Perioperative Medical Management Research Articles

Prediction model for poor short-term prognosis in patients with chronic subdural hematoma after burr hole drainage: a retrospective cohort study.

Chronic subdural hematoma (CSDH) is a common condition in neurosurgery. With an aging population, there is increasing attention on the prognosis of patients following surgical intervention. We developed a postoperative short-term prognostic prediction model using preoperative clinical indicators, aiming to assist in perioperative medical decision-making and management. The dataset was randomly divided into training and validation cohorts. An mRS score greater than 2 one month after discharge was considered indicative of a poor prognosis. In the training cohort, the least absolute shrinkage and selection operator (LASSO) regression analysis was used for multivariate analysis to identify independent risk factors and construct a prediction nomogram for poor prognosis one month after discharge. The performance of the nomogram was assessed using the Receiver Operating Characteristic (ROC) curve and calibration curve. A Decision Curve Analysis (DCA) was also conducted to determine the net benefit threshold of the prediction model. Among the 505 participants, 18.8% (95/505) had a poor prognosis one month after discharge. The baseline characteristics did not significantly differ between the training cohort and the validation cohort. LASSO regression analysis in the training cohort reduced the predictors to four potential factors. Further multivariate logistic analyses in the training cohort identified four independent predictors: age, admission Glasgow Coma Scale (GCS) score, hemiparesis, and hemoglobin count. These predictors were incorporated into the nomogram prediction model. Internal validation using ROC analysis, calibration curves, and other methods demonstrated a strong correlation between the observed and predicted likelihood of poor prognosis one month after discharge. The visualized nomogram prediction model we developed for short-term postoperative prognosis of chronic subdural hematoma after burr hole drainage aids in predicting short-term outcomes and guiding clinical treatment decisions. Further external validation is needed in the future to confirm its effectiveness.

Perioperative antithrombotic medication: An approach for the primary care clinician.

The primary care clinician faces many challenges and is often left to manage complex pathology because of resource constraints at higher levels of care. One of these complex conditions is the perioperative management of antithrombotic medication. This narrative review is focused on helping the clinician navigate the complex path and multiple guidelines related to the perioperative use of antithrombotic medication. Perioperative antithrombotic guidelines (American College of Chest Physicians, European Society of Regional Anaesthesia, and American Society of Regional Anesthesia) and relevant publications were identified by a PubMed search using the terms perioperative AND anticoagulants OR antithrombotics AND guideline. Issues relevant to clinical practice were identified, and attempts were made to explain any ambiguity that arose. Adhering to basic pharmacological principles and evidence-based guidelines allows for the safe usage of antithrombotics. Knowing when to stop, continue, bridge and restart antithrombotic medication prevents perioperative morbidity and mortality. Stopping antithrombotic medication too early can lead to thromboembolic complications associated with their primary disease process. Not stopping antithrombotic medication or stopping it too late can potentially cause life-threatening bleeding, haematomas and increased transfusion requirements.

Perioperative Management of Antiplatelet and Anticoagulation in Brain Tumor Surgery: A Survey of International Practices

Perioperative management of antithrombotic therapy is a necessary preprocedural consideration for patients prescribed direct oral anticoagulants (DOACs), vitamin K antagonists, or antiplatelet medications. There is a lack of evidence-based guidelines to help inform decision-making in managing antiplatelet and anticoagulation medications in the perioperative period around brain tumor resection. The objective of this study was to provide an example of the heterogeneity in practice and raise awareness for the need to create standardized guidelines for managing these medications. A survey was sent to a list of over 800 international neurosurgeons who are members of the Neurosurgery Research Listserv. The survey comprised 70 questions assessing individual practices for managing thromboprophylaxis, antiplatelet medications, and anticoagulation in the perioperative period. The survey was sent via e-mail invitation between March 2021 and June2021. A total of 72 surgeons responded to the survey. There was no difference in medication management preoperatively or postoperatively when comparing intra- and extra-axial tumor resections. Cessation of antiplatelet medications varied between 3 and 11 days while restart varied between 1 and 14 days. Preoperative management of vitamin K antagonists varied between indication for use (P < 0.001) while DOAC management did not. In our group of respondents, 90% started heparin products within 5 days of surgery, while the same fraction restarted DOAC within 14 days. Respondents demonstrated significant heterogeneity in their perioperative management of antiplatelet and anticoagulation medication in brain tumor resection. This may lead to an unacceptable level of heterogeneity in practice that has the potential to cause patient harm due to errors in medication management.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Payer Status and Medication Management-Part Six of the Movement Is Life Special ONJ Series.

This article is the sixth in the Movement is Life series and focuses on insurance coverage and medication management in the perioperative period, 2 tangentially related variables that affect patient outcomes. Our aim is to use current practices and literature to develop recommendations for nurse navigators' execution of preoperative optimization protocols related to payer status and medication management. Discussions with nurse navigators and a literature search were used to gather information and develop recommendations specific to optimizing payer status and medication management. Nurse navigators connected patients to resources and provided education regarding financial concerns and medications, and findings from the literature discussed insurance status among TJA patients. Nurse navigators can contribute to payer status and medication management optimization by providing patient education and resource referrals. In addition, we recommend conducting repeated medication reconciliation and developing awareness of financial resources and perioperative medication management guidelines.

Preoperative management of medications for psychiatric disorders.

Perioperative medication management is a complex topic. Physicians working in the perioperative space are frequently called upon to make decisions regarding continuing or stopping certain medications. For patients with psychiatric disorders, the overwhelming recommendation is to continue therapy with heightened awareness of anesthesiologists regarding potential side effects or medication interactions.

The pharmacist's role in optimizing medication management before, during, and after minimally invasive and bariatric surgery.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Minimally invasive surgery (MIS) with integrated enhanced recovery pathways (ERPs) helps reduce length of stay and improve surgical outcomes. As these procedures have become more prevalent over time, pharmacists are in key positions to manage medications in the perioperative space to help optimize transitions of care and reduce safety events. Here we identify several clinical areas across phases of care for these procedures in which the knowledge and guidance of pharmacists, as members of the interprofessional team, are paramount. Perioperative pharmacy expertise is often required for MIS procedures in the areas of acid suppression, antithrombotic management, blood glucose control, drug formulation, immunosuppressant optimization, pain mitigation, and postoperative nausea and vomiting prevention and treatment. For each MIS procedure, pharmacists should identify and consider diet and anatomical changes as well as patient- and surgery-specific risk factors. Pharmacists can then utilize their knowledge of the pharmacokinetics and pharmacodynamics of individual medications along with evidence-based medicine to recommend selection of appropriate agents. Pharmacist contributions to perioperative medication management for MIS procedures can improve care as surgical patients navigate transitions through the perioperative setting. Pharmacists can further incorporate medication expertise through development and implementation of institutional MIS protocols within the context of ERPs. As such, any pharmacist should feel empowered to aid in the care of surgical patients.

Research on the Application and Effectiveness of the DRG Model on Perioperative Medical Management of Cholecystectomy

Objective: This study aimed to explore the application and effectiveness of the DRG model in the perioperative management of cholecystectomy. By comparing the DRG model with traditional management methods, this study focused on evaluating the potential impact of the DRG model in improving surgical efficiency and reducing complication rates and medical costs. Methods: The random envelope method was used to divide patients scheduled for cholecystectomy from January 2021 to October 2023 into two groups: one group underwent surgery under the DRG model (experimental group), and the other group underwent the traditional management model (control group). Data including basic information, surgery-related data, length of stay, complication records, and medical expenses were collected. Data analysis was carried out using a t-test and chi-square (χ2) test. Results: Results showed that the DRG model shortened the average length of stay, decreased the incidence of complications, reduced medical expenses, and increased patient satisfaction. These results demonstrate the effectiveness of the DRG model in the perioperative management of cholecystectomy, especially in improving surgical efficiency, reducing medical costs, and improving patient satisfaction. Conclusion: The DRG model in the perioperative management of cholecystectomy can significantly improve medical service quality and efficiency and enhance patient satisfaction as compared to traditional treatment methods.

Medication management in general surgical patients made nil by mouth perioperatively: A quality improvement study.

Perioperative medication management in patients who are nil by mouth for surgery or endoscopy is often suboptimal. Inappropriate medication management can prolong postoperative recovery and increase morbidity and mortality. This quality improvement study, carried out in general surgical patients at an 800-bed general hospital, aimed to improve perioperative medication management in accordance with the recommendations of the UK Clinical Pharmacy Association Handbook of Perioperative Medicine. Increasing awareness and educating general surgical team members, including doctors and non-medical prescribers, about perioperative medication management led to a non-significant improvement in medication management. However, a statistically significant improvement was achieved when nursing staff were also included. This study highlights the importance of involving different members of the multidisciplinary team in perioperative medication management.

PERSUADE Survey—PERioperative AnestheSia and Intensive Care Management of Left VentricUlar Assist DevicE Implantation in Europe and the United States

ObjectiveTo comprehensively assess relevant institutional variations in anesthesia and intensive care management during left ventricular assist device (LVAD) implantation. DesignProspective data analysis. SettingOnline survey. ParticipantsLVAD-centers in Europe and the United States. InterventionsAfter investigating initial interest, 91 of 202 European and 93 of 195 US centers received a link to the survey targeting institutional organization and experience, perioperative hemodynamic monitoring, medical management, and post-operative intensive care aspects. Measurements and Main ResultsThe survey was completed by 73 (36.1%) European and 60 (30.8%) US centers. Although most LVAD implantations were performed in university hospitals (>5 years’ experience), significant differences were observed in the composition of the preoperative multidisciplinary team and provision of intraoperative care. No significant differences in monitoring or induction agents were observed. Propofol was more often used for maintenance in Europe (p<0.001). Choice for inotropes changed significantly from preoperatively (more levosimendan in Europe) to intraoperatively (more use of epinephrine in both Europe and US). Use of quantitative methods for defining right ventricular function was reported more often from European compared to US centers (p<0.05). Temporary mechanical circulatory support for treatment of right ventricular failure was more often used in Europe. Nitric oxide appears to play a major role only intraoperatively. There were no significant differences in early postoperative complications reported from European vs. US centers. ConclusionsDespite the perioperative practice of care for patients undergoing LVAD implantation differs in several aspects between Europe and the US, there were no perceived differences in early postoperative complications.

Perioperative medication management for chronic disease in rhinology

Perioperative medication management for chronic disease in rhinology

Patients Who Have Pre-Existing Atrial Fibrillation Require Increased Postoperative Care Following Total Joint Arthroplasty

BackgroundApproximately 9% of total joint arthroplasty (TJA) patients have pre-existing atrial fibrillation (AF). This study examined the effect of pre-existing AF on TJA outcomes. MethodsWe conducted a 1:3 propensity match of 545 TJA patients who have pre-existing AF to TJA patients who do not have AF at a tertiary care center between January 1st, 2012, and January 1st, 2021. Bivariate and multivariate regressions were performed. Changes over time were evaluated. ResultsPatients undergoing total knee arthroplasty (TKA) who have pre-existing AF, experienced more post-operative AFs (P < .001), acute kidney injuries (P = .026), post-operative complications (POC) (P < .001), and 30-day readmissions (P = .036). Patients undergoing total hip arthroplasty (THA) who have pre-existing AF experienced more post-operative AFs (P < .001), pulmonary embolisms (P < .001), increased estimated blood losses (P = .007), more blood transfusions (P = .002), more POCs (P < .001), and longer lengths of stay (LOS) (P < .002). Over time, POC and LOS decreased in both groups, but remained increased in TJA patients who have pre-existing AF. Multivariate analyses of TKA patients showed an increased odds ratio (OR) of any POCs (P < .001), while THA patients had an increased OR of any POCs (P = .01), and LOS (P = .002). ConclusionPatients who have pre-existing AF undergoing TJA have more POCs. TKA patients have more readmissions. THA patients have longer LOS. These findings demonstrate the importance of enhanced peri-operative medical management in patients who have pre-existing AF undergoing TJA.

Influence of perioperative antiplatelet and anticoagulant medication management on bleeding events in dermatosurgery-A prospective observational study.

Perioperative management of antiplatelet and anticoagulant (AP/AC) therapy is a matter of balancing the risks of bleeding and thromboembolic events. Reliable data for dermatosurgery are still lacking, especially for direct oral anticoagulants (DOAC). The aim was to prospectively evaluate the influence of AP/AC-medication on bleeding risk in dermatosurgery with focus on exact intervals between DOAC intake and procedure performed on post-operative bleeding. Patients with or without AP/AC-therapy were included in the study without randomization. Exact times of DOAC-intake, procedure performed and post-operative bleeding were documented. Data collection was prospectively and standardized done by one person. We evaluated 1852 procedures in 675 patients. Post-operative bleeding occurred after 15.93% (n = 295) of all procedures, but only a few of them were severe (1.57%, n = 29). Compared to patients without AP/AC-medication, severe post-operative bleeding occurred significantly more often under dual antiplatelet therapy (11.76%, n = 2; p = 0.0166) and bridging of either vitamin K antagonist (9.09%, n = 2; p = 0.0270) or DOAC (15.38%, n = 2; p = 0.0099). There was no significant difference in the frequency of severe bleeding regarding to the preoperative DOAC-free period. Although AP/AC-therapy is associated with a significant higher rate of post-operative bleeding, no life-threatening bleeding was recorded. Long preoperative pausing or bridging of DOAC does not lead to significantly less severe bleeding events.

Updated American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty 2022

The article presents updated guidelines developed by the American College of Rheumatology and the American Association of Hip and Knee Surgeons on the perioperative treatment of patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, juvenile idiopathic arthritis and systemic lupus erythematosus undergoing elective total hip or total knee arthroplasty. The perioperative use of anti-rheumatic drug therapy, including traditional disease-modi fying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs and glucocorticoids. All recommendations are conditional and based on the results of retrospective clinical studies, which should be taken into account in decisionmaking when choosing perioperative antirheumatic therapy.

Outcomes Following Total Hip Arthroplasty in Patients Who Have Charcot Neuroarthropathy of the Hip

BackgroundHistorically, Charcot neuroarthropathy hip (CNH) was deemed a contraindication for total hip arthroplasty (THA). However, as implant design and surgical techniques advance, THA for CNH has been performed and documented in literature. Information regarding the outcomes of THA for CNH is limited. The objective of the study was to assess outcomes following THA in patients who have CNH. MethodsPatients who have CNH underwent primary THA and had at least 2 years of follow-up were identified in a national insurance database. For comparison, a 1:10 matched control cohort of patients who did not have CNH was created based on age, sex, and relevant comorbidities. Eight hundred and ninety-five CNH patients who underwent primary THA were compared to 8,785 controls. Medical outcomes, emergency department visits, hospital readmissions, and surgical outcomes including revisions between cohorts were evaluated using multivariate logistic regressions. ResultsThe CNH patients were found to have higher risks of 90-day wound complications (P = .014), periprosthetic joint infection (P = .013) (P = .021), dislocation (P < .001) (P < .001), aseptic loosening (P = .040) (P = .002), periprosthetic fracture (P = .003) (P < .001), and revision (P < .001) (P < .001) at 1-year and 2-year follow-up, respectively. ConclusionWhile patients who have CNH are at a higher risk of wound and implant-related complications, they are comparatively lower than previously reported in literature. Orthopaedic surgeons should be cognizant of the increased risk in this population to provide appropriate preoperative counseling and enhanced perioperative medical management.

Sex Disparities in Infra-inguinal Vein Bypass for Peripheral Artery Disease

Although studies demonstrate sex-based differences in peripheral arterial disease (PAD), contemporary outcomes in surgically managed PAD remains largely under-characterized. We sought to discern the differences in perioperative outcomes between males and females with PAD who received infra-inguinal vein bypasses. The infra-inguinal bypass Vascular Quality Initiative (VQI) registry was queried between 2010 and 2020. We evaluated patients with infra-inguinal vein bypasses for occlusive disease, excluding non-occlusive disease, asymptomatic, acute limb ischemia, and emergent procedures. Baseline demographics, comorbidities, prior medical and surgical management, and perioperative outcomes were compared between men and women using the χ2 analysis and t test. Socioeconomic status was defined using Distressed Community Index (DCI). Bypass patency at 1 year was compared between single-segment vein bypasses of the same inflow and outflow targets, using Kaplan-Meier analysis. We identified 28,845 infra-inguinal vein bypasses; 30.6% of patients were female. Female patients were older and had a higher portion of black race, non-ambulatory status, and disadvantaged socioeconomic DCI (Table I). Males had higher rates of smoking, chronic obstructive pulmonary disease, cardiac disease, and coronary percutaneous/bypass interventions. More women were on more likely to be taking P2Y inhibitors, possibly related to a significantly higher rate of prior lower extremity endovascular interventions (P < .001). Alternatively, males had higher rates of prior ipsilateral bypass. Men presented with less clinical disease severity, with a higher proportion of claudication in men vs rest pain in women. Females had a higher rate of popliteal bypass targets suggestive of proximal disease, whereas more males had tibial bypass targets suggestive distal disease (Table II). Women had a higher utilization of non-reversed GSV compared with men (24.2% vs 22.6%; P < .001). No significant differences were seen in total procedure time, blood loss, or postoperative infection. More males underwent postoperative amputation. Fewer women returned home or were ambulatory on discharge. Males were also more likely to be on aspirin and statin both prior to intervention and on discharge (P < .001). There was no significant differences between men and women in 5-year survival (74.6% vs 74.2%; P = .98) or 1-year primary patency in femoral-above knee popliteal (58.6% vs 58.0%; P = .720), femoral-below knee popliteal (57.2% vs 56.7%; P = .816), femoral-tibial (56.5% vs 57.7%; P = .520), or popliteal-tibial (58.0% vs 55.7%; P = .950) bypass. Females present with a unique demographic, socioeconomic, and PAD disease pattern, with diminished perioperative medical management and advanced clinical disease. Acknowledgment of these differences should guide increasing attention to screening programs, medical optimization, and post intervention disposition planning. Although less women were discharged on optimal medical management, bypass patency was similar to men at 1 year.Table ICategorical variables for patients receiving infra-inguinal vein bypassMaleFemaleP-valueDemographics Age, years66 ± 1067 ± 12<.001 Body mass index, kg/m227.7 ± 5.728.0 ± 6.9.042 Race<.001White82.2%76.7%Black13.8%19.7%Others4.0%3.6% Ambulatory status<.001Ambulatory95.5%93.5%Non-ambulatory4.5%6.5% DCI<.001Prosperous23.1%20.8%Comfortable21.3%20.3%Mid-tier20.7%19.4%At-risk18.3%19.6%Distressed16.7%19.9% Smoking history87.0%76%<.001 Chronic obstructive pulmonary disease24.6%26.3%<.001 Hypertension87.8%89.6%<.001 Diabetes mellitus52.6%49.0%.008 Coronary disease31.2%27.1%<.001 Heart failure17.1%16.9%.018 Peripheral endovascular42.9%47.9%<.001 Peripheral bypass25.3%23.6%.015 Minor amputation10.7%8.6%<.001 Percutaneous coronary22.6%20.1%<.001 Coronary bypass19.1%16.9%<.001 Aspirin74.3%73%.071P2Y inhibitor28.9%32.9%<.001 Statin75.1%71.7%<.001 Claudication26.6%21.0%<.001 Rest pain24.3%28.6% Tissue loss49.2%50.4%DCI, Disadvantaged Community Index. Open table in a new tab Table IIPerioperative outcomes for patients receiving infra-inguinal vein bypassMale, %Female, %P-valueBypass category<.001 Femoral-above knee popliteal13.319.8 Femoral-below knee popliteal31.635.1 Femoral-tibial42.235.3 Popliteal-tibial12.89.8Perioperative antibiotics82.779.7<.001SSI3.03.9<.002Postoperative amputation12.111.9<.001Discharge medications Aspirin86.684.7<.001 P2Y inhibitor41.645.1<.001 Statin83.979.2<.001Discharge status<.001 Home72.364.6 Rehab16.019.8 Nursing home10.914.5 Other0.81.1Discharge graft patency.002 Primary95.093.5 Primary-assisted2.53.1 Secondary1.72.2 Occluded0.81.2SSI, Surgical site infection. Open table in a new tab

Management of Patients undergoing Elective Craniotomy under Antiplatelet or Anticoagulation Therapy: An International Survey of Practice.

The literature concerning the management of antiplatelet (AP) and anticoagulation (AC) medication in the perioperative phase of craniotomy remains scarce. The aim of this international survey was to investigate the current practice among neurosurgeons regarding their perioperative management of AP and AC medication. We distributed an online survey to neurosurgeons worldwide with questions concerning their perioperative practice with AP and AC medication in patients undergoing craniotomy. Descriptive statistics were performed. A total of 130 replies were registered. The majority of responders practice neurosurgery in Europe (79%) or high-income countries (79%). Responders reported in 58.9 and 48.8% to have institutional guidelines for the perioperative management of AP and AC medication. Preoperative interruption time was reported heterogeneously for the different types of AP and AC medication with 40.4% of responders interrupting aspirin (ASA) for 4 to 6 days and 45.7% interrupting clopidogrel for 6 to 8 days. Around half of the responders considered ASA safe to be continued or resumed within 3 days for bypass (55%) or vascular (49%) surgery, but only few for skull base or other tumor craniotomies in general (14 and 26%, respectively). Three quarters of the responders (74%) did not consider AC safe to be continued or resumed early (within 3 days) for any kind of craniotomy. ASA was considered to have the lowest risk of bleeding. Nearly all responders (93%) agreed that more evidence is needed concerning AP and AC management in neurosurgery. Worldwide, the perioperative management of AP and AC medication is very heterogeneous among neurosurgeons.

Hemodynamic instability predicts in-hospital and 1-year mortality after transcarotid artery revascularization and transfemoral carotid stenting

ObjectiveBlood pressure fluctuations are a common hemodynamic alteration following carotid artery stenting either with transfemoral (TFCAS) or transcarotid (TCAR) approach and are thought to be related to alteration in baroreceptor function due to angioplasty and stent expansion. These fluctuations are particularly worrisome in the high-risk patient population referred for CAS. This study aims to evaluate the outcomes of patients who required the administration of intravenous blood pressure medication (IVBPmed) for hypotension or hypertension after CAS. MethodsAll patients undergoing carotid revascularization in the Vascular Quality Initiative (VQI) database between 2016 and 2021 were included. We compared outcomes of patients who required postoperative IVBPmed to treat hyper- or hypotension with normotensive patients. In-hospital outcomes were compared using multivariable logistic regression. One-year outcomes were assessed using Kaplan-Meier survival and multivariable Cox proportional hazard regression analyses. ResultsWe identified 38,510 patients undergoing CAS (57.7% TCAR and 42.3% TFCAS), of which, 30% received IVBPmed for treatment of either postoperative hypertension (12.6%) or hypotension (16.4%). In multivariable analysis, postoperative hypotension was associated with a higher risk of stroke, death, or myocardial infarction (MI) (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.6-3.6; P < .001), stroke or death (OR, 2.9; 95% CI, 2.4-3.5; P < .001), stroke (OR, 2.6; 95% CI, 2.1-3.2; P < .001), death (OR, 3.5; 95% CI, 2.6-4.8; P < .001), MI (OR, 4.7; 95% CI, 3.3-6.7; P < .001), and bleeding (OR, 1.96; 95% CI, 1.4-2.7; P < .001) compared with normotensive patients. Postoperative hypertension was associated with a higher risk of stroke, death, or MI (OR, 3.6; 95% CI, 3-4.4; P < .001), stroke or death (OR, 3.3; 95% CI, 2.7-4.1; P < .001), stroke (OR, 3.7; 95% CI, 3-4.7; P < .001), death (OR, 2.7; 95% CI, 1.9-3.9; P < .001), MI (OR, 5.7; 95% CI, 3.9-8.3; P < .001), and bleeding (OR, 1.9; 95% CI, 1.4-2.7; P < .001) compared with normotensive patients. ConclusionsPostoperative hypertension or hypotension requiring IVBPmed after CAS is associated with an increased risk of in-hospital stroke, death, MI, and bleeding. Postoperative hypertension is associated with worse survival at 1 year. This study indicates that the need for IVBPmed after CAS is not benign; therefore, these patients necessitate aggressive perioperative medical management and safe techniques to avoid hypo and hypertension. Close follow-up and continue medical management are needed to maximize these patients’ survival.

Clinical characteristics of flares in patients with rheumatoid arthritis after total hip and total knee arthroplasty.

Clinical characteristics of flares in patients with rheumatoid arthritis after total hip and total knee arthroplasty.

Anesthetic Management of a Child with Adrenocortical Virilizing Tumour Excision

Introduction: A multidisciplinary team that includes an endocrinologist, radiologist, anesthesiologist, and surgeon is a prerequisite for adrenal gland surgeries. The prime indications for adrenal gland surgery can include both hormonal and non-hormonal secreting tumors. Adrenal hormone-secreting tumors usually present to the anesthesiologist with a unique set of challenges that require a good preoperative evaluation and hemodynamic control, corrections of all electrolytes and metabolic imbalances, a carefully planned anesthetic strategy, detailed knowledge about the specific diseases, maintaining of postoperative adrenal function, and finally a good collaboration with other involved colleagues. This review will mainly focus on endocrine issues and anesthetic management during the resection of a hormone-secreting adrenal gland tumor. Case Presentation: This is a case report of a 1.5-year-old boy weighing 13.5 kg who was admitted to our hospital with complaints of an increase in height and weight more than appropriate for age, macroglossia, facial oedema, abnormally enlarged genitals and development of pubic hair for 6 months. On examination along with signs of precocious puberty, he had presented raised blood pressure for which he was started on medication. Results: On ultrasonography, a 6*4 cm mass was seen in the right supra renal fossa which was confirmed on the CECT scan. He underwent surgery for the excision of the tumor mass under general anesthesia with a regional blockade (epidural). The histopathological report of the tumor specimen revealed Adrenocortical Carcinoma. The child required post-operative steroid treatment and subsequently was started on chemotherapy as well. Conclusion: The perioperative medical management of active Adreno Cortical Carcinomas is complex enough, but anesthesia causes even more substantial changes in physiology. Treatment with steroids helps to maintain hemodynamics to a great extent.

Perioperative Drug Treatment in Pancreatic Surgery—A Systematic Review and Meta-Analysis

Pancreatic resections for malignant or benign diseases are associated with major morbidity and changes in physiology. To reduce perioperative complications and enhance recovery, many types of perioperative medical management have been introduced. The aim of this study was to provide an evidence-based overview on the best perioperative drug treatment. The electronic bibliographic databases Medline, Embase, CENTRAL, and Web of Science were systematically searched for randomized controlled trials (RCT) evaluating perioperative drug treatments in pancreatic surgery. The investigated drugs were somatostatin analogues, steroids, pancreatic enzyme replacement therapy (PERT), prokinetic therapy, antidiabetic drugs, and proton pump inhibitors (PPI). Targeted outcomes in each drug category were meta-analyzed. A total of 49 RCT were included. The analysis of somatostatin analogues showed a significantly lower incidence of postoperative pancreatic fistula (POPF) in the somatostatin group compared to the control group (OR 0.58, 95% CI: 0.45 to 0.74). The comparison of glucocorticoids versus placebo showed significantly less POPF in the glucocorticoid group (OR 0.22, 95% CI: 0.07 to 0.77). There was no significant difference in DGE when erythromycin was compared to placebo (OR 0.33, 95% CI: 0.08 to 1.30). The other investigated drug regimens could only be analyzed qualitatively. This systematic review provides a comprehensive overview on perioperative drug treatment in pancreatic surgery. Some often-prescribed perioperative drug treatments lack high quality evidence and further research is needed.