Risk Of Adverse Postoperative Outcomes Research Articles

Preoperative Opioid Use Increases Postoperative Opioid Demand, but Not Length of Stay After Spine Trauma Surgery

BackgroundPreoperative opioid use has been well-studied in elective spinal surgery and correlated with numerous postoperative complications including increases in immediate postoperative opioid demand (POD), continued opioid use postoperatively, prolonged length of stay (LOS), readmissions, and disability. There is a paucity of data available on the use of preoperative opioids in surgery for spine trauma, possibly because there are minimal options for opioid reduction prior to emergent spinal surgery. Nevertheless, patients with traumatic spinal injuries are at a high risk for adverse postoperative outcomes. This study investigated the effects of preoperative opioid use on POD and LOS in spine trauma patients. Methods130 patients were grouped into two groups for primary comparison: Group 1 (Preoperative Opioid Use, N=16) and Group 2 (No Opioid Use, N=114). Two subgroups of Group 2 were used for secondary analysis against Group 1: Group 3 (No Substance Abuse, N=95) and Group 4 (Other Substance Abuse, N=19). Multivariable analysis was used to determine if there were significant differences in POD and LOS. ResultsPrimary analysis demonstrated that preoperative opioid users required an estimated 97.5 mg/day more opioid medications compared to non-opioid users (p<0.001). Neither primary nor secondary analysis showed a difference in LOS in any of the comparisons. ConclusionsPreoperative opioid users had increased POD compared to non-opioid users and patients abusing other substances, but there was no difference in LOS. We theorize the lack of difference in LOS may be due to the enhanced perioperative recovery protocol used, which has been demonstrated to reduce LOS.

Existing Psychiatric Diagnoses Among Breast Cancer Patients Interact with Outcomes After Autologous and Implant-Based Bilateral Breast Reconstruction: A Propensity Score Matched Analysis

BackgroundBreast reconstruction is an integral postoncologic procedure that has been associated with improved mental health and psychological outcomes. The possible interaction between existing psychiatric diagnoses hospital courses and postoperative complications warrants further exploration. MethodsBilateral breast reconstruction patients were identified from the 2016 to 2018 Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP - NIS). Number and type of psychiatric diagnoses within the cohort were then evaluated using a host of ICD-10 codes. A propensity score analysis was applied to control for confounding variables such as demographics, existing comorbidities, and hospital characteristics. A binary logistic regression model was then used to identify the prediction value of psychiatric diagnosis and its interaction with modality of reconstruction for objective outcomes like length of hospital stay, treatment charge, and postoperative complications. ResultsA total of 10,114 patients were identified as the final cohort of breast reconstruction patients. 2621 (25.9%) patients possessed an average of 1.4 ± 0.6 existing psychiatric diagnoses. Presence of at least 1 psychiatric diagnosis was a strong predictor alone for extended length of stay (OR: 1.34, 95% CI: 1.28-1.41, P < .001) and occurrence of postoperative complications (OR: 1.31, 95% CI: 1.21-1.41, P < .001). Psychiatric diagnosis displayed a significant interaction with modality of breast reconstruction and conferred a lower increase in risk of extended length of stay in autologous reconstruction when compared to implant-based reconstruction (OR: 0.80, 95% CI: 0.72-0.89, P < .001). ConclusionExisting psychiatric diagnoses were shown to strongly predict and modulate risk of adverse postoperative outcomes depending on modality of reconstruction.

Intraoperative Opioid Waste and Association of Intraoperative Opioid Dose with Postoperative Adverse Outcomes: A Hospital Registry Study.

Perioperative opioid use has been associated with adverse clinical outcomes. Additionally, opioid disposal carries significant costs, due to the waste of pharmaceutical products and the time needed by skilled labor to report the waste. In this study, we aimed to estimate costs and predict factors of opioid-associated intraoperative product waste, as well as to evaluate whether higher intraoperative opioid doses are associated with increased risk of adverse postoperative outcomes. We included 170,607 patients undergoing general anesthesia and receiving intraoperative fentanyl, hydromorphone, or morphine at Beth Israel Deaconess Medical Center, Boston, MA, USA, between January 2010 and June 2020. We estimated product waste-associated costs based on various opioid syringe sizes and determined predictors of opioid waste. Further, we evaluated whether higher opioid doses were associated with postoperative adverse events according to the severity-indexed, incident report-based medication error-reporting program classification. The primary outcome included post-extubation desaturation, postoperative nausea or vomiting, or postoperative somnolence or sedation. The use of the smallest syringe sizes (50 mcg for fentanyl, 0.2mg for hydromorphone, and 2mg for morphine) resulted in the lowest product waste-associated costs. The main predictor of opioid waste was the administration of more than one intraoperative opioid (adjusted odds ratio [aOR] = 7.64, 95% CI 7.40-7.89, P < 0.001). Intraoperative doses of fentanyl > 50-100 mcg (aOR = 1.17 [1.10-1.25], P < 0.001, adjusted risk difference [ARD] 2%) and > 100 mcg (aOR = 1.24 [1.16-1.33], P < 0.001, ARD 3%), hydromorphone > 1mg (aOR = 1.13 [1.06-1.20], P < 0.001, ARD 2%), and morphine > 2-4mg (aOR = 1.26 [1.02-1.56], P = 0.04, ARD 3%) and > 4mg (aOR = 1.45 [1.18-1.77], P < 0.001, ARD 5%) were associated with higher risk of the primary outcome. Smaller syringe sizes of intraoperative opioids may help to reduce product waste and associated costs, as well postoperative adverse events through utilization of lower intraoperative opioid doses.

Postoperative outcomes of pediatric patients with perioperative COVID-19 infection: a systematic review and meta-analysis of observational studies.

To quantify the risk of adverse postoperative outcomes in pediatric patients with COVID-19 infection. We searched PubMed, Embase, Cochrane Library from December 2019 to 21 April 2023. Observational cohort studies that reported postoperative early mortality and pulmonary complications of pediatric patients with confirmed COVID-19-positive compared with COVID-19-negative were eligible for inclusion. We excluded pediatric patients underwent organ transplantation or cardiac surgery. Reviews, case reports, letters, and editorials were also excluded. We used the Newcastle-Ottawa Scale to assess the methodological quality and risk of bias for each included study. The primary outcome was postoperative early mortality, defined as mortality within 30days after surgery or during hospitalization. The random-effects model was performed to assess the pooled estimates, which were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). 9 studies involving 23,031 pediatric patients were included, and all studies were rated as high quality. Compared with pediatric patients without COVID-19, pediatric patients with COVID-19 showed a significantly increased risk of postoperative pulmonary complications (PPCs) (RR = 4.24; 95% CI 2.08-8.64). No clear evidence was found for differences in postoperative early mortality (RR = 0.84; 95% CI 0.34-2.06), postoperative intensive care unit (ICU) admission (RR = 0.80; 95% CI 0.39-1.68), and length of hospital stay (MD = 0.35, 95% CI -1.81-2.51) between pediatric patients with and without COVID-19. Perioperative COVID-19 infection was strongly associated with increased risk of PPCs, but it did not increase the risk of postoperative early mortality, the rate of postoperative ICU admission, and the length of hospital stay in pediatric patients. Our preplanned sensitivity analyses confirmed the robustness of our study findings.

Validity of computed tomography defined body composition as a prognostic factor for functional outcome after kidney transplantation.

The prevalence of sarcopenia is markedly higher in kidney transplant candidates than in the general population. It is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength, which increases the risk of adverse postoperative outcomes. We studied the impact of computed tomography defined preoperative sarcopenia, defined as a skeletal muscle index below age and gender specific cut-off values, on postoperative physical functional outcomes (grip strength, 4-m walking test, timed up and go, and sit to stand) at 6months follow up. A total of 107 patients transplanted between 2015 and 2019 were included in this single-centre study. Mean age was 60.3 (±13.1), and 68.2% of patients were male. Ten patients (9.4%) were identified as sarcopenic. Sarcopenic patients were younger (55.6 (±15.1) vs. 60.8 (±12.9) years), more likely to be female (60.0% vs. 28.9%), and had an increased dialysis vintage (19 [2.5-32.8] vs. 9 [0.0-21.0] months) in comparison with their non-sarcopenic counterparts. In univariate analysis, they had a significantly lower body mass index and skeletal muscle area (P≤0.001). In multivariate regression analysis, skeletal muscle index was significantly associated with grip strength (β=0.690, R2 =0.232) and timed up and go performance (β=-0.070, R2 =0.154). We identified a significant association between sarcopenia existing pre-transplantation and poorer 6months post-transplantation physical functioning with respect to hand grip strength and timed up and go tests in kidney transplant recipients. These results could be used to preoperatively identify patients with an increased risk of poor postoperative physical functional outcome, allowing for preoperative interventions to mitigate these risks.

Severity of Prior Coronavirus Disease 2019 is Associated With Postoperative Outcomes After Major Inpatient Surgery.

To determine how the severity of prior history (Hx) of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection influences postoperative outcomes after major elective inpatient surgery. Surgical guidelines instituted early in the coronavirus disease 2019 (COVID-19) pandemic recommended a delay in surgery of up to 8 weeks after an acute SARS-CoV-2 infection. This was based on the observation of elevated surgical risk after recovery from COVID-19 early in the pandemic. As the pandemic shifts to an endemic phase, it is unclear whether this association remains, especially for those recovering from asymptomatic or mildly symptomatic COVID-19. Utilizing the National COVID Cohort Collaborative, we assessed postoperative outcomes for adults with and without a Hx of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from infection to surgery were each used as independent variables in multivariable logistic regression models. This study included 387,030 patients, of whom 37,354 (9.7%) were diagnosed with preoperative COVID-19. Hx of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of respiratory failure. Impact of COVID-19 on postoperative outcomes is dependent on the severity of illness, with only moderate and severe disease leading to a higher risk of adverse outcomes. Existing perioperative policies should be updated to include consideration of COVID-19 disease severity and vaccination status.

Low albumin-to-fibrinogen ratio predicts adverse clinical outcomes after primary total joint arthroplasty: A retrospective observational investigation.

Nutritional markers for adverse clinical outcomes following total joint arthroplasty (TJA) remain controversial. This study attempted to explore the validity of the albumin-to-fibrinogen ratio (AFR) in nutritional assessment and assess its predictive value for adverse postoperative outcomes in patients receiving TJA. 2137 patients who underwent primary TJA between January 2016 and June 2021 were screened. We performed receiver operating characteristic curves and area under the curve (AUC) to assess predictive value and establish optimal thresholds. Multivariate regression models were then used to assess potential associations between AFR and adverse postoperative outcomes. AFR might predict postoperative deep surgical site infections (AUC = 0.699, P = .023). The optimal threshold for wound complications, determined by the Youden index, was 12.96. Compared with patients with reduced AFR, patients with high AFR exhibited an enhanced risk of adverse postoperative outcomes (adjusted OR: 4.010-8.832, all P < .05). Using multivariate Cox regression analysis, we further confirmed a higher risk of adverse postoperative outcomes in patients with low AFR (adjusted HR: 3.733-7.335, all P < .05). Reduced preoperative AFR markedly enhanced adverse postoperative outcomes. Hence, AFR may serve as a potential biomarker for nutritional assessment, and may predict postoperative wound complications following primary TJA.

Impact of Hepatitis B virus infection on postoperative complications and length of stay in elderly patients with hip fracture: A retrospective cohort study

BackgroundOsteoporosis and subsequent fractures are common in the chronic hepatitis B (CHB) population, especially in the elderly. This study investigated the effects of hepatitis B virus (HBV) infection on postoperative outcomes following hip fracture surgery. MethodsThe study identified elderly patients who underwent hip fracture surgery at three academic tertiary care centres between January 2014 and December 2020. Propensity score matching was performed to compare the outcomes of 1,046 patients with HBV infection to 1,046 controls. ResultsThe seroprevalence of HBV among elderly patients undergoing hip surgery was 4.94%. The HBV cohort had significantly higher rates of medical complications (28.1 vs. 22.7%, p = 0.005), surgical complications (14.0 vs. 9.7%, p = 0.003), and unplanned readmissions (18.9 vs. 14.5%, p = 0.03) within 90 days of surgery. Patients with HBV infection were more likely to have increased length of stay (6.2 vs. 5.9 days, p = 0.009) and in-hospital charges (¥52,231 vs. ¥49,832, p < 0.00001). Multivariate logistic regression suggested that liver fibrosis and thrombocytopenia were independent risk factors for major complications and extended LOS. ConclusionPatients with HBV infection were at greater risk of adverse postoperative outcomes. We should pay more attention to the considerable burden of perioperative management of CHB patients. Due to the high proportion of undiagnosed patients in the Chinese elderly population, universal HBV screening should be considered preoperatively.

Estimated Risk of Adverse Surgical Outcomes Among Patients With Recent COVID-19 Infection Using Target Trial Emulation Methods

This cohort study emulates a trial within a large national veteran population to assess the risk of adverse postoperative outcomes among patients with recent COVID-19 infection.

Steep ramp test protocol for preoperative risk assessment and short-term high-intensity interval training to evaluate, improve, and monitor cardiorespiratory fitness in surgical oncology.

Steep ramp test protocol for preoperative risk assessment and short-term high-intensity interval training to evaluate, improve, and monitor cardiorespiratory fitness in surgical oncology.

The Impact of Osteoporosis on 2-Year Outcomes in Patients Undergoing Long Cervical Fusion

Osteoporosis affects nearly 200 million individuals worldwide. Given this notable disease burden, there have been increased efforts to investigate complications in patients with osteoporosis undergoing cervical fusion (CF). However, there are limited data regarding long-term outcomes in osteoporotic patients in the setting of ≥4-level cervical fusion. The New York State Statewide Planning and Research Cooperative System database was used to identify patients who underwent posterior or combined anterior-posterior ≥4-level CF for cervical radiculopathy or myelopathy from 2009 to 2011, with a minimum follow-up surveillance of 2 years. The following were compared between patients with and without osteoporosis: demographics, hospital-related parameters, medical/surgical complications, readmissions, and revisions. Binary multivariate stepwise logistic regression was used to identify independent predictors of outcomes. A total of 2,604 patients were included (osteoporosis: n = 136 (5.2%); nonosteoporosis: n = 2,468). Patients with osteoporosis were older (66.9 ± 11.2 vs. 60.0 ± 11.4 years, P < 0.001), more often female (75.7% vs. 36.2%, P < 0.001), and White (80.0% vs. 65.3%, P = 0.007). Both cohorts had comparable comorbidity burdens (Charlson/Deyo: 1.1 ± 1.2 vs. 1.0 ± 1.3, P = 0.262), total hospital charges ($100,953 ± 94,933 vs. $91,618 ± 78,327, P = 0.181), and length of stay (9.7 ± 10.4 vs. 8.4 ± 9.6 days, P = 0.109). Patients with osteoporosis incurred higher rates of overall medical complication rates (41.9% vs. 29.4%, P = 0.002) and individual surgical complications, such as nonunion (2.9% vs. 0.7%, P = 0.006). Osteoporosis was associated with medical complications (OR = 1.57, P = 0.021), surgical complications (OR = 1.52, P = 0.030), and readmissions (OR = 1.86, P = 0.003) at 2 years. Among patients who underwent multilevel cervical fusion, those with osteoporosis had higher risk of adverse postoperative outcomes at two years. These data indicate that preoperative screening and management of osteoporosis may be important for optimizing long-term outcomes in patients who require multilevel CF. The data used in this study are available for public use at https://www.health.ny.gov/statistics/sparcs/.

Obesity Is Associated With Increased Risk for Adverse Postoperative Outcomes After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

IntroductionConflicting reports exist about the effect obesity has on adverse postoperative surgical outcomes after distal pancreatectomy (DP). The aim of this study is to explore the role of obesity in terms of morbidity and pancreas-specific complications following DP for pancreatic ductal adenocarcinoma (PDAC). MethodsAll patients who underwent DP at a single institution over 10 y were analyzed (2009-2020). Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). Independent predictors of adverse postoperative outcomes were calculated using multivariate logistic regression models. Overall survival was assessed using Kaplan–Meier survival analysis. ResultsOf the 178 patients included, 58 (32.5%) were obese. Clinically relevant postoperative pancreatic fistula (CR-POPF) formation rate was significantly higher in the obese group (20.6% versus 7.5%, P value = 0.011). We did not identify any significant difference between obese and nonobese patients in median overall survival (30.2 mon versus 28.9 mon, P value = 0.811). On multivariate binary logistic regression analysis, BMI ≥ 30 was an independent predictor of morbidity (any complication) and CR-POPF formation after DP for PDAC. ConclusionsObesity is associated with a significantly increased risk for CR-POPF in patients undergoing DP for PDAC. Obesity should be considered as a variable in fistula risk calculators for DP.

Anemia and Its Severity Is Associated With Worse Postoperative Outcomes Following Open Reduction Internal Fixation of Ankle Fractures.

Ankle fractures are often treated in a nonemergent fashion and therefore offer the chance for treatment of preoperative anemia. Although preoperative anemia has been associated with postoperative morbidity following certain types of orthopaedic procedures, its effect on postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures has not been evaluated. The purpose of this study was to determine the influence of preoperative anemia on 30-day postoperative outcomes following ankle fracture ORIF. The American College of Surgeons National Surgical Quality Improvement Program (ASC-NSQIP) registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into nonanemic, mildly anemic, and moderately to severely anemic. Univariate analyses were used to assess differences in patient characteristics between cohorts. Multivariate logistic regressions adjusting for these differences were performed to assess the effect of preoperative anemia on 30-day postoperative outcomes. We obtained data for 21 211 patients, of whom 14 931 (70.39%) were not anemic, 3982 (18.77%) were mildly anemic, and 2298 (10.83%) were moderately to severely anemic. After adjustment, mild preoperative anemia was associated with higher odds of any adverse event (P < .001), deep surgical site infections (SSIs; P = .013), sepsis (P = .001), 30-day readmission (P < .001), and extended length of stay (LOS) (P < .001). Similarly, moderate to severe anemia in these patients was also associated with increased odds of any adverse event (P < .001), deep SSIs (P = .003), sepsis (P = .001), readmission (P < .001), and extended LOS (P < .001). Both mild (P = .004) and moderate to severe (P < .001) anemia groups had higher odds of requiring a blood transfusion. Preoperative anemia is associated with an increased risk of adverse postoperative outcomes in patients undergoing ORIF for ankle fractures. Future studies should evaluate whether optimization of hematocrit in these patients results in improved outcomes. Level III, comparative study.

Psoas muscle mass index as a predictor of long-term mortality and severity of complications after major intra-abdominal colorectal surgery – A retrospective analysis

Study objectiveDetermine if psoas muscle area measured in routine preoperative computed tomography scans (CT) can be used to identify patients at increased risk of adverse postoperative outcomes after major elective abdominal surgery. DesignRetrospective analysis of data from a single-centre cohort study conducted in York Hospital between the 1st August of 2015 and the 31st of august of 2020. SettingPreoperative clinic. Patients639 patients who attended the preoperative assessment clinic prior to major elective colorectal surgery and had an abdominal CT scan done up to 120 days before surgery. InterventionsNone. MeasurementsPsoas muscle area at the L3 level was measured in preoperative CT scans and normalised to patient height (psoas muscle index). The lowest sex-stratified tertile of psoas muscle index (PMI) was classed as sarcopenic.The primary outcome was 2-year mortality. Secondary outcomes included postoperative complications assessed using Clavien-Dindo graded major and minor complications, comprehensive complication index (CCI), and length of stay. Main resultsMultivariable regression analysis showed that sarcopenia was associated with 2-year mortality (aOR 1.79, 95% CI 1.03–3.10; p = 0.037) and survival at 2-years was significantly reduced in sarcopenic patients (log-rank test, p = 0.012). Sarcopenia was the only statistically significant predictor of major complications in multivariable logistic regression analysis (aOR 1.69, 95% CI 1.04–2.74, p = 0.034) and associated with an estimated increase of 16.6% in the comprehensive complication index (CCI) score of patients that had complications in multivariable linear regression analysis. Sarcopenia was not associated with length of stay. ConclusionsSarcopenia defined by psoas muscle mass is an independent predictor of 2-year mortality, major complications and severity of complications after major colorectal surgery and may be used for preoperative risk assessment.

Frailty assessment tools and associated postoperative outcomes in older patients undergoing elective surgery: A prospective pilot study.

There is a need for a feasible tool to assess the risk of frailty prior to surgery. We aimed to identify the ratio of abnormal results for three clinically applicable screening tools to assess the risk of frailty, and their association with adverse outcomes in a cohort of elderly surgical patients. In this prospective pilot study, patients ≥65 years undergoing preoperative evaluation for elective surgery were included and subjected to three frailty screening tests; Program of Research to Integrate Services for the Maintenance of Autonomy 7-item questionnaire (PRISMA7), Timed Up and Go (TUG), and Clock Drawing Test (CDT). The primary outcome was the incidence of abnormal testing, and secondary outcomes were the association between abnormal tests and mortality, readmission, delirium, surgical complications and non-home discharge. Out of 99 patients, 41%, 37%, and 43% had abnormal PRISMA7, TUG, and CDT screening, respectively. Postoperative delirium was more likely to occur in patients with abnormal TUG screening (19% vs. 3%, p= .011) and CDT (17% vs. 2%, p= .019). When analyzing screening tool combinations, patients with abnormal PRISMA7 and TUG had a higher rate of non-home discharge (38% vs. 17%, p= .029); and patients with abnormal TUG and CDT had a higher rate of postoperative delirium (25% vs. 3%, p= .006) and any surgical complication (58% vs. 38%, p= .037); and patients with abnormal results from all three tools had a higher rate of postoperative delirium (21% vs. 5%, p= .045) and non-home discharge (42% vs. 18%, p= .034). Approximately 40% of elderly surgical patients have abnormal PRISMA7, TUG, and CDT screening tests for frailty, and they are associated individually or in combination with increased risk of adverse postoperative outcomes. The results will aid in designing studies to further risk-stratify patients at risk of frailty and attempt to modify associated outcomes.

Can Frailty Indices Predict Surgical Risk in Open Reduction and Fixation of Facial Fractures?

PURPOSE: Facial fractures, often resulting from high impact trauma, necessitate surgical fixation with postoperative complications occurring in 3-30% of patients.1 Thus, risk prediction of unfavorable postoperative complications is essential for preoperative planning and postoperative management. Existing literature has linked smoking, alcohol use, age, BMI, and comorbidities to increased risk of adverse postoperative outcomes following facial fracture repair.1 More recently, frailty indices, including the Modified Five-Item Frailty Index (mFI-5) and the Modified Charlson Comorbidity Index (mCCI), have emerged as potentially more accurate predictors of surgical risk and 30-day postsurgical complications than their historical counterparts.2,3 The authors aimed to evaluate whether the mFI-5 and mCCI are stronger predictors of 30-day postoperative complications after open facial fracture reduction, versus historic risk proxies. METHODS: A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database was performed of patients undergoing open facial fracture reduction from 2013-2019. Age, smoking, BMI, comorbidities, and American Society of Anesthesiologists (ASA) class were extracted, and mFI-5 and mCCI scores were calculated using this data. Univariate logistic regressions were performed (p<0.05). RESULTS: A total of 2,667 patients were analyzed, of which 2,131 (80%) were male. Most patients were nonfrail across both indices, with 86% (n=2,292) having an mFI-5 of 0, and 75% (n=1,994) having a mCCI of 0. Both mCCl score ≥2 (OR=2.19, p<0.001) and mFI-5 =1 (OR=1.96, p<0.001) were strong independent predictors of overall 30-day complication rate and complication severity. However, ASA class ≥3 was the strongest predictor (OR=3.60, p<0.001). Age was statically significant, but a low-impact, predictor of complications and complication severity (OR= 1.02, p<0.001). The only significant predictors of surgical site infections (SSI) were smoking (OR=1.56, p=0.042) and ASA class ≥3 (OR=2.37, p=0.013). An mFI-5 of 1 was also found to be a significant predictor of hospital readmission rates (7% vs 3% p<0.001). BMI was not associated with any increased risk. CONCLUSION: The mCCI and mFI-5 are significant independent predicators of total complications and complication severity following facial fracture repair. ASA class ≥3 was the strongest predictor of postoperative complications, likely attributable to concurrent multi-organ system trauma and its global impact on risk in facial fracture injury. An mFI-5 ≥1 was additionally predictive of increased readmission rates. Smoking increased risk of surgical site infections specifically but not overall complications. Newer frailty indices (mFI-5 and mCCI) predicted adverse postsurgical events more strongly than several historic risk proxies, offering potential utility as risk predictors during surgical planning. Further research should continue to clarify their predictive value. REFERENCES: 1. Perez D, Ellis E, 3rd. Complications of Mandibular Fracture Repair and Secondary Reconstruction. Semin Plast Surg. 2020;34(4):225-231. 2. Austin SR, Wong YN, Uzzo RG, Beck JR, Egleston BL. Why Summary Comorbidity Measures Such As the Charlson Comorbidity Index and Elixhauser Score Work. Med Care. 2015;53(9):e65-72. 3. Lee CC, Hunter WP, Hajibandeh JT, Peacock ZS. Does the Modified Frailty Index (mFI-5) Predict Adverse Outcomes in Maxillofacial Fracture Repair? J Oral Maxillofac Surg. 2021.

Presence of Anemia and Its Severity is Associated with Worse Outcomes Following Open Reduction Internal Fixation of Ankle Fractures

Category: Trauma; Ankle Introduction/Purpose: Preoperative anemia has been associated with significant postoperative morbidity following various types of orthopaedic procedures. However, to our knowledge, there is no study assessing postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures with varying severity of anemia. The purpose of this study was to determine the influence of preoperative anemia severity on 30-day postoperative outcomes following ankle fracture ORIF. Methods: The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into 3 cohorts: non-anemic (hematocrit &gt; 36% for women, &gt;39% for men), mildly anemic (hematocrit 33%-36% for women, 33%-39% for men), and moderately to severely anemic (hematocrit &lt;33% for both women and men) based on World Health Organization definitions. Patients with missing hematocrit data were excluded. Univariate analyses were utilized to assess differences in patient characteristics between cohorts. Multivariate logistic regressions controlling for differences between subgroups were performed to assess the effect of preoperative anemia on 30-day postoperative outcomes. Statistical significance was set at P&lt;0.05. Results: In total, 22,413 patients that underwent ORIF for ankle fractures were included. Of these, 15,739 (70.22%) were not anemic, while 4,243 (18.93%) and 2,431 (10.85%) were mildly and moderately to severely anemic, respectively. Multivariate analysis revealed that mild preoperative anemia in patients undergoing ankle fracture ORIF was associated with higher odds of any adverse event (OR 1.62, P&lt;0.001), superficial surgical site infections (SSIs) (OR 1.46, P=0.047), deep SSIs (OR 2.06, P=0.022), sepsis (OR 2.83, P=0.002), 30-day readmission (OR 1.61, P&lt;0.001), and extended length of stay (LOS) (OR 1.56, P&lt;0.001). Similarly, moderate to severe anemia in these patients was also associated with increased odds of any adverse event (OR 1.94, P&lt;0.001), deep SSIs (OR 2.77, P=0.006), sepsis (OR 3.55, P=0.001), readmission (OR 2.07, P&lt;0.001), and extended LOS (OR 2.21, P&lt;0.001). In addition, moderate to severe anemia patients were associated with higher odds of unplanned reoperation (OR 2.31, P&lt;0.001) and progressive renal insufficiency (OR 3.74, P=0.048). Conclusion: Preoperative anemia is associated with an increased risk of adverse postoperative outcomes in patients undergoing ORIF for ankle fractures. This association seems to be dose dependent, as the odds of adverse events increases with increases in anemia severity. Medical optimization of patients with moderate to severe anemia should take precedence.

Diastolic Blood Pressure Alleles Improve Congenital Heart Defect Repair Outcomes.

Congenital heart defects (CHDs) affect 40 000 US births per year, half of which require surgical intervention. Individual differences in surgical outcomes including mortality and complications are not well understood but may be due to genetic variability. We hypothesized that polygenic risk scores (PRSs) for blood pressure in adults are associated with treatments and postsurgical outcomes in children with CHD, as CHD survivors are at higher risk of negative cardiometabolic disease. We used imputed genotype data from pediatric participants requiring surgery for CHD (median age at surgery, 201 days; nmax=2498). Base data for the systolic and diastolic blood pressure PRSs (nmax=760 226) came from published genome-wide association study. The blood pressure PRSs were tested for association with postsurgical outcomes. All effects presented are per SD increase in PRS and adjusted for age, sex, body mass index, surgical complexity score, and first 10 principal components of ancestry. A higher diastolic blood pressure PRS was associated with decreased in-hospital mortality risk (odds ratio, 0.57 [0.39-0.82]; P=0.0022). Additional analyses suggest an interaction between diastolic blood pressure PRS and vasopressor dose. Those with a diastolic blood pressure PRS 1 SD above the mean, receiving a vasopressor dose in the top tertile, were estimated to have 52% (32%-66%) lower risk of in-hospital mortality compared with those with a vasopressor dose in the bottom tertile. These results suggest a genetically determined postsurgical survival advantage for CHD patients with blood pressure increasing alleles. Further study may reveal novel mechanisms contributing to postoperative morbidity and mortality, and this approach may assist in early identification of children at risk for adverse postoperative outcomes.

Association of Dual Medicare and Medicaid Eligibility With Outcomes and Spending for Cancer Surgery in High-Quality Hospitals

Although dual eligibility (DE) status for Medicare and Medicaid has been used for social risk stratification in value-based payment programs, little is known about the interplay between hospital quality and disparities in outcomes and spending by social risk. To assess whether treatment at high-quality hospitals mitigates DE-associated disparities in outcomes and spending for cancer surgery. Retrospective cohort study from January 1, 2014, to December 31, 2018, evaluating inpatient surgery at acute care hospitals. A total of 119 757 Medicare beneficiaries aged 65 years or older who underwent colectomy, rectal resection, lung resection, or pancreatectomy were evaluated. Data were analyzed between November 1, 2020, and April 30, 2021. Medicare and Medicaid DE status and hospital quality. Postoperative complications, readmission, and mortality by DE status and hospital quality. Overall, 119 757 Medicare beneficiaries underwent colectomy, rectal resection, lung resection, or pancreatectomy. The mean (SD) age was 75.3 (6.7) years, 61 617 (51.5%) were women, 7677 (6.4%) were Black, 106 099 (88.6%) were White, and 5981 (5.0%) identified as another race or ethnicity; 11.3% had DE status. Dually eligible patients were more likely to be discharged to a facility (colectomy, 15.0% [95% CI, 14.7%-15.3%] vs 23.9% [95% CI, 22.9%-24.9%]; proctectomy, 18.7% [95% CI, 18.0%-19.3%] vs 26.9% [95% CI, 24.9%-28.9%]; lung resection, 11.0% [95% CI, 10.7%-11.3%] vs 17.9% [95% CI, 16.8%-18.9%]; pancreatectomy, 23.5% [95% CI, 22.5%-24.4%] vs 30.0% [95% CI, 26.5%-33.5%]). Differences in postacute care use persisted even after accounting for postoperative complications and contributed to variation in spending. Compared with the lowest-quality hospitals, DE patients had improved rates of discharge to a facility (22.7% vs 19.3%) and spending ($22 577 vs $20 100) but rates remained increased compared with Medicare patients even at the highest-quality hospitals. The findings of this study indicate that, even among the highest-quality hospitals, DE patients had poorer outcomes and higher spending. Dually eligible patients were more likely to be discharged to a facility and therefore incurred higher postacute care costs. Although treatment at high-quality hospitals is associated with reduced differences in outcomes, DE patients remain at high risk for adverse postoperative outcomes and increased readmissions and postacute care use.

New horizons in the perioperative care of older adults.

Older adults undergoing surgery have high perioperative morbidity and mortality. Age-related physiological changes and prevalence of geriatric syndromes such as frailty increase the risk of adverse postoperative outcomes. Geriatricians utilise comprehensive geriatric assessment (CGA) and management to identify and manage geriatric syndromes, and deliver patient-centred perioperative care. Perioperative models of CGA are established for older patients undergoing hip fracture surgery. Recent trials support the benefits of perioperative models of CGA for non-orthopaedic surgery, and have influenced current care recommendations for older surgical patients. Areas for further action include addressing the implementation gap between recommended evidence-based perioperative care and routine perioperative care, evaluating the clinical and cost-effectiveness of perioperative models of CGA for patients living with frailty, and embedding routine use of patient-reported outcome measures to inform quality improvement.