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Cross RE, de Klerk HH, Hilgersom NF, Bhashyam AR, van den Bekerom MPJ. Does Literature on Elbow Arthroscopy Put Complications Into Perspective? Arthroscopy 2024; 40:1386-1388. [PMID: 38342284 DOI: 10.1016/j.arthro.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/06/2024] [Indexed: 02/13/2024]
Affiliation(s)
| | - Huub H de Klerk
- Hand and Arm Center, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Nick F Hilgersom
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Abhiram R Bhashyam
- Hand and Arm Center, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
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Vernooij LM, van Klei WA, Moons KG, Takada T, van Waes J, Damen JA. The comparative and added prognostic value of biomarkers to the Revised Cardiac Risk Index for preoperative prediction of major adverse cardiac events and all-cause mortality in patients who undergo noncardiac surgery. Cochrane Database Syst Rev 2021; 12:CD013139. [PMID: 34931303 PMCID: PMC8689147 DOI: 10.1002/14651858.cd013139.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Revised Cardiac Risk Index (RCRI) is a widely acknowledged prognostic model to estimate preoperatively the probability of developing in-hospital major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the RCRI does not always make accurate predictions, so various studies have investigated whether biomarkers added to or compared with the RCRI could improve this. OBJECTIVES Primary: To investigate the added predictive value of biomarkers to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Secondary: To investigate the prognostic value of biomarkers compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Tertiary: To investigate the prognostic value of other prediction models compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. SEARCH METHODS We searched MEDLINE and Embase from 1 January 1999 (the year that the RCRI was published) until 25 June 2020. We also searched ISI Web of Science and SCOPUS for articles referring to the original RCRI development study in that period. SELECTION CRITERIA We included studies among adults who underwent noncardiac surgery, reporting on (external) validation of the RCRI and: - the addition of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of the RCRI to other models. Besides MACE, all other adverse outcomes were considered for inclusion. DATA COLLECTION AND ANALYSIS We developed a data extraction form based on the CHARMS checklist. Independent pairs of authors screened references, extracted data and assessed risk of bias and concerns regarding applicability according to PROBAST. For biomarkers and prediction models that were added or compared to the RCRI in ≥ 3 different articles, we described study characteristics and findings in further detail. We did not apply GRADE as no guidance is available for prognostic model reviews. MAIN RESULTS We screened 3960 records and included 107 articles. Over all objectives we rated risk of bias as high in ≥ 1 domain in 90% of included studies, particularly in the analysis domain. Statistical pooling or meta-analysis of reported results was impossible due to heterogeneity in various aspects: outcomes used, scale by which the biomarker was added/compared to the RCRI, prediction horizons and studied populations. Added predictive value of biomarkers to the RCRI Fifty-one studies reported on the added value of biomarkers to the RCRI. Sixty-nine different predictors were identified derived from blood (29%), imaging (33%) or other sources (38%). Addition of NT-proBNP, troponin or their combination improved the RCRI for predicting MACE (median delta c-statistics: 0.08, 0.14 and 0.12 for NT-proBNP, troponin and their combination, respectively). The median total net reclassification index (NRI) was 0.16 and 0.74 after addition of troponin and NT-proBNP to the RCRI, respectively. Calibration was not reported. To predict myocardial infarction, the median delta c-statistic when NT-proBNP was added to the RCRI was 0.09, and 0.06 for prediction of all-cause mortality and MACE combined. For BNP and copeptin, data were not sufficient to provide results on their added predictive performance, for any of the outcomes. Comparison of the predictive value of biomarkers to the RCRI Fifty-one studies assessed the predictive performance of biomarkers alone compared to the RCRI. We identified 60 unique predictors derived from blood (38%), imaging (30%) or other sources, such as the American Society of Anesthesiologists (ASA) classification (32%). Predictions were similar between the ASA classification and the RCRI for all studied outcomes. In studies different from those identified in objective 1, the median delta c-statistic was 0.15 and 0.12 in favour of BNP and NT-proBNP alone, respectively, when compared to the RCRI, for the prediction of MACE. For C-reactive protein, the predictive performance was similar to the RCRI. For other biomarkers and outcomes, data were insufficient to provide summary results. One study reported on calibration and none on reclassification. Comparison of the predictive value of other prognostic models to the RCRI Fifty-two articles compared the predictive ability of the RCRI to other prognostic models. Of these, 42% developed a new prediction model, 22% updated the RCRI, or another prediction model, and 37% validated an existing prediction model. None of the other prediction models showed better performance in predicting MACE than the RCRI. To predict myocardial infarction and cardiac arrest, ACS-NSQIP-MICA had a higher median delta c-statistic of 0.11 compared to the RCRI. To predict all-cause mortality, the median delta c-statistic was 0.15 higher in favour of ACS-NSQIP-SRS compared to the RCRI. Predictive performance was not better for CHADS2, CHA2DS2-VASc, R2CHADS2, Goldman index, Detsky index or VSG-CRI compared to the RCRI for any of the outcomes. Calibration and reclassification were reported in only one and three studies, respectively. AUTHORS' CONCLUSIONS Studies included in this review suggest that the predictive performance of the RCRI in predicting MACE is improved when NT-proBNP, troponin or their combination are added. Other studies indicate that BNP and NT-proBNP, when used in isolation, may even have a higher discriminative performance than the RCRI. There was insufficient evidence of a difference between the predictive accuracy of the RCRI and other prediction models in predicting MACE. However, ACS-NSQIP-MICA and ACS-NSQIP-SRS outperformed the RCRI in predicting myocardial infarction and cardiac arrest combined, and all-cause mortality, respectively. Nevertheless, the results cannot be interpreted as conclusive due to high risks of bias in a majority of papers, and pooling was impossible due to heterogeneity in outcomes, prediction horizons, biomarkers and studied populations. Future research on the added prognostic value of biomarkers to existing prediction models should focus on biomarkers with good predictive accuracy in other settings (e.g. diagnosis of myocardial infarction) and identification of biomarkers from omics data. They should be compared to novel biomarkers with so far insufficient evidence compared to established ones, including NT-proBNP or troponins. Adherence to recent guidance for prediction model studies (e.g. TRIPOD; PROBAST) and use of standardised outcome definitions in primary studies is highly recommended to facilitate systematic review and meta-analyses in the future.
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Affiliation(s)
- Lisette M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Anesthesiologist and R. Fraser Elliott Chair in Cardiac Anesthesia, Department of Anesthesia and Pain Management Toronto General Hospital, University Health Network and Professor, Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Karel Gm Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Judith van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Johanna Aag Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System. Anesthesiology 2021; 135:904-919. [PMID: 34491303 DOI: 10.1097/aln.0000000000003947] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The American Society of Anesthesiologists (ASA) Physical Status classification system celebrates its 80th anniversary in 2021. Its simplicity represents its greatest strength as well as a limitation in a world of comprehensive multisystem tools. It was developed for statistical purposes and not as a surgical risk predictor. However, since it correlates well with multiple outcomes, it is widely used-appropriately or not-for risk prediction and many other purposes. It is timely to review the history and development of the system. The authors describe the controversies surrounding the ASA Physical Status classification, including the problems of interrater reliability and its limitations as a risk predictor. Last, the authors reflect on the current status and potential future of the ASA Physical Status system.
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Laporta ML, Kruthiventi SC, Mantilla CB, Johnson RL, Sprung J, Portner ER, Schroeder DR, Weingarten TN. Three Risk Stratification Tools and Postoperative Pneumonia After Noncardiothoracic Surgery. Am Surg 2020; 87:1207-1213. [PMID: 33342277 DOI: 10.1177/0003134820956299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Postoperative in-hospital pneumonia is a serious complication. This study aims to investigate the association between 3 preoperative stratification tools (American Society of Anesthesiologists Physical Status [ASA-PS] score, Charlson Comorbidity Index [CCI], and Rockwood Frailty Deficit Index [FI]) and risk for postoperative pneumonia. METHODS We identified adult patients who developed postoperative pneumonia following noncardiothoracic surgery under general anesthesia, between January 1, 2016 and December 31, 2017. Patients with postoperative pneumonia were 1:1 matched to control subjects based on age, sex, and the exact type of operations. Medical records were reviewed to identify variables that may be associated with risk for developing postoperative pneumonia. Analyses adjusted for clinical characteristics were performed using the conditional logistic regression, taking into account 1:1 matched set case-control study design. RESULTS We identified 211 cases of postoperative pneumonia, and all 3 tested stratification tools were associated with increased risk: ASA-PS (after all adjustments of American Society of Anesthesiologists (ASA) III, odds ratio 4.17 [95% confidence interval 1.74-10.01]; ASA > III 24.03 [6.54-88.32]), CCI (CCI values > 3, 1.29 [1.02-1.63] per unit CCI score), and frail FI score 3.25 (1.45-7.27). Because of incomplete intake documentation, the FI could not be calculated in 57 (13.5%) patients, but these "unknown frailty" patients were also at increased risk for postoperative pneumonia, 3.15 (1.29-7.72). DISCUSSION Three commonly used stratification indices (ASA-PS score, CCI, and FI) were associated with increased risk for postoperative pneumonia. Patients unable to complete intake form to calculate the FI were also at increased risk.
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Affiliation(s)
- Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Carlos B Mantilla
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erica R Portner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Eminovic S, Vincze G, Eglseer D, Riedl R, Sadoghi P, Leithner A, Bernhardt GA. Malnutrition as predictor of poor outcome after total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2020; 45:51-56. [PMID: 33244636 PMCID: PMC7801298 DOI: 10.1007/s00264-020-04892-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 12/28/2022]
Abstract
Introduction The aim of this study was to assess the prevalence of protein energy malnutrition (PEM) and correlation with poor post-operative outcome in the elderly undergoing primary total hip arthroplasty (THA). Hypothesis Patients with PEM would have inferior post-operative outcome after THA. Materials and method We retrospectively evaluated the nutritional status of 220 hospitalized patients undergoing THA, 65 years and older. PEM was assessed using serum albumin and total lymphocyte count (TLC). Studied outcome parameters were length of pre-operative and post-operative stay, complications up to six months after surgery and 12-month mortality. Clinical and demographic data were retrieved from medical records from the hospital database. Results The prevalence of PEM among patients undergoing THA was 12.3% (27/220). Patients with PEM were significantly older (mean age 81.3 ± 7.0, p < 0.001), had a lower BMI (24.7 ± 4.1 kg/m 2, p = 0.022), and showed more comorbid conditions (mean CCI 2.8 ± 2.0, p = 0.002) compared with well-nourished patients (age 75.6 ± 6.2, BMI 26.8 ± 4.3 kg/m 2, CCI: 1.7 ± 1.7). Length of pre-operative stay differed significantly (p < 0.001) between PEM (median 7, range 1–36 days) and non PEM (median 1, range 1–22 days). In the PEM group, 12 (44.4%) patients had post-operative complications within six months after OP and 15 (7.8%) patients in the non PEM group (HR = 6.3, 95% CI 1.7–23.1). Conclusion We observed a higher post-operative complication rate for malnourished patients undergoing elective THA. These results underline the importance of pre-operative nutritional assessment in the elderly. Therefore, serum albumin and TLC are valuable clinical markers of PEM and the post-operative outcome.
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Affiliation(s)
- Sandra Eminovic
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Gabor Vincze
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Doris Eglseer
- Institute of Nursing Science, Medical University of Graz, Universitätsplatz 4, 8010, Graz, Austria
| | - Regina Riedl
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Auenbruggerplatz 2, 8036, Graz, Austria
| | - Patrick Sadoghi
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Andreas Leithner
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Gerwin A Bernhardt
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
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Cengic S, Zuberi M, Bansal V, Ratzlaff R, Rodrigues E, Festic E. Hypotension after intensive care unit drop-off in adult cardiac surgery patients. World J Crit Care Med 2020; 9:20-30. [PMID: 32577413 PMCID: PMC7298587 DOI: 10.5492/wjccm.v9.i2.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 05/08/2020] [Accepted: 05/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypotension is a frequent complication in the intensive care unit (ICU) after adult cardiac surgery.
AIM To describe frequency of hypotension in the ICU following adult cardiac surgery and its relation to the hospital outcomes.
METHODS A retrospective study of post-cardiac adult surgical patients at a tertiary academic medical center in a two-year period. We abstracted baseline demographics, comorbidities, and all pertinent clinical variables. The primary predictor variable was the development of hypotension within the first 30 min upon arrival to the ICU from the operating room (OR). The primary outcome was hospital mortality, and other outcomes included duration of mechanical ventilation (MV) in hours, and ICU and hospital length of stay in days.
RESULTS Of 417 patients, more than half (54%) experienced hypotension within 30 min upon arrival to the ICU. Presence of OR hypotension immediately prior to ICU transfer was significantly associated with ICU hypotension (odds ratio = 1.9; 95% confidence interval: 1.21-2.98; P < 0.006). ICU hypotensive patients had longer MV, 5 (interquartile ranges 3, 15) vs 4 h (interquartile ranges 3, 6), P = 0.012. The patients who received vasopressor boluses (n = 212) were more likely to experience ICU drop-off hypotension (odds ratio = 1.45, 95% confidence interval: 0.98-2.13; P = 0.062), and they experienced longer MV, ICU and hospital length of stay (P < 0.001, for all).
CONCLUSION Hypotension upon anesthesia-to-ICU drop-off is more frequent than previously reported and may be associated with adverse clinical outcomes.
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Affiliation(s)
- Sabina Cengic
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
- Department of General Surgery, Stadtspital Triemli, Zurich 8063, Switzerland
| | - Muhammad Zuberi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Vikas Bansal
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Robert Ratzlaff
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Eduardo Rodrigues
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Emir Festic
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
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Ferrari LR, Leahy I, Staffa SJ, Johnson C, Crofton C, Methot C, Berry JG. One Size Does Not Fit All. Anesth Analg 2020; 130:1685-1692. [DOI: 10.1213/ane.0000000000004277] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kim S, Choi N, Shin M, Jung D. Clinical Safety of Laparoscopic Cholecystectomy in Elderly Patients: A Comparison of Clinical Outcomes in Patients Aged 65 to 79 Years and over 80 Years. JOURNAL OF ACUTE CARE SURGERY 2020. [DOI: 10.17479/jacs.2020.10.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Joynt GM, Gopalan PD, Argent A, Chetty S, Wise R, Lai VKW, Hodgson E, Lee A, Joubert I, Mokgokong S, Tshukutsoane S, Richards GA, Menezes C, Mathivha LR, Espen B, Levy B, Asante K, Paruk F. The Critical Care Society of Southern Africa Consensus Guideline on ICU Triage and Rationing (ConICTri). SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2019; 35:10.7196/SAJCC.2019.v35i1b.380. [PMID: 37719328 PMCID: PMC10503493 DOI: 10.7196/sajcc.2019.v35i1b.380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2019] [Indexed: 11/08/2022] Open
Abstract
Background In South Africa (SA), administrators and intensive care practitioners are faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience the consequences of limited resources daily. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are routinely necessary in SA, particularly in the publicly funded health sector. Purpose The purpose of this guideline is to utilise the relevant recommendations of the associated consensus meeting document and other internationally accepted principles to develop a guideline to inform frontline triage policy and ensure the best utilisation of adult intensive care in SA, while maintaining the fair distribution of available resources. Recommendations An overall conceptual framework for the triage process was developed. The components of the framework were developed on the basis that patients should be admitted preferentially when the likely incremental medical benefit derived from ICU admission justifies admission. An estimate of likely resource use should also form part of the triage decision, with those patients requiring relatively less resources to achieve substantial benefit receiving priority for admission. Thus, the triage system should maximise the benefits obtained from ICU resources available for the community. Where possible, practical examples of what the consensus group agreed would be considered appropriate practice under specified South African circumstances were provided, to assist clinicians with practical decision-making. It must be stressed that this guideline is not intended to be prescriptive for individual hospital or regional practice, and hospitals and regions are encouraged to develop specified local guidelines with locally relevant examples. The guideline should be reviewed and revised if appropriate within 5 years. Conclusion In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, this guideline has been developed to guide policy-making and assist frontline triage decision-making in SA. This document is not a complete plan for quality practice, but rather a template to support frontline clinicians, guide administrators and inform the public regarding appropriate triage decision-making.
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Affiliation(s)
- G M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - P D Gopalan
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - A Argent
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | - S Chetty
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Cape Town, South Africa
| | - R Wise
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, and Edendale Hospital,
Pietermaritzburg, South Africa
| | - V K W Lai
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - E Hodgson
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, and Inkosi Albert Luthuli
Central Hospital, Durban, South Africa
| | - A Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - I Joubert
- Department of Anaesthesia and Peri-operative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - S Mokgokong
- Department of Neurosurgery, University of Pretoria, South Africa
| | - S Tshukutsoane
- Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
| | - G A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C Menezes
- Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - L R Mathivha
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - B Espen
- Centre for Health Professions Education, Stellenbosch University, Cape Town, South Africa
| | - B Levy
- Netcare Rosebank Hospital, Johannesburg, South Africa
| | - K Asante
- African Organization for Research and Training in Cancer, Cape Town, South Africa
| | - F Paruk
- Department of Critical Care, University of Pretoria, South Africa
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Huynh TT, Liesching TN, Cereda M, Lei Y, Frazer MJ, Nahouraii MR, Diette GB. Efficacy of Oscillation and Lung Expansion in Reducing Postoperative Pulmonary Complication. J Am Coll Surg 2019; 229:458-466.e1. [PMID: 31362061 DOI: 10.1016/j.jamcollsurg.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 06/25/2019] [Accepted: 06/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postoperative pulmonary complications (PPCs) cause high morbidity and mortality. Targeted treatment for patients at risk for PPCs can improve outcomes. This multicenter prospective trial examined the impact of oscillation and lung expansion (OLE) therapy, using continuous high-frequency oscillation and continuous positive expiratory pressure on PPCs in high-risk patients. METHODS In stage I, CPT and ICD codes were queried for patients (n = 210) undergoing thoracic, upper abdominal, or aortic open procedures at 3 institutions from December 2014 to April 2016. Patients were selected randomly. Age, comorbidities, American Society of Anesthesiologists physical status classification scores, and PPC rates were determined. In stage II, 209 subjects were enrolled prospectively from October 2016 to July 2017 using the same criteria. Stage II subjects received OLE treatment and standard respiratory care. The PPCs rate (prolonged ventilation, high-level respiratory support, pneumonia, ICU readmission) were compared. We also compared ICU length of stay (LOS), hospital LOS, and mortality using t-tests and analysis of covariance. Data are mean ± SD. RESULTS There were 419 subjects. Stage II patients were older (61.1 ± 13.7 years vs 57.4 ± 15.5 years; p < 0.05) and had higher American Society of Anesthesiologists scores. Treatment with OLE decreased PPCs from 22.9% (stage I) to 15.8% (stage II) (p < 0.01 adjusted for age, American Society of Anesthesiologists score, and operation time). Similarly, OLE treatment reduced ventilator time (23.7 ± 107.5 hours to 8.5 ± 27.5 hours; p < 0.05) and hospital LOS (8.4 ± 7.9 days to 6.8 ± 5.0 days; p < 0.05). No differences in ICU LOS, pneumonia, or mortality were observed. CONCLUSIONS Aggressive treatment with OLE reduces PPCs and resource use in high-risk surgical patients.
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Affiliation(s)
- Toan T Huynh
- Division of Acute Care Surgery, The FH "Sammy" Ross Jr Trauma Center, Carolinas Medical Center, Atrium Health, Charlotte, NC.
| | - Timothy N Liesching
- Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Yuxiu Lei
- Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA
| | - Michael J Frazer
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Michael R Nahouraii
- Division of Acute Care Surgery, The FH "Sammy" Ross Jr Trauma Center, Carolinas Medical Center, Atrium Health, Charlotte, NC
| | - Gregory B Diette
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
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Patel J, Fang J, Taylor LJ, Adler DG, Gawron AJ. Safety and efficacy of non-anesthesiologist administration of propofol sedation during esophagogastroduodenoscopy in the intensive care unit. Endosc Int Open 2019; 7:E625-E629. [PMID: 30993168 PMCID: PMC6461546 DOI: 10.1055/a-0829-6284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/15/2018] [Indexed: 12/17/2022] Open
Abstract
Background and study aims Propofol sedation is an increasingly popular method of sedation for gastrointestinal endoscopic procedures. The safety and efficacy of the non-anesthesiologist administration of propofol (NAAP) sedation has been demonstrated in the ambulatory setting. However, NAAP sedation in intensive care unit (ICU) patients has not been reported. The purpose of this study is to determine safety and efficacy of NAAP sedation in an ICU population. Methods We retrospectively reviewed esophagogastroduodenoscopies (EGD) performed with NAAP sedation in our intensive care units from June 2014 to September 2016. All EGDs were performed for evaluation of gastrointestinal bleeding. The primary end point of this study was to analyze the incidence of sedation-related adverse events (AEs). The secondary end points included successful completion of procedure and any endoscopic interventions performed. Results Two of 161 procedures (1.2 %) had sedation-related AEs requiring procedure termination. One hundred forty-six of 161 procedures (90.7 %) were successfully completed. Incomplete procedures were due to excess heme, retained food or obstructive lesions (13/161, 8.1 %). Endoscopic intervention was performed successfully in 17/24 cases (70.8 %) that had endoscopically treated lesions identified. One hundred six of 161 patients (66 %) were American Society of Anesthesiologists (ASA) classification III or IV. Conclusion Our retrospective analysis demonstrated that EGDs can be successfully completed in ICU patients using NAAP sedation. When procedures cannot be completed, it is rarely due to sedation-related AEs. NAAP sedation further allows adequate examination and successful treatment of high-risk lesions. NAAP sedation appears safe and effective for endoscopic procedures in the ICU setting.
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Affiliation(s)
- Janaki Patel
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - John Fang
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Linda J. Taylor
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Douglas G. Adler
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Andrew J. Gawron
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States,Corresponding author Andrew J. Gawron 30 N 1900 E, SOM 4R118Salt Lake City, UT 84132+1-801-581-7476
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Miyamoto S, Nakamura J, Iida S, Shigemura T, Kishida S, Abe I, Takeshita M, Otsuka M, Harada Y, Orita S, Ohtori S. The influence of bone cement and American Society of Anesthesiologists (ASA) class on cardiovascular status during bipolar hemiarthroplasty for displaced femoral-neck fracture: A multicenter, prospective, case-control study. Orthop Traumatol Surg Res 2018; 104:687-694. [PMID: 29783039 DOI: 10.1016/j.otsr.2018.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/23/2018] [Accepted: 03/26/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Little is known about how bone cement and American Society of Anesthesiologists (ASA) classification influence the cardiovascular system in elderly patients with femoral-neck fractures treated with cemented hemiarthroplasty. Therefore, we performed a case-control study to investigate these questions and compared the following:≥ASA III with≤ASA II patients who underwent cemented hemiarthroplasty; and cemented with cementless hemiarthroplasty in≥ASA III patients. HYPOTHESIS ASA classification influences the cardiovascular system during cemented hemiarthroplasty and bone cement influences intraoperative blood pressure [IBP] in patients rated≥ASA III. MATERIALS AND METHODS This multicenter, prospective study included patients with acute displaced femoral-neck fractures. Baseline data, medical history, anesthesia, FiO2, vasopressor use, femoral component, IBP, SpO2, and complications were evaluated. Of 200 patients, 100 were cemented (mean age, 77±10 years), and 100 were cementless (mean age, 78±9 years). Cemented hemiarthroplasty employed a third-generation technique (plugging, irrigating, drying and filling the canal with cement under pressurization). RESULTS Systolic blood pressure (SBP) decreased significantly during cementing, versus pre-rasping in≤ASA II patients (from 117.9±24.5 [range, 65-199] to 106.9±20.3 [range, 59-172]; p=0.007), in≥ASA III patients (from 129.5±21.0 [range, 90-169] to 110.4±17.9 [range, 79-157]; p=0.006), and post-stem-insertion, versus pre-rasping in≤ASA II patients (from 117.9±24.5 [range, 65-199] to 103.9±20.7 [range, 53-178]; p=0.0004), and in≥ASA III patients (from 129.5±21.0 [range, 90-169] to 111.2±24.6 [range, 70-156]; p=0.009). In≥ASA III patients, SBP decreased significantly during cementing or rasping, versus pre-rasping in cemented patients (from 129.5±21.0 [range, 90-169] to 110.4±17.9 [range, 79-157]; p=0.006), in cementless patients (from 115.0±17.7 [range, 85-150] to 100.7±15.7 [range, 75-142]; p=0.004), and post-stem-insertion, versus pre-rasping in cemented patients (from 129.5±21.0 [range, 90-169] to 111.2±SD [range]; p=0.009), and in cementless patients (from 115.0±17.7 [range, 85-150] to 89.4±17.5 [range, 58-140]; p<0.0001). There were no lethal complications. CONCLUSIONS This study indicate a similar hemodynamic change intraoperatively between≤ASA II patients and≥ASA III patients in the cemented group, and between patients with cemented and cementless hemiarthroplasty in the≥ASA III patients. With modern hemiarthroplasty techniques, bone cement might be as safe as cementless techniques in elderly,≥ASA III patients. LEVEL OF EVIDENCE III, multicenter case-control cohort study.
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Affiliation(s)
- Shuichi Miyamoto
- Kimitsu Central Hospital, 1010 Sakurai, 292-8535 Kisarazu city, Chiba, Japan.
| | - Junichi Nakamura
- Graduate School of Medicine, Chiba University, 1-8-1, Inohana Chuo-ku, 260-8677 Chiba city, Chiba, Japan
| | - Satoshi Iida
- Matudo City Hospital, 4005 Kamihongou, 271-8511 Matudo city, Chiba, Japan
| | | | - Shunji Kishida
- Seirei Sakura Citizen Hospital, 2-36-2 Eharadai, 285-8765 Sakura city, Chiba, Japan
| | - Isao Abe
- National Hospital Organization Chiba Medical Center, 4-1-2 Tubakinomori, 260-8606 Chuo-ku, Chiba city, Chiba, Japan
| | - Munenori Takeshita
- Kimitsu Central Hospital, 1010 Sakurai, 292-8535 Kisarazu city, Chiba, Japan
| | - Makoto Otsuka
- Kimitsu Central Hospital, 1010 Sakurai, 292-8535 Kisarazu city, Chiba, Japan
| | - Yoshitada Harada
- Saiseikai Narashino Hospital, 1-1-1 Izumichou, 275-8580 Narashino City, Chiba, Japan
| | - Sumihisa Orita
- Graduate School of Medicine, Chiba University, 1-8-1, Inohana Chuo-ku, 260-8677 Chiba city, Chiba, Japan
| | - Seiji Ohtori
- Graduate School of Medicine, Chiba University, 1-8-1, Inohana Chuo-ku, 260-8677 Chiba city, Chiba, Japan
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Noticewala MS, Trofa DP, Vance DD, Jobin CM, Levine WN, Ahmad CS. Elbow Arthroscopy: 30-Day Postoperative Complication Profile and Associated Risk Factors. Arthroscopy 2018; 34:414-420. [PMID: 29273253 DOI: 10.1016/j.arthro.2017.08.286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 08/18/2017] [Accepted: 08/19/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze (1) the incidence and type of complications after elbow arthroscopy, (2) the incidence of returning to the operating room (OR) after elbow arthroscopy, and (3) patient and risk factors for complications across a national surgical outcome database. METHODS Patients who underwent elbow arthroscopy from January 2005 through December 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database by use of Current Procedural Terminology codes. Basic patient demographic data and medical comorbidities were recorded. Postoperative adverse events and a return to the OR occurring within 30 days after the index procedure were identified, and patient and procedural risk factors were investigated. RESULTS Five hundred thirty elbow arthroscopy cases were available for analysis. The aggregate rate of 30-day adverse events was 2.83%, whereas the rate of any patient having an adverse event was 1.89%. The most common adverse event was deep infection (0.57%). Univariate analyses showed that renal disease, preoperative steroid use, higher American Society of Anesthesiologists (ASA) class, and preoperative diagnosis were associated with the occurrence of an adverse event. Multivariate analyses showed that increasing ASA class, specifically ASA class 3 and class 4, was an independent predictor of a postoperative adverse event. Furthermore, 0.94% of cases required a return to the OR. Univariate analyses showed that preoperative steroid use and diagnosis of trauma were associated with a return to the OR. These findings were confirmed by multivariate analyses. CONCLUSIONS Overall, the incidence of 30-day postoperative adverse events (1.89%) and need to return to the OR (0.94%) is low. Increased ASA class is an independent risk factor for the occurrence of a postoperative adverse event; preoperative steroid use and diagnoses relating to a traumatic or inflammatory cause are predictive of the need to return to the OR. These results can assist surgeons in patient selection, preoperative optimization, and preoperative risk stratification. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Manish S Noticewala
- Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York, U.S.A..
| | - David P Trofa
- Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York, U.S.A
| | - Danica D Vance
- Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York, U.S.A
| | - Charles M Jobin
- Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York, U.S.A
| | - William N Levine
- Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York, U.S.A
| | - Christopher S Ahmad
- Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York, U.S.A
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Patel SK, Kacheriwala SM, Duttaroy DD. Audit of Postoperative Surgical Intensive Care Unit Admissions. Indian J Crit Care Med 2018; 22:10-15. [PMID: 29422726 PMCID: PMC5793015 DOI: 10.4103/ijccm.ijccm_387_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective The objective of this study was to conduct an audit of Surgical Intensive Care Unit (SICU) for identifying the admission risk factors and evaluating the outcomes of postoperative surgical patients. Design This was a prospective, observational study. Setting This study was conducted at SICU of a 1500-bedded tertiary care university hospital in Western India. Subject and Methods Two hundred and forty patients admitted to the SICU postoperatively over a period of 15 months. Results Planned and unplanned postoperative SICU admission rate was 4.45% and 0.09% of the 5284 patients operated. Indications for planned admissions included preoperative medical illnesses, anticipated blood loss, and anticipated mechanical ventilation while unpredicted intraoperative hypotension was the principal cause of unplanned admittance. Univariate analysis for two groups of the American Society of Anesthesiologists (ASA) physical status indicated that advanced age, high American College of Cardiology/American Heart Association (ACC/AHA) surgical risk, emergency surgery, planned admissions, and mortality were related to high ASA class. Analysis for ACC/AHA surgical risk showed association of high ACC/AHA surgical risk with advanced age, male gender, high ASA physical status, emergency surgery, planned admissions, and mortality. High mortality was observed in patients with SICU stay of >7 days (75.86%) and readmitted cases (72.73%). Conclusion The need for postoperative critical care is significantly higher in males, elderly, patients with poor preoperative risk stratification scores, preexisting medical illness, major intraoperative hemorrhage, hypotension requiring inotropic support, perioperative respiratory problems and patients undergoing abdominal, trauma, and emergent surgeries. A larger study inclusive of other surgical subspecialties would aid in optimal decision-making for admissions to the SICU.
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Affiliation(s)
- Shaili K Patel
- Department of Surgery, Medical College Baroda, Sir Sayajirao General Hospital, Vadodara, Gujarat, India
| | - Samir M Kacheriwala
- Department of Surgery, Medical College Baroda, Sir Sayajirao General Hospital, Vadodara, Gujarat, India
| | - Dipesh D Duttaroy
- Department of Surgery, Medical College Baroda, Sir Sayajirao General Hospital, Vadodara, Gujarat, India
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Moran GW, Li G, Robins DJ, Matulay JT, McKiernan JM, Anderson CB. Systematic Review and Meta-Analysis on the Efficacy of Chemotherapy with Transurethral Resection of Bladder Tumors as Definitive Therapy for Muscle Invasive Bladder Cancer. Bladder Cancer 2017; 3:245-258. [PMID: 29152549 PMCID: PMC5676763 DOI: 10.3233/blc-170134] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: Bladder-sparing treatment of muscle invasive bladder cancer (MIBC) with systemic chemotherapy plus transurethral resection of bladder tumors (TURBT) is increasingly seen in the literature –both in case series and subanalyses of patients who opt out of or are unfit for radical cystectomy (RC). Survival outcomes among these patients are often impressive, but these are typically small retrospective studies from single institutions and therefore of limited clinical value. Objectives: Our aim is to summarize the literature regarding definitive treatment of MIBC with systemic chemotherapy plus TURBT and provide a meta-analysis of survival outcomes for patients who received this treatment. Methods: A systematic literature search was performed consistent with the Prisma statement to identify publications reporting the outcomes of patients treated with TURBT and systemic chemotherapy as definitive treatment for locally confined MIBC. Identified studies were screened in a two-stage process: first by title and abstract; then by full-text reading. 18 publications (518 patients) were included in the qualitative systematic review and 10 publications (266 patients) were included in the meta-analysis. The primary objective was overall survival (OS). Results: Overall survival ranged from 20% to 87.5% across studies at median follow-up ranging 4 to 120 months. 5-year survival rate for all patients included in the meta-analysis was estimated to be 72% [95% CI: 64%, 82%]. Conclusions: Definitive treatment with systemic chemotherapy plus TURBT can lead to favorable survival outcomes in select patients. Further study to improve patient selection for this method of treatment is needed.
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Affiliation(s)
- George W Moran
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Gen Li
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dennis J Robins
- Department of Urology, Columbia University Irving Medical Center, New York, NY, USA
| | - Justin T Matulay
- Department of Urology, Columbia University Irving Medical Center, New York, NY, USA
| | - James M McKiernan
- Department of Urology, Columbia University Irving Medical Center, New York, NY, USA
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Bateni SB, Bold RJ, Meyers FJ, Canter DJ, Canter RJ. Comparison of common risk stratification indices to predict outcomes among stage IV cancer patients with bowel obstruction undergoing surgery. J Surg Oncol 2017; 117:479-487. [PMID: 29044598 DOI: 10.1002/jso.24866] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/01/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Among patients with disseminated malignancy (DMa), bowel obstruction is common with high operative morbidity. Since preoperative risk stratification is critical, we sought to compare three standard risk indices, the American Society of Anesthesiology (ASA) classification, Charlson comorbidity index (CCI), and modified frailty index (mFI). METHODS We identified 1928 DMa patients with bowel obstruction who underwent an abdominal operation from 2007 to 2012 American College of Surgeons National Surgical Quality Improvement Program. Multivariate analyses assessed predictors of prolonged length of stay (LOS), 30-day serious morbidity and mortality. Receiver operating characteristics' areas under the curves (AUCs) for risk indices scores and 30-day mortality were assessed. RESULTS Serious morbidity and mortality rates were 20.4% and 14.8%. ASA and CCI did not predict serious morbidity or prolonged LOS, but were predictors of mortality. The mFI did not predict prolonged LOS, but did predict serious morbidity and mortality. Subgroup analyses showed similar results. There were no significant differences between ASA, CCI, and mFI AUCs for mortality. CONCLUSIONS ASA, CCI, and mFI are limited in their ability to predict postoperative adverse events among DMa patients undergoing surgery for bowel obstruction. These data suggest that a more tailored preoperative risk stratification tool would improve treatment planning.
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Affiliation(s)
- Sarah B Bateni
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Richard J Bold
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Frederick J Meyers
- Division of Hematology/Oncology, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California
| | - Daniel J Canter
- Department of Urology, Ochsner Clinic, New Orleans, Louisiana
| | - Robert J Canter
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California
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Fariña-Castro R, Roque-Castellano C, Marchena-Gómez J, Rodríguez-Pérez A. Five-year survival after surgery in nonagenarian patients. Geriatr Gerontol Int 2017; 17:2389-2395. [PMID: 28675571 DOI: 10.1111/ggi.13081] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/14/2017] [Accepted: 03/28/2017] [Indexed: 11/26/2022]
Abstract
AIM In countries with longer life expectancies, the nonagenarian population is increasing. Therefore, there is greater demand for healthcare, including surgical procedures. The aim of the present study was to determine the outcomes of surgery carried out on nonagenarians in terms of long-term survival after the procedure. METHODS We carried out a cross-longitudinal study on a cohort of 159 nonagenarian patients, who underwent a non-cardiac, non-traumatic surgical procedure in our institution between January 1999 and December 2011. The following variables were recorded: sociodemographic characteristics, American Society of Anesthesiologists score, Charlson Comorbidity Index, surgical site, postoperative complications, operative mortality and long-term survival. The output variable was long-term survival. RESULTS Of the 159 patients,99 women (62%) and 60 men (38%), with a mean age of 91.8 years (SD ± 2.0 years), 44 cases were operations for malignant disorders (28%), 117 cases (74%) under emergency conditions and 42 cases (26%) were elective treatments. The operative mortality was 29%, 4.8% for elective surgery and 37.6% for emergency surgery (P < 0.001). The postoperative complication rate, including death, was 60%. The probability of survival at 1, 3, and 5 years was 59.6%, 35.8% and 24.1%, respectively. In multivariate analysis, American Society of Anesthesiologists score (HR 2.07, 95% CI 1.58-2.72), emergency surgery (HR 1.64, 95% CI 1.05-2.57) and postoperative medical complications (HR 2.58, 95% CI 1.73-3.85) were independently related to 5-year survival. CONCLUSIONS These findings support the perioperative safety of elective general surgery in nonagenarian patients. In selected nonagenarian patients with no cognitive impairment, surgery must not be denied. These data might be useful for surgical decision-making or informed consent for nonagerians. Geriatr Gerontol Int 2017; 17: 2389-2395.
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Affiliation(s)
- Roberto Fariña-Castro
- Department of Anesthesiology, University Hospital of Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Cristina Roque-Castellano
- Department of General and Digestive Surgery, University Hospital of Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Joaquín Marchena-Gómez
- Department of General and Digestive Surgery, University Hospital of Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Aurelio Rodríguez-Pérez
- Department of Anesthesiology, University Hospital of Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Smith MD, Barletta M, Young CN, Hofmeister EH. Retrospective study of intra-anesthetic predictors of prolonged hospitalization, increased cost of care and mortality for canine patients at a veterinary teaching hospital. Vet Anaesth Analg 2017; 44:1321-1331. [PMID: 29174211 DOI: 10.1016/j.vaa.2017.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 02/22/2017] [Accepted: 04/24/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the impact of intraoperative anesthetic variables on the length of hospitalization, cost of care and mortality in dogs. STUDY DESIGN Retrospective, observational study. ANIMALS A total of 235 dogs undergoing general anesthesia. METHODS Medical records of dogs undergoing general anesthesia between 2007 and 2014 at the University of Georgia Veterinary Teaching Hospital were reviewed. Data collected included demographic data, American Society of Anesthesiologists (ASA) physical status, type and duration of anesthesia, hemodynamic variables, temperature, ventilation, fluid therapy and adjunctive drugs administered. Outcome variables were length of hospitalization in the intensive care unit (ICU), hospital charges and survival to discharge. RESULTS The only factor significantly associated with duration of ICU care was higher ASA status (p<0.0001). Factors associated with increased cost of hospitalization were ICU duration (p<0.0001), anesthesia duration (p<0.0001), hemorrhage amount (p<0.0001), colloid use (p=0.0081), increased age (p=0.0253), increased weight (p = 0.0293) and presence of hypertension (p=0.0179). Overall mortality rate was 5.1%. The only factors negatively associated with survival were the administration of colloids (p<0.0008) and ASA status (p=0.0314). CONCLUSIONS AND CLINICAL RELEVANCE Several intrinsic patient factors and intraoperative hemodynamic variables were significantly associated with postoperative morbidity and mortality in dogs. These factors might have prognostic value in conjunction with preoperative risk assessment, and patient outcome may be improved by stricter intraoperative control of these variables.
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Affiliation(s)
- Melissa D Smith
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA, USA.
| | - Michele Barletta
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
| | - Courtni N Young
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
| | - Erik H Hofmeister
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
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Copeland CC, Young A, Grogan T, Gabel E, Dhillon A, Gudzenko V. Preoperative risk stratification of critically ill patients. J Clin Anesth 2017; 39:122-127. [PMID: 28494887 DOI: 10.1016/j.jclinane.2017.03.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/07/2017] [Accepted: 03/31/2017] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE Risk assessment historically emphasized cardiac morbidity and mortality in elective, outpatient, non-cardiac surgery. However, critically ill patients increasingly present for therapeutic interventions. Our study investigated the relationship of American Society of Anesthesiologists (ASA) class, revised cardiac risk index (RCRI), and sequential organ failure assessment (SOFA) score with survival to discharge in critically ill patients with respiratory failure. DESIGN Retrospective cohort analysis over a 21-month period. SETTING Five adult intensive care units (ICUs) at a single tertiary medical center. PATIENTS Three hundred fifty ICU patients in respiratory failure, who underwent 501 procedures with general anesthesia. MEASUREMENTS Demographic, clinical, and surgical variables were collected from the pre-anesthesia evaluation forms and preoperative ICU charts. The primary outcome was survival to discharge. MAIN RESULTS Ninety-six patients (27%) did not survive to discharge. There were significant differences between survivors and non-survivors for ASA (3.7 vs. 3.9, p=0.001), RCRI (1.6 vs. 2.0, p=0.003), and SOFA score (8.1 vs. 11.2, p<0.001). Based on the area under the receiver operating characteristic curve for these relationships, there was only modest discrimination between the groups, ranging from the most useful SOFA (0.68) to less useful RCRI (0.60) and ASA (0.59). CONCLUSIONS This single center retrospective study quantified a high perioperative risk for critically ill patients with advanced airways: one in four did not survive to discharge. Preoperative ASA score, RCRI, and SOFA score only partially delineated survivors and non-survivors. Given the existing limitations, future research may identify assessment tools more relevant to discriminating survival outcomes for critically ill patients in the perioperative environment.
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Affiliation(s)
- Curtis C Copeland
- U.S. Air Force School of Aerospace Medicine, Center for the Sustainment of Trauma and Readiness Skills, Baltimore, United States; University of Maryland School of Medicine, Department of Anesthesiology, R Adams Cowley Shock Trauma Center, US Air Force C-STARS Baltimore, 22 S. Greene Street, T4M14, Baltimore, MD 21201, United States; David Geffen School of Medicine, Ronald Reagan Medical Center, UCLA, 757 Westwood Plz. Suite 3325, Los Angeles, CA 90095, United States.
| | - Andrew Young
- David Geffen School of Medicine, Ronald Reagan Medical Center, UCLA, 757 Westwood Plz. Suite 3325, Los Angeles, CA 90095, United States
| | - Tristan Grogan
- David Geffen School of Medicine, Ronald Reagan Medical Center, UCLA, 757 Westwood Plz. Suite 3325, Los Angeles, CA 90095, United States
| | - Eilon Gabel
- David Geffen School of Medicine, Ronald Reagan Medical Center, UCLA, 757 Westwood Plz. Suite 3325, Los Angeles, CA 90095, United States
| | - Anahat Dhillon
- David Geffen School of Medicine, Ronald Reagan Medical Center, UCLA, 757 Westwood Plz. Suite 3325, Los Angeles, CA 90095, United States
| | - Vadim Gudzenko
- David Geffen School of Medicine, Ronald Reagan Medical Center, UCLA, 757 Westwood Plz. Suite 3325, Los Angeles, CA 90095, United States
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Loeffelbein D, Ritschl L, Güll F, Roth M, Wolff KD, Mücke T. Influence of possible predictor variables on the outcome of primary oral squamous cell carcinoma: a retrospective study of 392 consecutive cases at a single centre. Int J Oral Maxillofac Surg 2017; 46:413-421. [DOI: 10.1016/j.ijom.2016.11.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/11/2016] [Accepted: 11/25/2016] [Indexed: 12/15/2022]
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Hansen MS, Petersen EE, Dahl JB, Wetterslev J. Post-operative serious adverse events in a mixed surgical population - a retrospective register study. Acta Anaesthesiol Scand 2016; 60:1209-21. [PMID: 27417678 DOI: 10.1111/aas.12762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/11/2016] [Accepted: 06/15/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The number of surgical procedures is increasing, and knowledge of surgical risk factors, post-operative mortality and serious adverse events (SAE) is essential. The aim with our study was to determine the risk of a composite outcome of post-operative: death; myocardial infarction; pulmonary embolism; stroke; gastrointestinal bleeding; dialysis or reoperation. METHODS Data of surgical procedures in the period from January 1, 2012 to June 30, 2012 were retrieved from the Danish Anaesthesia Database (DAD). Follow-up of all patients undergoing hip or knee replacement, abdominal or gynaecological surgery was conducted retrieving data from The Danish Civil Registration System and the National Patient Register. Total observation time was from January 1, 2012 to June 6, 2013. RESULTS A total7449 adult patients were included in the final analysis. The risk of the composite outcome during a follow-up until 342 days after inclusion of the last patient was estimated to 8.3%, 95% Confidence Intervals (CI) (7.8-9.0), with a median observation time of 437 days (IQR 387-485, range 0-522). The risk of the composite outcome within 90- and 180-day follow-up of each patient was 4.8% (4.4-5.3) and 5.9% (5.4-6.5), respectively. Mortality within longest follow-up as well as 90 and 180 days post-operatively was 3.6% (3.1-4.0), 1.7% (1.4-2.0), and 2.2% (1.9-2.6), respectively. CONCLUSION We found a risk of one or more events in the composite outcome within 342 days after inclusion of the last patients of 8.3% (7.8-9.0). The results are applicable in estimations of adequate sample sizes in future clinical trials investigating effects of interventions on SAEs.
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Affiliation(s)
- M. S. Hansen
- Department of Anaesthesiology; Dep. 4231; Centre of Head and Orthopaedics; Rigshospitalet; Copenhagen Denmark
| | - E. E. Petersen
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Dep. 7812; Copenhagen Denmark
| | - J. B. Dahl
- Department of Anaesthesiology; Dep. Z; Bispebjerg Hospital; København Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Dep. 7812; Copenhagen Denmark
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22
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Yurtlu DA, Aksun M, Ayvat P, Karahan N, Koroglu L, Aran GÖ. Comparison of Risk Scoring Systems to Predict the Outcome in ASA-PS V Patients Undergoing Surgery: A Retrospective Cohort Study. Medicine (Baltimore) 2016; 95:e3238. [PMID: 27043696 PMCID: PMC4998557 DOI: 10.1097/md.0000000000003238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Operative decision in American Society of Anesthesiology Physical Status (ASA-PS) V patient is difficult as this group of patients expected to have high mortality rate. Another risk scoring system in this ASA-PS V subset of patients can aid to ease this decision. Data of ASA-PS V classified patients between 2011 and 2013 years in a single hospital were analyzed in this study. Predicted mortality of these patients was determined with acute physiology and chronic health evaluations (APACHE) II, simplified acute physiology score (SAPS II), Charlson comorbidity index (CCI), Porthsmouth physiological and operative severity score for enumeration of mortality and morbidity (P-POSSUM), Surgical apgar score (SAS), and Goldman cardiac risk index (GCRI) scores. Observed and predicted mortality rates according to the risk indexes in these patients were compared at survivor and nonsurvivor group of patients. Risk stratification was made with receiver operator characteristic (ROC) curve analysis. Data of 89 patients were included in the analyses. Predicted mortality rates generated by APACHE II and SAPS II scoring systems were significantly different between survivor and nonsurvivor group of patients. Risk stratification with ROC analysis revealed that area under curve was 0.784 and 0.681 for SAPS II and APACHE II scoring systems, respectively. Highest sensitivity (77.3) is reached with SAPS II score. APACHE II and SAPS II are better predictive tools of mortality in ASA-PS V classified subset of patients. Discrimination power of SAPS II score is the best among the compared risk stratification scores. SAPS II can be suggested as an additional risk scoring system for ASA-PS V patients.
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Affiliation(s)
- Derya Arslan Yurtlu
- From the Anesthesiology and Reanimation Department, İzmir Atatürk Education and Research Hospital, İzmir, Turkey
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23
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Nordin A, Freedman J. Laparoscopic versus open surgical management of small bowel obstruction: an analysis of clinical outcomes. Surg Endosc 2016; 30:4454-63. [PMID: 26928189 DOI: 10.1007/s00464-016-4776-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/16/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Laparotomy is the standard surgical approach for treatment of small bowel obstruction (SBO). Laparoscopic management could be beneficial in terms of less complications and shorter hospital stay. As the minimal invasive approach is gaining more acceptances in the treatment of SBO, there is an increased need of studies to analyze outcomes. The aim of the present study was to compare the short-term clinical outcomes of laparoscopy versus laparotomy in the surgical management of non-bariatric, non-malignant SBO. METHODS A retrospective analysis of patients treated for SBO during 2010-2015 was made by a comprehensive search of medical records. A matched-pair review was performed on patients managed surgically for non-bariatric, non-malignant SBO at Danderyd University Hospital, Stockholm, Sweden. Completed laparoscopic surgeries were matched against patients treated with open surgery. RESULTS Laparoscopy for SBO was initiated in 71 patients. Conversion to open surgery was performed in 42 %. Results from the matched-pair analysis showed that post-operative length of stay was reduced by 60 % (P < 0.001) in the laparoscopic cohort. Additionally, less major complications were reported and duration of surgery was reduced by 50 % (P < 0.001). CONCLUSIONS Laparoscopic management is a safe and feasible alternative to laparotomy. Hospital length of stay was significantly shorter and morbidity rate acceptable.
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Affiliation(s)
- Ann Nordin
- Karolinska Institutet, Stockholm, Sweden
| | - Jacob Freedman
- Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden. .,Department of Surgery, Danderyd Hospital, 18288, Stockholm, Sweden.
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