Preoperative Clinic Research Articles

Retinal small vessel dilatation in the systemic inflammatory response to surgery

Retinal microvascular calibre has been proposed as a predictor of cardiac events. Surgery is a major stimulus for inflammation which potentially affects small vessel calibre. This study examined the effects of surgery on retinal, and thus systemic, small vessel size, and the potentially confounding effect of surgery when retinal vessel calibre is used to predict cardiac risk in hospital patients. Consecutive participants were recruited from a preoperative assessment clinic at a teaching hospital. They provided demographic and clinical details, and underwent retinal imaging before and again, within 3 days after surgery, with a non-mydriatic retinal camera. Images were graded for vessel calibre using semi-automated software based on the Parr-Hubbard formula with Knudtson’s modification (IVAN, U Wisconsin). Differences were examined using Fisher’s exact test or a paired t-test, and calibre determinants identified from univariate and multiple linear regression analysis (STATA version 11.2). Sixty-eight participants (23 men, 34%) with a mean age of 55 ± 14.5 years, were recruited. Fourteen (21%) underwent a laparotomy which was considered major surgery and 54 (79%) had Other surgery. Mean C-reactive protein (CRP) levels increased post-operatively from 7.8 ± 20.2 mg/L to 43.9 ± 55.1 mg/L (p < 0.01), and mean serum albumin decreased from 38.9 ± 4.4 g/L to 33.9 ± 5.5 g/L (p < 0.01). Mean central retinal arteriole and venular equivalent calibre (CRAE, CRVE) increased post-operatively (142.4 ± 13.3 µm to 146.4 ± 13.0 µm, p < 0.01 and 213.1 ± 16.8 µm to 217.9 ± 18.3 µm, p < 0.01, respectively). The systemic microvasculature dilates post-operatively possibly secondary to inflammation and endothelial dysfunction. These changes were present within 3 days of surgery and may confound the use of small vessel calibre to predict cardiac risk in surgical inpatients. Microvascular dilatation in response to other inflammatory stimuli such as pneumonia is a known potential confounder in hospital patients.

The Association of Medical Preoperative Evaluation Using Clinical Video Telehealth With Hospital Length of Stay: Descriptive Analysis

BackgroundPreoperative medical evaluation serves to identify risk factors and optimize patients before surgery. Providing a telehealth option in the perioperative setting has played a significant role in reducing barriers to quality perioperative health care.ObjectiveWe aimed to evaluate how telemedicine preoperative evaluations using Clinical Video Telehealth (CVT) impact hospital length of stay.MethodsWe performed a retrospective chart review between 2016 and 2017 of adult patients who underwent evaluations in our hospitalist-run preoperative medicine clinic. Patients seen in our preoperative CVT program were compared to patients seen in person to evaluate the association of visit type (preoperative CVT versus in-person evaluation) with hospital length of stay, defined as hospital stay from postoperative day 0 to discharge. There were 62 patients included in this retrospective study.ResultsThe adjusted incidence rate ratio (IRR) for hospital length of stay was significantly shorter in patients who underwent preoperative CVT compared to an in-person visit (IRR 0.52, 95% CI 0.29-0.92, P=.02).ConclusionsAfter adjusting for age and comorbidities, we show that preoperative telemedicine in the perioperative setting is associated with a shorter hospital length of stay compared to in-person visits. This suggests that telemedicine can play a viable role in this clinical setting.

Association of SARC-F Score and Rockwood Clinical Frailty Scale with CT-Derived Muscle Mass in Patients with Aortic Aneurysms.

Patients with aortic aneurysms (AA) are often co-morbid and susceptible to frailty. Low core muscle mass has been used as a surrogate marker of sarcopenia and indicator of frailty. This study aimed to assess association between core muscle mass with sarcopenia screening tool SARC-F and Clinical Frailty Scale (CFS) in patients with AA. Prospective audit of patients in pre-operative aortic clinic between 01/07/2019-31/01/2020 including frailty assessment using Rockwood CFS and sarcopenia screening using SARC-F questionnaire. Psoas and sartorius muscle area were measured on pre-operative CT scans and adjusted for height. Association was assessed using Spearman's rank correlation coefficient. Of 84 patients assessed, median age was 75 years [72,82], 84.5% were men, 65.5% were multimorbid and 63.1% had polypharmacy. Nineteen percent were identified as frail (CFS score >3) and 6.1% positively screened for sarcopenia (SARC-F score 4 or more). Median psoas area (PMA) at L3 was 5.6cm2/m2 [4.8,6.6] and L4 was 7.4cm2/m2 [6.3,8.6]. Median sartorius area (SMA) was 1.8 cm2/m2 [1.5,2.2]. CFS demonstrated weak but statistically significant negative correlation with height-adjusted PMA at L3 (r=-0.25, p=0.034) but not at L4 (r=-0.23, p=0.051) or with SMA (r=-0.22, p=0.065). No association was observed between SARC-F score and PMA or SMA (L3 PMA r=-0.015, p=0.9; L4 PMA r=-0.0014, p= 0.99; SMA r=-0.051, p=0.67). CFS showed higher association with CT-derived muscle mass than SARC-F. Comprehensive pre-operative risk-stratification tools which incorporate frailty assessment and body composition analysis may assist in decision making for surgery and allow opportunity for pre-habilitation.

Identification of Preanesthetic History Elements by a Natural Language Processing Engine.

Methods that can automate, support, and streamline the preanesthesia evaluation process may improve resource utilization and efficiency. Natural language processing (NLP) involves the extraction of relevant information from unstructured text data. We describe the utilization of a clinical NLP pipeline intended to identify elements relevant to preoperative medical history by analyzing clinical notes. We hypothesize that the NLP pipeline would identify a significant portion of pertinent history captured by a perioperative provider. For each patient, we collected all pertinent notes from the institution's electronic medical record that were available no later than 1 day before their preoperative anesthesia clinic appointment. Pertinent notes included free-text notes consisting of history and physical, consultation, outpatient, inpatient progress, and previous preanesthetic evaluation notes. The free-text notes were processed by a Named Entity Recognition pipeline, an NLP machine learning model trained to recognize and label spans of text that corresponded to medical concepts. These medical concepts were then mapped to a list of medical conditions that were of interest for a preanesthesia evaluation. For each condition, we calculated the percentage of time across all patients in which (1) the NLP pipeline and the anesthesiologist both captured the condition; (2) the NLP pipeline captured the condition but the anesthesiologist did not; and (3) the NLP pipeline did not capture the condition but the anesthesiologist did. A total of 93 patients were included in the NLP pipeline input. Free-text notes were extracted from the electronic medical record of these patients for a total of 9765 notes. The NLP pipeline and anesthesiologist agreed in 81.24% of instances on the presence or absence of a specific condition. The NLP pipeline identified information that was not noted by the anesthesiologist in 16.57% of instances and did not identify a condition that was noted by the anesthesiologist's review in 2.19% of instances. In this proof-of-concept study, we demonstrated that utilization of NLP produced an output that identified medical conditions relevant to preanesthetic evaluation from unstructured free-text input. Automation of risk stratification tools may provide clinical decision support or recommend additional preoperative testing or evaluation. Future studies are needed to integrate these tools into clinical workflows and validate its efficacy.

Cancellation of Elective Cases in Songklanagarind Hospital: Identification of Reason: A Retrospective Study

Background: The operating theatre is the most important department of a hospital as it involves significant resources. One of the significant obstacles in overseeing a theater managing system is scheduled elective case cancellation. Objective: The present study was conducted to identify preventable reasons for cancellation. Materials and Methods: A retrospective study was conducted between January and December 2018. Data from scheduled elective cases were retrieved from a database of the Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University. All patients who required anesthetization for surgery were divided into two groups, proceeding with the operation, and case cancellation. Baseline characteristics of the two groups were compared using the chi-square test, Fisher’s exact test, and analysis of variance. All statistical analyses were performed using the R software, and the correlation was considered significant at p of less than 0.05. The reason for case cancellations was categorized into three groups, preventable, unpreventable, inconclusive, then displayed as percentages. Results: In all, 12,423 patients were identified as being scheduled elective cases. The case cancellation rate was 6.4%. Cancellation rates of males and females were 7.3% and 5.6%, respectively. Patients aged 65 to 79 years exhibited a 7.6% cancellation rate, and the cancellation rate was the highest at 17.3% in the American Society of Anesthesiologists (ASA) physical status classification 4. Of the 797 canceled surgeries, 397 cases (50%) were preventable, 192 cases (24%) were unpreventable, and 208 cases (26%) involved inconclusive reasons. The preventable reasons for cancellation comprised incomplete medical evaluations in 179 cases (22.5%), overtime in 74 cases (9.3%), and the patient refused surgery in 52 cases (6.5%). Conclusion: The most common cause of elective case cancellation is an incomplete preoperative evaluation, which is a preventable reason.Therefore, preoperative evaluation protocol as a one-stop service preoperative clinic should be established to prevent and decrease the cancellation rate of elective cases. Keywords: Cancellation case; Elective surgery; Preventable reason

Targeting patient blood management's first pillar: A multicentric retrospective study on preoperative anemia

IntroductionAnemia is a common issue in surgical patients and has been associated with worse clinical outcomes, such as a higher probability of transfusions and longer hospital stay. Therefore, Patient Blood Management programs are actively aiming to achieve early identification and treatment of anemia, previous to the surgery. Methods and materialsIn this study, preoperative hemoglobin within the Blood Order Schedule (BOS) at 16 blood centers in several Brazilian regions were retrospectively evaluated. Data regarding hemoglobin, age, gender and Brazilian regions were further analyzed. Results: From the 20,201 BOSs evaluated, the mean age was 55.65 ± 23.52 years old, with an overall prevalence of preoperative anemia of 60.9%. Women had a lower mean preoperative hemoglobin (11.74 ± 2.84 for women and 12.27 ± 3.06 for men) and higher prevalence of anemia than men (66% of females and 52.2% of males). The individuals over 65 years old and under 18 were the most affected by preoperative anemia. All regions had a high prevalence of preoperative anemia, without any direct association with the Human Development Index. ConclusionIn summary, upon evaluating the BOS, our study showed a high prevalence of preoperative anemia in all Brazilian regions, regardless of the gender and age group, but that women and individuals less than 18 or over 65 years old have an even higher prevalence of preoperative anemia. This information can identify the institutions in which preoperative anemia is a critical issue and in which new strategies, such as preoperative screening clinics, might be helpful.

The Role of Preoperative Educational Intervention in Reducing Parental Anxiety.

Background and objectiveThe parents of pediatric patients admitted for elective surgery exhibit significant levels of anxiety. The reduction in parental anxiety is directly proportional to the information and counseling provided to the parents preoperatively. The parenting style in South Asian culture is different from that of western cultures and may influence the response to these interventions. In this study, we aimed to compare the mean anxiety levels between parents of children (aged three to eight years) undergoing outpatient infraumbilical surgery equipped with standardized preoperative parental education and those without.MethodsThis was a randomized, controlled, and blinded trial. Parents of 72 pediatric patients (aged three to eight years) undergoing elective infraumbilical daycare surgery were enrolled and were divided into two groups: an intervention (Group I) and a non-intervention (Group NI) group. Both groups received routine verbal counseling at the preoperative clinic, but a standardized brochure was provided only to Group I. Parental anxiety was measured by using the Visual Analog Scale (VAS) at three different time points: in the outpatient surgery suite on the day of surgery, in the preoperative area 10 minutes before shifting the child to the operating room, and finally in the recovery room.ResultsThe baseline mean VAS score was significantly higher in Group I compared to Group NI (p=0.017). After the intervention, the mean pain score significantly decreased from baseline in Group I as compared to Group NI (mean ±SD: 4.08 ±1.6 vs. 6.08 ±1.66; p=0.0005).ConclusionThe information provided through standardized written material to the parents on the day of surgery before anesthesia helped to significantly attenuate preoperative parental anxiety.

The current and future role of nurses within enhanced recovery after surgery pathways.

Enhanced recovery after surgery (ERAS) pathways have been proven to expedite recovery after many procedures and reduce lengths of stay in hospital and surgical complications. However, improvements are still needed, especially in postoperative ERAS components delivered by nurses such as early mobilisation and oral feeding. This article summarises the current and possible future role of nurses within ERAS, and recommends areas for future research. Nurses are the professionals who spend the most time with patients throughout the perioperative pathway and are known to play a vital role in delivering many components of an ERAS pathway. They frequently co-ordinate care across disciplines and ensure continuity of care. However, there is a paucity of ERAS research specific to nurses compared to other professional groups. Continual training on ERAS will be required to ensure nurses are highly educated and for the best possible ERAS implementation. In certain types of surgery, nurses may fulfil extended roles in the postoperative period, such as taking over responsibility and leadership for co-ordinating pain management, mobilisation and discharge. However, this requires a well-defined care programme, a clear definition of nursing responsibilities from surgeons, agreed discharge criteria and highly qualified nurses, along with the collection and analysis of data to test safety and efficacy. Increasing nurse involvement in ERAS research is vital to drive improvements in care and to develop nursing roles. Nurses should have a major role in the preoperative clinic, the early postoperative phase and the follow-up post-discharge period, where the benefits of ERAS need to be further documented.

Utilizing previous patient opioid experiences for pain plan implementation: Role of opioid use categorization on inpatient and outpatient opioid use, length of stay, pain scores, and clinic resource utilization following elective spine surgery

BackgroundA Pain Plan was formulated for all patients undergoing elective spine surgery at our institution. It was based on prior opioid experiences and developed collaboratively between the patient and the surgeon at a preoperative clinic visit. Category 1 patients had no previous opioid experience, Category 2 patients had remote previous opioid experience with acceptable pain control and no side effects, Category 3 patients had remote previous opioid experience with unacceptable pain control and/or side effects, and Category 4 patients had opioid use leading up to surgery. MethodsThis is a retrospective cohort study comparing adult patients within four different pain plan categories over one year (n = 313) to determine if categorization is predictive. Demographic data collected included age, gender, ASA class, BMI, smoking status, insurance status, substance abuse, and comorbid psychiatric diagnoses. Demographic factors between categories were compared and controlled for as covariates within analyses. Outcomes measures comprised self-reported pain scores and functional measurements, including inpatient opioid use, outpatient opioid prescription quantities, and postoperative healthcare utilization. ResultsInpatient and outpatient opioid use were statistically significant amongst the categories, with prescription quantities greatest in Category 4, followed by Categories 2, 3, and 1, respectively. There was no difference in LOS or complexity of communication encounters amongst any of the groups. Patient-reported pain scores showed statistically significant differences and followed the same trend as opioid quantities, 4, 2, 3, and 1. The number of communication encounters was significant exclusively for Category 3 vs. 4. ConclusionsThe use of categorization in Pain Plan formation has been a helpful tool for postoperative pain management at our institution. Categorization is predictive of pain scores and opioid use after surgery, allowing the surgical team to tailor their care and counseling towards individual patients. In addition, the plan's collaborative nature enables patients to be involved in their pain management decisions while also setting limits and expectations.

Abstract LB553: Empowering tobacco using cancer patient initiation of tobacco cessation by a personal pathway to success program during preoperative patient counseling: A feasibility study

Abstract Background: Cancer patients who use tobacco often decline to participate in structured tobacco cessation programs. and personal barriers and priorities vary. To overcome barriers and improve pt engagement, we constructed a Personal Pathway to Success (PPS) program which enabled patients to choose cessation components they could effectively use. Methods: City of Hope (COH) constructed a comprehensive list of cessation tools. Patients completed tobacco use and Lifestress social domain stress assessments. PPS was then proposed to patients who selected tools they would initially use in quit attempts. Pts could add or delete tools at any time but were encouraged to add likely effective tools. Since tobacco use is associated with adverse surgical outcomes, the PPS program was pilot tested at the preoperative anesthesia testing clinic (PATC). Patients were evaluated for acceptance of cessation and follow through with counseling. Results were compared by Chi square statistic to pt cessation results before PPS program implementation. Study data collection was 9/11/21 to 1/3/22.Results: The tools in PPS were Individual cessation counseling, nicotine replacement and cessation medications, signed personal commitment agreement, cessation support group, choosing a buddy partner (family, friends or support group), lung cancer screening, letter to primary care physicians requesting assistance for non-responding patients, SmokeFree Text support, Kick It California or Asian Quitline support, rapid action plan for relapses, 5Ds cessation and 7 self-care skills, COH relaxation and/or hypnosis videos, guidance for cinnamon stick/bubble blowing, stress management and smoking cessation apps, cessation videos and audios, educational brochures, advice on vaping, assistance with internet and digital devices, family education and support, and psycho-social or substance abuse referrals. At PATC 36 evaluable patients were offered the PPS program, counseling and/or video education. Nineteen patients (53%) agreed to cessation, 14 (74%) scheduled a definite date for counseling. 42% completed the counseling. Video education was watched by 6 (32%) patients. Thirty two % had future appointments, but 26% had not yet scheduled. Three patients (8%) desired more time to evaluate cessation. Fourteen patients did not respond despite 3 attempts and were referred back to their attending physician. Compared to results pre-PPS, patient initiation was increased from 8.7% to 53% (p&amp;lt;.001). Conclusions: The Personal Pathway to Success program empowered patients to select among different cessation tools and increased pt acceptance of cessation. Offering comprehensive tobacco cessation during cancer surgery pre-anesthesia visits represents a teachable moment when patients are more motivated to accept behavioral interventions and tobacco cessation. Further research will develop additional methods to further increase engagement of hard to reach patients, family and caregivers. Citation Format: Cary A. Presant, Kimlin Ashing, Sophia Yeung, Jonjon Macalintal, Brenda Gascon, Argelia Sandoval, Brian Tiep, Mary Cianfrocca, Ravi Salgia, Dan Raz, Loretta Erhunmwunsee, Yuman Fong, Steven Rosen. Empowering tobacco using cancer patient initiation of tobacco cessation by a personal pathway to success program during preoperative patient counseling: A feasibility study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB553.

Cognitive impairment and frailty screening in older surgical patients: a rural tertiary care centre experience

IntroductionDespite a clear association between cognitive impairment and physical frailty and poor postoperative outcomes in older adults, preoperative rates are rarely assessed. We sought to implement a preoperative cognitive impairment...

Addressing comorbidities in the perioperative setting and optimizing perioperative medicine education.

Preoperative clinics and patient optimization are examples of collaborative, multidisciplinary care pathways that create value. This article reviews current literature to demonstrate the importance of preoperative enhancement of patients' cognitive and functional status. This article underscores the importance of formal training in multidisciplinary topics, such as frailty, brain health, and shared decision-making for anesthesiology house staff. Preoperative cognitive screening of older patients is a valuable metric for risk stratification and detection of patients at risk of postoperative delirium. Frailty is another syndrome that can be identified and optimized preoperatively. Sarcopenia has been shown to correlate with frailty; this shows promise as a method to detect frailty preoperatively. Anesthesiologists as perioperative physicians are in a unique position to lead and coordinate interdisciplinary conversations that incorporate patient goal concordant care and realistic assessment of perioperative complications. Formal house staff training in early recognition and management of patients at risk of adverse outcomes in the short and long term postoperatively improves patient outcomes and decreases healthcare spending.

Evaluation of the usefulness of non-invasive serum haemoglobin measurement in a perioperative setting in a prospective observational study

Patient Blood Management (PBM) programmes seek to reduce the number of missed anaemic patients in the run-up to surgery. The aim of this study was to evaluate the usefulness of haemoglobin (Hb) measured non-invasively (SpHb) in preoperative screening for anaemia. We conducted a prospective observational study in a preoperative clinic. Adult patients undergoing examination for surgery who had their Hb measured by laboratory means also had their Hb measured non-invasively by a trained health care provider. 1216 patients were recruited. A total of 109 (9.3%) patients (53 men and 56 women) was found to be anaemic by standard laboratory Hb measurement. Sensitivity for SpHb to detect anaemic patients was 0.50 (95% CI 0.37–0.63) in women and 0.30 (95% CI 0.18–0.43) in men. Specificity was 0.97 (95% CI 0.95–0.98) in men and 0.93 (95% CI 0.84–1.0) in women. The rate of correctly classified patients was 84.7% for men and 89.4% for women. Positive predictive value for SpHb was 0.50 (95% CI 0.35–0.65) in men and 0.40 (95% CI 0.31–0.50) in women; negative predictive value was 0.93 (95% CI 0.92–0.94) in men and 0.95 (95% CI 0.94–0.96) in women. We conclude that due to low sensitivity, SpHb is poorly suitable for detecting preoperative anaemia in both sexes under standard of care conditions.

The significance of widely split P waves: a case report

BackgroundP wave morphology on electrocardiogram is often overlooked but indicates abnormal cardiac conduction from various etiologies. Split P waves on electrocardiogram have been reported previously but not in a perioperative setting.Case presentationA 69-year-old Caucasian male patient with widely split P waves on his preoperative electrocardiogram was scheduled for a reimplantation right total hip replacement under a combined spinal–general anesthetic technique. The patient was evaluated prior to surgery by a cardiologist and the preoperative anesthesia clinic without any comment on the abnormal P wave morphology on electrocardiogram. The patient was cleared to proceed with anesthesia and surgery. Following induction of general anesthesia, his cardiac rhythm changed to a Mobitz type II pattern. The surgical procedure was cancelled, and a permanent cardiac pacemaker was inserted.ConclusionsAnesthesiologists should be aware that the presence of widely split P waves on electrocardiogram indicates the presence of atrial conduction abnormalities, likely from an ischemic or infiltrative process that can lead to more serious cardiac arrhythmias. P wave morphology should be observed and noted during the perioperative period for all patients.

Racial variation in baseline characteristics and wait times among patients undergoing bariatric surgery.

Although bariatric surgery is the most effective treatment for obesity and weight-related comorbid diseases, utilization rates are disproportionately low among non-white patients. We sought to understand if variation in baseline characteristics or access to care exists between white and non-white patients. Using a statewide bariatric-specific data registry, we evaluated all patients who underwent bariatric surgery between 2006 and 2020 and completed a preoperative baseline questionnaire, which included a question about self-identification of race. Patient characteristics, co-morbidities, and time from initial preoperative clinic evaluation to date of surgery were compared among racial groups. A total of 73,141 patients met inclusion criteria with 18,741 (25.5%) self-identified as non-white. These included Black/African American (n = 11,904), Hispanic (n = 3448), Asian (n = 121), Native Hawaiian/Pacific Islander (n = 41), Middle Eastern (n = 164), Multiple (n = 2047) and other (n = 608). Non-white males were the least represented group, accounting for only 4% of all bariatric cases performed. Non-white patients were more likely to be younger (43.0years vs. 46.6years, p < 0.0001), disabled (16% vs. 11.4%, p < 0.0001) and have Medicaid (8.4% vs. 3.8%, p < 0.0001) when compared to white patients, despite having higher rates of college education (78.0% vs. 76.6, p < 0.0001). In addition, median time from initial evaluation to surgery was also longer among non-white patients (157days vs. 127days, p < 0.0001), despite having higher rates of patients with a body mass index above 50kg/m2(39.0% vs. 33.2%, p < 0.0001). Non-white patients undergoing bariatric surgery represent an extremely diverse group of patients with more socioeconomic disadvantages and longer wait times when compared to white patients despite presenting with higher rates of severe obesity. Current guidelines and referral patterns for bariatric surgery may not be equitable and need further examination when considering the management of obesity within diverse populations to reduce disparities in care-of which non-white males are particularly at risk.

Association of Preoperative Pain Severity and Pain Catastrophizing with Increased Risk for Prolonged Postoperative Opioid Use

Prolonged postoperative opioid use (PPOU) is considered an unfavorable post-surgical outcome. Demographic, clinical, and psychosocial factors have been associated with PPOU, but methods to prospectively identify patients at increased risk are lacking. We sought to determine whether individual or a combination of several psychological factors could identify a subset of patients at increased risk for PPOU. We conducted a prospective cohort study of patients undergoing elective surgery at a single VA Medical Center. Participants were recruited from a preoperative anesthesia clinic where they were undergoing evaluation prior to elective surgery, and they completed a survey before surgery. The primary outcome was PPOU, defined as outpatient receipt of a prescribed opioid 31 to 90 days after surgery as determined from pharmacy records. Primary covariates of interest were pain catastrophizing, self-efficacy, and optimism. Additional covariates included social and demographic factors, pain severity, medication use, depression, anxiety, and surgical fear. Of 123 participants included in the final analyses, 30 (24.4%) had PPOU. In bivariate analyses, preoperative opioid use, preoperative NSAID use, and preoperative pain were significantly associated with PPOU. The combination of high pain catastrophizing and high preoperative pain (OR 3.32, 95% CI 1.41 - 7.79) was associated with higher odds of PPOU than either alone, and the association remained significant after adjusting for preoperative opioid use (OR 2.56, 95% CI 1.04 - 6.29). A combination of high pain catastrophizing and high preoperative pain has the potential to be a clinically useful means of identifying patients at elevated risk of PPOU. Grant support from AHRQ K12 HS023009.

Novel 3D MRI fusion penile imaging modality for Peyronie's disease: A pilot study

ABSTRACT Introduction Penile imaging for Peyronie's disease (PD) can be challenging. Traditional cross-sectional imaging modalities such as computerized tomography (CT) or magnetic resonance imaging (MRI) can delineate and characterize pathological penile anomalies; however, limitation in imaging interpretations do exist. Optimal imaging of the penis aids in surgical planning and patient counseling. Objective In this study, we aim to utilize a novel three-dimensional (3D) MRI fusion penile imaging modality for men undergoing surgical reconstruction for PD. Methods Men with PD, palpable plaques, and deformed corpora were included in this study. We obtained preoperative cross-sectional MRI penile images and Sexual Health Inventory for Men (SHIM) Questionnaire (SHIM) scores on all included patients. We fused MRI images with Ceevra (Ceevra, Inc., San Francisco, CA, USA) 3D imaging software to develop detailed imaging aiding surgical reconstruction. 3D models were used for preoperative patient counseling and surgical planning as well as intraoperatively. Results A total of six patients were included, 3 African American men and 3 White men. The mean age was 65 and mean BMI was 35. There was no difference in preoperative SHIM scores (4 severe and 2 mild erectile dysfunction). Preoperative MRI images were fused with Ceevra software to develop detailed 3D models of corporal plaques and its related structures. The 3D models were easily accessible to surgeons during preoperative clinic visits and at time of reconstruction (Figure 1). Conclusions In this study, 3D MRI fusion penile imaging for PD has emerged as a potential preoperative advanced imaging modality useful for preoperative counseling and planning, especially in complex PD cases. Further evaluation is prerequisite to evaluate its potential role in aiding intraoperative decision making. Disclosure Work supported by industry: no.

Impact of a geriatric assessment and optimisation-based preoperative clinic on the management of older patients receiving dental treatment under general anaesthetic or conscious sedation: A service evaluation.

The main objectives of the study were to review patient characteristics, recommendations made and treatment outcomes of frail/older patients referred to a specialist multidisciplinary geriatric assessment and optimisation-based preoperative clinic (PROKARE), prior to patients receiving dental treatment under general anaesthesia (GA) or conscious sedation (CS). Although the use of preoperative comprehensive geriatric assessment to improve pre/peri and postoperative mortality has been reported for many surgical domains, its use prior to dental surgery has not been reported previously. The data were collected retrospectively from the dental notes of 52 patients referred from the Special Care Dental (SCD) Department to the PROKARE service for optimisation prior to dental treatment under GA/CS using a case note study approach. The data extracted included patient demographic characteristics, medical history, clinical management and the treatment outcomes for each patient. The data extracted was analysed with descriptive statistics. Key reasons for referral were caries management, retained roots and poor co-operation. Multiple co-morbidities were noted among the patients referred, with 14 (27%) having four or more co-morbidities. The PROKARE assessment identified issues such as treatment could be carried out under CS instead of GA; consent; and the need for medication change and/or further medical investigations. As per recommendations from PROKARE, 39 patients (75%) received dental treatment while five (10%) did not receive treatment, and a further eight (15%) died prior to treatment. Geriatric assessment and optimisation-based preoperative clinics in the dental management of frail, elderly patients having treatment under GA or CS techniques is valuable, but further research and assessment of current service provision are needed to increase the evidence base.

The association between preoperative Mini-Cog\xa9 score and postoperative delirium (POD): a retrospective cohort study

BackgroundThe onset of delirium after major surgery is associated with worse in-hospital outcomes for major surgical patients. Best practice recommends assessing surgical patients for delirium risk factors and this includes screening for cognitive impairment. The Mini-Cog© is a short instrument which has been shown to predict postoperative delirium (POD) and other complications in elderly patients undergoing major elective surgery. The primary aim of this study was to ascertain whether a positive preoperative Mini-Cog© is associated with postoperative delirium in elective colorectal surgery patients at high-risk of mortality due to age or comorbidity. Secondary outcomes were 90-day mortality and length of stay.MethodsThis is a retrospective analysis of data gathered prospectively between October 2015 and December 2017. Baseline data were collected at a preoperative screening clinic, and postoperative data during daily ward rounds by the Perioperative Medicine team at The York Hospital.ResultsThree hundred nineteen patients were included in the final analysis, of which 52 (16%) were found to be cognitively impaired on the Mini-Cog©. Older patients (median difference 10 years, p < 0.001) and patients with cognitive impairment (OR 3.04, 95%CI 1.15 to 8.03, p = 0.019) were more likely to develop postoperative delirium in univariate analysis; however, cognitive impairment (OR 0.492, 95%CI 0.177 to 1.368, p = 0.174) loses its significance when controlled for by confounding factors in a logistic regression model. Cognitive impairment (OR 4.65, 95%CI 1.36 to 15.9, p = 0.02), frailty (OR 7.28, 95%CI 1.92 to 27.58, p = 0.009), American Society of Anesthesiologists (ASA) grade (OR 5.95, 95%CI 1.54 to 22.94, p = 0.006) and age (median difference 10 years, p = 0.002) were significantly associated with 90-day mortality in univariate analysis. Sex was the only factor significantly associated with length of stay in the multiple regression model, with males having a 3-day longer average length of stay than females (OR = 2.94, 95%CI 0.10–5.78).ConclusionsMini-Cog© is not independently associated with post-operative delirium in high-risk elective colorectal surgery patients in this cohort. Mini-Cog© shows promise as a possible predictor of 90-day mortality. Larger studies exploring preoperative cognitive status and postoperative confusion and mortality could improve risk-stratification for surgery and allocation of resources to those patients at higher risk.

Chronic Pain as a Complication in Open Inguinal Hernia Repair: A Retrospective Study of Consenting Practice in a Single Centre.

IntroductionInguinal hernia repair is one of the most commonly performed procedures in general surgery in the United Kingdom. Chronic pain as a long-term postoperative complication of this procedure has been extensively documented in the literature. However, this complication is often undisclosed during the consenting process. This omission impairs the patients’ informed decision-making process. The Montgomery v Lanarkshire Health Board case, in 2015, changed the way in which patient consent is viewed legally. This has made proper consent practices more important to surgeons undertaking procedures.AimThe objective is to assess if there has been an improvement in consenting practices by comparing consent forms from 2015 (the year of the Montgomery ruling) and 2019, specifically in regard to the risk of chronic groin pain following open inguinal hernia repair with mesh.MethodsThis was a retrospective review of patients who underwent open inguinal hernia repair using a prosthetic mesh in 2015 and 2019. The medical records were retrieved on the trust’s electronic medical record system using the patient's hospital number. The following parameters were obtained: patient demographics, preoperative clinic letters, operation notes and consent forms. The clinic letters and consent forms were systematically reviewed for any mention of chronic groin pain.ResultsIn 2015 and 2019, 163 and 56 open inguinal hernia repairs with mesh were performed, respectively. The median age of patients was 63 (28-88) and 64.5 (19-88) in the respective years. Throughout both years there was a predominance in male patients, and the majority of cases were performed on an elective basis. Consent for chronic pain was present in 60.7% and 62.5% of cases in 2015 and 2019, respectively (p=0.055).ConclusionDespite the importance of adequate consenting practice, we found no significant improvement in consenting practice for chronic pain following open inguinal hernia repair in the four years following the Montgomery ruling.