Preoperative Clinic Research Articles

Patients With Preoperative Clinical Depression Symptomology Experience Significant Improvements in Postoperative Pain, Function, and Depressive Symptoms Following Rotator Cuff Repair

To determine the impact of clinical depression on outcomes after rotator cuff repair (RCR), as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) health domains. RCR patients were given PROMIS CAT assessments for physical function (PROMIS UE), pain interference (PROMIS PI), and depression (PROMIS D) during preoperative and postoperative clinic visits. PROMIS D scores ≥55 correlate with mild clinical depression; thus patients with PROMIS D scores ≥ 55 were placed in the clinical depression (CD) group, whereas patients with scores <55 were placed in the "no clinical depression" (NCD) group. Categorical variables were compared at preoperative and postoperative (6 months and ≥1 year) timepoints using χ2 tests. Continuous variables were compared using Student's t-tests. Of the 340 RCR patients included in this study, 65 (19.1%) were found to have mild clinical depression preoperatively, with that number being reduced to 23 (6.8%) at 6 months and 19 (5.6%) at ≥1 year after surgery. Compared with preoperative PROMIS scores, CD patients had significant postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (26.7 vs 35.5 vs 38.9; P < .001) and PROMIS PI (67.6 vs 56.7 vs 56.4; P < .001). NCD patients had similar postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (30.8 vs 38.6 vs 46.9; P < .001) and PROMIS PI (61.7 vs 53.0 vs 47.6; P < .001). The improvement in PROMIS scores was similar for the CD and NCD groups in both PROMIS UE (12.2 vs 16.1, respectively) and PROMIS PI (-11.2 vs-14.1, respectively). Despite starting with worse PROMIS UE and PROMIS PI scores, patients undergoing RCR with symptoms of CD experienced significant improvement in function, pain, and depressive symptoms. Preoperative depression should not be a contraindication to arthroscopic RCR in patients who are otherwise appropriate operative candidates. Level III, retrospective comparative trial.

PPE training and the effectiveness of universal masking in preventing exposures: The importance of the relationship between anesthesia and infection prevention

Early in the pandemic, infection prevention (IP), in collaboration with our local anesthesia leadership, took the approach of ensuring all members of the Anesthesia Department understood the importance of universal masking, were individually trained on the use of the Controlled Air Purifier Respirator, as well the appropriate method for donning/doffing N95 respirators. Multiple providers in the department tested positive for COVID, resulting in the IP Department to conduct the routine contact tracing investigation. During the investigation, it was determined that all persons who met the CDC (Centers for Disease Control & Prevention) contact exposure guidelines would undergo COVID testing, which consequently was 109 team members due to the exposure risk identified in the break room space. IP worked with the Anesthesia Preoperative Clinic to test all team members identified over a 3-day period (approximately 5-7 days postexposure). Out of the 109 team members who were tested postexposure, there were 0 conversions. The department attributes this to the consistency in personal protective equipment training, support and collaboration between anesthesia and IP which led to successful care for COVID patients with a limited provider infection rate.

Immediate haemoglobin testing in association with a dedicated anaemia clinic: Effectiveness for primary total knee replacement patients.

Preoperative anaemia is associated with higher transfusion rates, increased hospital stays and poorer outcomes. Addressing preoperative anaemia is a crucial pillar of Patient Blood Management. Conventionally, patients are listed for surgery and then screened for anaemia in the pre-assessment clinic, followed by referral to their general practitioner. This process involves substantial delays, and poorly treated anaemia often results in perioperative transfusions. We assessed our pathway of immediate haemoglobin testing at the time of listing in conjunction with a dedicated preoperative anaemia clinic for detecting and treating anaemia in primary total knee replacement patients. We compared transfusion rates between anaemic patients undergoing a primary total knee replacement who were treated in this pathway with those who were not. We reviewed the preoperative haemoglobin levels, transfusion rates and treatment for all primary total knee arthroplasty patients over three years amounting to 2296. Transfusion rates were significantly lower in the group treated in this pathway compared to those who were not. The treated group also had significantly higher preoperative haemoglobin levels.Discussion and conclusion: Immediate haemoglobin testing in association with a dedicated preoperative anaemia clinic is effective at detecting and treating anaemia in primary total knee replacement patients and reduces transfusion requirements.

Developing a virtual geriatric perioperative medicine clinic: a mixed methods healthcare improvement study.

Backgroundthe Geriatric Perioperative Care clinic at North Bristol NHS Trust was suspended in March 2020 during the COVID-19 pandemic. A virtual clinic was piloted to deliver preoperative health optimisation and shared decision-making for patients undergoing critical elective surgery. No literature existed on virtual preoperative clinics for older people to support the development.Objectivethis healthcare improvement study describes the setup and delivery of the virtual clinic as its primary aim. Secondary aims included: assessing older people’s access to technology and their digital literacy for virtual consultation; to describe barriers and facilitators for consultations, as well as evaluation of patient and clinician satisfaction with the consultations' mode of delivery and outcomes.Methodsa mixed methods healthcare improvement study was undertaken through plan-do-study-act cycles, semi-structure interviews, and quantitative service benchmarking.Resultsthe pilot evaluated 67 preoperative consultations (43.3% video, 56.7% telephone, mean age 75) with a mix of surgical pathology (vascular 88.1%, colorectal 10.4%, urological 1.5%). Patient feedback demonstrated improved understanding of conditions (90.6%), and adequate opportunity to express opinions and questions (96.2%). Clinicians preferred video consultations (adequate to deliver services: 89.7% video; 68.4% telephone). The greatest barriers to engagement, none of which were exclusions to participation, included cognitive impairment, sensory impairment, or needing technical assistance setting up video consultations (52.2%).Conclusionsdelivering a virtual preoperative medical optimisation and shared decision clinic for older people is feasible. This study will aid other units in developing their own virtual preoperative clinics. Future work should evaluate perioperative outcomes of delivering a face-to-face versus virtual clinic.

Association of Multimorbidity With Frailty in Older Adults for Elective Non-Cardiac Surgery.

IntroductionFrailty is associated with adverse surgical outcomes. While existing studies describe the prevalence of multimorbidity and frailty in the community, the surgical population may have more severe disease and significant surgical stress. This study aims to describe the distribution of frailty and multimorbidity in the older surgical population and examine if specific comorbidities are more strongly associated with frailty.MethodsThis is a single-centre retrospective cohort study using an electronic database in the preoperative evaluation clinic, conducted in Singapore General Hospital, Singapore. All patients above 70 years old going for elective non-cardiac surgery were included. Demographics and comorbidities were analysed for their association with frailty according to the Edmonton Frail Scale.ResultsA total of 1396 out of 1398 patients were analyzed. The overall incidence of frailty was 27.8% and multimorbidity was 63.4%. Factors independently associated with frailty were age (adjusted Odds Ratio [aOR] = 1.07), female gender (aOR = 1.67), type 2 diabetes mellitus (aOR = 1.69), chronic kidney disease (aOR = 1.47), end-stage renal failure (aOR = 3.58), history of cerebrovascular accident or transient ischemic attack (aOR = 1.87), moderate anaemia (aOR = 2.11), dementia (aOR = 6.38), depression (aOR = 3.82), and peptic ulcer disease (aOR = 1.98). The presence of multi-morbidity was significantly associated with frailty, with overall increasing strength of association.ConclusionAs the number of comorbidities increases, the odds of frailty increase. Only a small proportion of those with multimorbidity accumulate enough biological deficits to develop frailty, putting them at higher risk than with solely multimorbidity or frailty. Dementia and depression are comorbidities with strong associations that have yet to see coordinated interventional efforts in the preoperative setting.

Environmental emissions reduction of a preoperative evaluation center utilizing telehealth screening and standardized preoperative testing guidelines

The healthcare sector is responsible for 8.5% of greenhouse gas (GHG) emissions in the United States. To prevent catastrophic effects of climate change, urgent reductions in GHG emissions are needed. Unnecessary preoperative testing and clinic visits contribute to excessive utilization of healthcare resources and patient travel, and addressing them may help reduce emissions. A retrospective cross-sectional analysis of GHG emissions associated with pre- and post- implementation of a novel telehealth preoperative evaluation process was performed on 298 American Society of Anesthesiologists Class I-III patients undergoing elective spine surgery at Yale New Haven Hospital. Electronic health records were evaluated to determine patient health status and necessary or unnecessary preoperative tests and clinic visits. Life cycle assessment and U.S. EPA GHG calculator were used to estimate carbon dioxide equivalent (CO2e) emissions from preoperative testing, clinic visits, and patient commuting. GHG emissions were reduced by 8.09 kg CO2e (9.6%) per patient, from 84.52 kg CO2e pre-intervention to 76.43 kg CO2e post-intervention (p = 0.019). The largest reduction, 14.71 kg CO2e, stemmed from fewer in-person clinic evaluations. An additional reduction of 18.07 kg CO2e per patient would have been possible if clinic performance were optimized (only necessary testing performed), resulting in a total reduction of 26.16 kg CO2e (31%). A preoperative clinic using established testing guidelines and telehealth can reduce environmental emissions. With more than 40 million annual surgeries nationwide, concerted effort to reduce unnecessary testing and visits should help curtail healthcare GHG emissions.

Impact of Patient Socioeconomic Disparities on Time to Tympanostomy Tube Placement.

Extensive literature exists documenting disparities in access to healthcare for patients with lower socioeconomic status (SES). The objective of this study was to examine access disparities and differences in surgical wait times in children with the most common pediatric otolaryngologic surgery, tympanostomy tubes (TT). A retrospective cohort study was performed at a tertiary children's hospital. Children ages <18 years who received a first set of tympanostomy tubes during 2015 were studied. Patient demographics and markers of SES including zip code, health insurance type, and appointment no-shows were recorded. Clinical measures included risk factors, symptoms, and age at presentation and first TT. A total of 969 patients were included. Average age at surgery was 2.11 years. Almost 90% were white and 67.5% had private insurance. Patients with public insurance, ≥1 no-show appointment, and who lived in zip codes with the median income below the United States median had a longer period from otologic consult and preoperative clinic to TT, but no differences were seen in race. Those with public insurance had their surgery at an older age than those with private insurance (P < .001) and were more likely to have chronic otitis media with effusion as their indication for surgery (OR: 1.8, 95% CI: 1.2-2.5, P = .003). Lower SES is associated with chronic otitis media with effusion and a longer wait time from otologic consult and preoperative clinic to TT placement. By being transparent in socioeconomic disparities, we can begin to expose systemic problems and move forward with interventions. 4.

Preoperative cardiovascular assessment as an opportunity to (re)affirm the 2019 ESC/EAS guidelines recommended LDL-C goal

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The novel 2019 ESC/EAS Guidelines on lipids recommend a more intensive reduction on LDL-C across CV risk categories in comparison with the 2016 edition. Purpose This cross-sectional observation study aimed to assess whether patients on lipid lowering therapy were aware of the new set LDL-C goals and if they achieved them. Methods Patients, taking at the time any statin, attending the preoperative CV assessment outpatient clinic at a city hospital in northern Greece were invited to participate. Results In total 625 eligible patients (45.1% female) were enrolled during 2020 (mean age 67 ± 9 years old). Mean duration of statin prescription was about 10 years (9.7 ± 7 years). About two thirds of the patients (402, 64.3%) had established atherosclerotic cardiovascular disease (ASCVD) and the rest were allocated into CV risk categories: low (24, 10.8%), medium (135, 60.5%), high (59, 26.5%) and very high (5, 2.2%). The estimated 10-year risk of CV death was calculated using SCORE. The majority (552, 88.3%) of the patients reported lab tests at least biannually. The majority of the participants (556, 89.0%) were taking a statin as monotherapy of either low (17, 2.7%), medium (237, 37.9%) or high (302, 48.3%) potency. One tenth (65, 10.4%) were prescribed a combination of ezetimibe with a medium or high potency statin. Lastly, only four patients (0.6%) were prescribed a PCSK9 inhibitor. Less than a quarter of the participants (143, 22.9%) had achieved the recommended LDL-C levels. Approximately, one out of six patients with established ASCVD had a LDL-C lower than 55mg/dL (68, 16.9%), while only one out of three primary prevention patients (75, 33.6%) had reached the LDL-C levels recommended for their allocated risk category. As expected, the higher the potency of the statin, the higher the percentage of patients reaching the goal. Moreover, twelve out of the sixty five the patients (18.5%) on ezetimibe combination therapy achieved the LDL-C goal. Lastly, three of the four patients (75.0%) on a PCSK9 inhibitor had attained the desired LDL-C level. No information could be collected regarding why patients not reaching the goal were not offered a statin of higher potency and/or dosing, a combination with ezetimibe or a PCSK9 inhibitor, accordingly. Disturbingly enough, none of the patient was aware that the LDL-C goals recommended by scientific societies had been lowered in 2019, although 94 patients (15.0%) could recall discussing LDL-C goals with their physician. The majority of the patients (427, 93.0%) reported that they would like to know the recommended (personal) LDL-C goals. Conclusions Greek patients taking statins were overall unaware of the novel set LDL-C goals. Hardly acceptable attainment of the LDL-C goal was observed. The preoperative assessment visit can be used to monitor the guidelines implementation. Further research is warranted to assess the barriers that obstruct a satisfactory goal achievement. Abstract Figure. Patients achieving LDL-C goal

Preoperative patient blood management during the SARS-CoV-2 pandemic.

Preoperative patient blood management during the SARS-CoV-2 pandemic.

Early Improvement in Patient-Reported Outcome Scores After Operative Treatment of Osteochondritis Dissecans of the Humeral Capitellum

Outcome measures that lack sensitivity for the detection of clinical changes early after surgery for capitellar osteochondritis dissecans (OCD) make it difficult to determine the optimal treatment for these defects. We sought to evaluate the early responsiveness of patient-reported outcomes measurement information system (PROMIS) scores in a cohort of patients operatively treated for capitellar OCD. Four PROMIS questionnaires (mobility, upper extremity [UE], pain interference, and peer relations) were electronically administered to patients treated for capitellar OCD at a single tertiary academic medical center between January 1, 2015, and July 1, 2018. The questionnaires were administered at the initial preoperative outpatient clinic visit as well as at the 2-week, 6-week, and final return-to-play (RTP) visits. Twenty-nine patients (31 elbows, mean age 12.9 years) with available preoperative and postoperative PROMIS data were included. The mean final follow-up period was 26 weeks. Compared with that before surgery, there was a significant improvement in the mobility, pain interference, and UE scores at 6 weeks following surgery. The scores improved most significantly by 6 weeks, reached a relative plateau, and remained significantly improved through the RTP visit thereafter. Patients with preoperative, intra-articular loose bodies scored significantly better than those without them during the 6-week and RTP visits. Patients with lesions >1 cm2, compared with those with lesions ≤1 cm2, demonstrated greater improvement in the UE scores during the RTP visit. In patients undergoing operative treatment for capitellar OCD, a significant improvement in the PROMIS domains of mobility, pain interference, and UE can be expected early in the postoperative period, with majority of patients reaching their greatest improvement in scores by 6 weeks following surgery. This is important information for preoperative counseling. In addition, this information is helpful in confirming that PROMIS scores are responsive in the detection of changes in outcomes during the early postoperative period in this population.

P94 Pre-Operative Fasting in Surgical Patients at Good Hope Hospital – Reducing incidents of unnecessary prolonged fasting periods in patients undergoing surgery

Patients are often fasted from food and liquid for unnecessarily long periods of time prior to surgery. There is often misunderstanding amongst patients and even members of staff as to what exactly is meant by the pre-operative fasting rules, specifically the meaning of ‘clear fluids’. Prolonged fluid fasting can result in significant distress to adult and children patients through feelings of thirst, hunger and anxiety. Prolonged fasting can also negatively affect insulin resistance and severe cases of hypoglycaemia and hypovolaemia.A questionnaire was handed out to elective surgical patients over a month period between September and October 2019. Data was then collated and compared to the 2011 ESA Guidelines standard where 100% of patients should be fasted appropriately. Results were presented and a poster was created which will be distributed at pre-operative assessment clinic and displayed in clinical areas and the day-case unit.68 responses to the questionnaire were collected. The results showed that 58% of patients received both written and verbal advice about pre-operative fasting. However, 42% of patients stated they received no information about being able to drink clear fluids until 2 hours prior to their operation and therefore fasted from fluids for longer than required.In conclusion there was still disparity between what exactly was meant by ‘clear fluids’ and many did not realise the list included coffee and tea without added milk. The next steps would be to implement clear posters outlining correct fasting rules and reinforce education to healthcare staff about this matter. Patients are often fasted from food and liquid for unnecessarily long periods of time prior to surgery. There is often misunderstanding amongst patients and even members of staff as to what exactly is meant by the pre-operative fasting rules, specifically the meaning of ‘clear fluids’. Prolonged fluid fasting can result in significant distress to adult and children patients through feelings of thirst, hunger and anxiety. Prolonged fasting can also negatively affect insulin resistance and severe cases of hypoglycaemia and hypovolaemia.

Integrating Prehabilitation in the Preoperative Clinic: A Paradigm Shift in Perioperative Care.

Integrating Prehabilitation in the Preoperative Clinic: A Paradigm Shift in Perioperative Care.

Myocardial Injury After Noncardiac Surgery-Slightly Heavier May Be Better.

Myocardial Injury After Noncardiac Surgery-Slightly Heavier May Be Better.

Educating surgical patients about safe use of opioids: a randomized controlled trial

BackgroundCurrently, it is not routine practice in the preoperative clinic to provide standardized patient education for safe postoperative opioid use. We aimed to evaluate the impact of an educational pamphlet for surgical patients on knowledge about safe opioid use. MethodsThis multi-center randomized controlled study recruited 100 adult patients in the preoperative clinic. All patients completed a baseline knowledge questionnaire consisting of 10 questions. Patients were randomized to intervention: educational pamphlet, or control: no pamphlet. Questionnaires were repeated immediately post-education in the intervention group, and at 15, and 30 days after surgery in both groups. The primary outcome was change in knowledge score post-education in the intervention compared to control group. ResultsBetween groups, the immediate post-education score in the intervention group was significantly higher than control group baseline 34.2 [95% Confidence interval (CI) 33.1-35.3] vs 28.3 [95% CI 26.6-29.9]; P<0.0001). In intervention vs control group, mean scores were significantly higher 31.6 (95% CI 30.5-32.7) vs 29.1 (95% CI 27.9-30.2; P=.002) at 15 days, and 32.4 (95%CI 31.4-33.5) vs 30.5 (95% CI 29.2-31.7; P=.017) at 30 days postoperatively. ConclusionsEducating surgical patients with a simple educational pamphlet improved patients’ scores on a standardized test about opioids up to 30 days after surgery.

Preoperative weight loss in women with obesity in gynaecologic oncology: A retrospective study.

To retrospectively review the efficacy of short term supervised medical weight loss for women with obesity, body mass index (BMI ≥40 kg/m2 ) in gynaecologic oncology, and the associated perioperative and pathologic outcomes. A retrospective study of a dedicated preoperative weight loss clinic for gynaecologic oncology patients from March to December 2019. Statistical analysis was performed with McNemar's test for correlated proportions, Pearson's correlation tests for continuous variables, and paired t-tests to compare means. Generalized estimating equations (GEE) were used to determine the factors associated with weight loss over time. A P-value of <.05 was used for statistical significance. Review of cases up-graded after surgery was performed by a gynaecologic pathologist. There were a total of 49 women included in the study. The most common referral reason was endometrioid carcinoma or hyperplasia of the endometrium (77.6%). Mean initial weight was 130.2 kg, and corresponding mean BMI 48.1 kg/m2 . Patients attended on average nine preoperative weight loss visits. A significant difference between initial weight and weight at surgery was demonstrated, from 129.6 to 118.0 kg (8.4% weight loss) (P < .0001). This difference persisted to their post-surgical visit, with an additional mean loss of 1.89 kg (9.4% weight loss) (P = .044). The majority (92.1%) of patients with endometrial pathology had surgical management, and of these 85.7% were minimally invasive. Preoperative weight loss is a feasible option in gynaecologic oncology patients. Greater understanding of clinical significance, follow-up, and ideal target population for this intervention is needed.

Preventing Surgical Delay and Cancellation with Patient-Centered Interventions

Delay and cancellation can significantly impact cost and outcomes among surgical patients. While the causes of delay and cancellation are not fully enumerated, possible reasons include delivery-related causes such as facility, equipment, and provider availability as well as patient-related issues such as readiness and health status. Despite limited research explaining patient-related causes, there are many studies that evaluate patient-centered interventions to decrease delay and cancellation. This article highlights patient-centered interventions including preoperative clinics, preoperative screening, and focused education that have been shown to reduce delay and cancellation. This information provides perianesthesia nurses and advanced practice nurses ideas to maximize their roles in improving efficiency by prevention of delay and cancellation. This article should also stimulate additional research to help better understand the causes and the role of the nurse in the implementation of evidence-based practice projects that use patient-centered interventions.

Preoperatively elevated RDW-SD and RDW-CV predict favorable survival in intrahepatic cholangiocarcinoma patients after curative resection

BackgroundRecent studies suggest red blood cell distribution width (RDW) was a prognostic factor in various types of cancer patients, although the results are controversial. The objective of this study was to investigate the significance of RDW in patients with intrahepatic cholangiocarcinoma (ICC) after radical resection.MethodThe relationship between the preoperative serum RDW value and clinic pathological characteristics was analyzed in 157 ICC patients between January 2012 and June 2018 who underwent curative resection. X-tile software was used to determine 40.2 fl, 12.6% as the optimal cut-off value for RDW-SD and RDW-CV respectively. 153 patients were classified into the low RDW-SD (≤ 40.2, n = 53) group and the high RDW-SD (> 40.2, n = 104) group, low RDW-CV (≤ 12.6, n = 94) group and the high RDW-CV (> 12.6, n = 63). Based on the RDW-SD combined with RDW-CV (SCC), classified into SCC = 0, 1 and 2 group. Kaplan–Meier survival analysis and Cox proportional hazard models were used to examine the effect of RDW on survival.ResultsKaplan–Meier curve analysis showed that Patients with RDW-SD > 40.2 were significantly associated with better OS (P = 0.004, median OS: 68.0 months versus 17.0 months). Patients with RDW-CV > 12.6 were significantly associated with better OS (p = 0.030, median OS: not reach versus 22.0 months). Compared with a SCC = 0 or SCC = 1, SCC = 2 was significantly associated with better OS (p < 0.001, median OS: not reach versus 33.0 months versus 16, respectively). In the multivariate analysis, RDW-SD > 40.2 fl (HR = 0.446, 95% CI: 0.262–0.760, p = 0.003), RDW-CV > 12.6% (HR = 0.425, 95%CI: 0.230–0.783, p = 0.006), SCC = 2 (HR = 0.270, 95%CI: 0.133–0.549, p < 0.001) were associated with favorable OS. The multivariate analysis showed RDW-SD, RDW-CV and SCC level were not independent prognostic factors for DFS.ConclusionsPreoperative low levels of RDW are associated with poor survival in ICC after curative resection. This provides a new way for predicting the prognosis of ICC patients and more targeted intervention measures.

The Impact of Nonpharmacological Interventions on Patient Experience, Opioid Use, and Health Care Utilization in Adult Cardiac Surgery Patients: Protocol for a Mixed Methods Study.

BackgroundDespite pharmacological treatments, patients undergoing cardiac surgery experience severe anxiety and pain, which adversely affect outcomes. Previous work examining pediatric and nonsurgical adult patients has documented the effectiveness of inexpensive, nonpharmacological techniques to reduce anxiety and pain as well as health care costs and length of hospitalization. However, the impact of nonpharmacological interventions administered by a dedicated comfort coach has not been evaluated in an adult surgical setting.ObjectiveThis trial aims to assess whether nonpharmacological interventions administered by a trained comfort coach affect patient experience, opioid use, and health care utilization compared with usual care in adult cardiac surgery patients. This study has 3 specific aims: assess the effect of a comfort coach on patient experience, measure differences in inpatient and outpatient opioid use and postoperative health care utilization, and qualitatively evaluate the comfort coach intervention.MethodsTo address these aims, we will perform a prospective, randomized controlled trial of 154 adult cardiac surgery patients at Michigan Medicine. Opioid-naive patients undergoing first-time, elective cardiac surgery via sternotomy will be randomized to undergo targeted interventions from a comfort coach (intervention) versus usual care (control). The individualized comfort coach interventions will be administered at 6 points: preoperative outpatient clinic, preoperative care unit on the day of surgery, extubation, chest tube removal, hospital discharge, and 30-day clinic follow-up. To address aim 1, we will examine the effect of a comfort coach on perioperative anxiety, self-reported pain, functional status, and patient satisfaction through validated surveys administered at preoperative outpatient clinic, discharge, 30-day follow-up, and 90-day follow-up. For aim 2, we will record inpatient opioid use and collect postdischarge opioid use and pain-related outcomes through an 11-item questionnaire administered at the 30-day follow-up. Hospital length of stay, readmission, number of days in an extended care facility, emergency room, urgent care, and an unplanned doctor’s office visit will be recorded as the primary composite endpoint defined as total days spent at home within the first 30 days after surgery. For aim 3, we will perform semistructured interviews with patients in the intervention arm to understand the comfort coach intervention through a thematic analysis.ResultsThis trial, funded by Blue Cross Blue Shield of Michigan Foundation in 2019, is presently enrolling patients with anticipated manuscript submissions from our primary aims targeted for the end of 2020.ConclusionsData generated from this mixed methods study will highlight effective nonpharmacological techniques and support a multidisciplinary approach to perioperative care during the adult cardiac surgery patient experience. This study’s findings may serve as the foundation for a subsequent multicenter trial and broader dissemination of these techniques to other types of surgery.Trial RegistrationClinicalTrials.gov NCT04051021; https://clinicaltrials.gov/ct2/show/NCT04051021International Registered Report Identifier (IRRID)DERR1-10.2196/21350

THE The Management of Anaesthesia in Caesarean Section of Pregnant Women with COVID-19

Objective: In this study, we aimed to investigate the effect of preoperative clinical status on the choice of anesthesia method and the postoperative maternal and fetal outcomes in the caesarean section of pregnant women with COVID-19 related acute respiratory distress syndrome.&#x0D; Materials and Methods: Pregnant women with COVID-19 related acute respiratory distress syndrome, for whom caesarean sections were planned, were included in this retrospective study. Clinical features, preoperative findings and treatments, maternal and fetal outcomes in the preoperative period, intensive care needs, and hospital stay were evaluated.&#x0D; Results: Ten patients who underwent caesarean section were included in the study. The mean age of the patients was 34±1.82 and the mean gestational week was 33.1±3.88. Chronic disease was present in 44.4% of them. Sixty percent of the patients were admitted to the postoperative intensive care unit. Eighty percent of the newborns were preterm and half of the newborns needed intensive care unit hospitalization.&#x0D; Conclusion: The clinical features of pregnant women with COVID-19 are similar to those reported for non-pregnant adults with COVID-19, but respiratory parameters of pregnant women with COVID-19 related acute respiratory distress syndrome deteriorate rapidly and should be monitored closely. Preoperative clinic status and oxygenation are the most important determinants in the selection of anesthesia type for the caesarean section.

Preoperative Anemia in Primary Arthroplasty Patients—Prevalence, Influence on Outcome, and the Effect of Treatment

BackgroundThis study aims to: 1) Determine the prevalence of preoperative anemia in arthroplasty; 2) Assess whether preoperative anemia is associated with inferior outcomes; and 3) Ascertain whether optimization in a dedicated blood management program (BMP) is associated with improved outcomes. MethodsAll primary arthroplasties performed at an academic, tertiary-care, arthroplasty center between 2012 and 2017 were reviewed. Hemoglobin level obtained in the preoperative assessment clinic was recorded. Patients with anemia were then considered for further review in BMP. Outcomes included improvement in hemoglobin level post-BMP; length of stay; perioperative transfusion; 90-day readmission, complication, and reoperation rates. The effect of preoperative anemia and the effect of treatment at the BMP on outcomes were evaluated through multivariable regression analysis controlling for relevant covariates. Results17% of patients (932/5384) were found to have anemia; 115/357 patients who attended the BMP were no longer anemic. Thus, at time of operation, 15% of patients (817/5384) had anemia. Anemic patients were 4.09 times more likely (95% CI: 2.64-6.35) to require a transfusion; 1.42 times more likely (95% CI: 0.99-2.03) to sustain complications and had 19% longer (95% CI: 13%-26%) length of stay.Those who attended the BMP were less likely to receive a transfusion (OR = 0.32, 95% CI: 0.16-0.66), suffer from postoperative complications (OR = 0.30, 95% CI: 0.14-0.63), or require readmission compared with anemic patients not seen in the BMP (OR = 0.25, 95% CI: 0.09-0.71). ConclusionsThe prevalence of anemia in this arthroplasty cohort was 15%. Preoperative, timely, optimization of anemia should be strongly considered as it is likely to reduce “anemia-associated burden” after arthroplasty.