Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data

Does the "Morning Morality Effect" Apply to Prehospital Anaesthesiologists? An Investigation into Diurnal Changes in Ethical Behaviour

The “morning morality effect”—the alleged phenomenon that people are more likely to act in unethical ways in the afternoon when they are tired and have less self-control than in the morning—may well be expected to influence prehospital anaesthesiologist manning mobile emergency care units (MECUs). The working conditions of these units routinely entail fatigue, hunger, sleep deprivation and other physical or emotional conditions that might make prehospital units predisposed to exhibit the “morning morality effect”. We investigated whether this is in fact the case by looking at the distribution of patient transports to hospital with and without physician escort late at night at the end of the shift as a surrogate marker for changing thresholds in ethical behaviour. All missions over a period of 11 years in the MECU in Odense were reviewed. Physician-escorted transports to hospital were compared with non-physician-escorted transports during daytime, evening, and night-time (which correlates with time on the 24 h shifts). In total, 26,883 patients were transported to hospital following treatment by the MECU. Of these, 27.4% (26.9%–27.9%) were escorted to the hospital. The ratio of patient transports to hospital with and without physician escort during the three periods of the day did not differ (p = 1.00). We found no evidence of changes in admission patterns over the day. Thus, no evidence of the expected “morning morality effect” could be found in a prehospital physician-manned emergency care unit.

After-hours elective spine deformity corrective surgery for patients with Adolescent Idiopathic Scoliosis: Is it safe?

OBJECTIVE

The aim of this study was to compare the outcome of after-hours electively planned Posterior Spinal Fusion surgeries for Adolescent Idiopathic Scoliosis (AIS) patients with daytime surgeries.

METHODS

This was a retrospective propensity score-matched study using prospectively collected data. Surgeries performed between 08:00 and 16:59 h were labeled as daytime surgeries (group 1) and surgeries performed between 17:00 and 06:00 h were labeled as after-hours surgeries (group 2). The perioperative outcome parameters were average operation time in and out, operation duration, intraoperative blood loss, blood transfusion, intraoperative hemodynamic parameters, preoperative hemoglobin, postoperative hemoglobin, and total patient-controlled anesthesia (PCA) morphine usage. Radiological variables assessed were Lenke subtypes, preoperative Cobb angle, number of fusion levels, number of screws used, postoperative Cobb angle, correction rate, side bending flexibility, side bending correction index, complications rate, and length of hospitalization.

RESULTS

Average operation time in for daytime group was 11:32 ± 2:33 h versus 18:20 ± 1:05 h in after-hours group. Comparing daytime surgeries with after-hours surgeries, there were no significant differences ( p > 0.05) in the operation duration, intraoperative blood loss, intraoperative pH, bicarbonate, lactate, postoperative hemoglobin, hemoglobin drift, blood transfusion, postoperative Cobb angle, correction rate, side bending flexibility, side bending correction index, length of hospitalization, and complications rate. Total PCA morphine usage was significantly lesser in the after-hours group (18.2 ± 15.3 mg) compared with the daytime group (24.6 ± 16.6 mg; p = 0.042).

CONCLUSIONS

After-hours elective spine deformity corrective surgeries for healthy ambulatory patients with AIS were as safe as when they were done during daytime.

Perioperative Outcome of Severe Idiopathic Scoliosis (Cobb Angle ≥ 90°): Is There Any Difference Between "Daytime" Versus "After-hours" Surgeries?

STUDY DESIGN

Retrospective study from a prospectively collected database.

OBJECTIVE

To compare the perioperative outcome between after-hours and daytime surgery carried out by a dedicated spinal deformity team for severe Idiopathic Scoliosis (IS) patients with Cobb angle ≥ 90°.

SUMMARY OF BACKGROUND DATA

There were concerns that after-hours corrective surgeries in severe IS have higher morbidity compared to daytime surgeries.

METHODS

Seventy-one severe IS patients who underwent single-staged Posterior Spinal Fusion (PSF) were included. Surgeries performed between 08:00H and 16:59H were classified as "daytime" group and surgeries performed between 17:00H and 06:00H were classified as "after-hours" group. Perioperative outcome parameters were average operation start time and end time, operation duration, intraoperative blood loss, intraoperative hemodynamic parameters, preoperative and postoperative hemoglobin, blood transfusion rate, total patient-controlled anesthesia (PCA) morphine usage, length of postoperative hospitalization, and complications. Radiological variables assessed were preoperative and postoperative Cobb angle, side bending flexibility, number of fusion levels, number of screws used, Correction Rate, and Side Bending Correction Index.

RESULTS

Thirty patients were operated during daytime and 41 patients were operated after-hours. The mean age was 16.1 ± 5.8 years old. The mean operation start time for daytime group was 11:31 ± 2:45H versus 19:10 ± 1:24H for after-hours group. There were no significant differences between both groups in the operation duration, intraoperative blood loss, intraoperative hemodynamic parameters, postoperative hemoglobin, hemoglobin drift, transfusion rate, length of postoperative hospitalization, postoperative Cobb angle, Correction Rate, and Side Bending Correction Index. There were four complications (1 SSEP loss, 1 massive blood loss, and 2 superficial wound infections) with no difference between daytime and after-hours group.

CONCLUSION

After-hours elective spine deformity corrective surgeries in healthy ambulatory patients with severe IS performed by a dedicated spinal deformity team using dual attending surgeon strategy were as safe as those performed during daytime.

LEVEL OF EVIDENCE

4.

Internal clock and the surgical ICU patient

PURPOSE OF REVIEW

The alteration of circadian rhythms in the postoperative period has been demonstrated to influence the outcomes. With this narrative review we would revise how anesthesia, surgery and intensive care can interfere with the circadian clock, how this could impact on the postsurgical period and how to limit the disruption of the internal clock.

RECENT FINDINGS

Anesthesia affects the clock in relation to the day-time administration and the type of anesthetics, N-methyl-D-aspartate receptor antagonists or gamma-aminobutyric acid receptors agonists. Surgery causes stress and trauma with consequent alteration in the circadian release of cortisol, cytokines and melatonin. ICU represents a further challenge for the patient internal clock because of sedation, immobility, mechanical ventilation and alarms noise.

SUMMARY

The synergic effect of anesthesia, surgery and postoperative intensive care on circadian rhythms require a careful approach to the patient considering a role for therapies and interventions aimed to re-establish the normal circadian rhythms. Over time, approach like the Awakening and Breathing Coordination, Delirium Monitoring and Management, Early Mobility and Family engagement and empowerment bundle can implement the clinical practice.

Risk Factors Related to Operative Duration and Their Relationship With Clinical Outcomes in Pediatric Patients Undergoing Roux-en-Y Hepaticojejunostomy

Background: Operative duration might be important for perioperative morbidity, and its involvement has not been fully characterized in pediatric patients. We identified perioperative variables associated with operative duration and determined their influence on clinical outcomes in pediatric patients. Methods: We retrospectively reviewed 701 patients who underwent elective removal of choledochal cysts followed by Roux-en-Y hepaticojejunostomy. The patients were separated into the long operative time group (>165 min) and short operative time group (<165 min) based on the median operative time (165 min). Propensity score matching was performed to adjust for any potential selection bias. The independent risk factors for operative time were determined using multivariable logistic regression analyses. Results: The operative time was often increased by excision difficulty caused by a larger choledochal cyst size (OR = 1.56; 95% CI, 1.09-2.23; p < 0.001), a greater BMI (OR = 1.02; 95% CI, 1.00-1.15; p = 0.018), and older age (OR = 1.17; 95% CI, 1.02-1.39; p = 0.012) in the multivariate analysis. A long surgical duration was associated with delayed gastrointestinal functional recovery, as measured using the time to first defecation (p = 0.027) and first bowel movement (p = 0.019). Significantly lower levels of serum albumin were found in the long operative time group than in the short operative time group (p = 0.0035). The total length of postoperative hospital stay was longer in patients in the long operative time group (7.51 ± 2.03 days) than in those in the short operative time group (6.72 ± 1.54 days, p = 0.006). Conclusions: Our data demonstrated that a short operative time was associated with favorable postoperative results. The influencing factors of operative time should be ameliorated to achieve better outcomes.

Back-to-Back Surgeries in AIS Patients Can be Performed Safely Without Compromising Radiographic or Perioperative Outcomes: A 10-year Review

STUDY DESIGN

A retrospective chart review of prospectively collected data.

OBJECTIVE

The aim of this study was to determine whether back-to-back scoliosis surgeries can be performed safely without compromising outcomes and the reproducibility of the practice between institutions.

SUMMARY OF BACKGROUND DATA

During the summer, spinal surgeons will often book multiple cases in one day. The complexity and demands of spinal fusion surgery call into question the safety. Change of operating room staff including anesthesiologists, nurses, and neurologists may introduce new risks.

METHODS

From 2009 to 2018, index AIS surgeries were included. In Groups 1, 2, and 3, surgeries were performed by a single surgeon. In Group 4, they were performed by other institutional surgeons. Group 1: first surgery of the day, Group 2: second surgery of the day, Group 3: only surgery of the day, Group 4: only surgery of the day by different institutional surgeon. Additional analysis was done to determine reproducibility after a surgeon was moved from Institution 1 to Institution 2.

RESULTS

Five hundred sixty-seven AIS patients were analyzed. Group 1 patients had similar radiographic outcomes compared with Group 2 (P > 0.05). Surgical time was similar (P = 0.51), but significantly more levels fused (P = 0.01). Compared with Group 3, Group 2 had a smaller preoperative Cobb (P = 0.02), shorter surgeries (P < 0.001), and length of stay (P = 0.04) but similar complication rate (P = 1). Compared with Group 4, Group 2 had smaller preoperative Cobb (P < 0.001), shorter surgery, and lower complication rate (P = 0.03). When determining reproducibility, institution 2 patients had significantly less blood loss, shorter surgeries, and shorter lengths of stay (P < 0.05).

CONCLUSION

Although long and involved, back-to-back AIS surgeries do not compromise radiographic or perioperative outcomes. Changes in operating team do not appear to impact safety, efficiency, or outcomes. This study also found that the practice is reproducible between institutions.

LEVEL OF EVIDENCE

3.

Effects of time of day on radiological interpretation

Accurate interpretation of radiological images involves a complex visual search that relies on several cognitive processes, including selective attention, working memory, and decision-making. Patient outcomes often depend on the accuracy of image interpretations, and yet research has revealed that conclusions vary significantly from one radiologist to another. A myriad of factors has been shown to contribute to the likelihood of interpretative errors and discrepancies, including the radiologist's level of experience and fatigue, and these factors are well reported elsewhere; however, a potentially important factor that has been given little previous consideration is how radiologists' interpretations might be impacted by the time of day at which the reading takes place, a factor that other disciplines have shown to be a determinant of competency. The available literature shows that while the time of day is known to significantly impact some cognitive functions that likely relate to reading competence, including selective visual attention and visual working memory, little is known about the impact of the time of day on radiology interpretation performance. This review explores the evidence regarding the relationship between time of day and performance, with a particular emphasis on radiological activities.

Case Start Time Affects Intraoperative Transfusion Rates in Adult Cardiac Surgery: A Single-Center Retrospective Analysis

OBJECTIVE

The goal of the study was to investigate the role time of day plays in perioperative outcomes. The authors examined intraoperative transfusion rates throughout the day in adult cardiac surgery patients. They hypothesized that the rate of transfusion changes with later case start times in scheduled cardiac surgery.

DESIGN

Retrospective observational study.

SETTING

Single academic medical center.

PARTICIPANTS

Adults undergoing cardiac surgery involving cardiopulmonary bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a composite variable of transfusion. The association between the time of day and the rate of transfusion was explored with a multivariate logistic regression to fit the effect of starting time as a cubic spline. There were 1,421 cases that met inclusion criteria. There were 1,220 cases that were matched for modeling. The estimated probability of a patient receiving a transfusion changed significantly with later case start times in the multivariable model after adjusting for initial hemoglobin, age, sex, height, ideal body weight, diabetes, peripheral vascular disease, stroke, chronic kidney disease, chronic obstructive pulmonary disease, duration of cardiopulmonary bypass, aortic cross clamp time, attending surgeon, and attending anesthesiologist (p = 0.032, C-statistic = 0.807, n = 1220). The estimated probability of receiving an intraoperative red blood cell transfusion increased with later case start times in the multivariable model (p = 0.027, C-statistic = 0.902, n = 1220). There was no difference in the probability of transfusion for plasma, cryoprecipitate, or platelets.

CONCLUSIONS

The observed rate of intraoperative blood product transfusion changed with later case start times in a multivariable model of scheduled cardiac surgery.

Revisit Rates for Pediatric Tonsillectomy: An Analysis of Admit and Discharge Times

Objective:

To determine the association between intraday timing of outpatient pediatric tonsillectomy and revisit outcomes and complications.

Study Design:

Cross-sectional analysis of New York databases.

Setting:

Ambulatory surgery, emergency department and inpatient hospital settings.

Subjects and Methods:

The State Ambulatory Surgery, State Emergency Department and State Inpatient Databases for 2010-2011 were analyzed for revisits. Outcomes assessed were revisits for any reason, bleeding, acute pain or fever, nausea, vomiting and dehydration. The relationships between the hour of admission for surgery, the hour of discharge and the revisit outcomes were analyzed.

Results:

The study included 33,611 children (mean age, 6.62 years; 45.7% female) and 62.0% were admitted in the early morning. Discharges were most common in the early afternoon (28.3%). Revisit rates were significantly higher for the early evening discharges (6.0%) versus late morning discharges (3.1%) ( P < .001). Revisits for bleeding were 1.8% for discharge in the early evening versus 0.6% in the late morning ( P < .001). Revisits for fever, nausea, vomiting or dehydration were 1.8% for discharge in the early evening versus 0.9% in the late morning ( P = .002). Late afternoon admission was significantly associated with higher revisit rates (10.9%, P < .001). Bleeding revisits were highest for late afternoon admit hour (1.5%, P = .001). Revisits for acute pain were also highest for late afternoon admit hour (2.3%, P = .005).

Conclusion:

Revisit are significantly higher when the patient is discharged late. Late afternoon surgery is also significantly associated with higher revisit rates. Surgeons may wish to consider these findings when a late tonsillectomy or late discharge is anticipated post-tonsillectomy.

Clinical outcomes of single-site laparoscopic interval appendectomy for severe complicated appendicitis: Comparison to conventional emergency appendectomy

AIM

Single-site laparoscopic interval appendectomy (SLIA) for severe complicated appendicitis after conservative treatment (CT) to ameliorate inflammation and eradicate the abscess should be safer and less invasive than emergency appendectomy (EA). However, only a few reports have been published regarding SLIA.

METHODS

We retrospectively collected data on 264 consecutive patients admitted to Kinan Hospital for treatment of appendicitis between 2012 and 2018. The safety and feasibility of SLIA and its perioperative outcomes for severe complicated appendicitis were investigated.

RESULTS

A total of 61 patients were included in this study, 25 of whom underwent CT and 36 EA. Among the 25 patients who underwent CT, 23 (92.0%) succeeded; a total of 16 patients (69.5%) underwent SLIA. Compared to the EA group, the SLIA group had less bleeding (median volume 8.5 vs 50 mL, P = .005) and lower rate of expansion surgery (0% vs 27.8%, P = .022). Although the postoperative hospital stay was shorter in the SLIA group than in the EA group (9 vs 12 days, P = .008), the total hospital stay, including the CT period, was longer in the SLIA group than in the EA group (24 vs 12 days, P < .001).

CONCLUSION

SLIA is safe, feasible, and less invasive than EA and may provide the advantages of minimally invasive surgery even if appendicitis is severe. SLIA may be a promising option for complicated appendicitis in select cases despite its disadvantage of prolonging the hospital stay.

Analysis of the Effects of Day-Time vs. Night-Time Surgery on Renal Transplant Patient Outcomes

Sleep deprivation and disruption of the circadian rhythms could impair individual surgical performance and decision making. For this purpose, this study identified potential confounding factors on surgical renal transplant patient outcomes during day and night. Our retrospective cohort study of 215 adult renal cadaver transplant recipients, of which 132 recipients were allocated in the “day-time” group and 83 recipients in the “night-time” group, primarily stratified the patients into two cohorts, depending on the start time. Within a 24 h operational system, “day-time” was considered as being from 8 a.m. to 8 p.m. and “night-time” from 8 p.m. to 8 a.m.. Primary outcomes examined patient and graft survival after three months and one year. Secondary outcomes included the presence of acute rejection (AR) and delayed graft function (DGF), as well as the rate of postoperative complications. In log-rank testing, “day-time” surgery was associated with a significantly higher risk of patient death (p = 0.003), whereas long-term graft survival was unaffected by the operative time of day. The mean cold ischemia time (CIT), which was 12.4 ± 5.3 h in the “night-time” group, was significantly longer compared to 10.7 ± 3.6 for those during the day (p = 0.01). We observed that “night-time” kidney recipients experienced more wound complications. From our single-centre data, we conclude that night-time kidney transplantation does not increase the risk of adverse events or predispose the patient to a worse outcome. Nevertheless, further research is required to explore the effect of fatigue on nocturnal surgical performance.

Longer Operating Time During Gastrectomy Has Adverse Effects on Short-Term Surgical Outcomes

BACKGROUND

Gastric cancer continues to be one of the malignant tumor types with high morbidity and mortality worldwide. Although remarkable improvements have been made to combat gastric cancer, surgery is still the first choice of treatment for gastric cancer.

METHODS

This was a single-center and retrospective study. A total of 110 patients who underwent radical gastrectomy with D2 lymph node dissection between 2014 and 2017 were included in this study, and all patients were treated by the same medical staff. Based on the median operating time, patients were grouped into a long-time group (>180 min) and a short-time group (≤180 min). Influences of operating time on outcomes of patients in the short-term and long-term groups were analyzed.

RESULTS

The long-time group showed a higher incidence of postoperative complications compared with the short time group (P < 0.01) with a significant decrease in serum albumin and the prognostic nutritional index value. Moreover, a long operating time was often caused by the operating start time (P < 0.001), excision difficulty caused by lager tumor size (P < 0.001), worse tumor differentiation, and deeper tumor invasion (P < 0.05). However, length of operating time did not significantly influence overall survival of patients who underwent radical gastrectomy.

CONCLUSIONS

The results suggested that operating time might be an indicator of the incidence of postoperative complication and that several important variables, such as prognostic nutritional index, serum albumin, operating start time, and excision time, could be intervened in the perioperative period to help patients gain a better outcome after gastrectomy.

Effects of surgery start time on postoperative cortisol, inflammatory cytokines, and postoperative hospital day in hip surgery: Randomized controlled trial

BACKGROUND

The aim of this study was to compare morning surgery (Group A), characterized by high cortisol levels, with afternoon surgery (Group B), characterized by low cortisol levels, with respect to cortisol, inflammatory cytokines (interleukin [IL]-6, IL-8), and postoperative hospital days (POHD) after hip surgery.

METHODS

The study was conducted in a single center, prospective, randomized (1:1) parallel group trial. Patients undergoing total hip replacement or hemiarthroplasty were randomly divided into two groups according to the surgery start time: 8 AM (Group A) or 1-2 PM (Group B). Cortisol and cytokine levels were measured at 7:30 AM on the day of surgery, before induction of anesthesia, and at 6, 12, 24, and 48 hours (h) after surgery. Visual analogue scale (VAS) and POHD were used to evaluate the clinical effect of surgery start time. VAS was measured at 6, 12, 24, and 48 h postoperatively, and POHD was measured at discharge.

RESULTS

In total, 44 patients completed the trial. The postoperative cortisol level was significantly different between the two groups. (24 h, P < .001; 48 h, P < .001). The percentage of patients whose level returned to the initial level was higher in Group B than in Group A (P < .001). Significant differences in IL-6 levels were observed between the two groups at 12, 24, and 48 h after surgery (P = .015; P = .005; P = .002), and in IL-8 levels at 12 and 24 h after surgery (P = .002, P < .001). There was no significant difference between the two groups in VAS and POHD. However, only three patients in Group A were inpatients for more than 3 weeks (P = .233).

CONCLUSIONS

Afternoon surgery allowed for more rapid recovery of cortisol to the baseline level than morning surgery, and IL-6 and IL-8 were lower at 1-2 days postoperatively. The results of this study suggest that afternoon surgery may be considered in patients with postoperative delayed wound healing or inflammation because of the difference in cortisol, IL-6 and 8 in according to surgery start time.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03076827 (ClinicalTRrial.gov).

Organ procurement center allows for daytime liver transplantation with less resource utilization: May address burnout, pipeline, and safety for field of transplantation

Abdominal organ transplantation faces several challenges: burnout, limited pipeline of future surgeons, changes in liver allocation potentially impacting organ procurement travel, and travel safety. The organ procurement center (OPC) model may be one way to mitigate these issues. Liver transplants from 2009 to 2016 were reviewed. There were 755 liver transplants performed with 525 OPC and 230 in-hospital procurements. The majority of transplants (87.4%) were started during daytime hours (5 am-7 pm). Transplants with any portion occurring after-hours were more likely to have procurements in-hospital (P < .001). Daytime cases (n = 400) had more OPC procured livers and hepatitis C recipients and were less likely to have a donation after circulatory death donor (all P < .05). In adjusted analyses, daytime cases were independently associated with extubation in the operating room and less postoperative transfusion. There were no significant differences in short- or long-term postoperative outcomes. For exported livers, 54.3% were procured by a local team, saving 137 flights (151 559 miles). The OPC resulted in optimally timed liver transplants and decreased resource utilization with no negative impact on patient outcomes. It allows for ease in exporting organs procured by local surgeons, and potentially addresses provider burnout, the transplant surgery pipeline, and surgeon travel.

Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis

Background

The traditional fear that every case of acute appendicitis will eventually perforate has led to the generally accepted emergency appendicectomy with minimized delay. However, emergency and thereby sometimes night‐time surgery is associated with several drawbacks, whereas the consequences of surgery after limited delay are unclear. This systematic review aimed to assess in‐hospital delay before surgery as risk factor for complicated appendicitis and postoperative morbidity in patients with acute appendicitis.

Methods

PubMed and EMBASE were searched from 1990 to 2016 for studies including patients who underwent appendicectomy for acute appendicitis, reported in two or more predefined time intervals. The primary outcome measure was complicated appendicitis after surgery (perforated or gangrenous appendicitis); other outcomes were postoperative surgical‐site infection and morbidity. Adjusted odds ratios (ORs) were pooled using forest plots if possible. Unadjusted data were pooled using generalized linear mixed models.

Results

Forty‐five studies with 152 314 patients were included. Pooled adjusted ORs revealed no significantly higher risk for complicated appendicitis when appendicectomy was delayed for 7–12 or 13–24 h (OR 1·07, 95 per cent c.i. 0·98 to 1·17, and OR 1·09, 0·95 to 1·24, respectively). Meta‐analysis of unadjusted data supported these findings by yielding no increased risk for complicated appendicitis or postoperative complications with a delay of 24–48 h.

Conclusion

This meta‐analysis demonstrates that delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical‐site infection or morbidity. Delaying appendicectomy for up to 24 h may be an acceptable alternative for patients with no preoperative signs of complicated appendicitis.

Delay is safe

Risk Factors for Nerve Injury After Total Hip Arthroplasty: A Case-Control Study

BACKGROUND

Postsurgical acute nerve injury is rare but potentially devastating following total hip arthroplasty (THA). Previous literature suggests a wide range of incidence from 0.1% to 7.6%. Confirmed risk factors for these injuries remain unclear.

METHODS

THA patients at our institution who developed nerve injury during their admission for THA between January 1, 1998, and December 31, 2013, were systematically identified and matched with 2 control subjects by surgical date. Relevant patient and surgical data were obtained through review of patient charts and electronic health records. We identified potential risk factors and calculated odds ratios (OR) using a conditional logistic regression model with a parsimonious stepwise approach.

RESULTS

We identified 93 nerve injuries in 43,761 THAs (0.21%). The mean age of cases was 63 years. Adjusting for other factors in the model, patients <45 years were found to be at increased risk of developing nerve injury (OR, 7.17; P = .033). Similarly, patients with a history of tobacco use (OR, 1.90; P = .030) and a history of spinal surgery or disease (OR, 10.06; P < .001) were also associated with increased risk of nerve injury. For every 30-minute increase in surgery time after 1 hour, risk of nerve injury risk increased (OR, 1.48; P = .034). Assignment as first operative case of the morning was associated with a decreased risk of nerve injury (OR, 0.37, P = .043).

CONCLUSION

This study demonstrates that nerve injury is a rare complication following THA at our institution. We found risk factors that are possibly modifiable factors such as lumbar spine disease, smoking, and time of surgical scheduling.

Surgical timing and presence of a vitreoretinal fellow on postoperative adverse events following pars plana vitrectomy

INTRODUCTION

To evaluate the adverse event rate following pars plana vitrectomy as a function of surgical start time and the presence of a vitreoretinal fellow.

METHODS

Single-institution retrospective cohort study of patients undergoing pars plana vitrectomy from 1 January 2016 to 31 December 2016 at Stanford University School of Medicine (Palo Alto, CA, USA). Records were reviewed for surgical start time, the presence of vitreoretinal fellow, and postoperative adverse events defined as any finding deviating from the expected postoperative course requiring observation or intervention.

RESULTS

A total of 310 pars plana vitrectomies were performed. There was no statistical difference in the rate of any adverse event when comparing cases starting after 16:01 (9/13, 69.2%) and after 12:01 (42/99, 42.4%) to a morning start time (69/198, 34.9%, adjusted p = 0.083). There was a statistically significant increase in the risk of postoperative vitreous hemorrhage with afternoon and evening cases as compared to morning cases (adjusted p = 0.021). In addition, there was no difference in any adverse event with a fellow present (93/244, 38.1%) compared to without (27/66, 40.9%, adjusted p = 0.163). There was a higher risk of postoperative hypotony when a fellow was involved (6.6% vs 0%, p = 0.028), though this difference disappeared after adjusting for confounders (adjusted p = 0.252). There was no difference in the length of surgery with and without a fellow (49 vs 54 min, respectively; p = 0.990).

DISCUSSION

Afternoon start time and the presence of a fellow were not independent risk factors for postoperative adverse events.

Analysis of hospital infection register indicates that the implementation of WHO surgical safety checklist has an impact on early postoperative neurosurgical infections

WHO surgical safety checklist has been proven to reduce postoperative infections in several studies. The aim of our study was to focus on surgical site infections (SSIs) after neurosurgical operations, and to determine whether the checklist implementation would have an impact on the reported SSIs. We used hospital-acquired infection (HAI) register to evaluate the effects of WHO surgical safety checklist in neurosurgery. The HAI register was searched for superficial and deep SSIs, deep organ SSIs, infections following orthopaedic implantation, and other surgical infections of 4678 neurosurgical patients operated on between 2007 and 2011. The data analysis consisted of 95 and 104 neurosurgical postoperative infections before and after the checklist implementation. Time from operation to infection was shorter before than after checklist implementation (p = 0.039), indicating a positive effect of the checklist use in the onset of early HAIs. The overall incidence of SSIs of all neurosurgical patients did not differ (4.1% and 4.5%, respectively) and no differences were noticed in the incidences of the subgroups of superficial SSIs, deep SSIs, and deep organ SSIs. The reduction in early postoperative infection rate along with checklist implementation, but not in the long run indicates the complexity of preventing HAIs in neurosurgical patients and need for a multistep infection control approach.

Outcome of transplantation performed outside the regular working hours: A systematic review and meta-analysis of the literature

Transplant procedures are frequently performed outside the regular working hours (after hours). In general surgery, several studies observed worse outcomes for operations performed after hours. The predetermined hypothesis was that patients undergoing transplantation during after hours might suffer from an excess in post-operative mortality and morbidity when compared to patients undergoing transplantations during the regular working hours. A systematic review of the PubMed database identified 11,993 records, of which eleven cohort studies including a total of 287,741 patients investigated the association between the starting time of transplant surgery and postoperative mortality (primary outcome) and/or morbidity (secondary outcome). Eight studies evaluated kidney transplants (in 165,277 patients), two studies analyzed liver transplants (in 95,346 patients), and one study investigated transplantations of thoracic organs (in 27,118 patients). Results were conflicting with two studies (in liver and lung transplantation) showing an increased mortality for transplantations performed after hours, and five studies showing no effects on mortality. A meta-analysis on estimates from four studies yielded a hazard ratio of 1.01 (95% CI, 0.98 to 1.04) for mortality comparing transplantations performed during versus outside the regular working hours. The evidence was also inconclusive for a variety of morbidity outcomes with studies demonstrating either a deterioration of outcome, no effect or an improved outcome for after hours procedures. On the basis of the available evidence, it appears impossible to give an unequivocal recommendation regarding starting times in transplant surgery.

Twenty-four-hour emergency intervention versus early intervention in aneurysmal subarachnoid hemorrhage

OBJECTIVE Recent observational data suggest that ultra-early treatment of ruptured aneurysms prevents rebleeding, thus improving clinical outcomes. However, advances in critical care management of patients with ruptured aneurysms may reduce the rate of rebleeding in comparison with earlier trials, such as the International Cooperative Study on the Timing of Aneurysm Surgery. The objective of the present study was to determine if an ultra-early aneurysm repair protocol will or will not significantly reduce the number of incidents of rebleeding following aneurysmal subarachnoid hemorrhage (SAH). METHODS A retrospective analysis of data from a prospectively collected cohort of patients with SAH was performed. Rebleeding was diagnosed as new or expanded hemorrhage on CT, which was determined by independent review conducted by multiple physicians. Preventability of rebleeding by ultra-early aneurysm clipping or coiling was also independently reviewed. Standard statistics were used to determine statistically significant differences between the demographic characteristics of those with rebleeding compared with those without. RESULTS Of 317 patients with aneurysmal SAH, 24 (7.6%, 95% CI 4.7-10.5) experienced rebleeding at any time point following initial aneurysm rupture. Only 1/24 (4.2%, 95% CI -3.8 to 12.2) incidents of rebleeding could have been prevented by a 24-hour ultra-early aneurysm repair protocol. The other 23 incidents could not have been prevented for the following reasons: rebleeding prior to admission to the authors' institution (14/23, 60.9%); initial diagnostic angiography negative for aneurysm (4/23, 17.4%); postoperative rebleeding (2/23, 8.7%); patient unable to undergo operation due to medical instability (2/23, 8.7%); intraoperative rebleeding (1/23, 4.3%). CONCLUSIONS At a single tertiary academic center, the overall rebleeding rate was 7.6% (95% CI 4.7-10.5) for those presenting with ruptured aneurysms. Implementation of a 24-hour ultra-early aneurysm repair protocol would only result in, at most, a 0.3% (95% CI -0.3 to 0.9) reduction in the incidence of rebleeding.

Impact of surgical case order on peri-operative outcomes for total joint arthroplasty

INTRODUCTION

There is growing support in the literatures that peri-operative outcomes are adversely affected by surgical case order in some certain surgical procedures. This study aimed to examine if similar phenomenon is also shared in total joint arthroplasty (TJA).

METHODS

A total of 6548 joints (5183 patients) treated with primary TJA by a total of five surgeons at our institution from December 2011 to December 2015 were retrospectively reviewed in this study. Demographic data, operative duration, blood loss, peri-operative adverse events, medical cost, and length of hospital stay were collected and analyzed. Logistic regression was used to determine risk factors for adverse events.

RESULTS

Of the 6548 cases in this cohort, 1643 TJAs were classified as first round cases, 1744 TJAs were second round cases, 1600 TJAs were third round cases, and 1561 TJAs were fourth or later round cases. Mean operating time was shorter in the intermediate cases (45.0 vs. 41.0 vs. 41.8 vs. 54.1 min, P < 0.01). Peri-operative arthroplastic adverse events were increased in later surgical cases (2.07% vs. 2.18% vs. 3.06% vs. 4.87%, P < 0.01). Later case order (OR = 1.40 [95% CI: 1.22-1.61], P < 0.01) was a significant risk factor of arthroplastic adverse events. Patients undergoing TJA later in the day were more likely to have longer length of stay and higher cost than earlier cases. Peri-operative systemic complications and blood loss did not significantly differ between groups.

CONCLUSION

Surgical case order is an independent risk factor for arthroplastic adverse events in TJA. TJA procedures performed later in the day have a higher risk for arthroplastic adverse events, but not for systematic adverse events. Significantly increased operative time, higher cost, and longer LOS were noted for fourth or later TJA cases. Data in our study reveals that performing more than three TJAs within a single day may imply compromised outcomes.

Operating at night does not increase the risk of intraoperative adverse events

BACKGROUND

We sought to investigate the association between nighttime (NT) operating and the occurrence of intraoperative adverse events (iAEs).

STUDY DESIGN

Our 2007-2012 institutional ACS-NSQIP and administrative databases were screened for iAEs using the ICD-9-CM-based Patient Safety Indicator "accidental puncture or laceration". Procedures were defined as AM (06.00-14.00 h), PM (14.00-22.00 h), or NT (22.00-06.00 h). Univariate and multivariable analyses were performed to investigate the association between PM and NT operating and the occurrence of iAEs.

RESULTS

9136 surgical procedures were included: 7445 AM, 1303 PM, 388 NT. iAEs occurred in 183 procedures. NT patients were younger and less comorbid, but sicker, and with less complex surgeries. There was no correlation between PM or NT operations and iAEs (multivariable analysis [reference: AM operations]: OR = 0.66 [95% CI = 0.40-1.12], P = 0.123; OR = 1.22 [95% CI = 0.51-2.93], P = 0.659, respectively).

CONCLUSION

Operating at night does increase the risk of iAEs.

Laparoscopic appendectomy for acute appendicitis: How to discourage surgeons using inadequate therapy

Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 wk after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient’s factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients. The surgeon’s skill and cooperation of the hospital are important for successful LA. Delaying appendectomy for less than 24 h from diagnosis is safe. Additionally, a semi-elective manner (i.e., LA within 24 h after onset of symptoms) may be paradoxically acceptable, according to the factors of the patient, physician, and institution. Prompt LA is mandatory for AA. Fortunately, the Japanese government uses a universal health insurance system, which covers LA.

Day of Surgery and Surgical Start Time Affect Hospital Length of Stay After Total Hip Arthroplasty

BACKGROUND

The United States spends $12 billion each year on ∼332,000 total hip arthroplasty (THA) procedures with the postoperative period accounting for ∼40% of costs. The purpose of this study was to evaluate the effect of surgical scheduling (day of week and start time) on clinical outcomes, hospital length of stay (LOS), and rate of nonhome discharge in THA patients.

METHODS

Analysis of perioperative variables was performed for patients who underwent THA at an urban tertiary care teaching hospital from 2009 to 2014.

RESULTS

A total of 580 THA patients were included for analysis. LOS was higher for the Thursday/Friday cohort compared to Monday/Tuesday (3.7 vs 3.4 days; P = .03). Patients who had a surgical start time after 2 PM had longer LOS compared to patients operated on before 2 PM (3.9 vs 3.5 days; P = .03). After controlling for patient comorbidities and THA surgical approach (direct anterior vs posterior), Thursday/Friday THAs were associated with a 3.27 times risk of extended LOS (>75th percentile LOS) compared to Monday/Tuesday THAs (P < .001). Additionally, case start before 2 PM was protective and associated with a 0.46 times odds of extended LOS (P = .01). LOS reduction opportunity for changing surgical start time to before 2 PM was 0.9 days for high-risk patients (American Society of Anesthesiology class 3/4 and/or liver disease) and 0.2 days for low-risk patients (American Society of Anesthesiology class 1/2).

CONCLUSION

Patients who underwent THA Thursday/Friday or had start times after 2 PM had significantly extended hospital LOS. Preoperative risk modification along with adjustments to surgical scheduling and/or perioperative staffing may reduce LOS and thus hospital expenditures for THA procedures.

Effect of timing of cannulation on outcome for pediatric extracorporeal life support

PURPOSE

Literature reports worse outcomes for operations performed during off-hours. As this has not been studied in pediatric extracorporeal life support (ECLS), we compared complications based on the timing of cannulation..

METHODS

This is a retrospective review of 176 pediatric ECLS patients between 2004 and 2015. Patients cannulated during daytime hours (7:00 A.M. to 7:00 P.M., M-F) were compared to off-hours (nighttime or weekend) using t-test and Chi-square.

RESULTS

The most common indications for ECLS were congenital diaphragmatic hernia (33 %) and persistent pulmonary hypertension (23 %). When comparing regular hours (40 %) to off-hours cannulation (60 %), there were no significant differences in central nervous system complications, hemorrhage (extra-cranial), cannula repositioning, conversion from venovenous to venoarterial, mortality on ECLS, or survival-to-discharge. The overall complication rate was slightly lower in the off-hours group (45.7 % versus 61.9 %, P = 0.034).

CONCLUSION

Outcomes were not significantly worse for patients undergoing ELCS cannulation during off-hours compared to normal weekday working hours.

Impact of day of week on outcomes of endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

Outcomes for some surgical procedures are discrepantly affected by the day of the week when surgery is performed. It remains unknown whether this finding is applicable to endoscopic sinus surgery (ESS).

METHODS

A retrospective analysis of a cohort from a prospective observational study of patients undergoing ESS for chronic rhinosinusitis. Primary outcome measures included major postoperative complications (epistaxis that required physician intervention, orbital injury, and cerebrospinal fluid leak) as well as Sinonasal Outcomes Test 22 (SNOT-22) and Chronic Sinusitis Survey (CSS) quality-of-life symptom scores at 3 months, 1 year, and 2 years. Associations between the day of the week when ESS was performed and outcome measures were performed when controlling for patients' clinical and demographic characteristics.

RESULTS

The study population consisted of 544 patients with a 30-day major postoperative complications rate of 1.2%. There was no predilection for ESS complications by the day of the week. In comparison with ESS on a Monday, improvement in the SNOT-22 score was no different than with ESS performed on Tuesday (p = 0.800 at 3 months, p = 0.149 at 12 months, p = 0.123 at 24 months), Wednesday (p = 0.533 at 3 months, p = 0.708 at 12 months, p = 0.107 at 24 months), and Thursday (p = 0.965 at 3 months, p = 0.959 at 12 months, p = 0.501 at 24 months). No surgeries were performed on Friday. Similar results were found for improvement in CSS scores.

CONCLUSION

The day of the week on which ESS was performed did not impact surgical outcomes. These results provided novel insights, which may be useful for preoperative discussions with patients and scheduling of ESS.

Operative Start Time Does Not Affect Post-Operative Infection Risk

BACKGROUND

Surgical care is delivered 24 h a day at most institutions. Alarmingly, some authors have found that certain operative start times are associated with greater morbidity and mortality rates. This effect has been noted in both the public and private sector. Although some of these differences may be related to process, they may also be caused by the human circadian rhythm and corresponding changes in host defenses. We hypothesized that the time of day of an operation would impact the frequency of certain post-operative outcomes significantly.

METHODS

Cases at a single tertiary-care center reported to the American College of Surgeons National Surgical Quality Improvement Program over a 10-year period were identified. Operative start times were divided into six-hour blocks, with 6 am to noon serving as the reference. Standard univariable techniques were applied. Multivariable logistic regression with mixed effects modeling then was used to determine the relation between operative start times and infectious outcomes, controlling for surgeon clustering. Statistical significance was set at p < 0.01.

RESULTS

A total of 21,985 cases were identified, of which 2,764 (12.6%) were emergency procedures. Overall, 9.7% (n = 2,142) of patients experienced some post-operative infectious complication. Seventy percent of these infections (n = 1,506) were surgical site infections. On univariable analysis considering all cases, nighttime and evening operations had higher rates of post-operative infections than those in performed during the day (9.1% from 6 am to noon; 9.7% from noon to 6 pm; 14.8% from 6 pm to midnight; and 14.4% from midnight to 6 am; p < 0.001). On multivariable analysis, operative start time was not associated with the risk of post-operative infection, even when emergency cases were considered independently.

CONCLUSION

Our data suggest that operative start times have no correlation with post-operative infectious complications. Further work is required to identify the source of the time-dependent outcome variability observed in previous studies.

Night Shift Fatigue among Anaesthesia Trainees at a Major Metropolitan Teaching Hospital

Night shifts expose anaesthesia trainees to the risk of fatigue and, potentially, fatigue-related performance impairment. This study examined the workload, fatigue and coping strategies of anaesthesia trainees during night shifts. A blinded survey-based study was undertaken at a major single centre metropolitan teaching hospital in Australia. All ten anaesthesia trainees who worked night shifts participated. The survey collected data on duration of night shifts, workload, and sleep patterns. Fatigue was assessed using the Karolinska Sleepiness Scale (KSS). There were 93 night shifts generating data out of a potential 165. Trainees tended to sleep an increasing amount before their shift as the nights progressed from 1 to 5. Night 1 was identified as an ‘at risk’ night due to the amount of time spent awake before arriving at work (32% awake for >8 hours); on all other nights trainees were most likely to have slept 6–8 hours. The KSS demonstrated an increase in sleepiness of 3 to 4 points on the scale from commencement to conclusion of a night shift. The Night 1 conclusion sleepiness was markedly worse than any other night with 42% falling into an ‘at-risk’ category. The findings demonstrate fatigue and inadequate sleep in anaesthesia trainees during night shifts in a major metropolitan teaching hospital. The data obtained may help administrators prepare safer rosters, and junior staff develop improved strategies to reduce the likelihood of fatigue.

Impact of operation timing on post-operative infections following colorectal cancer surgery

BACKGROUND

To investigate the impact of operation timing on post-operative infections in a cohort of patients undergoing colorectal cancer surgery.

METHODS

We prospectively analysed surgical outcomes in patients who underwent colorectal cancer surgery at the First Affiliated Hospital, College of Medicine, Zhejiang University, from January to December in 2014. In this non-randomized trial, patients were divided into three groups according to the surgery start time: CT1 (07:00 to 12:00 h), CT2 (12:01 to 18:00 h), and CT3 (18:01 h to midnight). The primary outcome was the proportion of patients developing infections within 4 weeks of the surgical procedure.

RESULTS

Out of 756 patients that were enrolled in the study, 118 developed post-operative infections. The results from blood and pus culture showed 97.1% specimen as being pathogen-free. The overall incidence of post-operative infection was 14.5% (38 of 262), 15.3% (46 of 300) and 17.5% (34 of 194) in the CT1, CT2 and CT3 group, respectively, with no significant inter-group differences. However, white blood cell counts, C-reactive protein and glucose levels at 24 h after the surgical procedure showed significant differences between the three groups (one-way ANOVA, P < 0.05).

CONCLUSION

The occurrence of post-operative infection in patients undergoing colorectal cancer surgery was not associated with operation timing. The expression of several inflammatory markers, such as white blood cell counts, C-reactive protein and blood glucose levels tended to correlate with the surgery start time.

The long-term outcome after treatment for patients with tibial fracture treated with intramedullary nailing is not influenced by time of day of surgery and surgeon experience

INTRODUCTION

The objective of the present study was to evaluate the relationship between clinical outcome and time of day of surgery and experience level of the surgeon. Secondly, we examined the relationship between the length of hospital stay and the time of day of surgery.

METHODS

This retrospective cross-sectional cohort design study included patients treated with intramedullary nailing at Aalborg University Hospital from 1998 to 2008 after tibial shaft fractures (N = 294). At follow-up, the participants completed the Knee Injury and Osteoarthritis Outcome Score (KOOS). Age, sex, complications, length of hospital stay, start time of surgery, and education level of surgeons were recorded.

RESULTS

The long-term analysis of the KOOS assessment shows no significant association between time of day of surgery and the level of surgeon experience. There was no difference in complication rates between time of day of surgery and the level of surgeon experience. The secondary outcome analysis showed an estimated increased risk of 25 % (p = 0.001), for a longer length of hospital stay when operated by a trainee at night-hours compared to day-hours, and an estimated increased risk of 17 % (p = 0.002) for longer length of stay, when operated at day-hours by a trauma surgeon compared to a trainee.

CONCLUSION

Complication rates and KOOS outcome after surgery with intramedullary nailing were not influenced by time of day of surgery and experience level of the surgeon. The lengths of hospital stay increase significantly when surgery is performed at night by trainee surgeons, but not when performed by trauma surgeons.

Perioperative Mortality, 2010 to 2014

Background

The National Anesthesia Clinical Outcomes Registry collects demographic and outcome data from anesthesia cases, with the goal of improving safety and quality across the specialty. The authors present a preliminary analysis of the National Anesthesia Clinical Outcomes Registry database focusing on the rates of and associations with perioperative mortality (within 48 h of anesthesia induction).

Methods

The authors retrospectively analyzed 2,948,842 cases performed between January 1, 2010, and May 31, 2014. Cases without procedure information and vaginal deliveries were excluded. Mortality and other outcomes were reported by the anesthesia provider. Hierarchical logistic regression was performed on cases with complete information for patient age group, sex, American Society of Anesthesiologists physical status, emergency case status, time of day, and surgery type, controlling for random effects within anesthesia practices.

Results

The final analysis included 2,866,141 cases and 944 deaths (crude mortality rate, 33 per 100,000). Increasing American Society of Anesthesiologists physical status, emergency case status, cases beginning between 4:00 pm and 6:59 am, and patient age less than 1 yr or greater than or equal to 65 yr were independently associated with higher perioperative mortality. A post hoc subgroup analysis of 279,154 patients limited to 22 elective case types, post hoc models incorporating either more granular estimate of surgical risk or work relative value units, and a post hoc propensity score–matched cohort confirmed the association with time of day.

Conclusions

Several factors were associated with increased perioperative mortality. A case start time after 4:00 pm was associated with an adjusted odds ratio of 1.64 (95% CI, 1.22 to 2.21) for perioperative death, which suggests a potentially modifiable target for perioperative risk reduction. Limitations of this study include nonstandardized mortality reporting and limited ability to adjust for missing data.

Outcomes variability in non-emergent esophageal foreign body removal: Is daytime removal better?

OBJECTIVE

The objective of this study is to investigate differences between esophageal foreign body removal performed during standard operating room hours and those performed after-hours in asymptomatic patients.

METHODS

A retrospective chart review at a tertiary children's hospital identified 264 cases of patients with non-emergent esophageal foreign bodies between 2006 and 2011. Variables pertaining to procedure and recovery times, hospital charges, complications, length of stay, American Society of Anesthesiology (ASA) classification, and presence of mucosal injury were summarized and compared between cases performed during standard operating hours and those performed after-hours.

RESULTS

Cases performed during standard hours had significantly longer average wait times compared with after-hours cases (13.1h versus 9.0h, p<0.001). No other clinical characteristics or outcomes were significantly different between groups. Longer wait times are not associated with mucosal injury or postoperative complications.

CONCLUSION

There were no significant differences in procedure time, charges, or safety in after-hours removal of non-emergent esophageal foreign bodies compared to removal during standard operating hours. OR wait time was about 4h longer during standard hours compared with after-hours. This study could not assess the factors to determine the impact in differences in hospital resource utilization or work force, which may be significant between these two groups.

Nighttime kidney transplantation is associated with less pure technical graft failure

Purpose

To minimize cold ischemia time, transplantations with kidneys from deceased donors are frequently performed during the night. However, sleep deprivation of those who perform the transplantation may have adverse effects on cognitive and psychomotor performance and may cause reduced cognitive flexibility. We hypothesize that renal transplantations performed during the night are associated with an increased incidence of pure technical graft failure.

Methods

A retrospective analysis of data of the Dutch Organ Transplant Registry concerning all transplants from deceased donors between 2000 and 2013 was performed. Nighttime surgery was defined as the start of the procedure between 8 p.m. and 8 a.m. The primary outcome measure was technical graft failure, defined as graft loss within 10 days after surgery without signs of (hyper)acute rejection.

Results

Of 4.519 renal transplantations in adult recipients, 1.480 were performed during the night. The incidence of pure technical graft failure was 1.0 % for procedures started during the night versus 2.6 % for daytime surgery (p = .001). In a multivariable model, correcting for relevant donor, recipient and graft factors, daytime surgery was an independent predictor of pure technical graft failure (p < .001).

Conclusions

Limitation of this study is mainly to its retrospective design, and the influence of some relevant variables, such as the experience level of the surgeon, could not be assessed. We conclude that nighttime surgery is associated with less pure technical graft failures. Further research is required to explore factors that may positively influence the performance of the surgical team during the night.

Displaced supracondylar humeral fractures: influence of delay of surgery on the incidence of open reduction, complications and outcome

BACKGROUND

Closed reduction and pinning is the accepted treatment choice for dislocated supracondylar humeral fractures in children (SCHF). Rates of open reduction, complications and outcome are reported to be dependent on delay of surgery. We investigated whether delay of surgery had influence on the incidence of open reduction, complications and outcome of surgical treatment of SCHFs in the authors' institution.

METHODS

Three hundred and forty-one children with 343 supracondylar humeral fractures (Gartland II: 144; Gartland III: 199) who underwent surgery between 2000 and 2009 were retrospectively analysed. The group consisted of 194 males and 149 females. The average age was 6.3 years. Mean follow-up was 6.2 months. Time interval between trauma and surgical intervention was determined using our institutional database. Clinical and radiographical data were collected for each group. Influence of delay of treatment on rates of open reduction, complications and outcome was calculated using logistic regression analysis. Furthermore, patients were grouped into 4 groups of delay (<6 h, n = 166; 6-12 h, n = 95; 12-24 h, n = 68; >24 h, n = 14) and the aforementioned variables were compared among these groups.

RESULTS

The incidence of open procedures in 343 supracondylar humeral fractures was 2.6 %. Complication rates were similar to the literature (10.8 %) primarily consisting of transient neurological impairments (9.0 %) which all were fully reversible by conservative treatment. Poor outcome was seen in 1.7 % of the patients. Delay of surgical treatment had no influence on rates of open surgery (p = 0.662), complications (p = 0.365) or poor outcome (p = 0.942).

CONCLUSIONS

In this retrospective study delay of treatment of SCHF did not have significant influence on the incidence of open reduction, complications, and outcome. Therefore, in SCHF with sufficient blood perfusion and nerve function, elective treatment is reasonable to avoid surgical interventions in the middle of the night which are stressful and wearing both for patients and for surgeons.

LEVEL OF EVIDENCE

III (retrospective comparative study).