Preoperative Optimization Research Articles

Beyond the surface: exploring contributing factors to bone anchored hearing implant complications.

Bone anchored hearing implants (BAHI) are considered for conductive and mixed hearing loss, relying on osseointegration of a titanium implant. Limitations relate to constant skin contact, with resultant percutaneous infections and granulation. This study investigates whether patient characteristics and implant-specifications contribute to BAHIs' skin complications in a cohort with a uniform surgical approach. A 10year (2014-2024) retrospective cohort study was conducted on BAHI procedures that were undertaken using a tissue-preserving 'punch' technique. Data on patient demographics, co-morbidities, implant type, surgical approach, and complications were collected. Poisson regression analysis was used to identify predictors of complications. A total of 53 patients undergoing 55 BAHI surgeries by three ENT consultants were included. Factors that greatly increased implant-related percutaneous infections included the Cochlear™ BIA400 implant when compared to the Ponto™ BHX implant (twofold, CI 2.03-2.16), abutment sizes ≤ 10mm (fourfold, CI 3.99-4.12) and male gender (9%, CI 1.07-1.12). Granulation episodes were affected by cardiovascular disease (CVD) status (1.5-fold, CI 0.26-0.78), BIA400 implant (threefold, CI 8.8.-9.2) and abutment sizes ≤ 10mm (fourfold, CI 3.6-3.73). Revision surgery episodes increased with diabetic status (1.2-fold, CI 0.06-0.37) and abutment sizes ≤ 10mm (threefold, 3.303-3.304). Larger cohort studies are required to confirm findings, particularly for implant and abutment size contributions. However, the findings suggest that using a larger abutment size when skin thickness meassuremets are borderline, improved hygiene education in male patients, pre-operative optimisation of CVD and diabetes, and adjusted patient follow-up based on risk stratification of the contributing factors to complication rates could reduce complication rates.

Higher modified frailty index score is associated with 30-day postoperative complications following simultaneous bilateral total knee arthroplasty

BackgroundThere is no clear consensus regarding patient populations at highest risk for complications from simultaneous bilateral total knee arthroplasty (TKA). The purpose of this study was to determine whether the comorbidities comprising the modified Frailty Index (mFI) were correlated with poor outcomes following simultaneous bilateral TKA. MethodsFrom 2006 to 2019, patients undergoing bilateral TKA aged 50 years or older were identified in a national database. The 5-item mFI was calculated based on the presence of five comorbidities: diabetes, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and dependent functional status. Chi-squared and multivariable regression analyses were used to evaluate the association of mFI scores with postoperative complications. ResultsThe study analyzed 8,776 patients with an average age of 65 years. After adjustment on multivariable regression analysis, compared to patients with a mFI score of 0, those with a score of 1 had an increased risk of pulmonary complication (OR 3.14; p = 0.011), renal problem (OR 12.86; p = 0.022), sepsis complication (OR 2.82; p = 0.024), postoperative transfusion (OR 1.19; p = 0.012), and non-home discharge (OR 1.17; p = 0.002).Patients with a score of 2 compared to 0 had similar complications when compared. These patients had an increased risk of cardiac complication (OR 4.84; p = 0.009) and prolonged hospital stay (OR 4.06; p < 0.001). ConclusionIncreased mFI scores were associated with significantly higher complication rates in patients undergoing simultaneous bilateral TKA compared to unilateral TKA. Our results can be used to identify which patients may need a staged bilateral TKA or preoperative optimization to safely undergo a simultaneous bilateral TKA.Level of Evidence: III.

Patient selection for nonoperating room anesthesia.

Given the rapid growth of nonoperating room anesthesia (NORA) in recent years, it is essential to review its unique challenges as well as strategies for patient selection and care optimization. Recent investigations have uncovered an increasing prevalence of older and higher ASA physical status patients in NORA settings. Although closed claim data regarding patient injury demonstrate a lower proportion of NORA cases resulting in a claim than traditional operating room cases, NORA cases have an increased risk of claim for death. Challenges within NORA include site-specific differences, limitations in ergonomic design, and increased stress among anesthesia providers. Several authors have thus proposed strategies focusing on standardizing processes, site-specific protocols, and ergonomic improvements to mitigate risks. Considering the unique challenges of NORA settings, meticulous patient selection, risk stratification, and preoperative optimization are crucial. Embracing data-driven strategies and leveraging technological innovations (such as artificial intelligence) is imperative to refine quality control methods in targeted areas. Collaborative efforts led by anesthesia providers will ensure personalized, well tolerated, and improved patient outcomes across all phases of NORA care.

Preventive Paradox? Postoperative Outcomes After Risk-Reducing Mastectomy and Direct-to-Implant Breast Reconstruction

BackgroundRisk-reducing mastectomy (RRM) with direct-to-implant (DTI) breast reconstruction is becoming increasingly important in breast cancer prevention. While the oncological benefits of RRM-DTI are well documented, there is a paucity of studies investigating its perioperative safety. MethodsThe ACS-NSQIP database (2008-2022) was queried to identify all patients who underwent RRM-DTI. Outcomes of interest included 30-day occurrence of reoperation, readmission, and surgical and medical complications. Multivariate logistic regression was used to determine factors associated with postoperative complications. ResultsA total of 1019 patients were included, with a mean age and BMI of 42.8 ± 10.9 years and 25.7 ± 5.8 kg/m², respectively. Complications occurred in 142 (14.0%) cases, with 103 (10.1%) reoperations and 51 (5.0%) readmissions. 62 (6.3%) surgical complications were recorded, the majority of which were superficial incisional infection (n = 19; 1.9%) and organ space infections (n = 19; 1.9%). Medical complications were rare (n = 13; 1.3%). Multivariable analyses revealed that higher BMI was significantly associated with any (OR:1.06, P < .0001), surgical (OR:1.08, P < .0001), and medical complications (OR:1.08, P = .04). Patients with bleeding disorders were at a significantly higher risk of any complications (OR:5.5, P = .03), while outpatient setting (OR:1.9, P = .03) and corticosteroid use (OR:6.6, P = .01) were identified as independent predictors of surgical complications. ConclusionThe risk of adverse events following RRM-DTI should not be underestimated, with a 30-day complication rate of 14%. Higher BMI, bleeding disorders, outpatient setting, and corticosteroid use were identified as risk factors. These findings underscore the need for thorough preoperative risk stratification, patient counseling, and health optimization to optimize surgical outcomes.

Impact of opioid-related disorders on complications in patients undergoing bariatric surgery: a propensity score-matched analysis of the national inpatient sample.

The opioid crisis caused a huge health concern in the United States. Despite this, few studies haveexamined the influence of opioid-related disorders (OD) on outcomes after bariatric surgery. The major goal of this study is to determine the impact of OD on in-hospital outcomes for patients undergoing bariatric surgery. The National Inpatient Sample (NIS) database from 2016 to 2020 was used to evaluate patients with OD who underwent bariatric operations including sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch. The non-OD comparison group was created using a propensity score match (1:1). Weighted analysis was carried out utilizing NIS-provided weights. The odds ratios were obtained using multivariate logistic regression. A total of 159,455 patients who underwent bariatric surgery were evaluated. Propensity score matching and weighted analysis were used to compare 11,025 in the OD group and 11,025 in the non-OD group. OD was an independent predictor for postoperative complications (odds ratio: 1.29, 95% confidence interval: 1.19-1.39, p < 0.001). Among complications, OD was a predictor for bleeding complications, postoperative nausea and vomiting, anastomotic leak, and mechanical ventilation. In addition, the OD group experienced significantly longer lengths of stay (LOS) and a higher total hospital charges. In patients undergoing bariatric surgery, OD is associated with a significantly higher risk of postoperative complications, as well as increased LOS and total hospital charges. These patients may benefit from further preoperative optimization, including decreasing the opioid dose and closer postoperative monitoring.

Laparoscopic totally extraperitoneal management of giant inguinoscrotal hernia with loss of domain.

A giant inguinoscrotal hernia extends below the level of the midpoint of the thigh, in an upright position. They are usually due to the neglect of the patient and fear of surgical intervention. Patients typically present with lower urinary tract symptoms, ulcers over the scrotum caused due to dribbling of urine and rarely with obstruction or strangulation. Here, we present a similar case of an uncomplicated giant inguinoscrotal hernia with a Tanaka index of 74% who was preoperatively optimised with BOTOX (BOtulinum TOXin-A) and pre-operative progressive pneumoperitoneum and was managed laparoscopically with enhanced totally extraperitoneal repair. This signifies the importance of optimisation of the patients, especially with loss of domain help in managing such cases without any resection of bowel or omentum. Moreover, this proper pre-operative optimisation also helped us in managing such a case laparoscopically.

The Association of Preoperative Bone Mineral Density and Outcomes after Anterior Cervical Discectomy and Fusion: A Systematic Review.

This is a systematic review. To evaluate anterior cervical discectomy and fusion (ACDF) outcomes and complications as a function of preoperative bone mineral density (BMD). Preoperative BMD optimization is commonly initiated before lumbar spinal fusion, but the effects of BMD on ACDF are less known. Consequently, it remains unclear whether preoperative BMD optimization is recommended before ACDF. This systematic review included relevant clinical articles using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Web of Science, SCOPUS, and MEDLINE from database inception until October 1, 2023. Eligible studies included those evaluating low BMD and outcomes after ACDF. All articles were graded using the Methodological Index for Non-Randomized Studies (MINORS) scale and Critical Appraisal Skills Programme (CASP) assessment tools. The initial retrieval yielded 4271 articles for which 4 articles with 671 patients were included in the final analysis. The mean patient age was 56.4 ± 3.9 years, and 331 patients (49.3%) were female. A total of 265 (39.5%) patients had low BMD (T score<-1.0) before ACDF. Preoperative low BMD was associated with cage subsidence in single-level ACDF (odds ratio (OR) 2.57; P=0.063; 95% Confidence Interval (CI): 0.95-6.95), but this result did not reach statistical significance. Osteoporosis (T score<-2.5) was associated with the development of adjacent segment disease following ACDF (OR 4.41; P<0.01; 95% CI: 1.98-9.83). Low pre-operative BMD was associated with reoperation within 2 years (P<.05) and strongly associated with pseudarthrosis (OR: 11.01; P=0.002; 95% CI 2.4-49.9). Patients with low BMD who undergo ACDF have higher rates of subsidence, adjacent segment disease, and pseudarthrosis than those with normal BMD. Given the individual and system-wide burdens associated with these complications, some patients may benefit from preoperative BMD screening and optimization before undergoing ACDF.

The Tumor Risk Score (TRS) – next level risk prediction in head and neck tumor surgery

PurposeHead and neck cancer surgery often requires postoperative monitoring in an intensive care unit (ICU) or intermediate care unit (IMC). With a variety of different risk scores, it is incumbent upon the investigator to plan a risk-adapted allocation of resources. Tumor surgery in the head and neck region itself offers a wide range of procedures in terms of resection extent and reconstruction methods, which can be stratified only vaguely by a cross-disciplinary score. Facing a variety of different risk scores we aimed to develop a new Tumor Risk Score (TRS) enabling anterograde preoperative risk evaluation, resource allocation and optimization of cost and outcome measurements in tumor surgery of the head and neck.MethodsA collective of 547 patients (2010–2021) with intraoral tumors was studied to develop the TRS by grading the preoperative tumor size and location as well as the invasiveness of the planned surgery by means of statistical modeling. Two postoperative complications were defined: (1) prolonged postoperative stay in IMC/ICU and (2) prolonged total length of stay (LOS). Each parameter was analyzed using TRS and all preoperative patient parameters (age, sex, preoperative hemoglobin, body-mass-index, preexisting medical conditions) using predictive modeling design. Established risk scores (Charlson Comorbidity Index (CCI), American Society of Anesthesiologists risk classification (ASA), Functional Comorbidity Index (FCI)) and Patient Clinical Complexity Level (PCCL) were used as benchmarks for model performance of the TRS.ResultsThe TRS is significantly correlated with surgery duration (p < 0.001) and LOS (p = 0.001). With every increase in TRS, LOS rises by 9.3% (95%CI 4.7–13.9; p < 0.001) or 1.9 days (95%CI 1.0-2.8; p < 0.001), respectively. For each increase in TRS, the LOS in IMC/ICU wards increases by 0.33 days (95%CI 0.12–0.54; p = 0.002), and the probability of an overall prolonged IMC/ICU stay increased by 32.3% per TRS class (p < 0.001). Exceeding the planned IMC/ICU LOS, overall LOS increased by 7.7 days (95%CI 5.35–10.08; p < 0.001) and increases the likelihood of also exceeding the upper limit LOS by 70.1% (95%CI 1.02–2.85; p = 0.041). In terms of predictive power of a prolonged IMC/ICU stay, the TRS performs better than previously established risk scores such as ASA or CCI (p = 0.031).ConclusionThe lack of a standardized needs assessment can lead to both under- and overutilization of the IMC/ICU and therefore increased costs and losses in total revenue. Our index helps to stratify the risk of a prolonged IMC/ICU stay preoperatively and to adjust resource allocation in major head and neck tumor surgery.

The use of self-expanding metallic stents in the management of benign colonic obstruction: a systematic review and meta-analysis

IntroductionPatients presenting with large bowel obstruction (LBO) frequently undergo emergency surgery that is associated with significant morbidity. In malignant LBO, endoscopic approaches with placement is a self-expanding metal stent (SEMS), have been proposed to prevent emergency surgery and act as a bridge to an elective procedure—with the intention of avoiding a stoma and reducing morbidity. This systematic review aims to assess the quality and outcomes of data available on the use of SEMS in benign causes of colonic obstruction.MethodsThis systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the protocol was registered on Prospero (ID: CRD42021239363). PUBMED, MEDLINE, HMIC, CINAHL, AMED, EMBASE, APA and Cochrane databases were searched. Studies were assessed for quality utilising the MINORS criteria. Pooled odds ratios with 95% confidence intervals (95% CI) were calculated using random effects models.ResultsSixteen studies were included for analysis. 300 patients were included with an average age of 68, and a male predominance of 57%. The quality of the papers included were at risk of bias. The pooled rate of technical success of procedure was 94.4% (95% CI 90.5–96.8%) The pooled rate of clinical success was 77.6% (95% CI: 66.6–85.7%). Adverse effects were low, with perforation 8.8% (4.5–16.6%), recurrence 26.5% (17.2–38.5%) and stent migration 22.5% (14.1–33.8%).DiscussionThis systematic review demonstrated that SEMS for benign colonic obstruction can be a safe and successful procedure. The utilisation of SEMS in malignant disease as a bridge to surgery has been well documented. Whilst the limitations of the data interpreted are appreciated, we postulate that SEMS could be utilised to decompress patients acutely and allow pre-operative optimisation, leading to a more elective surgery with less subsequent morbidity.

Preoperative optimization of modifiable risk factors is associated with decreased superficial surgical site infections after total joint arthroplasty: a prospective case-control study.

The aim of our study was to investigate change in modifiable risk factors following preoperative optimization and whether risk of superficial surgical site infection (SSI) after total joint arthroplasty (TJA) could be reduced. This is a prospective study of implementation of a preoperative optimization pathway for patients waiting for primary TJA. Information regarding the intervention arm was collected from January 2019 to January 2021, first at decision for operation and then at preoperative assessment 1 week prior to operation. The control arm was included between August 2018 and September 2020 after receiving conventional preoperative preparation and information gathered at preoperative assessment. Follow up occurred 6 weeks postoperatively for both groups. The primary outcome was postoperative superficial SSI. The optimization effort resulted in improvement of weight, anemia, HbA1c, vitamin D, and patient engagement. At preoperative assessment the baseline characteristics of the 2 groups were similar except that the intervention group had substantially more comorbidities. Regarding superficial SSI, association was found with BMI ≥ 30 and HbA1c ≥ 42 mmol/mol in the control group but not in the intervention group. When corrected for differences in ASA classification (reflecting comorbidities), age, and sex, being in the intervention group was associated with lower odds of occurrence of superficial SSI compared with the control group (OR 0.64, 95% confidence interval 0.42-0.97). We showed that preoperative optimization in a structured cooperation between hospital and primary care was associated with a reduced risk of superficial SSI.

Nursing Interventions in Surgical Patients with Hypertension: Strategies for Optimal Perioperative Blood Pressure Management

This study explores nursing interventions for surgical patients with hypertension, emphasizing strategies for optimal perioperative blood pressure management. Hypertension significantly increases surgical risk, necessitating tailored perioperative care. The objective of this research is to identify and evaluate effective nursing interventions that mitigate these risks and improve patient outcomes. A systematic review was conducted, including randomized controlled trials, cohort studies, and clinical guidelines from 2010 to 2023. The analysis focused on preoperative, intraoperative, and postoperative phases, assessing interventions such as medication management, lifestyle modification counseling, patient education, and monitoring protocols. The findings reveal that preoperative optimization of blood pressure through medication adherence and lifestyle adjustments is crucial. Education about the importance of blood pressure control and adherence to prescribed antihypertensive regimens significantly reduces perioperative complications. Intraoperative strategies include continuous blood pressure monitoring and the administration of antihypertensive agents as needed to maintain stability. Postoperative care focuses on regular blood pressure monitoring, early identification of complications, and patient education to ensure long-term management. The study concludes that a multidisciplinary approach involving nurses, surgeons, and anesthesiologists is essential for effective perioperative management in hypertensive patients. Continuous patient education and engagement in their care, combined with vigilant monitoring and timely intervention, significantly reduce adverse outcomes. These findings underscore the importance of comprehensive, patient-centered nursing interventions in enhancing surgical outcomes for hypertensive patients. Future research should focus on developing standardized protocols and exploring the long-term effects of these interventions on surgical morbidity and mortality.

1215 Cardiovascular Compromise and Hypertensive Crisis Secondary to Phaeochromocytoma

Abstract Phaeochromocytoma is a rare tumour of the chromaffin cells in the adrenal medulla, which secretes catecholamines. While associated with genetic disorders e.g., MEN-2, they tend to occur sporadically, and are often initially asymptomatic, found incidentally on imaging. Classical symptoms of Phaeochromocytoma include headaches, sweating, and palpitations, with sustained or paroxysmal hypertension which is refractory to a cocktail of antihypertensives. A variety of presentations have been reported in the literature including, but not limited to colitis, intracerebral haemorrhage, and PRES syndrome. We present a case of a 64-year-old man with an incidental left adrenal nodule. This radiologically indeterminate lesion was initially asymptomatic. Secretion studies revealed elevated metadrenaline levels, and an MIBG scan with positive avidity unveiled the lesion's pheochromocytoma nature. Whilst awaiting surgical intervention, the patient required emergency admission with a hypertensive crisis, presenting with left-sided flank pain and a blood pressure peaking at 220mmHg systolic. ECG findings were consistent with a myocardial infarction-like picture, and echocardiogram demonstrated regional wall motion abnormalities. CT coronary angiography revealed no significant coronary arterial disease – confirming that the patient’s presentation was in fact secondary to the pheochromocytoma. Pre-operative optimization is crucial for safe surgery. After the crisis, surgery was delayed by 6 weeks for cardiac rehabilitation. The patient was admitted a week before the procedure for optimal haemodynamics. Adrenalectomy proceeded as planned after alpha-blockade. A structured endocrine surgery clinic follow-up was established to assess the patient's ongoing recovery, and cardiovascular status. This case highlights cardiovascular implications of phaeochromocytoma, stressing a multidisciplinary approach for hypertensive crises and optimising outcomes.

1082 Maximising Surgical Outcomes in Midline Incisional Hernia Repairs: Are We Employing Every Possible Optimisation?

Abstract Introduction Large midline Incisional hernia repair can involve complex surgery which poses many challenges, with a high recurrence and complication rate. The recently published European Hernia Society Guidelines has identified several risk factors contributing to the increased complications after surgical repair. We aim to assess the effect of these modifiable risk factors for adverse outcomes within our patient population. Method All adult patients who underwent a repair of midline incisional hernias larger than 3cm in a DGH hospital between July 2021 and July 2022 were included. Data on patient demographics, modifiable risks factors and complications were collected. Analysis was performed using Microsoft Excel. Results 26 patients (age: 64 [33-84] years; M:F, 9:17) underwent a midline incisional hernia repair were included. The average hernia size was 8cm. The average body mass index (BMI) was 33.1, seven were smokers and three had diabetes mellitus. Of the three patients who developed a recurrence, average BMI was 36 and two were smokers. None of the patients were counselled for weight loss or smoking cessation. Conclusions In our cross-sectional study, patients with a large hernia, high BMI, diabetes, a smoking history are associated with adverse outcomes. We aim to highlight and raise the awareness to surgeons who perform these repairs to counsel their patients on their modifiable risk factors and its associated risk of hernia recurrence. Preoperative optimisation improves surgical outcome and subsequently reduces healthcare costs.

Inferior vena cava ultrasound to predict hypotension after general anesthesia induction: a systematic review and meta-analysis of observational studies.

Hypotension after induction of general anesthesia is common and is associated with significant adverse events. Identification of patients at high risk can inform the use of preoperative mitigation strategies. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the inferior vena cava collapsibility index (IVC-CI) and maximal diameter (dIVCmax) in predicting postinduction hypotension and to identify their predictive performance across different threshold ranges. We searched MEDLINE, PubMed®, and Embase from inception to March 2023 for prospective observational studies exploring the performance of IVC-CI and dIVCmax in predicting postinduction hypotension in adults presenting for elective surgery under general anesthesia. We excluded studies reporting on IVC parameters predicting postinduction hypotension in the obstetric patient population or exclusively in patients with obesity. Trials screening and data extraction were conducted independently. We performed meta-analyses to identify the performance of IVC parameters in predicting postinduction hypotension, followed by subgroup analyses that sought the IVC-CI range with the highest hierarchical summary receiver-operating characteristic area under the curve (HSROC-AUC). We used a bivariate random effects model to calculate summary estimates. We evaluated study quality using Newcastle-Ottawa scores and certainty of evidence using the GRADE framework. We included 14 studies involving 1,166 patients. Pooled sensitivity and specificity of the IVC-CI to predict postinduction hypotension was 0.68 (95% confidence interval [CI], 0.55 to 0.79; coverage probability, 0.91) and 0.78 (95% CI, 0.69 to 0.85; coverage probability, 0.9), respectively, with an HSROC-AUC of 0.80 (95% CI, 0.68 to 0.85, high quality of evidence). An IVC-CI threshold range of 40-45% had an HSROC-AUC of 0.86 (95% CI, 0.69 to 0.93, high quality of evidence). Preoperative IVC-CI is a strong predictor of postinduction hypotension. We recommend that future studies use an IVC-CI threshold of 40-45% (low certainty of evidence). Future studies are needed to establish whether ultrasound-guided preoperative optimization improves outcomes in high-risk patients. PROSPERO ( CRD42022316140 ); first submitted 10 March 2022.

Malnutrition in total joint arthroplasty: what should the orthopaedic surgeon consider?

Total joint arthroplasty (TJA) is rising globally, with an associated increase in associated complications, necessitating increased efforts in prevention of these complications with pre-operative optimisation. Malnutrition has been highlighted as one of the most important pre-operative modifiable risk factors to be addressed in TJA, with the term malnutrition in orthopaedic surgery having a broad definition that encompasses a wide range of nutritional abnormalities from undernutrition to overnutrition contributing to the outcomes of TJA. Complications associated with malnutrition include periprosthetic joint infection (PJI), periprosthetic fracture, dislocations, aseptic loosening, anaemia, prolonged length of stay (LOS), increased mortality, and raised health care costs. Standardised nutritional scoring tools, anthropometric measurements, and serological markers are all options available in pre-operative nutritional assessment in TJA, but there is no consensus yet regarding the standardisation of what parameters to assess and how to assess them. Abnormal parameters identified using any of the assessment methods results in the diagnosis of malnutrition, and correction of these parameters of overnutrition or undernutrition have shown to improve outcomes in TJA. With the multiple nutritional parameters contributing to the success of total joint arthroplasty, it is imperative that orthopaedic surgeon has a thorough knowledge regarding nutritional peri-operative optimisation in TJA.

Preoperative workup and optimization for the AUS patient

Preoperative workup and optimization for the AUS patient

The Effect of Varying Preoperative Hemoglobin Levels on the Risk of Major Complications and Surgical Site Infections After Single Level Lumbar Fusion.

Blood transfusions are associated with an increased risk of complications after lumbar fusion, and current anemia hemoglobin thresholds are not surgery specific. We aimed to calculate single-level lumbar fusion-specific preoperative hemoglobin strata that observe the likelihood of 90-day transfusion and evaluate whether these strata are associated with increased risk of 90-day complications and 2-year infections. A national database identified patients undergoing primary single-level lumbar fusion with preoperative hemoglobin values (g/dL). Stratum-specific likelihood ratio analysis calculated sex-based hemoglobin strata associated with the risk of 90-day transfusion. Incidence and risk of 90-day major complications and 2-year infections were observed between strata. Three female (hemoglobin strata, likelihood ratio [<10.9, 2.41; 11.0 to 12.4, 1.35; 12.5 to 17.0, 0.78]) and male (<11.9, 2.95; 12.0 to 13.4, 1.46; 13.5 to 13.9, 0.71) strata were associated with varying likelihood of 90-day blood transfusion. Increased 90-day complication risk was associated with two female strata (hemoglobin strata, relative risk [11.0 to 12.4, 1.52; <10.9, 3.40]) and one male stratum (<11.9, 2.02). Increased 2-year infection risk was associated with one female (<10.9, 3.67) and male stratum (<11.9, 2.11). Stratum-specific likelihood ratio analysis established sex-based single-level lumbar fusion-specific hemoglobin strata that observe the likelihood of 90-day transfusion and the risk of 90-day major complications and 2-year infections. These thresholds are a unique addition to the literature and can assist in counseling patients on their postoperative risk profile and in preoperative patient optimization. Level III.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Payer Status and Medication Management-Part Six of the Movement Is Life Special ONJ Series.

This article is the sixth in the Movement is Life series and focuses on insurance coverage and medication management in the perioperative period, 2 tangentially related variables that affect patient outcomes. Our aim is to use current practices and literature to develop recommendations for nurse navigators' execution of preoperative optimization protocols related to payer status and medication management. Discussions with nurse navigators and a literature search were used to gather information and develop recommendations specific to optimizing payer status and medication management. Nurse navigators connected patients to resources and provided education regarding financial concerns and medications, and findings from the literature discussed insurance status among TJA patients. Nurse navigators can contribute to payer status and medication management optimization by providing patient education and resource referrals. In addition, we recommend conducting repeated medication reconciliation and developing awareness of financial resources and perioperative medication management guidelines.

Anesthesia considerations for pediatric metabolic and bariatric surgery

Childhood obesity is a rapidly growing global health issue, linked to significant lifelong morbidity and mortality. Its impact on various organ systems increases perioperative complications. Obesity treatment in children and adolescents involves lifestyle, dietary, and behavioral modifications, as well as pharmacologic interventions that targets hormonal, metabolic, and neurochemical abnormalities. Metabolic and bariatric surgery, proven safe and effective for adults with severe obesity (class 2 or higher), is now being recommended for adolescents. Key anesthetic considerations for these surgeries include preoperative optimization, advanced airway management, targeted ventilation strategies, and opioid-sparing analgesic regimens. Comprehensive presurgical evaluations must address co-morbid conditions such as hypertension, obstructive sleep apnea, asthma, and impaired glycemic control. Preoperative management should also consider the effects of antiobesity medications on gastric emptying and hemodynamic stability. Ventilation strategies should prevent atelectasis while avoiding barotrauma, and drug dosages must be adjusted for altered pharmacokinetics due to increased adipose tissue. Employing enhanced recovery after surgery protocols may reduce perioperative complications, shorten postsurgical stays, and improve outcomes.

NCPD Tests: Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization:Payer Status and Medication Management.

NCPD Tests: Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization:Payer Status and Medication Management.