Physical Status Classification Research Articles

Risk factors for the delayed discharge from anesthesia intensive care unit: a single-center retrospective study

BackgroundA single-center retrospective study was designed to investigate the risk factors associated with delayed discharge from the Anesthesia Intensive Care Unit (AICU).MethodsThis retrospective study involved patients admitted in the AICU from January 2017 to December 2022. Risk factors for the delayed discharge from the AICU were analyzed by the binary multivariate logistic regression analysis. Nomogram was constructed to predict the risk of delayed discharge from AICU. The performance of the nomogram was assessed using the receiver operating characteristic curve and calibration curve. A decision curve analysis was also performed to determine the net benefit threshold of prediction.ResultsA total of 14,338 patients admitted in the AICU were retrospectively recruited, involving 9,271 males and 5,067 females. The incidence of delayed discharge from the AICU in the cohort was 1.54% (221/14,338). Binary multivariate logistic regression analysis showed that younger than 18 years or older than 64 years, the American Society of Anesthesiologists physical status of class III-IV, body mass index of less than 18 kg/m2 or greater than 25 kg/m2, preoperative complications, emergency surgeries and intraoperative massive hemorrhage were risk factors for the delayed discharge from an AICU. We utilized nomograms to visually express data analysis results. Based on receiver operating characteristic analysis, calibration plots, and decision curve analysis, we concluded that the nomogram model exhibited excellent performance. Patients undergoing spine surgeries suffered from the highest proportion of delayed discharge from the AICU, followed by those receiving orthopedic and vascular surgeries. Postoperative hemorrhage was the major cause of delayed discharge from an AICU, followed by septic shock, hypoperfusion and pulmonary insufficiency.ConclusionThe incidence of delayed discharge from the AICU in a single-center tertiary hospital is 1.54%. It is influenced by various risk factors, including age, ASA physical status classification, BMI, preoperative complications, type of surgery and intraoperative blood loss. The nomogram model exhibits excellent performance.Trial registrationThe single-center retrospective study was approved by the Ethics Committee of Nanjing Drum Tower Hospital (No. 2021-563-01, Data: 22 November 2021) and registered on the Chinese Clinical Trial Registry (No. ChiCTR2300078251, Data: 01 December 2023).

Strabismus Surgery in Patients Aged Over 80 Years: Indications, Safety, and Outcomes.

Strabismus in the elderly can cause functional and psychological difficulties, particularly due to the impact of diplopia. Surgical intervention may alleviate diplopia and diminish psychosocial impact. However, the complexity of strabismus types, along with related ocular conditions and general health issues, pose unique challenges. This study explores the indications, safety, and outcomes of strabismus surgery in patients aged 80 years or more. Retrospective clinical cohort study. We reviewed patients aged 80 years and older who underwent strabismus surgery at Stein Eye Institute, University of California, Los Angeles, between 2014 and 2024. The study included 165 patients with a mean age of 83 ± 3 (standard deviation, range 80-94) years, of whom 52% were female. Diplopia was the primary complaint in 94% of patients, with 5 ± 9 years mean symptom duration. The most prevalent diagnosis was sagging eye syndrome, which accounted for 46% of cases. The most common pre-operative deviation was combined esotropia and hypertropia (30%). Surgery was performed in 48 patients under general anesthesia and 116 under topical anesthesia. The mean American Society of Anesthesiologists physical status classification score was 2.6 ± 0.5 (range 1-4). No complications occurred during anesthesia or surgery. Diplopia resolved in 124 patients (75%) after the initial surgery, increasing to 145 patients (87%) after one or two additional surgeries. Reoperation was required in 13% of patients overall. Strabismus surgery in patients over 80 years resolves diplopia and improves binocular alignment and stereopsis, without significant complications.

Machine Learning Modeling for American Society of Anesthesiologists Physical Status Classification Assignment in Children.

Machine Learning Modeling for American Society of Anesthesiologists Physical Status Classification Assignment in Children.

Surgical stabilisation of rib fractures in non-ventilated patients: a retrospective propensity-matched analysis using the data from the trauma registry of the German Trauma Society (TraumaRegister DGUⓇ)

PurposeSevere thorax trauma including multiple rib fractures and flail chest deformity are leading causes of death in trauma patients. Increasing evidence supports the use of surgical stabilisation of rib fractures (SSRF) in these patients. However, there is currently a paucity of evidence for its use in non-ventilator-dependent patients.MethodsA retrospective propensity-matched analysis of the data of the TraumaRegister DGU® for non-ventilator-dependent patients with severe rib injury (abbreviated injury score ≥ 3) was performed. Subgroup analyses with respect to injury severity score, American society of anaesthesiologists physical status classification and age were performed. Furthermore, the effect of time to surgery was analysed.RegistrationTR-DGU project ID 2023-007; ClinicalTrials.gov protocol ID: NCT06464289.ResultsSSRF led to reduced mortality compared to conservative treatment (1.6% vs. 4.8%; p = 0.002) and in comparison to the mortality prognosis of the revised injury severity classification II (RISC II) of 5.2%. Interestingly, SSRF was associated with increased length of hospital and intensive care unit stay, higher rates of organ failure and secondary intubation. The patients with organ failure received SSRF later than those without organ failure.ConclusionHere we report on the largest currently published dataset of non-intubated patients receiving SSRF, which showed reduced mortality in the SSRF cohort. The data indicates that SSRF is a viable treatment option for non-intubated patients. The observed late surgical time points, which may be due to cross over after failed conservative treatment, might be the cause for the observed increased rate of organ failure.

Blunt Traumatic Aortic Injury Treated with Endovascular Aortic Repair: Does Age Influence the Outcome?

Background: Blunt traumatic aortic injury (BTAI) is the second most common cause of death following blunt trauma, and it can affect people of all ages. The aim of this study was to evaluate age-related differences in outcomes among patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI. Methods: All patients treated with TEVAR for BTAI at a tertiary care center in Europe between 2005 and 2023 were included in this study. All clinical and imaging data were collected and analyzed retrospectively. Results: A total of 70 patients with a median age of 43 years were included, and 89% were male. Older patients had significantly higher American Society of Anesthesiologists (ASA) physical status classification scores (p < 0.001) compared to younger patients. All age groups (<18, 18–40, 41–65, and >65) exhibited low to borderline low initial hemoglobin levels with a further decline over time (p = 0.063, p < 0.001, p < 0.001, and p = 0.018, respectively). Age groups were comparable regarding injury mechanism, Injury Severity Score (ISS), concomitant injuries and postoperative complications. The age-independent ISS showed a moderate to strong correlation to the length of intensive care unit stay (r = 0.594, p < 0.001). Total in-hospital mortality was 6% and none was from aortic-related complications. There was a generally high rate of loss of follow-up (59%). Conclusions: Although older patients presented worse ASA scores in comparison to younger patients, no significant differences regarding postoperative morbidity/mortality were noted. These findings imply that patient age and preinjury physical status might not substantially influence outcomes when treating BTAI with TEVAR.

Association of the Revised Cardiac Risk Index with 1-year postoperative mortality: A single-center retrospective study.

To explore risk factors for 1-year postoperative mortality and to identify its association with the Revised Cardiac Risk Index (RCRI). This was a retrospective cohort study involving 54,933 patients aged 18years and above who were surgically treated under general or regional anesthesia in a tertiary hospital in Singapore. Independent risk factors for 1-year postoperative mortality were identified by univariate Cox regression analysis. The association between the RCRI and 1-year postoperative mortality was assessed by the Kaplan-Meier estimator and multivariate Cox regression analysis and was further validated in subgroup analyses stratified by the sex, age, and type of anesthesia. A total of 54,933 eligible patients were enrolled in this study that included 23,922 patients classified as RCRI Class I, 25,979 as Class II, 3700 as Class III, and 1332 as Class IV. Cox regression analysis demonstrated that male sex, age, higher American Society of Anesthesiologists (ASA) physical status classification level, regional anesthesia, emergency surgery, degree of anemia, and increased RCRI were significantly associated with the increased risk of 1-year postoperative mortality (HR>1, all P<0.001). The significant association between RCRI and 1-year postoperative mortality still existed after adjusting for confounding factors. An RCRI Class IV was associated with a mortality risk greater than two-fold larger than that observed at an RCRI Class I (adjusted HR 2.14, 95% CI 1.78 to 2.56, p<0.001). Subgroup analyses revealed that the 1-year postoperative mortality was significantly higher in patients with RCRI Class IV than that of Classes I-III regardless of the sex, age, and type of anesthesia. RCRI is significantly correlated with 1-year postoperative mortality regardless of sex, age, and type of anesthesia. Further studies to validate these findings are warranted.

Predictive Factors for 24-h Survival After Perioperative Cardiopulmonary Resuscitation: Single-Center Retrospective Cohort Study.

Background: Perioperative cardiac arrest (POCA) remains a major challenge in surgical settings, with low survival after cardiopulmonary resuscitation (CPR). This study aims to identify predictive factors for 24 h survival after CPR and cause of POCA. Method: A retrospective, single-center study was conducted on patients aged ≥18 years who experienced POCA and received CPR in the operating room or within 2 h postoperatively at Chiang Mai University Hospital from 2010 to 2019. The multivariable analysis of independent survival predictors was performed using risk regression models. Results: There were 288 cases of cardiopulmonary arrest requiring CPR, with 61 patients surviving. Significant predictors of survival after perioperative CPR included the American Society of Anesthesiologists physical status classification (ASA) 1-2 (RR 2.53; 95%CI 1.69-3.77; p < 0.001), preoperative hemoglobin ≥ 8 g/dL (RR 2.27; 95%CI 1.05-4.89; p = 0.036), preoperative oxygen saturation ≥ 90% (spontaneous breathing in room air) (RR 3.19; 95%CI 1.21-8.41; p = 0.019), initial end-tidal carbon dioxide between 35 and 45 mmHg (RR 1.55; 95%CI 0.98-2.44; p = 0.059), and duration of CPR ≤ 30 min (RR 3.68; 95%CI 1.51-8.98; p = 0.004). The major cause of POCA was hypovolemia (74.30%). Conclusions: This study identifies several critical predictors for 24 h survival following POCA, which can inform pre-operative optimization and perioperative management. Timely interventions, such as blood transfusions and volume resuscitation, are crucial in improving survival outcomes, particularly in trauma and high-risk patients. Further multi-center studies are needed to validate these findings and explore long-term outcomes to refine perioperative cardiac arrest management.

Procedural Sedation in the Emergency Department – An Observational Study: Does Nil Per Os Status Matter?

Introduction: Procedural sedation (PS) is commonly performed in the emergency department (ED). Nil per os (nothing by mouth) (NPO) guidelines extrapolated from standards for patients undergoing elective procedures in the operating room have been applied to ED PS patients. There has been no large study of ED PS patients comparing differences in adverse events and PS success rates based on NPO status. Methods: From a cohort of consecutive ED PS patients of all ages in the 20 EDs of one hospital system—one quaternary ED, four tertiary EDs, six community hospital EDs, one rural ED, two pediatric EDs, and six freestanding EDs in two states in the Midwest and South—we conducted a retrospective analysis on a prospective database over 183 months from April 2000–June 2015. Primary outcome was the incidence of side effects and complications, which comprised the adverse effects. The side effects were nausea, vomiting, itching/rash, emergence reaction, myoclonus, paradoxical reaction, cough, and hiccups. Complications were oxygen desaturation &amp;lt;90%, respiratory depression (respiratory rate &amp;lt;8), apnea, tachypnea, hypotension, hypertension, bradycardia, and tachycardia. Normal vital signs were age dependent. Secondary outcome was successful sedation defined as completion of the procedure. We examined the association between adverse events and successful sedation with NPO status. Results: Of 3,274 visits, exact NPO status was known in 2,643 visits. Comparison of NPO &amp;lt;8 hours in 1,388 patients vs ≥ 8 hours in 1,255 patients revealed side effects 5.5% vs 4.5% (P = 0.28); complications 11.9% vs 17.7% (P &amp;lt; 0.001); adverse events 16.3% vs 21.5% (P &amp;lt; 0.001), interventions 4.1% vs 4.4% (P = 0.73), and procedural completions 94.3% vs 89.7% (P &amp;lt; 0.001). After adjustment for age, sex, transfer status, American Society of Anesthesiology physical status classification, race, primary sedative, multiple sedatives, sedative plus analgesic, and primary analgesic, we found no association betweenNPOstatus and side effects (P = 0.68), complications (P = 0.48), or adverse effects (P = 0.26); however, procedural completion rate remained significantly higher for NPO &amp;lt; 8 hours (P = 0.007). Conclusion: A nil per os status ≥8 hours may have similar or worse outcomes than NPO &amp;lt;8 hours, which is contrary to many suggested guidelines. Strict adherence to NPO guidelines in ED procedural sedation patients may not be necessary.

Risk factors for prolonged surgical duration of tracheobronchial foreign body removal in children: a single-center retrospective study.

This study aims to analyze the clinical characteristics of children with tracheobronchial foreign body and to investigate the factors influencing the surgical duration of rigid bronchoscopic foreign body removal under general anesthesia. We retrospectively identified 421 children diagnosed with tracheobronchial foreign body undergoing rigid bronchoscopy between January 2020 and December 2021. A comprehensive analysis was conducted on patient demographics, including age, weight, gender, American Society of Anesthesiologists (ASA) physical status classification, foreign body type and location, duration of foreign body retention, preoperative symptoms, signs, imaging findings, tracheobronchial manifestations observed during bronchoscopy, and surgical durations. Statistical analysis utilized both univariate and multivariate linear regression models to assess factors influencing the surgical duration of tracheobronchial foreign body removal in children. The mean age of children with tracheobronchial foreign body was 1.59 years (1.32, 2.04). The male-to-female ratio was 1.8:1, and the ASA physical status classification was predominantly ASA II (96.7%). Organic foreign body accounted for 94.8% of cases, with 91.7% located unilaterally. Univariate and multivariate linear regression analyses revealed that ASA III, pulmonary rales, and the presence of one, two, or three specific tracheobronchial manifestations observed during bronchoscopy-including mucosal hyperemia and edema, purulent exudate, and granulation tissue-were independent risk factors associated with prolonged surgical duration for foreign body removal (P < 0.05). ASA III, pulmonary rales, and various tracheobronchial manifestations observed during bronchoscopy are significant risk factors associated with prolonged surgical duration for foreign body removal in children.

Prediction of In-Hospital Mortality after Emergency Laparotomy Using Glasgow Coma Scale, ASA Physical Status Classification, and P-POSSUM Score.

To determine the importance of the Glasgow Coma scale (GCS), ASA physical status classification system, and P-POSSUM score in predicting mortality among patients undergoing emergency laparotomies. An analytical study. Place and Duration of the Study: Department of General Surgery, Sheikh Khalifa Bin Zayed Al-Nahyan Hospital Muzaffarabad, Pakistan, from October 2020 to January 2022. All emergency laparotomies performed during the above-mentioned period were included consecutively, excluding trauma laparotomies, re-do laparotomies after elective surgery, appendectomies, cholecystectomies, pancreatectomies, organ transplantation surgeries, and laparotomies due to gynaecological or vascular causes such as ruptured abdominal aortic aneurysm. The GCS scores were broken down into mild (14-15), moderate (9-13), and severe (3-8) categories. The ASA scoring was classified into five classes, i.e., Classes I to V. The P-POSSUM scores were assessed for each of the following five groups: (≤10, 11-20, 21-30, 31-40, and ≥41). Out of 50 patients (mean age: 47 ± 19 years), there were 39 (78%) males and 11 (22%) females. The median values for GCS and P-POSSUM scores were 15 and 11.1, respectively. According to the ASA, most patients (21, 42%) fit into Class II. Twelve (24%) patients died, while 38 (76%) survived. The mortality rate increased with an increasing P-POSSUM score, a lowering GCS score, and a higher class of ASA (all p <0.001). The ROC curve analysis showed that P-POSSUM had the best performance at 0.987, followed by ASA (0.951) and GCS (0.411). The ASA Physical Status Classification System and P-POSSUM scoring were significantly predictive of mortality after an emergency laparotomy. ASA Physical Status Classification System, Emergency laparotomy, Glasgow coma scale, Mortality, Outcome, P-POSSUM.

Racial disparities in extended venous thromboembolism prophylaxis after hysterectomy.

Venous thromboembolism (VTE) is a significant preventable cause of postoperative morbidity and mortality after major abdominopelvic surgery that calls for extended VTE prophylaxis (eVTEp). Literature suggests that significant racial disparities may exist in post-operative care. The study sought to examine if racial disparities exist in the administration of eVTEp after hysterectomy in a statewide collaborative. We conducted a retrospective cohort study of post-hysterectomy patients across 69 hospitals in the Michigan Surgical Quality Collaborative from January 2016 to February 2020. The variable of interest was race (Black/African or White American). The primary outcome was administration or absence of eVTEp. Descriptive statistics and mixed effects logistic regression were performed for risk adjustment with covariates such as age, cancer occurrence, inflammatory bowel disease, American Society of Anesthesiologists physical status classification, perioperative VTE prophylaxis, postoperative VTE prophylaxis, surgical approach, and surgical duration, among other variables. In total, 24,513 patients underwent hysterectomy. Of these patients, 1,107 (4.45%) received eVTEp, 153 (13.24%) of which were Black and 954 (82.53%) of which were White. Mixed effects logistic regression analysis suggested that Black patients were significantly less likely to receive eVTEp than White patients (odds ratio = 0.776; 95% CI: 0.615-0.979; P = 0.039). Additionally, tobacco use, coronary artery disease, bleeding disorder, cancer occurrence, functional status, perioperative VTE prophylaxis, surgical duration, length of stay, and surgical approach were associated with a higher likelihood of receiving eVTEp. eVTEp is recommended for the prevention of post-discharge VTE in select patients after hysterectomy. Regression analysis showed that, compared to their White counterparts, Black females were significantly less likely to receive eVTEp. The underlying reasons for this disparity require further investigation into possible socioeconomic influences and inherent biases.

Exploring Case Acceptance and Referral Needs in Pre-Anesthetic Checkup Clinic: A Tertiary Care Center Based Study

Introduction: The pre-anesthetic checkup clinic is a crucial component of perioperative care, assessing patients scheduled for elective surgery to determine their readiness. The acceptance of cases for surgery hinges on adequate preoperative investigations and the optimization of comorbidities. This study aimed to evaluate the case acceptance rate and identify the reasons for non-acceptance among patients visiting a PAC clinic in a tertiary care center in Nepal. Methods: A prospective observational study was conducted on 357 patients visiting the pre-anesthetic clinic for the first time. Patient demographics, American Society of Anesthesiologists physical status classification, acceptance rates, and reasons for non-acceptance were recorded and analyzed. Results: Of the 357 patients evaluated, 217 (60.8%) were accepted for surgery during their initial visit. The remaining 39.2% were not cleared due to insufficient investigations (20.1%) or the need for referral to subspecialty departments for the optimization of comorbidities (19%). The majority of referrals were related to cardiovascular and endocrine issues. Conclusion: The study reported a 60.8% acceptance rate for first-time preanesthetic clinic visits, with 39.2% of cases requiring further investigations or specialty referrals for comorbidity optimization.

The effect of supplementary parenteral nutrition with different energy intakes on clinical outcomes of patients after gastric cancer surgery

BackgroundTo investigate the effect of postoperative supplementary parenteral nutrition (SPN) containing varying energy intake levels during the early postoperative period on the clinical outcomes of patients diagnosed with gastric cancer.MethodsData from 237 patients, who were diagnosed with gastric cancer between January 2016 and June 2022, were retrospectively analyzed. Patients were divided into 2 groups based on mean daily SPN energy intake: low (L-SPN; < 20 kcal/kg/day); and high (H-SPN; ≥ 20 kcal/kg/day). Data regarding gender, age, body mass index, preoperative Nutrition Risk Screening 2002 (NRS 2002) score, American Society of Anesthesiologists Physical Status classification system, age-adjusted Charlson Comorbidity Index, diabetes, hypertension, chronic lung disease, and the Tumor-Node-Metastasis (TNM [Eighth edition]) classification were collected for propensity score matching (PSM). Postoperative indicators were monitored. A power analysis was performed during the design phase of this study to ensure that statistical power exceeded 80% to reliably detect differences between the 2 groups.ResultsAfter PSM, data from 128 patients were analyzed (H-SPN, n = 64; L-SPN, n = 64). The H-SPN group experienced shorter postoperative hospital stay (8.11 ± 6.00 days vs. 10.38 ± 7.73 days; P = 0.045) and a lower number of infectious complications (36 [56.3%] vs. 60 [93.8%]; P < 0.001), particularly pulmonary infections, compared with the L-SPN group. Additionally, no increase in hospitalization costs or non-infectious complications occurred in the H-SPN group. Subgroup analysis revealed that H-SPN significantly reduced the incidence of infectious complications among those < 65 years of age (hazard ratio [HR] [95% confidence interval (CI) 0.240 0.069–0.829]; P = 0.024), NRS 2002 score ≥ 3 (HR 0.417 [95% CI 0.156–0.823]; P = 0.028), age-adjusted Charlson Complexity Index < 2 (HR 0.106 [95% CI 0.013–0.835]; P = 0.033), and TNM stage III (HR 0.504 [95% CI 0.224–0.921]; P = 0.046).ConclusionsH-SPN effectively reduced postoperative infectious complications and the length of hospital stay, suggesting that early postoperative H-SPN may be an advantageous nutritional support strategy for patients diagnosed with gastric cancer.

Comprehensive assessment of risk factors and development of novel predictive tools for perioperative hidden blood loss in intertrochanteric femoral fractures: a multivariate retrospective analysis

ObjectivesTo identify independent risk factors for perioperative hidden blood loss (HBL) in intertrochanteric femoral fractures (ITFs) and to develop a predictive model.MethodsWe enrolled 231 patients with ITFs who underwent proximal femoral nail antirotation (PFNA) surgery at the Orthopedics Department of Northern Jiangsu People’s Hospital, Jiangsu Province, China, from January 2021 to December 2023. Hidden blood loss was calculated using the OSTEO formula, and independent risk factors were screened using the Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression. A nomogram prediction model was subsequently constructed based on multivariate logistic regression.ResultsThe LASSO regression identified eight key predictive factors: sex, body mass index (BMI), Admission serum calcium (mmol/L), American Society of Anesthesiologists (ASA) physical status classification, fracture type (Evans), hypertension, preoperative blood transfusion, and preoperative hemoglobin (HGB, g/L). The nomogram model demonstrated excellent predictive performance in both the training and validation sets, with area under the curve (AUC) values of 0.947 and 0.902, respectively. Calibration curves and decision curve analyses further confirmed the strong agreement between model predictions and actual observations, as well as the net clinical benefit.ConclusionsThe nomogram model facilitates an intuitive and quantitative assessment of the risk of perioperative hidden blood loss in patients with ITFs, providing robust support for clinical decision-making.

THE EFFECT OF PREOPERATIVE FLUID REGIMEN ON CARDIAC PERFORMANCE IN BARIATRIC SURGERY

Objective: We must strive to minimize the intraoperative and postoperative risks for patients who will undergo surgery. In the treatment of obesity, which is becoming an increasingly pressing issue, bariatric surgery has become a recommended option for suitable patients. This study aimed to minimize potential complications in obese patients by considering the frequency of cardiac problems and using preoperative fluid therapy. Material and Methods: The study included 31 obese patients with a Body Mass Index of 30 or above, aged 18-50, who were in the American Society of Anesthesiologists Physical Status Classifications 1-2 group and were scheduled to undergo laparoscopic sleeve gastrectomy. Patients were randomly divided into two groups. The first group did not receive fluid therapy during the preoperative period. In the second group, intravenous crystalloid fluid was administered at a rate of 10 ml/kg/hour over 3 hours in the preoperative period, based on their ideal weight. Cardiac output, stroke volume variation, and stroke volume index measurements were taken at specific times intraoperatively in patients from both groups. These parameters were compared between the groups. Results: Among the cardiac parameters measured with the FloTrac™ sensor, only the stroke volume variation values measured after extubation showed a difference between the groups. There was no statistically significant difference between the groups for the other values. Conclusion: The cardiac output, stroke volume variation, and stroke volume index values measured at various times during the surgery are similar between patients who received preoperative fluid therapy and those who did not. There is a need for more comprehensive studies that involve different fluid therapy models and more patients in this area.

The First Report on Liver Resection Using the Novel Japanese hinotori™ Surgical Robot System: First Case Series Report of 10 Cases.

Background: In Japan, the hinotori™ surgical robot system (Medicaroid Corporation, Kobe, Japan) was approved for gastrointestinal surgeries in October 2022. This report details our initial experience performing liver resection using the hinotori™ system. Methods: Ten patients, who were assessed as cases that would benefit from the robot-assisted procedure, underwent liver resections using the hinotori™ system at Fujita Health University, Okazaki Medical Center, between August 2023 and October 2024. The backgrounds (patient, tumor, and liver function conditions, along with types of liver resections and previous surgical procedures) and short-term outcomes (operation time, blood loss, postoperative complications, open conversion, length of hospital stay, and mortality) of the cases were evaluated. Results: Eight cases of partial liver resection, one extended left medial sectionectomy, and one left hemi-hepatectomy were performed. Six cases of hepatocellular carcinomas, three cases of liver metastases, and one case of hepatolithiasis were included. There were seven male and three female patients with a median age of 70 years. Three physical status class III and seven class II patients were included. The median body mass index was 24. Five patients had previous upper abdominal surgical histories and five patients had liver cirrhosis. The median operation time was 419.5 min, and the median intraoperative blood loss was 276 mL. An open conversion in one hepatocellular carcinoma case was carried out due to bleeding from collateral vessels in the round ligament. The median length of hospital stay was 7.5 days. A grade IIIa complication (delayed bile leakage) was developed in one case. All patients with tumors underwent R0 resection. There were no cases of mortality. Conclusions: Liver resection using the hinotori™ system was feasibly performed. This study reports the first global use of the hinotori™ system for liver resection.

A quality improvement program to reduce surgical site infections after cardiac surgery: A 10-year cohort study.

To assess trends in surgical site infection (SSI) incidence in cardiosurgery following a quality improvement initiative in infection prevention and control (IP&C). This is a historical cohort study encompassing a 10-year surveillance period (2014-2023) in a cardiosurgical department in a multi-organ transplant center. The study encompassed three periods: a baseline period (Phase_1: January 2014-December 2018); an implementation phase covering quality improvement initiatives targeting various aspects of IP&C including organizational factors, pre-operative, intra-operative, post-operative measures, and post-hospitalization care (Phase_2: January 2019-June 2021); a post-implementation phase (Phase_3: July 2021-September 2023). A general linear mixed model was used to assess differences in SSI rates between distinct phases, adjusted for length of hospitalization, American Society of Anaesthesiologists (ASA) physical status classification, and Diagnostic-Related Groups (DRG) weight. The latter two were used as random effects. Results are reported as odds ratios [OR] with 95% confidence interval [CI]. All cardiac surgery patients were included (n=5851). A total of 208 patients developed SSI (3.5%). SSI incidence for phase_1, phase_2 and phase_3 were 4.5%, 4.1%, and 1.2%, respectively. The mixed model regression analysis indicated that, compared with the reference period (Phase1), SSI risk did not drop during the implementation phase (OR 0.81, 95% CI 0.59-1.13, P<0.001 vs. reference period). A decrease in SSI risk was observed during the post-implementation phase (OR 0.19, 95% CI 0.11-0.32) CONCLUSIONS: A quality improvement initiative encompassing measurements at all levels potentially impacting SSI risk was implemented over a 2.5years period. While no risk reduction was observed during the implementation phase, a significant reduction in SSI risk took place in the post-implementation phase. This study suggests that considerable time may be required to achieve a substantial SSI risk reduction. We assume this may be attributed to the time required to achieve appropriate adherence with IP&C protocols.

Coaching inexperienced clinicians before a high stakes medical procedure: randomized clinical trial

ObjectiveTo assess whether training provided to an inexperienced clinician just before performing a high stakes procedure can improve procedural care quality, measuring the first attempt success rate of trainees performing...

Comparison of Hemodynamic Responses to Ketofol versus Etomidate During Anesthesia Induction in Elderly Patients

Background: Nausea While elderly patients are at an increased risk of perioperative morbidity and mortality; old age alone is not a contraindication for surgery. General factors that should be considered in preoperative risk assessments include age, functional status, cognition, nutritional status, and comorbidities, such as cardiac, pulmonary, renal, and endocrine disorders. Induction of anesthesia is a critical step in surgery, particularly for elderly patients and those with a high physical status. Commonly used drugs for this purpose include etomidate and propofol. Therefore, this study aimed to compare the impact of Ketofol versus etomidate alone on the hemodynamic status of patients who fall under the ASA class II or higher. Methods: The study was a prospective randomized double-blind clinical trial, with a study population of age of ≥65 years, ASA physical status class II or higher, that were randomized into two groups. Ketofol (n=45) and, Etomidate (n=45) groups. Patients followed for clinical outcomes including their hemodynamic status during the induction period. Results: The present study showed that, the examination of hemodynamic parameters up to 10 minute after laryngoscopy showed that none of these parameters were significantly different between the two groups, while immediately after anesthesia induction, heart rate and blood pressure were found to be significantly different. However, there was no significant difference in terms of SPO2 among the two groups in any given interval. Conclusion: The results of the present study revealed that Ketofol resulted in better regulation and stability of blood pressure and heart rate in patients undergoing endotracheal intubation, compared to etomidate alone.

Cardiac output-guided haemodynamic therapy for patients undergoing major gastrointestinal surgery: OPTIMISE II randomised clinical trial

ObjectivesTo evaluate the clinical effectiveness and safety of a perioperative algorithm for cardiac output-guided haemodynamic therapy in patients undergoing major gastrointestinal surgery.DesignMulticentre randomised controlled trial.SettingSurgical services of 55 hospitals worldwide.Participants2498...