Perioperative Problems Research Articles

先天性気管狭窄症に対するslide tracheoplasty : 周術期管理の諸問題

先天性気管狭窄症に対するslide tracheoplasty : 周術期管理の諸問題

Abstract: Does Extraction of Third Molars at the Time of Orthognathic Surgery Increase Intra-Operative and Peri-Operative Complications? - A Follow-Up Study

INTRODUCTION: Third molar extractions are traditionally performed prior to orthognathic surgery. In a preliminary report, we showed that removal of third molars at the time of orthognathic surgery does not lead to increased complications or perioperative problems. The purpose of this follow-up study is to test these findings using a larger patient cohort. METHODS: A retrospective analysis of patients who underwent orthognathic surgery from 2013–2015. Two groups, concurrent and previous extraction (E3M and PE3M), were stratified. The occurrence of unfavorable splits, infection, bleeding, malocclusion and hardware failure were the primary outcome variables. Pearson’s chi-squared tests were performed to determine if there was an association between the simultaneous removal of third molars and these variables. Procedure time, post-operative pain and length of stay were the secondary outcome variables. Two tailed unpaired t-tests were performed to determine the effect of extractions on these measures. RESULTS: 157 patients were included. 70 had their third molars extracted at the time of surgery, 87 did not. The only intraoperative complication was one unfavorable split, in the PE3M group. This was not statistically significant (p=0.368). There were no cases of uncontrolled bleeding, inferior alveolar nerve transection, or anesthesia complications. One patient in each group experienced a post-operative infection requiring additional treatment. Mild post-operative bleeding, controlled with local measures, was encountered in 1 patient in the E3M and 2 patients in the PE3M group. This difference was not statistically significant (p=0.692). One patient in each group experienced a post-operative malocclusion. There was one case of hardware failure in the PE3M group, which was not statistically significant (p=0.368). Procedure time was not considerably increased when third molars were extracted. There was no statistically significant difference in post-operative pain (p=0.538) or length of stay in the hospital (p=0.979) between both groups. CONCLUSIONS: This study confirms that removing third molars concurrently with orthognathic surgery does not increase risk of adverse outcomes or complications, nor does it significantly influence hospital course. REFERENCE: Steinbacher DM, Kontaxis KL. Does Simultaneous Third Molar Extraction Increase Intraoperative and Perioperative Complications in Orthognathic Surgery? J Craniofac Surg. 2016 Jun;27(4):923–6.

Complications After Resection of Os Trigonum or Posterior Talar Process

Category: Sports Introduction/Purpose: The resection of os trigonum or posterior talar process for posterior ankle impingement is a technically easy and frequent operation. So far, the scientific literature has focused only on the surgical approach and perioperative problems. However, the author has encountered unfavorable followup results (professional athletes had to stop their career), which also other surgeons tell to have encountered. This study aims to describe for the first time this complication rate and possible reasons therefore. Methods: From 3/11 to 7/15 29 patients (17male, 12 female, 32+/-14 years) with 30 feet were operated (22 endoscopic, 8 open resections). Average followup was 27+/-13 months. All charts and pre- and postoperative radiographs were retrospectively evaluated. Patients were grouped into “no complications”, “minor temporary (< 3 months)”, “major follow up (end of athletic career)” complications. The following radiographic parameters were measured referenced on the intersection of the talar radius with the calcaneus (Fig. 1): (1) length of posterior talar process/ os trigonum, (2) length of the calcaneus below the posterior process/os trigonum, (3) length of the uncovered subtalar joint after resection. Results: The major complication rate was 13.3% (4 of 30 feet, 2 os trigonum, 2 posterior talar process): all 4 had symptomatic talar edema and 3 of 4 had symptomatic subtalar osteoarthritis. 1 minor complication (persistent pain for 3 months) was found. The length of the posterior talar process was preoperatively 9.37 +/- 2.89 mm (os trigonum 8.62+/- 2.62 mm) postoperatively 0.64+/-1.8 mm. The length of the posterior calcaneus preoperatively was 8.35 +/- 4.63 mm, postoperatively 1.97 +/-3.0 mm. The uncovered subtalar joint surface postoperatively was 1.77+/- 2.92 mm. All patients with major complications showed retrospectively what we call the “deadly configuration”: the radius of the talus ends within the subtalar joint. Consequently the free subtalar joint surface was significantly larger (6.4 mm +/- 3.33) in feet with major complications than in feet without (1.06 mm +/- 2.15, P < 0.001). Feet without complications but with this deadly configuration (7/26) had a lower free subtalar surface (3.27 mm +/- 1.81, P=0.09) than feet with major complications. Conclusion: The resection of os trigonum or posterior talar process has a high complication rate of 13.3% with symptomatic talar edema and subtalar osteoarthritis at follow up which can be career-ending in professional athletes. The only risk factor found was what we call the “deadly configuration” characterized by the ending of the talar radius into the subtalar joint. In such cases, the resection has to be made sparingly preferably not anterior into the subtalar joint and patients have to be informed about this possible unfavorable course.

Obstructive Sleep Apnea-a Perioperative Risk Factor.

Obstructive sleep apnea (OSA) is a common disorder of breathing but is probably underappreciated as a perioperative risk factor. This review is based on pertinent articles, published up to 15 August 2015, that were retrieved by a selective search in PubMed based on the terms "sleep apnea AND anesthesia" OR "sleep apnea AND pathophysiology." The guidelines of multiple specialty societies were considered as well. OSA is characterized by phases of upper airway obstruction accompanied by apnea/hypoventilation, with hypoxemia, hypercapnia, and recurrent overactivation of the sympathetic nervous system. It has been reported that 22% to 82% of all adults who are about to undergo surgery have OSA. The causes of OSA are multifactorial and include, among others, an anatomical predisposition and /or a reduced inspiratory activation of the bronchodilator muscles, particularly when the patient is sleeping or has taken a sedative drug, anesthetic agent, or muscle relaxant. OSA is associated with arterial hypertension, coronary heart disease, and congestive heart failure. It can be assessed before the planned intervention with polysomnography and structured questionnaires (STOP/STOP-BANG), with sensitivities of 62% and 88%. The utility of miniaturized screening devices is debated. Patients with OSA are at risk for perioperative problems including difficult or ineffective mask ventilation and/or intubation, postoperative airway obstruction, and complications arising from other comorbid conditions. They should be appropriately monitored postoperatively depending on the type of intervention they have undergone, and depending on individually varying, patient-related factors; postoperative management in an intensive care unit may be indicated, although no validated data on this topic are yet available. OSA patients need care by specialists from multiple disciplines, including anesthesiologists with experience in recognizing OSA, securing the airway of OSA patients, and managing them postoperatively. No randomized trials have yet compared the modalities of general anesthesia for OSA patients with respect to postoperative complications or phases of apnea or hypopnea.

Simple, rapid and effective technique for intracorporeal defogging of laparoscopic lens

Even today, despite brisk and enormous developments in the field of minimally invasive technology and optics, surgeons continue to face the perioperative problem of recurrent fogging and smearing of the laparoscopic lens - a source of considerable frustration. It adversely affects the efficacy of the ongoing operation and also adds to the cost. Most of the countermeasures described in the recent literature either lack procedural simplicity or steady favourable results. In this regard, we describe an intracorporeal, easy-to-use technique for regaining clear and undisturbed laparoscopic vision without the need for any specialized equipment or solutions. We have used this technique in over 4500 cases with no complications and hence recommend it for routine use.

The Use of Somatosensory Evoked Potentials to Determine the Relationship Between Intraoperative Arterial Blood Pressure and Intraoperative Upper Extremity Position-Related Neurapraxia in the Prone Surrender Position During Spine Surgery: A Retrospective Analysis.

Peripheral nerve injury is a significant perioperative problem. Intraoperative position-related neurapraxia may indicate impending peripheral nerve injury and can be detected by changes in somatosensory evoked potentials (SSEP). The purpose of this retrospective analysis of spine surgeries performed under general anesthesia with SSEP monitoring was to determine the relationship between intraoperative mean arterial blood pressure (MAP) and intraoperative upper extremity position-related neurapraxia in the prone surrender (superman) position. We reviewed a computerized database of spine surgeries performed on adult patients in the prone surrender position. The authors reviewed intraoperative SSEP monitoring reports to identify the patients who developed intraoperative upper extremity position-related neurapraxia (case group) and patients who did not (control group). Propensity matching was performed to derive 2 demographically matched groups. Preoperative and intraoperative variables were included in the univariate Cox regression analysis of risk factors associated with neurapraxia. Multivariate Cox regression models were used to identify the independent risk factors. One hundred fifty-two patients were included in the analysis. The case group included 32 patients, whereas the control group included 120 matched patients. Intraoperative MAP <55 mm Hg for a total duration of ≥5 minutes was an independent risk factor associated with a greater incidence of upper extremity position-related neurapraxia compared with a duration of <5 minutes with MAP <55 mm Hg (hazard ratio, 3.43; confidence interval, 1.445-8.148; P = 0.0052). Intraoperative MAP >80 mm Hg for a total duration of >55 minutes was an independent predictor associated with a lower incidence of neurapraxia compared with a total duration ≤55 minutes (hazard ratio, 0.341; confidence interval, 0.163-0.717; P = 0.0045). In this study, we identified the changes in intraoperative MAP as independent predictors associated with upper extremity position-related neurapraxia in the prone surrender position under general anesthesia.

Is Preoperative Eosinopenia an Independent Predictor of Early Mortality for Coronary Artery Bypass Surgery?

Coronary artery bypass graft surgery in one of the most effective and widely used methods employed in the treatment of ischemic heart disease, but many factors to various degrees are directly associated with perioperative and postoperative problems. In this study, we evaluated the relationship between preoperative eosinophil count and postoperative mortality in patients who underwent coronary artery bypass graft operation. A total of 241 patients (157 males, 84 females) who underwent isolated on-pump coronary artery bypass graft operation between 2011 and 2013 in two centers were evaluated retrospectively. The mean age of patients was 64 ± 11 years. After the mean 6.2 ± 0.8 month follow-up period, 36 (15%) of the 241 patients experienced cardiovascular death. Patients were classified into two groups as those who survived versus those who died. Eosinophil levels were lower among the patients who died compared to the patients who survived (0.8 [0-3.8] versus 1.7 [0-9.4] ×1000 cells/mm3; P &lt; .001). Optimal cut-off level of eosinophils for predicting mortality was determined as ≤1.6 ×1000 cells/mm3, with a sensitivity of 85.7% and specificity of 51.0% (area under curve, 0.703; 95% CI, 0.641-0.760). Eosinopenia was used as the predictor of mortality in pediatric and adult patients in the intensive care units. Eosinopenia after coronary artery bypass graft can be related to the endogenous stress hormones, and insufficiency of the existing cardiac status. Eosinophil levels can assist and facilitate risk stratification for patients with coronary artery bypass graft.

A Secure Technique for Microvascular Anastomosis in Arteries with Intimal Dissection: Intimal Sleeve Fold-Over Technique.

Intimal dissection can cause an irregular internal surface with intimal flaps and subendothelial collagen exposure. This has been associated with a high risk of thrombosis. Trimming the artery to a healthy level is routinely recommended to avoid intimal dissection. However, this method is limited when there is inadequate vascular length to work with. We dealt with an artery exhibiting severe intimal dissection by using a new suture technique: the intimal sleeve fold-over technique. Severe arterial intimal dissections were observed in 9 (6.9%) of 130 arterial microvascular anastomoses in free flap reconstruction for oral cancer patients from January 2013 to December 2013. We used this technique in 6 of the 9 patients. All 6 patients were discharged as scheduled without perioperative problems and complications during follow-ups. The mean diameters of the recipient and pedicle arteries with intimal dissection were 2.13 and 2.20 mm. The mean time for performing sleeve fold-over procedure of on each artery was 5.1 minutes. A secure intima-to-intima contact can be achieved using this technique. This technique can provide an alternative method to intimal dissection when the length of the artery is limited.

Successful Anaesthetic Management of Elderly Patients with Leprosy.

Leprosy is a chronic granulomatous infection that is caused by Mycobacterium leprae (1), wherein autonomic function is affected to varying degrees, and the important manifestations of such a dysfunction include orthostatic hypotension, baroreflex dysfunction and postprandial hypotension (2). Patients with leprosy have impaired respiratory function, breath holding time and response to cough (3). Hence, anaesthesiologists should be aware of complications, including difficult intubation and perioperative anaesthetic problems, in the management of patients with leprosy. Herein we present a case of a patient with leprosy having a transtrochanteric femur fracture who was successfully operated under spinal anaesthesia. A 70-year-old male patient with lepromatous leprosy, Parkinson’s disease and coronary artery disease was scheduled for a surgical repair of a transtrochanteric fracture of the femur. The patient was a known case of lepromatous leprosy for at least 2 years and received 100 mg dapsone per day po. The patient was symptomatic for cardiovascular disease. Preoperative electrocardiogram (ECG) revealed sinus rhythm, complete left bundle branch block and inferior wall ischaemia. Echocardiography revealed an ejection fraction of 50% with left ventricular diastolic dysfunction. After explaining the procedure and the risks involved to the patient, written informed consent was obtained. In the operating room, ECG, non-invasive blood pressure (NIBP) and pulse oximetry were attached and baseline parameters were noted. An 18-G intravenous cannula was secured. Preoperative heart rate was 90/min, blood pressure was 170/100 mm Hg, respiratory rate was 22/min and SpO2 (on room air) was 90%. An 18-G epidural catheter was inserted via the L3-L4 space with the patient in the left lateral position using midline approach and fixed at 11 cm. At the same level, 15 mg of 0.5% heavy bupivacaine was administered in the subarachnoid space using a 25-G Quincke’s spinal needle. Supplemented oxygen was administered via a venturi facemask (FiO2 0.5). A sensory loss up to T7 level was achieved with adequate motor paralysis after 9 min, and surgery was then initiated. ECG, NIBP and SpO2 were monitored. No complication was developed during operation. Leprosy is an uncommon disease in developed countries. A literature review suggests that there is limited information regarding the surgical management of patients with leprosy. During the course of leprosy, cell-mediated immunity reduces because of a decline in T-cell responses (4). In addition, patients with leprosy may have cardiac and respiratory dysautonomia and autonomic involvement. Therefore, proper pre-anaesthetic assessment and optimization with intraoperative period, adequate monitoring and preparation are essential while managing patients with leprosy. In our patient with leprosy, the other risk factor was advanced age. However, no adverse events were observed in the intra- and postoperative period. In conclusion, anaesthesiologists can use both spinal and epidural anaesthesia in elderly patients with leprosy.

Perioperative problems in patients with brainstem tumors and their influence on patient outcome.

Background and Aims:Patients with brainstem tumors have many associated systemic abnormalities and are prone to develop perioperative complications. We studied the problems associated with brainstem tumors and their influence on the postoperative neurological outcome.Material and Methods:Retrospective review of records of patients who underwent surgery for brainstem tumors over a period of 8 years was done. Preoperative variables, perioperative complications and neurological outcome as assessed by Glasgow Outcome Scale at the time of hospital discharge were noted. Association between perioperative factors and the unfavorable neurological outcome was evaluated.Results:Data of 70 patients were retrieved, 7 patients were excluded from the study because of incomplete data and data analysis was carried out for 63 patients. We found that lower cranial nerve palsies (32%) and hydrocephalus (43%) were common preoperatively. Various intraoperative problems encountered were hemodynamic instability (56%), major blood loss requiring blood transfusion (40%) and venous air embolism (11%), and postoperative problems were meningitis (51%), hypokalemia (38%), chest infection (21%), seizure (11%), deterioration of Glasgow Coma Scale (GCS, 11%), hyponatremia (8%), hydrocephalus (6%), respiratory distress (3%) and operatives site hematoma (3%). Fifty-six (89%) patients had favorable outcome at hospital discharge whereas, 7 (11%) had an unfavorable outcome. There was no association between pre- and intra-operative factors and the neurological outcome. Deterioration of GCS, chest infection, and the need for reintubation and tracheostomy were associated with unfavorable neurological outcome.Conclusion:Patients of brainstem tumors are at increased risk of perioperative complications. Some of the postoperative complications were associated with unfavorable neurological outcome.

The obese patient: a problem of larger consequence.

Obesity is a worldwide epidemic that has both economic and health implications of enormous consequence. The obese patients tend to have earlier symptoms related to osteoarthritis, more peri-operative medical problems, higher rates of infection and more technical difficulties intra-operatively following hip and knee arthroplasty. Nevertheless, these patients have good long-term clinical outcomes and implant survival rates and are often some of the most satisfied patients after joint arthroplasty. Therefore, obese patients should not be denied surgery based on their weight alone.

Difficult mask ventilation made easy: Three cases of Parry Romberg syndrome.

Parry Romberg syndrome presenting as hemifacial atrophy poses various perioperative problems due to multi-system involvement. These patients have several anaesthetic implications which are published as case reports. In spite of several case reports, airway issues associated with this disease is under-discussed. This report of three cases discusses airway difficulties and the multiple methods to tackle them in an easier way by focussing concentration on airway assessment and appropriate preoperative planning.

Short and Long-Term Outcomes in Hemophilia Patients with Inhibitors Undergoing Orthopedic Prosthetic Surgery

Introduction: Major orthopedic surgery is still a difficult challenge in hemophilic patients with high titer of inhibitor. In addition to possible peri-operative problems, the long-term outcomes are anecdotal.Aim of the study: to evaluate the short and long term outcomes in prosthetic orthopedic procedures done in hemophilic patients with inhibitor from 1998 to 2014Results: Sixteen knee replacements have been performed in 12 patients affected by hemophilia A with inhibitors. At the time of surgery 11 out of 12 patients had an inhibitor titer > 5UB (range 5 - 2,500). A preoperative pharmacokinetic with rFVIIa was made in 8 out of 12 patients, with the following mean values of clearance rate: 35 ml/h/kg and half-life: 2.85 hours. The average age was 46 years (range 29-55). All patients were treated with 2-3 doses of rFVIIa (90-120 mg/kg) every two hours during surgery up to suturing of the wound, followed by continuous infusion of rFVIIa at dose of 30-50 mg/kg/h on days 1-3 and 15 mg/kg/h on days 4-14. Plasma levels of FVII:C were maintained > 15U/mL. All but one patients were transfused with 2 units of red blood cells (RBC), according to standard procedure. Two peri-operative complications occurred: 1 pulmonary embolism and 1 major bleeding at the operated site, poorly responsive to rFVIIa and aPCC, treated with 6 units of RBC. Only two patients underwent to prosthesis revision for infection, while another due to rupture of the prosthesis metal cup. After surgery all patients showed a significant improvement in pain and a favorable functional recovery. After a median follow-up of 7 years (1-18 years), a good quality of life as to pain and function of the replaced knee were recorded.Conclusions: The orthopedic prosthetic surgery in hemophilic patients with inhibitors can be done, with a good outcome. The continuous infusion of rFVIIa provides stable haemostatic coverage, saving on the rFVIIa total dose compared to the bolus standard dose. However, costs remain high and the possible risks of thromboembolic complications should not be overlooked DisclosuresNo relevant conflicts of interest to declare.

Clinical Usefulness of Somatosensory Evoked Potentials for Detection of Peripheral Nerve and Brachial Plexus Injury Secondary to Malpositioning in Microvascular Decompression.

Neurologic injury secondary to positioning is a significant perioperative problem and a common cause of patient injury in the practice of surgery. Somatosensory evoked potentials' (SSEPs) monitoring has also been noted useful in evaluating upper extremity conduction changes related to positioning. The purpose of this article was to evaluate the effectiveness of intermittent monitoring of SSEPs, which detects peripheral nerve and brachial plexus injury caused by malpositioning during microvascular decompression (MVD). This article will also discuss the etiology and pathogenesis of nerve injury after MVD and the means to prevent them. Intraoperative SSEP monitorings for 485 patients who underwent MVD surgery were reviewed. A greater than or equal to 50% decrease in SSEPs amplitude and/or a greater than or equal to 10% increase in latency are considered significant change to produce potential postoperative neurological deficit. Risk factors were reviewed and a Student t-test was performed for significant differences. The overall incidence of position-related upper extremity SSEP changes was 2.89%. No patient with a reversible SSEP change developed a new postoperative deficit in the affected extremity. Patients with low body mass index, diabetes mellitus had a higher rate of brachial plexus injury during MVD. Gender, age, and operation duration did not increase the risk of brachial plexus injury. Of the 14 patients who had a significant change of SSEP, there were 6 ulnar nerve on the contralateral side and 8 median nerve on the ipsilateral side. All the changes occurred within 10 minutes after the patients were positioned. When positioning the patient for MVD with lateral position, careful attention should be paid to both the dependent (lower) arm extremities and the upper shoulders to prevent peripheral nerve injury. Additional precautions should be taken if the patient has a low body mass index or diabetes. Continuous intraoperative SSEP monitoring of ulnar/median nerve function is a valid and useful technique to minimize intraoperative neurologic injuries during surgery.

Elektrodenextraktion

Percutaneous lead extraction represents one of the most difficult and challenging interventions in the therapy with cardiac implantable electronic devices (CIEDs). Despite the progress in outcome and safety of these procedures in the last decade, the first published results of the ELECTRa registry point out that the risk of life-threatening complications should not be underestimated. Therefore, pre-operative screening for indications, present infections, pacemaker dependency, age and type of implanted leads, previous cardiac surgery and presence of anatomic variations are prerequisite to assess the individual operation risk. Apart from the decision for any particular operative approach, the risk-adjusted settings should be selected in order to enable intraoperative escalation of extraction methods, if needed. A good theoretical knowledge of potential perioperative problems and complications as well as the intraoperative use of TEE enables early detection and management of complications. Furthermore, preoperative arrangements with other professionals and a team approach in emergency management enable fast and structured action when needed, thus, reducing mortality in case of life-threatening complications.

Autism spectrum disorder (ASD) and its perioperative management.

Autism spectrum disorder (ASD) is now diagnosed in more than 1 in 100 children, so it is not surprising that anesthetists are increasingly providing care for children with this diagnosis. The diagnostic classification for ASD has recently changed and our understanding of the causes and management of ASD are also changing rapidly. This review provides a timely update to increase understanding and awareness of the problems that children with ASD experience, and to minimize perioperative problems. Current literature on premedication and the increasing use of alpha-2 agonists such as clonidine and dexmedetomidine as well as the use of old favorites midazolam and ketamine is reviewed. Some simple strategies that will improve care and decrease anxiety, like social stories, the use of tablet computers, other comfort items or games for distraction, and using favorite drinks to disguise the bitter taste of medications, are described. Remember, the parents are their child's expert and will know what agitates and settles them. Talking to them prior to the day of the procedure is ideal. The importance of staff training and having a clinical practice guideline available at every institution cannot be overstated.

The role of curcumin as an inhibitor of oxidative stress caused by ischaemia re-perfusion injury in tetralogy of Fallot patients undergoing corrective surgery.

Cardiopulmonary bypass during tetralogy of Fallot corrective surgery is associated with oxidative stress, and contributes to peri-operative problems. Curcumin has been known as a potent scavenger of reactive oxygen species, which enhances the activity of antioxidants and suppresses phosphorylation of transcription factors involved in inflamation and apoptosis. To evaluate the effects of curcumin as an antioxidant by evaluating the concentrations of malondialdehyde and glutathione, activity of nuclear factor-kappa B, c-Jun N-terminal kinase, caspase-3, and post-operative clinical outcomes. Tetralogy of Fallot patients for corrective surgery were randomised to receive curcumin (45 mg/day) or placebo orally for 14 days before surgery. Malondialdehyde and glutathione concentrations were evaluated during the pre-ischaemia, ischaemia, re-perfusion phases, and 6 hours after aortic clamping-off. Nuclear factor-kappa B, c-Jun N-terminal kinase, and caspase-3, taken from the infundibulum, were assessed during the pre-ischaemia, ischaemia, and re-perfusion phases. Haemodynamic parameters were monitored until day 5 after surgery. In all the observation phases, malondialdehyde and glutathione concentrations were similar between groups. There was no significant difference in nuclear factor-kappa B activity between the groups for three observations; however, in the curcumin group, c-Jun N-terminal kinase significantly decreased from the pre-ischaemia to the re-perfusion phases, and caspase-3 expression was lower in the ischaemia phase. Patients in the curcumin group had lower temperature and better ventricular functions, but no significant differences were found in mechanical ventilation day or length of hospital stay in the two groups. Cardioprotective effects of curcumin may include inhibition of the c-Jun N-terminal kinase pathway and caspase-3 in cardiomyocytes, particularly in the ischaemia phase.

Do Surgical Trainees Believe They Are Adequately Trained to Manage the Ageing Population? A UK Survey of Knowledge and Beliefs in Surgical Trainees

Increasing numbers of older patients are undergoing surgery. Older surgical patients are at a higher risk of perioperative complications and mortality. Multimorbidity, frailty, and physiological changes of ageing contribute to adverse outcomes. These complications are predominantly medical, rather than directly surgical. Guidelines recommend preoperative assessment of comorbidity, disability, and frailty in older patients undergoing surgery and closer perioperative collaboration between surgeons and geriatricians. We conducted a survey to assess knowledge and beliefs of surgical trainees toward common perioperative problems encountered in older surgical patients. Paper-based survey. Unselected UK surgical training-grade physicians (CT1-ST8) attending the 2013 Congress of The Association of Surgeons of Great Britain and Ireland, Glasgow, UK, May 1-3, 2013. A total of 160 eligible UK surgical trainees attending the conference were invited to participate in the survey. Of them, 157 participated. Of the trainees, 68% (n = 107) reported inadequate training and 89.2% (n = 140) supported the inclusion of geriatric medicine issues in surgical curricula. Of the respondents, 77.2% (n = 122) were unable to correctly identify the key features required to demonstrate mental capacity, and only 3 of 157 respondents were familiar with the diagnostic criteria for delirium. Support from geriatric medicine was deemed necessary (84.7%, n = 133) but often inadequate (68.2%, n = 107). Surgical trainees support closer collaboration with geriatric medicine and shared care of complex, older patients (93.6%, n = 147). UK surgical trainees believe that they receive inadequate training in the perioperative management of complex, older surgical patients and are inadequately supported by geriatric medicine physicians. In this survey sample, trainee knowledge of geriatric issues such as delirium and mental capacity was poor. Surgical trainees support the concept of closer liaison and shared care of complex, older patients with geriatric medicine physicians. Changes to surgical training and service development are needed.

Experience of anaesthesia nurses of perioperative communication in hip fracture patients with dementia.

Perioperative care in hip fracture patients with dementia can be complex. There is currently little scientific evidence on how care should be undertaken. The aim of the study was to describe the experience of anaesthesia nurses of the difficulties that emerge in care situations and how communication with patients can be maintained in the perioperative setting of hip fracture surgery. Individual interviews were conducted with ten anaesthesia nurses (5 men and 5 women). The interviews were carried out at a university hospital in Gothenburg (Sweden), and the data were analysed using qualitative content analysis. Three main response categories were discerned: 'Communication', 'Dementia as a special issue' and 'Practical issues'. Dementia was viewed as one of the most difficult and shifting diseases an individual may suffer from. Time must be allocated to communicate clearly and patiently, to meticulously plan and carry out care while providing distinct information to enable patient participation. Establishing a mental bridgehead by confirming the patients' perceptions/feelings significantly reduced distress in a majority of the patients. A holistic and respectful approach was deemed mandatory at all times. Patients are sometimes dependent on recognition, so that small personal items brought close to the patient during surgery can calm the patient. State-of-the-art analgesia and anxiolytic medications are mandatory. Perioperative problems can be overcome with patience, empathy and profound knowledge of how patients with dementia respond prior to surgery. Our results may serve as a source for future care and provide information about hospital settings for better perioperative care in patients with dementia.

Perioperative management of Parkinson's disease

Several studies have demonstrated the serious impact of surgeries on patients with Parkinson's disease (PD). In addition, PD is a risk factor for postoperative complications and prolonged hospital stays. Discontinuation of anti-Parkinsonian drugs due to surgery causes an exacerbation of Parkinsonism and sometimes Parkinsonism-hyperpyrexia syndrome (PHS). Therefore, surgeries involving patients with PD require careful perioperative management. During the preoperative period, cooperation among neurologists, surgeons, and anesthesiologists is imperative. Administration of the same oral anti-Parkinsonian drug regimen that was prescribed during home care is important. Methods of both general and regional anesthesia should be chosen based on general health status and symptoms of Parkinsonism and agents should be selected with due consideration of their possible interaction with anti-Parkinsonian drugs. In patients with PD showing autonomic disturbance, changes in blood pressure and body temperature should be monitored. During the postoperative phase, postoperative pain, aspiration pneumonia, ileus, and psychotic symptoms should be managed, taking into consideration the interactions between anti-Parkinsonian drugs and therapeutic agents. Currently, new anti-Parkinsonian drugs, such as rotigotine and apomorphine are available for patients with PD requiring parenteral treatment. It is important that medical experts share awareness about perioperative problems and their management in patients with PD.