Preventing postoperative complications in the elderly

Do we need a re-TUR after en bloc resection of T1 stage bladder cancer?

BACKGROUND

A second look trans-urethral resection of the bladder (re-TUR) is recommended after the diagnosis of T1 high grade (T1HG) bladder cancer. Few studies have evaluated the results of re-TUR after a first en bloc resection (EBR) and none of them have specifically reported the pathological results on the field of previous T1 disease.

OBJECTIVE

To report the rate of upstaging and the rate of residual disease (RD) on the field of T1HG lesions resected with EBR.

MATERIALS AND METHODS

Between 01/2014 and 06/2022, patients from 2 centers who had a re-TUR after an EBR for T1HG urothelial carcinoma were retrospectively included. Primary endpoint was the rate of RD including the rate of upstaging to T2 disease on the scar of the primary resection. Secondary endpoints were the rate of any residual disease outside the field.

RESULTS

Seventy-five patients were included. No muscle invasive bladder cancer lesions were found after re-TUR. Among the 16 patients who had a RD, 4 were on the resection scar. All of these lesions were papillary and high grade. RD outside the field of the first EBR was observed in 12 patients.

CONCLUSION

After EBR of T1HG disease, none of our patients had an upstaging to MIBC. However, the rate of RD either on and outside the field of the EBR remains quite significant. We suggested that predictive factors of residual papillary disease (number of tumors at the initial TUR and concomitant CIS) might be suitable to select patient who will benefit of the re-TUR.

Primary Care Use and 90-Day Mortality Among Older Adults Undergoing Cancer Surgery

Importance

Multimorbidity and postoperative clinical decompensation are common among older surgical patients with cancer, highlighting the importance of primary care to optimize survival. Little is known about the association between primary care use and survivorship among older adults (aged ≥65 years) undergoing cancer surgery.

Objective

To examine primary care use among older surgical patients with cancer and its association with mortality.

Design, Setting, and Participants

In this retrospective cohort study, data were abstracted from the electronic health record of a single health care system for older adults undergoing cancer surgery between January 1, 2017, and December 31, 2019. There were 3 tiers of stratification: (1) patients who had a primary care practitioner (PCP) (physician, nurse practitioner, or physician assistant) vs no PCP, (2) those who had a PCP and underwent surgery in the same health system (unfragmented care) vs not (fragmented care), and (3) those who had a primary care visit within 90 postoperative days vs not. Data were analyzed between August 2023 and January 2024.

Exposure

Primary care use after surgery for colorectal, head and neck, prostate, ovarian, pancreatic, breast, liver, renal cell, non-small cell lung, endometrial, gastric, or esophageal cancer.

Main Outcomes and Measures

Postoperative 90-day mortality was analyzed using inverse propensity weighted Kaplan-Meier curves, with log-rank tests adjusted for propensity scores.

Results

The study included 2566 older adults (mean [SEM] age, 72.9 [0.1] years; 1321 men [51.5%]). Although 2404 patients (93.7%) had health insurance coverage, 743 (28.9%) had no PCP at the time of surgery. Compared with the PCP group, the no-PCP group had a higher 90-day postoperative mortality rate (2.0% vs 3.6%, respectively; adjusted P = .03). For the 823 patients with unfragmented care, 400 (48.6%) had a primary care visit within 90 postoperative days (median time to visit, 34 days; IQR, 20-57 days). Patients who had a postoperative primary care visit were more likely to be older, have a higher comorbidity burden, have an emergency department visit, and be readmitted. However, they had a significantly lower 90-day postoperative mortality rate than those who did not have a primary care visit (0.3% vs 3.3%, respectively; adjusted P = .001).

Conclusions and Relevance

These findings suggest that follow-up with primary care within 90 days after cancer surgery is associated with improved survivorship among older adults.

Onset time, duration of action, and intubating conditions after mivacurium in elderly and younger patients

BACKGROUND

The neuromuscular blocking agent mivacurium can be used during anesthesia to facilitate tracheal intubation. Data on onset time, duration of action, and effect on intubating conditions in patients 80 years and older are however limited. We hypothesized that onset time and duration of action of mivacurium would be longer in elderly patients than in younger adults.

METHODS

This prospective observational study included 35 elderly (≥80 years) and 35 younger (18-40 years) patients. Induction of anesthesia comprised fentanyl 1-3 μg kg-1 and propofol 1.5-2.5 mg kg-1 and propofol and remifentanil for maintenance. Acceleromyography was used for monitoring neuromuscular blockade. The primary outcome was onset time defined as time from injection of mivacurium 0.2 mg kg-1 to a train-of-four (TOF) count of zero. Other outcomes included duration of action (time to TOF ratio ≥0.9), intubating conditions using the Fuchs-Buder scale and the intubating difficulty scale (IDS), and occurrence of hoarseness and sore throat postoperatively.

RESULTS

No difference was found in onset time comparing elderly with younger patients; 219 s (SD 45) versus 203 s (SD 74) (difference: 16 s (95% CI: -45 to 14), p = .30). Duration of action was significantly longer in elderly patients compared with younger patients; 52 min (SD 17) versus 30 min (SD 8) (difference: 22 min [95% CI: 15 to 28], p < .001). No difference was found in the proportion of excellent intubating conditions (Fuchs-Buder); 31/35 (89%) versus 26/35 (74%) (p = .12) or IDS score (p = .13). A larger proportion of younger patients reported sore throat 24 h postoperatively; 34% versus 0%, p = .0002. No difference was found in hoarseness.

CONCLUSION

No difference in onset time of mivacurium 0.2 mg kg-1 was found comparing elderly and younger patients. However, elderly patients had significantly longer duration of action. No difference was found in intubating conditions.

Chronic Subdural Hematoma Drainage under Local versus General Anesthesia: Systematic Review and Meta-Analysis

BACKGROUND

Chronic subdural hematoma (CSDH) is one of the most frequently encountered neurosurgical conditions. Although the mainstay treatment of chronic subdural hematoma has been burr-hole drainage, no consensus yet exists on the optimal anesthetic strategy between general anesthesia (GA) and local anesthesia (LA). This systematic review compares postoperative outcomes after CSDH evacuation under LA and GA.

METHODS

A search was conducted in MEDLINE (1946 to November 2023), Embase (1974 to November 2023), and PubMed (up to November 2023). We followed the PRISMA guidelines to systematically screen studies.

RESULTS

Our literature search identified 629 studies, out of which 12 were included. There were 1035 patients in the LA group and 699 patients in the GA group. Our meta-analysis found that the LA group had significantly shorter operative time (mean difference, -29.28 minutes; P < 0.0001), length of admission (mean difference, -1.58 days; 95% confidence interval [CI], -2.40 to -0.76 days; P = 0.0002), and postoperative complications rate (odds ratio [OR], 0.38; 95% CI, 0.25-0.59; P < 0.0001) compared with GA. There was no significant difference between the 2 groups in revision rate (OR, 0.77; 95% CI, 0.39-1.51; P = 0.45) and mortality (OR, 1.23; 95% CI, 0.63-2.43; P = 0.55).

CONCLUSIONS

In this meta-analysis, LA shows benefits in shorter operative time, shorter admission length, and fewer postoperative complications. This finding makes LA a less invasive alternative to GA, especially in elderly patients.

Shoulder arthroscopy in elderly patients: malnutrition and early postoperative outcomes

Background

This study investigates the association between the Geriatric Nutritional Risk Index (GNRI), a simple, readily available malnutrition risk index, and 30-day postoperative complications following shoulder arthroscopy.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients aged ≥65 years who underwent shoulder arthroscopy between 2015 and 2021. The study population was indexed into 3 cohorts of preoperative GNRI: normal/reference (GNRI >98), moderate malnutrition (92≤ GNRI ≤98), and severe malnutrition (GNRI <92). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative GNRI and postoperative complications.

Results

Severe malnutrition was independently significantly associated with a greater likelihood of any complication (odds ratio [OR]: 11.70, 95% confidence interval [CI]: 8.58-15.94; P < .001), sepsis (OR: 26.61, 95% CI: 10.86-65.21; P < .001), septic shock (OR: 7.53, 95% CI: 1.56-36.32; P = .012), blood transfusions (OR: 25.38, 95% CI: 6.40-100.59; P < .001), pulmonary embolism (OR: 7.25, 95% CI: 1.27-41.40; P = .026), surgical site infection (OR: 22.08, 95% CI: 7.51-64.97; P < .001), nonhome discharge (OR: 15.75, 95% CI: 9.83-25.23; P < .001), readmission (OR: 2.69, 95% CI: 1.52-4.74; P < .001), unplanned reoperation (OR: 6.32, 95% CI: 2.23-17.92; P < .001), length of stay >2 days (OR: 23.66, 95% CI: 16.25-34.45; P < .001), and mortality (OR: 14.25, 95% CI: 2.89-70.40; P = .001).

Conclusion

GNRI-based malnutrition is strongly predictive of perioperative complications following shoulder arthroscopy in geriatric patients and has utility as an adjunctive risk stratification tool.

Advances in the Development of Nano-Engineered Mechanically Robust Hydrogels for Minimally Invasive Treatment of Bone Defects

Injectable hydrogels were discovered as attractive materials for bone tissue engineering applications given their outstanding biocompatibility, high water content, and versatile fabrication platforms into materials with different physiochemical properties. However, traditional hydrogels suffer from weak mechanical strength, limiting their use in heavy load-bearing areas. Thus, the fabrication of mechanically robust injectable hydrogels that are suitable for load-bearing environments is of great interest. Successful material design for bone tissue engineering requires an understanding of the composition and structure of the material chosen, as well as the appropriate selection of biomimetic natural or synthetic materials. This review focuses on recent advancements in materials-design considerations and approaches to prepare mechanically robust injectable hydrogels for bone tissue engineering applications. We outline the materials-design approaches through a selection of materials and fabrication methods. Finally, we discuss unmet needs and current challenges in the development of ideal materials for bone tissue regeneration and highlight emerging strategies in the field.

The elderly in the post-anesthesia care unit

It is increasingly conceivable that elderly patients will be treated in perioperative settings as the world's population shifts toward an older age distribution. They are more prone to a variety of unfavorable outcomes as a consequence of the physiological changes that accompany aging and the coexistence of multiple medical conditions. Postoperative complications in elderly patients are linked to a large increase in morbidity and mortality and the burden placed on the healthcare system. Our goal is to determine how elderly patients' recovery after anesthesia differs from that of younger patients. In addition, we will discuss the main postoperative complications experienced by elderly patients and the measures that are utilized to limit the risk of these complications developing.

Are There Differences in Postoperative Opioid Prescribing Across Racial and Ethnic Groups? Assessment of an Academic Health System

BACKGROUND

Previous studies have demonstrated racial disparities in opioid prescribing in emergency departments and after surgical procedures. Orthopaedic surgeons account for a large proportion of dispensed opioid prescriptions, yet there are few data investigating whether racial or ethnic disparities exist in opioid dispensing after orthopaedic procedures.

QUESTIONS/PURPOSES

(1) Are Black, Hispanic or Latino, or Asian or Pacific Islander (PI) patients less likely than non-Hispanic White patients to receive an opioid prescription after an orthopaedic procedure in an academic United States health system? (2) Of the patients who do receive a postoperative opioid prescription, do Black, Hispanic or Latino, or Asian or PI patients receive a lower analgesic dose than non-Hispanic White patients when analyzed by type of procedure performed?

METHODS

Between January 2017 and March 2021, 60,782 patients underwent an orthopaedic surgical procedure at one of the six Penn Medicine healthcare system hospitals. Of these patients, we considered patients who had not been prescribed an opioid within 1 year eligible for the study, resulting in 61% (36,854) of patients. A total of 40% (24,106) of patients were excluded because they did not undergo one of the top eight most-common orthopaedic procedures studied or their procedure was not performed by a Penn Medicine faculty member. Missing data consisted of 382 patients who had no race or ethnicity listed in their record or declined to provide a race or ethnicity; these patients were excluded. This left 12,366 patients for analysis. Sixty-five percent (8076) of patients identified as non-Hispanic White, 27% (3289) identified as Black, 3% (372) identified as Hispanic or Latino, 3% (318) identified as Asian or PI, and 3% (311) identified as another race ("other"). Prescription dosages were converted to total morphine milligram equivalents for analysis. Statistical differences in receipt of a postoperative opioid prescription were assessed with multivariate logistic regression models within procedure, adjusted for age, gender, and type of healthcare insurance. Kruskal-Wallis tests were used to assess for differences in the total morphine milligram equivalent dosage of the prescription, stratified by procedure.

RESULTS

Almost all patients (95% [11,770 of 12,366]) received an opioid prescription. After risk adjustment, we found no differences in the odds of Black (odds ratio 0.94 [95% confidence interval 0.78 to 1.15]; p = 0.68), Hispanic or Latino (OR 0.75 [95% CI 0.47 to 1.20]; p = 0.18), Asian or PI (OR 1.00 [95% CI 0.58 to 1.74]; p = 0.96), or other-race patients (OR 1.33 [95% CI 0.72 to 2.47]; p = 0.26) receiving a postoperative opioid prescription compared with non-Hispanic White patients. There were no race or ethnicity differences in the median morphine milligram equivalent dose of postoperative opioid analgesics prescribed (p > 0.1 for all eight procedures) based on procedure.

CONCLUSION

In this academic health system, we did not find any differences in opioid prescribing after common orthopaedic procedures by patient race or ethnicity. A potential explanation is the use of surgical pathways in our orthopaedic department. Formal standardized opioid prescribing guidelines may reduce variability in opioid prescribing.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Postoperative pulmonary complications in older patients undergoing elective surgery with a supraglottic airway device or tracheal intubation

The two most commonly used airway management techniques during general anaesthesia are supraglottic airway devices and tracheal tubes. In older patients undergoing elective non-cardiothoracic surgery under general anaesthesia with positive pressure ventilation, we hypothesised that a composite measure of in-hospital postoperative pulmonary complications would be less frequent when a supraglottic airway device was used compared with a tracheal tube. We studied patients aged ≥ 70 years in 17 clinical centres. Patients were allocated randomly to airway management with a supraglottic airway device or a tracheal tube. Between August 2016 and April 2020, 2900 patients were studied, of whom 2751 were included in the primary analysis (1387 with supraglottic airway device and 1364 with a tracheal tube). Pre-operatively, 2431 (88.4%) patients were estimated to have a postoperative pulmonary complication risk index of 1-2. Postoperative pulmonary complications, mostly coughing, occurred in 270 of 1387 patients (19.5%) allocated to a supraglottic airway device and 342 of 1364 patients (25.1%) assigned to a tracheal tube (absolute difference -5.6% (95%CI -8.7 to -2.5), risk ratio 0.78 (95%CI 0.67-0.89); p < 0.001). Among otherwise healthy older patients undergoing elective surgery under general anaesthesia with intra-operative positive pressure ventilation of their lungs, there were fewer postoperative pulmonary complications when the airway was managed with a supraglottic airway device compared with a tracheal tube.

A Restaging Transurethral Resection of Bladder Tumor Is Always Necessary For High-grade T1 Non-muscle-invasive Bladder Cancer

Patients with high-grade T1 non-muscle-invasive bladder cancer (NMIBC) have a high risk of recurrence and upstaging. Restaging transurethral resection of bladder tumor allows better staging so that patients can proceed to the appropriate treatment in a timely manner. This should be done in all patients with high-grade T1 NMIBC.

NF2 mutation associated with accelerated time to recurrence for older patients with atypical meningiomas

PURPOSE

Meningiomas occur more frequently in older adults, with the incidence rates increasing from 5.8/100,000 for adults 35-44 years old to 55.2/100,000 for those 85+. Due to the increased risk of surgical management in older adults, there is a need to characterize the risk factors for aggressive disease course to inform management decisions in this population. We therefore sought to determine age-stratified relationships between tumour genomics and recurrence after resection of atypical meningiomas.

METHODS

We identified 137 primary and recurrent Grade 2 meningiomas from our existing meningioma genomic sequencing database. We examined the differential distribution of genomic alterations in those older than 65 compared to younger. We then performed an age stratified survival analysis to model recurrence for a mutation identified as differentially present.

RESULTS

In our cohort of 137 patients with grade 2 meningiomas, alterations in NF2 were present at a higher rate in older adults compared to younger (37.8% in < 65 vs. 55.3% in > 65; recurrence adjusted p-value =0.04). There was no association between the presence of NF2 and recurrence in the whole cohort. In the age-stratified model for those less than 65 years old, there was again no relationship. For patients in the older age stratum, there is a relationship between NF2 and worsened recurrence outcomes (HR = 3.64 (1.125 - 11.811); p = 0.031).

CONCLUSIONS

We found that mutations in NF2 were more common in older adults. Further, the presence of mutant NF2 was associated with an increased risk of recurrence in older adults.

Potential value of cerebrospinal fluid α-synuclein in the identification of postoperative delirium undergoing knee/hip arthroplasty: The perioperative neurocognitive disorder and biomarker lifestyle study

Objective

Postoperative delirium (POD) is a common postoperative complication, which may be associated with α-synuclein (α-syn). The purpose of this study was to explore the association between the expression level of α-syn in cerebrospinal fluid (CSF) and POD.

Methods

We conducted a prospective observational cohort study, which involved in 740 participants (mean age of 61.86 years, range 40–90 years; 40% female) from the Perioperative Neurocognitive Disorder And Biomarker Lifestyle (PNDABLE) study in the final analysis. POD was diagnosed using the Confusion Assessment Scale (CAM), and its severity was measured using the Memorial Delirium Assessment Scale (MDAS). Enzyme-linked immune-sorbent assay (ELISA) was used to detect the concentrations of α-syn, Aβ40, Aβ42, T-tau, and P-tau in CSF.

Results

The incidence of POD was 11.22% (83/740). The logistic regression analysis showed that the increased concentrations of CSF α-syn (OR = 1.005, 95%CI 1.004–1.006, P < 0.001), P-tau (OR = 1.093, 95%CI 1.071–1.115, P < 0.001), and T-tau (OR = 1.008, 95%CI 1.006–1.009, P < 0.001) were risk factors of POD. Linear regression showed that CSF α-syn had positive correlations with P-tau (β = 0.480, P < 0.001), T-tau (β = 0.334, P < 0.001), while negative correlations with Aβ40 (β = –0.378 P < 0.001), Aβ42 (β = -0.800, P = 0.001) in POD patients. Mediation analyses showed the association between α-syn and POD was partially mediated by tau pathologies (proportion: 16–17%).

Conclusion

CSF α-syn is one of the preoperative risk factors for POD, which may be mediated through tau pathologies.

Clinical trial registration

[www.ClinicalTrials.gov], identifier [ChiCTR20 00033439].

Establishment and assessment of postoperative cognitive impairment in intermittent hypoxia rats

OBJECTIVES

Obstructive sleep apnea hypopnea syndrome (OSAHS) is a chronic disease characterized by repeated episodes of apnea or hypopnea, accompanied by intermittent awakening and sleep disturbances. The incidence of OSAHS is increasing and has become a serious disease. In recent years, more and more evidence shows that OSAHS is closely related to postoperative neurocognitive disorders, and the preparation of models of postoperative cognitive impairment in intermittent hypoxia animals is an important way to study its pathogenesis and intervention targets. This study aims to explore the establishment and evaluation of the animal model of postoperative cognitive impairment in intermittent hypoxia rats.

METHODS

A total of 108 male SD rats were randomly divided into 8 groups: a control group (C group, n=27), a surgery group (S group, n=27), an intermittent hypoxia 7 d group (H1 group, n=9), an intermittent hypoxia 14 d group (H2 group, n=9), an intermittent hypoxia 21 d group (H3 group, n=9), an intermittent hypoxia 7 d operation group (O1 group, n=9), an intermittent hypoxia 14 d operation group (O2 group, n=9), and an intermittent hypoxia 21 d operation group (O3 group, n=9). The rats in the H1, H2 and H3 group treated with intermittent hypoxia for 7, 14, and 21 d, respectively. The rats in the O1, O2 and O3 groups received left lateral hepatic lobectomy after 7, 14, and 21 d intermittent hypoxia, respectively. The rats in each group were subjected to open field test, new object recognition test, and Barnes Maze test. The expression of IL-1β mRNA in hippocampus of rats was detected at the 1st day after the surgery.

RESULTS

Compared with the C, S, and H2 groups, the discrimination index in novel object recognition test 6 h and 1 d after the surgery of the O2 group was significantly lower (P<0.05), the latency and errors in Barnes maze at the 1st day and 2nd day after the surgery were increased significantly (P<0.05) and the expression of IL-1β mRNA in hippocampus was significantly increased at the 1st day after the operation (P<0.05). However, there was no difference in the preference index in NORT 6 h and 1 d after the surgery, the latency and errors in Barnes maze and the expression of IL-1β mRNA in hippocampus between the O1 group and the H1 group, the H3 group and the O3 group (all P>0.05).

CONCLUSIONS

The rate with intermittent hypoxia 14 d pretreatment with anesthesia and laparotomy could be established the animal model of postoperative cognitive impairment.

Vascularized Lymph Node Transfer Improved Outcomes of Elderly Patients with Secondary Upper Extremity Lymphedema

BACKGROUND

Secondary lymphedema is a debilitating morbidity. This study investigated the outcomes of vascularized lymph node transfer (VLNT) in elderly patients with secondary upper extremity lymphedema.

METHODS

Between 2008 and 2018, elderly (≥65 years) patients with secondary upper extremity lymphedema who underwent VLNT were retrospectively reviewed. Cheng's Lymphedema Grading, Taiwan Lymphoscintigraphy Staging, and indocyanine green lymphography were used to select the procedures. Outcome measurements included complications, circumferential difference, episodes of cellulitis, and the Lymphedema-Specific Quality of Life questionnaire (LYMQoL).

RESULTS

Eleven patients with a mean age of 70.2 ± 5.3 years (range 65-80 years) who underwent VLNT survived and no major complications were encountered. At a mean follow-up of 6.5 ± 3.6 years (range 2-13 years), the mean limb circumferential difference was significantly improved from 25.6 ± 11.5% to 8.3 ± 4.2% (p = 0.016), and the mean episode of cellulitis was statistically reduced from 2.4 ± 1.3 to 0.4 ± 0.9 times/year (p = 0.007). At a follow-up of 24 months, four domains of Function (from 30.6 ± 2.8 to 14.5 ± 2.5), Appearance (from 18.2 ± 1.9 to 8.5 ± 2.1), Symptoms (from 30.4 ± 5.9 to 10.9 ± 1.0) and Mood (from 29.2 ± 4.4 to 10.7 ± 1.0), as well as overall LYMQoL score (from 3.9 ± 1.1 to 7.4 ± 0.5), showed statistical improvement (all p < 0.05).

CONCLUSIONS

VLNT for secondary upper extremity lymphedema in elderly patients significantly decreased the limb circumferential difference and frequency of cellulitis and improved quality of life without using compression garments postoperatively.

The local soft tissue status and the prediction of local complications following fractures of the ankle region

INTRODUCTION

Well-known risk factors (RF) for soft tissue complications following surgical treatment of fracture of the ankle region include diabetes, smoking, and the local soft tissue status. A weighted analysis might provide a risk profile that guides the surgical treatment strategy. The aim of this meta-analysis was to provide a risk profile for soft tissue complications following closed fractures of the ankle region.

METHODS

This review provides a meta-analysis of studies that investigate potential risk factors for complications in fractures of the ankle region.

INCLUSION CRITERIA

Original articles that were published between 2000 and 2020 in English or German language that calculated odds ratios (OR) of RF for soft tissue complications. Further, this study only includes articles that investigated fractures of the ankle region including pilon fracture, calcaneal fractures, and fractures of the malleoli. This study excluded articles that provide exploratory analyses, narrative reviews, and case reports. RF were stratified as patient specific systemic RF (PSS), patient specific local RF (PSL), and non-patient specific RF (NPS). PSS RF includes comorbidities, American society of anaesthesiology (ASA), requirement of medication, additional injuries, and smoking or substance abuse. PSL RF includes soft tissue status, wounds, and associated complications. NPS RF includes duration of surgery, staged procedure, or time to definitive surgery. Random effect (RE) models were utilized to summarize the effect measure (OR) for each group or specific RF.

RESULTS

Out of 1352 unique articles, 34 were included for quantitative analyses. Out of 370 complications, the most commonly assessed RF were comorbidities (34.6%). Local soft tissue status accounted for 7.5% of all complications. The overall rate for complication was 10.9% (standard deviation, SD 8.7%). PSS RF had an OR of 1.04 (95%CI 1.01 to 1.06, p = 0.006), PSL an OR of 1.79 (95% 1.28 to 2.49, p = 0.0006), and NPS RF an OR of 1.01 (95%CI 0.97 to 1.05, p = 0.595). Additional injuries did not predict complications (OR 1.23, 95%CI 0.44 to 3.45, p = 0.516). The most predictive RF were open fracture (OR 3.47, 95%CI 1.64 to 7.34, p < 0.001), followed by local tissue damage (OR 3.05, 95%CI 1.23 to 40.92, p = 0.04), and diabetes (OR 2.3, 95%CI 1.1 to 4.79, p = 0.26).

CONCLUSION

Among all RFs for regional soft tissue complications, the most predictive is the local soft tissue status, while additional injuries or NPS RF were less predictive. The soft tissue damage can be quantified and outweighs the cofactors described in previous publications. The soft tissue status appears to have a more important role in the decision making of the treatment strategy when compared with comorbidities such as diabetes.

Incidence and predictive factors associated with hemodynamic instability among adult surgical patients in the post-anesthesia care unit, 2021: A prospective follow up study

Background

Hemodynamic instability, which is an independent predictor of long-term patient morbidity and duration of stay in the hospital, is a risk for patients in the post-anesthesia care unit. Multiple factors contribute to the development of postoperative hemodynamic instability. Prevention and treatment of these factors may reduce patients' hemodynamic instability, and its associated morbidity and mortality.

Objective

The aim of this study was to determine the incidence and factors associated with hemodynamic instability among adult surgical patients in the post-anesthesia care unit.

Method

An institution-based prospective follow up study was conducted from April 20, 2021 to June 28, 2021. Four hundred and seventeen (417) adult surgical patients were involved in this study. Descriptive and analytic statistics were used to describe our results. Both the bivariable and multivariable logistic regression with crude odds ratio and adjusted odds ratio were used with a 95% confidence interval to evaluate the strength of association. In multivariable regression, a p-value < 0.05 was considered as statistically significant.

Result

The overall incidence of hemodynamic instability was 59.47% (CI: 0.55, 0.64). The incidence of tachycardia, bradycardia, hypotension, and hypertension were 27.34%, 21.82%, 13.67%, and 15.35% respectively. Preoperative use of beta-blockers, ASA class III, procedure longer than 4 h, intraoperative hemodynamic instability, and regional anesthesia were significantly associated with hemodynamic instability in the post-anesthesia care unit.

Conclusion and recommendation

The incidence of hemodynamic instability in the post anesthesia care unit was high. Preoperative use of beta-blockers, intraoperative hemodynamic instability, and prolonged duration of procedures were predictors of hemodynamic instability after operation. Early detection and management of these perioperative risk factors is necessary to reduce hemodynamic instability in the post-anesthesia care unit.

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HDI is a common complication after surgery and anaesthesia

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It results in severe morbidity and mortality

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HDI is associated with multiple predictive factors

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Early detection and intervention of HDI improves outcome after surgery

A blinded randomized study comparing intubating conditions after either rocuronium 0.6 mg·kg-1 or remifentanil 2 µg·kg-1 in elderly patients

BACKGROUND

To facilitate tracheal intubation, either a neuromuscular blocking agent or a bolus dose of remifentanil can be administered. We hypothesized that rocuronium 0.6 mg·kg^-1 provided a larger proportion of excellent intubating conditions compared to remifentanil 2 µg·kg^-1 in patients above 80 years.

METHODS

A total of 78 patients were randomized to either rocuronium 0.6 mg·kg^-1 or remifentanil 2 µg·kg^-1 . General anaesthesia was initiated with fentanyl and propofol. Two minutes after the administration of either rocuronium or remifentanil, tracheal intubating conditions were evaluated using the Fuchs-Buder scale by a blinded investigator, and our primary outcome was the proportion of patients presenting intubating conditions deemed as excellent. Further outcomes included the Intubating Difficulty Scale (IDS), hoarseness or sore throat 24 h postoperatively, and intervention against hypotension.

RESULTS

No difference in the occurrence of excellent intubating conditions was found comparing the rocuronium group with the remifentanil group; 10 (28%) versus 15 (39%) (p = .29), respectively, relative risk = 0.72. Interventions against hypotension were used in 24 (67%) versus 28 (74%) (p = .51), respectively. Hoarseness and sore throat 24 h postoperatively were found in 37% versus 35% p = .86, and 14% versus 5% p = .20, respectively. The IDS score was 2 versus 2 p = .48.

CONCLUSION

No difference in intubating conditions was found 2 min after the administration of either rocuronium 0.6 mg·kg^-1 or remifentanil 2 µg·kg^-1 in patients aged above 80 years. Intubation conditions were less than optimal in a large proportion of this patient population.

CLINICAL TRIALS REGISTRATION

NCT04287426.

Predictors of clinical outcome following transcatheter aortic valve implantation: a prospective cohort study

OBJECTIVE

In recent years, transcatheter aortic valve implantation (TAVI) has become the treatment of choice for patients with symptomatic aortic valve stenosis considered to be at increased or high surgical risk. The aim of this study was to identify predictors of postoperative adverse events in older adults undergoing TAVI.

METHODS

A prospective observational cohort study of patients who were referred to a geriatric outpatient clinic for a geriatric assessment prior to TAVI was conducted. The outcomes were mortality and hospital readmission within 3 months of TAVI and the occurrence of major postoperative complications during hospitalisation according to the Clavien-Dindo classification. These three outcomes were also combined to a composite outcome. Univariate and multivariate logistic regression analyses were performed to identify predictors of the outcomes and composite outcome of adverse events.

RESULTS

This cohort included 490 patients who underwent TAVI (mean age 80.7±6.2 years, 47.3% male). Within 3 months of TAVI, 19 (3.9%) patients died and 46 (9.4%) patients experienced a hospital readmission. A total of 177 (36.1%) patients experienced one or more major complications according to the Clavien-Dindo classification during hospitalisation and 193 patients (39.4%) experienced the composite outcome of adverse events. In multivariate analyses, cognitive impairment was identified as an independent predictor of major postoperative complications (OR 2.16; 95% CI 1.14 to 4.19) and the composite outcome of adverse events (OR 2.40; 95% CI 1.21 to 4.79). No association was found between the other variables and the separate outcomes and composite outcome.

CONCLUSION

Cognitive impairment is associated with postoperative adverse events in older patients undergoing TAVI. Therefore, it is important to screen for cognitive impairment prior to TAVI and it is recommended to include this in current TAVI guidelines.

Neuromuscular block in patients 80 years and older: a prospective, controlled study

Background

An increasing number of patients older than 80 years are undergoing anesthesia, but little information is available regarding pharmacodynamic effects of myorelaxants in this population. This study aims to compare the time course of rocuronium neuromuscular block in patients ≥ 80 years with those of younger adults.

Methods

Under total intravenous anesthesia with propofol and sufentanil, time course of a bolus of rocuronium 0.6 mg/kg neuromuscular block was assessed with acceleromyography in patients ≥ 80 and in patients 20–50 years old. Onset time, clinical duration, duration until 90% and 100% recovery of baseline were determined.

Results

Data from 32 patients were analyzed, 16 were ≥ 80 years and 16 were 20–50 years old. Demographic data are shown in Table 1. In the group ≥ 80, onset time was 190 s ± 46 s compared to 123 s ± 40 s in the group 20–50, P < 0.001 and the clinical duration was 52 [48–69.5] min and 36 [34–41] min, respectively, P < 0.001. Duration to 90% recovery of baseline was 77.5 [71–88.5] min and duration to 100% recovery of baseline was 91.2 [82.2–98] min in patients ≥ 80 years and the corresponding values in the patients 20–50 years old were 53.5 [49–55.5] min and 59.5 [56.5–70.25] min, respectively, P < 0.001.

Conclusion

Compared to younger adults rocuronium shifted in patients ≥ 80 years from a rapid onset, intermediate acting compound to a slower onset, long-acting compound.

Trial registration

ClinicalTrials.gov identifier: NCT03551652 (29/05/2018).

Factors associated with the severity of delirium

BACKGROUND

Various factors affecting the development of delirium have been identified. However, the associations between the severity of delirium and potentially related factors have not been adequately investigated. The aim of the present study was to explore factors associated with the severity of delirium and to identify the reversible contributing factors.

METHODS

A total of 577 patients with delirium referred to the Department of Psychiatry during the 5 years from May 2015 to April 2020 at a general hospital were included. The Delirium Rating Scale-revised-98 (DRS-R-98) was used to measure the severity of delirium. Multiple regression analysis was used to determine whether individual factors were associated with the severity of delirium.

RESULTS

Intensive care unit admission (p = 0.003), use of benzodiazepines (p = 0.01), dementia (p = 0.02), and older age (p = 0.045) were all positively associated the severity of delirium, while use of β-blockers (p = 0.001) was negatively associated with the severity of delirium.

CONCLUSIONS

Reversible contributing factors, that is use of benzodiazepines, should be avoided as much as possible, especially in elderly patients or patients with dementia or patients who need critical care in ICU. Reducing the dose of benzodiazepines or switching them to other drugs should be a priority.

Risk factors for postoperative pulmonary complications and prolonged hospital stay in pulmonary resection patients: a retrospective study

BACKGROUND

Postoperative pulmonary complications are the main cause of morbidity and mortality after pulmonary resection. This study was undertaken to determine the risk factors associated with postoperative pulmonary complications (PPCs) and length of hospital stay (LOS) in pulmonary resection patients in a tertiary teaching hospital in Brazil.

METHODS

A retrospective data gathering from 196 patients who underwent pulmonary resection between 2012 and 2016 was conducted. Demographic and hospital admission data were collected from patients with complete medical records. Univariate analysis was performed, followed by Poisson's regression for predicting the prevalence of postoperative pulmonary complications and length of hospital stay.

RESULTS

Thirty-nine patients (20%) displayed pulmonary complications in the postoperative period. The risk factors associated with an increased prevalence of postoperative pulmonary complications in a multivariate analysis were: American Society of Anesthesiologists physical status (ASA) ≥ 3 (PR 4.77, p = 0.03, 95% CI: 1.17 to 19.46), predicted diffusion capacity of the lungs for carbon monoxide - corrected single breath (PR 0.98, p < 0.001, 95% CI: 0.96 to 0.99) and age of the patient (PR 1.04; p = 0.01; 95% CI: 1.01 to 1.06). Those associated with an increased prevalence of prolonged hospital stay were: duration of surgical procedure longer than five hours (PR 6.94, p = 0.01, 95% CI: 1.66 to 12.23), male sex (PR 5.72, p < 0.001, 95% CI: 1.87 to 9.58), and presence of postoperative pulmonary complications (PR 11.92, p < 0.001, 95% CI: 7.42 to 16.42).

CONCLUSIONS

The rate of postoperative pulmonary complications in the study population is in line with the world average. Recognizing risk factors for the development of PPCs may help optimize allocation resources and preventive efforts.

A Literature Review to Assess Blood Loss in Minimally Invasive Liver Surgery Versus in Open Liver Resection

Aim and objectives The aim of the study was to assess the amount of blood loss in minimally invasive hepatectomy and open liver resection for both benign and neoplastic conditions. Introduction Minimally invasive surgery has progressively developed to a stage where once-novel and highly specialized surgical techniques are now common practice. Colorectal surgery is the key example that has shown minimally invasive surgery as highly beneficial. Successes in the colorectal laparoscopic approach have now been integrated into the speciality of hepatopancreaticobiiary (HPB) surgery. In this review, we will compare the amount of blood loss in minimally invasive liver resection with the more traditional approach of open liver resection. Methods A literature review was conducted which included the length of patient mobilization as a postoperative complication following laparoscopic and open liver resections. Medline, PubMed, and Cochrane were accessed to review previously published studies. Twelve studies were selected, and all of them were in English, ranged from the year 2000 to 2020. Results Eleven out of the 12 included studies indicated that minimally invasive liver resection is associated with reduced blood loss. Conclusion In comparing both minimally invasive liver resection and classic open surgery, minimally invasive liver resection was shown to have reduced blood loss; this was seen in both malignant and benign tumours. Therefore, laparoscopic liver resection could be favoured over the classical open approach to avoid excessive blood loss intra-operatively.

Can physical prehabilitation prevent complications after colorectal cancer surgery in frail older patients?

INTRODUCTION

Frail patients with colorectal cancer (CRC) are at increased risk of complications after surgery. Prehabilitation seems promising to improve this outcome and therefore we evaluated the effect of physical prehabilitation on postoperative complications in a retrospective cohort of frail CRC patients.

METHODS

The study consisted of all consecutive non-metastatic CRC patients ≥70 years who had elective surgery from 2014 to 2019 in a teaching hospital in the Netherlands, where a physical prehabilitation program was implemented from 2014 on. We performed both an intention-to-treat and per protocol analysis to evaluate postoperative complications in the physical prehabilitation (PhP) and non-prehabilitation (NP) group.

RESULTS

Eventually, 334 elective patients were included. The 124 (37.1%) patients in the PhP-group presented with higher age, higher comorbidity scores and walking-aid use compared to the NP-group. Medical complications occurred in 26.6% of the PhP-group and in 20.5% of the NP-group (p = 0.20) and surgical complications in 19.4% and 14.3% (p = 0.22) respectively. In all frailty subgroups, the medical complications were lower in the PhP-group compared to the NP-group (35.9% vs. 45.5% for patients with ≥2 comorbidities, 36.2% vs. 39.1% for ASA score ≥ III, 29.2% vs. 45.8% for walking-aid use). Differences were not significant.

CONCLUSIONS

In this study, patients selected for physical prehabilitation had a worse frailty profile and therefore a higher a priori risk of postoperative complications. However, the postoperative complication rate was not increased compared to patients who were less frail at baseline and without prehabilitation. Hence, physical prehabilitation may prevent postoperative complications in frail CRC patients ≥70 years.

Multidimentional Preoperative Frailty Assessment and Postoperative Complication Risk in Egyptian Geriatric Patients Undergoing Elective Cardiac Surgery

BACKGROUND

Frailty affects up to 51%of the geriatric population in developing countries which leads to increased morbidity and mortality.

OBJECTIVE

To determine the association between pre-operative frailty through multidimentional assessment score, and the incidence of post-operative complications and to validate Robinson score in geriatric Egyptian patients undergoing elective cardiac surgery.

METHODS

We recruited 180 elderly participants aged 60 years old and above, who underwent elective cardiac surgery. They were divided into frail, pre-frail, and non-frail groups after application of Robinson score (which includes cognitive and functional and fall risk assessment, number of comorbidities, and different laboratory data). Type and duration of operations and the presence and severity of complications at days 3 and 7 post-surgery, and the 30-day readmission rate were assessed.

RESULTS

Operation duration and the occurrence of postoperative complications at days 3 and 7 were lowest in non-frail and highest in the frail group (p < 0.001 for both). Length of hospital stay and 30-day readmission rate also increased in the frail group. A positive, moderate correlation between frailty and blood transfusion (r = 0.405) and functional dependence (r = 0.552) was found at day-3 post-surgery. Finally, logistic regression analysis identified a 6-fold increase in postoperative complications in the frail group (OR = 6).

CONCLUSION

Preoperative frailty was associated with higher incidence of postoperative complications among geriatric patients undergoing elective cardiac surgery. Frailty assessment by Robinson score can be considered as an accurate tool to predict postoperative complications during preoperative assessment of elderly patients.

Proportion and risk factors for death by euthanasia in dogs in the UK

The loss of a pet can be particularly distressing for owners, whether the method of death is euthanasia or is unassisted. Using primary-care clinical data, this study aimed to report the demographic and clinical factors associated with euthanasia, relative to unassisted death, in dogs. Method of death (euthanasia or unassisted) and clinical cause of death were extracted from a random sample of 29,865 dogs within the VetCompass Programme from a sampling frame of 905,544 dogs under UK veterinary care in 2016. Multivariable logistic regression modelling was used to evaluate associations between risk factors and method of death. Of the confirmed deaths, 26,676 (89.3%) were euthanased and 2,487 (8.3%) died unassisted. After accounting for confounding factors, 6 grouped-level disorders had higher odds in euthanased dogs (than dogs that died unassisted), using neoplasia as the baseline. The disorders with greatest odds included: poor quality of life (OR 16.28), undesirable behaviour (OR 11.36) and spinal cord disorder (OR 6.00). Breed, larger bodyweight and increasing age were additional risk factors for euthanasia. The results highlight that a large majority of owners will face euthanasia decisions and these findings can support veterinarians and owners to better prepare for such an eventuality.

The association between residual neuromuscular blockade (RNMB) and critical respiratory events: a prospective cohort study

Background

Inadequate neuromuscular recovery might impair pulmonary function among adult patients who undergo general anaesthesia and might thus contribute to critical respiratory events in the post-anaesthesia care unit (PACU). The pilot study aims to understand the baseline incidence of residual neuromuscular blockade (RNMB) and postoperative critical respiratory events (CREs), which are described in a modified Murphy’s criteria in the PACU.

Method

This is a prospective cohort study from January to March 2017 from a tertiary hospital in Saudi Arabia with thirty adult patients over 18 years old scheduled for elective surgery under general anaesthesia with neuromuscular blocking drugs (NMBDs) who were enrolled in the study. The Mann-Whitney U tests, chi-square tests and independent-samples T tests were used. The train-of-four (TOF) ratios were measured upon arrival in the PACU by using acceleromyography with TOF-Scan. Subjects’ demographics, perioperative data and the occurrence of postoperative CREs in the PACU were recorded.

Results

Twenty-six (86.7%) patients out of thirty in the study have received rocuronium as NMBDs whilst neostigmine as a reversal drug with only 23 (76.7%). The incidence of RNMB (TOF ratio < 0.9) was in 16 patients (53.3%). The incidence of RNMB was significantly higher in female patients (p = 0.033), in patients who had not undergone quantitative neuromuscular monitoring before extubation (p = 0.046) and in patients with a shorter duration of surgery (p = 0.001). Postoperative CREs occurred in twenty patients (66.7%), and there were significantly more of these CREs among patients with RNMB (p = 0.001). In addition, a statistically significant difference was observed in the occurrence of CREs according to body mass index (p = 0.047).

Conclusion

This research showed that RNMB is a significant contributing factor to the development of critical respiratory events during PACU stay. Therefore, routine quantitative neuromuscular monitoring is recommended to reduce the incidence of RNMB.

Perioperative outcomes and survival in elderly patients aged ≥ 75 years undergoing gastrectomy for gastric cancer: an 18-year retrospective analysis in a single Western centre

PURPOSE

Surgical resection for elderly patients with gastric cancer is controversial. This study aims to evaluate the preoperative features and postoperative short- and long-term outcomes of elderly patients following surgical resection for gastric adenocarcinoma.

METHODS

Between January 2000 and May 2018, a total of 177 consecutive patients underwent curative gastrectomy for gastric adenocarcinoma was retrospectively reviewed. Propensity score matching (PSM) analysis was used to balance confounding covariates between the elderly and non-elderly groups. Clinicopathological characteristics, intraoperative characteristics, postoperative complications and long-term survival outcomes including overall survival (OS) and Disease Specific Survival (DSS) were compared and analysed using the Kaplan-Meier log-rank test. Multivariate cox proportional hazards regression analysis of clinicopathological factors influencing survival were evaluated.

RESULTS

There were 50 patients in the elderly group (age ≥ 75 years) and 127 patients in the non-elderly group (age < 75 years). Elderly patients had more comorbid conditions (p < 0.001), lower albumin concentration (p = 0.034), lower haemoglobin levels (p = 0.001), and poorer renal function (p = 0.043). TNM stage was similar between both groups (p = 0.174); however, lymphatic invasion (p = 0.006) and lymph node metastasis (p = 0.029) were higher in the elderly group. Elderly patients were much less likely to receive any chemo- (p < 0.001) or radiotherapy treatment (p = 0.007) with surgical treatment. After PSM, there were 50 patients in each group. Elderly patients were more likely to develop complications (Clavien Dindo ≥ 2: 50% vs. 26%, p = 0.003). The most common postoperative complications were pneumonia (12% vs. 6%, p = 0.498) and delirium (10% vs. 0%, p = 0.066). Elderly patients had a longer median length of hospital stay (median (IQR): 15.6(9.5) vs. 11.3 (9.9), p = 0.030). There were no differences in 30-day mortality (elderly vs. non-elderly: 1% vs. 1%, p = 0.988). Before and after PSM, age remains an independent predictor of postoperative complications. Before PSM, the estimated mean OS for the elderly and non-elderly patients were 108 months (95%CI, 72.5-143.5) and 143 months (95%CI, 123.0-163.8), respectively (p = 0.264). After PSM, the estimated mean OS for the elderly and non-elderly patients were 108 months (95%CI, 72.5-143.5) and 140 months (95%CI, 112.1-168.2), respectively, (p = 0.360). Before PSM, the estimated mean DSS for the elderly and non-elderly patients were 94 months (95%CI, 61.9-127.5) and 121 months (95%CI, 100.9-141.0), respectively (p = 0.405). After PSM, the estimated mean DSS for the elderly and non-elderly patients were 94 months (95%CI, 61.9-127.5) and 115 months (95%CI, 87.3-143.3), respectively (p = 0.721). Age was not an independent predictor of mortality following gastrectomy for gastric cancer in both PSM matched and unmatched cohort.

CONCLUSION

Chronological age alone is not a contraindication to curative resection of gastric adenocarcinoma in elderly patients with acceptable risk. Whilst age affects perioperative complications, the incidence of postoperative mortality and overall survival were not significantly different between elderly and non-elderly gastric cancer patients treated with curative surgery. Gastrectomy with D2 lymphadenectomy can also be performed in carefully selected elderly patients by surgeons with expertise in gastric resection along with appropriate perioperative management.

How safe are elective craniotomies in elderly patients in neurosurgery today? A prospective cohort study of 1452 consecutive cases

OBJECTIVE

With global aging, elective craniotomies are increasingly being performed in elderly patients. There is a paucity of prospective studies evaluating the impact of these procedures on the geriatric population. The goal of this study was to assess the safety of elective craniotomies for elderly patients in modern neurosurgery.

METHODS

For this cohort study, adult patients, who underwent elective craniotomies between November 1, 2011, and October 31, 2018, were allocated to 3 age groups (group 1, < 65 years [n = 1008], group 2, ≥ 65 to < 75 [n = 315], and group 3, ≥ 75 [n = 129]). Primary outcome was the 30-day mortality after craniotomy. Secondary outcomes included rate of delayed extubation (> 1 hour), need for emergency head CT scan and reoperation within 48 hours after surgery, length of postoperative intensive or intermediate care unit stay, hospital length of stay (LOS), and rate of discharge to home. Adjustment for American Society of Anesthesiologists Physical Status (ASA PS) class, estimated blood loss, and duration of surgery were analyzed as a comparison using multiple logistic regression. For significant differences a post hoc analysis was performed.

RESULTS

In total, 1452 patients (mean age 55.4 ± 14.7 years) were included. The overall mortality rate was 0.55% (n = 8), with no significant differences between groups (group 1: 0.5% [95% binominal CI 0.2%, 1.2%]; group 2: 0.3% [95% binominal CI 0.0%, 1.7%]; group 3: 1.6% [95% binominal CI 0.2%, 5.5%]). Deceased patients had a significantly higher ASA PS class (2.88 ± 0.35 vs 2.42 ± 0.62; difference 0.46 [95% CI 0.03, 0.89]; p = 0.036) and increased estimated blood loss (1444 ± 1973 ml vs 436 ± 545 ml [95% CI 618, 1398]; p <0.001). Significant differences were found in the rate of postoperative head CT scans (group 1: 6.65% [n = 67], group 2: 7.30% [n = 23], group 3: 15.50% [n = 20]; p = 0.006), LOS (group 1: median 5 days [IQR 4; 7 days], group 2: 5 days [IQR 4; 7 days], and group 3: 7 days [5; 9 days]; p = 0.001), and rate of discharge to home (group 1: 79.0% [n = 796], group 2: 72.0% [n = 227], and group 3: 44.2% [n = 57]; p < 0.001).

CONCLUSIONS

Mortality following elective craniotomy was low in all age groups. Today, elective craniotomy for well-selected patients is safe, and for elderly patients, too. Elderly patients are more dependent on discharge to other hospitals and postacute care facilities after elective craniotomy. Clinical trial registration no.: NCT01987648 (clinicaltrials.gov).

Regional anaesthesia quality indicators for adult patients undergoing non-cardiac surgery: a systematic review

Improvement in healthcare delivery depends on the ability to measure outcomes that can direct changes in the system. An overview of quality indicators within the field of regional anaesthesia is lacking. This systematic review aims to synthesise available quality indicators, as per the Donabedian framework, and provide a concise overview of evidence-based quality indicators within regional anaesthesia. A systematic literature search was conducted using the databases MEDLINE, Embase, CINAHL and Cochrane from 2003 to present, and a prespecified search of regional anaesthesia society websites and healthcare quality agencies. The quality indicators relevant to regional anaesthesia were subdivided into peri-operative structure, process and outcome indicators as per the Donabedian framework. The methodological quality of the indicators was determined as per the Oxford Centre for Evidence-Based Medicine's framework. Twenty manuscripts met our inclusion criteria and, in total, 68 unique quality indicators were identified. There were 4 (6%) structure, 12 (18%) process and 52 (76%) outcome indicators. Most of the indicators were related to the safety (57%) and effectiveness (19%) of regional anaesthesia and were general in nature (60%). In addition, most indicators (84%) were based on low levels of evidence. Our study is an important first step towards describing quality indicators for the provision of regional anaesthesia. Future research should focus on the development of structure and process quality indicators and improving the methodological quality and usability of these indicators.

Impact of Comorbidities and Frailty on Early Shunt Failure in Geriatric Patients With Normal Pressure Hydrocephalus

Background/Aim: Older patients are considered to bear a higher perioperative risk. Since idiopathic normal pressure hydrocephalus (NPH) predominantly concerns older patients, identifying risk factors for early shunt failure for preoperative risk/benefit assessment is indispensable for indication and/or consultation of patients for ventriculoperitoneal shunting (VPS).

Methods: We performed a retrospective study design, including data acquired from two university hospital neurosurgical institutions between 2012 and 2019. Overall, 211 consecutive patients with clinical/radiological signs for NPH who additionally showed alleviation of symptoms after lumbar cerebrospinal fluid (CSF) drainage, received VPS and were included for further analysis. Frailty was measured using the Clinical Frailty Scale (CFS). Main outcome was early shunt failure or post-operative complications within 30 days after initial VPS surgery.

Results: The overall complication rate was 14%. Patient-related complications were observed in 13 patients (6%) and procedure-related complications in 16 patients (8%). Early post-operative complications resulted in a significantly prolonged length of hospital stay 6.9 ± 6.8 vs. 10.8 ± 11.8 days (p = 0.03). Diabetes mellitus with end-organ damage (OR 35.4, 95% CI 6.6 – 189.4, p < 0.0001) as well as preexisting Parkinson's disease were associated with early patient-related post-surgical complications after VPS for NPH.

Conclusions: Patients comorbidities but not frailty were associated with early post-operative patient-related complications in patients suffering NPH. While frailty may deter patients from other (neurosurgical) procedures, VPS surgery might contribute to treating NPH in these patients at a tolerable risk.

Thirty-Day Hospital Readmission and Surgical Complication Rates for Shunting in Normal Pressure Hydrocephalus: A Large National Database Analysis

BACKGROUND

Research on age-related complications secondary to shunts in normal pressure hydrocephalus (NPH) is primarily limited to single-center studies and small cohorts.

OBJECTIVE

To determine the rates of hospital readmission and surgical complications, and factors that predict them, following shunt surgery for NPH in a large healthcare network.

METHODS

Surgical procedures, complications, and readmissions for adults undergoing ventricular shunting for NPH were determined using de-identified claims from a privately insured United States healthcare network in years 2007-2014. Univariate and multivariate statistics were used to determine factors that predict poor surgical outcomes. The primary outcome variable was surgical complications or readmissions (composite variable for any major perioperative complication or 30-d readmission).

RESULTS

The 30-d readmission rate for 974 patients with NPH who underwent ventricular shunting was 7.29%; the most common reasons for readmission were shunt-related complications, infection, hemorrhage, altered mental status, and cardiopulmonary and musculoskeletal problems. The perioperative complication rate was 21.15%, including intraparenchymal hemorrhage (5.85%) and extra-axial (subdural or epidural) hematoma (5.54%). The overall rate of having a surgical complication or 30-d readmission was 25.15%. Age did not predict surgical complication or 30-d readmission. Preoperative comorbidities independently associated with poor outcome were myocardial infarction within 1 yr (OR = 3.984, 95% CI = 1.105-14.368); existing cerebrovascular disease (odds ratio [OR] = 2.206, 95% CI = 1.544-3.152); and moderate/severe renal disease (OR = 2.000, 95% CI = 1.155-3.464).

CONCLUSION

The rate of complications or readmission within 30 d of ventricular shunting for NPH is 25.15%. Preoperative comorbidities of myocardial infarction within 1 yr, cerebrovascular disease, and moderate/severe renal disease are independent risk factors for poor outcome.

Effects of an Alveolar Recruitment Maneuver During Lung Protective Ventilation on Postoperative Pulmonary Complications in Elderly Patients Undergoing Laparoscopy

Purpose

Controversy remains over whether alveolar recruitment maneuvers (ARMs) can reduce postoperative pulmonary complications. We hypothesized that performing an ARM in addition to lung protective ventilation (LPV) could improve intraoperative arterial oxygenation and postoperative pulmonary complications (PPCs) in elderly patients undergoing laparoscopy in the Trendelenburg position.

Patients and Methods

Sixty-two patients (aged 65-85) scheduled for laparoscopic low anterior resection were randomized to receive LPV only (LPV group, n = 32) or LPV with an ARM (ARM group, n = 30). LPV was set to a tidal volume of 6 mL/kg with a positive end expiratory pressure (PEEP) of 5 cmH₂O. The ARM was performed by serially increasing the PEEP to 10 cmH₂O for 3 breaths, 15 cmH₂O for 3 breaths, then 20 cmH₂O for 10 breaths, both immediately before and after abdominal insufflation. The primary end-point was the frequency of PPCs such as desaturation (SpO₂ <90%), atelectasis, and pneumonia. Secondary end-points were changes in intraoperative respiratory and gas exchange parameters and hemodynamic variables.

Results

One patient in the LPV group experienced desaturation on the first postoperative day. The frequency of chest X-ray abnormalities such as atelectasis or pleural effusion was comparable between groups (6 (19%) and 5 (17%) patients, respectively, P = 0.676). Changes in other respiratory, gas exchange and hemodynamic parameters over time were not significantly different between the groups. However, vasopressor requirements during surgery were higher in the ARM than the LPV group (9 (30%) and 2 (6%) patients, respectively, P = 0.014).

Conclusion

This study suggests that performing an ARM during LPV may not improve postoperative respiratory outcomes and intraoperative oxygenation compared to LPV alone in geriatric patients undergoing laparoscopy in the Trendelenburg position. In addition, since the ARM could cause a significant deterioration in hemodynamic parameters, applying ARM to elderly patients should be carefully considered.

Onset time and duration of action of rocuronium 0.6 mg/kg in patients above 80 years of age: A comparison with young adults

BACKGROUND

The number of elderly is increasing, and a large proportion of these people will require surgery and anaesthesia. However, little data exist regarding rocuronium in patients above 80 years of age. The aim of this study was to determine the onset time and duration of action for rocuronium 0.6 mg/kg in patients above 80 years compared with young adults.

METHODS

This prospective observational study included 16 young (18-40 years) and 16 elderly (>80 years) patients scheduled for total intravenous anaesthesia. Neuromuscular block following rocuronium 0.6 mg/kg was monitored with acceleromyography using train-of-four (TOF) stimulation. The primary outcome was onset time (from administration of rocuronium until TOF count = 0). Secondary outcomes were duration of action (from administration to TOF ratio >0.9) and intubating conditions according to Intubation Difficulty Score.

RESULTS

Elderly patients, median age of 84 years, had significantly prolonged onset time compared to younger patients; median 135 seconds (135-158) vs 90 seconds (90-105), respectively, a mean difference of 82 seconds (40-124) and Wilcoxon Mann-Whitney odds (WMW) of 19.48 (7.48-X). Duration of action in elderly patients was significantly longer, with a median time of 81 minute (71-97) vs 53 minute (42-73), respectively, a mean difference of 31 minute (14-48), and WMW odds of 6.35 (2.59-X). There was no significant difference in intubating conditions.

CONCLUSIONS

Patients above 80 years had significantly prolonged onset time and duration of action after rocuronium 0.6 mg/kg compared with patients aged 18-40 years.

Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus

BACKGROUND

Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue.

AIMS

To develop evidence-based recommendations for the integrated care of geriatric surgical patients.

METHODS

A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria.

RESULTS

A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items).

CONCLUSIONS

These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.

Nefopam hydrochloride as a component of multimodal analgesia in the postoperative period

The modern approach to the multimodal scheme of postoperative analgesia includes the mandatory use of drugs that have a small number of side effects and at the same time have a polymodal effect on the pathogenetic links of pain development. Nefopam hydrochloride is able to prevent the development of: opioid hyperalgesia, stop pain stimuli without respiratory depression, affect platelet aggregation and the condition of the mucous membrane and motility of the gastrointestinal tract, which distinguishes it from classical NSAIDs. Nefopam hydrochloride is characterized by a low risk of addiction with prolonged use, a pronounced anti-sensory effect, especially significant at the stage of awakening and in the early postoperative period. Postoperative analgesia based on nefopam hydrochloride as a component of multimodal analgesia is effective and safe in the absence of absolute contraindications. The planned use of nefopam hydrochloride for the correction of pain reduces complications in the postoperative period and improves the quality of life of patients. Nefopam hydrochloride is one of the most effective drugs for the correction of postoperative tremor syndrome. The use of nefopam hydrochloride as a drug, which is a part of premedication before surgical interventions and a component of multimodal analgesia, improves the quality of the postoperative period due to: reduction of pain syndrome, planned correction of postoperative tremor syndrome and correction of complications arising from inadequate treatment of pain syndrome.

Utility of Frailty Screening Tools in Older Surgical Patients

Frailty is a loss of functional reserve that compromises a person's ability to cope with stressors such as surgery. Identifying and quantifying frailty may enable intensive rehabilitation interventions, caregiver support, or consideration of palliative care before surgery. This study describes the characteristics of five frailty screening tools, namely the Geriatric 8, Vulnerable Elders Survey-13, the Groningen Frailty Indicator, Edmonton Frailty Scale (EFS), and Clinical Frailty Scale. We further propose an approach incorporating a frailty scale into preoperative assessment, wherein older patients undergoing elective general surgery are screened using EFS, and frail patients are offered comprehensive geriatric assessment. The expected outcome is an individualized patient-centered care plan that will reduce frailty and optimize the patient's condition before surgery.

Relationship between Surgery under General Anesthesia and the Development of Dementia: A Systematic Review and Meta-Analysis

Objective

To investigate the association between exposure to general anesthesia and the development of Alzheimer's disease (AD) and dementia by reviewing and integrating the evidence from epidemiological studies published to date.

Methods

We searched MEDLINE, EMBASE, and Google Scholar to identify all relevant articles up to April 2018 reporting the risk of AD/dementia following exposure to general anesthesia and finally updated in February 2020. We included patients older than 60 or 65 years who had not been diagnosed with dementia or AD before the study period. The overall pooled effect size (ES) was evaluated with a random-effect model. Subgroup analyses were conducted and possibility of publication bias was assessed.

Results

A total of 23 studies with 412253 patients were included in our analysis. A statistically significant positive association between exposure to general anesthesia and the occurrence of AD was detected in the overall analysis (pooled ES = 1.11, 95%confidence interval = 1.07–1.15), but with substantial heterogeneity (p_χ² < 0.001, I² = 79.4). Although the overall analysis revealed a significant association, the results of the subgroup analyses were inconsistent, and the possibility of publication bias was detected.

Conclusion

s. This meta-analysis demonstrated a significant positive association between general anesthesia and AD. However, considering other results, our meta-analysis must be interpreted with caution. Particularly, it should be considered that it was nearly impossible to discriminate the influence of general anesthesia from the effect of surgery itself on the development of AD. Further, large-scale studies devised to reduce the risk of bias are needed to elucidate the evidence of association between general anesthesia and AD. Trial registration. PROSPERO International prospective register of systematic reviews CRD42017073790.

Utilisation of Adjuvant Chemotherapy and 5-Year Survival Analysis of Prospectively Recorded Cohort Data for Older Adults Versus Younger Adults with Resected Primary Colon Cancer

PURPOSE

Colon cancer is predominantly a disease of older adults. Studies determining the influence of age on outcomes of colon cancer have conflicting results. We aim to determine the long-term outcomes and utilisation of adjuvant chemotherapy of older adults compared with younger adults who had had a resection of a primary colon cancer.

METHODS

Consecutive patients who had resection of a primary colon cancer between January 1, 2000 and December 31, 2010 were identified from a prospective database and stratified into three age groups: ≤ 69 years, 70 to 79 years, and ≥ 80 years. Age-related differences in patients, cancer, and treatment characteristics were determined by chi-square tests. Five-year overall survival and cancer-specific survival were determined by Kaplan-Meier method and by multivariable Cox regression analysis to adjust for potential confounding factors.

RESULTS

Of 1135 included patients, 469 (41%) patients were aged ≤ 69 years, 382 (34%) were 70-79 years, and 284 (25%) were ≥ 80 years. Increasing age group predicted more comorbidity (p < 0.001), cardiac comorbidity (p < 0.001), right-sided cancers (p < 0.001), and less adjuvant chemotherapy (stage III only; p < 0.001). Increasing age group was associated with worse overall survival by stage (p < 0.001) but not cancer-specific survival by stage (p = 0.83). Adjuvant chemotherapy in patients with stage III colon cancer independently predicted improved overall survival (p < 0.001) and cancer-specific survival (p = 0.01).

CONCLUSIONS

Compared with younger adults, older adults with colon cancer had worse survival outcomes and received less adjuvant chemotherapy.

[Research progress of the role of postoperative pain in the development of postoperative cognitive dysfunction in geriatric patients]

Previous studies have shown that postoperative cognitive dysfunction (POCD) is related to multiple factors including age, postoperative trauma, inflammation, postoperative pain, and anesthesia, among which postoperative pain is thought to play an important role in the development of POCD. This review summarizes the recent findings in the study of the role of postoperative pain in the pathogenesis of POCD in light of nerve injuries, neural remodeling and stress, and the progress in the prevention and treatment of POCD in elderly patients. It is of vital important to assess the postoperative pain and formulate adequate analgesic regimens for effective prevention and management of POCD to protect the brain functions of elderly patients.

The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly

STUDY OBJECTIVE

To determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly.

DESIGN

Retrospective cohort study.

SETTING

Postoperative recovery.

PATIENTS

8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class.

INTERVENTIONS

We used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate.

MEASUREMENTS

Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality.

MAIN RESULTS

After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94-11.14), pulmonary complications (OR 1.83, 95% CI 1.4-2.36), extended hospital stay (OR 1.47, 95% CI 1.26-1.72), readmission (OR 1.27, 95% CI 1.01-1.59) and mortality (OR 1.92, 95% CI 1.54-2.39) were all significantly higher in patients with preoperative delirium compared to those without.

CONCLUSIONS

After controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.

Elective lumbar fusion in the United States: national trends in inpatient complications and cost from 2002-2014

BACKGROUND

Elective fusions for degenerative spine disease have increased over the past two decades in the United States, with variability in complications and hospital costs. The additional service costs associated with adverse perioperative events remain unknown. Our objective is to improve understanding of trends in safety and cost of elective lumbar fusions on a national scale.

METHODS

A weighted sample of 1,526,386 adults undergoing elective lumbar fusion for degenerative indications were identified in the National Inpatient Sample (NIS) years 2002-2014. Twelve categories of major complications by system, and patient/hospital variables, were evaluated as predictors of the overall reimbursed cost. Mean differences (B) and 95% confidence intervals [95% CI] are reported. Significance is assessed at p<0.001.

RESULTS

Nineteen percent of patients experienced inpatient complication. After adjusting for inflation, the mean overall cost was $32802±19557. Costs increased with presence of each of the 12 categories of complications, and by number of levels fused. Rates of most frequent complications and their adjusted cost-of-care were acute postoperative anemia (11.2%, B=$1817 [$1722-$1913], p<0.001), renal/urinary (1.9%, B=$510 [$288-$732], p<0.001), pulmonary (1.8%, B=$6014 [$5785-6243], p<0.001) and gastrointestinal (1.8%, B=$3699 [$3490-$3908, p<0.001). The costliest adverse events were infection (B=$15882 [$15424-$16339], p<0.001), thromboembolism (B=$8856 [$8400-$9311], p<0.001), hematoma/seroma/vascular (B=$8050 [$7784-$8316], p<0.001).

CONCLUSIONS

The number of elective lumbar fusions for degenerative spine disease increased 276% in the United States from 2002-2014 with growing surgeon preference for lateral techniques, and an increasing proportion of combined anterior and posterior approaches. Overall complication rates decreased from 2002-2014, despite an older patient population. After adjusting for inflation, cost was relatively stable across years 2002-2014. Complications by system were associated with increased cost, underscoring the need to address sources of complications and optimize early postoperative recovery in order to reduce healthcare expenditure.

The impact of older age on patient outcomes following primary total knee arthroplasty

Aims

As the population ages, there is projected to be an increase in the level of demand for total knee arthroplasty (TKA) in octogenarians. We aimed to explore whether those aged ≥ 80 years achieved similar improvements in physical function to younger patients while also comparing the rates of length of stay (LOS), discharge to rehabilitation, postoperative complications, and mortality following TKA in older and younger patients.

Patients and Methods

Patients from one institution who underwent primary elective TKA between 1 January 2006 and 31 December 2014 were dichotomized into those ≥ 80 years old (n = 359) and those < 80 years old (n = 2479) for comparison. Multivariable regression was used to compare the physical status component of the 12-Item Short-Form Health Survey (SF-12), LOS, discharge to rehabilitation, complications, and mortality between the two groups.

Results

Both age groups demonstrated a clinically meaningful improvement in their self-reported physical health relative to their baseline with no clinically relevant difference noted between them. Being ≥ 80 years old was associated with a 0.58-day increase in LOS and older patients were more likely to be discharged to rehabilitation (odds ratio (OR) 3.06, p < 0.001). Medical complications and mortality were higher in elderly patients (OR 1.92 for complications, p < 0.001; hazard ratio 3.40 for death, p < 0.001). There was no statistically significant association between age group and experiencing a postoperative surgical or wound-related complication.

Conclusion

Those aged over 80 years achieved a statistically significant lower median SF-12 physical score than the younger group, after adjusting for the preoperative score, but this difference of 4.46 was not considered to be clinically meaningful. However, clinicians should be aware that the elderly are at a higher risk of experiencing longer hospital stays, postoperative medical complications, and mortality. Cite this article: Bone Joint J 2018;100-B:1463–70.