Time Of Admission For Surgery Research Articles

Operative Management of Hip Fractures Within 24 Hours in the Elderly is Achievable and Associated With Reduced Opiate Use

Morbidity and mortality benefits have been associated with prompt surgical treatment of geriatric hip fractures. The purpose of this study was to evaluate the impact of early (≤24hr) vs delayed (>24hr) time to operating room (TTOR) on 1) hospital length of stay and 2) total and post-operative opiate use in geriatric hip fractures. This study was a retrospective review of patients ≥65years-old at the time of admission for surgery for hip fracture at a Level II academic trauma center. Outcome measures were length of stay (LOS), oral morphine equivalents (OME) throughout hospitalization. Patients were stratified into early and delayed TTOR groups and comparisons were made between groups. Between the early (n = 75, 80.6%) and late (n = 18, 19.4%) groups, there were no differences in age, fracture pattern, type of treatment, preoperative opiate use, and perioperative non-oral pain management. The early group trended toward shorter total LOS (108.0 ± 67.2hours vs 144.8 ± 103.7hours, P = .066), but not post-operative LOS. Total OME usage was less in the early intervention group (92.5 ± 188.0 vs 230.2 ± 296.7, P = .015), in addition to reduced post-operative OME (81.3 ± 174.9 vs 213.3 ± 271.3, P = .012). There were no differences in evaluated potential delay sources such as primary language, use of surrogate decision makers, or need for advanced imaging. Surgical treatment of geriatric hip/femur fractures in ≤24hours from presentation is achievable and may be associated with reduced total inpatient opiate use, although daily use did not differ. Establishing institutional TTOR goals as part of an interdisciplinary hip fracture co-management clinical pathway can facilitate prompt care and contribute to recovery and less opiate use in these patients with highly morbid injuries.

Postoperative Outcomes of Cardio-Thoracic Surgery in Post-COVID versus Non-COVID Patients - Single-Center Experience

Objective: The aim of this study is to investigate the postoperative outcomes in post COVID versus non-COVID patients undergone cardiac surgery. Materials and Methods: A retrospective cohort study to analyze the impact of COVID-19 in patients undergoing elective or emergency cardiac surgeries. A total of 512 patients were included in the study over a period of 6 months. The study consists of 35 post-COVID patients and 477 non-COVID patients. All data were collected from previous medical records and hospital database. The clinical outcomes and mortality of post-COVID patients were compared with a cohort of non-COVID patients. The endpoints were compared using t-test or Chi-squared test. Results: Among the post-COVID patients, 54.3% (19) of the post-COVID patients were under COVID category A followed by category B 28.6% (10) and category C 17.1% (6). About 50% of post-COVID patients had complications, especially pneumonia and myocardial infarction following COVID-19. Around 43% of patients showed fibrotic changes in computed tomography (CT) Thorax at the time of admission for surgery. 63% showed CT score in between 1 and 5. The mean COVID antibody titer was 158 U/ml. Majority of the surgeries were coronary artery bypass graft and significant difference was observed in the requirement of intra-aortic balloon pump in post-COVID patients (P < 0.0001). No postoperative mortality reported in post-COVID patients. The postoperative outcomes and survival rates were almost similar in both groups. Conclusion: In our study, the post-COVID patients were recover in a similar way as non-COVID patients after cardiac surgery.

The Risk of Preoperative Central Nervous System-Acting Medications on Delirium Following Hip or Knee Surgery: A Matched Case-Control Study.

Medicines acting on the central nervous system can increase the risk of postoperative delirium, but the specific medicines associated with greatest risk remain unclear. We aimed to examine the risk of individual central nervous system-acting medicines used preoperatively on delirium after hip or knee surgery. A matched case-control study was conducted using data from the Australian Government Department of Veterans' Affairs. We included people aged 65 years or older who had knee or hip surgery between 2000 and 2019. People with hip or knee surgery who developed postoperative delirium were cases and controls were people with hip or knee surgery but who did not develop postoperative delirium. Use of medicines including anxiolytics, sedatives, and hypnotics, opioid analgesics and antidepressants prior to surgery was compared between cases and controls. A total of 2614 patient cases with postoperative delirium were matched by same sex, age (±2 years), and year of admission (±2 years) with 7842 controls without postoperative delirium. Cases were more likely to be exposed to nitrazepam (odds ratio [OR] = 1.81, 95% confidence interval [CI] 1.24-2.64), sertraline (OR = 1.50, 95% CI 1.20-1.87), mirtazapine (OR = 1.38, 95% CI 1.11-1.74), venlafaxine (OR = 1.42, 95% CI 1.02-1.98), citalopram (OR = 1.54, 95% CI 1.19-1.99), escitalopram (OR = 1.42, 95% CI 1.06-1.89) or fluvoxamine (OR = 5.01, 95% CI 2.15-11.68) prior to surgery than controls. At the class level, exposure to benzodiazepines (OR = 1.20, 95% CI 1.05-1.37) and antidepressants (OR = 1.64, 95% CI 1.47-1.83) prior to surgery was significantly higher in cases than in controls. The numbers needed to treat to harm for one additional delirium case were 43 for sertraline, 40 for citalopram, 57 for mirtazapine and 26 for nitrazepam. Whereas, the numbers needed to treat to harm were found to be 20 for sertraline, 17 for citalopram, 19 for mirtazapine and 10 for nitrazepam in the 85 years or older age group, indicating that the harmful effect of these medicines is pronounced as age advances. People who developed delirium following hip or knee surgery were more likely to be exposed to nitrazepam, sertraline, mirtazapine, venlafaxine, citalopram, escitalopram or fluvoxamine at the time of admission for surgery. Planning to reduce use of these medicines well prior to surgery may decrease the risk of postoperative delirium.

Family History of Pilonidal Sinus Predisposes to Earlier Onset of Disease and a 50% Long-Term Recurrence Rate

It has long been suspected that a family history of pilonidal sinus disease may predispose to higher disease incidence. The influence of family history on recurrence rate has not been investigated. The purpose of this study was to evaluate the recurrence rate in patients with both a personal and a family history of pilonidal sinus disease. A standardized telephone interview was used to retrospectively study 578 patients who underwent primary surgery between 1980 and 1996. Differences concerning the long-term recurrence rate between patients with a positive or negative family history were analyzed using Kaplan-Meier statistics. Sixty-eight of 578 patients (12%) had a positive family history with first-degree relatives, in which 28 brothers and 25 fathers were similarly involved. The long-term recurrence rate was significantly elevated when family history was positive (35% vs. 22% after 15 years and 52% vs. 28% after 25 years; P = 0.02). The long-term recurrence rate was elevated if surgery was needed at a younger age (P = 0.03). The body mass index measured at time of admission for surgery did not seem to have any negative influence on recurrence rates (P = 0.31). Although a positive family history predisposes a person to earlier onset of disease, recurrences occur within 5.1 +/- 6.2 years (mean +/- standard deviation) in patients with a positive family history and within 5.3 +/- 5.2 years in patients with a negative family history (P = 0.95). Patients with a positive family history need closer surgical monitoring because primary disease will manifest earlier. A remarkable long-term recurrence rate exceeding 50% after 25 years places a much higher disease burden on patients with a positive family history. All available interventions known to reduce recurrence rate should be applied to this group of patients.

Unexpected Periaortic Cavity During Heart Surgery

A 43-year-old man was referred to our institution for surgical correction of aortic valvular disease discovered in the context of new onset aortic insufficiency with acute pulmonary edema. The patient had no medical history of cardiac disease besides an “innocent” heart murmur since youth, which had never been investigated. Of note, he had an acute episode of glomerulonephritis with secondary renal insufficiency and systemic hypertension 6 mo before, and septicemia from an infected percutaneous hemodialysis catheter 5 mo before admission. The patient was afebrile, appeared nonseptic at the time of admission for surgery. Preoperative transthoracic echocardiography (TTE) revealed Grade IV aortic insufficiency and moderate aortic stenosis. There were no other abnormalities described. Intraoperative transesophageal echocardiography (TEE) examination revealed a pulsatile cavity on the mitral-aortic intervalvular fibrosa in the mid-esophageal long-axis view, close to the noncoronary cusp of a bicuspid aortic valve. The cavity had pronounced systolic enlargement (Fig. 1). Systolic flow in the cavity was apparent using color flow Doppler (Fig. 2; video loop can be accessed at www.anesthesia-analgesia.org).Figure 1.: Mid-esophageal long-axis view in end systole. The left ventricular outflow tract pseudoaneurysm (arrow) is at maximal size.Figure 2.: Mid-esophageal long-axis view displaying M-mode of the left ventricular outflow tract showing the holosystolic filling (white arrow) and diastolic emptying of the pseudoaneurysm.Visual inspection of the aortic valve showed no evidence of endocarditis. The presence of this undiagnosed cavity was confirmed by the surgeon, who isolated it from the left ventricle by means of an autologous pericardial patch. After aortic valve replacement, TEE showed significant reduction of flow in the cavity. The postoperative course was uneventful. A subsequent TTE study failed to show any residual cavity. Left ventricular outflow tract (LVOT) pseudoaneurysms, or pseudoaneurysms of the mitral-aortic intervalvular fibrosa, are rare complications of infective aortic endocarditis, trauma, and aortic valve replacement surgery. This is the first case of LVOT abscess that we have encountered in a 13-year-TEE database of approximately 8500 examinations. The incidence of fistulas or pseudoaneurysm complicating aortic annular abscesses is estimated to be 11% (1). Pseudoaneurysms associated with infective endocarditis of the aortic valve can occur anywhere from the left ventricle to more distal arteries, such as the superior mesenteric artery. Echocardiographic criteria of an LVOT pseudoaneurysm include a pulsatile nature (with systolic enlargement, easily diagnosed using M-mode) and communication with the LVOT (2). These can be associated with aortic regurgitation and rarely, mitral regurgitation. In one small study, it was shown that pseudoaneurysms of the LVOT are more readily observed with TEE than with TTE or aortography (3). In this case, the bicuspid aortic valve may have predisposed the patient to infective endocarditis, which may have been effectively treated with antibiotic therapy of his infected dialysis catheter. The pseudoaneurysm may have developed shortly thereafter.

Estrogen replacement therapy and the surgeon

Background: The number of patients over the age of 65 years has increased to 33.2 million, with a life expectancy of 76.5 years. With an aging population, the number of surgical procedures is expected to increase as much as 50%. The majority of individuals over 65 years are women. Estrogen replacement therapy is commonly recommended to postmenopausal women for relief of vasomotor symptoms, protection against heart disease, and prevention of osteoporosis. Purpose: The purpose of this review is to address estrogen replacement therapy with regard to wound healing, fracture repair, perioperative cardiac morbidity, and thrombosis. Data source: Medline Literature review. Conclusions: There is insufficient evidence to withdraw estrogen replacement therapy at the time of admission for surgery. Patients not receiving estrogen replacement therapy should be offered therapy upon return to ambulatory status.

Profile of patients presenting for cataract surgery in the UK: national data collection

AIMS/METHODSA national data collection exercise was carried out in more than 100 hospital eye service units within the UK to provide clinical and administrative information on patients undergoing cataract surgery....

Spontaneous Delayed Closure Of Postangiographic Femoral Artery Aneurysms

To the Editor.— Recently I have seen two similar cases that are thought to be instructive. The first is in a 51-year-old man with hypertension (blood pressure, 220/150 mm Hg) who had a transfemoral abdominal aortogram with a 7F Teflon catheter. The procedure went smoothly, total catheter time being less than 30 minutes. Small amounts of heparinized saline were used as a flushing solution. A small hematoma was present following the procedure. Two days later, he had sudden recurrence of bleeding and a large hematoma appeared. Two weeks later, a 4-cm aneurysm was palpated and a loud bruit was heard over the puncture site. However, at the time of admission for surgery, six weeks after arterial puncture, aneurysm and bruit had disappeared, leaving only a small lump of scar tissue. The second patient is a 68-year-old male hypertensive (blood pressure, 190/100 mm Hg) who had a transfemoral arch aortogram to