Perioperative Care Research Articles

Enhanced Recovery after Surgery (ERAS) in Pediatric Cardiac Surgery - Status quo of implementation in Europe

ObjectivesEnhanced Recovery After Surgery (ERAS) is a multimodal care pathway to enhance recovery after surgery that is well established in various surgical disciplines. In pediatric cardiac surgery, implementation of ERAS protocols remains inconsistent. We conducted a survey of active European pediatric cardiac surgical centers to assess the current state of ERAS concepts and the current practice in perioperative pediatric cardiac care. DesignProspective, 79-item, web-based cross-sectional survey. SettingWeb-based survey endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC). ParticipantsAnesthesiologists of European pediatric cardiac surgical centers. InterventionsNone Measurements and Main resultsOut of a total of 98 centers, 50 responded. Eight responses were excluded due to incomplete survey forms or non-European location, leaving 42 responses (42,9%) for statistical analysis. Sixteen of the 42 centers (38,1%) follow an ERAS concept. Only 3 (7,1%) have formalized and detailed the ERAS concept in a written document, covering the entire perioperative period, while 13 (31%) have formalized it solely for the intraoperative period.Regarding regional and local anesthesia, 13 (31%) centers regularly practice regional anesthesia blocks, and 11 (26,2%) centers utilize wound infiltration by the surgical team. ConclusionThis European survey revealed that implementation of ERAS concepts in pediatric cardiac surgery is generally low, with considerable heterogeneity in clinical practice regarding the timing of extubation, the choice of surgical procedures triggering on-table extubation, the choice of anesthetic drugs and the use of regional anesthesia. More coordinated efforts are needed to implement ERAS concepts in pediatric cardiac surgery and harvest the benefits of ERAS concepts for the pediatric cardiac population.

Utilising a modified accelerated Delphi process to develop a national multidisciplinary consensus on peri-operative optimisation of patients with obesity undergoing non-bariatric surgery

BackgroundIn the last three decades, the worldwide prevalence of obesity has increased by threefold. Using a modified Delphi consensus technique, the Irish Surgical Research Collaborative (ISRC) aimed to formulate consensus guidelines on the peri-operative optimisation of patients with obesity undergoing non-bariatric surgery. MethodsSubgroups within the ISRC were established to formulate consensus statements using a nominal group technique (NGT) to address the three domains of pre-operative, intra-operative and post-operative care. Three Delphi rounds were circulated nationally to multidisciplinary members of the peri-operative team via electronic survey. Consensus was considered achieved for any statement with >80 % agreement. Data was analysed using Microsoft Excel (Microsoft Corp, Redmond, WA). ResultsFollowing three Delphi rounds, a total of 94 statements centred around optimising peri-operative care for patients with obesity undergoing non-bariatric surgery reached consensus. Pre-operatively, access to prehabilitation, use of pre-operative risk stratification tools and strategies to reduce obesity-related co-morbidities were all deemed important along with nomination of a hospital obesity lead. Intra-operatively, the prioritised domains were involvement of consultant anaesthetist and surgeon for safe and considered patient positioning, utilisation of minimally invasive surgical techniques, adherence to venous thromboembolism prophylaxis and surgical site infection prevention strategies as well as adoption of multimodal analgesia. Appropriate analgesia prescription, nutritional support, enhanced recovery after surgery and the role of physiotherapy were all deemed essential elements of post-operative care. ConclusionAs a multidisciplinary peri-operative group, through Delphi consensus, we report agreed perioperative standards to optimise the perioperative care of patients with obesity undergoing non-bariatric surgery. This consensus can be utilised to standardise clinical practice and identify areas for quality improvement.

Analysis of hospitalization costs in adult inguinal hernia: based on quantile regression model.

Inguinal hernia repair is a common surgical procedure with significant variability in hospitalization costs. Traditional cost analysis methods often overlook the distribution of costs across patient demographics and clinical factors. This study employs a quantile regression model to explore the determinants of hospitalization costs for adult inguinal hernia surgery, providing a detailed understanding of cost variations across different quantiles. We analyzed data from adult patients who underwent inguinal hernia surgery at Beijing Chaoyang Hospital from January 2015 to June 2023. The study included patient demographics, hernia-related information, surgery-related details, and cost-related data. A quantile regression model was used to assess the impact of various factors on hospitalization costs at different quantiles (10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%). Data were processed using StataSE 15.0 software. Our study included 16,602 patients, predominantly male (91.86%) and Han Chinese (96.48%), with the 51-64 years age group being the largest (26.80%). The quantile regression analysis revealed significant cost variations across different quantiles. Younger patients incurred higher costs, with age coefficients ranging from -40.541 at the 90th quantile to -3.082 at the 10th quantile. Uninsured patients faced higher costs, with coefficients from 214.747 at the 80th quantile to 501.78 at the 10th quantile. Longer hospital stays correlated with increased costs, with coefficients from 342.15 at the 80th quantile to 405.613 at the 90th quantile. Patients hospitalized multiple times(≥3) had lower costs, with coefficients from-767.353 at the 40th quantile to -311.575 at the 80th quantile. Comorbidities significantly raised costs, with coefficients for three or more comorbidities ranging from806.122 at the80th quantile to1,456.02 at the40th quantile. Laparoscopic surgery was more expensive than open surgery, with coefficients from 1,834.206 at the 80th quantile to 2,805.281 at the 10th quantile. Bilateral surgeries and the use of biological mesh also resulted in higher costs, with coefficients for bilateral surgeries ranging from 1,067.708 at the 10th quantile to 2,871.126 at the 90th quantile and for biological mesh from 3,221.216 at the 40th quantile to 6,117.598 at the 90th quantile. Hospitalization costs for inguinal hernia surgery are influenced by multiple factors, with significant variations across different patient groups. Strategies to control costs should be tailored to address the specific needs of patients, optimize surgical methods, and improve perioperative care. Future research should extend these findings across different healthcare settings and consider the latest advancements in medical technology and policy changes.

Unintended readmissions and reoperations within 30 and 90 days following adult spinal deformity surgery.

This study investigated the rates and etiologies of unintended readmissions and reoperations within 30 and 90 days after adult spinal deformity (ASD) surgery. The authors aimed to identify the risk factors for readmission and reoperation by analyzing patient demographic and surgical characteristics. This retrospective cohort study included 307 consecutive patients who underwent surgery for ASD from 2012 to 2022 at a single academic institution. Data were collected on patient demographic characteristics, comorbidities, operative details, and postoperative complications. Chi-square and multivariable logistic regression models were used to identify the risk factors associated with 30- and 90-day readmissions and reoperations. The mean ± SD age at surgery was 66.6 ± 10.5 years, and the majority (80.8%) of patients were female. The 30-day and 90-day readmission rates were 11.7% and 15.3%, respectively. Multivariable regression for 30-day readmissions revealed that length of hospital stay (LOS) after index surgery of > 20 days (OR 2.48) and surgical factors such as vertebral column resection (VCR) (OR 4.26) and pelvic fixation (OR 4.38) were risk factors. Other factors such as the American Society of Anesthesiologists Physical Status Classification System (ASA) class, prior spine surgery, and age were not associated with 30-day readmissions. Ninety-day readmission was associated with high ASA class (OR 2.37) and LOS > 20 days (OR 2.82). The 30- and 90-day reoperation rates were 7.8% and 10.1%, respectively. The variables associated with 30-day reoperations were intraoperative VCR (OR 3.34) and LOS > 20 days (OR 9.38). Ninety-day reoperations were associated with dural tears (OR 3.33) and LOS > 20 days (OR 3.68). This study provides valuable insights into the incidence of unintended readmission and reoperation within 30 and 90 days after ASD surgery in an Asian population. By identifying the associated risk factors, healthcare providers can customize surgical strategies and optimize perioperative care to effectively mitigate these events.

Effective regional anesthesia for pediatric surgical care

This review highlights the significant role of pediatric regional anesthesia in optimizing perioperative care and improving surgical outcomes. We examine common local anesthetics, adjuvant medications, and techniques. Safety, efficacy, adverse events, and controversies are addressed while spotlighting the broad utility of regional anesthesia to contribute to better outcomes and quality of life for pediatric surgical patients and their families.

EVOLUTION OF ARTIFICIAL INTELLIGENCE IN ANESTHESIA AND ITS PATH FORWARD

Artificial intelligence (AI) has brought a paradigm shift in patient management in the modern healthcare industry. This narrative literature review aims to explore the evolution of AI in the field of anesthesia and discuss its potential path forward. The increased demand for personalized care, smart decision-making tools, precision in practice, and growth in telemedicine, particularly in the realm of perioperative care, has brought AI to the forefront. By examining the existing research and applications of AI in anesthesia, this review seeks to provide insights into the current state of AI technology, its applications, implications for practicing clinicians, and the challenges and limitations that need to be addressed for its successful integration into perioperative care. This review encourages interdisciplinary teamwork between anesthesiologists, technologists, engineers, and technicians to simplify the complexities of AI implementation, address ethical issues, mitigate risks, and ensure safe perioperative care.

Exploring the Lived Experiences of Post-basic Nursing Students: Insights into Continuous Learning

Continuous learning in clinical settings is essential for optimum quality of care. This study examines the lived experiences of post-basic nursing students specialising in critical care, emergency care, and peri-operative care in a tertiary university hospital. Using a descriptive phenomenological approach, three focus group interviews were conducted with 23 purposively sampled post-basic critical care nursing students. Four overarching themes emerged from the data analysis: (1) the programme’s benefits to students; (2) feedback on programme implementation; (3) avenues for future improvement; and (4) challenges encountered during the programme. The findings emphasise the critical role of ongoing education in clinical contexts, particularly in post-basic critical care nursing education. Students’ lived experiences underscore the programme’s positive effects on their knowledge, skills, and organisational benefits, emphasising the crucial role of continuous education in enhancing the quality of nursing care. The identified themes offer valuable insights into the advantages, obstacles, and areas needing improvement in post-basic critical care nursing education. They showed the importance of a sustained commitment to continuous learning to ensure the delivery of high-quality care in clinical practice. This study contributes to the existing body of knowledge on nursing education and offers valuable insights for educators, administrators, and policymakers to optimise the training and development of nurses to achieve quality patient outcomes.

Perioperative Management for Microvascular Free Tissue Transfer for Head and Neck Reconstruction – Commentary

Le et al. provided a comprehensive commentary on perioperative management for head and neck oncologic patients undergoing microvascular reconstructive surgery. This commentary is based on a detailed review and consensus statements from the Society for Head and Neck Anesthesia (SHANA), an international organization dedicated to enhancing perioperative care for these patients. The consensus statement, published in 2021 by Healy et al., addressed preoperative, intraoperative, and postoperative considerations to optimize clinical outcomes. It included 14 statements from 16 SHANA members across 11 institutions, following two rounds of literature reviews. The commentary emphasized the importance of preoperative nutrition optimization, tobacco cessation, and early recognition of alcohol withdrawal symptoms. In the intraoperative phase, key aspects such as airway management in cases of extensive tumor burden (including awake fiberoptic intubation and tracheostomy), fluid management, hemodynamic monitoring, and multimodal analgesia were briefly discussed. Notably, vasopressors can be used to optimize hemodynamic management without compromising flap perfusion. Additionally, careful fluid resuscitation is crucial to avoid fluid overload, which could increase the risk of flap failure. Multimodal pain management strategies were highlighted, including inhalational anesthetics, anti-inflammatories, narcotics, and regional anesthesia. In the postoperative period, effective communication between healthcare provider teams is essential. Airway management was linked to three of the five consensus statements, underscoring the need for clear and concise communication between the anesthesia and surgical teams. This includes coordinating ventilatory support weaning, extubation planning, and preparation for reintubation if necessary. Such measures help reduce intensive care unit (ICU) utilization, minimize airway-related adverse events, and shorten the length of hospitalization. Overall, the commentary hopes to serve as a guide for multidisciplinary head and neck oncology units across all international centers in managing this complex patient population.

Assessing the predictive value of pre- and post-operative inflammatory markers in patients undergoing total knee arthroplasty

Background and objectiveTotal Knee Arthroplasty (TKA) has proven highly effective in improving quality of life for patients with severe knee conditions. Despite advancements, surgical complications such as periprosthetic joint infections (PJIs) pose risks. The potential predictive value of pre- and post-operative inflammatory markers like neutrophil-to-lymphocyte ratio (NLR), D-dimer, and albumin levels on surgical outcomes is garnering attention. There is a growing interest in leveraging these markers to enhance patient selection and outcome prediction in the context of TKA.Focusing on the natural course of these markers, and the incidence of PJIs and to refine perioperative care strategies, improve patient outcomes, and identify high-risk patients for targeted intervention.MethodsThe study included 94 patients who underwent total knee arthroplasty (TKA) between 2019 and 2023. Blood tests were conducted before surgery and at 1, 3, 7, and 15 days after surgery to assess various parameters including white blood cell count, neutrophils, lymphocytes, platelets, hemoglobin, C-reactive protein, D-dimers, total protein, albumin, and total cholesterol values and ratios.ResultsFollowing total knee arthroplasty (TKA), key observations in blood markers included a sharp rise in white blood cell (WBC) counts from 5.81 to 10.22 (*10^9/L) on the first day post-surgery, with levels returning close to preoperative values by day-15. Neutrophil counts similarly increased from 3.46 to 8.50 (*10^9/L) on day-1, decreasing to 4.01 by day-15. Hemoglobin levels significantly decreased from 115.70 g/L to 90.62 by day-3 before improving to 100.30 by day-15. C-reactive protein (CRP) levels also saw a significant rise from 6.15 mg/L to a peak of 47.07 on day-3, then reducing to 10.55 by day-15, indicating a response to inflammation.ConclusionFollowing total knee arthroplasty (TKA), a significant initial postoperative increase in white blood cell count, neutrophils, and C-reactive protein levels, indicative of an acute inflammatory response, before returning towards baseline values by day 15. Hemoglobin levels displayed a notable dip post-surgery, gradually improving by the study’s end. These patterns emphasize the dynamic nature of inflammatory and hematological responses after TKA, highlighting their potential role in predicting surgical outcomes and guiding postoperative care.

Unveiling the Impact of Enhanced Recovery After Surgery Programs on Post-Operative Morbidity and Mortality

Enhanced recovery after surgery is an evidence-based and holistic perioperative care approach and a real revolution in surgical settings. Initially, this concept referred to as “fast-track surgery’’ has evolved to enhanced recovery after surgery and acquired remarkable attention for its potential to improve patient recovery and surgical adverse outcomes, reduce the length of hospital stay, and yield beneficial impact on post-surgical mortality and morbidity. Objective: To evaluate the impact of enhanced recovery after surgery programs on Post-Operative Morbidity and Mortality. Methods: A comprehensive overview was provided based on several studies' data on the impact of enhanced recovery after surgery programs on postoperative mortality and morbidity. Nine years of epidemiological studies published between 2014-2023 were included based on the presence of qualitative and quantitative data. Results: Enhanced recovery after surgery significantly reduces the overall morbidity, surgical site infections, and complications associated with different surgeries, and shortens the length of stay at the hospital without escalating the readmission and mortality rate. However, only one study reported a significant difference in mortality rate between enhanced recovery after surgery and the control group. Conclusions: It was concluded that enhanced recovery after surgery protocols have increasingly been recognized as pivotal tools in reducing postsurgical mortality and morbidity, highlighting their efficacy in optimizing surgical consequences. By synthesizing core insights this review emphasizes the concrete advantage of enhanced recovery after surgery programs inpatient rehabilitation mobilization, encompassing faster recovery, and reducing surgical-related adverse effects.

POST-MASTECTOMY SURGICAL SITE INFECTION RATES IN FEMALES WITH BREAST CARCINOMA IN PREMENOPAUSAL AGE: A SINGLE CENTER STUDY

Breast surgery, like mastectomy, is generally considered a low-risk procedure for surgical site infections (SSIs), but when SSIs do occur, they can lead to significant complications. Identifying risk factors to improve patient outcomes and minimize complications is essential. Objective: This study aimed to determine the frequency of post-mastectomy surgical site infections (SSI) in premenopausal females with breast carcinoma and to identify the associated risk factors. Methods: This descriptive case study included 100 premenopausal females diagnosed with breast carcinoma who underwent mastectomy at a tertiary care hospital, Shaikh Zayed Hospital Lahore, from April 2024 to August 2024. The age range of participants was 25-45 years, with a mean age of 39 ± 5.3 years. Demographic data, including age, gender, body mass index (BMI), comorbidities, and American Society of Anesthesiologists (ASA) score, were collected. Intraoperative variables such as blood loss (mean: 350 ± 50 ml) and surgery duration (mean: 120 ± 15 minutes) were also recorded. All patients received standard postoperative antibiotic prophylaxis, including cefazolin or clindamycin, for those allergic to penicillin. The surgical site was assessed 30 days postoperatively for signs of infection, including erythema, pus discharge, or fever exceeding 38°C. SSIs were categorized based on the Centers for Disease Control and Prevention (CDC) guidelines into superficial, deep, and organ/space infections. Results: The overall infection rate was 7.5% (n=7). Of these, 4 cases were superficial infections, while 3 involved deeper tissue layers, requiring drainage and further antibiotics. Factors significantly associated with an increased risk of disease in the multivariate logistic regression model included a high wound class (contaminated or dirty; OR: 3.2, p=0.01), elevated ASA score (ASA III-IV; OR: 2.8, p=0.03), high BMI >30 (OR: 3.5, p=0.002), diabetes (OR: 4.1, p=0.001), use of surgical drains (OR: 2.9, p=0.02), and reoperation (OR: 4.3, p=0.005). The mean hospital stay was extended by 4.5 days (from 5.2 ± 1.5 days in non-infected patients to 9.7 ± 3.1 days in infected cases). Conclusion: The study found a post-mastectomy surgical site infection rate of 7.5% in premenopausal females, with significant risk factors including high BMI, diabetes, use of surgical drains, and the need for reoperation. A high wound class and elevated ASA score also predicted increased infection risk. Addressing these modifiable risk factors through optimized perioperative care, such as better glycemic control, judicious use of surgical drains, and minimizing reoperations, may help reduce SSI rates and improve outcomes for breast cancer patients.

Adaptação da lista de verificação de cirurgia segura em um hospital universitário

Introduction: The checklist is a tool that ensures important decisions and actions are taken during surgery. It contains critical items that should not be overlooked in any situation, preventing serious failures in the Surgical Center. Objective: To adapt the safe surgery checklist to the institution’s specific context. Methods: This is an applied research study on technological development. The checklist was used in 24 surgeries: 12 utilized the World Health Organization’s checklist, and the other 12 used lists adapted to the sector’s context. These adaptations were carried out by the researcher at three different stages. After applying the lists, the professionals present in the operating room completed a semi-structured questionnaire. Results: The study involved 72 participants: surgeons, anesthesiologists, residents, nurses, technicians, and nursing assistants. They were involved in the three stages of checklist application: before anesthesia induction, before the surgical incision, and before the patient left the operating room. The results from the pilot test (1st phase) and the adapted checklist (2nd phase) were categorized to better understand the findings. Conclusion: The checklist was adapted based on the suggestions from the participants. It also served as a communication tool, providing technical guidance, preventing process failures, and ensuring effectiveness and efficiency during surgeries. Keywords: Checklist; patient safety; perioperative care; technological development.

Drapes in Routine Aseptic Procedures for Environmental Sustainability (project DRAPES): a protocol for a multi-centre randomised controlled trial comparing post-operative wound complication rates following routine neutering of dogs and cats using reusable or disposable surgical drapes

BackgroundReusable surgical drapes have a lower lifetime environmental impact than disposable drapes in most cases. There is limited evidence regarding whether drape choice impacts patient outcomes including post-operative wound complications. The aim of this study is to compare wound complication rates following routine neutering surgeries in cats and dogs when reusable drapes are used as compared with disposable drapes.MethodsThe trial will be conducted as a pragmatic, multi-centre, parallel group randomised controlled trial in the UK. Dogs and cats undergoing routine neutering will be randomised to disposable or reusable drapes with all other aspects of care occurring as they usually would at the practice. The required sample size is 2,850, with 4750 animals to be recruited from up to ten practices to allow for a 40% loss to follow-up. Demographic data and details on peri-operative care will be collected at the time of surgery. Post-operative wound complications will be assessed and recorded as usual at each practice using clinical codes. The post-operative wound clinical codes and any antibiotic use within 30 days of surgery will be retrieved from the practice management software. The primary outcome that will be compared between the two groups is the rate of post-operative wound complications within 30 days of surgery which will be analysed by multivariable logistic regression with a binary outcome of wound complication (yes/no). Secondary outcomes are the prevalence of different types of complications and antibiotic use within 30 days of surgery which will be compared between the two groups by chi square analysis.DiscussionOur hypothesis is that there will be no difference in post-operative wound complication rates between disposable and reusable drapes. If the likely rate of post-surgical wound complications with reusable drapes is similar to that with disposable drapes, then veterinary clinical teams can choose the more sustainable option, confident that their patients will not be impacted by this choice.Trial registrationWe have retrospectively registered the protocol on the Open Science Framework on 14 Nov 2023 (Trial registration entry: https://doi.org/10.17605/OSF.IO/72HMA).

Endovascular Treatment versus Open Surgical Repair for Isolated Iliac Artery Aneurysms.

Endovascular treatment (EVT) has been shown to be effective and safe for isolated iliac artery aneurysms (IAAs). However, concerns remain regarding the lack of consideration to recent advances in perioperative care and surgical techniques, as well as a significant number of re-interventions with EVT. This study compares the outcomes of open surgical repair (OSR) and EVT using recent clinical data. This retrospective, single-center study included patients who underwent OSR or EVT for isolated degenerative IAAs between January 2007 and December 2018. Primary outcomes were procedure time, number of transfusions during admission, length of hospital stay, complications, and number of preserved internal iliac arteries. Secondary outcomes included all-cause and aneurysm-related mortality, and re-intervention rates. Fifty-eight consecutive patients underwent treatment for isolated IAAs (25 underwent OSR and 33 underwent EVT), with a median follow-up of 75 months (range: 39-133 months). Baseline characteristics were similar between the groups, except for a lower mean age in the OSR group than in the EVT group (66.0±8.2 vs. 73.1±8.6, P=0.003). Both groups had a mild risk of comorbidity severity score. Early complications (within 30 days of the procedure) occurred more frequently in the OSR group, though not statistically significant (24.0% vs. 6.1%, P=0.07). Late complications, including sac expansion and thrombotic occlusion, were significantly more common in the EVT group (15.2% vs. 0%, P=0.04). Re-intervention rate was higher in the EVT group but not statistically significant (9.1% vs. 4.0%, P=0.44). No significant differences were observed in major adverse cardiovascular events and mortality between the groups (P=0.66 and P=0.27), and there were no aneurysm-related deaths. For patients with mild risk factors, EVT does not offer a survival or re-intervention advantages over OSR in the treatment of isolated IAAs. However, EVT is associated with an increased risk of late complications. Although larger randomized studies are necessary, OSR may be considered the first-line treatment for isolated IAAs in younger and mild-risk patients.

Survey-based qualitative exploration of user perspectives on the philips visual patient avatar in clinical situation management

Philips Visual Patient Avatar is an innovative approach to patient monitoring. Computer-based simulation studies have shown that it can improve diagnostic accuracy and confidence while reducing perceived workload. Following its integration into clinical practice, we conducted a single-centre qualitative study at the University Hospital Zurich to explore the views of anaesthesia, post-anaesthesia and intensive care providers on their experience with the technology. We used an online survey to assess its contributions in different clinical situations. We analysed the data thematically to identify key themes. Of the 510 healthcare providers contacted, 131 (25.7%) completed the survey and 154 comments were collected. Key themes included the detection of specific vital sign changes, focusing on temperature and oxygen saturation (41.9%, 34/81 comments in the operating room; 38.6%, 17/44 comments in the intensive care unit; 10.3%, 3/29 comments in the post-anaesthesia care unit). Additionally, the technology was perceived to support daily routines and situational awareness (28.4%, 23/81 comments in the OR; 9.1%, 4/44 comments in the ICU; 10.3%, 3/29 comments in the PACU). The study provides early, but strong evidence that the Philips Visual Patient Avatar assists healthcare providers in specific clinical situations in the perioperative and critical care settings.

Frailty as a mediator of postoperative delirium in older adults undergoing orthopedic surgery: A causal mediation analysis

BackgroundPostoperative delirium has a high prevalence in hospitalized older adults. Frail older adults have an increased risk for developing it. Preoperative pain—a common symptom in older adults with orthopedic conditions—shows a connection with frailty through an inflammatory process. However, an association among preoperative pain, frailty, and postoperative delirium remains unexplored among older adults undergoing orthopedic surgery. ObjectivesTo examine the magnitude, direction, and mediation effect of frailty on the association between preoperative pain and postoperative delirium among older adults undergoing orthopedic surgery. DesignA secondary analysis of a prospective cohort study. Setting and participantsA cohort of 200 older adults (60 years and older) who underwent major orthopedic surgery at a university hospital in Thailand was recruited for the study. MethodsParticipants responded to the Demographic and Health Information Form, the Reported Edmonton Frailty Scale-Thai version, and the Thai version of the 4 A's test. Analyses were conducted using a causal mediation analysis with 95 % confidence intervals. ResultsWe found that 12.5 % of participants developed postoperative delirium. For the direct paths associated with postoperative delirium, statistically significant effects were observed for frailty, preoperative pain, and comorbidity. Considering frailty as a mediator of postoperative delirium, a significant positive indirect effect was identified from preoperative pain. Controlling for age and comorbidities, frailty mediated the association between preoperative pain and postoperative delirium in a statistically significant manner; the average direct effect was 0.014 (95 % confidence interval: 0.008–0.020), the average causal mediating effect was 0.002 (95 % confidence interval: 0.000–0.010), the total effects was 0.017 (95 % confidence interval: 0.010–0.020), and the probability mediation accounted for 14 % (95 % confidence interval: 0.031–0.300). ConclusionIntegrating the concept of age-related decline and frailty assessment may offer opportunities to provide disease-specific care and strengthen precision perioperative care, which ultimately enhance quality of life in older adults undergoing orthopedic surgery.

Anesthesiological Preoperative Interview with a Palliative Care Patient: A Simulation-Based Experiment Using Standardized Patients.

Background and Objectives: Anesthesiologists come into contact with patients under palliative care in different clinical settings. They also routinely encounter these patients in their primary field of work, the operating room. Patients receiving palliative care who are scheduled for surgery will pose unique challenges in perioperative management, often presenting with advanced disease and with different psychosocial and ethical issues. This study aims to evaluate whether anesthesiologists without specialty training in palliative medicine will spot perioperative challenges presented by patients under palliative care and address them adequately. Materials and Methods: In this study, we simulated a preoperative anesthesiological interview using standardized patients and anesthesiologists (specialists as well as trainees). The standardized patients were asked to represent a patient under palliative care in need of surgery because of a mechanical ileus. We conducted 32 interviews, dividing the anesthesiologists into two groups. In one group, the standardized patients were instructed to address four problems, i.e., use of a port catheter for anesthesia, nausea and vomiting, pain medication, and an advance directive including a limitation of treatment (DNR-order). In the other group, these problems were also present, but were not actively addressed by the standardized patients if not asked for. The interviews were recorded, transcribed, and then analyzed. Results: In most cases, the medical problems were spontaneously identified and discussed. In only a few cases, however, was a therapy recommendation made for improved symptom control. The advance directive was spontaneously discussed by only 3 of the 32 (9%) anesthesiologists. In another 16 cases, the advance directive was discussed at the request of the standardized patients. The limitation of treatment stayed in place in all cases, and the discussion of the advance directives remained short, with an average duration of just over 5 min. Conclusions: In this study, the complex problems of patients under palliative care are not sufficiently taken into account in a preoperative anesthesiological interview. To improve treatment of the medical problems, therapists who have palliative medicine expertise, should be involved in the perioperative medical care, ideally as a multi-professional team. The discussion about perioperative limitations of treatment should be held beforehand, for example, as part of a structured advanced care planning discussion.

Current trends and future directions in surgery: A brief scoping review

Surgery is undergoing rapid transformation due to advancements in technology, innovative techniques, and a shift toward patient-centered care. This review explores current trends and future directions in the field of surgery, focusing on five major areas: minimally invasive surgery (MIS), robotic-assisted surgery, personalized medicine, enhanced recovery after surgery (ERAS) protocols, and the use of telemedicine. MIS techniques, including laparoscopy and NOTES, continue to evolve, offering benefits such as reduced recovery times and fewer complications. Robotic-assisted surgery has advanced with systems such as the da Vinci Surgical System, which enhances surgical precision and has expanded into new specialties. Personalized medicine, driven by genomics and bioinformatics, aims to tailor surgical interventions to individual patient profiles, improving treatment outcomes. ERAS protocols represent a significant shift toward optimizing perioperative care, with a focus on multimodal pain management and early mobilization to improve recovery. Additionally, the rise of telemedicine and remote monitoring has facilitated preoperative and postoperative care, mostly in the context of the COVID-19 pandemic. The future of surgery promises continued technological advancements, with potential developments including enhanced robotic systems, AI integration, and expanded applications of ERAS principles. However, challenges such as high costs, the need for ongoing training, and the integration of new technologies into healthcare systems must be addressed to fully realize these advancements. This review provides an overview of these trends and highlights areas for future research and development in the surgical field.

COMPARISON OF SURGICAL SITE INFECTIONS IN DIABETIC VERSUS NON-DIABETIC PATIENTS UNDERGOING CLEAN SURGICAL PROCEDURES AT A TERTIARY CARE HOSPITAL

Surgical site infections (SSIs) are a common complication that can significantly impact recovery, particularly in patients with diabetes. Understanding the incidence of SSIs in diabetic versus non-diabetic patients undergoing clean surgical procedures is critical for improving postoperative outcomes. Objective: This study aims to compare the incidence of surgical site infections (SSIs) in diabetic and non-diabetic patients undergoing clean surgical procedures at a tertiary care hospital. Methods: An observational cohort study was conducted with 110 patients, divided into two groups: Group A (diabetic patients) and Group B (non-diabetic patients). All patients underwent clean surgeries, including hernia repair and laparoscopic cholecystectomy. Postoperative complications, including SSIs, wound dehiscence, and seroma formation, were assessed. Statistical analysis was performed to evaluate differences in complication rates between the two groups, with a significance level set at p < 0.05. Results: SSIs were observed in 10.9% of diabetic patients compared to 3.6% in non-diabetic patients, though this difference was not statistically significant (P = 0.14). Wound dehiscence occurred in 3.6% of diabetics versus 1.8% of non-diabetics (P = 0.55), while seroma formation was noted in 1.8% of diabetics, with no cases in the non-diabetic group (P = 0.31). Conclusion: The incidence of surgical site infections was higher in diabetic patients than in non-diabetic patients undergoing clean surgical procedures, though the difference was not statistically significant. Diabetic patients remain at an increased risk of postoperative complications, highlighting the need for enhanced perioperative care to mitigate infection risks.

Perioperative Care for Bariatric Surgery.

This review will start with a brief pathophysiology of obesity and the requirement for bariatric surgery, and it continues with a preoperative assessment, which includes a surgical mortality risk assessment, respiratory and cardiovascular assessments, and a psychological assessment. In-hospital postoperative care will be discussed, including which patients need a surgical intensive care unit and the monitoring tools required. The need for postoperative medications, postoperative complications, strategies for management, and a follow-up plan are also reviewed. This manuscript is written in a narrative review form with a chance of bias as a possible limitation.