Surgery In Population Research Articles

Implementation and validation of a novel instrument for the grading of unexpected events in paediatric surgery: Clavien-Madadi classification.

Inconsistent definitions of complications and unexpected events have limited accurate analysis of surgical outcomes. Perioperative outcome classifications currently used for adult patients have limitations when used for children. A multidisciplinary group of experts modified the Clavien-Dindo classification to increase its utility and accuracy in paediatric surgery cohorts. Organizational and management errors were considered in the novel Clavien-Madadi classification, which focuses on procedural invasiveness rather than anaesthetic management. Unexpected events were prospectively documented in a paediatric surgery cohort. Results of the Clavien-Dindo and Clavien-Madadi classifications were compared and correlated with procedure complexity. Unexpected events were prospectively documented in a cohort of 17 502 children undergoing surgery between 2017 and 2021. The results of both classifications were highly correlated (ρ = 0.95), although the novel Clavien-Madadi classification identified 449 additional events (organizational and management errors) over the Clavien-Dindo classification, increasing the total number of events by 38 per cent (1605 versus 1158 events). The results of the novel system correlated significantly with the complexity of procedures in children (ρ = 0.756). Furthermore, grading of events > grade III according to the Clavien-Madadi classification showed a higher correlation with procedure complexity (ρ = 0.658) than the Clavien-Dindo classification (ρ = 0.198). The Clavien-Madadi classification is a tool for the detection of surgical and non-medical errors in paediatric surgery populations. Further validation in paediatric surgery populations is required before widespread use.

Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society

BackgroundOpioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery. MethodsAn interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence. ResultsThe panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices. ConclusionsBased on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population.

Antithrombin substitution practice in pediatric cardiac surgery: A European survey.

The antithrombin concentration of neonates is approximately half that of adults. Low preoperative antithrombin concentration in this population have been associated with increased transfusion requirements.1 Similarly, low antithrombin concentration result in poor response to unfractionated heparin and inability to establish adequate anticoagulation during extracorporeal circulation (e.g., cardiopulmonary bypass, CPB), placing patients at risk for thrombosis.2 Despite obvious mode of action, there are no well-described clinical benefits of antithrombin usage in clinical practice. The aim of this survey was to identify the practice of antithrombin usage in pediatric cardiac surgery across Europe. The authors developed a 55-item electronic questionnaire to evaluate the following areas: the local practice of antithrombin management and substitution, including antithrombin monitoring and target levels, antithrombin administration techniques, and monitoring of anticoagulation. The survey was endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC) and distributed among its members. Respondents had to identify themselves as pediatric cardiac anesthetists before they were allowed to enter the questionnaire. A total of 118 responses were received. The half of respondents confirmed that they were currently working as pediatric cardiac anesthesiologists and were allowed to participate in the survey. Sixty-eight percent of participants (39/57) regularly measure antithrombin concentration and 79% (31/39) regularly substitute antithrombin in different pathophysiological scenarios in pediatric congenital heart surgery (Table 1). Thirty-two percent (12/37) substitute antithrombin in all cardiac surgery cases with low antithrombin concentration. In the setting of CPB, 41% (15/37) substitute antithrombin. In patients <6 months of age scheduled for cardiac surgery, half of the respondents (54%, 20/37) not routinely substitute antithrombin. In pediatric patients with low antithrombin concentration on veno-arterial extracorporeal membrane oxygenation (ECMO), 78% (29/37) replace antithrombin. In all cardiac patients (with or without cardiac surgery), more than 65% (21/32) of respondents measure antithrombin concentration only when specifically indicated, 28% (9/32) before administration, and 25% (8/32) preoperatively (in case of cardiac surgery). In patients on veno-arterial ECMO, 50% (16/32) measure antithrombin once daily, 31% (10/32) before administration, 28% (9/32) only on specific indication, 25% (8/32) after administration or before ECMO implantation, respectively. The primary strategy for antithrombin concentration below target was immediate substitution in 54% (14/26) of respondents. Twenty-seven (7/26) percent opted for repeated measurements to make a final decision. In a situation with low antithrombin concentration and known heparin resistance, 100% (31/31) of responders substitute antithrombin. In a situation with known heparin resistance and unmeasured antithrombin concentration, half of the participants (52%, 16/31) did not substitute antithrombin. In unclear clinical situations with suspected low antithrombin concentration (e.g., disseminated intravascular coagulation), 77% (24/31) did not substitute antithrombin without a previous level measurement. Antithrombin substitution occurred in 66% (18/27) using calculations as provided by the manufacturer, in 22% (6/27) using a standard dose (e.g., 500 U antithrombin concentrate), and in 11% (3/27) using a calculation based on a custom formula. Antithrombin substitution - YES - Antithrombin substitution - NO - Antithrombin substitution - no answer - In this European survey examining the use of antithrombin in pediatric cardiac patients, we found widespread use of antithrombin measurement and substitution strategies. The most important areas for antithrombin monitoring and substitution were ECMO, in patients with inadequate elevation of activated clotting time during cardiac surgery with CPB, and in patients with known heparin resistance in combination with low antithrombin concentration. The most common consensus in the literature regarding antithrombin administration is inadequate response to heparin.3, 4 In our survey, antithrombin was substituted in all cases when a low antithrombin concentration was present in combination with detected heparin resistance. Regarding the use of antithrombin in different procedures without surgery, this study confirms large differences between institutions. One possible explanation is the lack of evidence in the literature for the use of antithrombin in specific cardiac lesions including specific cardiac surgery populations as for example cyanotic patients with high hematocrit. This survey underlines again the need for further, adequately powered studies regarding antithrombin monitoring and substitution in the pediatric cardiac patients undergoing surgery or interventions. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Information Technology-Enhanced Telehealth Consultations Reduce Preoperative Evaluation Center Visits in a Bariatric Surgery Population.

Background: Preoperative patient evaluation and optimization in a preoperative evaluation center (PEC) has been shown to improve operating room (OR) efficiency and patient care. However, performing preoperative evaluation on all patients scheduled for surgery or procedure would be time- and resource-consuming. Therefore, appropriate patient selection for evaluation at PECs is one aspect of improving PEC efficiency. In this study, we evaluate the effect of an enhanced preoperative evaluation process (PEP), utilizing a nursing triage phone call and information technology (IT) optimizations, on PEC efficiency and the quality of care in bariatric surgery patients. We hypothesized that, compared to a traditional PEP, the enhanced PEP would improve PEC efficiency without a negative impact on quality. Methods: The study was a retrospective cohort analysis of 1550 patients from January 2014 to March 2017 at a large, tertiary care academic health system. The study was a before/after comparison that compared the enhanced PEP model to the traditional PEP model. The primary outcome was the efficiency of the PEC, which was measured by the reduction of in-person patient visits at the PEC. The secondary outcome was the quality of care, which was measured by delays, cancellations, and the need for additional testing on the day of surgery (DOS). Results: The enhanced PEP improved the primary outcome of efficiency, as evident by an 80% decrease in in-person patient visits to the PEC. There was no reduction in the secondary outcome of the quality of care as measured by delays, cancellations, or the need for additional testing on the DOS. The implementation of the enhanced PEP did not result in increased costs or resource utilization. Conclusions: The enhanced PEP in a multi-disciplinary preoperative process can improve the efficiency of PEC for bariatric surgery patients without any decrease in the quality of care. The enhanced PEP process can be implemented without an increase in resource utilization and can be particularly useful during the COVID-19 pandemic.

Pharmacologic management of weight regain following bariatric surgery.

While bariatric surgery restults in significant long-term weight loss for most patients with obesity, post-surgical weight gain affects a considerable percentage of patients to varying degrees of severity. Furthermore, a small but significant percentage of patients experience inadequate post-surgical weight loss. Although many studies have examined the role of anti-obesity medications to address post-operative weight regain, an evidence-based consensus has not yet been achieved because of the heterogeneity of populations studied and the studies themselves. Observational studies in the post-bariatric surgery population consistently demonstrate the benefit of medical weight management after bariatric surgery, with most evidence highlighting liraglutide, topiramate, and phentermine/topiramate. New anti-obesity medications are anticipated to be helpful for post-surgical weight optimization given their efficacy in the non-surgical population.

The use of POTTER (Predictive Optimal Trees in Emergency Surgery Risk) calculator to predict mortality and complications in patients submitted to Emergency Surgery.

the ability of the care team to reliably predict postoperative risk is essential for improvements in surgical decision-making, patient and family counseling, and resource allocation in hospitals. The Artificial Intelligence (AI)-powered POTTER (Predictive Optimal Trees in Emergency Surgery Risk) calculator represents a user-friendly interface and has since been downloaded in its iPhone and Android format by thousands of surgeons worldwide. It was originally developed to be used in non-traumatic emergency surgery patients. However, Potter has not been validated outside the US yet. In this study, we aimed to validate the POTTER calculator in a Brazilian academic hospital. mortality and morbidity were analyzed using the POTTER calculator in both trauma and non-trauma emergency surgery patients submitted to surgical treatment between November 2020 and July 2021. A total of 194 patients were prospectively included in this analysis. regarding the presence of comorbidities, about 20% of the population were diabetics and 30% were smokers. A total of 47.4% of the patients had hypertensive prednisone. After the analysis of the results, we identified an adequate capability to predict 30-day mortality and morbidity for this group of patients. the POTTER calculator presented excellent performance in predicting both morbidity and mortality in the studied population, representing an important tool for surgical teams to define risks, benefits, and outcomes for the emergency surgery population.

Medicaid Expansion: the impact of health policy on bariatric surgery.

Underutilization of bariatric surgery in uninsured and marginalized communities is well-documented. When discussing population health, healthcare access and equity are crucial components often influenced by health policy. This study aims to determine if disparities in the use of bariatric surgery were influenced by changes in healthcare policy from the Affordable Care Act's 2014 expansion of Medicaid. A retrospective analysis of the 2012-2018 Healthcare Cost and Utilization Project National Inpatient Sample was performed for elective Roux-en-Y gastric bypass and sleeve gastrectomy surgeries performed within the United States. States were grouped into regions as defined by the U.S. Census Bureau. Medicaid as the primary payor for bariatric surgery was compared by region and year, as well as utilization by marginalized populations. Analysis included 212,776 bariatric surgeries. Medicaid as the primary payor increased from 9% to 19% from 2012 to 2018. A greater share of bariatric surgeries with Medicaid as the primary payor was located in the Northeast and West, as compared with those located in the Midwest and South. Medicaid beneficiaries in marginalized communities (Black race, Hispanic race, lowest income quartile, rural communities) made up a larger share of the bariatric surgery population over time. The Affordable Care Act's Medicaid Expansion improved health coverage and access to care, including bariatric surgery. An increase in bariatric surgeries among Medicaid beneficiaries correlated with the 2014 expansion of Medicaid. Social and economic disparities regarding bariatric surgery have improved though more progress may be seen with the adoption of Medicaid Expansion by the remaining U.S. states.

Hospital length of stay prediction for general surgery and total knee arthroplasty admissions: Systematic review and meta-analysis of published prediction models.

Systematic review of length of stay (LOS) prediction models to assess the study methods (including prediction variables), study quality, and performance of predictive models (using area under receiver operating curve (AUROC)) for general surgery populations and total knee arthroplasty (TKA). LOS prediction models published since 2010 were identified in five major research databases. The main outcomes were model performance metrics including AUROC, prediction variables, and level of validation. Risk of bias was assessed using the PROBAST checklist. Five general surgery studies (15 models) and 10 TKA studies (24 models) were identified. All general surgery and 20 TKA models used statistical approaches; 4 TKA models used machine learning approaches. Risk scores, diagnosis, and procedure types were predominant predictors used. Risk of bias was ranked as moderate in 3/15 and high in 12/15 studies. Discrimination measures were reported in 14/15 and calibration measures in 3/15 studies, with only 4/39 externally validated models (3 general surgery and 1 TKA). Meta-analysis of externally validated models (3 general surgery) suggested the AUROC 95% prediction interval is excellent and ranges between 0.803 and 0.970. This is the first systematic review assessing quality of risk prediction models for prolonged LOS in general surgery and TKA groups. We showed that these risk prediction models were infrequently externally validated with poor study quality, typically related to poor reporting. Both machine learning and statistical modelling methods, plus the meta-analysis, showed acceptable to good predictive performance, which are encouraging. Moving forward, a focus on quality methods and external validation is needed before clinical application.

Identifying Borderline Ovarian Tumor Recurrence Using Routine Ultrasound Follow-Up.

Borderline ovarian tumors (BOTs) are non-invasive tumors frequently diagnosed in young patients. Surgical removal of the uterus, fallopian tubes, ovaries, and omentum is considered definitive management, however fertility-sparing approach is a recognized option. Surveillance is important due to known recurrence, but there is controversy over the effectiveness of follow-up modalities. The objective is to determine the efficacy of ultrasound screening in identifying tumor recurrence. This retrospective chart review evaluated all patients consulted and/or treated surgically at our institution from January 2015 to June 2020 diagnosed with BOT. Patients were excluded if concurrently diagnosed with another gynecologic malignancy, did not have yearly ultrasound follow-up, or were lost to follow-up. This study included 56 patients, 17 of whom underwent fertility preserving surgery. The overall rate of recurrence was 10.7%; with recurrence rates of 23.5% for the fertility preserving surgery population and 5.1% for the definitive surgery population. Ultrasound first identified 5 of the 6 (83.3%) recurrences. Overall time to recurrence was 51.5 months. In conclusion, recurrences were identified on routine ultrasound screening prior to symptom onset or detection via physical exam in 83.3% of cases. While the best modality of follow-up remains controversial, this review provides evidence supporting the use of routine ultrasound follow-up for early detection of BOT recurrence.

Summary document on safety and recommendations on liposuction for lipoedema: Joint British association of aesthetic plastic surgeons (BAAPS)/British association of plastic reconstructive and aesthetic surgeons (BAPRAS) expert liposuction group

Liposuction plays an important role as a surgical treatment option for lipoedema. This article serves to critically review the evidence in the literature, as well as explain the differences between the lipoedema population compared with the aesthetic surgery population undergoing liposuction. It is not a comprehensive text on lipoedema management but serves to guide surgeons. This guidance was produced on behalf of the British Association of Aesthetic Plastic Surgeons (BAAPS) and the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) by the expert liposuction group. The guidance is based on the evidence available in the literature, along with a specialist expert opinion on liposuction for lipoedema, to provide plastic surgeons with a consensus recommendation for surgical treatment. The aim is to identify best practice to maximise the safety of patients. This article summarises current practices and safety considerations and outlines recommendations covering various aspects of patient care.

Just What the Doctor Ordered: Missed Ordering of Venous Thromboembolism Chemoprophylaxis Is Associated With Increased VTE Events in High-risk General Surgery Patients.

To define the impact of missed ordering of venous thromboembolism (VTE) chemoprophylaxis in high-risk general surgery populations. The primary cause of preventable death in surgical patients is VTE. Although guidelines and validated risk calculators assist in dosing recommendations, there remains considerable variability in ordering and adherence to recommended dosing. All adult inpatients who underwent a general surgery procedure between 2016 and 2019 and were entered into Atrium Health National Surgical Quality Improvement Program registry were identified. Patients at high risk for VTE (2010 Caprini score ≥5) and without bleeding history and/or acute renal failure were included. Primary outcome was 30-day postoperative VTE. Electronic medical record identified compliance with "perfect" VTE chemoprophylaxis orders (pVTE): no missed orders and no inadequate dose ordering. Multivariable analysis examined association between pVTE and 30-day VTE events. A total of 19,578 patients were identified of which 4252 were high-risk inpatients. Hospital compliance of pVTE was present in 32.4%. pVTE was associated with shorter postoperative length of stay and lower perioperative red blood cell transfusions. There was 50% reduced odds of 30-day VTE event with pVTE (odds ratio: 0.50; 95% CI, 0.30-0.80) and 55% reduction in VTE event/mortality (odds ratio: 0.45; 95% CI, 0.31-0.63). After controlling for relevant covariates, pVTE remained significantly associated with decreased odds of VTE event and VTE event/mortality. pVTE ordering in high-risk general surgery patients was associated with 42% reduction in odds of postoperative 30-day VTE. Comprehending factors contributing to missed or suboptimal ordering and development of quality improvement strategies to reduce them are critical to improving outcomes.

447: EFFICACY OF NASAL DECONTAMINATION WITH POVIDONE-IODINE COMPARED TO MUPIROCIN IN CARDIAC SURGERY

Introduction: Surgical site infections (SSIs) are considered the most common and costly healthcare-associated infection; coronary artery bypass graft (CABG) surgeries have the second highest cumulative incidence. Mupirocin is considered the gold standard intranasal decontamination treatment; however, povidone-iodine has emerged as an alternative. The objective of this study is to determine if universal nasal decontamination with povidone-iodine is as effective as targeted mupirocin in the prevention of SSIs in cardiac surgery patients. Methods: A single-center, retrospective, pre/post intervention analysis was conducted on adult patients admitted to Prisma Health–Upstate January 2017 to December 2021. Included patients received cardiac surgery for CABG and preoperative nasal decontamination with mupirocin (January 2017-December 2018) or povidone-iodine (January 2019-December 2021). The primary outcome assessed was SSI incidence. Secondary outcomes included S. aureus SSIs, non-surgical site S. aureus infection, in-hospital and 30-day mortality, hospital, and intensive care unit (ICU) length of stay (LOS), and cost. Results: Five hundred patients were screened, and 237 patients met inclusion criteria. Included patients were grouped into those receiving mupirocin (N=70) and povidone-iodine (N=167). Significant differences in baseline characteristics included the number of males and composite of past medical history. There was no difference in incidence of SSIs identified between the povidone-iodine and mupirocin (6 versus 3, p=0.726), even when stratified by SSI type (p=0.786). No differences were identified in any of the secondary outcomes between the povidone-iodine and mupirocin groups; however, evaluation of the safety outcome revealed more adverse events in the mupirocin group (p=0.025). Conclusions: This study provides evidence of efficacy and safety of povidone-iodine for preoperative nasal decontamination in cardiac surgery patients. Povidone-iodine may be considered as an alternative to mupirocin in the cardiac surgery population.

1258: USE OF CAUSAL INFERENCE TO COMPARE NOREPINEPHRINE- AND VASOPRESSIN-RELATED ICU MORTALITY

Introduction: The choice of vasopressor has been studied extensively in septic shock, however limited data exists in other shock types. Norepinephrine and vasopressin were compared in a retrospective study of the cardiac surgery population. Vasopressin as first-line treatment of post-cardiac surgery vasoplegic shock was found to improve clinical outcomes. However, the study was associated with biases which limits its validity. As there are no prospective studies, we use causal inference to analyze retrospective data. An observational study allows individual observation under one treatment scenario, while a counterfactual outcome is unknown. Targeted Maximum Likelihood Estimation (TMLE) models counterfactual outcomes with limited confounding by generating a pseudo-population. By adjusting for common causes of death, we were able to compare mortality outcomes between norepinephrine and vasopressin. Methods: An anonymous, publicly available database was analyzed using pre-existing IRB approval. The eICU Collaborative Research Database contains data on over 200,000 ICU admissions. The analysis used 27,388 patients with 25 initial features. Missing values greater than 50% were dropped. Machine Learning Extensions Library (MLxtend) was used to select features sequentially. The primary outcome was ICU mortality. Imputation was performed using Sklearn Iterative Imputuer, data scaled using Sklearn Standard Scaler. Our primary model was TMLE with Logistic Regression. We analyzed vasopressin and norepinephrine administration, accounting for their co-administration by using them as covariates. Net fluid balance, Apache IV, albumin, admission weight, age, diabetes, and metastatic cancer were confounder covariates for both groups. Before analysis, a causal diagram was constructed based on these covariates. Our primary metric was Average Treatment Effect (ATE). Results: Mortality analysis on the norepinephrine group showed an ATE of -0.179, 95% CI [-0.188, -0.167]. Vasopressin showed an ATE of 0.03 (95% CI [0.01,0.051]). Compared to vasopressin, norepinephrine showed a reduction in mortality. Conclusions: We found that norepinephrine was associated with decreased mortality compared to vasopressin in this setting. We hope this study’s results will help guide prospective studies moving forward.

144: COMPARISON OF FIXED VERSUS WEIGHT-BASED PROTHROMBIN COMPLEX CONCENTRATE DOSING IN CARDIAC SURGERY

Introduction: Excessive bleeding after cardiac surgery is a major complication associated with increased morbidity and mortality. Intraoperative use of plasma-derived coagulation factors, such as four-factor prothrombin complex concentrate (4F-PCC), have been introduced into clinical practice to attenuate adverse effects attributable to postoperative hemorrhage. Although recent literature reports positive outcomes with the use of lower, fixed doses of 4F-PCC for emergent anticoagulation reversal, there is a paucity of literature evaluating fixed dosing in the cardiac surgery setting. The purpose of this study is to compare the rates of moderate- or higher severity postoperative bleeding associated with use of a fixed-dose versus weight-based 4F-PCC dosing strategy in cardiac surgery patients. Methods: A retrospective cohort study was performed of adult patients who received either weight-based (25 IU/kg) or fixed-dose (1500 IU) 4F-PCC during a cardiac surgical procedure over a 2-year period. Bleeding outcomes were determined by postoperative blood product transfusion requirements, chest tube output volume, and the need for surgical reexploration due to bleeding complications. Results: Of the 122 patients included, 58 received weight-based 4F-PCC whereas 62 were managed with a fixed-dose strategy. Rates of moderate- or higher severity bleeding were similar between weight-based and fixed dosing groups (56.9% vs. 46.8%, respectively; χ2 = 3.8467, p = .278) despite the use of significantly lower total 4F-PCC doses in the fixed-dose 4F-PCC cohort (25.5 U/kg vs. 21.6 U/kg; z = -2.11, p = .04). Postoperative deep vein thrombosis occurred more frequently in the weight-based dosing group as compared to the fixed-dose cohort (8.6% vs. 0%; p = .02). Conclusions: Compared to a weight-based dosing strategy, intraoperative administration of fixed-dose 4F-PCC was associated with similar postsurgical bleeding outcomes and lower rates of deep vein thrombosis in postoperative cardiac surgery patients. Larger, prospective studies are needed to validate these findings and further evaluate the impact of fixed-dose 4F-PCC on patient-centered outcomes in the postoperative cardiac surgery population.

The importance of liver function assessment before cardiac surgery: A narrative review.

The demand for cardiac surgery procedures is increasing globally. Thanks to an improvement in survival driven by medical advances, patients with liver disease undergo cardiac surgery more often. Liver disease is associated with the development of heart failure, especially in patients with advanced cirrhosis. Cardiovascular risk factors can also contribute to the development of both cardiomyopathy and liver disease and heart failure itself can worsen liver function. Despite the risk that liver disease and cirrhosis represent for the perioperative management of patients who undergo cardiac surgery, liver function is often not included in common risk scores for preoperative evaluation. These patients have worse short and long-term survival when compared with other cardiac surgery populations. Preoperative evaluation of liver function, postoperative management and close postoperative follow-up are crucial for avoiding complications and improving results. In the present narrative review, we discuss the pathophysiological components related with postoperative complications and mortality in patients with liver disease who undergo cardiac surgery and provide recommendations for the perioperative management.

The Surgical Apgar Score: A Systematic Review of Its Discriminatory Performance.

The SAS is a simple metric calculated at the end of surgery that provides clinicians with information about a patient's postoperative risk of morbidity and mortality. The SAS differs from other prognostic models in that it is calculated from intraoperative rather than preoperative parameters. The SAS was originally derived and validated in a general and vascular surgery population. Since its inception, it has been evaluated in many other surgical disciplines, large heterogeneous surgical populations, and various countries. A database and gray literature search was performed on March 3, 2020. Identified articles were reviewed for applicability and study quality with prespecified inclusion criteria, exclusion criteria, and quality requirements. Thirty-six observational studies are included for review. Data were systematically extracted and tabulated independently and in duplicate by two investigators with differences resolved by consensus. All 36 included studies reported metrics of discrimination. When using the SAS to correctly identify postoperative morbidity, the area under the receiver operating characteristic curve or concordance-statistic ranged from 0.59 in a general orthopedic surgery population to 0.872 in an orthopedic spine surgery population. When using the SAS to identify mortality, the area under the receiver operating characteristic curve or concordance-statistic ranged from 0.63 in a combined surgical population to 0.92 in a general and vascular surgery population. The SAS provides a moderate and consistent degree of discrimination for postoperative morbidity and mortality across multiple surgical disciplines.

Implementation of Enhanced Recovery After Surgery Protocol in a Second-level Hospital

Background: Enhanced recovery after surgery (ERAS) became standard perioperative care in the western world. However, little is known about the implementation of fast-track pathways (FTP) in developing countries. The objectives of the study were to assess the feasibility of the FTP program and adherence to the ERAS protocol in general surgery patients implemented in low-resource setting. Methods: In this retrospective, observational study, we evaluated perioperative care for elective and emergency surgical population changed in accordance with the ERAS program in a second-level hospital in Zambia. Ninety-eight patients aged two weeks to 87 years (median 32 years) with a male to female ratio of 2.3:1 and categorised by the American Society of Anaesthesiologists (ASA) in classes I to IV were included. Outcomes of interest were functional recovery, postoperative complications, length of hospital stay, and compliance with the protocol. Results: All elements of the ERAS protocol, including minimal access surgery (through mini-laparotomy incisions) and accelerated postoperative care, were employed. A successful recovery with discharge home by day 4 after the operation and the absence of complications and readmissions was achieved in 45.5% of patients. The postoperative period was complicated in 18.8% of cases, with a total mortality rate of 6.3%. The overall adherence level to the protocol was 72.2%. The highest levels of adaptation (≥95%) were reported for preoperative stratification, antimicrobial prophylaxis, modification of preanaesthetic medications, and prevention of intraoperative hypothermia. The poor compliance to the program was recorded for fasting and carbohydrate loading before surgery and postoperative thromboprophylaxis (17.9% and 21.4%, respectively). Conclusion: The study indicates that the employment of the ERAS program for the general surgery population at a second-level hospital is feasible and safe. It is possible to achieve a high level of adherence to the ERAS pathway in a resource-limited environment. A reasonable modification of the protocol can bring additional clinical benefits. Integrating elements of FTP into perioperative care and including the ERAS program in postgraduate education in developing nations is recommended. Further studies are needed, first, to frame ERAS pathways for application in emergency general surgery, and second, to present the local initiatives and identify barriers to the implementation of FTP in low-income countries. Doi: 10.28991/SciMedJ-2022-04-04-04 Full Text: PDF

AntiPORT: adaptation of a transfusion prediction score to an Australian cardiac surgery population

Introduction: Risk scoring systems exist to predict perioperative blood transfusion risk in cardiac surgery, but none have been validated in the Australian or New Zealand population. The ACTA-PORT score was developed in the United Kingdom for this purpose. In this study, we validate and recalibrate the ACTA-PORT score in a large national database. Methods: We performed a retrospective validation study using data from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database between 1 September 2016 and 31 December 2018. The ACTA-PORT score was calculated using an equivalent of EuroSCORE I. Discrimination and calibration was assessed using area under the receiver operating characteristic (AUROC) curves, Brier scores, and calibration plots. ACTA-PORT was then recalibrated in a development set using logistic regression and the outcome of transfusion to develop new predicted transfusion rates, termed "AntiPORT", using AusSCORE "all procedures" as the regional equivalent of EuroSCORE I. The accuracy of these new predictions was assessed as for ACTA-PORT. Results: 30 388 patients were included in the study at 37 Australian centres. The rate of red blood cell transfusion was 33%. Discrimination of ACTA-PORT was good but calibration was poor, with overprediction of transfusion (AUROC curve, 0.76; 95% CI, 0.75-0.76; Brier score, 0.19). The recalibrated AntiPORT showed significantly improved calibration in both development and validation sets without compromising discrimination (AUROC curve, 0.76; 95% CI, 0.75-0.76; Brier score, 0.18). Conclusions: The AntiPORT is the first red cell transfusion risk scoring system for cardiac surgery patients to be validated using Australian data. It is accurate and simple to calculate. The demonstrated accuracy of AntiPORT may help facilitate benchmarking and future research in patient blood management, as well as providing a useful tool to help clinicians target these resource-saving strategies.

In this Issue of CCR

Point of View: A four-step model to aid teaching, clinical assessment and communication of circulatory disorders amongst junior clinicians Editorial: Midodrine – why don't you just work better? Review: Midodrine Use in Critically Ill Patients – A Narrative Review Original Articles: Study protocol and statistical analysis plan for the 20% Human Albumin Solution Fluid Bolus Administration Therapy in Patients after Cardiac Surgery-II (HAS FLAIR-II) trial Early sedation in traumatic brain injury: a multicentre international observational study The association between vital signs abnormalities during post-anaesthesia care unit stay and deterioration in the general ward following major abdominal cancer surgery assessed by continuous wireless monitoring Mortality associated with Acute Respiratory Distress Syndrome 2009-2019: A systematic review and meta-analysis The prevalence of post extubation dysphagia in critically ill adults: An Australian data linkage study ANTIPORT: adaptation of a transfusion prediction score to an Australian cardiac surgery population

Association Between the Modified Frailty Index and Outcomes Following Lobectomy

Elective thoracic surgery is safe in well-selected elderly patients. The association of frailty with postoperative morbidity in elective-lobectomy patients is understudied. We examined frailty as defined by abbreviated modified frailty index (mFI-5), mFI-11 in the thoracic surgery population, and the correlation between frailty and postoperative complications. We studied outcomes of patients in two cohorts, 2010-2012 and 2013-2019, from the National Surgical Quality Improvement Program (NSQIP) database and used multivariable logistic regression models to predict all postoperative morbidity, mortality, and major morbidity. The mFI-5 could be calculated for all subjects (both 2010-2012, and 2013-2019); the mFI-11 could only be calculated for the 2010-2012 cohort. Patient frailty was defined as mFI≥3 (with either index). We used odds ratios (ORs) to examine associations of preoperative characteristics with postoperative complications and C-statistics to assess overall predictive power. Complications were less prevalent in the 2013-2019 cohort (17.9% versus 19.5%, P=0.008). Open lobectomies were more common in the 2010-2012 cohort (53.9% versus 34.6%) and were strongly associated with postoperative morbidity and mortality (ORs >1.5) in both cohorts. Each frailty measure was associated with morbidity and mortality (ORs >1.4) after adjusting for other significant preoperative factors. Models on the 2010-2012 cohort had nearly identical C-statistics using the mFI-11 versus mFI-5 frailty indices (0.6142 versus 0.6139; P>0.8). Frailty, as captured in the mFI-5, is a significant associated factor of postoperative morbidity and mortality following elective lobectomies. As a modifiable risk factor, frailty should be considered in surgical decision-making and when counseling patients regarding perioperative risks.