Anemia - the Neglected Problem in Patients with Orthopedic Conditions

Anemia and the necessity of blood product transfusion in perioperative procedures is an important and frequently discussed clinical issue. Presently, a constantly growing interest in this problem is observed among clinicians who search the ways to reduce the number of blood or blood product transfusions in patients after surgical procedures, both during the preoperative period and during and after the surgery. Generally, the decision whether to start transfusion or not should follow the analysis of pros and cons, considering the beneficial effect of transfusion and the risk of undesirable effects. The most effective approach in prophylaxis and treatment of anemia among patients on the orthopedic service should combine surgical anesthetic and pharmacological procedures during the preoperative, perioperative and postoperative periods. The aim of the paper is presenting the latest knowledge of the practical determinants concerning anemia pharmacological treatment, especially considering the principles, value and therapeutic effectiveness of iron supplementation, both at orthopedic injury clinics and outpatient clinics.

Factors associated with prolonged length of stay for elective hepatobiliary and neurosurgery patients: a retrospective medical record review

BACKGROUND

Patients with prolonged length of hospital stay (LOS) not only increase their risks of nosocomial infections but also deny other patients access to inpatient care. Hepatobiliary (HPB) malignancies have some of highest incidences in East and Southeast Asia and the management of patients undergoing HPB surgeries have yet to be standardized. With improved neurosurgery techniques for intracranial aneurysms and tumors, neurosurgeries (NS) can be expected to increase. Elective surgeries account for far more operations than emergencies surgeries. Thus, with potentially increased numbers of elective HPB and NS, this study seeks to explore perioperative factors associated with prolonged LOS for these patients to improve safety and quality of practice.

METHODS

A retrospective cross-sectional medical record review study from January 2014 to January 2015 was conducted at a 1250-bed tertiary academic hospital in Singapore. All elective HPB and NS patients over 18 years old were included in the study except day and emergency surgeries, resulting in 150 and 166 patients respectively. Prolonged LOS was defined as above median LOS based on the complexity of the surgical procedure. The predictor variables were preoperative, intraoperative, and postoperative factors. Student's t-test and stepwise logistic regression analyses were conducted to determine which factors were associated with prolonged LOS.

RESULTS

Factors associated with prolonged LOS for the HPB sample were age and admission after 5 pm but for the NS sample, they were functional status, referral to occupational therapy, and the number of hospital-acquired infections.

CONCLUSION

Our findings indicate that preoperative factors had the greatest association with prolonged LOS for HPB and NS elective surgeries even after adjusting for surgical complexity, suggesting that patient safety and quality of care may be improved with better pre-surgery patient preparation and admission practices.

[Current Options and Importance of Imaging of the Hyaline Articular Cartilage of the Knee Prior to the Surgery - a Different Perspective of an Orthopaedic Surgeon and a Radiologist]

The authors present an overview of the commonly used techniques and new trends of the cartilage imaging, especially postoperatively, and also discuss the potential of MRI imaging of the cartilage from the perspective of an experienced orthopaedic surgeon. In conclusion, the authors propose possible explanations for the potential discrepancies between the MRI and the arthroscopic findings. Hyaline cartilage damage and subsequent reparation of this tissue is one of the topical issues of orthopaedics and traumatology. Due to the expanding possibilities of treatment of this tissue and a relatively good effect of the surgery, the number of patients indicated for magnetic resonance imaging prior to the surgery has been on an increase. To make a decision concerning the subsequent type of treatment, it is necessary to get an idea of the cartilage cover condition, articular surfaces and also of the associated pathologies. The degree of cartilage damage can be assessed by arthroscopy or magnetic resonance imaging, which provides also the possibility of the subchondral lesion detection. Thanks to the noninvasive nature of the MRI examination, it has become the most important method in full imaging of the articular cartilage. The MRI of the cartilage has many options and at present the evaluation of the hyaline cartilage should be an integral part of each MRI examination of joints. For a more accurate assessment of the cartilage there are several advanced techniques available that can be used not only for preoperative diagnostics, but also for monitoring after the surgery. Key words: hyaline cartilage, magnetic resonance, arthroscopy.

Effects of perioperative briefing and debriefing on patient safety: a prospective intervention study

OBJECTIVES

This study was carried out to improve patient safety in the operating theatre by the introduction of perioperative briefing and debriefing, which focused on an optimal collaboration between surgical team members.

DESIGN

A prospective intervention study with one pretest and two post-test measurements: 1 month before and 4 months and 2.5 years after the implementation of perioperative briefing and debriefing, respectively.

SETTING

Operating theatres of a tertiary care hospital with 875 beds in the Netherlands.

PARTICIPANTS

All members of five surgical teams participated in the perioperative briefing and debriefing.

INTERVENTION

The implementation of perioperative briefing and debriefing from July 2012 to January 2014.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was changes in the team climate, measured by the Team Climate Inventory. Secondary outcomes were the experiences of surgical teams with perioperative briefing and debriefing, measured with a structured questionnaire, and the duration of the briefings, measured by an independent observer.

RESULTS

Two and a half years after the introduction of perioperative briefing and debriefing, the team climate increased statistically significant (p≤0.05). Members of the five surgical teams strongly agreed with the positive influence of perioperative briefing and debriefing on clear agreements and reminding one another of the agreements of the day. They perceived a higher efficiency of the surgical programme with more operations starting on time and less unexpectedly long operation time. The perioperative briefing took less than 4 min to conduct.

CONCLUSIONS

Perioperative briefing and debriefing improved the team climate of surgical teams and the efficiency of their work within the operating theatre with acceptable duration per briefing. Surgical teams with alternating team compositions have the most benefit of briefing and debriefing.

Effectiveness of preoperative medical consultations by internal medicine physicians: a systematic review

OBJECTIVE

Clinics have been established to provide preoperative medical consultations, and enable the anaesthetist and surgeon to deliver the best surgical outcome for patients. However, there is uncertainty regarding the effect of such clinics on surgical, in-hospital and long-term outcomes. A systematic review of the literature was conducted to determine the effectiveness of preoperative medical consultations by internal medicine physicians for patients listed for elective surgery.

DESIGN

Systematic searches of MEDLINE, EMBASE, CINAHL, PubMed, Current Contents and the NHS Centre for Reviews and Dissemination were conducted up to 30 April 2017.

SETTING

Elective surgery.

STUDY SELECTION

Randomised controlled trials and non-randomised comparative studies conducted in adults.

OUTCOME MEASURES

Length of hospital stay, perioperative morbidity and mortality, costs and quality of life.

RESULTS

The one randomised trial reported that preadmission preoperative assessment was more effective than the option of an inpatient medical assessment in reducing the frequency of unnecessary admissions with significantly fewer surgical cancellations following admission for surgery. A small reduction in length of stay in patients was also observed. The three non-randomised studies reported increased lengths of stay, costs and postoperative complications in patients who received preoperative assessment. The timing and delivery of the preoperative medical consultation in the intervention group differed across the included studies.

CONCLUSION

Further research is required to inform the design and implementation of coordinated involvement of physicians and surgeons in the provision of care for high-risk surgical patients. A standardised approach to perioperative decision-making processes should be developed with a clear protocol or guideline for the assessment and management of surgical patients.

Does digestive symptoms require esophago gastroscopy prior to bariatric procedure? Assessment of 6 years' experience

AIM

Performance of routine preoperative esophagogastroduodenal endoscopy (EGE) in patients undergoing bariatric surgery is still a controversial subject. The purpose of our study was to evaluate the benefits of performing preoperative EGE in a cohort of bariatric patients.

MATERIAL AND METHODS

The present retrospective study was performed between March 2010 and June 2016. We divided the study participants into two groups: group A comprised subjects without disturbing upper digestive signs, while group B comprised patients with disturbing upper digestive signs. Logistic regression analysis was used to identify the pre-dictors that might be associated with abnormal outcomes.

RESULTS

Our study included 232 patients (who had undergone sleeve gastrectomy, gastric bypass, ileal interposition, or transit bipartition). The average age was 41.4 ± 10.3 years, and the average body mass index (BMI) was 43.6 ± 5.1 kg/m2. Of all the observed gastroscopic abnormalities, the prevalence for gastritis (17.3%), followed by esophagitis (10.2%), hiatus hernia (9.4%), and bulbitis (8.7%). In multivariate regression analysis, the Gastrointestinal Symptom Rating Scale (GSRS) score and upper gastric symptoms were found to be the only independent predictive markers (OR = 2.822, 95% CI: 1.674-3.456 and OR =2.735, 95% CI: 1.827-3.946, respectively). We identified a positive corre-lation between abnormal EGE findings and postoperative complications.

CONCLUSION

Preoperative EGE had a high rate of detection for the possible abnormalities prior to bariatric surgery. Upper gastric symptoms are significant predictive factors of postoperative complications. Performing preoperative EGE for symptomatic patients could help reduce the morbidity and mortality rates in these patients.

KEY WORDS

Bariatric surgery, Preoperative endoscopy, Upper digestive symptoms.

Complete Versus Incomplete Angiography Prior to Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction

OBJECTIVES

Shorter reperfusion times in ST-elevation myocardial infarction (STEMI) are associated with improved survival. Prehospital strategies have been developed to minimize door-to-balloon (DTB) time, but few strategies within the catheterization laboratory itself have been evaluated. Incomplete angiography (IA) prior to percutaneous coronary intervention (PCI) is undertaken in clinical practice as a means to further reduce DTB time. We sought to determine whether or not those with STEMI who underwent IA prior to PCI had different preprocedural characteristics or post-PCI outcomes.

METHODS

We retrospectively reviewed patients presenting to our institution between March 2013 and December 2015. Clinical, demographic, and angiographic data were reviewed. The frequency, predictors, and outcomes among those who received IA vs complete angiography (CA) prior to PCI were compared with analysis of variance.

RESULTS

Two hundred fifty-six patients were identified; 68 patients (26.6%) underwent IA and 188 patients (73.4%) had CA prior to PCI. Patients who received IA were younger, but no other preprocedural factors were predictive of IA. The practice of IA did vary by operator (range, 0%-47%; P<.01). DTB times were shorter in the IA group (28.1 min vs 37.3 min; P<.01). Overall outcomes, including peak troponin values, length of stay, in-hospital mortality, and discharge ejection fraction did not differ between the groups.

CONCLUSION

IA is associated with shorter DTB times, although in this population was not associated with improvements in short-term outcomes.

Four-dimensional Computed Tomography (4DCT) for Preoperative Localization of Parathyroid Adenomas

BACKGROUND

Four-dimensional parathyroid computed tomography (4DCT) is a relatively new parathyroid imaging technique that provides functional and highly detailed anatomic information about parathyroid tumors.

OBJECTIVES

To assess the accuracy of 4DCT for the preoperative localization of parathyroid adenomas (PTAs) in patients with biochemically confirmed primary hyperparathyroidism (PHPT) and a history of failed surgery or unsuccessful localization using 99mTc-sestamibi scanning and ultrasonography.

METHODS

Between January 2013 and January 2015, 55 patients with PHPT underwent 4DCT at Hillel Yaffe Medical Center, Hadera, Israel. An initial unenhanced scan was followed by an IV contrast injection of nonionic contrast material (120 ml of at 4 ml/s). Scanning was repeated 25, 60, and 90 seconds after the initiation of IV contrast administration. An experienced radiologist blinded to the earlier imaging results reviewed the 4DCT for the presence and location (quadrant) of the suspected PTAs. At the time of the study, 28 patients had undergone surgical exploration following 4DCT and we compared their scans with the surgical findings.

RESULTS

4DCT accurately localized 96% (27/28) of abnormal glands, all of which were hypervascular and showed characteristic rapid enhancement on 4DCT that could be distinguished from Level II lymph nodes. Surgery found hypovascular cystic PTA in one patient who produced a negative 4DCT scan. All patients had solitary PTAs. The scan at 90 seconds provided no additional information and was abandoned during the study.

CONCLUSIONS

4DCT accurately localized hypervascular parathyroid lesions and distinguished them from other tissues. A three-phase scanning protocol may suffice.

[Prevention and treatment of anastomosis complications after radical gastrectomy]

The anastomotic complications following radical gastrectomy mainly include anastomotic leakage, anastomotic hemorrhage, and anastomotic stricture. Theanastomotic complications are not rare and remain the most common complications resulting in the perioperativedeath of patients with gastric cancer. Standardized training could let surgeons fully realize that strict selection of operative indications, thorough preoperative assessment and preparation, and refined operation in surgery are the essential measures to prevent the anastomotic complications following radical gastrectomy. In addition, identifying these complications timely and taking effective measures promptly according to the clinical context are the keys to treating these complications, reducing the treatment cycle, and decreasing the mortality.

Is there an optimal preoperative management strategy for phaeochromocytoma/paraganglioma?

Phaeochromocytomas and paragangliomas (PPGLs) are catecholamine secreting neuroendocrine tumours that predispose to haemodynamic instability. Currently, surgery is the only available curative treatment, but carries potential risks including hypertensive and hypotensive crises, cardiac arrhythmias, myocardial infarction and stroke, due to tumoral release of catecholamines during anaesthetic induction and tumour manipulation. The mortality associated with surgical resection of PPGL has significantly improved from 20-45% in the early 20th century (Apgar & Papper, AMA Archives of Surgery, 1951, 62, 634) to 0-2·9% in the early 21st century (Kinney et al. Journal of Cardiothoracic and Vascular Anesthesia, 2002, 16, 359), largely due to availability of effective pharmacological agents and advances in surgical and anaesthetic practice. However, surgical resection of PPGL still poses significant clinical management challenges. Preoperatively, alpha-adrenoceptor blockade is the mainstay of management, although various pharmacological strategies have been proposed, based largely on reports derived from retrospective data sets. To date, no consensus has been reached regarding the 'ideal' preoperative strategy due, in part, to a paucity of data from high-quality evidence-based studies comparing different treatment regimens. Here, based on the available literature, we address the Clinical Question: Is there an optimal preoperative management strategy for PPGL?

A Randomised Controlled Trial to Compare a Nurse Practitioner to Medical Staff in the Preparation of Patients for Diagnostic Cardiac Catheterisation: The Study of Nursing Intervention in Practice (SNIP)

BACKGROUND

A number of initiatives have employed nurses in roles traditionally associated with the medical profession but few have been evaluated in prospective randomised studies. This paper reports the results of a randomised controlled trial to assess the performance of a nurse practitioner (NP), trained to prepare patients for diagnostic cardiac catheterisation.

METHODS

Eligible and consenting patients were randomised to preparation by either the NP or junior medical staff (JMS). The safety outcome measure was the rate of in-hospital major adverse clinical events including death, myocardial infarction and emergency bypass coronary surgery. Other outcome measures included rate of minor adverse events, cardiologist assessment of case preparation and presentation, patient satisfaction and duration of pre-admission clinic.

RESULTS

From April 1997 to May 1998 a series of 355 patients scheduled for elective, day-case, diagnostic cardiac catheterisation were screened. Of these, 345 patients were eligible for the study. A total of 339 patients consented to participate and were randomised. Major adverse clinical events occurred in 0/175 (0%) patients in the NP group and 2/161 (1.2%) patients in the JMS group. (Risk difference = -1.2%, upper boundary of the 95% confidence interval = +2.0%) The cardiologist's evaluation that the patient's preparation was acceptable was high in both groups: NP group 98.3% vs. JMS group 98.8%: P = 1.0). Patient satisfaction, assessed by questionnaire, was greater in the NP group (P = 0.04). The median duration of the pre-admission clinic visit was lower in the NP group 165 min vs. 185 min in the JMS group, P = 0.01).

CONCLUSIONS

The preparation of patients for diagnostic cardiac catheterisation can be safely performed by an appropriately trained NP. This approach may be associated with improved patient satisfaction and reduced clinic duration times.

CABG and PTCA Patients' Expectations of Informational Support in Health-Related Quality of Life Themes and Adequacy of Information in 1-Year Follow-Up

The purpose of this study was to describe coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) patients' need for nursing informational support in health-related (HRQoL) items before and after coronary artery procedures. As well we present the adequacy of informational support from patients' viewpoint. The study sample (N=625) consisted of consecutive male (N=439) and female (N=176) patients with CAD who were treated with elective CABG or PTCA. The data were collected by structured interview before coronary artery procedures and by mailed questionnaires 6 and 12 months afterwards in 1999-2001. Patients in both groups reported needing the most information about recovery and psychosocial functioning before and after the treatments. Single HRQoL items identified that the expectations of women and men differed during the follow-up period. Women in the PTCA group needed more informational support than men before procedures, while men needed more support afterwards. Our results suggest that the content of informational support is different for male and female patients before and after the coronary artery procedures. The effects of nursing interventions and instruments for measuring change in patients' outcome resulting from nursing interventions should be developed further.

The coexistence of primary hyperparathyroidism and thyroid nodules: should the preoperative work-up of the parathyroid and the thyroid diseases be specifically adjusted?

INTRODUCTION AND OBJECTIVES

Primary hyperparathyroidism (PHPT) can be found in concomitance with thyroid disease (TD) in a high frequency of cases. In this context the diagnostic exams for localizing the enlarged parathyroid(s) gland(s) could be less reliable or nonconclusive. Moreover, the thyroid carcinoma seems to be more frequent compared to that isolated thyroid desease and, therefore, carefully investigated. The main goal of the present study is to evaluate which diagnostic tool (US, MIBI) is more reliable for localizing the site of the PTH hypersecretion and to confirm if it is always advantageous a combination of both exams. Besides, we evaluated the incidence of thyroid carcinoma in our series of patients.

PATIENTS AND METHODS

A review of available data of 73 patients who underwent total thyroidectomy + parathyroidectomy from 2003 and 2014 was performed. The preoperative workup included systematically US and MIBI whose results were considered true positive when at least the side (left/right) of the parathyroid affected were concordant with the surgical report, settled as the gold standard, according to the Cox nonnested model. The connection between the diagnostic results of US versus MIBI was calculated with the Cohen K index for evaluating their overlap. The average of the thyroid carcinoma were also calculated.

RESULTS

The difference between respectively US versus surgical report (p value=0.73) and MIBI versus surgical report (p value=0.81) were not significant. The low Cohen K index showed that both US and MIBI are complementary. In 23 patients (32,9%) a thyroid carcinoma was found.

CONCLUSIONS

The association of MIBI and neck US is mandatory in the first evaluation of patients undergoing thyroidectomy and parathyroid excision simultaneously. The high prevalence of thyroid carcinoma in this specific context suggests a more aggressive diagnostic and surgical behaviour.

Lack of national consensus in preoperative airway assessment

INTRODUCTION

Difficult airway management is associated with an increased risk of morbidity and mortality. Several preoperative risk factors associated with airway management difficulties have been proposed; however, no clear guideline for airway assessments exists. We therefore hypothesised that Danish airway assessment was lacking uniformity. We aimed to examine whether multivariable risk assessment tools and predictors for difficult intubation and mask ventilation were used systematically.

METHODS

Heads of anaesthesia departments were sent a six-question survey at the beginning of 2012. We asked if systematic risk assessment tools, particularly the Simplified Airway Risk Index (SARI), and predictors for difficult intubation and mask ventilation were used. Additionally, we asked if any risk factors were pre-printed on the anaesthesia record.

RESULTS

In all, 29 of 31 (94%) departments responded. The SARI was implemented in 8 of 29 (28%, 95% confidence interval (CI): 15-46%) departments with major regional differences. There was no significant association between using the SARI and a reduced number of unanticipated difficult intubation (p = 0.06). Mallampati classification (95.2%, 95% CI: 77.3-99.2%), history of airway management difficulties (85.7%, 95% CI: 65.4-95.0%), ability to prognath (81.0%, 95% CI: 60.0-92.3%) and neck mobility (81.0%, 95% CI: 60.0-92.3%) were the main predictors registered.

CONCLUSION

We found considerable inter-departmental variance in the standards employed for airway assessment and no uniform pattern in the registration of risk factors for airway management difficulties. Better prediction of difficult intubation could not be detected in departments that used the SARI.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Preoperative evaluation: A time-saving algorithm

Our preop evaluation method combines the latest guidelines and tools to help you avoid unnecessary testing and complete the process in one visit.

[RECOMMENDATIONS FOR PERIOPERATIVE FASTING IN CHILDREN]

Perioperative fasting is a standard procedure for the preparation of patients for surgery. The current guidelines for perioperative fasting in children recommend adherence to the instructions, “2-4-6” i.e. taking clear liquids up to 2 hours, breast milk up to 4 hours, and other non-human milk and solids up to 6 hours prior to surgery. Oral fluid intake is allowed within the first 3 postoperative hours in most pediatric patients. Too long perioperative fasting is not recommended, and may be harmful, both for healthy children so for a specific group of pediatric patients such as cancer patients. It is possible to avoid the adverse effects of prolonged perioperative fasting by appropriate planning of operating programs, good coordination of anesthetic and surgical team and compliance to the guidelines. Although recent studies suggest an advantage of more liberal perioperative approach in relation to the current guidelines in children, for now there is no enough evidence to change existing recommendations. However, according to ongoing studies it is possible that soon there will be evidence enough to support additional shortening of perioperative fasting time interval.

Prognostic Value of the Blink Reflex in Acoustic Neuroma Surgery

OBJECTIVE: The study goal was to demonstrate that blink reflex analysis can predict postoperative facial nerve outcome in cerebellopontine angle tumor surgery.

STUDY DESIGN, SETTING, AND PATIENTS: In an open and prospective study conducted at a single tertiary care center over 3 years, 91 subjects with a vestibular schwannoma filling the internal auditory meatus were enrolled and operated on via a translabyrinthine approach. The difference in latency of the early response (δR1) of the blink reflex between the pathologic side and the healthy side was calculated in every patient during a complete electrophysiologic examination of the facial nerve performed on the day before surgery.

MAIN OUTCOME MEASURES: δR1 was compared with the other preoperative data (tumor volume, facial function), with the perioperative observations (difficulties with the dissection of the facial nerve), and especially with the postoperative status after 1 year. The statistical study was conducted using polynomial regression.

RESULTS: Patients with a negative or zero δR1 have normal facial function at 1 year. For those with a positive δR1 the outcome is not favorable unless the tumor is small. For patients presenting with an immediate complete facial paralysis, the value of δR1 is also indicative of facial function outcome.

CONCLUSION: Statistical analysis shows that the blink reflex, through δR1, has an excellent prognostic value in anticipating the difficulties with facial nerve dissection and postoperative facial function after 1 year.

National Institute for Health and Clinical Excellence guidelines on preoperative tests: the use of routine preoperative tests for elective surgery

Clinical Guideline CG3 from the National Institute for Health and Clinical Excellence (NICE) makes recommendations on appropriate clinical practice in preoperative testing for elective surgery. Unfortunately, there is minimal evidence on which the guidelines could be based and therefore they were constructed on the basis of professional opinion. This resulted in the construction of a decision matrix of Byzantine complexity built on foundations of sand: surgical risk is estimated using an unvalidated ad hoc risk estimation method; anaesthetic risk is estimated using the American Society of Anesthesiologists (ASA) risk method that has been demonstrated to be incapable of generating consistent risk assessments. The resultant matrix may be suitable for use as a template for future research, but is extremely complex and inadequately rigorous for routine use.

Preoperative Optimization of Total Joint Arthroplasty Surgical Risk: Obesity

Obesity is a problem that is increasing in prevalence in the United States and in other countries, and it is a common comorbidity in patients seeking total joint arthroplasty for degenerative musculoskeletal diseases. Obesity, as well as commonly associated comorbidities such as diabetes mellitus, cardiovascular disease, and those contributing to the diagnosis of metabolic syndrome, have been shown to have detrimental effects on total joint arthroplasty outcomes. Although there are effective surgical and nonsurgical interventions which can result in weight loss in these patients, concomitant benefit on arthroplasty outcomes is not clear. Preoperative optimization of surgical risk in obese total joint arthroplasty patients is an important point of intervention to improve arthroplasty outcomes.

Two studies pave the way for preoperative therapy in pancreatic cancer patients

The delivery of chemotherapy and/or radiation in the preoperative setting (before surgical resection, instead of after it) has been hypothesized to improve both rates of margin-negative resection and survival.