Perioperative Risk Stratification Research Articles

The Predictive Value of a Modified Frailty Index on Perioperative Morbidity and Mortality Following Otologic Surgery.

Recently, determinants of frailty have become an increasingly recognized perioperative risk stratification tool. This study examines the predictive value of a 5-factor modified frailty index (mFI-5) on perioperative morbidity and mortality in patients undergoing otologic surgery, with a subgroup analysis based on surgery site. Cross-sectional analysis. National surgical quality improvement program dataset 2005-2019. Current procedural terminology (CPT) codes were used to identify patients undergoing all otologic surgeries. Otologic surgeries as indicated by CPT codes, including external ear, middle ear/mastoid, implants, and inner ear/facial nerve subgroups. Primary outcomes examined in this study included rates of overall complications and life-threatening complications within 30 days after surgery. Overall complications included superficial surgical site infections (SSI), deep incisional SSI, readmission, deep vein thrombosis, life-threatening complications, and mortality. Life-threatening complications included those classified as Clavien-Dindo grade IV: cerebrovascular accident, mechanical ventilation for more than 48 hours, reintubation, pulmonary embolism, acute renal failure, cardiac arrest, and myocardial infarction. A total of 16,859 patients who underwent otologic surgery were identified, resulting in a cohort that was 47.5% male with an average age of 47.6 years (17.1 SD). Multivariable regression analysis of the entire cohort demonstrated a score of 3 or more on the mFI-5 was independently predictive of all postoperative complications (odds ratio (OR): 2.02, P < 0.0001). However, subgroup analysis showed that only "external ear" surgery correlated with mFi-5 (OR 8.03, P = 0.013). Higher frailty scores as measured by the mFI-5 correlate with postoperative morbidity and mortality after otologic surgery, though subgroup analysis reveals an association only with cases performed on the external ear. These findings suggest that for most otologic surgery, the mFI-5 frailty score is not predictive of postoperative complications.

The Association Between Body Mass Index and Death Following Elective Endovascular and Open Repair of Abdominal Aortic Aneurysms in the Vascular Quality Initiative

The effect of body mass index (BMI) on post-operative outcomes after abdominal aortic aneurysm (AAA) repair remains poorly defined. The association between BMI and death following elective endovascular aneurysm repair (EVAR) and open aneurysm repair (OAR) of AAA in a large national quality registry is investigated. All elective AAA repairs within the Society for Vascular Surgery Vascular Quality Initiative (VQI; 2010 to September 2021) were reviewed (EVAR, n= 53 426; OAR, n= 9 479). All analyses were conducted separately for EVAR and OAR patients. The primary end points were 30 day mortality and five year survival rates. Study cohorts were divided into World Health Organisation BMI categories (C1 < 18.5, C2 18.5 ≤ BMI < 25, C3 25 ≤ BMI < 30, C4, 30 ≤ BMI < 35, C5 35 ≤ BMI < 40, C6 ≥ 40). BMI was examined as both a categorical and continuous variable. Logistic and Cox proportional hazards regression were used for risk adjustment. Among EVAR patients, BMI distribution was C1, 1 216 (2%); C2, 14 687 (28%); C3, 20 516 (38%); C4, 11 352 (21%); C5, 3 947 (7%); C6, 1 708 (3%). Class 1, 2, and 6 BMI patients experienced an increased 30 day mortality rate (C1 2.6%; C2 1.3%; C6 1.4% vs. C3 - 5 0.7%; p < .001) and C1 and C2 had correspondingly inferior long term survival (five years: C1 69 ± 3%; C2 79 ± 1% vs. C3 - 6 86 - 88 ± 2%; log rank p < .001). These survival disparities persisted after risk adjustment for multiple confounders. In the OAR cohort, BMI distribution was C1, 280 (3%); C2, 2 862 (30%); C3, 3 587 (38%); C4, 1 940 (21%); C5, 581 (6%); C6, 229 (2%). Crude 30 day mortality rates were increased for both the lowest and highest BMI patients (C1 12%, C6 7% vs. C2 - 5 3 - 4%; p < .001); these differences also persisted in long term survival (five years: C1 71 ± 6%, C6 82 ± 6% vs. C2 - 6 85 - 88 ± 3%; log rank p < .001). In risk adjusted analysis, both low and high BMI OAR patients had an increased 30 day and long term mortality rate. Within the VQI, both the extreme low (< 18.5) and high (≥ 40) BMI groups experienced an increased 30 day mortality rate after both elective EVAR and OAR. By comparison, while the lowest BMI cohort was significantly associated with decreased long term survival after both procedures, the highest BMI group only experienced reduced long term survival after OAR. Based upon this large real world registry analysis of elective AAA repairs, differential metabolic signatures exist within extreme BMI categories, which may inform peri-operative risk stratification and clinical decision making.

Steep ramp test protocol for preoperative risk assessment and short-term high-intensity interval training to evaluate, improve, and monitor cardiorespiratory fitness in surgical oncology.

Steep ramp test protocol for preoperative risk assessment and short-term high-intensity interval training to evaluate, improve, and monitor cardiorespiratory fitness in surgical oncology.

Preoperative optimization: Physical and cognitive pre-habilitation and management of chronic medication.

Surgery is a significant stressor for older patient. Most are at higher risk of complications due to frailty and comorbidities. This article will review the impact of surgery on the older patient, perioperative risk assessment and stratification, prehabilitation, and specific screenings and interventions. Electronic searches of PubMed were conducted to identify relevant literature using the following search terms: prehabilitation, sarcopenia, osteosarcopenia, frailty, perioperative evaluation, and polypharmacy. Using the frailty phenotype allows for the early identification of geriatric syndromes and potential targets for interventions. However, it does not inform on potential cognitive impairment, which must be assessed separately. Prehabilitation, especially using multimodal interventions, aims to increase functional capacity during the preoperative period in anticipation of the upcoming stress of surgery and the metabolic cost of recovery. It comprises aerobic and resistance training, dietary interventions, psychological interventions, and cessation of adverse health behaviors. Addressing polypharmacy is also important during the perioperative period. Several frailty assessment tools exist, and special tests only take minutes to perform such as the gait speed and chair stand test. Early identification by surgeons leads to early referral to prehabilitation, which needs about four to six weeks to improve function. The decision to enroll patients in a prehabilitation program is based on the understanding of the needs to maintain a structured and personalized intervention taking into consideration the patient's health status, the type of surgery, and the state of the disease. Perioperative evaluation and prehabilitation for older adults are evolving fields, which are generating clinical and scientific interest. This article will review relevant topics to help clinicians adapt usual perioperative care to older patients' particular needs.

The problem of preoperative assessment of patients of older age groups

Age-associated processes combined with comorbidity affect the physiological reserves of patients of older age groups, having a negative impact on the surgery and the postoperative period. One of the most important geriatric syndromes, closely related to the treatment outcome in patients over 60, is frailty. The prevalence of frailty increases with age, and that is associated with a worsening of the perioperative prognosis, prolonged hospitalization, and an increase in mortality. The methods widely used for perioperative risk stratification do not take into account the presence and severity of frailty, changes in the functional state and reserve capabilities of the body, which reduces their sensitivity for patients of older age groups. The article considers the generally accepted approaches to risk stratification and identifies further development prospects in this area.

Incidence of unplanned intensive care unit admission following surgery and associated factors in Amhara regional state hospitals

Unplanned postoperative critical care admission poses a potential risk to patients and places unanticipated pressure on clinical services and it has become an important parameter to assess patient safety in perioperative services. This study was aimed to determine the incidence of unplanned intensive care unit admission following surgery and the associated factors. A multi-center cross-sectional study was conducted on postoperative patients admitted to the ICU of three hospitals located in the Amhara region. Data were collected via a structured survey tool and analyzed using SPSS version 23 software with binary logistic regression analysis. The statistical significance to identify patient, anesthetic and surgical related factors in the preoperative, intraoperative, and postoperative period was < 0.05 for multivariable regression with a 95% confidence interval. Predominantly patients were admitted to the ICU in an unplanned manner. ASA status, preoperative hemoglobin (Hgb) level, intraoperative estimated blood loss, and adverse events occurring in the operating room were significantly associated with intensive care unit admission following surgery. Patients who had a low preoperative Hgb value were 35.1 times more likely to be admitted to the intensive care unit in an unplanned manner compared with their counterparts [(Adjust odds ratio (AOR) 35.16; CI 12.82, 96.44)]. Patients with ASA II and III were 19.4 and 16.2 times more likely to be admitted to ICU in an unplanned way compared to patients who had ASA I physical status [(AOR 51.79; CI 8.28, 323.94) (AOR 67.8 CI 14.68, 313.53)]. Unplanned ICU admission after surgery was high in this study, suggesting poor perioperative planning, risk stratification, and optimization of patients.

Perioperative risk stratification of spine trauma patients with ankylosing spinal disorders: a comparison of 3 quantitative indices.

Patients with ankylosing spinal disorders (ASDs), including ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), have been shown to experience significantly increased rates of postoperative complications. Despite this, very few risk stratification tools have been validated for this population. As such, the purpose of this study was to identify predictors of adverse events and mortality in ASD patients undergoing surgery for 3-column fractures. All adult patients with a documented history of AS or DISH who underwent surgery for a traumatic 3-column fracture between 2000 and 2020 were identified. Perioperative variables, including comorbidities, time to diagnosis, and number of fused segments, were collected. Three instruments, including the Charlson Comorbidity Index (CCI), modified frailty index (mFI), and Injury Severity Score (ISS), were computed for each patient. The primary outcomes of interest included 1-year mortality, as well as postoperative complications. A total of 108 patients were included, with a mean ± SD age of 73 ± 11 years. Of these, 41 (38%) experienced at least 1 postoperative complication and 22 (20.4%) died within 12 months after surgery. When the authors controlled for potential known confounders, the CCI score was significantly associated with postoperative adverse events (OR 1.20, 95% CI 1.00-1.42, p = 0.045) and trended toward significance for mortality (OR 1.19, 95% CI 0.97-1.45, p = 0.098). In contrast, mFI score and ISS were not significantly predictive of either outcome. Complications in spine trauma patients with ASD may be driven by comorbidity burden rather than operative or injury-related factors. The CCI may be a valuable tool for the evaluation of this unique population.

Study and validation of an explainable machine learning-based mortality prediction following emergency surgery in the elderly: A prospective observational study

IntroductionThe heterogeneity of procedures and the variety of comorbidities of the patients undergoing surgery in an emergency setting makes perioperative risk stratification, planning, and risk mitigation crucial. In this optic, Machine Learning has the capability of deriving data-driven predictions based on multivariate interactions of thousands of instances. Our aim was to cross-validate and test interpretable models for the prediction of post-operative mortality after any surgery in an emergency setting on elderly patients. MethodsThis study is a secondary analysis derived from the FRAILESEL study, a multi-center (N = 29 emergency care units), nationwide, observational prospective study with data collected between 06-2017 and 06–2018 investigating perioperative outcomes of elderly patients (age≥65 years) undergoing emergency surgery. Demographic and clinical data, medical and surgical history, preoperative risk factors, frailty, biochemical blood examination, vital parameters, and operative details were collected and the primary outcome was set to the 30-day mortality. ResultsOf the 2570 included patients (50.66% males, median age 77 [IQR = 13] years) 238 (9.26%) were in the non-survivors group. The best performing solution (MultiLayer Perceptron) resulted in a test accuracy of 94.9% (sensitivity = 92.0%, specificity = 95.2%). Model explanations showed how non-chronic cardiac-related comorbidities reduced activities of daily living, low consciousness levels, high creatinine and low saturation increase the risk of death following surgery. ConclusionsIn this prospective observational study, a robustly cross-validated model resulted in better predictive performance than existing tools and scores in literature. By using only preoperative features and by deriving patient-specific explanations, the model provides crucial information during shared decision-making processes required for risk mitigation procedures.

Major elective non-cardiac operations in adults with congenital heart disease

ObjectiveTo assess the impact of congenital heart disease (CHD) on resource utilisation and clinical outcomes in patients undergoing major elective non-cardiac operations.BackgroundDue to advances in congenital cardiac management in recent...

Adverse Respiratory Events After Pediatric Endoscopic Airway Surgeries.

Perioperative risk stratification of pediatric patients undergoing airway intervention remains crucial in identifying those at a higher risk of requiring postoperative intensive care unit (ICU) care. Here we determined the likelihood of and possible risk factors for developing perioperative adverse respiratory events (PAREs) requiring ICU care after various pediatric endoscopic airway surgeries (EASs). We conducted a retrospective chart review of pediatric patients who were aged <18 years and underwent EAS between 2015 and 2021. Early postoperative adverse events within 24 h of surgery were recorded and analyzed. Overall, 99 patients who underwent EAS were included. The age at the time of the intervention ranged from 8 months to 18years. Fifty-eight patients, median age was 4.83 years, underwent papilloma debulking with no high likelihood of PARE in this patient subgroup (OR = 0.48; 0.16-1.44). Twenty-five patients, median age was 9.72years, underwent balloon dilation of laryngotracheal stenosis with no increase in the likelihood of PARE in this patient population (OR = 2.02; 0.65-6.28). Early postoperative respiratory events occurred in 16 patients (16.2%). Most of these events (75%) manifested within 4 h after surgery. In a univariate analysis, intervention at the level of the subglottis or 2 or more laryngeal subsites increased the risk of PARE (OR = 6.57; 1.11-12.52 and OR = 3.73; 1.93-22.34, respectively). In a multivariate analysis, only intervention in the subglottic area maintained its effect (OR = 6.84; 1.82-25.65). Respiratory adverse events following pediatric EAS are not uncommon, and the majority are encountered shortly after surgery. Intervention in the subglottic area was an independent predictor of PARE.

Radiological Features for Frailty Assessment in Patients Requiring Emergency Laparotomy.

Introduction: As the number of elderly patients requiring surgical intervention rises, it is believed that frailty syndrome has a greater impact on perioperative course than on chronological age. The aim of this study was to evaluate the efficacy of various imaging features for frailty assessment in patients undergoing emergency laparotomy. Methods: The study included all patients that qualified for emergency surgery with preoperative CT scans between 2016 and 2020 in the Second Department of General Surgery. Multiple trauma patients were excluded from the analysis. The modified frailty index and brief geriatric assessment were used in the analysis. CT images were reviewed for the assessment of osteopenia, sarcopenia, sarcopenic obesity, renal volume and abdominal aorta calcification rate. Results: A total of 261 patients were included in the analysis. Multivariate logistic regression identified every next ASA class (OR: 4.161, 95%CI: 1.672–10.355, p = 0.002), intraoperative adverse events (OR: 12.397, 95%CI: 2.166–70.969, p = 0.005) and osteopenia (OR: 4.213, 95%CI: 1.235–14.367, p = 0.022) as a risk factor for 30-day mortality. Our study showed that every next ASA class (OR: 1.952, 95%Cl: 1.171–3.256, p = 0.010) and every point of the BGA score (OR: 1.496, 95%Cl: 1.110–2.016, p = 0.008) are risk factors for major complications. Conclusions: Osteopenia was the best parameter for perioperative mortality risk stratification in patients undergoing emergency surgical intervention. Sarcopenia (measured as psoas muscle area), sarcopenic obesity, aortic calcifications and mean kidney volume do not predict poor outcomes in those patients. None of the radiological markers appeared to be useful for the prediction of perioperative morbidity.

Comparing the predictive accuracy of frailty instruments applied to preoperative electronic health data for adults undergoing noncardiac surgery

BackgroundPreoperative frailty is associated with increased risk of postoperative mortality and complications. Routine preoperative frailty assessment is underperformed. Automation of preoperative frailty assessment using electronic health data could improve adherence to guideline-based care if an accurate instrument is identified. MethodsWe conducted a retrospective cohort study of adults >65 yr undergoing elective noncardiac surgery between 2012 and 2018. Four frailty instruments were compared: Frailty Index, Hospital Frailty Risk Score, Risk Analysis Index-Administrative, and Adjusted Clinical Groups frailty-defining diagnoses indicator. We compared the predictive performance of each instrument added to a baseline model (age, sex, ASA physical status, and procedural risk) using discrimination, calibration, explained variance, net reclassification, and Brier score (binary outcomes); and explained variance, root mean squared error, and mean absolute prediction error (continuous outcomes). Primary outcome was 30-day mortality. Secondary outcomes included 365-day mortality, length of stay, non-home discharge, days alive at home, and 365-day costs. ResultsFor this study, 171 576 patients met the inclusion criteria; 1370 (0.8%) died within 30 days. Compared with the baseline model predicting 30-day mortality (area under the curve [AUC] 0.85; R2 0.08), the addition of Hospital Frailty Risk Score led to the greatest improvement in discrimination (AUC 0.87), explained variance (R2 0.09), and net reclassification (Net Reclassification Index 0.65). Brier and calibration scores were comparable. ConclusionsAll four frailty instruments significantly improved discrimination and risk reclassification when added to typically assessed preoperative risk factors. Accurate identification of the presence or absence of preoperative frailty using electronic frailty instruments may improve perioperative risk stratification. Future research should evaluate the impact of automated frailty assessment in guiding surgical planning and patient-centred optimisation amongst older surgical patients.

Chronic steroid use and readmission following total shoulder arthroplasty.

BackgroundDegenerative arthritis is a major indication for both anatomic and reverse total shoulder arthroplasty (TSA). Degenerative arthritis is an age-related process that can be secondary to mechanical wear or inflammatory or autoimmune diseases, such as rheumatoid arthritis or systemic lupus erythematosus. Management of these diseases can include chronic corticosteroid for their anti-inflammatory and immunosuppressive effects. Given the well-known complications of chronic steroid use on other surgical procedures, investigation into postoperative complications specific to TSA will assist physicians in risk stratification and preoperative planning. The purpose of this study was to investigate the association between chronic preoperative steroid use and postoperative complications following TSA.MethodsThe American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2020. Patient demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. Multivariate logistic regression was used to identify postoperative complications associated with chronic preoperative steroid use. Reasons and risk factors for readmission among chronic steroid users were subsequently identified, as well.ResultsA total of 26,669 patients were included in this study: 25,376 (95.2%) were included in the nonsteroid cohort and 1293 (4.8%) were included in the chronic steroid cohort. The postoperative complications that were significantly associated with chronic preoperative steroid use were septic shock (P = .007), urinary tract infection (P = .016), myocardial infarction (P = .022), ventilator >48 hours (P = .028), readmission (P < .001), nonhome discharge (P < .001), and mortality (P = .007). The only postoperative complication independently associated with chronic preoperative steroid use was readmission (odds ratio, 1.36; 95% confidence interval, 1.04-1.79; P = .027).ConclusionPreoperative chronic steroid use is an independent predictor for readmission following TSA. As procedural improvement increases surgical volume for TSA, a better understanding of preoperative risk factors can improve perioperative risk stratification and help to minimize adverse outcomes.

Cost-minimisation analysis of polysomnography and pulse oximetry in a risk stratification protocol for paediatric adenotonsillectomy.

Severe obstructive sleep apnoea (OSA) is associated with increased risk of respiratory compromise in the post-operative period following adenotonsillectomy (AT). This study analyses the economic cost of polysomnography or overnight oximetry as part of pre-operative risk stratification in paediatric AT, supplementing previously published research demonstrating the efficacy of this protocol in predicting respiratory complications. This cost-minimisation analysis examines costs associated with pre-operative overnight oximetry and polysomnography in triaging paediatric patients older than 2 years old, with no major comorbidities except for OSA, undergoing AT for OSA (n=1801) to either a secondary or quaternary Australian hospital. Decision analysis modelling via probability trees were utilized to estimate pre- and peri-operative costs. A third hypothetical 'no investigation' model based upon conducting all AT at a secondary hospital was performed. Costs are derived from the financial year 2020-2021, censored at discharge. The total cost per patient of AT including pre-operative investigations of oximetry and polysomnography, and associated inpatient costs, were AUD4181.34 and 5013.99 respectively. This is more expensive compared to a hypothetical no-investigation model (AUD3958.98). Within the scope of this partial economic evaluation, this study finds a small additional cost for a model of care involving overnight oximetry as a pre-operative triage tool, balanced by the reduced cost of care in a lower acuity centre for low-risk patients and potential high cost of complications if all children are treated in a low acuity centre. This supports oximetry in peri-operative risk stratification for paediatric AT from a financial perspective.

Preoperative leukocytosis is an independent risk factor for morbidity and survival after resection of colorectal liver metastases

Although surgical resection of colorectal liver metastases (CRLM) remains to be the only option for long term survival, traditional surgical concepts have been challenged by the introduction of the liver first approach or neoadjuvant chemotherapy in resectable CRLM and interventional therapies. The aim of this study was to identify prognostic factors for postoperative morbidity and survival and to externally evaluate the recently introduced resection severity index (RSI), in order to optimize patient selection and treatment strategies. This is a retrospective single centre analysis of 213 patients undergoing surgery for CRLM in curative intent between January 2010 and December 2018. Median follow up after liver resection was 28.56 (0.01-111.46) months. Severe postoperative complications (Clavien-Dindo ≥ IIIa) were observed in 46 (21.6%) cases. Preoperative leukocytosis (OR: 3.114, CI-95%: 1.089-8.901; p=0.034) and operation time in minutes (OR: 1.007, CI-95%: 1.002-1.011; p=0.002) were determined as independent risk factors. Overall survival (OS) was 46.68 months with a 5-year survival rate of 40.5%. Independent prognostic factors were preoperative leukocytosis (HR: 2.358, CI-95%: 1.170-4.752; p=0.016), major hepatectomy (HR: 1.741, CI-95%: 1.098-2.759; p=0.018) and low grading of the primary intestinal tumour (HR: 0.392, CI-95%: 0.231-0.667; p < 0.001). The RSI (ASAT (U/l) divided by Quick (%) multiplied by the extent of liver resection in points) was identified as independent risk factor for OS only in patients without neoadjuvant chemotherapy. Detection of leukocytosis in patients prior resection of CRLM was associated with increased postoperative morbidity and decreased OS and could therefore prove valuable for perioperative risk stratification.

Perioperative Risk Stratification Model for Readmission after Panniculectomy.

Readmission is an important metric for surgical quality of care. This study aimed to develop a validated risk model that reliably predicts readmission after panniculectomy using the American College of Surgeons National Surgical Quality Improvement Program database. The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients who had undergone panniculectomy from 2005 to 2018. The outcome of interest was 30-day readmission. The cohort was divided randomly into 70 percent development and 30 percent validation groups. Independent predictors of 30-day readmission were identified using multivariable logistic regression on the development group. The predictors were weighted according to beta coefficients to generate an integer-based clinical risk score predictive of readmission, which was validated against the validation group. For the model selection, 22 variables were identified based on criteria of p < 0.05 percent and complete data availability. Variables included in the development model included inpatient surgery, hypertension, obesity, functional dependence, chronic obstructive pulmonary disease, wound class greater than or equal to 3, American Society of Anesthesiologists class greater than 3, and liposuction. Receiver operating characteristic curve analysis of the validation group rendered an area under the curve of 0.710, which demonstrates the accuracy of this prediction model. The predicted incidence within each risk stratum was statistically similar to the observed incidence in the validation group ( p < 0.01), further highlighting the accuracy of the model. The authors present a validated risk stratification model for readmission following panniculectomy. Prospective studies are needed to determine whether the implementation of the authors' clinical risk score optimizes safety and reduces readmission rates. Risk, III.

Radioactive iodine therapy: multiple faces of the same polyhedron.

The incidence of differentiated thyroid carcinoma (DTC) has increased in recent decades with early stage, low risk papillary thyroid cancer (PTC) being detected and diagnosed. As a result, the psychological, financial, and clinical ramifications of overdiagnosis and excessively aggressive therapy are being increasingly recognized with many authorities calling for a re-evaluation of the traditional "one size fits all" management approaches. To address these critical issues, most thyroid cancer guidelines endorse a more risk adapted management strategy where the intensity of therapy and follow up is matched to the anticipated risk of recurrence and death from DTC for each patient. This "less is more" strategy provides for a minimalistic management approach for properly selected patients with low-risk DTC. This has re-kindled the long-standing debate regarding the routine use of radioactive iodine therapy (RIT) in DTC. Although recent guidelines have moved toward a more selective use of RIT, particular in patients with low-intermediate risk DTC, the proper selection of patients, the expected benefit, and the potential risks continue to be a source of ongoing controversy and debate. In this manuscript, we will review the wide range of clinical, imaging, medical team, and patient factors that must be considered when evaluating individual patients for RIT. Through a review of the current literature evaluating the potential benefits and risks of RIT, we will present a risk adapted approach to proper patient selection for RIT which emphasizes peri-operative risk stratification as the primary tool that clinicians should use to guide initial RIT management recommendations.

Artificial intelligence in perioperative medicine: a narrative review.

Recent advancements in artificial intelligence (AI) techniques have enabled the development of accurate prediction models using clinical big data. AI models for perioperative risk stratification, intraoperative event prediction, biosignal analyses, and intensive care medicine have been developed in the field of perioperative medicine. Some of these models have been validated using external datasets and randomized controlled trials. Once these models are implemented in electronic health record systems or software medical devices, they could help anesthesiologists improve clinical outcomes by accurately predicting complications and suggesting optimal treatment strategies in real-time. This review provides an overview of the AI techniques used in perioperative medicine and a summary of the studies that have been published using these techniques. Understanding these techniques will aid in their appropriate application in clinical practice.

Lung Biopsy With a Non-intubated VATS Approach in an Obese Population: Indications and Results.

BackgroundAccording to the international guidelines, patients affected by interstitial lung disease with unusual clinical presentation and radiological findings that are not classic for usual interstitial pneumonia end up meeting criteria for surgical lung biopsy, preferably performed with video-assisted thoracic surgery. The growing appeal of non-intubated thoracic surgery has shown the benefits in several different procedures, but the strict selection criteria of candidates are often considered a limitation to this approach. Although several authors define obesity as a contraindication for non-intubated thoracoscopic surgery, the assessment of obesity as a dominant risk factor represents a topic of debate when minor tubeless procedures such as lung biopsy are considered. Our study aims to investigate the impact of obesity on morbidity and mortality in non-intubated lung biopsy patients with interstitial lung disease, analyzing the efficacy and safeness of this procedure.Materials and MethodsThe study group of 40 obese patients consecutively collected from 202 patients who underwent non-intubated lung biopsy was compared with overweight and normal-weight patients, according to their body mass index. Post-operative complications were identified as the primary endpoint. The other outcomes explored were the early 30-day mortality rate and intraoperative complications, length of surgery, post-operative hospitalization, patient's pain feedback, and diagnostic yield.ResultsThe overall median age of the patients was 67.4 years (60, 73.5). No 30-day mortality or significant differences in terms of post-operative complications (P = 0.93) were noted between the groups. The length of the surgery was moderately longer in the group of obese patients (P = 0.02). The post-operative pain rating scale was comparable among the three groups (P = 0.45), as well as the post-operative length of stay (P = 0.96). The diagnosis was achieved in 99% of patients without significant difference between groups (P = 0.38).ConclusionOur analysis showed the safety and efficacy of surgical lung biopsy with a non-intubated approach in patients affected by lung interstitiopathy. In the context of perioperative risk stratification, obesity would not seem to affect the morbidity compared to normal-weight and overweight patients undergoing this kind of diagnostic surgical procedure.

Perioperative Risk Stratification and Modification.

This article discusses the important topic of perioperative risk stratification and the interventions that can be used in the perioperative period for risk modification. It begins with a brief overview of the commonly used scoring systems, risk-prediction models, and assessments of functional capacity and discusses some of the evidence behind each. It then moves on to examine how perioperative risk can be modified through the use of shared decision making, management of multimorbidity, and prehabilitation programs, before considering what the future of risk stratification and modification may hold.