Perioperative Management Plan Research Articles

Pay attention to the identification and management of perioperative stroke

Perioperative stroke is a serious complication that leads to perioperative death, prolonged hospitalization, and permanent or temporary neurological impairment. Early identification and diagnosis is the key of improving the prognosis of perioperative stroke patients, which requires surgeons to have a complete understanding of patient risk factors, early rapid identification of symptoms and timely diagnosis. The core of the prevention strategy is delaying the operating time, reducing known risk factors, drug intervention (such as the use of antiplatelet drugs or anticoagulants), optimizing the control of the basic disease, and identifying high-risk patients in the preoperative evaluation to implement a more personalized perioperative management plan, to reduce the incidence of perioperative stroke and related adverse consequences.

Children and the Opioid Crisis: We Can Make a Difference

The use of opioid-sparing and opioid-free strategies in children can provide adequate analgesia while decreasing the risk of adverse events and contributing to the ongoing battle against the opioid crisis. However, every child must be evaluated individually so that a safe and efficacious perioperative pain management plan can be created. A working knowledge of the risks and benefits of opioids, nonopioid adjuncts, and regional anesthesia along with the ethical considerations for balancing stewardship and beneficent care is essential to the success of these strategies. As perioperative practitioners caring for children, we have an obligation to consider opioid-sparing and opioid-free strategies to promote overall best outcomes. We can make a difference, one child at a time.

Development and validation of a nomogram for predicting poor operative visibility during FESS in Chinese adult patients with CRS.

The purpose of this study is to develop and evaluate a nomogram that is capable of predicting poor operative visibility during functional endoscopic sinus surgery. To identify potential risk factors, patients with chronic rhinosinusitis who underwent functional endoscopic sinus surgery (FESS) between January 2019 and December 2022 were selected from our hospital's electronic medical record system. Data on general patient information, clinical manifestations, clotting-related test indices, Lund-Machay score of sinuses CT scanning, Lund-kennedy score of nasal endoscopies, anesthesia methods, intraoperative blood pressure and heart rate, and Boezaart bleeding score were collected. Minimum absolute convergence and selection operator (LASSO) regression, as well as multivariate logistic regression, were used to determine the risk factors. A nomogram was developed in order to predict poor operating visibility during FESS, and its performance was evaluated utilizing both the training and verification datasets via various measures including receiver operating characteristic (ROC) curve analysis, area under the curve (AUC), Hosmer-Lemeshow goodness-of-fit test, calibration curve, and decision curve analysis. Of the 369 patients who met the inclusion criteria, 88 of them exhibited POV during FESS. By deploying LASSO and multivariate logistic regression analyses, six risk factors were identified and used to construct a nomogram for predicting POV during FESS. These factors include prothrombin time (PT), prothrombin activity (PTA), Lund-Mackay score (LMS), Lund-Kennedy score (LKS), anesthetic method, and intraoperative hypertension. The AUC of the training set was found to be 0.820 while that of the verification set was 0.852. The Hosmer-Lemeshow goodness-of-fit test and calibration curve analysis revealed good consistency between predicted and actual probabilities. Also, the decision curve demonstrated that the nomogram had a high degree of clinical usefulness and net benefit. The constructed nomogram has a strong ability to predict the poor intraoperative field in patients with chronic rhinosinusitis, which can help preoperative judgment of high-risk patients and provide evidence for perioperative management and preoperative plan formulation.

Risk Factors for Rescue Opioid Prescription After Cubital Tunnel Surgery.

Concerns regarding the ongoing opioid epidemic have led to heightened scrutiny of postoperative opioid prescribing patterns for common orthopedic surgical procedures. This study investigated patient- and procedure-specific risk factors for additional postoperative opioid rescue prescriptions following ambulatory cubital tunnel surgery. A retrospective review was performed of patients who underwent cubital tunnel surgery at 2 academic medical centers between June 1, 2015 and March 1, 2020. Patient demographics, comorbidities, prior opioid history, and surgical variables were recorded. The primary outcome was postoperative rescue opioid prescription. Univariate and bivariate statistical analyses were performed. Two hundred seventy-four patients were included, of whom 171 (62%) underwent in situ ulnar nerve decompression and 103 (38%) underwent ulnar nerve decompression with anterior transposition. The median postoperative opioid prescription amount was 90 morphine equivalent units (MEU) for the total cohort, 77.5 MEU for in situ ulnar nerve decompression, and 112.5 MEU for ulnar nerve decompression with transposition. Twenty-two patients (8%) required additional rescue opioid prescriptions postoperatively. Female sex, fibromyalgia, chronic opioid use, chronic pain diagnosis, and recent opioid were associated with the need for additional postoperative rescue opioid prescriptions. While most patients do not require additional rescue opioid prescriptions after cubital tunnel surgery, chronic pain patients and patients with pain sensitivity syndromes are at risk for requiring additional rescue opioid prescriptions. For these high-risk patients, preoperative collaboration of a multidisciplinary team may be beneficial for developing a perioperative pain management plan that is both safe and effective.

Perioperative management in haemophilia with extended half-life factors: a case series

Hemophilia B is a hereditary bleeding disorder characterized by deficient or defective coagulation factor IX, leading to a propensity for recurrent bleeding episodes, particularly in the joints. Management of Hemophilia B in surgical settings poses unique challenges due to the risk of excessive bleeding. This paper presents a series of two cases that demonstrate the effective use of perioperative extended half-life (EHL) factor IX products, specifically N9-GP (Refixia), in the surgical management of Hemophilia B. The cases include total knee replacement and total hip replacement. In each case, early initiation of EHL was observed to maintain adequate factor IX levels and control perioperative bleeding effectively, leading to successful surgical outcomes. These findings support the growing body of evidence suggesting the advantages of EHL perioperative treatment in patients with Hemophilia B, particularly in preparation for surgery. The implementation of EHL factor IX products as part of perioperative management plans may contribute to improved surgical outcomes and overall quality of life in Hemophilia B patients.

The effectiveness of a transitional pain service in patients undergoing surgery with an increased risk of developing chronic postsurgical pain (TRUSt study). A randomized clinical trial

Study objectivePoorly controlled acute postsurgical pain is associated with delayed recovery, chronic postsurgical pain (CPSP), chronic opioid use and impaired functioning in daily activities. The aim was to determine the effectiveness of a transitional pain service (TPS) to improve quality of recovery for patients at risk of CPSP. We hypothesized that a TPS improves the quality of recovery in patients at risk of CPSP. DesignSingle-center, pragmatic, randomized, superiority trial. SettingTertiary hospital in the Netherlands. PatientsAssessed for eligibility if ≥18 years of age, undergoing elective surgery, and had an increased risk of developing CPSP. After being stratified for sex, 176 patients were included. InterventionPatients were randomized to receive TPS or standard of care (SOC). TPS was a multidisciplinary intervention providing a patient-tailored perioperative pain management plan, throughout all phases of surgery. MeasurementsThe primary outcome was the difference in quality of recovery on the third postoperative day, measured by the Quality of Recovery (QoR)-15 questionnaire. Secondary outcomes include the between group differences in opioid consumption. Main resultsThe primary outcome was available in 169 (96.0%) patients. No difference between groups was found in QoR-15 on the third postoperative day (mean difference 2.0, 95% CI -5.5 to 9.4, p = 0.607). A decrease in opioid usage (compared to baseline) was observed in chronic opioid users, the median [IQR] reduction in total daily oral morphine milligram equivalents (MME) for TPS was −30 [−60, 0] at three and − 29.3 [−65.6, 0] at six months, whereas SOC had a median reduction of 0 [−56, 0] at three, and 0 [−60, 7.5] at six months. ConclusionsTPS did not significantly affect short-term quality of recovery but might improve long-term outcomes, such as the incidence of chronic pain, opioid consumption, and functioning in daily life. However, sample size in the present study was too small to provide solid evidence for this positive signal.

Anesthetic management of pediatric patients with congenital heart disease posted for cochlear implant: a case series

Congenital heart disease (CHD) is the most common birth defect which might be a part of a broader syndrome. Such patients pose many challenges when subjected to anesthesia for non-cardiac surgery. Therefore, a patient-specific peri-operative management plan needs to be employed to reduce peri-operative morbidity.
 We conducted 10 pediatric cases with CHD posted for cochlear implant surgery. The study was conducted in GMERS Medical College, Gandhinagar, India. Each case was managed peri-operatively with a standardized protocol. All patients had acyanotic CHD, and no patient had complex CHD. They were pre-operatively assessed in detail and optimized if required. As part of intra-operative management, care was taken to avoid sudden hemodynamic fluctuations by using etomidate as induction agent and atracurium as muscle relaxant. Inj. lignocaine was used to prevent hemodynamic response to intubation. Adequate analgesia was achieved. None of the patients had any adverse cardiac event peri-operatively. We were able to manage each patient successfully without any untoward consequences.
 Key words: Congenital heart disease; Cochlear implant; General anesthesia; Pulmonary hypertension; Pulmonary vascular resistance; Systemic vascular resistance
 Citation: Gadani HN, Jariwala ND, Kureshi MM, Shah VM, Thakkar PD. Anesthetic management of pediatric patients with congenital heart disease posted for cochlear implant: A case series. Anaesth. pain intensive care 2023;27(4):590−595; DOI: 10.35975/apic.v27i4.2272
 Received: May 11, 2023; Reviewed: May 25, 2023; Accepted: Jun 07, 2023

Practical strategies for the prevention and management of chronic postsurgical pain

Chronic postsurgical pain (CPSP) is a multifactorial condition that affects a significant proportion of patients undergoing surgery. The prevention and management of CPSP require the identification of preoperative risk factors to screen high-risk patients and establish appropriate perioperative pain management plans to prevent its development. Active postoperative pain management should be provided to prevent CPSP in patients with severe pain following surgery. These tasks have become important for perioperative team members in the management of CPSP. This review article provides a comprehensive overview of the latest research on the role of perioperative team members in preventing and managing CPSP. Additionally, it highlights practical strategies that can be employed in clinical practice, covering the definition and risk factors for CPSP, including preoperative, intraoperative, and postoperative factors, as well as a risk prediction model. The article also explores various treatments for CPSP, as well as preventive measures, including preemptive analgesia, regional anesthesia, pharmacological interventions, psychoeducational support, and surgical technique modification. This article emphasizes the importance of a comprehensive perioperative pain management plan that includes multidisciplinary interventions, using the transitional pain service as an example. By adopting a multidisciplinary and collaborative approach, perioperative team members can improve patient outcomes, enhance patient satisfaction, and reduce healthcare costs. However, further research is necessary to establish targeted interventions to effectively prevent and manage CPSP.

Risk factors for incisional complications after lumbar internal fixation via posterior midline approach: A case-control study of 455 consecutive cases.

To analyse the clinical data of patients who developed incisional complications and those who did not develop incisional complications after lumbar internal fixation, and investigate the risk factors for incisional complications in patients after lumbar internal fixation with posterior midline incision. A standardised data collection form was used to collect the clinical data of patients who were admitted and underwent lumbar internal fixation in our hospital from July 2018 to July 2021. Patients who experienced any one of the incisional complications, such as incision exudates, swelling, blisters, bruising, superficial/deep incisional infections, poor healing and scarring, after surgery were included in the incisional complication group, and patients who did not develop the above-mentioned incisional complications were included in the control group. Univariate logistic regression analysis was first performed to identify potential risk factors, significant factors from univariate analysis were then included in multivariable logistic regression analysis to identify independent risk factors for incisional complications after lumbar spine surgery. Among 455 patients included in the study, postoperative incision complications occurred in 82 patients, with an incidence rate of 18.02%. Multivariate regression analysis identified seven independent risk factors for incisional complications: age, body mass index, preoperative albumin level, hypertension, diabetes mellitus, operation time and local anaesthetic infiltration at the incision site after surgery. Our findings documented that age, body mass index, preoperative albumin level, hypertension, diabetes mellitus, operation time, and postoperative local anaesthetic infiltration at the incision site were risk factors for incisional complications after lumbar internal fixation with posterior median incision. Awareness of these risk factors can enable surgeons to develop a more appropriate perioperative management plan for patients undergoing lumbar internal fixation, thus helping them recover faster.

Perioperative Management of Elective Surgery in Patients with COVID-19 Infection

SARS-CoV2 is a deadly virus belonging to the family Corona-viridae, with the primary target pulmonary system, known as the coronavirus pandemic disease (COVID-19). This virus has caused a high death rate of approximately 9,500 deaths as of December 2020. Along this pandemic, the hospital will treat non-emergent conditions in COVID-19 patients require nonemergent surgery. Anesthesiologists have an important role in the anesthesia management in patients with COVID-19 utilization and require airway management. This article explains optimal preoperative evaluation, intraoperative management, and postoperative management of COVID-19 patients. Optimal treatment is expected to minimize complications and the spread of COVID-19 disease. The optimal time for elective surgery should be decided by a multidisciplinary committee that considers the risk of complications either the patient, the disease itself, the surgical procedure, or other alternatives with lower risk. Perioperative management is carried out preoperatively, intraoperatively, and postoperatively. The safety of anesthesiologists using personal protective equipment (PPE) to carry out preoperative evaluations is important. The number of disease severity can use a scoring system, the results of which can be used as a reference for multidisciplinary discussions related to perioperative management plans. General anesthesia can contribute to the spread of disease resulting from the risk of droplets resulting from airway action, so regional anesthesia can be considered to reduce the risk of spread. For this reason, optimal management is needed to reduce risks to patients as well as medical personnel.

Risk assessment of severe postpartum hemorrhage after invasive placenta accreta based on three-dimensional reconstruction of magnetic resonance imaging.

The aim of this study was to investigate the significance and feasibility of risk assessments based on the three-dimensional (3D) reconstruction of magnetic resonance imaging (MRI) of invasive placenta accreta (IPA) to create individualized surgical protocols and perioperative management plans in late pregnancy. MRI and clinical data of 36 pregnant women with IPA admitted to Southwest Hospital from January 2017 to June 2021 were retrospectively analyzed. The patients were divided into the following 4 groups: peripartum hysterectomy (PH), abdominal aortic balloon block (AABB), PH with AABB, and nonsurgical treatment. Each group was then divided into severe and nonsevere postpartum hemorrhage subgroups based on postpartum hemorrhage volumes of not more than 2,000 mL and more than 2,000 mL, respectively. The uteri, placentas, IPA, and urinary bladders in each group were segmented and 3-dimensionally reconstructed using Amira 5.2.2 (Visage Imaging, Richmond, Australia) software, and their surface areas and volumes were calculated. A multifactorial unconditional logistic regression analysis was performed to evaluate the 3D morphological parameters of postpartum hemorrhage and calculate the optimal threshold. The bleeding volume, IPA area, placental area:uterine area ratio, IPA area:placental area ratio, maximum depth of IPA, placental position score, IPA position score, and implantation volume were greater in the severe postpartum hemorrhage subgroup than in the nonsevere postpartum hemorrhage subgroup of all groups. In the multifactorial regression analysis, the areas under the receiver operating characteristic curve of the implantation area, implantation volume, maximum depth of implantation, and implantation area:placental area ratio exceeded 0.9 and correlated strongly with severe postpartum hemorrhage, while those of the uterine area, uterine volume, placental area, placental volume, and placental area:uterine area ratio were between 0.5 and 0.7 and correlated with severe postpartum hemorrhage. The threshold (cutoff values) determining severe postpartum hemorrhage were 20,286.25 mm2 of the implantation area, 0.01271 of the implantation area:placental area ratio, 15.03 mm of the maximum depth of implantation, and 46,846 mm3 of the implantation volume. The MRI 3D reconstruction of IPA and its adjacent structures can accurately display the location, anatomical morphology, and spatial relationship of IPA, which can be used to improve the accuracy of IPA diagnosis, predict postpartum hemorrhage, and provide optimized treatment decisions for obstetricians.

Association of Bleeding Disorders and Risk of Complications Following Open Reduction and Internal Fixation of the Ankle

Category: Ankle; Other Introduction/Purpose: Open reduction and internal fixation (ORIF) of the ankle is a common procedure performed to correct ankle fractures in many different patient populations. Diabetes, peripheral vascular disease, and osteoporosis have been identified as risk factors for postoperative complications following surgery for ankle fractures. To date, there have not been any studies evaluating postoperative outcomes in patients with bleeding disorders undergoing operative treatment for ankle fractures. The aim of this study was to determine the postoperative complication rate following ORIF of the ankle in patients with a bleeding disorder versus those without a bleeding disorder. Methods: From 2006 to 2018, patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database. Two patient cohorts were defined: patients with a bleeding disorder and patients without a bleeding disorder. Patients who underwent either inpatient or outpatient ORIF of the ankle were included in this study. In this analysis, demographics, medical comorbidities, and postoperative complications variables were assessed between the two cohorts. Bivariate and multivariate analyses were performed. Results: Of 10,306 patients undergoing operative treatment for ankle fracture, 9,909 patients (96.1%) had no bleeding disorder whereas 397 patients (3.9%) had a bleeding disorder. Following adjustment on multivariate analysis, compared to patients who did not have a bleeding disorder, those with a bleeding disorder had an increased risk of any postoperative complications (OR 1.479; p=0.024), requirement for postoperative blood transfusion (OR 2.863; p=0.001), and extended length of hospital stay greater than 5 days (OR 1.455; p=0.010) (Table 1). Conclusion: Patients with bleeding disorders are at an increased risk of postoperative complications following ORIF for ankle fractures. Our study found that patients with bleeding disorders had greater odds of postoperative complications following ORIF of the ankle. Determining patient risk factors and creating optimal preoperative and perioperative management plans in patients with bleeding disorders undergoing ORIF can be beneficial in reducing postoperative complications, improving patient outcomes, and reducing overall cost.

Pre-operative screening for sleep disordered breathing: obstructive sleep apnoea and beyond.

To review different types of sleep disordered breathing and available screening methods in pre-operative assessment.To understand the pathophysiology behind sleep disordered breathing and how it can lead to complications in the peri-operative setting.To review the planning and treatment strategies that should be considered as part of peri-operative management.

Management of Postoperative Pain in Patients Following Spine Surgery: A Narrative Review.

Perioperative pain management is a unique challenge in patients undergoing spine surgery due to the increased incidence of both pre-existing chronic pain conditions and chronic postsurgical pain. Peri-operative planning and counseling in spine surgery should involve an interdisciplinary approach that includes consideration of patient-level risk factors, as well as pharmacologic and non-pharmacologic pain management techniques. Consideration of psychological factors and patient focused education as an adjunct to these measures is paramount in developing a personalized perioperative pain management plan. Understanding the currently available body of knowledge surrounding perioperative opioid management, management of opioid use disorder, regional/neuraxial anesthetic techniques, ketamine/lidocaine infusions, non-opioid oral analgesics, and behavioral interventions can be useful in developing a comprehensive, multi-modal treatment plan among patients undergoing spine surgery. Although many of these techniques have proved efficacious in the immediate postoperative period, long-term follow-up is needed to define the impact of such approaches on persistent pain and opioid use. Future techniques involving the use of precision medicine may help identify phenotypic and physiologic characteristics that can identify patients that are most at risk of developing persistent postoperative pain after spine surgery.

Machine learning algorithms as early diagnostic tools for pancreatic fistula following pancreaticoduodenectomy and guide drain removal: A retrospective cohort study

ObjectiveClinically relevant postoperative pancreatic fistula (CR-POPF) remains the major cause of morbidity following pancreaticoduodenectomy (PD). Several model score systems such as the Fistula Risk Score (FRS) have been developed to predict CR-POPF using preoperative and intraoperative data. Machine learning (ML) algorithms are increasingly applied in the medical field and they could be used to assess the risk of CR-POPF, identify clinically meaningful data and guide drain removal. MethodsData from consecutive patients who underwent PD between January 1, 2010 and March 31, 2021 at a single high-volume center was collected retrospectively in this study. Demographics, clinical features, intraoperative parameters, and laboratory values were used to conduct the ML model. Four different ML algorithms (CatBoost, lightGBM, XGBoost and Random Forest) were used to train this model with cross-validation. ResultsA total of 2421 patients with 62 clinical parameters were enrolled in this ML model. The majority of patients (76.3%) underwent open PD while others underwent robot-assisted PD. CR-POPF occurred in 424 (17.5%) patients. The CatBoost algorithm outperformed other algorithms with a mean area under the receiver operating characteristic curve (AUC) of 0.81 (95% confidence interval: 0.80–0.82) from the 5-fold cross-validation procedure. In the test dataset, the CatBoost algorithm also achieved the best mean-AUC of 0.83. The most important value was mean drain fluid amylase (DFA) in the first seven postoperative days (POD). The performance of models that used only preoperative data and intraoperative data was marginally lower than that of models that used combined data. ConclusionOur ML algorithms could be applied as early diagnostic tools for CR-POPF in patients who underwent PD. Such real-time clinical decision support tools can identify patients with a high risk of CR-POPF, help in developing the perioperative management plan and guide the optimal timing of drain removal.

The Pro-Diab Melbourne Perioperative Study: A structured pre-admission perioperative diabetes management plan to improve medication usage in elective surgery.

BackgroundPerioperative diabetes management has become increasingly complex; management is often inconsistent resulting in dysglycaemia and associated morbidity.AimTo evaluate a structured pre‐admission perioperative diabetes management plan (PDMP) for safe and appropriate recommendation, prescription and administration of diabetes medications in the perioperative period for people with diabetes undergoing elective, non‐cardiac surgery.MethodsA multidisciplinary team developed the intervention, a structured PDMP (including diabetes medication reconciliation, management guide, individualised plan) to standardise optimal perioperative diabetes management. A single centre prospective pre‐ and post‐intervention pilot study was performed, including all individuals with diabetes medications attending the pre‐admissions clinic during two 4‐month periods (February to May) in 2016 (control period) and 2017 (intervention period). The primary outcome was appropriate recommendation, prescription and administration of diabetes medications (including insulin), according to the PDMP, in the perioperative period. Secondary outcomes measures were glycaemia. Analysis was by intention to treat.ResultsControl and intervention groups included 131 and 133 participants, respectively; they were well matched in clinical characteristics. The PDMP was completed correctly in 100 (75%) individuals in the intervention group. The appropriate use of diabetes medications increased from 30% in the control group to 71% in the intervention group (p < 0.001). Following the PDMP implementations, glycaemia improved in the overall perioperative period (8.7 ± 2.9 vs. 9.8 ± 3.3 mmol/L, p = 0.005) and at all time points (from admission and over entire hospital stay).ConclusionA structured pre‐admission perioperative diabetes management plan for elective surgery improved safe and appropriate diabetes medication use and glycaemia in the perioperative period.

Perioperative Management of Patients with Cardiac Implantable Electronic Devices and Utility of Magnet Application.

With the demographic evolution of the population, patients undergoing surgery today are older and have an increasing number of sometimes complex comorbidities. Cardiac implantable electronic devices (CIED) are also getting more and more complex with very sophisticated programming algorithms. It may be generally assumed that magnet application reverts pacing to an asynchronous mode in pacemakers and disables tachycardia detection/therapy in internal cardioverter-defibrillators. However, depending on device type, manufacturer and model, the response to magnet application may differ substantially. For these reasons, perioperative management of CIED patients is getting more and more challenging. With this review article we provide an overview of optimal perioperative management of CIED patients with a detailed description of CIED response to magnet application depending on manufacturer and device-type, which may help in providing a safe perioperative management plan for the CIED patient.

Association of Bleeding Disorders and Risk of Complications Following Open Reduction and Internal Fixation of the Ankle.

Open reduction and internal fixation (ORIF) of the ankle is a common procedure performed to correct ankle fractures in many different patient populations. Diabetes, peripheral vascular disease, and osteoporosis have been identified as risk factors for postoperative complications following surgery for ankle fractures. To date, there have not been any studies evaluating postoperative outcomes in patients with bleeding disorders undergoing operative treatment for ankle fractures. The aim of this study was to determine the postoperative complication rate following ORIF of the ankle in patients with a bleeding disorder vs those without a bleeding disorder. From 2006 to 2018, patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database. Two patient cohorts were defined: patients with a bleeding disorder and patients without a bleeding disorder. Patients who underwent either inpatient or outpatient ORIF of the ankle were included in this study. In this analysis, demographics, medical comorbidities, and postoperative complications variables were assessed between the 2 cohorts. Bivariate and multivariate analyses were performed. Of 10 306 patients undergoing operative treatment for ankle fracture, 9909 patients (96.1%) had no bleeding disorder whereas 397 patients (3.9%) had a bleeding disorder. Following adjustment on multivariate analysis, compared to patients who did not have a bleeding disorder, those with a bleeding disorder had an increased risk of any postoperative complications (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.05-2.08, P = .024), requirement for postoperative blood transfusion (OR 2.86, 95% CI 1.53-5.36, P = .001), and extended length of hospital stay greater than 5 days (OR 1.46, 95% CI 1.10-1.93, P = .010). Patients with bleeding disorders are associated with increased risk of postoperative complications following ORIF for ankle fractures. Determining patient risk factors and creating optimal preoperative and perioperative management plans in patients with bleeding disorders undergoing ORIF can be beneficial in reducing postoperative complications, improving patient outcomes, and reducing overall morbidity. Level III, retrospective cohort study.

Aortic root repair in a patient with acquired hemophilia A: case report

BackgroundPatients with acquired hemophilia A (AHA) who require open heart surgery have a life-threatening risk of hemorrhage. Limited data exist to guide perioperative management of these patients.Case presentationA 53-year-old female with rheumatoid arthritis, concomitant aortic valve endocarditis, and severe aortic regurgitation presented to our hospital. Bleeding and abnormal coagulation tests were noted during the initial workup, and she was diagnosed with AHA. The perioperative management plan included the use of pharmaceuticals, porcine recombinant factor VIII, and blood products. Extensive preoperative coagulation data were obtained, and factor VIII levels were continuously monitored to mitigate bleeding complications. The aortic valve replacement and root repair were uneventful.ConclusionCardiac surgery in patients with AHA is possible as long as complex perioperative hemostatic and hematology management is used.

Perioperative Management of Pediatric Patients with Moyamoya Arteriopathy.

Pediatric patients with moyamoya arteriopathy are at high risk for developing new onset transient or permanent neurologic deficits secondary to cerebral hypoperfusion, particularly in the perioperative period. It is therefore essential to carefully manage these patients in a multidisciplinary, coordinated effort to reduce the risk of new permanent neurologic deficits. However, little has been published on perioperative management of pediatric patients with moyamoya, particularly in the early postoperative period during intensive care unit admission. Our pediatric neurocritical care team sought to create a multidisciplinary periprocedural evidence- and consensus-based care pathway for high-risk pediatric patients with moyamoya arteriopathy undergoing anesthesia for any reason to decrease the incidence of periprocedural stroke or transient ischemic attack (TIA). We reviewed the literature to identify risk factors associated with perioperative stroke or TIA among patients with moyamoya and to gather data supporting specific perioperative management strategies. A multidisciplinary team from pediatric anesthesia, neurocritical care, nursing, child life, neurosurgery, interventional neuroradiology, neurology, and hematology created a care pathway for children with moyamoya undergoing anesthesia, classifying them as either high or standard risk, and applying an individualized perioperative management plan to high-risk patients. The incidence of neurologic sequelae before and after pathway implementation will be compared in future studies.