Preoperative Screening Research Articles

The association of C-reactive protein with major depressive symptoms in nonmetastatic renal cell carcinoma

Abstract Introduction and Objective: Patients with kidney cancer experience higher rates of depression compared with other cancer subtypes. Inflammation has been shown to contribute to depression associated with malignancy. Here, we assess the association between preoperative C-reactive protein (CRP) and major depression, as screened by the eight-item Patient Health Questionnaire (PHQ-8) depression scale, in patients undergoing nephrectomy for nonmetastatic renal cell carcinoma (RCC). Methods: Retrospective review of prospectively administered PHQ-8 surveys in patients who underwent nephrectomy for nonmetastatic RCC was conducted. Patients with available PHQ-8 within 180 days before and after surgery were included. The association of major depressive symptoms on preoperative PHQ-8 and clinical improvement on postoperative survey with patient/tumor characteristics and CRP levels was determined by the generalized chi-square test for categorical variables and analysis of variance for continuous variables. Multivariable logistic regression was used to analyze variables associated with major depression on PHQ-8 and postoperative survey improvement. Results: Two hundred forty-five patients were analyzed. Most were male (66%). Median age and body mass index were 65 and 28.9 kg/m2, respectively. 64.5% of patients were White, and 29.0% were Black. 30.2% had an elevated CRP (≥10 mg/L). 45 (18.4%) patients screened positive for major depressive symptoms on PHQ-8 (≥10 points). Patients with elevated CRP were more likely to have positive preoperative depression screening (odds ratio [OR] 2.66, 95% CI 1.08–6.52, P = .033) but had higher probability of demonstrating meaningful change on PHQ-8 after nephrectomy (OR 3.50, 95% CI 1.04–11.85, P = .044). Conclusion: In nonmetastatic RCC, patients with elevated preoperative CRP had higher scoring for major depressive symptoms on PHQ-8 and were more likely to demonstrate clinical improvement in depressive symptomatology after nephrectomy.

IMPACT OF ACTIVE SURVEILLANCE SCREENING OF MRSA ON SURGICAL SITE INFECTION RATES- A PROSPECTIVE INTERVENTIONAL STUDY

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common cause of surgical site infections. Different methods are employed to reduce nosocomial spread including application of Isolation precautions, admission screening cultures and MRSA decolonization 3,4,5,6,7. Preoperative MRSA screening in patients undergoing cardiac surgeries can reduce the risk of surgical site infections. To evaluate the significance of preoperative MRSA screening on rates of surgical site infections in cardiac surgery patients Material and Methods: This was a prospective interventional study, conducted at the National Institute of Cardiovascular diseases, Karachi from 1st February 2022- 31st July 2022. Preoperative MRSA screening in patients undergoing cardiac surgeries was performed at the Microbiology Laboratory. Patients identified as colonized were isolated and decolonized with chlorhexidine baths prior to surgeries. Surgical site infections (SSIs) rates were recorded by Infection control nurse through active surveillance for the screening period. SSI rates for a prescreening period of 6 months (August 2021- January 2022) was retrieved through electronic medical records for comparison. Results: Total 359 patients were screened from 1st February 2022- 31st July 2022, out of which 20 were colonized with MRSA. None of the patients who screened positive for MRSA developed SSI. 11 SSIs with MRSA were reported from August 2021- January 2022 and 4 SSIs were reported from February 2022-July 2022 (p value < 0.05). Conclusion: It can be concluded that active MRSA screening and subsequent implementation of decolonization policy would decrease the percentage of SSI in cardiac surgery Keywords: MRSA, Screening, Surgical site infection, Surveillance

Analysis of COVID-19 real time polymerase chain reaction test results at preoperative screening before elective surgeries and interventional procedures: A retrospective study

Amaç: Bu retrospektif kohort çalışmada, bir üniversite hastanesinde preoperatif hasta popülasyonunun Coronavirus Disease 2019 (COVID-19) testi pozitifliğinin oranının belirlenmesi ve preoperatif COVID-19 pozitif hasta sayısı ile demografik özelliklerin, operasyona özgü bulguların ve özellikle kan grupları ile ilişkisinin ortaya konması amaçlanmıştır.
 
 Yöntemler: Bu retrospektif kohort tek merkezli çalışma, üniversite hastanesinde gerçekleştirildi. Çalışmaya Haziran 2020 ile Nisan 2021 tarihleri arasında farklı cerrahi branşlarda elektif cerrahi planlanan ve preoperatif COVID-19 taraması yapılan tüm yetişkin hastalar dahil edildi. Hastaların demografik özellikleri, operasyona özgü bulguları ve kan grupları incelendi.
 
 Bulgular: COVID-19 pozitif grubuna ait hastaların yaşı COVID-19 negatif grubuna göre anlamlı olarak daha yüksek idi (50,20±18,3, 47,27±17,28, sırasıyla, p=0,030). COVID-19 pozitif grubuna ait ASA fiziksel durum sınıflamasında skoru yüksek hastalar anlamlı olarak daha fazla idi (p

Development of a machine learning model to predict intraoperative transfusion and guide type and screen ordering

Study objectiveTo develop an algorithm to predict intraoperative Red Blood Cell (RBC) transfusion from preoperative variables contained in the electronic medical record of our institution, with the goal of guiding type and screen ordering. DesignMachine Learning model development on retrospective single-center hospital data. SettingPreoperative period and operating room. PatientsThe study included patients ≥18 years old who underwent surgery during 2019–2022 and excluded those who refused transfusion, underwent emergency surgery, or surgery for organ donation after cardiac or brain death. InterventionPrediction of intraoperative transfusion vs. no intraoperative transfusion. MeasurementsThe outcome variable was intraoperative transfusion of RBCs. Predictive variables were surgery, surgeon, anesthesiologist, age, sex, body mass index, race or ethnicity, preoperative hemoglobin (g/dL), partial thromboplastin time (s), platelet count x 109 per liter, and prothrombin time.We compared the performances of seven machine learning algorithms. After training and optimization on the 2019–2021 dataset, model thresholds were set to the current institutional performance level of sensitivity (93%). To qualify for comparison, models had to maintain clinically relevant sensitivity (>90%) when predicting on 2022 data; overall accuracy was the comparative metric. Main resultsOut of 100,813 cases that met study criteria from 2019 to 2021, intraoperative transfusion occurred in 5488 (5.4%) of cases. The LightGBM model was the highest performing algorithm in external temporal validity experiments, with overall accuracy of (76.1%) [95% confidence interval (CI), 75.6–76.5], while maintaining clinically relevant sensitivity of (91.2%) [95% CI, 89.8–92.5]. If type and screens were ordered based upon the LightGBM model, the predicted type and screen to transfusion ratio would improve from 8.4 to 5.1. ConclusionsMachine learning approaches are feasible in predicting intraoperative transfusion from preoperative variables and may improve preoperative type and screen ordering practices when incorporated into the electronic health record.

Does preoperative screening VCUG affect the outcomes and complications of pyeloplasty in patients with ureteropelvic junction obstruction?

The role of voiding cystourethrogram (VCUG) in evaluating vesicoureteral reflux (VUR) in patients with known ureteropelvic junction obstruction (UPJO) remains unclear. While VCUG is frequently performed, the incidence of concomitant VUR and UPJO is low, and VUR is often low-grade with high rates of spontaneous regression. To analyze the clinical relevance of VCUG in patients with UPJO by determining its incidence and studying the difference in clinical outcomes between patients with known, unknown, and negative VUR. Retrospective review of patients with UPJO who underwent pyeloplasty from 2012 to 2020 with <18 years-old, unilateral UPJO, postoperative follow-up of ≥2 months and had at least 1 renal ultrasound (US) after pyeloplasty. Results were compared among 3 groups: patients who underwent VCUG before pyeloplasty and were found to have VUR (group 1), patients who underwent VCUG before pyeloplasty without VUR (group 2), and patients who did not have a VCUG before pyeloplasty (group 3). A total of 275 patients met the inclusion criteria, of which 21 patients were classified in group 1, 166 patients in group 2, and 88 patients in group 3 (Table). The age at preoperative VCUG was 14.7±32.9 months in group 1 and 15.17±35.8 months in group 2 (p=0.960). Overall, the incidence of concomitant UPJO and VUR was 11.2%. In group 1 the initial VUR grade was 5 in 2 patients, 4 in 3, 3 in 5, 2 in 7, and 1 in 4 patients. Of these, only 1 patient required ureteral reimplantation after pyeloplasty. Post-pyeloplasty, no significant differences were observed in complications (p=0.7436), length of follow up (p=0.3212), SFU grade 4 hydronephrosis (p=0.2247), postoperative UTIs (p=0.1047) and pyeloplasty success rate (p=0.4206) among the 3 groups. Despite the use of antibiotic prophylaxis being significantly different amongst the three groups (p<0.001), it was not associated with a lower incidence of postoperative UTIs (group 1 p=0.068, group 2 p=0.486, group 3 p=1). In patients with reflux, an increase in age was associated with a decrease in the rates of complications (p=0.019). We found no significant difference in the outcomes in patients who had a preoperative VCUG as compared to those who did not. The preoperative diagnosis of VUR by VCUG changed the management in less than 1% of the study population and thus its role in patients with UPJO should be reevaluated.

Comprehensive geriatric assessment to predict adverse events in elderly patients undergoing posterior lumbar fusion surgery.

Although comprehensive geriatric assessment (CGA) has been used widely, its impact on adverse events in elderly patients has not been fully examined. The present study aimed to investigate the relationships between subcomponents of CGA and adverse events (AEs) in elderly patients undergoing posterior lumbar fusion surgery. A total of 242 eligible elderly patients enrolled. Our CGA included activities of daily living, instrumental activities of daily living, nutritional status, cardiac function, pulmonary function, renal function, frailty, cognition, anxiety, depression, delirium, chronic pain score, comorbidity and polypharmacy. Comprehensive complication index was used to summarize postoperative complications and its severity. Logistic regression was performed to determine the relationships between subcomponents of a CGA and postoperative AEs. Present study found that female were more vulnerable to have AEs. Postoperative major AEs were associated with delirium (odds ratio (OR): 4.302, 95% confidence interval (CI) 1.720-10.761, p = 0.002), nutritional status (OR: 3.030, 95%CI 1.218-7.541, p = 0.017), cognitive impairment (OR: 4.122, 95%CI 1.179-14.407, p = 0.027), Charlson comorbidity index (CCI) (OR: 4.800, 95%CI 1.852-12.440, p = 0.001) and severe dependent (OR: 3.772, 95%CI 1.116-9.841, p = 0.007). Further analysis showed that delirium (OR: 2.824, 95%CI 1.068-7.467, p = 0.036) and CCI (OR: 3.221, 95%CI 1.184-8.766, p = 0.022) were independently related to major AEs. These results indicate that preoperative screening preoperative delirium, cognitive, nutrition and CCI are essential to prevent postoperative major AEs of the surgical elderly.

GERD-screening before bariatric surgery: the predictive value of the GERD-HRQL questionnaire score compared with preoperative EGD findings.

There is an ongoing debate on how to best identify patients with gastroesophageal reflux disease (GERD) before bariatric surgery. The value of routine preoperative esophagogastroduodenoscopy (EGD) is questioned, and patient reported symptoms are commonly used for screening. The goal of this study is to determine if patient reported symptoms using a validated questionnaire correlate with preoperative EGD findings. A prospective cohort study at a single institution was performed. Patients undergoing bariatric surgery between December 2020 and March 2023 were required to report symptoms of reflux by completing a preoperative GERD. Health-Related Quality of Life (GERD-HRQL) questionnaire and undergo a mandatory preoperative screening EGD. Patients were stratified into two cohorts: (group A) asymptomatic (score = 0) and (group B) symptomatic (score > 0). Statistical analysis was conducted using Pearson's chi-squared test and Wilcoxon rank-sum test in RStudio version 4.2.2. The predictive value of the GERD-HRQL score was analyzed using Areas Under the Curve (AUC; AUC = 0.5 not predictive, 0.5 < AUC ≥ 6 poor prediction & AUC > 0.9 excellent prediction) calculated from Receiver Operating Characteristic (ROC) curves. 200 patients were included; median age was 42.0years (IQR 36.0 to 49.2). There were 79 patients (39.5%) in Group A and 121 patients (60.5%) in Group B. There was no difference in the frequency esophagitis (27.8% vs 32.2%, p = 0.61) or hiatal hernias (49.4% vs 47.1%, p = 0. 867) between group A and group B, respectively. ROC analysis revealed that the total GERD HRQL scores, heartburn only scores and regurgitation only scores, were poor predictors of esophagitis found on EGD (AUC 0.52, 0.53, 0.52), respectively. In asymptomatic patients, higher BMI was significantly associated with esophagitis (OR 1.15, 95% CI 1.06-1.27, p = 0.002). Symptoms, identified through the GERD-HRQL questionnaire, are a poor indicator of esophagitis or its severity in patients undergoing workup for bariatric surgery. Therefore, liberal screening upper endoscopy is recommended for pre-bariatric surgery patients to guide appropriate procedure selection.

Perioperative management of pancreatic exocrine insufficiency–evidence-based proposal for a paradigm shift in pancreatic surgery

BackgroundDespite exocrine pancreatic insufficiency (EPI) being a significant consequence of pancreatic surgery, there is still no consensus on its perioperative management. This study aimed to evaluate unselective pancreatic enzyme replacement therapy (PERT). MethodsA prospective, observational study of patients undergoing partial pancreatectomy was conducted. EPI status was assessed pre- and postoperatively, based on three fecal-elastase measurements each. Characteristic symptoms were evaluated by questionnaire. In 85 post-surgical patients, the subjective burden of PERT was measured. Results101 patients were followed prospectively. Preoperative EPI screening was available for 83 patients, of which 48% were diagnosed with preexisting EPI. Of those patients with regular exocrine function, 54% developed EPI de novo; this rate being higher following pancreatic head resections (72%) compared to left-sided pancreatectomies (LP) (20%) (p = 0.016). Overall postoperative EPI prevalence was significantly greater following pancreatic head resections (86%) than LP (33%) (p < 0.001). Only young and female patients described a significant burden related to PERT. ConclusionFor all patients undergoing pancreatic head resection PERT should be considered beginning prior to surgery, due to the subgroup's high EPI rate and the comparatively low burden of PERT. Patients with LP are at lower risk and should be pre- and postoperatively screened and supplemented accordingly.

Simultaneous occurrence of type 3b esophageal atresia and hypertrophic pyloric stenosis: A rare coexistence

Background: Hypertrophic pyloric stenosis (HPS) and Esophageal Atresia (EA) are two distinct congenital malformations that rarely occur simultaneously. However, there have been reported cases of the simultaneous occurrence of HPS and EA, suggesting a potential relationship between these two conditions. The clinical features of the simultaneous occurrence of HPS and EA can be modified and the diagnosis may be delayed. Case presentation: We present a rare case of a newborn with simultaneous Type 3b esophageal atresia and hypertrophic pyloric stenosis. Following surgical correction of esophageal atresia, the patient exhibited symptoms of projectile vomiting, which were subsequently confirmed through ultrasound examination to be associated with hypertrophic pyloric stenosis. The patient was successfully managed through surgical intervention, and the outcomes were favorable. Conclusion: This case report aims to highlight the significance of preoperative screening for hypertrophic pyloric stenosis in patients diagnosed with esophageal atresia, based on current literature.

Cognitive Deficits in Executive and Language Functions Predict Postoperative Delirium

Postoperative delirium (POD) remains the most common complication in older adults, with cognitive impairment being the main risk factor. Patients with mild cognitive impairment, in particular, have much to lose from delirium; despite this, their cognitive impairment might be clinically overlooked. Understanding which cognitive domains are particularly predictive in this regard may improve the sensitivity of preoperative testing and allow for a more targeted application of resource-intensive measures to prevent delirium in the perioperative period. The authors conducted this study with the aim of identifying the most indicative cognitive domains. A secondary analysis of a randomized controlled trial. At a single center, the University Medical Centre Hamburg in Hamburg, Germany. Patients ≥60 years without major neurocognitive disorders (dementia, Mini-Mental State Examination score ≤23) scheduled for cardiovascular surgery. Preoperative neuropsychologic testing and delirium screening were performed twice daily until postoperative day 5. A multiple logistic regression model was applied to determine the predictive ability of test performances for the development of delirium. A total of 541 patients were included in the analysis; the delirium rate was 15.6%. After controlling for confounders, only low performance within the Trail Making Test B/A (odds ratio [OR]=1.32; 95% CI: 1.05-1.66) and letter fluency (OR=0.66; 95% CI: 0.45-0.96) predicted a particularly high risk for delirium development. The discriminative ability of the final multiple logistic regression model to predict POD had an area under the curve of 0.786. Impairment in the cognitive domains of executive function and language skills associated with memory, inhibition, and access speed seem to be particularly associated with the development of delirium after surgery in adults ≥65 years of age without apparent preoperative neurocognitive impairment.

Celiac trunk stenosis by median arcuate ligament in orthotopic liver transplantation: a potential hidden foe to the biliary tree

BackgroundCeliac trunk compression by the median arcuate ligament (MAL) increases the risk of ischemic complications following gastrointestinal surgical procedures. Previous studies suggest increased risk of hepatic artery thrombosis (HAT) in orthotopic liver transplant (OLT) recipients. The aim of this study is to investigate the impact of untreated MAL compression (MAL-C) on biliary complications in OLT. MethodsContrast-enhanced imaging was used to classify celiac trunk stenosis by MAL-C. Medical records were reviewed to extract pre-transplant, transplant and post-transplant data. Patients were divided into two groups: no MAL compression (nMAL-C) and MAL-C. The primary endpoint was biliary complications. Secondary endpoints were HAT and graft survival. Results305 OLT were performed from 2010 to 2021, of which 219 were included for analysis: 185 (84.5%) patients without and 34 (15.5%) with MAL-C. The incidence of HAT was 5.9% in both groups. Biliary complications were more common in the MAL-C group (35.3% vs. 17.8%, p = 0.035). Graft survival was decreased in patients with MAL-C (p = 0.035). ConclusionsMAL-C of the celiac trunk was associated with increased risk of biliary complications and inferior graft survival in OLT patients. These findings highlight the importance of preoperative screening and treatment of MAL in this population.

Can Non-Invasive Spectrophotometric Hemoglobin Replace Laboratory Hemoglobin Concentrations for Preoperative Anemia Screening? A Diagnostic Test Accuracy Study.

Preoperative assessment of hemoglobin concentration in blood is important to diagnose anemia. The primary aim of this prospective diagnostic test accuracy study was to monitor non-invasive spectrophotometric hemoglobin (SpHb, g/dL) concentrations among adults prior to elective surgery and to investigate the correlation and agreement of SpHb with laboratory hemoglobin (Hb, g/dl). A secondary aim was to identify the anemia cut-off values for SpHb based on the World Health Organization (WHO) definitions for anemia. This study included 151 consecutive patients (age ≥ 18 year) presenting for preoperative evaluation prior to scheduled elective general or orthopedic surgery. Results identified the mean ± SD of SpHb at 11.43 ± 2.01 g/dL, which underestimated the mean laboratory Hb (12.64 ± 2.29 g/dL, p < 0.001). A bias mean difference (SpHb-Hb) of -1.21 g/dL, with a SD of 1.76, was reported. This bias (SpHb-Hb) was inversely correlated with the mean Hb concentrations. A positive correlation existed between SpHb and Hb, with a good degree of reliability and a significant Intra Class Correlation (ICC). SpHb diagnosed anemia in 32.3% and 60.3% of males and females, respectively. The SpHb cut-off values to identify anemia were 11.3 and 10.2 g/dL for males and females, respectively, with a sensitivity of 83.3% for males and only 62.9% for females. The specificity for males and females were 81% and 91.3%, respectively. SpHb sensitivity allows for anemia diagnosis among males, but not females. However, the specificity allows SpHb to rule out anemia for both.

Operational strategies to deal with the COVID-19 emergency: recommendations from the Italian national society SIAGASCOT following the introduction of vaccines against the SARS-CoV-2 infection

BackgroundThis article aims to present the operational recommendations adopted by the Italian national society for orthopaedic surgery, arthroscopy, and sports medicine (SIAGASCOT) in managing patients eligible to undergo elective orthopaedic surgery during the COVID-19 pandemic after the beginning of a national vaccination campaign.Materials and methodsAn extensive literature search, analysing medical databases and scientific societies protocols, was performed to support this document. A four-step approach was used: 1—definition of priorities; 2—definition of significant clusters of interventions; 3—extraction of recommendations from international literature; and 4—adaptation of the recommendations to the specific features of the Italian healthcare system.ResultsThree operational priorities were defined (“continuity of care and containment of the virus spread”, “examination of waiting lists”, and “definition of the role of vaccines”), six significant clusters of intervention were identified, and recommendations regarding the risk management for healthcare staff and hospital facility as well as the preoperative, in-hospital, and postoperative management were produced. Patient selection, preoperative screening, and pre-hospitalization procedures, which are regarded as pivotal roles in the safe management of patients eligible to undergo elective orthopaedic surgery, were analysed extensively.ConclusionsThis document presents national-wide recommendations for managing patients eligible to undergo elective orthopaedic surgery with the beginning of the vaccination campaign. This paper could be the basis for similar documents adapted to the local healthcare systems in other countries.Level of evidenceLevel IV.

Can the OSA patient be managed within an ERAS protocol? A narrative review

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder among surgical patients and is associated with an increased risk of perioperative cardiopulmonary complications leading to increased health expenses. Therefore, preoperative OSA screening should be instituted to inform patients of their increased perioperative risk and measures can be taken in to decrease this risk. Meanwhile ERAS (Enhanced recovery after surgery) guidelines are becoming standard of care and being widely implemented. The purpose of these recovery programs is to standardize medical care, enhance outcomes and decrease health care expenses using evidence-based protocols. According to the current evidence it is unclear if OSA patients could benefit from these protocols. The first part of this narrative review states the current evidence on OSA definition, classification, pathophysiology and risk factors, postoperative complications, endotypes and their relevance for the anesthesiologist. The second part investigated the feasibility of ERAS measures within the OSA-population. Preoperatively there are many parallels to be drawn between the ERAS measures and Society of Anesthesia and Sleep Medicine (SASM) guidelines on OSA management: Risk stratification by OSA-screening, information counselling on the increased perioperative risk and optimization of preoperative health conditions by initiation of CPAP-therapy. Perioperatively the use short acting anesthetics allows for both early mobilization and avoid postoperative respiratory compromise by sustained drug effect. ERAS measures to maintain the patient in the zone of normovolaemia are advantageous for OSA patients as excessive fluid administration can worsen OSA. The use of multimodal analgesia sparing opioids might be the most important element beneficial for OSA patients they are more prone to develop opioid induced respiratory depression (OIRD). As OSA patients are at risk for venous thromboembolism appropriate thromboprophylaxis should be applied. Postoperatively OSA patients should be closely monitored in the prevention of OIRD. In conclusion many ERAS measures seem to be applicable or of benefit for OSA patients. However, large prospective randomized controlled trials are needed to evaluate if these patients can be managed within an ERAS protocol.

Development of a Brief Cognitive Screening Tool for Predicting Postoperative Delirium in Patients with Parkinson's Disease: A Secondary Analysis.

A simple, rapid, and effective cognitive screening test appropriate for fast-paced settings with limited resources and staff is essential, especially preoperatively. This study aimed to develop and validate the short versions of Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) for predicting postoperative delirium (POD) in patients with Parkinson's disease (PD) who were scheduled for surgery. The current study was a secondary analysis of data collected from 128 inpatients scheduled for deep brain stimulation of the subthalamic nuclei (STN-DBS) lasting >60 min, at Tsinghua University Yuquan Hospital, China. Preoperative cognitive screening was performed during the preoperative visit using the MMSE and MoCA. The optimal MMSE and MoCA cut-off scores for detecting PD-MCI was 27 and 23 respectively. The POD was assessed twice a day on the first postoperative day until discharge by the confusion assessment method. The backward conditional logistic regression analysis was used to organize the reduced versions of the MMSE or MoCA. Also, the areas under the receiver operating characteristic curves (AUCs) were examined using the DeLong test. 125/128 PD patients were included in the analysis, and 27 (21.6%) developed POD. The MMSE reduced version (orientation to time, attention and calculation, and comprehension) demonstrated performance similar to the original MMSE in predicting POD (z=0.820, p=0.412). The AUC of the original MoCA and the short MoCA (visuospatial and executive attention and orientation) were 0.808 and 0.826, respectively. There was no significantly difference in the AUC values between the tests (z=0.561, p=0.575). Our simplified MMSE and MoCA could be efficiently used to identify patients at risk for POD. Also, short cognitive tests could be considered while predicting POD in fast-paced preoperative settings with limited resources and staff.

Prevention of Post-operative Delirium

Postoperative delirium (POD) is an adverse but often preventable complication of surgery and surgery-related anaesthesia, and increasingly prevalent. This article provides an overview on non-pharmacological preventive measures, divided into individualized and non-individualized measures. Non-individualized measures, such as the most minimally invasive surgical procedure, avoidance of unnecessary fasting before surgery, and the most tolerable anaesthesia are used to minimize the risk of POD in all patients. Based on the results of preoperative screenings for risk factors such as frailty or cognitive impairment, individualized measures may encompass prehabilitation, treatment of specific risk factors, operation room companionship or cognitive, motor, and sensory stimulation as well as social support. This article additionally lists several examples of best practice approaches already implemented in German-speaking countries and websites for further readings.

Performance Accuracy of Wrist-Worn Oximetry and Its Automated Output Parameters for Screening Obstructive Sleep Apnea in Children

Objectives: Obstructive sleep apnea (OSA) increases the risk of perioperative adverse events in children. While polysomnography (PSG) remains the reference standard for OSA diagnosis, oximetry is a valuable screening tool. The traditional practice is the manual analysis of desaturation clusters derived from a tabletop device using the McGill oximetry score. However, automated analysis of wearable oximetry data can be an alternative. This study investigated the accuracy of wrist-worn oximetry with automated analysis as a preoperative OSA screening tool. Methods: Healthy children scheduled for adenotonsillectomy underwent concurrent overnight PSG and wrist-worn oximetry. PSG determined the obstructive apnea-hypopnea index (OAHI). Oximetry data were auto-analyzed to determine 3% oxygen desaturation index (ODI3) and visually scored as per McGill criteria. The logistic regression model assessed the predictive performance of ODI3 for detecting the presence and severity of OSA after adjusting for covariates. Results: Seventy-six children (34 females), aged (mean±standard deviation) 5.7±1.6 years were classified, based on PSG-derived OAHI, as no OSA (n=31), mild (n=31), and moderate-severe OSA (n=14). Oximetric ODI3 was identified as the sole predictor of moderate-severe OSA (OAHI≥5 events/h) (odds ratio 1.38, 95% confidence interval 1.15, 1.65, &lt;i&gt;p&lt;/i&gt;=0.001). The best diagnostic performance was at ODI3=5 events/h (78.6% sensitivity, 75.8% specificity [receiver operating characteristic-area under the curve {ROC-AUC}=0.857]). ODI3 was also more sensitive than the McGill oximetry score in diagnosing moderate-severe OSA (78.6% by ODI3 vs. 33.0% by McGill). The performance was suboptimal for any level of OSA (OAHI≥1 event/h) (75.6% sensitivity, 61.3% specificity [ROC-AUC=0.709]). Conclusions: Wrist-worn oximetry-derived automated ODI3 can reliably identify moderate-severe OSA in children undergoing adenotonsillectomy, making it a potentially useful preoperative OSA screening tool.

Laparoscopic prophylactic total gastrectomy with limited lymphadenectomy for CDH1 gene carriers.

CDH1 gene mutations are the leading etiology of hereditary diffuse gastric cancer with cumulative lifetime risk ranging up to 83%. Prophylactic total gastrectomy (PTG) is, therefore, recommended for CDH1 carriers. A laparoscopic approach may reduce operative risk versus an open operation, thus leading more patients with CDH1 mutations to pursue PTG prior to cancer development. However, more experience and oncologic outcome data are needed for a laparoscopic approach and indicated lymphadenectomy. A retrospective descriptive cohort study of adult patients with CDH1 mutations who underwent laparoscopic PTG with D1 lymphadenectomy between 2012 and 2022 was conducted at a single institution. All patients had preoperative EGD screening, and those with visible tumor lesions on surveillance EGD were excluded and not considered prophylactic. Demographics, family history, pathology, and operative course were obtained. Outcomes included complications, readmission, and postoperative weight change. Among 23 patients, median age was 48years (IQR 37, 53) and 15 (65%) were female. Family history for gastric and/or lobular breast cancer was present in 22 (96%) patients. The median [IQR] time from positive genetic testing to PTG was 347days [140, 625]. Pathologic evaluation showed five (22%) patients with foci of gastric cancer on pre-operative EGD biopsies, 10 (44%) in resected stomach specimens. All lymph nodes were negative. To address early postoperative complications, EJ anastomotic technique changed from EEA to GIA over the course of the study and feeding jejunostomy was no longer placed during PTG with minimal change in postoperative weight loss. This is the largest series, spanning 10years at a single institution, dedicated solely to a laparoscopic approach for risk-reducing PTG. A laparoscopic approach with limited lymphadenectomy resulted in acceptable surgical and oncologic outcomes. Despite no visible cancer, over half of our patients had foci of early gastric cancer. Therefore, CDH1 carriers should consider laparoscopic PTG.

"The Big Three" of geriatrics: A review of perioperative cognitive impairment, frailty and malnutrition.

Cognitive impairment, frailty, and malnutrition are three of the most impactful pathologies facing an aging population, having dramatic effects on morbidity and mortality across nearly all facets of medical care and intervention. By 2050, the World Health Organization estimates that the population of individuals over the age of sixty worldwide will nearly double, and the public health toll of these demographic changes cannot be understated. With these changing demographics comes a need for a sharpened focus on the care and management of this vulnerable population. The average patient presenting for surgery is getting older, and this necessitates that clinicians understand the implications of these pathologies for both their immediate medical care needs and for appropriate procedural selection and prognostication of surgical outcomes. We believe it is incumbent on clinicians to consider the frailty, nutritional status, and cognitive function of each individual patient when offering a surgical intervention, as well as consider interventions that may delay the progression of these pathologies. Unfortunately, despite excellent evidence supporting things like routine pre-operative frailty screening and nutritional optimization, many interventions that would specifically benefit this population still have not been integrated into routine practice. In this review, we will synthesize the existing literature on these topics to provide a pragmatic approach and understanding for anesthesiologists and intensivists faced with this complex population.

Cost-Effectiveness of Universal Asymptomatic Preoperative SARS-CoV-2 Polymerase Chain Reaction Screening: A Cost-Utility Analysis.

An early report has shown the clinical benefit of the asymptomatic preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening test, and some clinical guidelines recommended this test. However, the cost-effectiveness of asymptomatic screening was not evaluated. We aimed to investigate the cost-effectiveness of universal preoperative screening of asymptomatic patients for SARS-CoV-2 using polymerase chain reaction (PCR) testing. We evaluated the cost-effectiveness of asymptomatic screening using a decision tree model from a payer perspective, assuming that the test-positive rate was 0.07% and the screening cost was 8500 Japanese yen (JPY) (approximately 7601 US dollars [USD]). The input parameter was derived from the available evidence reported in the literature. A willingness-to-pay threshold was set at 5 000 000 JPY/quality-adjusted life-year (QALY). The incremental cost of 1 death averted was 74 469 236 JPY (approximately 566 048 USD) and 291 123 368 JPY/QALY (approximately 2 212 856 USD/QALY), which was above the 5 000 000 JPY/QALY willingness-to-pay threshold. The incremental cost-effectiveness ratio fell below 5 000 000 JPY/QALY only when the test-positive rate exceeded 0.739%. However, when the probability of developing a postoperative pulmonary complication among SARS-CoV-2-positive patients was below 0.22, asymptomatic screening was never cost-effective, regardless of how high the test-positive rate became. Asymptomatic preoperative universal SARS-CoV-2 PCR screening is not cost-effective in the base case analysis. The cost-effectiveness mainly depends on the test-positive rate, the frequency of postoperative pulmonary complications, and the screening costs; however, no matter how high the test-positive rate, the cost-effectiveness is poor if the probability of developing postoperative pulmonary complications among patients positive for SARS-CoV-2 is sufficiently reduced.