Preoperative Patient Optimization Research Articles

Residents as Leaders: Using a Delphi Process to Conduct an Institutional Preoperative Patient Optimization Quality Improvement Initiative.

Many residency programs struggle to meet the ACGME requirement for resident participation in quality improvement initiatives. As part of an institutional quality improvement effort, trainees from the Departments of Surgery and Anesthesiology at a single academic medical center were teamed with institutional content experts in 7 key risk factor areas within preoperative patient optimization. A systematic review of each subject matter area was performed using the MEDLINE database. Institutional recommendations for the screening and management of each risk factor were developed and approved using modified Delphi consensus methodology. Upon project completion, an electronic survey was administered to all individuals who participated in the process to assess the perceived value of participation. Fifty-one perioperative stakeholders participated in recommendation development: 26 trainees and 25 content experts. Residents led 6 out of 7 groups specific to a subject area within preoperative optimization. A total of 4,649 abstracts were identified, of which 456 full-text articles were selected for inclusion in recommendation development. Seventeen out of 26 (65.4%) trainees completed the survey. The vast majority of trainees reported increased understanding of their preoperative optimization subject area (15/17 [88.2%]) as well as the Delphi consensus method (14/17 [82.4%]) after participation in the project. Fourteen out of 17 (82.4%) trainees stated that they would participate in a similar quality improvement initiative again. We demonstrate a novel way to involve trainees in an institutional quality initiative that served to educate trainees in quality improvement, the systematic review process, Delphi methodology, and preoperative optimization. This study provides a framework that other residency programs can use to engage residents in institutional quality improvement efforts.

Update on current enhanced recovery after surgery (ERAS) pathways for hip and knee arthroplasty: a review of the literature

Enhanced recovery after surgery (ERAS) pathways for total hip and knee arthroplasty require continuous, comprehensive updates with the most current evidence-based guidelines. Guidelines are rapidly evolving in this topic because of interest in rapid recovery and outpatient total joint arthroplasty. This review article summarizes current literature to provide recommendations involving preoperative patient education and patient optimization, preoperative fasting and carbohydrate loading, analgesia, mode of anesthesia, intraoperative temperature management, hemostasis, postoperative nausea and vomiting management, early mobilization, and thromboprophylaxis. By promoting consensus, the authors aim to improve ERAS utilization and ultimately improve patient outcomes while also decreasing lengths of stay.

Evaluating the Effect of a Low-Calorie Pre-Hepatectomy Diet on Perioperative Outcomes: A Systematic Review & Meta-Analysis

Background: Few studies have evaluated potential benefits of pre-operative calorie-restricted diets among patients undergoing hepatectomy. This systematic review aimed to assess the effect of low-calorie pre-hepatectomy diets on perioperative outcomes. Methods: This study was conducted in accordance with the PRISMA and MOOSE guidelines. Following a comprehensive literature search, two reviewers independently screened references and abstracted relevant study details. We included comparative studies of patients undergoing hepatectomy, with some receiving a pre-operative low-calorie diet of any type/duration. Pooled analyses of outcomes were performed where appropriate. Results: The search strategy yielded 210 citations, with 3 studies meeting inclusion criteria (1 randomized trial and 2 retrospective cohort studies; including one study of donor hepatectomies). In all, 243 patients were assessed, with 98 receiving a low-calorie pre-hepatectomy diet. Diet length was 1 week in two of the studies, and a median of 7.3 weeks in the third. Diet compliance was high. Patients receiving a pre-hepatectomy diet demonstrated significantly less steatosis, steatohepatitis, and intraoperative blood loss (mean difference: –319.0 [–486.9, –151.1] mL, p<0.001), compared to controls. One study showed decreased perioperative blood transfusions for patients receiving the low-calorie diet, though not statistically significant. There were no differences in post-operative complications, length of stay, or mortality. Conclusions: Low-calorie pre-hepatectomy diet is an understudied intervention for pre-operative patient optimization. Current literature shows promise, as evidenced by decreased steatosis, intraoperative blood loss, and potentially decreased transfusions. Further prospective trials are necessary to fully appreciate its role in improving perioperative and post-operative outcomes.

Multi-domain analysis of non-surgical risk factors amenable to pre-operative optimization in microvascular head and neck surgery

PurposeThe goal of this study was to conduct a multi-domain, organ system-based analysis of non-surgical comorbidities amenable to pre-operative optimization in patients undergoing free tissue transfer, in order to better understand factors that influence patient outcomes. Study designRetrospective review. SettingsTertiary academic center. Materials and methodsA retrospective analysis of 546 patients in a prospectively maintained database who underwent free tissue transfer reconstruction between 2007 and 2016 was performed. Analysis of the relationship between binary-coded system-based domains and log-transformed length of stay (LOS), rehabilitation requirement, 30-day readmission, and post-operative complications was conducted with multiple linear regression or logistic regression models. ResultsPoor nutritional status and the presence of anxiety/depression independently increased median hospital LOS. Endocrine and metabolic deficits, poor nutrition status, and psychiatric comorbidities were significant predictors for rehabilitation facility requirement upon discharge. ConclusionInterventions targeted to patient psychiatric and nutritional health may yield substantially improved outcomes in the head and neck cancer population receiving free tissue transfer surgery.

P-OGC74 Effect of pre-operative anaemia on short-term outcomes following oesophagectomy: a 10-year retrospective cohort study

Abstract Background Pre-operative anaemia is associated with increased length of hospital stay, requirement for allogenic blood transfusion, post-operative complications and mortality. Oesophagectomy is a complex procedure associated with significant physiological insult, thus pre-operative patient optimisation is imperative to improve clinical outcomes. This study aimed to determine the impact of pre-operative anaemia on short-term outcomes following oesophagectomy for benign and malignant disease. Methods A retrospective cohort study of all oesophagectomies performed in a single tertiary referral centre between 1 January 2010 and 31 December 2019 was performed. Patients were identified from a prospectively collected database and individual patient electronic records were interrogated. Patients were dichotomised into two groups, based on the most recent pre-operative haemoglobin. Patients with pre-operative anaemia (haemoglobin &amp;lt;130mg/L in males and &amp;lt;120mg/L in females) were compared to those without pre-operative anaemia. Patients with missing data were excluded from the study. Patients were followed up for a median of 32 months (IQR 18-66). Results Of 352 patients eligible for inclusion, 173 (49.1%) patients were anaemic immediately pre-operatively. Patients with pre-operative anaemia were older (66 vs. 64 years, p = 0.031), with a lower anaerobic threshold (11.7 vs. 12.3ml/min/kg, p = 0.011), and were significantly more likely to have undergone neoadjuvant chemotherapy (91.3% vs. 78.8%, p &amp;lt; 0.001). Patient comorbidities and disease-related characteristics were similar between the two groups. Patients with pre-operative anaemia were significantly more likely to require post-operative blood transfusion (34.7% vs. 16.8%; p &amp;lt; 0.001). However, pre-operative anaemia was not associated with increased post-operative complications, intensive care admission, length of hospital stay, or 30- and 90-day mortality rates following oesophagectomy. Conclusions Patients with anaemia immediately prior to undergoing an oesophagectomy were significantly more likely to require post-operative blood transfusion. However, pre-operative anaemia was not associated with an increased rate of post-operative morbidity or mortality. In addition, pre-operative iron transfusion is becoming increasingly utilised to minimise the incidence of pre-operative anaemia: this was not analysed in this study.

Enhanced recovery after surgery: anesthesia-related components

Background: Enhanced recovery after surgery (ERAS) is a multidisciplinary and multimodal evidence-based approach aimed at improving the recovery of surgical patients. Successful implementation of ERAS protocols requires proper perioperative communication and collaboration among surgeons, anesthesiologists, nurses, and other medical personnel.Current Concepts: The anesthesiologist is the clinical leader responsible for the ERAS program. Preoperative patient evaluation, optimization, and patient education are essential components of the ERAS program. The program also involves preoperative fasting and carbohydrate loading to minimize catabolic effects. Selection of an appropriate anesthetic regimen, fluid and temperature management, avoidance of intra/postoperative nausea and vomiting, and multimodal pain management are the key components of ERAS for which the anesthesiologist is responsible.Discussion and Conclusion: Factors that enable the successful implementation of ERAS include the willingness to change to ERAS, formation of multidisciplinary teams to improve cooperation, and support from the hospital management, as well as standardization of order sets and care processes and the appropriate use of audits. As the leader of the ERAS team, the anesthesiologist should be actively involved in comprehensive management of the patient during the perioperative period.

A predictive model of perioperative myocardial infarction following elective spine surgery

Myocardial infarction (MI), and its predictive factors, has been an understudied complication following spine operations. The objective was to assess the risk factors for perioperative MI in elective spine surgery patients as a retrospective case control study. Elective spine surgery patients with a perioperative MI were isolated in the NSQIP. The relationship between MI and non-MI spine patients was assessed using chi-squared and independent samples t-tests. Univariate/multivariate analyses assessed predictive factors of MI. Logistic regression with stepwise model selection was employed to create a model to predict MI occurrence. The study included 196,523 elective spine surgery patients (57.1 yrs, 48%F, 30.4 kg/m2), and 436 patients with acute MI (Spine-MI). Incidence of MI did not change from 2010 to 2016 (0.2%–0.3%, p = 0.298). Spine-MI patients underwent more fusions than patients without MI (73.6% vs 58.4%, p < 0.001), with an average of 1.03 levels fused. Spine-MI patients also had significantly more SPO (5.0% vs 1.8%, p < 0.001) and 3CO (0.9% vs 0.2%, p < 0.001), but less decompression-only procedures (26.4% vs 41.6%, p < 0.001). Spine-MI underwent more revisions (5.3% vs 2.9%, p = 0.003), had greater invasiveness scores (3.41 vs 2.73, p < 0.001) and longer operative times (211.6 vs 147.3 min, p < 0.001). Mortality rate for Spine-MI patients was 4.6% versus 0.05% (p < 0.001). Multivariate modeling for Spine-MI predictors yielded an AUC of 83.7%, and included history of diabetes, cardiac arrest and PVD, past blood transfusion, dialysis-dependence, low preoperative platelet count, superficial SSI and days from operation to discharge. A model with good predictive capacity for MI after spine surgery now exists and can aid in risk-stratification of patients, consequently improving preoperative patient counseling and optimization in the peri-operative period.

ASMBS position statement on preoperative patient optimization before metabolic and bariatric surgery.

The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to inquiries made to the society by patients, physicians, society members, hospitals, health insurance payors, the media, and others, regarding preoperative health optimization prior to bariatric and metabolic surgery. These recommendations are based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement is not intended to establish a local, regional, or national standard of care.

Preoperative Hemoglobin Optimization in Jehovah's Witness Cardiovascular Surgery Patients with Anemia and Barriers to Care

Cardiac surgery has a risk for extensive blood loss which poses a particular challenge in individuals refusing blood transfusions. Additionally, preoperative anemia with a hemoglobin (Hb) below 13 g/dL in men and 12 g/dL in women is associated with increased short and long-term complications and mortality and increases the need for blood transfusion support. The current guidelines for perioperative anemia management recommend optimizing hemoglobin levels prior to surgery and utilizing blood conservation techniques during the procedure. At present red blood cell (RBC) transfusions during cardiac surgery are usually recommended when Hb levels are below 7-8 g/dL a restrictive transfusion strategy to reduce complications. However, the use of any RBC transfusions is associated with worse outcomes in cardiac surgery compared with those who do not receive transfusions.We have found that JW seek out quality health care and accept the vast majority of medical treatments once they are educated. The Transfusion Free Medicine Coordinator's role in the Anemia Clinic is to endorse clinical strategies for managing hemorrhage and anemia without blood transfusion. They educate and counsel the patients so they can decide as to what blood fractions and cell salvage techniques they will accept. We have found that some Health Care Providers are unaware that ESAs also contain albumin so JW patients may be given this product without that knowledge. The vast majority of patients will accept the use of ESAs but find the cost prohibitive.Jehovah's Witness patients have provided a natural case study for examining how well adjuvant therapies can improve preoperative anemia without transfusions and continue with good outcomes. Hb optimization is achieved through the use of intravenous iron and, if needed, erythropoiesis stimulating agents (ESAs). In Table 1 we highlight our single center data in which all cardiovascular surgeries were performed by a surgeon experienced in blood-conservation strategies. Our thirty-day re-admission rates for all patients was zero percent, compared to state-specific data, which estimates about an 11.7% rate of re-admission. The data illustrate the need to have a target Hb 13 or above to allow for the decline that may occur during the hospital stay. Of note no thromboembolic events have occurred with the use of an ESA in this group.Although ESAs are approved to optimize Hb in orthopedic surgery, they are not covered for cardiac surgery which has presented a significant challenge to patients who can not safely proceed to surgery until a target Hb between 13 to 15 g/dL is achieved.These data highlight the utility and safety associated with the use of ESAs for patients who do not accept blood products at an experienced Center for Transfusion-Free Medicine, such as ours. At this time, since insurance companies do not cover the cost of ESAs for patients needing life-saving cardiovascular operations, cost is a prohibitive barrier for patients. Unfortunately, it is not uncommon for patients to have to borrow money from others or set up payment plans. We hope that analyses like ours will help drive changes in reimbursement policies, particularly for patients who based on religious convictions, cannot receive blood products, and thus for whom pre-operative hemoglobin optimization is of utmost importance. [Display omitted] DisclosuresNo relevant conflicts of interest to declare. OffLabel Disclosure:Erythropoiesis-stimulating agent (ESA) are indicated for the treatment of anemia due to Chronic Kidney Disease in patients on dialysis and not on dialysis, Zidovudine in patients with HIV-infection, anemia due to myelosuppressive chemotherapy and reduction of allogeneic RBC transfusions in patients undergoing elective, noncardiac, nonvascular surgery

Blood management in total hip arthroplasty: a nationwide trend analysis from 2011 to 2018.

With the advent of practice changes surrounding preoperative patient optimization and postoperative protocols, a marked reduction has been reported in blood transfusion rates following total hip arthroplasty (THA). Thus, the purpose of this study was to examine differences in the prevalence of preoperative anemia, thrombocytopenia, elevated international normalized ratio (INR), bleeding disorders, and pre- and postoperative blood transfusions over the last decade. From 2011 to 2018, the American College of Surgeons National Quality Improvement Program database was queried for all primary THA procedures (n = 208,796). The following continuous variables were examined using analysis of variance: preoperative hematocrit (HCT), platelet count, and INR. The following categorical variables were analyzed by chi-squared tests: anemia (HCT < 35.5% for females and < 38.5% for males), thrombocytopenia (platelet count < 150,000/µL), INR > 2.0, bleeding disorders, preoperative transfusions, and postoperative transfusions. There were decreases in preoperative anemia (2011: 16.2%; 2018: 11.4%, p < 0.001) and postoperative transfusions (2011: high = 22.2%; 2018: low = 1.3%, p < 0.001). Statistically significant but clinically irrelevant changes were observed in preoperative HCT (2011: low = 40.3, 2018: high = 41.1, p < 0.001), platelet count (2011: low = 248,700; 2018: high = 250,100, p < 0.001), thrombocytopenia (2011: high = 4.9%; 2018: low = 4.3%, p = 0.036), INR > 2.0 (2011: high = 1.1%; 2018: low = 0.7%, p = 0.001), bleeding disorders (2011: high = 2.9%; 2018: low = 2.0%, p < 0.001), and preoperative transfusions (2011: high = 0.2%; 2018: low = 0.1%, p = 0.007). Large decreases in the number of patients with preoperative anemia and those receiving postoperative blood transfusion were observed during the study period. Future investigation is needed to ascertain whether this is due to patient optimization, practice changes, "cherry-picking" of healthy patients, or a combination of these factors. III.

Assessing outcomes of surgical treatment in adult spinal deformity: a critical approach

Adult spinal deformity (ASD) comprises a range of aetiologies and pathologies affecting the lumbar, thoracic or thoracolumbar region during the ageing process. Management of ASD is an increasing health-care burden due to its prevalence in patients aged over 65 years and increasing age of populations in developed countries. Non-operative management of ASD has limited benefit, but may be appropriate for patients with a mild spinal deformity, who can cope with their level of symptoms, or those patients too frail for major spinal surgery. Surgical management of ASD is a major undertaking, associated with significant risks. Minimally invasive surgical (MIS) techniques are rapidly evolving and further research is required to determine the most suitable ASD patient profiles and clinical parameters for treatment by MIS, hybrid, or open techniques. Understanding the resources available for preoperative risk stratification, patient optimization and outcomes assessment following surgery can help to personalize risk-benefit discussions with patients and to develop pragmatic patient-specific surgical strategies for patients with ASD to obtain successful outcomes and reduce the risk of complications. This narrative review discusses patient assessment, treatment outcomes, and surgical strategies to manage patients with ASD.

Penile implant surgery-managing complications.

Penile prosthesis surgery represents the end-stage treatment for erectile dysfunction. It is conventionally used only in cases of erectile dysfunction refractory to pharmacological treatments or vacuum constriction devices. Contemporary literature suggests that penile prothesis surgery is associated with a high satisfaction rate and a low complication profile. However, it must be appreciated that the complications of surgery can have devastating consequences on a patient’s quality of life and satisfaction and include infection, prosthesis malfunction, penile corporal perforation and penile length loss. Several factors – such as appropriate patient selection, methodical preoperative assessment and patient optimization, specific intraoperative protocols and postoperative recommendations – can reduce the risk of surgical complications. This narrative review discusses the diagnosis and management of both intraoperative and postoperative complications of penile prosthesis surgery.

Preoperative optimization of geriatric and frail patients.

Preoperative optimization of geriatric and frail patients.

Preoperative Patient Optimization in Total Joint Arthroplasty-The Paradigm Shift from Preoperative Clearance: A Narrative Review.

Background: Total joint arthroplasty (TJA) is one of the most common procedures performed in the United States. Outcomes of this elective procedure may be improved via preoperative optimization of modifiable risk factors. Purposes: We sought to summarize the literature on the clinical implications of preoperative risk factors in TJA and to develop recommendations regarding preoperative optimization of these risk factors. Methods: We searched PubMed in August 2019 with an update in September 2020 for English-language, peer-reviewed publications assessing the influence on outcomes in total hip and knee replacement of 7 preoperative risk factors-obesity, malnutrition, hypoalbuminemia, diabetes, anemia, smoking, and opioid use-and recommendations to mitigate them. Results: Sixty-nine studies were identified, including 3 randomized controlled trials, 8 prospective cohort studies, 42 retrospective studies, 6 systematic reviews, 3 narrative reviews, and 7 consensus guidelines. These studies described worse outcomes associated with these 7 risk factors, including increased rates of in-hospital complications, transfusions, periprosthetic joint infections, revisions, and deaths. Recommendations for strategies to screen and address these risk factors are provided. Conclusions: Risk factors can be optimized, with evidence suggesting the following thresholds prior to surgery: a body mass index <40 kg/m2, serum albumin ≥3.5 g/dL, hemoglobin A1C ≤7.5%, hemoglobin >12.0 g/dL in women and >13.0 g/dL in men, and smoking cessation and ≥50% decrease in opioid use by 4 weeks prior to surgery. Surgery should be delayed until these risk factors are adequately optimized.

Applying plastic surgery principles to ovarian tissue transplantation.

Ovarian tissue cryopreservation (OTC) and transplantation is an innovative procedure increasingly utilized to help preserve fertility after gonadotoxic treatments especially in cancer patients. Approximately 30% of autotransplanted patients are able to achieve live birth, typically with the help of in-vitro fertilization. Numerous techniques and grafting sites have been described to continue to increase this figure. In the field of plastic surgery, tissue grafting has been successful performed for thousands of years and knowledge in this area has been significantly refined. A qualitative review of the literature using PubMed, Cochrane, SCOPUS and Medline databases was performed to look for articles relating to ovarian tissue transplantation (OTT) and comparisons made to plastic surgery tissue grafting. Many parallels were found between the principles of grafting in plastic surgery and the principles of OTT, including pre-operative patient optimization, suitable donor site selection, tissue harvest and preparation, graft site choice, immobilization of the graft and post-operative care. Consideration of the benefits and risks of using orthotopic versus heterotopic recipient sites is also highly important with regards to graft take, morbidity and ease of access of oocyte collection. We believe that ongoing discussion between disciplines can have the potential to improve knowledge, surgical techniques and patient outcomes.

Anesthesia management of renal transplantation: A retrospective analysis

Transplantation provides a near normal life and excellent rehabilitation compared to dialysis and is preferred method of treatment for end stage renal disease patients. After ethics committee approval, a retrospective analysis of recipients of renal transplantation was done at our hospital from January 2010 to December 2014. Preoperative patient status, fluid management, hemodynamic parameters, anesthesia management, and perioperative complications were recorded and analyzed.Total 100 patients were recorded, 92% living and 8% were cadaveric related transplant. 92% were done electively. Most common co-morbidity recorded was hypertension in 49% patients. Predominant cause of end stage renal disease was chronic glomerulonephritis (41%). General anesthesia was technique of choice in all patients, 27 also received epidural. Invasive blood pressure monitoring was done in 3 patients with cardiac co-morbidities. 15% patients required blood transfusion. CVP maintained &amp;#62; 12 mmHg and maximum at de-clamping. Mean arterial pressure maintained above 95 mmHg. Ionotropic support required in 2 patients. 76% patients were transfused with only crystalloid (NS and/or RL) while 24 patients received a combination of both crystalloid and colloid. 97% patients were extubated postoperatively while 3% required ventilator support. Recovery time with desflurane was significantly less as compared to other inhalational agents. One patient died postoperatively. Recent advances in surgical techniques, anesthesia management and immunosuppressive drugs have made renal transplantation safe and predictable. Preoperative patient optimization, intraoperative physiological stability and postoperative care of renal transplant patients have contributed to the success of renal transplant program in our hospital.

Preoperative optimization of patients undergoing interventional procedures: infrastructure, logistics, and evidence-based medicine.

Patients presenting for non-operating room procedures are often 'too sick' for surgery and require specific anesthesia care in remote areas with logistical and scheduling challenges. Increased complexity and scope of minimally invasive procedures have expanded this practice. In addition, the concept of therapeutic options other than conventional surgery is gaining traction. Our review of recent literature confirms the complexity and supports the safety of providing care in non-operating room anesthesia locations. Standard preanesthesia assessments and principles apply to these areas.

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice. To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions. This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019. The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites. Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%. This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.

Outcomes of infratentorial cranial surgery for tumor resection in older patients: An analysis of the National Surgical Quality Improvement Program.

Background: Poorer outcomes for infratentorial tumor resection have been reported. There is a lack of large multicenter analyses describing infratentorial surgery outcomes in older patients. We characterized outcomes in patients aged ≥65 years undergoing infratentorial cranial surgery.Methods: The National Surgical Quality Improvement Project database was queried from 2012 to 2018 for patients ≥18 years undergoing elective infratentorial cranial surgery for tumor resection. Patients were grouped into 65–74 years, ≥75 years, and 18–64 years cohorts. Multivariable regressions compared outcome measures.Results: Of 2212 patients, 28.3% were ≥65 years, of whom 24.8% were ≥75 years. Both older subpopulations had worse American Society of Anesthesiologists classification compared to controls (P < 0.01) and more comorbidities. Patients 65–74 and ≥75 years had higher rates of major complication (adjusted odds ratio [aOR] = 1.77, 95% CI = 1.13–2.79 and aOR = 3.44, 95% CI = 1.96–6.02, respectively), prolonged length of stay (LOS) (aOR = 1.89, 95% CI = 1.15–3.12 and aOR = 3.00, 95% CI = 1.65–5.44, respectively), and were more likely to be discharged to a location other than home (aOR = 2.43, 95% CI =1.73–3.4 and aOR = 3.41, 95% CI = 2.18–5.33, respectively) relative to controls. Patients ≥75 had higher rates of readmission (aOR = 1.86, 95% CI = 1.13–3.08) and mortality (aOR = 3.28, 95% CI = 1.21–8.89) at 30 days.Conclusion: Patients ≥65 years experienced more complications, prolonged LOS, and were less often discharged home than adults <65 years. Patients ≥75 years had higher rates of 30-day readmission and mortality. There is a need for careful preoperative optimization in older patients undergoing infratentorial tumor cranial surgery.

Peripartum optimization and coordination of collaborative care practice: a critical role for the obstetric anesthesiologist in combating maternal morbidity and mortality.

Antenatal anesthesia clinics remain uncommon despite the rising incidence of maternal morbidity and mortality in the United States. The purpose of the present review is to outline the major considerations and challenges surrounding antenatal anesthetic evaluation. Data from the general surgical population would suggest a mortality benefit associated with preoperative anesthesia evaluation, although no such data exists in the obstetric population.Robust systems for case ascertainment and referral are needed. Recent publications on obstetric comorbidity indices may provide useful tools to ascertain high-risk parturients for a referral to antenatal obstetric anesthesiology clinics and higher levels of maternal care. Major obstetric organizations have identified and laid out criteria for maternal level of care. Anesthesiology resources also play a role in these designations and can help triage patients to facilities with appropriate resources. Obstetric anesthesiologists have a critical role not only in preoperative patient optimization but also in coordinating multidisciplinary care for optimal patient outcomes.