survey was distributed to mostly Indian anesthesiologists practicing in various cities through electronic media. The first section included the electronic addresses and the informed consent. The second section contains the academic background and demography of the respondents. The third section includes their awareness about frailty and how they perceive it as a clinical entity. The last section focuses on the actual practice of frailty assessment by the participants. Results: We received 306 responses, among them 295 doctors practice anesthesia. Ninety-four percent of respondents agreed that the concept of frailty should be known to all anesthesiologists, 89% of the responses concurred that frailty affects postoperative outcomes. Only 54% respondents were properly trained in this topic during their training days and 45% of all were only confident to diagnose frailty in the preanesthetic check (PAC) clinic. Thirty seven percent of respondents lacked basic knowledge about different frailty tools. Forty-three percent of respondents revealed that they do not report the presence of frailty in patient files during PAC. Only 10% of the respondents have ever used any point-of-care ultrasound for frailty assessment. In 73% of cases, there was no geriatric team available in the hospitals, and 71% said that there is no well-implemented preoperative approach in their hospital for elderly frail patients for elective surgery. Conclusions: Despite the awareness of the importance of frailty in preoperative assessment, there is a huge void in the identification and assessment of frail patients in hospitals. There is an absolute need for a uniform and standardized national guideline.

A Systemic Review &amp; Meta-Analysis of the Impact of Vascular-Geriatric Service Models on Short-Term Outcomes in Vascular Surgery Inpatients

Abstract Background Vascular surgeons are treating progressively older, frailer and more medically complex patients. Care models including both surgeons and geriatricians have improved peri-operative outcomes in orthopaedics and surgical oncology. This meta-analysis investigates the impact of “vascular-geriatric” services on short-term inpatient outcomes. Methods Search strategy included PubMed, Scopus and Embase databases, conference abstracts and clinical trial registries. All study methodologies comparing outcomes before and after the introduction of a dedicated vascular-geriatrics service were eligible. Meta-analyses compared the relative risk (RR) of mortality, complications and 30-day readmission using a random-effects model. Risk of bias was assessed with the MINORS tool. Results Eight studies were identified, including one randomised trial and seven ‘before &amp; after’ observational studies. 2074 patients were included, 1065 in the “Vascular-Geriatrics” cohort and 1009 in standard care. Care models included comprehensive geriatric assessment as part of the pre-operative review process before elective aortic surgery, inpatient geriatric liaison services and formal vascular-geriatric co-management arrangements. Source studies were of moderate to high risk of bias. A meta-analysis of five studies demonstrated vascular-geriatrics models were significantly associated with lower mortality rates than standard care (pooled 2.4% vs 4.9%) (RR 0.51, 95% CI 0.28-0.94, p=.03) (I2=0%). Vascular-Geriatrics models were also significantly associated with lower risk of infective complications (RR 0.49, 95% CI 0.36–0.66, p&amp;lt;.001) (I2=0%) and delirium (RR 0.58, 95% CI 0.35–0.97, p=.04) (I2=48%). There was no difference in mean length of stay (SMD -2.20, 95% CI -4.6-0.19, p=.07) (I2=86%). or 30-day readmission rates between Vascular-Geriatrics models and standard care (RR 1.10, 95% CI 0.81-1.51, p=.54) (I2=38%). Conclusion While the source data is heterogenous and of limited quality, this meta-analysis suggests that dedicated geriatric intervention may reduce adverse peri-operative outcomes in vascular patients compared to traditional care models. Further studies are needed to investigate the most effective design of geriatrician-surgeon partnership.

Dose compliance of estramustine phosphate in neoadjuvant chemohormonal therapy combined with degarelix acetate predicts the biochemical recurrence in patients with very high-risk prostate cancer who underwent robot-assisted radical prostatectomy.

The objective of this study is to evaluate the safety and efficacy of neoadjuvant degarelix acetate and low-dose estramustine phosphate for high-/very high-risk prostate cancer. Overall, 187 patients diagnosed with National Comprehensive Cancer Network high-/very high-risk cTanyN0M0 localized prostate cancer who consented to undergo robot-assisted radical prostatectomy after receiving neoadjuvant chemohormonal therapy for 6 months were prospectively enrolled between December 2017 and March 2023. Adverse events, perioperative and histopathological outcomes, and biochemical recurrence-free survival rates were examined. Survival analysis compared the estramustine phosphate completion and reduction groups. Thirty-six patients discontinued neoadjuvant therapy in <5 months owing to adverse events (n = 34) or other reasons (n = 2). Eleven were excluded for being in the postoperative castration range. Of the 140 patients who underwent surgery, 124 continued with two tablets of estramustine phosphate and 16 with one tablet. Overall, 82 patients were very high-risk. Histopathological outcomes were significantly worse in the very high-risk group than those in the high-risk group. Very high-risk status and estramustine phosphate reduction were significant factors in biochemical recurrence in multivariate analysis. The biochemical recurrence-free survival rate in very high-risk patients was significantly lower in the estramustine phosphate dose reduction group than in the completion group but not significant in high-risk patients. Major adverse events were anemia (n = 174), elevated transaminase levels (n = 68), and deep vein thrombosis (n = 24). Severe adverse events included acute coronary syndrome (n = 4) and pulmonary embolism (n = 3). Dose compliance with estramustine phosphate predicted biochemical recurrence in patients with very high-risk prostate cancer undergoing robot-assisted radical prostatectomy with neoadjuvant chemohormonal therapy.

Relationship between amniotic fluid inflammatory factors and pregnancy outcomes after emergency cervical cerclage

Objective: To explore the relationship between amniotic fluid and peripheral blood inflammatory factors and the pregnancy outcomes after emergency cervical cerclage, and to identify effective indicators for predicting adverse pregnancy outcomes after the procedure. Methods: A case-control study was conducted, including pregnant women who were hospitalized at Sun Yat-sen Memorial Hospital, from January 1, 2013, to July 31, 2019, and underwent emergency cervical cerclage due to cervical dilatation at gestational age between 16 and 28 weeks. A total of 85 pregnant women who underwent amniocentesis for the detection of amniotic fluid inflammatory factors during the perioperative period were included. Based on whether their baby was perinatal death, the participants were divided into the case group (28 cases with perinatal death) and the control group (57 cases with live births). Univariate logistic regression analysis was performed to identify risk factors associated with adverse pregnancy outcomes, followed by multivariate logistic regression analysis to establish a regression model and nomogram. Results: (1) The levels of tumor necrosis factor α (TNF-α), interleukin (IL)-1β, IL-6, IL-8, IL-10 in the amniotic fluid during the perioperative period and postoperative serum C-reactive protein (CRP) were significantly higher in the case group compared to the control group (all P<0.05). The case group underwent emergency cervical cerclage at an earlier gestational age compared to the control group, and their cervical dilation was greater than that of the control group (all P<0.05). However, there were no significant differences in the white blood cell counts, neutrophil percentage, and the level of preoperative CRP in the peripheral blood of pregnant women during the perioperative period (all P>0.05). (2) Univariate logistic regression analysis showed that the levels of amniotic fluid WBC, TNF-α, IL-1β, IL-2 receptor (IL-2R), IL-6, IL-8, IL-10, postoperative CRP in the peripheral blood, gestational age at cerclage and cervical dilation were associated with adverse pregnancy outcomes (all P<0.05). Multivariate regression analysis indicated that only the levels of amniotic fluid WBC and TNF-α were independent risk factors for perinatal death. (3) Based on clinical practice, a multivariate logistic regression model was constructed including the levels of amniotic fluid TNF-α, WBC, gestational age at cervical cerclage, and cervical dilation. A nomogram and calibration curve were plotted, which suggested its good predictive value for adverse pregnancy outcomes. Conclusions: During the perioperative period of emergency cervical cerclage, the levels of amniotic fluid WBC, TNF-α, IL-1β, IL-2R, IL-6, IL-8, IL-10 are associated with adverse pregnancy outcomes, with amniotic fluid WBC and TNF-α showing the closest relationship. However, there is no significant correlation between maternal peripheral hemogram during the perioperative period and adverse pregnancy outcomes. A model constructed by amniotic fluid TNF-α, WBC, cervical cerclage gestational age, and cervical dilation has a good predictive effect on adverse pregnancy outcomes.

A Propensity-Matched Cohort Study of Intravenous Iron versus Red Cell Transfusions for Preoperative Iron-Deficiency Anemia.

While preoperative anemia is associated with adverse perioperative outcomes, the benefits of treatment with iron replacement versus red blood cell (RBC) transfusion remain uncertain. We used a national database to establish trends in preoperative iron-deficiency anemia (IDA) treatment and to test the hypothesis that treatment with preoperative iron may be superior to RBC transfusion. This study is a propensity-matched retrospective cohort analysis from 2003 to 2023 using TriNetX Research Network, which included surgical patients diagnosed with IDA within 3 months preoperatively. After matching for surgery type and comorbidities, we compared a cohort of patients with preoperative IDA who were treated with preoperative intravenous (IV) iron but not RBCs (n = 77,179), with a cohort receiving preoperative RBCs but not IV iron (n = 77,179). Propensity-score matching was performed for age, ethnicity, race, sex, overweight and obesity, type 2 diabetes, hyperlipidemia, essential hypertension, heart failure, chronic ischemic heart disease, neoplasms, hypothyroidism, chronic kidney disease, nicotine dependence, surgery type, and lab values from the day of surgery including ferritin, transferrin, and hemoglobin split into low (<7 g/dL), medium (7-<12 g/dL), and high (≥12 g/dL) to account for anemia severity. The primary outcome was 30-day postoperative mortality with the secondary outcomes being 30-day morbidity, postoperative hemoglobin level, and 30-day postoperative RBC transfusion. Compared with RBC transfusion, preoperative IV iron was associated with lower risk of postoperative mortality (n = 2550/77,179 [3.3%] vs n = 4042/77,179 [5.2%]; relative risk [RR], 0.63, 95% confidence interval [CI], 0.60-0.66), and a lower risk of postoperative composite morbidity (n = 14,174/77,179 [18.4%] vs n = 18,632/77,179 [24.1%]; RR, 0.76, 95% CI, 0.75-0.78) (both P = .001 after Bonferroni adjustment). Compared with RBC transfusion, IV iron was also associated with a higher hemoglobin in the 30-day postoperative period (10.1 ± 1.8 g/dL vs 9.4 ± 1.7 g/dL, P = .001 after Bonferroni adjustment) and a reduced incidence of postoperative RBC transfusion (n = 3773/77,179 [4.9%] vs n = 12,629/77,179 [16.4%]; RR, 0.30, 95% CI, 0.29-0.31). In a risk-adjusted analysis, preoperative IDA treatment with IV iron compared to RBC transfusion was associated with a reduction in 30-day postoperative mortality and morbidity, a higher 30-day postoperative hemoglobin level, and reduced postoperative RBC transfusion. This evidence represents a promising opportunity to improve patient outcomes and reduce blood transfusions and their associated risk and costs.

Potential perioperative cardiovascular outcomes in cannabis/cannabinoid users. A call for caution.

Cannabis is one of the most widely used psychoactive substances. Its components act through several pathways, producing a myriad of side effects, of which cardiovascular events are the most life-threatening. However, only a limited number of studies address cannabis's perioperative impact on patients during noncardiac surgery. Studies were identified by searching the PubMed, Medline, EMBASE, and Google Scholar databases using relevant keyword combinations pertinent to the topic. Current evidence shows that cannabis use may cause several cardiovascular events, including abnormalities in cardiac rhythm, myocardial infarction, heart failure, and cerebrovascular events. Additionally, cannabis interacts with anticoagulants and antiplatelet agents, decreasing their efficacy. Finally, the interplay of cannabis with inhalational and intravenous anesthetic agents may lead to adverse perioperative cardiovascular outcomes. The use of cannabis can trigger cardiovascular events that may depend on factors such as the duration of consumption, the route of administration of the drug, and the dose consumed, which places these patients at risk of drug-drug interactions with anesthetic agents. However, large prospective randomized clinical trials are needed to further elucidate gaps in the body of knowledge regarding which patient population has a greater risk of perioperative complications after cannabis consumption.

Acute normovolemic hemodilution in cardiac surgery: Rationale and design of a multicenter randomized trial

Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain. This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions. The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications. The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB. This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.

The Association of Cerebral Oxygen Desaturation with Postoperative Cognitive Dysfunction in Older Patients: A Review.

Postoperative cognitive dysfunction (POCD) is a neurological complication associated with surgery and anesthesia that is commonly observed in older patients, and it can significantly affect patient prognosis and survival. Therefore, predicting and preventing POCD is important. Regional cerebral oxygen saturation (rSO2) reflects cerebral perfusion and oxygenation, and decreased intraoperative cerebral oxygen saturation has been reported to increase the risk of POCD. In this review, we elucidated the important relationship between the decline in rSO2 and risk of POCD in older patients. We also emphasized the importance of monitoring rSO2 during surgery to predict and prevent adverse perioperative cognitive outcomes. The findings reveal that incorporating intraoperative rSO2 monitoring into clinical practice has potential benefits, such as protecting cognitive function, reducing perioperative adverse outcomes, and ultimately improving the overall quality of life of older adults.

Thoracotomy: An Overview of Perioperative Anaesthetic Management

Background: The anesthesiologist's role during open thoracotomy includes using a double lumen tube (DLT) for lung isolation, maintaining oxygenation with one-lung ventilation (OLV), and providing postoperative analgesia. This study aims to describe patient demographics, comorbidities, perioperative anesthetic management, complications, and the effectiveness of epidural catheter analgesia. Methods: In this prospective, observational study, patients who underwent open thoracotomy for decortications were evaluated. Thoracotomy was done under general anaesthesia, OLV with DLT, and epidural analgesia. Postoperatively, all the patients were shifted to the intensive care unit. Collected data included patient demographics, associated co-morbidities, severity of lung diseases, complications, and postoperative recovery. Postoperative analgesia was assessed by the visual analogue scale (0-10). Result: Of 20 patients, 16 were male, and 4 were female, with a mean age of 35 years (range 15-60) and a mean weight of 52 kg (range 36-66). History of hypertension (N=5), hypertension with diabetes (N=3), obstructive lung disease (N=6), restrictive lung disease (N=11), and both combined (N=3) were noted on pre-anesthetic check-ups. Intraoperative complications were hypotension (N=3), desaturation (N=3), respiratory acidosis (N =7), and metabolic acidosis (N=3). Postoperative analgesia was managed with an epidural catheter (N=18) &amp; systemic analgesia (N=2). All patients had uneventful postoperative courses except one patient who had pulmonary edema and did not survive. Conclusion: Patients undergoing open thoracotomy had an increased risk for adverse perioperative outcomes. The incidences of perioperative morbidity are high in patients with associated comorbidities. Proper OLV strategy helps to correct intraoperative desaturation. Epidural analgesia plays a key role in postoperative recovery.

Perioperative Health Interventions in Children With Chronic Neuromuscular Conditions Undergoing Major Musculoskeletal Surgery: A Scoping Review.

Children with chronic neuromuscular conditions (CCNMC) have many coexisting conditions and often require musculoskeletal surgery for progressive neuromuscular scoliosis or hip dysplasia. Adequate perioperative optimization may decrease adverse perioperative outcomes. The purpose of this scoping review was to allow us to assess associations of perioperative health interventions (POHI) with perioperative outcomes in CCNMC. Eligible articles included those published from January 1, 2000 through March 1, 2022 in which the authors evaluated the impact of POHI on perioperative outcomes in CCNMC undergoing major musculoskeletal surgery. Multiple databases, including PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, Web of Science, the Cochrane Library, Google Scholar, and ClinicalTrials.gov, were searched by using controlled vocabulary terms and relevant natural language keywords. Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines were used to perform the review. A risk of bias assessment for included studies was performed by using the Risk of Bias in Non-randomized Studies of Interventions tool. A total of 7013 unique articles were initially identified, of which 6286 (89.6%) were excluded after abstract review. The remaining 727 articles' full texts were then reviewed for eligibility, resulting in the exclusion of 709 (97.5%) articles. Ultimately, 18 articles were retained for final analysis. The authors of these studies reported various impacts of POHI on perioperative outcomes, including postoperative complications, hospital length of stay, and hospitalization costs. Because of the heterogeneity of interventions and outcome measures, meta-analyses with pooled data were not feasible. The findings reveal various impacts of POHI in CCNMC undergoing major musculoskeletal surgery. Multicenter prospective studies are needed to better address the overall impact of specific interventions on perioperative outcomes in CCNMC.