Preoperative Medical Management Research Articles

Rigid intramedullary nailing of lower limb segments in children and adolescents with metabolic bone disease.

Children and adolescents with metabolic bone disease present to the orthopedic surgeon with pain, fractures (which may be impending), and deformity. Different modalities of orthopedic management are available. Scant literature exists on the use of rigid intramedullary nailing in this population. This study sought to evaluate the utilization of this treatment modality in the pediatric cohort, focusing on indications, techniques, and outcomes of the procedures. A retrospective review was performed over an 11-year period at a single tertiary pediatric institution in the UK. Medical records and radiographs were reviewed. Preoperative surgical and medical management, time to bony union, and complications were specifically ascertained. Twenty-seven patients (63 lower limb segments) had rigid intramedullary nailing over the specified period. The majority of patients had an underlying diagnosis of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright Syndrome). Surgical indications included acute fractures, prophylactic stabilization, previous nonunion and malunions, deformity correction, and limb lengthening. All fractures healed and deformity correction was successful. In one patient, delayed union occurred after deformity correction and was successfully treated with dynamization. Fractures healed faster than corrective osteotomies. Complications included implant prominence, cortical penetrance, and screw loosening. Nonunion occurred with limb lengthening in one patient. Rigid intramedullary nailing is a safe and effective method of treatment for lower limb fractures and deformities in children and adolescents. This technique is, therefore, recommended for patients with metabolic bone disease. However, care must be taken in preoperative surgical planning and a multidisciplinary approach should be utilized.

Cost-effectiveness of preoperative pharmaceutical care consultations: a 5-year analysis

ObjectivesPreoperative medication errors can be prevented by screening patients through a preoperative pharmaceutical care consultation. The aim of this study was to analyse the cost-effectiveness of implementing such a consultation...

Association between diabetes mellitus and total hip arthroplasty outcomes: an observational study using the US National Inpatient Sample

ObjectivesTo investigate the association of diabetes with postoperative outcomes in patients undergoing primary total hip arthroplasty (THA).DesignRetrospective cohort study using data from the US National Inpatient Sample (NIS).SettingStudy cohort was...

Preoperative medication management turnkey order set for nonemergent adult cardiac surgery

ObjectiveThe management of preoperative medications is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Numerous guidelines and expert consensus documents have been published to provide guidance in preoperative medication management. Our objective is to integrate these documents into an evidence-based order set that will facilitate standardized implementation of best practices for preoperative medication management for nonemergent adult cardiac surgery. MethodsSubject matter experts were consulted to translate existing guidelines and peer reviewed literature into a sample turnkey order set for the preoperative management of patients’ medications. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type. ResultsHolding antiplatelet and anticoagulant medications before nonemergent cardiac surgical procedures may reduce the risk of bleeding. Sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 agonists should also be discontinued to prevent acidosis and aspiration, respectively. Specific guidance for frequently used medications are complied within the manuscript, less frequently used medications are listed seperately. ConclusionsDespite strong recommendations from major guidelines and consensus manuscripts, variation exists in preoperative medication orders, with limited availability of succinct implementation tools. This turnkey order set may facilitate standardized comprehensive preoperative medication management before nonemergent cardiac surgery.

Incidental but Not Insignificant: Thyroid Cancer in Patients with Graves Disease.

Graves disease is the most common cause of hyperthyroidism in the US. Treatment with antithyroid drugs and radioactive iodine is more commonly used than surgical management with total thyroidectomy (TTx). However, incidentally discovered thyroid cancer (TC) has been described on surgical pathology from patients who underwent surgical treatment of Graves disease, which would be missed with these other treatment strategies. We sought to determine the incidence rate of TC among patients with surgically treated Graves disease. We retrospectively reviewed patients with Graves disease who underwent TTx at a single institution from 2011 to 2023. Pathology reports were reviewed for TC. Patient demographics, preoperative laboratory and radiological evaluations, preoperative medical management, and surgical outcomes were compared between patients with and without incidental TC. There were 934 patients, of whom 60 (6.4%) patients had incidentally discovered TC on pathology. The majority (58.3%) of patients had papillary thyroid carcinoma, followed by 33.3% with papillary microcarcinoma. Preoperative ultrasound (US) was obtained in 564 (60.4%) of patients, with 44.3% with nodules, but only 34 (13.7%) of those with nodules had TC on final pathology. Preoperative fine needle aspiration was obtained in 15 patients with TC, and 8 patients (53.3%) were reported as benign lesions, which ultimately had TC on final pathology. There was no difference in sex, race or ethnicity, preoperative medical management, and postoperative outcomes between the 2 groups. Incidental TC was found on surgical pathology in 6.4% of patients undergoing TTx for Graves disease. Preoperative imaging with US and fine needle aspiration were often unreliable at predicting TC. The incidence of TC should not be underestimated when counseling patients on definitive management for Graves disease.

The combination of doxazosin and metyrosine as a preoperative treatment for pheochromocytomas and paragangliomas.

Preoperative medical management is critical to prevent intraoperative cardiovascular complications in patients with pheochromocytomas and paragangliomas (PPGLs). Initial treatment involves α-adrenergic receptor blockers. However, while the routine use of metyrosine alongside these blockers is not strongly recommended due to a lack of evidence supporting its efficacy and associated safety concerns, there are previous studies on combination therapy with phenoxybenzamine and metyrosine. There are few reports on combination therapy with the selective α1-adrenergic receptor blocker doxazosin. Therefore, we investigated this combination treatment, which theoretically can affect perioperative outcomes in patients with PPGLs. To our knowledge, this is the first such study. This retrospective single-center observational study involved 51 patients who underwent surgical resection of PPGLs at Kobe University Hospital between 2014 and 2022. All patients received doxazosin at maximum doses. Fourteen patients received concomitant metyrosine, while 37 received doxazosin alone. Their perioperative outcomes were compared. No severe event, such as acute coronary syndrome, was observed in either group. Intraoperatively, the doxazosin + metyrosine group exhibited a lower median minimum systolic blood pressure (56 [54-60] vs. 68 [59-74] mmHg, P = 0.03) and required lower median remifentanil (P = 0.04) and diltiazem (P = 0.02) doses than the doxazosin-alone group. The combination of metyrosine and doxazosin as a preoperative treatment for PPGLs affects intraoperative circulatory hemodynamics, such as a reduced occurrence of blood pressure elevation during surgery. Further research is necessary to identify patients who will benefit most from this combination treatment.

Surveillance and risk factors for early restenosis following transcarotid artery revascularization

ObjectiveRestenosis after transcarotid artery revascularization (TCAR) is a known complication. When identified in the early postoperative period, it may be related to technique. We evaluated our TCAR experience to identify potentially modifiable factors impacting restenosis. MethodsThis is a single-institution, retrospective review of patients undergoing TCAR from November 2017 to July 2022. Restenosis was defined as >50% stenosis on duplex ultrasound (DUS) examination or computed tomographic angiography (CTA). Continuous variables were compared using Kruskal-Wallis's test. Categorical variables were compared using the Fisher's exact test. ResultsOf 61 interventions, 11 (18%) developed restenosis within the median follow-up of 345 days (interquartile range, 103-623 days). Among these patients, 82% (9/11) had >50% stenosis, and 18% (2/11) had >80% stenosis. Both patients with high-grade restenosis were symptomatic and underwent revascularization. Diagnosis of post-TCAR restenosis was via DUS examination in 45% (5/11), CTA in 18% (2/11), or both CTA/DUS examination in 36% (4/11). Restenosis occurred within 1 month in 54% (6/11) and 6 months in 72% (8/11) of patients. However, three of the six patients with restenosis within 1 month had discordant findings on CTA vs DUS imaging. Patient comorbidities, degree of preoperative stenosis, medical management, balloon size, stent size, lesion characteristics, and predilatation angioplasty did not differ. Patients with restenosis were younger (P = .02), had prior ipsilateral endarterectomy (odds ratio [OR], 6.5; P = .02), had history of neck radiation (OR, 18.3; P = .01), and lower rate of postdilatation angioplasty (OR, 0.11; P = .04), without an increased risk of neurological events. ConclusionsAlthough post-TCAR restenosis occurred in 18% of patients, only 3% of patients had critical restenosis and required reintervention. Patient factors associated with restenosis were younger age, prior endarterectomy, and history of neck radiation. Although early restenosis may be mitigated by improved technique, the only technical factor associated with restenosis was less use of postdilatation angioplasty. Balancing neurological risk, this factor may have increased application in appropriate patients. Diagnosis of restenosis was inconsistent between imaging modalities; current surveillance paradigms and diagnostic thresholds may warrant reconsideration.

Impact of preoperative pharmaceutical care consultation on medication errors in surgical patients: a comprehensive analysis

ABSTRACT Objective Assessing the impact of introducing preoperative pharmaceutical care consultations by analyzing the severity of prevented medication errors (MEs) and their potential effects on the surgical process. Methods Preoperative pharmaceutical care consultation was implemented in our hospital to assess the preoperative medication management of surgical patients between the pre-anesthesia consultation and the day of surgery. Pharmacists evaluated the appropriateness of medication management based on a consensus multidisciplinary institutional protocol. All errors identified between 2016 and 2020 were analyzed, and their severity and potential impact on surgery were standardized. A list of therapeutic groups was created to prioritize patients for consultations Results During the study period, 3,105 patients attended the consultations and 1,179 MEs were prevented. According to severity, 30.6% of MEs were classified as category E and 26.2% as D. The Number Needed to Treat to prevent a category E or higher ME (indicating potential harm to patients) was 5 patients. About 14.84% of MEs belonged to the prioritized drug groups. One hundred and thirteen errors would have resulted in a surgery delay of more than 24 h, and 175 errors were classified as G-H (irreversible damage). Conclusions This study highlights the effectiveness of pharmaceutical care consultations in preventing MEs and improving surgical outcomes.

Shoulder endoprosthesis-When and which model?

Advanced omarthritis or an irreparable lesion of the rotator cuff are indications for the implantation of ashoulder prosthesis. Several models are available and the choice of model depends on the specific pathology of the patient. Preoperative medication management must be taken into account in rheumatism patients. The correct aftercare is essential for the proper functioning of the prosthesis.

Patient pathways to bariatric surgery: What preoperative medical weight management programs exist globally – Results of an international survey

Patient pathways to bariatric surgery: What preoperative medical weight management programs exist globally – Results of an international survey

Analysing and improving preoperative medication management in cardiac surgery.

The objective of this study was to analyse the preoperative medication management within the cardiac surgery patient population and measure the effectiveness of an interprofessional intervention in routine care. A jointly developed preoperative medication management was implemented in routine care on multiple levels (inclusion in admission letter to primary care, hotline for inquiries, pocket cards for physicians and correspondence with referring centres). The effectiveness was evaluated by analysing preoperative management before and after implementation. The primary endpoint was the number of drugs managed correctly according to the guidelines after implementation. Secondary endpoints consisted amongst others of bleeding on the intensive care unit, re-thoracotomy, postoperative infarction and cerebrovascular complications. Additionally, possible associations between the correct management and different variables were investigated by multivariate analysis. After the implementation, the number of drugs managed correctly according to guidelines increased from 54.0 to 73.5% (P< .001). The effect was more prominent for direct oral anticoagulants and prophylactic aspirin where the guideline adherence increased from 29.2 to 74.5% and from 78.6 to 95.1%, respectively. No difference was seen for sodium-glucose transporter-2 inhibitors, metformin, vitamin-K antagonists and dual-antiplatelet therapy. Secondary endpoints showed no safety signals with regard to bleeding or thrombotic events. In multivariate analysis, the intervention was effective (odds ratio 2.17, 95% confidence interval [1.32-3.62]) after adjusting for possible confounders. An interprofessional programme was effective to improve preoperative medication management in cardiac surgery patients. Sodium-glucose transporter-2 inhibitors, metformin and direct oral anticoagulants appear to be especially at risk for incorrect management before cardiac surgery with possible adverse events.

Implementation of an enhanced recovery after surgery program including a patient school: Impact on quality of life results

IntroductionEnhanced Recovery After Surgery (ERAS) protocols and educational programmes have been shown to accelerate orthopaedic surgery recovery with fewer complications, and improve patient-reported outcomes (PROs) for different types of surgery. The objective was to evaluate the impact of an ERAS programme including a patient school on health outcomes and PROs for Total Knee Replacement (TKR) surgery. Material and methodsA multidisciplinary group created the programme and the patient school (preoperative consultations where the patients’ surgical processes are explained and are also given instructions for an appropriate perioperative care management). An observational, prospective study was conducted on all patients operated for TKR from March 2021 to March 2022. Main health outcomes were: hospital stay length, surgical complications and surgery cancellations due to a wrong preoperative medication management. PROs evaluated were: patient satisfaction with pain management, the school, and quality of life before and after surgery (EQ-5D). ResultsOne hundred thirty-three patients were included. Median hospital stay length was 3 days (IQR 3-5). Rate of surgical complications was 25.6%. No surgery was cancelled. Patient satisfaction rates with pain management and with the school were 8.10/10 and 9.89/10, respectively. Concerning quality of life, mean improvement in mobility and knee pain after the surgery was 0.66 (p < 0.05) and 0.84 (p < 0.05), respectively. ConclusionsThe ERAS programme including a patient school was highly successful with a fast recovery, a short hospital stay length, no surgery cancellations, and improved PROs.

Lower Extremity Amputations Among Veterans: Have Ambulatory Outcomes and Survival Improved?

We hypothesize among patients undergoing lower extremity amputation, access to pre-, and post operative rehabilitation services; as well as improved medical care, have led to higher rates of postoperative ambulation, and improved survival. Retrospective single center review of all major lower extremity amputations performed at the Greater Los Angeles Veterans Affairs Healthcare System from 2000-2020 stratified into multiyear cohorts. We abstracted demographics, operative indication, comorbidities, preoperative medical management, perioperative complications, discharge location, and pre and postoperative ambulatory status. Odds of ambulation after amputation were analyzed using multivariate logistic regression. Survival was analyzed using multivariate logistic regression and Kaplan-Meier survival analysis. Multivariate logistic predictors were selected based on prior literature and clinical experience. We identified 654 operations in our study, noting fewer amputations performed in the latest 3 cohort years as compared to the initial cohort (2000-2004). Patients undergoing below-knee amputations (BKA) had 2.7 times (P<0.05) greater odds of postoperative ambulation and 86% (P<0.05) increased odds of survival compared to above-knee amputations (AKA). The odds of ambulation increased by 8.8% (P<0.05) for each consecutive study year. Ambulation post-amputation conferred 13.2 times (P<0.05) greater odds of survival. The odds of survival in "emergent" operations decreased by 48% (P<0.05) compared to an "elective" operation. For each additional comorbidity, the odds of survival decreased by 18% (P<0.05). Patients with any perioperative complication had a 48% (P<0.05) lower odds of survival. Kaplan-Meier survival estimates demonstrated significant survival difference between patients by amputation level and postoperative ambulatory status (P<0.05). Ambulatory status following distal amputation has improved over time and is significantly associated with increased survival post-amputation. Patients undergoing a BKA or discharged home were most likely to ambulate postoperatively. Amputation level, preoperative comorbidities, and perioperative complications remain strong predictors of survival.

Optimization of the Ocular Surface Through Treatment of Ocular Surface Disease Before Ophthalmic Surgery: A Narrative Review.

Ocular surface disease commonly exists in individuals requiring ophthalmic surgery and may compromise the structure and function of ocular surface components. Ophthalmic surgery may further affect the ocular surface by injuring the epithelium and sensory nerves, disrupting the tear film, or causing local inflammation. Medical management of ocular surface disease prior to ophthalmic surgery aids in reducing inflammation, resolving infection, improving epithelial pathology, stabilizing the tear film, and easing patient symptoms, promoting positive long-term outcomes and minimizing the incidence of postoperative complications. This review summarizes frequently encountered ocular surface diseases and available preoperative medical management options, discusses common ophthalmic surgeries and their effects on the ocular surface, examines potential postoperative complications, and defines recommendations for postoperative ocular surface maintenance.

A multi-institutional approach for decreasing narcotic prescriptions after laparoscopic appendectomy.

BackgroundAppendicitis is a common indication for surgical hospital admission. Uncomplicated appendicitis is typically treated with surgical intervention, most commonly a laparoscopic appendectomy. As with many procedures, narcotic utilization is highly varied among surgeons for postoperative pain control. With the opioid epidemic and a demonstrated link between excessive narcotic prescriptions paving the way to dependence and addiction, it is more important than ever to decrease the circulation of these medications. We hypothesized that a perioperative, multimodal analgesia strategy coupled with monthly feedback reports comparing hospitals narcotic prescribing habits would decrease, and in some cases eliminate, the use of outpatient narcotics in adults after laparoscopic appendectomy.MethodsA quality improvement project was initiated to provide monthly feedback to surgeons on narcotic prescribing habits after adult laparoscopic appendectomies. A multi-hospital database was created to include adult patients that were diagnosed with acute appendicitis, treated with laparoscopic appendectomy, and discharged within 48 h of surgery. The database provided information regarding the number of narcotic doses prescribed on discharge. Participating hospitals selected a site champion who distributed monthly prescribing reports. A protocol was created and distributed to participating sites that provided a guideline for preoperative and postoperative pain medication management. The intervention period was 10/1/2019–3/31/2020. We utilized the preceding year’s data (October 1, 2018–September 30, 2019) as the pre-intervention control group. We also compared results between local and distant sites to see if personal connection to surgeons influenced the results.ResultsA total of 1785 appendectomies were performed during the study period at participating hospitals. The average number of prescribed narcotics decreased from 23.6 doses during the control period to 14.2 during the intervention (p < 0.001). There was no change in the number of total narcotic prescriptions (8.9 vs 7.9%, p = 0.52). Overall, the average number of narcotics prescribed decreased by 40% with similar decrease in average prescribed narcotics for local and distant hospitals, respectively (47.7% vs 42.1%). Average narcotic dose during the first 2 months of intervention at the local hospitals was 9.7 and 11.1 for the last 2 months of intervention (p = 0.69). Average narcotic dose during the first 2 months of intervention at the distant hospitals was 19.5 and 13.4 for the last 2 months of intervention (p = 0.005).ConclusionA multimodal pain regimen combined with a monthly narcotic prescription report provided to prescribers decreases the average number of narcotic prescriptions after laparoscopic appendectomy. Local sites demonstrated immediate decrease in narcotic utilization compared to distant sites whose change occurred more gradually.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-022-09107-y.

Association between insurance-mandated precertification criteria and inpatient healthcare utilization during 1 year after bariatric surgery.

Insurance-mandated precertification requirements are barriers to bariatric surgery. The value of their prescription, based on insurance type rather that the clinical necessity, is unclear. To determine whether there is an association between insurance-mandated precertification criteria for bariatric surgery and short-term inpatient healthcare utilization. Pennsylvania Health Care Cost Containment Council's inpatient care databases for the years 2016-2017. The study included 2717 adults who underwent bariatric surgery in Southeastern Pennsylvania in 2016. Postoperative length of stay and rehospitalizations for these individuals were followed using clinical and claims data during the first year after bariatric surgery. The requirements for 3- to 6-month preoperative medical weight management, as well as pulmonology and cardiology examinations, were not associated with the patient length of stay, number of all-cause rehospitalizations, or number of all-cause rehospitalization days after adjusting for patient age, sex, race, ethnicity, the Elixhauser comorbidity score, type of the surgery, facility where the surgery was performed, primary payer type, and the estimated median household income. Among commercially insured individuals (n = 1499), the mean number of all-cause rehospitalizations during the study period was lower in patients with no medical weight management requirement by a factor of .57 (lower by 43.1%; 95% confidence interval, .35-.94, P = .03) and higher in patients with no requirement for preoperative cardiology and pulmonology evaluations by a factor of 2.09 (95% confidence interval 1.09-4.02, P = .03). The findings suggest that the precertification requirement for preoperative medical weight management is not associated with a reduction in inpatient healthcare utilization in the first postoperative year.

Preoperative Medication Management, Compliance and Adverse Events in Adult Patients Undergoing Elective Surgery: A Historical Chart Review

Purpose: Medication compliance for chronic medications has been well studied, but there is a gap in the literature regarding compliance within the perioperative period. Our objective was to determine the incidence of patient non-compliance with preoperative medication instructions for adult non-emergent surgery. Additional objectives were to identify predictors of compliance, describe medication instructions by drug type, and explore the impact of non-compliance. Patients and Methods: This historical chart review evaluated preoperative compliance to medication instructions in 393 adults undergoing non-emergent surgeries at Hamilton Health Sciences between May 1, 2012, and April 30, 2013. Seven patient factors (age; sex; American Society of Anesthesiologists class; number of medications; type of surgery; time between preoperative appointment to surgery; the individual collecting the medication list) were evaluated as potential predictors of non-compliance and analyzed using logistic regression analysis. Consequences of non-compliance were assessed by impact on intraoperative blood pressure, blood glucose level, drop in hemoglobin, bronchospasm, and case delays. Results: One hundred forty-six (37.2%) patients were non-compliant with one or more medication reconciliation instructions provided by the anesthesiologist. No significant associations were observed for any patient risk factors and non-compliance. Non-compliance was not associated with any clinically significant consequences. Conclusions: Our study shows that 37.15% of adult patients undergoing non-emergent surgery were non-compliant with medication instructions, although patients did not receive any written instructions for 46% of their medications. We did not identify any predictive patient factors or adverse outcomes associated with non-compliance.

Surgical management of parotid non-tuberculous mycobacteria lymphadenitis in children: A pediatric tertiary-care hospital's experience

ObjectiveNon-tuberculous mycobacteria (NTM) represents an important etiology of cervicofacial lymphadenitis (CFL) and skin/soft tissue infections in children. It can also affect the salivary glands, including the parotid gland, which is unique due to the presence of intra-salivary lymph nodes. There are no established guidelines for treatment of NTM CFL. NTM lymphadenitis was historically surgically treated; recently the literature supports initial medical treatment. Treatment decisions have been dependent on the extent of disease, preference of providers, and risk of surgical complications. The goal is to report our experience in surgical outcomes of NTM CFL with involvement of the parotid gland after pre-operative medical management. MethodsA retrospective case series of patients with NTM affecting the parotid gland at a tertiary care pediatric hospital between 2004 and 2020. ResultsSeventy-two patients were referred for surgical evaluation of possible parotid NTM. Thirty-three patients underwent surgical excision. Fifteen patients were identified with presumed NTM infection involving the parotid gland. There were twelve females and three males with a mean age of 2.0 years (SD 1.55; range 1–6 days) at the time of surgery. All underwent surgical excision with parotidectomy. The most common pre-operative antimycobacterial therapy used was a combination of clarithromycin and rifampin. All 15 patients had pathological findings consistent with NTM infection (granulomatous lymphadenitis). Forty percent (n = 6) of patients had positive stains with acid-fast bacilli (AFB), with Mycobacterium avium as the most common species (n = 5). The majority of patients, 86.67% (n = 13), had complete resolution of infection after surgery. Clarithromycin and rifampin were the most common post-operative antimycobacterial treatment (mean 81.5 days, SD 110.14, range 2–411 days). The most common complication experienced was acute (<3 months) lower facial nerve paresis (40%, n = 6), but no patient had permanent facial paralysis. Conclusion and RelevanceParotidectomy is a safe and efficacious treatment in patients with NTM CFL affecting the parotid gland after incomplete resolution with antimycobacterial therapy. Further investigation to optimize duration of antimycobacterial treatment is necessary. We highlight the experience of a high-volume tertiary care pediatric hospital with surgical management of this disease.

Neurosurgical intervention in children with ventricular assist devices: A single-center case series review.

The incidence of neurological complications related to ventricular assist devices (VAD) remains high and includes life-threatening conditions such as intracranial hemorrhage or ischemic stroke. Although no definitive management guidelines exist, operative interventions may be required for major neurological injuries. This case series describes the perioperative management of children at a single center who underwent neurosurgical procedures for major intracranial bleeds or ischemic strokes while on VAD support. A database review identified all pediatric VAD patients who underwent a neurosurgical procedure for an intracranial hemorrhage or ischemic stroke from April 2014 to January 2020. Data regarding patient characteristics, preoperative medical management, intraoperative anesthetic management, and postoperative outcomes were collected using retrospective chart review. Ninety VADs were implanted in 78 patients. Five neurosurgical interventions were performed: four for intracranial hemorrhages and one for an ischemic stroke. All four patients with hemorrhages were receiving anticoagulation at the time of their event and the three patients on warfarin received emergent reversal with prothrombin concentrate complex and vitamin K. Three patients also received pre-procedural platelet transfusions. Two of the five procedures were emergent bedside external ventricular drain placements, and three were surgical operations. All three patients who underwent operative procedures received invasive hemodynamic monitoring and were supported with a combination of inotropes and afterload reduction. One patient required a massive blood product transfusion. The two patients who underwent external ventricular drain placement had no further surgical interventions and died from the severity of their neurological injuries. All three patients who underwent operative procedures survived to transplantation and discharge home. Perioperative concerns for the anesthesiologist include VAD hemodynamic management, bleeding, VAD thrombosis, and prevention of secondary brain injury. A systematic, multidisciplinary approach to management is paramount to attain favorable outcomes.

Effect of Preoperative Aspirin, Beta-Blocker, and Statin Usage on Perioperative and One-Year Mortality of Abdominal Aortic Aneurysm Repair

Improved perioperative management and surgical techniques have significantly reduced morbidity and mortality after abdominal aortic aneurysm (AAA) repair in recent years. However, guidelines remain unclear regarding the role of preoperative medical management in long-term outcomes. Aspirin, statins, and beta-blockers have individually shown promising Results, but data assessing the efficacy and combinative effect remain limited. In our study, we evaluated the association between the preoperative use of these pharmacotherapeutic agents and the postoperative and long-term outcomes of AAA repair in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network.