Scheduled Surgery Research Articles

PO-02-175 HUMAN EPICARDIAL ADIPOCYTE-DERIVED SPARCL1 PLAYS AN IMPORTANT ROLE IN SUPPRESSION OF POSTOPERATIVE ATRIAL FIBRILLATION IN PATIENTS UNDERGOING CARDIOVASCULAR SURGERY

Postoperative atrial fibrillation (POAF) occurs in 20-50% after cardiac surgery and exacerbates the short and long-term morbidity/mortality. Potential predisposing factors may exist in the epicardial adipose tissue (EAT) because of its anatomical position. In order to explore a possible mechanistic link, we tried to identify the specific gene expression profile of secretome from the EAT in patients with POAF. We prospectively evaluated 104 patients who underwent scheduled open-heart surgery between May 2020 and May 2022 without known AF (male 69 (66.3%); mean age 68.1 ± 12.3). They are allocated to two groups with (POAF group) or without (no-POAF group) POAF, which is defined as AF lasting over 30 seconds documented by monitor or 12-lead electrocardiogram after the operation. Human EAT samples were obtained from those patients during surgery and preadipocytes were isolated from them. Isolated preadipocytes were terminally differentiated to mature adipocytes and the mRNAs were extracted. Genome-wide expression profiling of 6 vs. 6 matched samples representing POAF or no-POAF group was done using Human Clariom S Assay-HT 16-Array Plate. The secreted protein levels in the adipocytes-cultured medium were also evaluated using enzyme-linked sorbent assay test to confirm the consistency of mRNA expression levels of adipocytes and its secreted protein levels. POAF was observed in 41 patients (39%). Patients in POAF group were significantly older than those in no-POAF group (71.3 ± 9.91 vs 66.0 ± 13.4, p = 0.039). Microarray analysis revealed that there were 132 down- or up-regulated genes (fold change >2.0 or `−2.0, p < 0.05) in epicardial adipocytes of no-POAF group compared to POAF group. Of these genes, 11 genes cording secretable molecules were validated by qPCR, showing that only SPARCL1 had significantly higher expression in no-POAF group than in POAF group (p = 0.039). The mRNA expression of SPARCL1 in adipocytes is significantly correlated with the concentration of SPARCL1 protein in the adipocyte-cultured medium (p < 0.0001, r = 0.9068). Patients aged >75 years had lower mRNA expression of SPARCL1 than patients aged ≤75 years (p = 0.02). Our findings suggested that SPARCL1 expression in human epicardial adipocytes may play an important role in the suppression of POAF in patients undergoing cardiovascular surgery. The expression levels of SPARCL1 are potentially associated with aging.

Procedure-Based Telehealth Utilization in General Surgery.

The authors hypothesize that standardized telehealth (TH) scheduling processes will improve TH utilization without increasing adverse events. Fifty visits preimplementation and 67 visits postimplementation were audited from June 2021 to January 2022. Both leadership and frontline stakeholders were engaged to identify current workflows and potential interventions targeting outpatient elective procedures. Process mapping outlined current TH scheduling workflows. Outcomes related to TH completion, cost, and TH scheduling were collected after implementation. Preimplementation TH scheduling rate was 32%. The intervention required TH postoperative appointments to be scheduled in clinic at the time of surgery scheduling with TH being the default postsurgical appointment for a standardized list of eligible procedures. Following implementation, 95% of patients undergoing eligible procedures had TH follow-up. This provided improved access to surgical follow-up care, by reducing travel needs to the Veterans Affairs facility. Secondarily, this intervention increased clinic appointment availability and resulted in possible increased revenue for billable visits. Standardizing TH scheduling based on the procedure improves the utilization of TH resulting in improved clinic efficiency and increased revenue, without increasing adverse events.

Predictive factors for respiratory complications in pediatric anesthesia

We conducted a prospective observational, descriptive, and analytical study covering all patients under 16 years of age who were admitted to the operating room for scheduled or urgent surgery between July and August 2022. The purpose of this study was to identify the epidemiological characteristics of our population, describe the means of upper airway management in our practice, and analyze postoperative respiratory complications in pediatric anesthesia and their predictive factors. A total of 200 children were included in this study, with an average age of six years and an average weight of 21 kg. Of these, 53 (26.5%) underwent sedation with propofol 3 mg/kg and ketamine 1 mg/kg or a combination of a hypnotic (propofol or ketamine) and fentanyl at the dose of 2 gamma/kg. General anesthesia was used for 93 (46.5%) patients, while the remaining 54 (27%) were operated on under locoregional anesthesia associated with sedation. Depending on the type of surgery and anesthesia, the upper airway management protocol was chosen: 85 (42.5%) patients were operated on under an oxygen mask, 12 (6%) under a face mask, 10 (5%) under a laryngeal mask and 93 (46.5%) were intubated. Postoperative respiratory complications occurred in 28 patients (14%), with desaturation being the most common complication (10.5%). In multivariate statistical analysis, the factors found to be associated with the occurrence of postoperative respiratory complications were: weight less than 10 kg (p = 0.006, OR = 4.16 [1.54-11.22]) and unipulmonary ventilation (p = 0.008, OR = 14.77 [2.09-104.02]).

COMPLICATIONS OF SPINAL ANESTHESIA FOR SCHEDULED SURGERY EXPERIENCE OF THE MILITARY HOSPITAL MOULAY ISMAIL MEKNES

Spinal anesthesia is a widely practiced technique in anesthesia, it has advantages compared to general anesthesia. It requires little equipment and anesthetic drugs and is therefore inexpensive. Spinal anesthesia, like any medical act, is associated with certain accidents, and its complications, although rare, are becoming more and more a concern for anesthesia specialists. Our work focuses on the practice of spinal anesthesia in the operating room of the Moulay Ismail Military Hospital of Meknes (HMMIM) and especially on the morbidity and mortality due to this type of anesthesia. In addition, the objectives of our work are: - To report the incidence of this anesthetic practice. - To study the incidents and or intraoperative complications of spinal anesthesia (Morbi-mortality). - To compare our results with the data in the literature. The 5010 patients who underwent scheduled surgery under spinal anesthesia with an age ranging from 14 to 70 with a predominance of male 3557 cases or 71% against 1451 female cases or 29% (sex ratio 2.45). In our study series 38.90% had arterial hypertension in their history, 32.4% were diabetic, 13.20% had liver disease, 7.3% had renal failure, 5.5% had thromboembolic disease, 1.75% had psychiatric disorders, 1.40% were followed in oncology. 3206 cases were classified ASA I or 64%, 1102 cases ASA II or 22% and 701 cases ASA III or 14%. The puncture was performed in the sitting position in 3714 cases (74.14%) and in the lateral decubitus position in 1296 cases (25.85%). In our series 468 patients presented intraoperative complications including arterial hypotension, bradycardia, nausea and vomiting, failure and conversion to general anesthesia, impossible approach and cardio respiratory arrest. While the complications and risks are extremely rare, given their seriousness, prevention requires mastery of the technique, respect for simple safety measures, knowledge of the pharmacology of the products used, detection of prodromal signs announcing serious complications and rapid management of these manifestations. Rigor in the choice of the technique according to the clinic but also to the terrain must be the rule.

Kidney Transplantation After Renal Transcatheter Arterial Embolization for Cyst Infection in a Hemodialysis Patient With Autosomal Dominant Polycystic Kidney Disease: A Case Report

A 31-year-old woman with autosomal dominant polycystic kidney disease (ADPKD) required antibiotic therapy for repeated renal cyst infections. The patient was scheduled for a living donor renal transplant with her mother as the donor. Two months before surgery, the patient was admitted to the hospital due to a severe renal cyst infection that improved with antibiotic treatment and percutaneous drainage, but the scheduled surgery was postponed. Transcatheter arterial embolization (TAE) was performed to control repeated renal cyst infections. Seven months after TAE, the patient underwent living donor renal transplantation. The postoperative course was uneventful, and the patient was discharged from the hospital on immunosuppressive medication 26 days after surgery with no evidence of recurrent infection or deterioration of renal function. Thirty months after transplantation, there has been no recurrence of infection.

Prospective paired crossover evaluation of potential impact of investigator gender on perceived pain intensity early after acute or scheduled surgery

BackgroundPostoperative pain is common but often difficult to assess, and there are many potential confounders. Over the last decades, the gender of investigator as well as participant has been found to influence pain perception in both preclinical and clinical studies. However, to our knowledge this has not been studied in various postoperative patients. Objectives of this study were to test the hypotheses that pain intensity levels early after acute or scheduled in- or out-hospital surgery are lower when evaluated by a female investigator, and higher when reported by a female patient.MethodsIn this prospective observational paired crossover study, two investigators of opposite genders independently obtained individually reported pain intensity levels with a visual analogue scale in a mixed cohort of adult postoperative study patients at Skåne University Hospital in Malmö, Sweden.ResultsIn total, 245 (129 female) study patients were included and then one female excluded. The study patients rated their intensity of postoperative pain lower when evaluated by a female than by a male investigator (P = 0.006), where the male patients constituted the significant difference (P < 0.001). Pain intensity levels did not differ between female and male study patients (P = 0.210).ConclusionsMain findings of lower pain intensity reported by males to a female than to a male investigator early after surgery in this paired crossover study in mixed postoperative patients, indicate that potential impact of investigator gender on pain perception should be considered and further evaluated in clinical bedside practice.Trial registration Retrospectively registered in the ClinicalTrials.gov research database on 24th June 2019 with TRN number NCT03968497.

Immediate Results of Small Bowel Crohn’s Disease Surgery

Introduction: Despite the progress made in the medical management of Crohn's disease (CD), a vast number of patients are operated on at least once in their lifetime. Although this is a mild disease that occurs mainly in young patients with little comorbidity, CD surgery is accompanied by significant postoperative morbidity (PO). This study aims to analyse the PO complications of the small intestine's CD and look for the risk factors for its occurrence. Patients and methods: this is a single-centre prospective study that collected 83 files of patients operated on for CD of the small intestine for 28 months (May 2017 - September 2019). All patients had histologic confirmation of CD. Isolated anoperineal and colorectal forms were excluded from this work. PO morbidity is defined by all complications occurring during the first 30 days of PO. A statistical analysis of PO morbidity was performed as a function of 12 parameters: age; sex; comorbidity; history of abdominal surgery; history of surgery for CD; haemoglobin level (Hb &lt;or&gt; at 10 mg/dl); albumin level (&lt;or&gt; at 34g / l); BMI (&lt;or&gt; at 19); ASA score; mode of surgery (cold vs emergency); intra-abdominal abscess; operative procedure (resection-anastomosis vs resection-stoma). Statistical analysis was performed first univariate and then multivariate (SPSS 16 software). Results: These were 56 women and 27 men, with a sex ratio of 2. The mean age of the patients was 35 years (13-65). The overall PO morbidity rate was 26%; this morbidity was surgical in 86%, septic in 89.5% and intra-abdominal septic in 50% of cases. Complications were major (CMPO) in 39.5% of cases. The mode of emergency surgery was an independent risk factor for the occurrence of complications (p = 0.005). Conclusion: Small intestine CD surgery is associated with very high PO morbidity. The mode of emergency surgery is an independent risk factor for the onset of PO complications. Patients who require surgery should be operated on as elective or scheduled surgery. The indications for emergency surgery for CD are sporadic.

A reinforcement learning-based optimal control approach for managing an elective surgery backlog after pandemic disruption.

Contagious disease pandemics, such as COVID-19, can cause hospitals around the world to delay nonemergent elective surgeries, which results in a large surgery backlog. To develop an operational solution for providing patients timely surgical care with limited health care resources, this study proposes a stochastic control process-based method that helps hospitals make operational recovery plans to clear their surgery backlog and restore surgical activity safely. The elective surgery backlog recovery process is modeled by a general discrete-time queueing network system, which is formulated by a Markov decision process. A scheduling optimization algorithm based on the piecewise decaying [Formula: see text]-greedy reinforcement learning algorithm is proposed to make dynamic daily surgery scheduling plans considering newly arrived patients, waiting time and clinical urgency. The proposed method is tested through a set of simulated dataset, and implemented on an elective surgery backlog that built up in one large general hospital in China after the outbreak of COVID-19. The results show that, compared with the current policy, the proposed method can effectively and rapidly clear the surgery backlog caused by a pandemic while ensuring that all patients receive timely surgical care. These results encourage the wider adoption of the proposed method to manage surgery scheduling during all phases of a public health crisis.

Comparison of olanexidine versus povidone-iodine as a preoperative antiseptic for reducing surgical site infection in both scheduled and emergency gastrointestinal surgeries: A single-center randomized clinical trial.

Surgical site infection (SSI) is one of the most common postoperative complications in gastrointestinal surgery. To clarify the superiority of 1.5% olanexidine, we conducted a randomized prospective clinical trial that enrolled patients undergoing gastrointestinal surgery with operative wound classes II-IV. To evaluate the efficacy of 1.5% olanexidine in preventing SSIs relative to 10% povidone-iodine, we enrolled 298 patients in each group. The primary outcome was a 30-day SSI, and the secondary outcomes were incidences of superficial and deep incisional SSI and organ/space SSI. In addition, subgroup analyses were performed. The primary outcome of the overall 30-day SSI occurred in 38 cases (12.8%) in the 1.5% olanexidine group and in 53 cases (18.0%) in the 10% povidone-iodine group (adjusted risk ratio: 0.716, 95% confidence interval: 0.495-1.057, p = 0.083). Organ/space SSI occurred in 18 cases (6.1%) in the 1.5% olanexidine group and in 31 cases (10.5%) in the 10% povidone-iodine group, with a significant difference (adjusted risk ratio: 0.587, 95% confidence interval: 0.336-0.992, p = 0.049). Subgroup analyses revealed that SSI incidences were comparable in scheduled surgery (relative risk: 0.809, 95% confidence interval: 0.522-1.254) and operative wound class II (relative risk: 0.756, 95% confidence interval: 0.494-1.449) in 1.5% olanexidine group. Our study revealed that 1.5% olanexidine reduced the 30-day overall SSI; however, the result was not significant. Organ/space SSI significantly decreased in the 1.5% olanexidine group. Our results indicate that 1.5% olanexidine has the potential to prevent SSI on behalf of povidone-iodine.

Neoadjuvant Nivolumab Plus Gemcitabine/Cisplatin Chemotherapy in Muscle-Invasive Urothelial Carcinoma of the Bladder.

The activity and safety of neoadjuvant nivolumab plus gemcitabine/cisplatin (N+GC) were tested in patients with muscle-invasive bladder urothelial carcinoma (MIBC). In a prospective phase II trial, patients with cT2-T4a N0 MIBC who were eligible for cisplatin and medically appropriate to undergo radical cystectomy (RC) were enrolled. Treatment with nivolumab 3 mg/kg on days 1 and 15 plus GC (cisplatin 70 mg/m2 on day 1, and gemcitabine 1,000 mg/m2 on days 1, 8, and 15) was repeated every 28 days up to 3 or 4 cycles, depending on the surgery schedules. The primary endpoint was pathologic complete response (pCR, ypT0). Secondary endpoints included pathologic downstaging (≤ ypT1), disease-free survival (DFS), and safety. Between September 2019 and October 2020, 51 patients were enrolled. Neoadjuvant N+GC was well tolerated. Among 49 patients who completed neoadjuvant N+GC, clinical complete response (cCR) was achieved in 59% of intent-to-treat (ITT) population. RC was performed in 34 (69%) patients. pCR was achieved in 24% (12/49) of ITT population and 35% (12/34) of RC patients. Median DFS was not reached. Over a median follow-up of 24 months, 12 patients experienced disease recurrence and were treated with palliative therapy or surgery. Although 12 patients declined surgery and were treated with concurrent chemoradiotherapy, DFS was longer in patients with cCR after neoadjuvant therapy than those without. Preoperative programmed death-ligand 1 (PD-L1) did not correlate with pCR or pathologic downstaging rates. Neoadjuvant N+GC was feasible and provided meaningful pathologic responses in patients with MIBC, regardless of baseline PD-L1 expression (ONO-4538-X41; CRIS.nih.go.kr, KCT0003804).

The Prevalence of Back Pain in Patients Operated on Due to Colorectal Cancer Depending on the Type of Surgical Procedure Performed

Purpose: Low back pain presents a serious challenge for numerous medical specialties. The purpose of this study was to assess disability due to low back pain in patients operated on due to colorectal cancer depending on the type of surgery performed. Methods: This prospective observational study was carried out in the period of July 2019 through March 2020. Included in the study were patients with colorectal cancer for scheduled surgeries including anterior resection of rectum (AR), laparoscopic anterior resection of rectum (LAR), Hartmann’s procedure (HART), or abdominoperineal resection of rectum (APR). The Oswestry Low Back Pain Disability Questionnaire was used as the research tool. The study patients were surveyed at three time points: before surgery, six months after surgery, and one year after surgery. Results: The analysis of study results revealed that an increase in the degree of disability and functioning impairment occurred in all groups between time points I and II, with the differences being statistically significant (p &lt; 0.05). The inter-group comparative analysis of the total Oswestry questionnaire scores revealed statistically significant differences, with the impairment of function being most severe within the APR group and least severe within the LAR group. Conclusion: The study results showed that low back pain contributes to impaired functioning of patients operated on due to colorectal cancer regardless of the type of procedure performed. A reduction in the degree of disability due to low back pain was observed one year after the procedure in patients having undergone LAR.

Elective surgery scheduling considering transfer risk in hierarchical diagnosis and treatment system

With the aggravation of the shortage of staffing hospital beds, elective surgeries have to be postponed or even cancelled, which directly affects hospital income and patient health. Therefore, we propose a fuzzy scheduling model based on a patient transfer strategy in the hierarchical diagnosis and treatment system to ensure timely surgery. We propose a risk estimation method based on health failure mode and effect analysis to reduce the transfer risk and represent the surgery duration and the length of stay as fuzzy numbers to deal with the uncertainty. Given that solving the fuzzy model is challenging, we propose an equivalent formulation to transform the fuzzy model into a two-stage mixed integer linear programming (TMIP) model, which can reduce the loss of decision-making information. Finally, the column and constraint generation algorithm is used to solve the TMIP model that is suited for the structure of the main problem and subproblem. The experiment shows that the patient transfer strategy can effectively relieve the hospital bed shortage, and its potential can be further released if the transfer risk can be properly assessed. The proposed method for solving the fuzzy model can reduce the information loss comparing traditional methods.

Postponing surgery to optimise patients with acute right-sided obstructing colon cancer - A pilot study

BackgroundRight-sided obstructing colon cancer is most often treated with acute resection. Recent studies on right-sided obstructing colon cancer report higher mortality and morbidity rates than those in patients without obstruction. The aim of this study is to retrospectively analyse whether it is possible to optimise the health condition of patients with acute right-sided obstructing colon cancer, prior to surgery, and whether this improves postoperative outcomes. MethodAll consecutive patients with high suspicion of, or histologically proven, right-sided obstructing colon cancer, treated with curative intent between March 2013 and December 2019, were analysed retrospectively. Patients were divided into two groups: optimised group and non-optimised group. Pre-operative optimisation included additional nutrition, physiotherapy, and, if needed, bowel decompression. ResultsIn total, 54 patients were analysed in this study. Twenty-four patients received optimisation before elective surgery, and thirty patients received emergency surgery, without optimisation. Scheduled surgery was performed after a median of eight days (IQR 7–12). Postoperative complications were found in twelve (50%) patients in the optimised group, compared to twenty-three (77%) patients in the non-optimised group (p = 0.051). Major complications were diagnosed in three (13%) patients with optimisation, compared to ten (33%) patients without optimisation (p = 0.111). Postoperative in-hospital stay, 30-day mortality, as well as primary anastomosis were comparable in both groups. ConclusionThis pilot study suggests that pre-operative optimisation of patients with obstructing right sided colonic cancer may be feasible and safe but is associated with longer in-patient stay.

Resistive Warming Mattress, Forced-Air Warming System, or a Combination of the Two in the Prevention of Intraoperative Inadvertent Hypothermia: A Randomized Trial

To prevent intraoperative inadvertent hypothermia (IIH), resistive products and forced-air warming systems are often used simultaneously. There is insufficient evidence to show whether this application is clinically more effective than a single active warming device. The aim of this study is to compare the efficacy a single intraoperative active warming method with combined methods in IIH prevention. A randomized, prospective, experimental study. This study was conducted between June and October 2021 in the operating room of a training and research hospital. The study sample consisted of 123 patients who underwent scheduled orthopedic surgery under spinal anesthesia, were young (18-64), and had an ASA risk score of I to III. The patients were divided into three groups preoperatively according to the stratified randomization technique. To prevent IIH, a resistive warming mattress was used in group 1; a forced-air warming system was used in group 2; and a combination of the two methods were used in group 3. The body temperatures of the patients were measured and recorded every 15 minutes from admission to the operating room until the end of surgery. The mean intraoperative body temperature of the patients was 36.6±0.15˚C for group 1; 36.6±0.1˚C for Group 2 and 36.6 ± 0.15˚C for Group 3. There was no difference between the groups in terms of body temperature. The overall incidence of IIH was 8.1%; 9.8% in group 1, 9.8% in group 2 and 4.9% in group 3. There was no statistically significant difference between the groups in terms of IIH (p < .05). This study supports the efficacy of using resistive warming mattress and forced-air warming systems in preventing IIH. The use of both methods together made no difference in terms of IIH development.

Development and validation of a model to predict complex Mohs micrographic surgery in clinical practice: REGESMOSH scale.

There is still a need to develop a simple algorithm to identify patients likely to need complex Mohs micrographic surgery (MMS) and optimize MMS schedule. The main objectives of this study are to identify factors associated with a complex MMS and develop a predictor model of the number of stages needed in surgery and the need for a complex closure. A nationwide prospective cohort study (REGESMOHS, the Spanish Mohs surgery registry) was conducted including all patients with a histological diagnosis of basal cell carcinoma (BCC). Factors related to three or more stages and a complex closure (that needing a flap and/or a graft) were explored and predictive models were constructed and validated to construct the REGESMOSH scale. A total of 5226 patients that underwent MMS were included in the REGESMOHS registry, with 4402 (84%) having a histological diagnosis of BCC. A total of 3689 (88.9%) surgeries only needed one or two stages and 460 (11.1%) required three or more stages. A model to predict the need for three or more stages included tumour dimension, immunosuppression, recurrence, location in risk areas, histological aggressiveness and previous surgery. Regarding the closure type, 1616 (38.8%) surgeries were closed using a non-complex closure technique and 2552 (61.2%) needed a complex closure. A model to predict the need for a complex closure included histological aggressiveness, evolution time, patient age, maximum tumour dimension and location. We present a model to predict MMS needing ≥3 stages and a complex closure based on epidemiological and clinical data validated in a large population (with real practice variability) including different centres that could be easily implemented in clinical practice. This model could be used to optimize surgery schedule and properly inform patients about the surgery duration.

Cancellation of elective surgery and associated factors among patients scheduled for elective surgeries in public hospitals in Harari regional state, Eastern Ethiopia.

Canceling elective surgeries is a significant problem in many hospitals leading to patient dissatisfaction, increased costs, and emotional trauma for patients and their families. Despite this, there is limited information about the cancellation of elective surgeries in Ethiopia, mainly in the study area. This study aimed to assess the magnitude of cancellation and associated factors among patients scheduled for elective surgeries in public hospitals in the Harari Regional State, Eastern Ethiopia, from 1 August to 30 August 2021. A hospital-based cross-sectional study was conducted on 378 patients scheduled for elective surgeries. Data were gathered using a non-random sequential sampling approach. In addition, a structured face-to-face interviewer-administered questionnaire was employed. The gathered information was input into Epidata version 3.1 and then exported to Statistical Package for Social Software version 26. To find the variables associated with the cancellation of elective surgeries, binary and multi-variable logistic regression analyses were conducted. In the binary analysis, all variables with a p-value of less than 0.25 were included in the multivariable analysis. Finally, a 0.05 p-value with a 95% confidence interval and an adjusted odds ratio was used to declare a significant association. This study included 378 patients scheduled for elective surgeries. Among those, 35.2% of the surgeries were canceled (95% confidence interval: 29.4-39.6). Being female (adjusted odds ratio: 2.46; 95% confidence interval: 1.44-4.203), lack of formal education (adjusted odds ratio: 2.03; 95% confidence interval: 1.15-3.58), place of residence (adjusted odds ratio: 1.70; 95% confidence interval: 1.03-2.81), increase in blood pressure (adjusted odds ratio: 5.09; 95% confidence interval:1.90-13.59), and ophthalmologic surgery (adjusted odds ratio: 3.76; 95% confidence interval: 1.41-10.0) were factors associated with the cancellation of elective surgeries. In this study, nearly one third of scheduled elective surgery was canceled. The primary contributing variables to the surgery cancellations were being female, lack of formal education, place of residence, ophthalmologic surgery, and increased blood pressure. Therefore, timely evidence-based reporting through the supervision team was advised to decrease cancellations.

Anesthesia Incident Reporting System (AIRS) Case 2023-04: ‘All the Way, or Not at All’

Article| April 2023 Anesthesia Incident Reporting System (AIRS) Case 2023-04: ‘All the Way, or Not at All’ ASA Monitor April 2023, Vol. 87, 14–15. https://doi.org/10.1097/01.ASM.0000924960.48783.cc Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Anesthesia Incident Reporting System (AIRS) Case 2023-04: ‘All the Way, or Not at All’. ASA Monitor 2023; 87:14–15 doi: https://doi.org/10.1097/01.ASM.0000924960.48783.cc Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: incident reporting, weekend, surgical procedures, operative A complex, high-risk, nonemergent surgical procedure (revision thoracic-sacral spinal fusion, estimated duration 5 hours) was completed on a weekday during late night hours by surgery and anesthesiology physicians who were otherwise on a daytime work schedule in a tertiary academic hospital. The patient entered the OR at 6:15 p.m. (incision at 7:30 p.m.) and left the OR at 2:20 a.m. and was discharged from the PACU at 4:30 a.m. A second peripheral I.V., right IJ CVC, and radial arterial line were placed after induction. Until about 9:30 p.m. the staff anesthesiologist was also medically directing three additional major surgical cases; the final concurrent medically directed case ended at approximately midnight. All concurrent cases were also scheduled surgeries and were not emergent. No other anesthesiologists were available to assist with the care of these patients and no other general ORs were operating. Nearly every anesthesiologist will relate with the reporter... You do not currently have access to this content.

Photoplethysmography waveform analysis for classification of vascular tone and arterial blood pressure: Study based on neural networks

To test whether a Shallow Neural Network (S-NN) can detect and classify vascular tone dependent changes in arterial blood pressure (ABP) by advanced photopletysmographic (PPG) waveform analysis. PPG and invasive ABP signals were recorded in 26 patients undergoing scheduled general surgery. We studied the occurrence of episodes of hypertension (systolic arterial pressure (SAP) >140 mmHg), normotension and hypotension (SAP < 90 mmHg). Vascular tone according to PPG was classified in two ways: 1) By visual inspection of changes in PPG waveform amplitude and dichrotic notch position; where Classes I-II represent vasoconstriction (notch placed >50% of PPG amplitude in small amplitude waves), Class III normal vascular tone (notch placed between 20-50% of PPG amplitude in normal waves) and Classes IV-V-VI vasodilation (notch <20% of PPG amplitude in large waves). 2) By an automated analysis, using S-NN trained and validated system that combines seven PPG derived parameters. The visual assessment was precise in detecting hypotension (sensitivity 91%, specificity 86% and accuracy 88%) and hypertension (sensitivity 93%, specificity 88% and accuracy 90%). Normotension presented as a visual Class III (III-III) (median and 1st-3rd quartiles), hypotension as a Class V (IV-VI) and hypertension as a Class II (I-III); all p < .0001. The automated S-NN performed well in classifying ABP conditions. The percentage of data with correct classification by S-ANN was 83% for normotension, 94% for hypotension, and 90% for hypertension. Changes in ABP were correctly classified automatically by S-NN analysis of the PPG waveform contour.

Patient, clinical, surgical, and institutional factors associated with length of stay in scheduled degenerative thoracolumbar spine surgery: National Multicenter Cohort Analysis from the Canadian Spine Outcomes and Research Network.

Length of stay (LOS) is a contributor to costs and resource utilization. The primary goal of this study was to identify patient, clinical, surgical, and institutional variables that influence LOS after elective surgery for thoracolumbar degenerative pathology. The secondary objective was to examine variability in LOS and institutional strategies used to decrease LOS. This is a retrospective study of prospectively collected data from a multicentric cohort enrolled in the Canadian Spine Outcomes and Research Network (CSORN) between January 2015 and October 2020 who underwent elective thoracolumbar surgery (discectomy [1 or 2 levels], laminectomy [1 or 2 levels], and posterior instrumented fusion [up to 5 levels]). Prolonged LOS was defined as LOS greater than the median. Logistic regression models were used to determine factors associated with prolonged LOS for each procedure. A survey was sent to the principal investigators of the participating healthcare institutions to understand institutional practices that are used to decrease LOS. A total of 3700 patients were included (967 discectomies, 1094 laminectomies, and 1639 fusions). The median LOSs for discectomy, laminectomy, and fusion were 0.0 (IQR 1.0), 1.0 (IQR 2.0), and 4.0 (IQR 2.0) days, respectively. On multivariable analysis, predictors of prolonged LOS for discectomy were having more leg pain, higher Oswestry Disability Index (ODI) scores, symptom duration more than 2 years, having undergone an open procedure, occurrence of an adverse event (AE), and treatment at an institution without protocols to reduce LOS (p < 0.05). Predictors of prolonged LOS for laminectomy were increased age, living alone, higher ODI scores, higher BMI, open procedures, longer operative time, AEs, and treatment at an institution without protocols to reduce LOS (p < 0.05). For posterior instrumented fusion, predictors of prolonged LOS were older age, living alone, more comorbidities, higher ODI scores, longer operative time, AEs, and treatment at an institution without protocols to reduce LOS (p < 0.05). The laminectomy group had the largest variability in LOS (SD 4.4 days, range 0-133 days). Three hundred fifty-four patients (22%) had an LOS above the 75th percentile. Ten institutions (53%) had either Enhanced Recovery After Surgery or standardized protocols in place. Among the factors identified in this study, worse baseline ODI scores, experiencing AEs, and treatment at an institution without protocols aimed at reducing LOS were predictive of prolonged LOS in all surgical groups. The laminectomy group had the largest variability in LOS.

Hard cataract or heart attack

Miscommunication arises when interacting members connect, but one or more of its members in the communication chain does not fully understand what has been conveyed. This can happen for a variety of reasons, including the initiator's inappropriate word selection, existence of communication barrier between the initiator and receiver, the receiver's misperception, and less frequently, the receiver being “off-target” to the communication chain. This case involves a 54-year-old woman with no known comorbid conditions who experienced an acute panic attack just before the start of scheduled cataract surgery, which was managed with abandonment of surgery followed by monitoring and treatment in the intensive care, conducting the departmental root cause analysis, and subsequent performance of uneventful surgery with satisfactory outcome after addressing the root cause.