Preoperative Patient Optimization Research Articles

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

Incidence and Risk Factors of Postoperative Complications in General Surgery Patients.

Background Postoperative complications, which are undesirable consequences of surgery, need to be minimized to ensure the quality of surgical care. In this study, we aimed to estimate the incidence and identify the risk factors for postoperative complications which may help in planning appropriate preventive measures. Methodology A prospective observational study was conducted in the general surgery department of a tertiary care hospital in a metropolitan city in India. Patients undergoing elective or emergency surgery were included. Patients transferred postoperatively from other hospitals and those undergoing day-care operations or endoscopic procedures were excluded. Age, gender, body mass index (BMI),comorbidities, surgical risk as per American Society of Anesthesiologists(ASA) grading, scheduling of surgery (emergency, semi-emergency, or elective), approach (open or laparoscopic), intraoperative complications, operative blood loss, the extent of surgery (superficial or deep cavity), indication (diagnostic, therapeutic, or palliative), duration of surgery, wound class (clean, clean-contaminated, contaminated, or dirty), and duration of hospital stay in days were recorded.Patients were followed up for 30 days postoperatively for complications (defined as any undesirable, unintended event as a direct result of an operation). Clavien-Dindo classification was used to grade the severity of complications. The chi-square test was used for categorical data, and the t-test was used for numerical data. P-values <0.05 were considered significant. Results Postoperative complications were observed in 31.50%; minor complications (Grade I and II) in 19.75% and major complications (Grade III and IV) in 8.0% of patients. Postoperative mortality (Grade V) was 3.75%. Significant risk factors were the presence of comorbidities, higher ASA grade, higher BMI, emergency surgery, open surgery, palliative surgery, deeper cavity surgery, higher intraoperative blood loss, prolonged surgical duration, intraoperative complications, and contaminated surgical wounds. Postoperative complications significantly prolonged the hospital stay. Conclusions Understanding risk factors can guide surgeons to adopt appropriate strategic measures to reduce postoperative complications and improve the quality of surgical care. Three key measuresemerging from this study are (1) preoperative patient optimization; (2)diligence during surgery to reduce operative time, blood loss, and intraoperative complications; and (3) implementation of infection control practices.

Are 20% of Patients Actually Dissatisfied Following Total Knee Arthroplasty? A Systematic Review of the Literature

BackgroundTotal knee arthroplasty (TKA) is among the most performed orthopaedic surgeries in the United States with at least 1,000,000 cases performed per year. Dissatisfaction following TKA has often been reported as 20% or more, with a multitude of causes including sociodemographic, preoperative, and postoperative factors. The purpose of this study was to re-examine the rate and causes of dissatisfaction following TKA. MethodsA systematic review of the literature was performed searching databases from 2010 to 2022. Only primary TKA cases were included and all cases of unicompartmental arthroplasty and revisions were excluded. After abstracts were reviewed, 35 articles were selected for a full-length review, which was ultimately reduced to 21 articles for final inclusion. ResultsThe average rate of patient dissatisfaction was 10%. Excluding complications, the average rate of dissatisfaction was 7.3%. The most common sociodemographic factors for dissatisfaction were age < 65 years, lower income, and non-White patients. Preoperative factors included lower Kellgren-Lawrence scores, depression/anxiety, and pain catastrophizing. Postoperatively, most dissatisfaction was due to complications, unmet expectations, persistent pain, and stiffness. ConclusionBased on our review, the average rate of patient dissatisfaction following TKA is 10%. Improved counseling for known risk factors may have reduced dissatisfaction rates by increasing preoperative patient optimization. Many studies in recent years have demonstrated the issue of poor patient coping skills, such as pain catastrophizing and anxiety/depression as a common cause of dissatisfaction. Ultimately, dissatisfaction following TKA still continues to affect a high portion of patients but less than historical reports of 20%.

The Role and Effect of Multimodal Prehabilitation Before Major Abdominal Surgery: A Systemic Review and Meta-Analysis.

For patients undergoing abdominal surgery, multimodal prehabilitation, including nutrition and exercise interventions, aims to optimize their preoperative physical and physiological capacity. This meta-analysis aims to explore the impact of multimodal prehabilitation on surgical and functional outcomes of abdominal surgery. Medline, Embase and CENTRAL were searched for articles about multimodal prehabilitation in major abdominal surgery. Primary outcomes were postoperative complications with a Clavien-Dindo score ≥3, and functional outcomes, measured by the 6-Minute Walking Test (6MWT). Secondary outcome measures included the quality-of-life measures. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated, with DerSimonian and Laird random effects used to account for heterogeneity. Twenty-five studies were included, analysing 4,210 patients across 13 trials and 12 observational studies. Patients undergoing prehabilitation had significantly fewer overall complications (RR = 0.879, 95% CI 0.781-0.989, p = 0.034). There were no significant differences in the rates of wound infection, anastomotic leak and duration of hospitalization. The 6MWT improved preoperatively in patients undergoing prehabilitation (SMD = 33.174, 95% CI 12.674-53.673, p = 0.005), but there were no significant differences in the 6MWT at 4weeks (SMD = 30.342, 95% CI - 2.707-63.391, p = 0.066) and 8weeks (SMD = 24.563, 95% CI - 6.77-55.900, p = 0.104) postoperatively. As preoperative patient optimization shifts towards an interdisciplinary approach, evidence from this meta-analysis shows that multimodal prehabilitation improves the preoperative functional capacity and reduces postoperative complication rates, suggesting its potential in effectively optimizing the abdominal surgery patient. However, there is a large degree of heterogenicity between the prehabilitation interventions between included articles; hence results should be interpreted with caution.

205. Malnutrition increases risk of complications following posterior lumbar fusion independent of body mass index

205. Malnutrition increases risk of complications following posterior lumbar fusion independent of body mass index

P32. Impact of controlled vs uncontrolled mFI-5 frailty on perioperative complications following adult spinal deformity surgery

<h3>BACKGROUND CONTEXT</h3> Preoperative risk assessment is crucial before adult spinal deformity, due to its relatively high surgical invasiveness and likelihood of complications. Frailty has been found across multiple surgical subspecialties to be associated with risk of complications. However, the current frailty measures do not account for whether certain points refer to a controlled or uncontrolled condition. <h3>PURPOSE</h3> The goal of this study was to sub-stratify the mFI-5 frailty index into controlled or uncontrolled and assess the relationship to perioperative complications. We hypothesize that patients with uncontrolled frailty have a higher risk for perioperative complications following adult spinal deformity (ASD) surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective review. <h3>PATIENT SAMPLE</h3> ASD patients with fusion of=5 vertebral levels were identified. <h3>OUTCOME MEASURES</h3> The primary outcome of this study was perioperative complication rates. <h3>METHODS</h3> Frailty was calculated using mFI-5. Uncontrolled frailty was defined as having any of the following mFI-5 components: 1) blood pressure >140/90, 2) HbA1C > 7%, or 3) COPD exacerbation, while on medication. Patients were then divided into three cohorts: nonfrail, controlled frail and uncontrolled frail. Bivariate analysis was first performed. Multivariable analysis assessed the relationship between frailty state and perioperative complication. <h3>RESULTS</h3> A total of 178 ASD patients were identified. There were 97 nonfrail, 54 controlled frail and 27 uncontrolled frail patients. Patients with uncontrolled frailty were more likely to be >60 years old (84% vs 24%), have hyperlipidemia (42% vs 20%), ODI >42 (84% vs 52%) (p 60 years old (41% vs 24%), hyperlipidemia (52% vs 20%) (p 42, and age >65. Uncontrolled frailty was associated with 4.24x greater odds of any major complication and 9.47x odds of any wound complication. Controlled frailty was not associated with increased risk of perioperative complications (p>0.05 for all). <h3>CONCLUSIONS</h3> The results of this study suggest that patients with uncontrolled frailty have higher risk of perioperative complications compared to those with controlled frailty. Furthermore, components of uncontrolled frailty, that did not exist in the current mFI-5 frailty index, represent new modifiable risk factors that can be targeted for preoperative optimization in ASD patients. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The impact of stratified hypoalbuminemia and dialysis on morbidity/mortality after posterior spinal fusion surgery: An ACS-NSQIP study.

Background: Preoperative optimization in patients undergoing posterior spinal fusion is essential to limit the number and severity of postoperative complications. Here, we, additionally, evaluated the impact of hypoalbuminemia on morbidity and mortality after posterior spinal fusion surgery.Methods: This retrospective analysis was performed using data from a prospective multicentric database (ACSNSQIP:2015–2020) regarding patients undergoing posterior spinal fusions. Factors studied included; baseline demographics and 30-day postoperative complications (i.e., reoperations, readmissions, and mortality rates).Results: There were 6805 patients who met the inclusion criteria. They averaged 62 years of age and had an average BMI of 30.2. Within the 30-day postoperative period, 634 (9.3%) sustained complications; 467 (6.9%) were readmitted, 263 (3.9%) required reoperations, and 37 (0.5%) expired. Although multiple preoperative risk factors were analyzed, hypoalbuminemia, severe hypoalbuminemia, and dialysis were the strongest independent risk factors associated with complications (i.e., reoperations, readmissions, and mortality).Conclusion: Hypoalbuminemia, severe hypoalbuminemia, and dialysis were significant predictors for morbidity and mortality after posterior spinal fusion surgery.

Adverse postoperative outcomes associated with perioperative blood transfusion in gynecologic oncology surgery: a National Surgical Quality Improvement Program analysis (467)

Adverse postoperative outcomes associated with perioperative blood transfusion in gynecologic oncology surgery: a National Surgical Quality Improvement Program analysis (467)

Cardiac risk stratification of the liver transplant candidate: A comprehensive review.

Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.

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.

Update on How to Improve the Outcome of Radical Cystectomy: A Systematic Review

Context Radical cystectomy (RCX) is the most difficult urologic procedure. It is usually performed in patients with morbidities and associated with a high rate of complications. So, every effort must be done to improve the outcome of this surgery. Objective This systematic review tries to put an up to date analysis of the literature on how to improve the outcome of RCX. Evidence acquisition A systematic literature search in the PubMed and Cochrane databases was performed from 1990 to July 2022 in English language using the keywords ‘‘radical cystectomy’, ‘Enhanced recovery’ and ‘Improved outcome’. Prospective studies were preferred; however, retrospective studies were used when no prospective studies were available. Evidence synthesis In all, 237 relevant articles were identified and 46 articles were included in this systematic review. RCX may be associated by complications that may reach 70%. Preoperative patient preparation, optimization and counseling are critical. Enhanced recovery after surgery protocols should be adopted. The radicality of surgery is affected by the use of neo-adjuvant and/or adjuvant therapy, timing of surgery, the presence of a well-organized team and the surgeon experience. Ureteral dissection, urethral stump preparation and nerve sparing are three important steps during RCX greatly affecting the function of the following reconstructive step. Close follow up after RCX especially in the first two years is critical. Conclusions Multiple factors should be followed to achieve good RCX. Regular skilled operative team, high volume surgeon, well equipped operative theater, excellent postoperative care are keys of success.

Update on How to Improve the Outcome of Radical Cystectomy: A Systematic Review

Context Radical cystectomy (RCX) is the most difficult urologic procedure. It is usually performed in patients with morbidities and associated with a high rate of complications. So, every effort must be done to improve the outcome of this surgery. Objective This systematic review tries to put an up to date analysis of the literature on how to improve the outcome of RCX. Evidence acquisition A systematic literature search in the PubMed and Cochrane databases was performed from 1990 to July 2022 in English language using the keywords ‘‘radical cystectomy’, ‘Enhanced recovery’ and ‘Improved outcome’. Prospective studies were preferred; however, retrospective studies were used when no prospective studies were available. Evidence synthesis In all, 237 relevant articles were identified and 46 articles were included in this systematic review. RCX may be associated by complications that may reach 70%. Preoperative patient preparation, optimization and counseling are critical. Enhanced recovery after surgery protocols should be adopted. The radicality of surgery is affected by the use of neo-adjuvant and/or adjuvant therapy, timing of surgery, the presence of a well-organized team and the surgeon experience. Ureteral dissection, urethral stump preparation and nerve sparing are three important steps during RCX greatly affecting the function of the following reconstructive step. Close follow up after RCX especially in the first two years is critical. Conclusions Multiple factors should be followed to achieve good RCX. Regular skilled operative team, high volume surgeon, well equipped operative theater, excellent postoperative care are keys of success.

Preoperative Polypharmacy in Geriatric Patients Is Associated with Increased 90-Day All-Cause Hospital Readmission After Surgery for Adult Spinal Deformity Patients

We sought to investigate the effect of preoperative polypharmacy (PP) on the 90-day all-cause readmission rate in older adults undergoing corrective surgery for adult spinal deformity. Older adults with a diagnosis of adult spinal deformity undergoing spinal surgery at a quaternary medical center from January 2016 to March 2019 were enrolled in this study. Patients were dichotomized into 2 groups stratified by the number of preoperative prescription medications, with PP defined as 5 or more prescription medications. The primary outcome measure was 90-day all-cause readmission rate. Secondary outcomes included postoperative changes in health-related quality of life measures. Among 161 patients (mean [standard deviation], 69.59 [8.79] years), 97 patients were included in the PP cohort and 64 in the nonpolypharmacy (non-PP) cohort. Both groups were balanced at baseline. Duration of hospital stay (5.82 [1.93] vs. 6.50 [4.00] days), mean number of fusion levels, and duration of surgery were statistically similar between both groups (P > 0.05). There was no difference in the proportion of patients discharged directly home (31.25% vs. 40.42%, P= 0.36). The 90-day all-cause readmission rate was 3-fold higher in the PP cohort compared with the non-PP cohort. After adjusting for preoperative patient optimization, American Society of Anesthesiologists grade, surgical invasiveness, smoking, depression, and baseline functional disability, older adults with PP had a 9.79 increased odds of 90-day all-cause hospital readmission (P= 0.04). Changes in health-related quality of life measures were similar between both groups. This study's findings indicate that despite preoperative optimization, older adults exposed to polypharmacy are at a significantly increased risk of hospital readmission within 90 days of surgery.

Can machine learning models predict failure of revision total hip arthroplasty?

Revision total hip arthroplasty (THA) represents a technically demanding surgical procedure which is associated with significant morbidity and mortality. Understanding risk factors for failure of revision THA is of clinical importance to identify at-risk patients. This study aimed to develop and validate novel machine learning algorithms for the prediction of re-revision surgery for patients following revision total hip arthroplasty. A total of 2588 consecutive patients that underwent revision THA was evaluated, including 408 patients (15.7%) with confirmed re-revision THA. Electronic patient records were manually reviewed to identify patient demographics, implant characteristics and surgical variables that may be associated with re-revision THA. Machine learning algorithms were developed to predict re-revision THA and these models were assessed by discrimination, calibration and decision curve analysis. The strongest predictors for re-revision THA as predicted by the four validated machine learning models were the American Society of Anaesthesiology score, obesity (> 35kg/m2) and indication for revision THA. The four machine learning models all achieved excellent performance across discrimination (AUC > 0.80), calibration and decision curve analysis. Higher net benefits for all machine learning models were demonstrated, when compared to the default strategies of changing management for all patients or no patients. This study developed four machine learning models for the prediction of re-revision surgery for patients following revision total hip arthroplasty. The study findings show excellent model performance, highlighting the potential of these computational models to assist in preoperative patient optimization and counselling to improve revision THA patient outcomes. Level III, case-control retrospective analysis.

Routine Preoperative Nutritional Optimization Not Required in Patients Undergoing Breast Reconstruction

Purpose: There are no data describing the need for preoperative nutritional optimization in patients undergoing breast reconstruction surgery. The purpose of this research was to identify if preoperative breast reconstruction patients are grossly nutritionally deficient as defined by preoperative serum albumin and, thus, if routine preoperative nutrition screening and optimization is necessary in this patient population. Methods: Adult patients who underwent breast reconstruction surgery between 2015 and 2019 were identified within the National Safety and Quality Improvement Program database. Variables of interest for this group of patients were collected, and comparisons were made for these variables between three different breast reconstruction modalities (implant-based reconstruction [IBR], expander-based reconstruction [EBR], and free tissue-based reconstruction [FTBR]) with χ2 and ANOVA statistical tests. Results: A total of 14,509 patients were included. There was not a significant difference in preoperative serum albumin measurements between the three reconstruction modalities and mean measurements for the three reconstruction modalities were all within normal limits. Secondarily, when comparing groups, FTBR had higher incidence of superficial surgical site infection (SSI) (4.49% vs. 1.6% vs. 1.56%, respectively; p < 0.00001), deep SSI (1.57% vs. 0.48% vs. 0.94%, respectively; p < 0.00001), and wound disruption (2.16% vs. 0.78% vs. 0.94%, respectively; p < 0.00001) than IBR and EBR. Conclusion: Preoperative nutritional status was found to be grossly appropriate in a large population of breast reconstruction patients. Furthermore, the ordering of routine preoperative serum albumin is unnecessary and represents an extraneous healthcare cost that does not lead to improved outcomes in breast reconstruction. FTBR incurred the greatest risk of surgical complication independent of preoperative nutritional status.

Predictors of airway, respiratory, and pulmonary complications following elective anterior cervical discectomy and fusion

IntroductionAnterior cervical discectomy and fusion (ACDF) is a commonly performed procedure on the cervical spine. While the procedure is generally well tolerated, respiratory and pulmonary complications (RPC) are an unlikely yet possible complication following ACDF. Few previous studies have specifically identified risk factors associated with RPC following ACDF. As the incidence of an RPC is rare at a single institution, a large national database is required for meaningful analysis. ObjectiveThe goal of this study is to characterize the predictors for RPC following an ACDF by utilizing a large national database. MethodsThe National Inpatient Sample (NIS) was queried from 2016 to 2018 for all patients who had received elective ACDF for degenerative cervical spine disease. We categorized several complications as airway complications including various abscess, angioedema, laryngeal edema, vocal cord paralysis, dysphonia, various etiologies of pneumonia, and acute respiratory distress syndrome. A Firth’s logistic regression model was used to identify predictors of RPC. ResultsWe identified a final cohort of 52,575 admissions in which an ACDF was performed of which 1454 admissions had an RPC. Older patients were 1.03 times more likely to have an RPC (OR = 1.03, 95%CI: 1.02–1.04). African American patients compared to Caucasian patients were 1.44 times more likely to have an RPC (OR = 1.44, 95%CI: 1.23–1.68). Obese patients were found to be 1.64 to have an RPC (OR = 1.64, 95%CI: 1.45–1.85). Diabetic patients are 2.07 times more likely to have an RPC (OR = 2.07, 95%CI: 1.76–2.44). Hypertensive patients are 1.91 times more likely to have an RPC (OR = 1.91, 95%CI: 1.59–2.27). Urban based hospitals were 1.11 and 1.46 times more likely to have an RPC (OR = 1.11, 95%CI: 0.79–1.59; OR = 1.46, 95%CI: 1.06–2.08; teaching and non-teaching respectively). Patients who underwent multilevel procedure were 1.32 times more likely to experience a follow-on RPC (OR = 1.32, 95%CI: 1.17–1.49) DiscussionOur study identified modifiable predictors of RPC after elective ACDF (e.g. obesity, diabetes) which can be used to guide preoperative patient optimization.

Blood Management Following Total Joint Arthroplasty in an Aging Population: Can We Do Better?

To evaluate the transfusion rates for octogenarians and nonagenarians following total knee and hip arthroplasty (TKA, THA), we compared transfusion rates and associated risk factors among sexagenarians, septuagenarians, octogenarians, and nonagenarians. This retrospective cohort study included 13,603 sexagenarians, 9796 septuagenarians, 2706 octogenarians, and 158 nonagenarians that received a primary, unilateral THA or TKA between 2016 and 2020 at a high-volume institution. Using multivariable logistic regression analysis, the study analyzed risk factors for postoperative transfusions including use of tranexamic acid (TXA) and compared preoperative and postoperative hemoglobin (Hgb) levels and the drop in Hgb. Nonagenarians had significantly higher transfusion rates (THA 25.5%, TKA 26.7%) than octogenarians (THA 9.9%, TKA 9.2%), septuagenarians (THA 3.3%, TKA 4.5%), and sexagenarians (THA 1.9%, TKA 2.9%) (P < .01). Significant risk factors for transfusion requirement following THA were American Society of Anesthesiologists level III (odds ratio [OR] 5.3, P < .01) and American Society of Anesthesiologists level IV (OR 8.0, P= .01), nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), longer duration of surgery (OR 1.0, P < .01), and hepatopathy (OR 3.1, P < .01). Significant risk factors following TKA were nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01; combined: OR 0.2, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), and longer surgery time (OR 1.0, P < .01). The strongest independent risk factors for increased transfusion rates among octogenarians and nonagenarians were lack of TXA application and lower preoperative Hgb levels. Routine TXA application and preoperative patient optimization are recommended to reduce transfusion rates in patients aged 80+.

Artificial Neural Networks Can Predict Early Failure of Cementless Total Hip Arthroplasty in Patients With Osteoporosis.

Total hip arthroplasty (THA) done in the aging population is associated with osteoporosis-related complications. The altered bone density in osteoporotic patients is a risk factor for revision surgery. This study aimed to develop and validate machine learning (ML) models to predict revision surgery in patients with osteoporosis after primary noncemented THA. We retrospectively reviewed a consecutive series of 350 patients with osteoporosis (T-score less than or equal to -2.5) who underwent primary noncemented THA at a tertiary referral center. All patients had a minimum 2-year follow-up (range: 2.1 to 5.6). Four ML algorithms were developed to predict the probability of revision surgery, and these were assessed by discrimination, calibration, and decision curve analysis. The overall incidence of revision surgery was 5.2% at a mean follow-up of 3.7 years after primary noncemented THA in osteoporotic patients. Revision THA was done because of periprosthetic fracture in nine patients (50%), aseptic loosening/subsidence in five patients (28%), periprosthetic joint infection in two patients (11%) and dislocation in two patients (11%). The strongest predictors for revision surgery in patients after primary noncemented THA were female sex, BMI (>35 kg/m2), age (>70 years), American Society of Anesthesiology score (≥3), and T-score. All four ML models demonstrated good model performance across discrimination (AUC range: 0.78 to 0.81), calibration, and decision curve analysis. The ML models presented in this study demonstrated high accuracy for the prediction of revision surgery in osteoporotic patients after primary noncemented THA. The presented ML models have the potential to be used by orthopaedic surgeons for preoperative patient counseling and optimization to improve the outcomes of primary noncemented THA in osteoporotic patients.

Preoperative Nutritional Optimization of the Oncology Patient: A Scoping Review.

Malnutrition is common among patients with cancer and is a known risk factor for poor postoperative outcomes; however, preoperative nutritional optimization guidelines are lacking in this high-risk population. The objective of this study was to review the evidence regarding preoperative nutritional optimization of patients undergoing general surgical operations for the treatment of cancer. A literature search was performed across the Ovid (MEDLINE), Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCOhost), and Web of Science (Clarivate) databases. Eligible studies included randomized clinical trials, observational studies, reviews, and meta-analyses published between 2010 and 2020. Included studies evaluated clinical outcomes after preoperative nutritional interventions among adult patients undergoing surgery for gastrointestinal cancer. Data extraction was performed using a template developed and tested by the study team. A total of 5,505 publications were identified, of which 69 studies were included for data synthesis after screening and full text review. These studies evaluated preoperative nutritional counseling, protein-calorie supplementation, immunonutrition supplementation, and probiotic or symbiotic supplementation. Preoperative nutritional counseling and immunonutrition supplementation should be considered for patients undergoing surgical treatment of gastrointestinal malignancy. For malnourished patients, protein-calorie supplementation should be considered, and for patients undergoing colorectal cancer surgery, probiotics or symbiotic supplementation should be considered.

Perioperative screening and management in elective complex hepatobiliary surgery.

Preoperative optimization and structured evidence-based perioperative care of a patient undergoing complex hepatobiliary (HPB) surgery are essential components in their management. Apart from advances in surgical technique, these perioperative measures have resulted in substantial reductions in morbidity and mortality. There hence, remains a continued need to have evidence-based updation in their management algorithm to ensure optimal outcomes. We present an evidence-based overview of the preoperative screening, optimization and perioperative management of patients undergoing complex HPB surgery. Perioperative care of these fragile patients is an evidence-based dynamic process. Optimal patient management undergoing HPB surgery requires risk assessment and stratification, and meticulous attention to the correction of underlying conditions. Despite this, postoperative morbidity remains relatively high and requires a cohesive multidisciplinary approach to minimize complications.