Preoperative Medication Research Articles

Impact of regional anesthesia on outcomes of geriatric patients undergoing lower extremity revascularization: A propensity score-matched cohort study.

Lower extremity revascularization (LER) for peripheral artery disease in elderly patients is associated with a high risk of perioperative morbidity and mortality. This study aimed to a conduct retrospective review and propensity score matching analysis to determine whether the use of regional anesthesia (RA) instead of general anesthesia (GA) in geriatric patients undergoing LER for peripheral artery disease results in improved short-term mortality and health outcomes. We reviewed medical records of 1271 patients aged >65 years who underwent LER at our center between May 1998 and February 2016. According to the anesthesia method, patients were grouped in the GA and RA groups. The primary outcome was short-term mortality (7-day and 30-day). The secondary outcomes were 5-year survival rate, intraoperative events, postoperative morbidity, and postoperative length of stay. A propensity score-matched cohort design was used to control for potentially confounding factors including patient demographics, comorbidities, American Society of Anesthesiologists physical status, and preoperative medications. After propensity score matching, 722 patients that received LER under GA (n = 269) or RA (n = 453) were identified. Patients from the GA group showed significantly higher 7-day mortality than those from the RA group (5.6% vs 2.7% P = .048); however, there was no significant difference in 30-day mortality between the groups (GA vs RA: 6.3% vs 3.6%, P = .083). The 5-year survival rate and incidence of arterial and central venous catheter placement or intraoperative dopamine and epinephrine use were significantly higher in the GA group than in the RA group (P < .05). In addition, the frequency of immediate postoperative oxygen therapy or mechanical ventilation support was higher in the GA group (P < .05). However, there was no difference in the postoperative cardiopulmonary and cerebral complications between the 2 groups. These results suggest that RA can reduce intraoperative hemodynamic support and provide immediate postoperative respiratory intensive care. In addition, the use of RA may be associated with better short-term and 5-year survival rates in geriatric patients undergoing LER.

Characteristics of Electroencephalogram in the Prefrontal Cortex during Deep Brain Stimulation of Subthalamic Nucleus in Parkinson's Disease under Propofol General Anesthesia.

Monitoring the depth of anesthesia by electroencephalogram (EEG) based on the prefrontal cortex is an important means to achieve accurate regulation of anesthesia for subthalamic nucleus (STN) deep brain stimulation (DBS) under general anesthesia in patients with Parkinson's disease (PD). However, no previous study has conducted an in-depth investigation into this monitoring data. Here, we aimed to analyze the characteristics of prefrontal cortex EEG during DBS with propofol general anesthesia in patients with PD and determine the reference range of parameters derived from the depth of anesthesia monitoring. Additionally, we attempted to explore whether the use of benzodiazepines in the 3 days during hospitalization before surgery impacted the interpretation of the EEG parameters. We included the data of 43 patients with PD who received STN DBS treatment and SedLine monitoring during the entire course of general anesthesia with propofol in a single center. Eighteen patients (41.86%) took benzodiazepines during hospitalization. We divided the anesthesia process into three stages: awake state before anesthesia, propofol anesthesia state, and shallow anesthesia state during microelectrode recording (MER). We analyzed the power spectral density (PSD) and derived parameters of the patients' prefrontal EEG, including the patient state index (PSI), spectral edge frequency (SEF) of the left and right sides, and the suppression ratio. The baseline characteristics, preoperative medication, preoperative frontal lobe image characteristics, preoperative motor and non-motor evaluation, intraoperative vital signs, internal environment and anesthetic information, and postoperative complications are listed. We also compared the groups according to whether they took benzodiazepines before surgery during hospitalization. The average PSI of the awake state, propofol anesthesia state, and MER state were 89.86 ± 6.89, 48.68 ± 12.65, and 62.46 ± 13.08, respectively. The preoperative administration of benzodiazepines did not significantly affect the PSI or SEF, but did reduce the total time of suppression, maximum suppression ratio, and the PSD of beta and gamma during MER. Regarding the occurrence of postoperative delirium and mini-mental state examination (MMSE) scores, there was no significant difference between the two groups (chi-square test, p = 0.48; Mann-Whitney U test, p = 0.30). For the first time, we demonstrate the reference range of the derived parameters of the depth of anesthesia monitoring and the characteristics of the prefrontal EEG of patients with PD in the awake state, propofol anesthesia state, and shallow anesthesia during MER. Taking benzodiazepines in the 3 days during hospitalization before surgery reduces suppression and the PSD of beta and gamma during MER, but does not significantly affect the observation of anesthesiologists on the depth of anesthesia, nor affect the postoperative delirium and MMSE scores.

Effectiveness and safety of VISULAS® green selective laser trabeculoplasty: a prospective, interventional multicenter clinical investigation

PurposeTo evaluate the effectiveness and safety of Selective Laser Trabeculoplasty (SLT) with the SLT mode of the VISULAS® green laser in patients with primary open-angle glaucoma (POAG).MethodsThis prospective, interventional multicenter clinical investigation included patients with POAG who either needed a treatment escalation because the individual intraocular pressure (IOP) target was not met or treatment initiation and had an IOP ≥ 17 mmHg at baseline in the study eye. The study was conducted in five research centers across Germany. Approximately 100 laser applications were delivered to 360° of the trabecular meshwork. Glaucoma medications were not modified during the 3-month follow-up to allow evaluation of the sole effect of VISULAS® green with SLT. Efficacy outcomes were postoperatively absolute and relative IOP changes at 1 and 3 months. Safety outcomes analyzed the rate of intra- and postoperative adverse events.ResultsThirty-four eyes of 34 POAG patients were included. The overall mean number of preoperative glaucoma medications was 2.2 ± 1.4 in 29 treated eyes, 5 eyes were treatment naïve. Mean baseline IOP (mmHg) was 21.0 ± 2.69 and was reduced by − 3.53 ± 3.34 [95% CI − 4.61; − 2.45] and − 3.59 ± 3.41 [95% CI − 4.64; − 2.53] at the 1- and 3-month follow-up, respectively (p < 0.0001), with 48.5% of cases achieving a ≥ 20% IOP reduction at 3 months [95% CI = 30.8%; 66.5%]. The mean relative IOP reduction was − 16.4% and − 16.3% at 1 and 3 months, respectively (p < 0.0001). Potentially device- or procedure-related adverse events were mild to moderate and included 3 postoperative IOP-spikes and 6 reports regarding eye pain and discomfort. All were resolved without sequelae.ConclusionsSLT performed with the VISULAS® green laser achieved clinically significant additional IOP reductions in medically treated as well as in treatment naïve eyes with POAG and there were no relevant safety issues. The results are comparable to other reported SLT studies.

ALIGN-CARE: IMPLEMENTATION AND FEASIBILITY OF NEW GERIATRIC SURGERY CO-MANAGEMENT MODEL FOR PHYSICAL AND SOCIAL FRAILTY

Abstract Pre-operative geriatric evaluation in frail older patients that addresses both medical and psychosocial needs is often not completed prior to surgery, leaving frail older adults ill prepared for surgery. The ALIGN-CARE interprofessional co-management model uniquely serves to standardize care and coordination amongst the surgeon, geriatrician and social worker in ambulatory settings to allow a greater window of time to intervene for surgical optimization. Program elements include assessment of preoperative medications, functional status, cognition, nutrition, What Matters Most, advance care planning (ACP), and social determinants of health. Recommendations and action items from the geriatric-social work team are presented to surgeon and primary care physicians for follow-up and optimization. Program and process elements recorded in a REDCap database facilitate longitudinal evaluation of ALIGN-CARE model implementation feasibility. Initial data of 9 frail surgical oncology patients indicate increases in meaningful ACP discussions, patient-oriented decisions regarding surgery candidacy, and surgeon referrals for inpatient geriatric consultation post-operatively as a result of ALIGN-CARE. Current analyses to assess feasibility and quality of the program include thematic coding of program documents, semi-structured interviews of key stakeholders (surgeons, geriatricians, social workers, patients), and quantitative analysis of program outcomes, including uptake of program elements and process measures. Planned areas of analytic focus include workflow, cross-specialty coordination, and patient and primary care engagement and activation. We anticipate identifying specific barriers and facilitators of ALIGN-CARE implementation in our evaluation to aid the dissemination and upscaling of interprofessional co-management programs aimed to improve outcomes and quality of life for frail, older surgical patients.

Cold-stored Platelets for Bleeding Patients: Comment.

We read with great interest the recent article published in Anesthesiology by Strandenes et al., titled “A Pilot Trial of Platelets Stored Cold versus at Room Temperature for Complex Cardiothoracic Surgery.”1 We congratulate the authors on their pioneering work in the field of transfusion medicine and efforts to identify methods to prolong the shelf life of platelets and preserve its efficacy.2,3 We have a few comments.First, we were surprised to see that the authors used the clinical assessment, chest tube output, as the primary outcome, because cardiothoracic surgery is an extremely complex procedure that will potentially introduce multiple confounding factors for clinical outcome, such as surgical technique and patient’s baseline characteristics. In this specific study, we noticed a large difference in the logistic Euro-score, the percentage of patients receiving preoperative antiplatelet medication, and the percentage of patients who had previous sternotomy among the three groups, which will all affect the chest tube output and the need for blood transfusion. With a relatively small sample size as a pilot study, the possibility of detecting a difference in clinical outcome is reduced. We are wondering what the rationale was for the authors to choose chest tube output as the primary endpoint instead of a laboratory analytical result?Second, under the safety endpoints, there appears to be a large difference in terms of time to extubation among the three groups. Could the authors kindly provide an explanation for this and the perceived potential impact on patient care?Third, we are wondering if the authors could comment on how the cold stored platelets were transfused? Were they thawed and warmed up to room temperature before transfusion or were they transfused over fluid warmer directly? What was the turnaround time for this practice? Because most intraoperative transfusions are deemed to be urgent in nature, excessive preparation time for blood products should be avoided.Last, we would like the authors to provide more detail on their practice and decision-making in ordering blood products. Because a lot of clinicians would order blood products during the rewarming phase of the cardiopulmonary bypass based on the laboratory results, was there a similar practice at the authors’ institution? This detail in clinical practice could help us to determine if the difference in blood product utilization was actually associated with intervention (transfusion of different types of platelets), or if it was a reflection of empirical practice.Cold stored platelets have been reported to be effective in trauma patients with active bleeding.4,5 No doubt, immediately postoperative patients after cardiothoracic surgery are another major group of patients that can benefit from this practice. We look forward to reading the authors’ future pivotal trial results!Support was provided solely from institutional and/or departmental sources.The authors declare no competing interests.

Factors predicting treatment success in mixed urinary incontinence treated with midurethral sling.

We aimed to investigate success rates and predictive factors for midurethral slings (MUS) in women with mixed urinary incontinence (MUI). Women with MUI (urodynamically diagnosed detrusor overactivity and stress urinary incontinence) treated with MUS between 2013 and 2020 were retrospectively investigated. Prior to MUS, all participants completed bladder diary and questionnaires and underwent a urodynamic study. Six months after surgery, patients were evaluated for lower urinary tract symptoms with pelvic examination, pad test, and the 8-item Overactive Bladder Questionnaire (OAB-V8) and the International Consultation on Incontinence Questionnaire-Short-Form (ICIQ-SF). Success rates after MUS were determined separately according to the predominant component of MUI. In addition, multivariable logistic regression analysis was used to determine the most important independent variables affecting the surgical outcome. There were 117 participants. The overall MUI cure rate was 73.5%, but surgical success in the presence of postoperative urgency was 60.7%. Moreover, MUS success rate was 84.8% in those with preoperative stress-dominant MUI. However, the success rates for equally and urgency-dominant MUI were both 29.4%. Preoperative OAB-V8 score, symptom duration >9.5 years, and preoperative anticholinergic medication were risk factors for persistent urgency and urgency urinary incontinence (UUI) postoperatively (p < .05). In addition, diabetes mellitus (DM) for persistent urgency and voiding frequency (daily) for persistent UUI were predictive factors (p < .05). MUS may be offered to women with stress-dominant MUI. However, postoperative urgency might change a patient's perception of treatment despite successful incontinence treatment. MUS does not appear to be a good option when MUI patients have a high OAB-V8 score, symptom duration >9.5 years, DM, or use of anticholinergic medication preoperatively.

Prognostic Factors for Surgically Managed Spontaneous Spinal Epidural Hematoma: A Single-Center Case Series of 18 Patients.

Spontaneous spinal epidural hematoma (SSEH) is a rare pathology, which carries a significant morbidity. To review our institutional experience of surgically managed patients with SSEH, seeking to better understand clinical prognostic factors related to postoperative outcomes and thereby improve counseling of patients before treatment. All patients who underwent surgical management of SSEH between September 2011 and 2021. Baseline and postoperative clinical and radiological characteristics are presented, including the American Spinal Injury Association grade (ASIA). Statistical analyses were performed using Stata 13.1. Eighteen patients were identified in total (11 male patients and 7 female patients) with a median age of 59.5 (range 3-83) years. The most common spinal region affected was cervicothoracic (33.3%). Limb weakness (94.4%) and urinary dysfunction (83.3%) represented the most common presenting symptoms. Preoperatively, the presence of spinal cord edema on imaging was associated with worse preoperative Medical Research Council (MRC) grade ( P = .033), female sex was associated with preserved saddle sensation ( P = .04), and patients receiving antiplatelet medication were associated with a higher risk of preoperative axial back pain ( P = .005). Higher postoperative MRC grade was associated with higher preoperative ASIA ( P = .012) and MRC grade ( P = .005), and preservation of saddle sensation ( P = .018). Postoperative improvements in axial back pain were associated with higher preoperative ASIA grade ( P = .035) and anticoagulation treatment ( P = .029). Neurosurgical intervention for SSEH yields positive outcomes and benefits patients. Patients with higher preoperative ASIA, MRC grade, and those presenting with preserved saddle sensation may experience further improved clinical outcomes after intervention.

Amputation and mortality rates of patients undergoing upper or lower limb surgical embolectomy and their predictors.

To provide information on the outcomes of upper and lower limb surgical embolectomies and the factors influencing amputation and mortality. A retrospective, single-center analysis of 347 patients (female, N = 207; male, N = 140; median age, 76 years [interquartile range {IQR}, 63.2-82.6 years]) with acute upper or lower limb ischemia due to thromboembolism who underwent surgery between 2005 and 2019 was carried out. Patient demographics, comorbidities, medical history, the severity of acute limb ischemia (ALI), preoperative medication regimen, embolus/thrombus localization, procedural data, in-hospital complications/adverse events and their related interventions, and 30-day mortality were reviewed in electronic medical records. Statistical analysis was performed using the Mann-Whitney U test and Fisher's exact test; in addition, univariate and multivariate logistic regression was conducted. The embolus/thrombus was localized to the upper limb in 134 patients (38.6%) and the lower limb in 213 patients (61.4%). The median length of hospital stay was 3.8 days (IQR, 2.1-6.6 days). The in-hospital major amputation rates for the upper limb, lower limb, and total patient population were 2.2%, 14.1%, and 9.5%, respectively, and the in-hospital plus 30-day mortality rates were 4.5%, 9.4%, and 7.5%, respectively. In patients with lower limb embolectomy, the predictor of in-hospital major amputation was the time between the onset of symptoms and embolectomy (OR, 1.78), while the predictor of in-hospital plus 30-day mortality was previous stroke (OR, 7.16). In the overall patient cohort, there were two predictors of in-hospital major amputation: 1) the time between the onset of symptoms and embolectomy (OR, 1.92) and 2) compartment syndrome (OR, 3.51). Amputation and mortality rates after surgical embolectomies in patients with ALI are high. Patients with prolonged admission time, compartment syndrome, and history of stroke are at increased risk of limb loss or death. To avoid amputation and death, patients with ALI should undergo surgical intervention as soon as possible and receive close monitoring in the peri- and postprocedural periods.

The evolution of peri-operative care in the safe management of pheochromocytoma

The use of pre- and intra-operative vasoactive agents for improved blood pressure control has transformed the outcomes following pheochromocytoma (PC) resection. The first agent utilized was phenoxybenzamine, but selective alpha-1 antagonists (SAA) and calcium channel antagonists (CCA) have also been used with success. We sought to define the relationship between pre-operative treatment and intra-operative hemodynamics associated with each of these agents in patients with PC. A retrospective, single-institution review of patients >18 years with resected PC from 1996-2020 was performed. Pre-operative blockade was at the discretion of the treating providers. Adequacy of pre-operative blockade was determined by the attending surgeon prior to proceeding with PC resection. To determine the effectiveness of pre-operative blockade during surgery, vital signs throughout the operation were examined. The final dataset included 166 patients. Phenoxybenzamine (55%) and SAA (24%) were the most commonly used pre-operative medications but phenoxybenzamine use decreased over time. Patients who experienced a hypertensive crisis had a higher initial systolic blood pressure and were older. There was no predilection for developing a hypertensive crisis based on race, sex, tumor size or type of pre-operative medication used. Patients in the early group (2010-2015) were found to have more pronounced hemodynamic instability when compared to patients in the late group (2016-2020). Although there are no demonstrated differences between antihypertensives, the prescription pattern has evolved away from phenoxybenzamine. However, as this is transition happening, patients exhibit better hemodynamic control. We hypothesize that this is due to greater experience by the intra-operative team.

Effectiveness of an Endoscopic Recurrent Branch Release Procedure Combined with Standard Endoscopic Carpal Tunnel Release Surgery Compared to Standard Endoscopic Carpal Tunnel Release Surgery Alone: A Propensity Score-Matched Study

Background: The purpose of this study is to compare the effectiveness of endoscopic release of the recurrent branch from surrounding soft tissue in combination with standard endoscopic carpal tunnel release (ECTR) surgery to standard ECTR surgery alone in patients with established abductor pollicis brevis (APB) muscle weakness. Methods: Using propensity score matching, we compared the recovery rates of postoperative clinical symptoms in patients with idiopathic carpal tunnel syndrome in whom the preoperative Medical Research Council (MRC) scale of the APB muscle (MRC-APB) was zero (no contraction) and with undetectable distal motor latency (DML) of APB, to those who underwent standard ECTR surgery alone and those who underwent recurrent branch release in addition to standard ECTR. Results: Forty-nine hands in the recurrent branch release group and 49 hands in the standard ECTR surgery group were extracted. There were statistically significant differences in postoperative recovery rate from MRC-APB 0 to '4 or 5' at 30 months (OR: 2.42; 95% CI: 1.03-5.67; p = 0.04) and at final follow-up (OR: 2.64; 95% CI: 1.11-6.26; p = 0.03). There were statistically significant differences in postoperative recovery of MRC-APB scales at 24 months (p = 0.03), 30 months (p = 0.02) and at final follow-up (p = 0.02). There were statistically significant differences in postoperative recovery of DML (p = 0.04). Conclusions: Endoscopic release of the recurrent branch in combination with standard ECTR surgery showed better recovery rates in MRC-APB and DML recovery compared to standard ECTR surgery alone. Level of Evidence: Level III (Therapeutic).

Preoperative Optimization of the Asthmatic Patient

Introduction. Asthma is a common upper respiratory condition among patients across the developmental spectrum. The condition is estimated to affect over 300 million people worldwide with prevalence rate and condition severity continually increasing.1 With such a high prevalence rate worldwide, it is common to encounter asthmatic patients in need of elective surgery.1 Bronchospasm is a common pathophysiologic feature of asthma. During a bronchospasm, the smooth muscle of the airway contracts and narrows the diameter of the airway.1 As a result, a significant impedance to airflow can result. The obstruction to airflow makes ventilation difficult if not impossible. Patients who experience intraoperative bronchospasm are at increased risk for postoperative morbidity and mortality.1 Given the severe implications of intraoperative bronchospasm, the anesthetic care of the asthmatic patient should focus on preoperative assessment and optimization in order to mitigate the risk of intraoperative bronchospasm and postoperative pulmonary complications. The purpose of pursuing this topic is to educate anesthesia providers about the complications resulting from intraoperative bronchospasm and to provide guidelines for preventing bronchospasm during the surgical period. Case presentation. A recent case of intraoperative bronchospasm involved a 77-year-old, female, ASA 4 inpatient. The patient had significant medical history including asthma and COPD. The scheduled procedure was a closed reduction of the left hip with percutaneous pinning. During the preoperative assessment the patient was identified, the planned procedure and surgeon were confirmed, all allergies and medications were reviewed, medical and anesthetic history were reviewed, and a physical exam was conducted. During the preoperative interview the patient confirmed a history of reactive airway disease, but reported that her asthma was well-controlled with current medications and denied any recent exacerbations. The patient did not receive any preoperative medications other than analgesics for pain control. The patient was taken to the operating room for surgery and was preoxygenated prior to anesthetic induction. The patient was induced with IV propofol, fentanyl, and lidocaine. Succinylcholine was subsequently administered to achieve optimal conditions for intubation. The patient was successfully endotracheally intubated and sevoflurane administered for anesthetic maintenance. Prior to incision, the ventilator alarms were triggered by high peak pressures and low tidal volumes. Manual ventilation was initiated, but was found to be difficult, leading to a progressive oxygen desaturation. As bronchospasm was suspected, albuterol was administered endotracheally. The patient responded well to the bronchodilator, ventilation became easier, and the oxygen saturation improved. Once the patient was stabilized, the hip surgery continued without further incident. However, at the conclusion of the surgery and just prior to emergence, the patient experienced another severe bronchospasm. Again, albuterol and epinephrine treatment were initiated until the patient respiratory status stabilized again. The patient remained intubated and was transferred to ICU to allow for further pulmonary stabilization prior to extubating. Discussion. A literature review was conducted on the anesthetic management of the asthmatic patient undergoing surgery. The current literature emphasizes the importance of comprehensive assessment and pharmacologic optimization of the asthmatic patient during the preoperative period as the most efficacious method for reducing poor post-operative pulmonary outcomes. Bronchodilatory beta 2 adrenergic agents such as albuterol or salbutamol effectively reduce the incidence of intraoperative bronchospasm. The findings suggest that the intraoperative problems related to bronchospasm encountered in the presented case may have been avoidable. As discussed, the prevalence of asthma is significant among surgical patients. With a high number of asthmatic patients receiving general anesthesia for surgery, prevention of intraoperative bronchospasm is important for improving outcomes among this patient population. Based on the current literature, the recommendation for practice would be to preoperatively treat all asthmatic patients, regardless of the perceived severity of their asthma, with a bronchodilatory agent prior to surgery in an effort to reduce the incidence of intraoperative bronchospasm. Future research on the topic should consider the costs associated with added length of hospital stay and additional treatment following an intraoperative bronchospasm. Prevention of an asthma exacerbation during the preoperative period is likely the most cost-effective approach to managing a patient with reactive airway disease. Keywords Bronchodilators, bronchospasm, asthma, optimization

A Quality Improvement Project to Assess if Preoperative Trauma Patients Are Receiving Their Prescribed Medications Preoperatively.

Introduction All preoperative trauma patients should receive their preoperative medications regardless of being nil per os (NPO). Anticoagulants, angiotensin-converting enzyme inhibitors (ACE-I), and angiotensin II receptor blockers (ARBs) should be omitted.This is according to both local and national guidelines.We noticed that some preoperative patients have not been receiving their morning medications prior to having their operations. This has led to pre and perioperative complications. The aim of this study, therefore, was to conduct a quality improvement project to assess if preoperative trauma patients are receiving their prescribed medications preoperatively when placed NPO. We then aimed to determine the adverse outcome associated with omission and to furthermore devise a robust system to prevent recurrence. Methods Data were collected from the relevant patients' drug charts on the day of the operation. These cases were available on the daily trauma list.We evaluated if there was any clear reason documented for not providing the medications.Following the first round, we implemented our action plan for postersto be taped to drug trolleys on the orthopedic wards and informed the nursing staff of the need to give preoperative medications. We deemed the following to be important medication classes: calcium channel blockers, neuromodulators, beta-blockers, anti-epileptics, digoxin, bronchodilators, anti-anginals, anti-epileptics, and benzodiazepines. This was re-audited after one month to assess compliance and monitor for improvement. Results Forty patients were included in the first round and 41 in the re-audit. In the first round, 16/41 (39%) patients received their medications correctly. In patients who did not receive their medications (n=25), 22 had important medication classes omitted. Post implementation of the posters, 25/41 (61%) patients received their medications correctly. In patients who did not receive their medications (n=16), 10 had important medication classes omitted. The main reason why medications were incorrectly not given was that patients were NPO. Conclusion This quality improvement audit shows that our interventions between audit cycles have made a significant improvement in patients receiving their medications and therefore this has a direct positive impact on patient safety and outcomes. We should continue to have a close rapport with the nursing staff to maintain standards of correct practice, and these audit findings should be escalated to the emergency theatre thereafter.

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

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.

Preoperative Insulin Intensification to Improve Day of Surgery Blood Glucose Control.

Guidelines offer varying recommendations for preoperative long-acting basal insulin dosing, despite mounting evidence of the advantages of maintaining perioperative glucose levels between 80 and 180 mg/dL. We iteratively adjusted health care practitioner (HCP) instructions to intensify insulin dosing on the evening before surgery for 195 consecutive patients with diabetes mellitus treated with long-acting basal insulin with an evening dosage. Baseline data was collected in phase 1. In phase 2, the preoperative insulin dose on the evening before surgery was increased for patients with hemoglobin A1c (HbA1c) > 8%; in phase 3, it was increased for patients with HbA1c ≤ 8% while sustaining the phase 2 change. Increased preoperative insulin doses did not change the rates of day of surgery (DOS) hyperglycemia or hypoglycemia. Overall, HCP adherence to the modified protocols was high (89%). A decline in HCP adherence after phase 2 protocol change was associated with a transient increase in DOS hyperglycemia. Patient adherence to preoperative medication instructions was high (86%) and was not affected by protocol changes. Preoperative insulin intensification the evening before surgery did not change rates of DOS hyperglycemia or hypoglycemia. HCP adherence decreased transiently, which briefly increased DOS hyperglycemia rates in some patients. Perioperative hyperglycemia, defined as blood glucose levels ≥ 180 mg/dL in the immediate pre- and postoperative period, is associated with increased postoperative morbidity, including infections, preoperative interventions, and in-hospital mortality.1-3 Despite being identified as a barrier to optimal perioperative glycemic control, limited evidence is available on patient or health care practitioner (HCP) adherence to preoperative insulin protocols.4-6.

Outcomes of Functioning Free Gracilis Muscle Transplantation to Restore Elbow Flexion in Late Brachial Plexus Birth Injury.

Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction. A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed. Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation [SD] = 6.29, R = 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (p < 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (p < 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (p < 0.05). FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades. III.

Comparison between Bromazepam and Lorazepam as premedicant to reduce anxiety in patients undergoing elective surgery under General Anaesthesia

Background: The majority of patients admitted to the hospital for elective surgery experience anxiety preoperatively which can adversely influence the surgical procedure as well as the patient’s recovery. Reduction of anxiety and fear at the preoperative period in patients of elective surgery is essential for surgical preparation. Benzodiazepines are the most commonly used drugs for this purpose. Materials and Methods: The study was carried out on a series of 60 consecutivepatients, aged 18-60 years, admitted for elective surgery under General Anaesthesia, in Combined Military Hospital, Chattogram during the period September 2021 to February 2022. Patients receiving bromazepam or lorazepam as preoperative medication were selected. Anxiety was scored using VAS (Visual Analogue Scale), sedation was scored by using the Ramsay Sedation scale and anterograde amnesia by asking about preoperative events after 24 hours of premedication. Results: While evaluating mean anxiety reduction only, mean reduction is greater in the lorazepam group compared to that of bromazepam. Sedation level was less achieved with bromazepam. In the lorazepam group, a greater number of patients could not recall preoperative events but incidence of adverse effects was significantly more in this group. Conclusion: The standard administration of bromazepam before the procedure provides patients with a moderate reduction of periprocedural anxiety. Premedication of lorazepam is associated with a high incidence of adverse effects. Therefore, this study does not support the routine use of lorazepam as premedication to reduce anxiety before surgery. Bangladesh Crit Care J September 2022; 10(2): 110-115

Perioperative optimization of Crohn's disease.

Crohn's disease (CD) is a chronic inflammatory disease mainly affecting the gastrointestinal tract. With the increased availability of modalities in the last two decades, the treatment of CD has advanced remarkably. Although medical treatment is the mainstay of therapy, most patients require surgery during the course of their illness, especially those who experience complications. Nutritional optimization and ERAS implementation are crucial for patients with CD who require surgical intervention to reduce postoperative complications. The increased surgical risk was found to be associated with the use of corticosteroids, but the association of surgical risk with immunomodulators, biologic therapy, such as anti-TNF mediations, anti-integrin medications, and anti-IL 12/23 was low in certainty. Decisions about preoperative medication must be made on an individual case-dependent basis. Preoperative imaging studies can assist in the planning of appropriate surgical strategies and approaches. However, patients must be informed of any alterations to their treatment. In summary, the management of perioperative medications and surgery-related decision-making should be individualized and patient-centered based on a multidisciplinary approach.

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.

Association between Preoperative Medication Lists and Postoperative Hospital Length of Stay after Endoscopic Transsphenoidal Pituitary Surgery.

Background: Endoscopic transsphenoidal surgery is the most common technique for the resection of pituitary adenoma. Data on factors associated with extended hospital stay after this surgery are limited. We aimed to characterize the relationship between preoperative medications and the risk of prolonged postoperative length of stay after this procedure. Methods: This single-center, retrospective cohort study included all adult patients scheduled for transsphenoidal pituitary surgery from 1 July 2016 to 31 December 2019. Anatomical Therapeutic Chemical codes were used to identify patients’ preoperative medications. The primary outcome was a prolonged postoperative hospital length of stay. Secondary outcomes included unplanned admission to the Intensive Care Unit, and in-hospital and one-year mortality. We developed a descriptive logistic model that included preoperative medications, obesity and age. Results: Median postoperative length of stay was 3 days for the 704 analyzed patients. Patients taking ATC-H drugs were at an increased risk of prolonged length of stay (OR 1.56, 95% CI 1.26–1.95, p < 0.001). No association was found between preoperative ATC-H medication and unplanned ICU admission or in-hospital mortality. Patients with multiple preoperative ATC-H medications had a significantly higher mean LOS (5.4 ± 7.6 days) and one-year mortality (p < 0.02). Conclusions: Clinicians should be aware of the possible vulnerability of patients taking systemic hormones preoperatively. Future studies should test this medication-based approach on endoscopic transsphenoidal pituitary surgery populations from different hospitals and countries.