Postoperative outcome of neonatal emergency surgeries in a tertiary care institute-A prospective observational study

AIMS

Neonatal surgical mortality continues to be high in developing countries. A better understanding of perioperative events and optimization of causative factors can help in achieving a favorable outcome. The present study was designed to evaluate the perioperative course of surgical neonates and find out potential factors contributing to postoperative mortality.

METHODS

This prospective observational study enrolled neonates, undergoing emergency surgical procedures in a tertiary care institute. Primary outcome was 6 weeks postsurgical mortality. The babies were observed till discharge and subsequently followed up telephonically for 6 weeks after surgery. Multivariable logistic regression analysis of various parameters was performed.

RESULTS

Out of the 324 neonates who met inclusion criteria, 278 could be enrolled. The median age was 4 days. Sixty-two (27.7%) neonates were born before 37 weeks period of gestation (POG), and 94 (41.8%) neonates weighed below 2.5 kg. The most common diagnoses was trachea-esophageal fistula (29.9%) and anorectal malformation (14.3%). The median duration of hospital stay for survivors was 14 days. The in-hospital mortality was 34.8%. Mortality at 6 weeks following surgery was 36.2%. Five independent risk factors identified were POG < 34 weeks, preoperative oxygen therapy, postoperative inotropic support postoperative mechanical ventilation, and postoperative leukopenia. In neonates where invasive ventilation was followed by non-invasive positive pressure ventilation in the postoperative period, risk of postoperative surgical mortality was significantly reduced.

CONCLUSION

Present study identified preterm birth, preoperative oxygen therapy, postoperative positive pressure ventilation, requirement of inotropes, and postoperative leukopenia as independent predictors of 6-week mortality. The possibility of early switch to noninvasive positive pressure ventilation was associated with a reduction in neonatal mortality.

Perioperative Factors Impact on Mortality and Survival Rate of Geriatric Patients Undergoing Surgery in the COVID-19 Pandemic: A Prospective Cohort Study in Indonesia

Background: The COVID-19 pandemic continues to have an impact on geriatric patients worldwide since geriatrics itself is an age group with a high risk due to declined physiological function and many comorbidities, especially for those who undergo surgery. In this study, we determine the association between perioperative factors with 30-day mortality and a survival rate of geriatric patients undergoing surgery during COVID-19 pandemic. Methods: A prospective cohort study was conducted at 14 central hospitals in Indonesia. The recorded variables were perioperative factors, 30-day mortality, and survival rate. Analyses of associations between variables and 30-day mortality were performed using univariate/multivariable logistic regression, and survival rates were determined with Kaplan−Meier survival analysis. Results: We analyzed 1621 elderly patients. The total number of patients who survived within 30 days of observation was 4.3%. Several perioperative factors were associated with 30-day mortality (p < 0.05) is COVID-19 (OR, 4.34; 95% CI, 1.04−18.07; p = 0.04), CCI > 3 ( odds ratio [OR], 2.33; 95% confidence interval [CI], 1.03−5.26; p = 0.04), emergency surgery (OR, 3.70; 95% CI, 1.96−7.00; p ≤ 0.01), postoperative ICU care (OR, 2.70; 95% CI, 1.32−5.53; p = 0.01), and adverse events (AEs) in the ICU (OR, 3.43; 95% CI, 1.32−8.96; p = 0.01). Aligned with these findings, COVID-19, CCI > 3, and comorbidities have a log-rank p < 0.05. The six comorbidities that have log-rank p < 0.05 are moderate-to-severe renal disease (log-rank p ≤ 0.01), cerebrovascular disease (log-rank p ≤ 0.01), diabetes with chronic complications (log-rank p = 0.03), metastatic solid tumor (log-rank p = 0.02), dementia (log-rank p ≤ 0.01), and rheumatology disease (log-rank p = 0.03). Conclusions: Having at least one of these conditions, such as COVID-19, comorbidities, emergency surgery, postoperative ICU care, or an AE in the ICU were associated with increased mortality in geriatric patients undergoing surgery during the COVID-19 pandemic.

Length of Hospital Stay after Total Knee Arthroplasty: A Correlation Study on 1200 Patients

In countries with a high average population age, total knee arthroplasty is still carried out in an inpatient setting. The roadmap to performing major surgery on an outpatient basis passes through the understanding of those perioperative features that correlate with higher lengths of hospital stay (LOS). A retrospective database of 1200 patients was reviewed for retrieving preoperative and perioperative factors including anthropometric and demographic data, comorbidities, preoperative laboratory assessment, and surgical time. Considering the LOS as a discrete series, data were analyzed by means of logistic regression with multiple univariate and multivariate models. The results showed a median length of hospital stay of 3 (IQR 3, 4) days. According to multiple univariate analysis, arterial hypertension (p = 0.008), diabetes mellitus (p = 0.028), CCI score (p < 0.001), ASA score (p = 0.006), surgical time (p < 0.001) and intraoperative blood loss (p < 0.001) were significantly associated with the duration of hospital stay in days. Moreover, preoperative hemoglobin value was inversely correlated to the LOS (p = 0.008). Multivariate analysis showed a significant correlation between LOS and surgical time and intraoperative blood loss. Many factors influence the permanence of the inpatient and acting on those variables, by stabilizing comorbidities and optimizing laboratory values, may reduce the overall healthcare burden.

An enhanced recovery after surgery pathway: association with rapid discharge and minimal complications after anterior cervical spine surgery

OBJECTIVEEnhanced recovery after surgery (ERAS) pathways are associated with improved outcomes, lower morbidity and complications, and higher patient satisfaction in multiple surgical subspecialties. Despite these gains, there are few data to guide the application of ERAS concepts to spine surgery. The authors report the development and implementation of the first ERAS pathway for patients undergoing anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA).METHODSThis was a retrospective cohort study of prospectively collected data. The authors created a multidisciplinary pathway based on best available evidence for interventions that positively influence outcomes after anterior cervical spine surgery. Patients were followed prospectively up to postoperative day 90. Patient data were collected via electronic medical record review and included demographics, comorbidities, baseline and perioperative opioid use, postoperative complications, and length of hospital stay (LOS). ERAS process measures and compliance with pathway elements were also tracked.RESULTSThirty-three patients were cared for under the pathway (n = 25 ACDF; n = 8 CDA). The median LOS was 416 minutes (interquartile range [IQR] 210-1643 minutes). Eight patients required an extended stay-longer than 23 hours. Reasons for extended admission included pain (n = 4), dyspnea (n = 1), hypoxia (n = 1), hypertension (n = 1), and dysphagia (n = 1). The median LOS for the 8 patients who required extended monitoring prior to discharge was 1585 minutes (IQR 1423-1713 minutes). Overall pathway compliance with included process measures was 85.6%. The median number of ERAS process elements delivered to each patient was 18. There was no strong association between LOS and number of ERAS process elements provided (Pearson's r = -0.20). Twelve percent of the cohort was opioid tolerant on the day of surgery. There were no significant differences between total intraoperatively or postanesthesia care unit-administered opioid, or LOS, between opioid-tolerant and opioid-naïve patients. There were no complications requiring readmission.CONCLUSIONSAn ERAS pathway for anterior cervical spine surgery facilitates safe, prompt discharge. The ERAS pathway was associated with minimal complications, and no readmissions within 90 days of surgery. Pain and respiratory compromise were both linked with extended LOS in this cohort. Further prospective studies are needed to confirm the potential benefits of ERAS for anterior cervical spine surgery, including longer-term complications, cost, and functional outcomes.

Risk factors for delirium after esophagectomy

INTRODUCTION

Postoperative delirium is a common complication after major surgical procedures and affects outcomes and long-term survival. We identified factors associated with postoperative delirium in patients undergoing esophagectomy.

METHODS

Retrospective cohort analysis of 378 patients undergoing esophagectomy. We examined the association between postoperative delirium (DSM-V) criteria with respect to baseline variables and postoperative complications.

RESULTS

Postoperative delirium was diagnosed in 64 (16.93%) patients and associated with increasing age (P < .05), chronic obstructive pulmonary disease (P = .07), pneumonia (P = .01), transfusion intraoperatively or within 72 hours of surgery (P < .001), and sepsis (P = .001). Unplanned intubation and increased length of stay (median, 14 days) were significant in patients with delirium (P = .001 and P < .001, respectively). In a secondary analysis, surgical technique and operative approach were associated with delirium. Modified McKeown (three-hole) esophagectomy was twice more likely to develop delirium compared with Ivor Lewis (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.03-4.23). The strongest association was found between delirium and open techniques (thoracotomy and laparotomy) as compared with minimally invasive techniques (thoracoscopy and laparoscopy) (OR, 2.66; 95% CI, 1.22-5.76). Survival was similar between both groups.

CONCLUSIONS

Postoperative delirium is common and associated with complications following esophagectomy. Identification of predisposing factors such as age and pre-existing pulmonary diseases and proper selection of surgical treatment may reduce delirium and improve surgical outcomes.

Perioperative Factors Influencing Postoperative Satisfaction After Lateral Access Surgery for Degenerative Lumbar Spondylolisthesis

BACKGROUND

Lateral access surgery (LAS) for lumbar degenerative spondylolisthesis is a minimally invasive lumbar fusion technique which has been gaining increasing popularity in the recent years. This study aims to identify perioperative factors that influence postoperative satisfaction after LAS for lumbar degenerative spondylolisthesis.

METHODS

From August 2010 to November 2014, 52 patients with lumbar degenerative conditions (16 male: 36 female, mean age 64.0 ± 8.7 years) were prospectively recruited and underwent LAS by a single surgeon. All patients were assessed preoperatively and 2 years postoperatively with Numerical Pain Rating Scale (NPRS), Oswestry Disability Index, Short-Form 36 (SF-36) scores, North American Spine Society score for neurogenic symptoms, patient satisfaction, and expectation fulfillment. Cobb angles, global lumbar lordosis, disc heights, adjacent disc heights, fusion, and subsidence were rates assessed. Multiple linear regression performed with satisfaction as dependent variable to identify predictive independent variables.

RESULTS

Lower preoperative SF-36 general health scores (P = .03), higher NPRS leg pain scores (P = .04), and longer surgical duration (P = .02) were significant predictors of lower satisfaction (P < .05). NPRS back and leg pain decreased by 80.3 and 83.0%, respectively. Oswestry Disability Index and North American Spine Society score for neurogenic symptoms improved by 76.2 and 75.9%, respectively. Ninety percent of patients reported excellent/good satisfaction. Significant correction and maintenance of Cobb and global lumbar lordosis angles were achieved. There was significant increase in disc heights postoperatively (P = .05) and no significant difference in adjacent disc heights at 2 years (P > .05). Ninety-eight percent of patients achieved Bridwell Fusion Grade 1, and 5.8% had Marchi Grade 3 subsidence.

CONCLUSIONS

Lower preoperative SF-36 general health, higher NPRS leg pain, and longer surgical duration are predictors of lower satisfaction in patients undergoing LAS for lumbar degenerative spondylolisthesis.

LEVEL OF EVIDENCE

III.

CLINICAL RELEVANCE

Identifying preoperative predictors for postoperative clinical outcome can assist clinicians in patient education prior to operation.

Perioperative factors and pressure ulcer development in postoperative ICU patients: a retrospective review

OBJECTIVE

To identify variables during surgery that may contribute to the development of pressure ulcers (PUs) in postoperative, intensive care unit (ICU) patients within 72 hours of admission, as well as over their entire ICU admission. Furthermore, to investigate how these variables may impact on the number of PUs acquired.

METHOD

In a three-year retrospective audit, from 1 January 2014 to 31 December 2016, data from the electronic medical records of 3484 postoperative ICU patients in a major Australian metropolitan public hospital were retrieved and analysed to investigate associations between perioperative variables and PU occurrence.

RESULTS

A total of 69 ICU admissions (1.98%) out of 3484 resulted in at least one PU developing within the ICU. No specific variables were associated with the development of a PU within 72 hours of the patient's ICU admission. Multiple regression Cox analysis showed that length of time in the operating theatre (OT) (p=0.045), surgical specialty (p<0.001), 1-4 hypotensive episodes (p=0.017) and >5 hypotensive episodes (p<0.0005) were significantly associated with PU risk. Multivariable negative binomial regression demonstrated APACHE II score (p<0.01), OT time (p<0.01) and surgical specialty (p<0.01) were associated with PU number.

CONCLUSION

There are many risks to skin integrity at the perioperative period, and these risks may exert their effect well into the ICU admission period. It is imperative to identify and mitigate these factors in order to reduce PU incidence, morbidity and mortality.

Quantifying Blood Loss and Transfusion Risk After Primary vs Conversion Total Hip Arthroplasty

BACKGROUND

Primary total hip arthroplasty (THA) and conversion THA may result in substantial blood loss, sometimes necessitating transfusion. Despite the complexities of the latter, both are grouped in the same category for quality assessment and reimbursement. This study's purpose was to compare both blood loss and transfusion risk in primary and conversion THA and identify their associated predictors.

METHODS

A total of 1616 patients who underwent primary and conversion THA at a single hospital from 2009-2013 were reviewed (primary THA = 1575; conversion THA = 41). Demographics, comorbidities, and perioperative data were collected from electronic records. Blood loss was calculated using a validated method. Transfusion triggers were based on standardized criteria. Separate multivariable regression models for blood loss and transfusion were performed.

RESULTS

Conversion THA patients were younger (P = .002), had lower age-adjusted Charlson scores (P = .006), longer surgeries (P < .001), higher blood loss (P < .001), and more transfusions (P < .001). Primary and conversion THA groups were different in terms of surgical approach (P < .001), anesthesia type (P = .002), and venous thromboembolism prophylaxis (P = .01). Compared to primary THA, conversion THA had an average 478.9 mL higher blood loss (P = .003) and increased adjusted odds ratio of 3.2 (P = .019) for transfusion.

CONCLUSION

Conversion THA leads to higher blood loss and transfusion compared with primary THA. These differences were quantified in the present study and showed consistent results between the 2 metrics. The differences between these procedures should be addressed during quality assurance because conversion THA is associated with higher resource utilization, which is important in the allocation of resources and tiered reimbursement strategies.

Perioperative factors associated with acute kidney injury after partial nephrectomy

BACKGROUND

Partial nephrectomy is performed with the aim to preserve renal function. But the occurrence of postoperative acute kidney injury (AKI) can interfere with this goal. Our primary aim was to evaluate associations between pre-specified modifiable factors and estimated glomerular filtration rate after partial nephrectomy. Our secondary aims were to evaluate associations between pre-specified modifiable factors and both serum creatinine concentration and type of nephrectomy.

METHODS

The records of 1955 patients who underwent partial nephrectomy were collected. Postoperative estimated glomerular filtration rate (eGFR) was used as the primary outcome measure. Twenty modifiable risk factors were studied. A repeated-measures linear model with autoregressive within-subject correlation structure was used. The interaction between all the factors and type of nephrectomy was also studied.

RESULTS

A total of 1187 (61%) patients had no kidney injury, 647 (33%) had stage I, 80 (4%) had stage II, and 41 (2%) had stage III injury. The mean eGFR increased an estimated 0.83 (99.76% CI 0.79-0.88) ml min(-1) 1.73 m(-2) for a unit increase in baseline eGFR. Mean eGFR was 2.65 (99.76% CI: 0.13, 5.18) ml min(-1) 1.73 m(-2) lower in patients with hypertension. Mean eGFR decreased 0.42 (99.76% CI: 0.22, 0.62) ml min(-1) 1.73 m(-2) for a 10-minute longer in duration of procedure and decreased 2.09 (99.76% CI: 1.39, 2.80) ml min(-1) 1.73 m(-2) for a 10-minute longer in ischemia time. It was 3.53 (99.76% CI: 0.83, 6.23) ml min(-1) 1.73 m(-2) lower for patients who received warm ischemia as compared to cold ischemia.

CONCLUSION

Potentially modifiable factors associated with AKI in the postoperative period were identified as baseline renal function, preoperative hypertension, longer duration of surgical time and ischaemia time, and warm ischaemia.

Retrospective analysis of perioperative factors on outcome of patients undergoing surgery for Moyamoya disease

Background:

The short term outcome of patients undergoing surgery for Moyamoya disease can be affected by various perioperative factors. However, due to lesser prevalence of this disease in our country, data relating the effect of perioperative factors on the overall neurological outcomes of these patients is lacking.

Aims:

To analyze the effect of perioperative factors on the duration of postoperative hospital stay in patients undergoing surgery for Moyamoya disease.

Settings and Design:

It is a retrospective study analyzing various perioperative factors influencing the overall outcome of patients undergoing surgery for Moyamoya disease at a tertiary care centre in North India.

Methods and Material:

The medical records of all patients who underwent revascularization surgeries for Moyamoya disease from 2007 to till January 2014 were included for retrospective analysis. Various preoperative, intraoperative, and postoperative data were recorded. The data was statistically compared for short and prolonged hospital stay for various perioperative factors. The duration of post operative hospital stay was categorized as short (<5 days) and prolonged (>5 days).

Statistical Analysis:

Kolmogrov Smirnov test was applied to see the normality of continuous data. The association of various categorically classified data with 2 groups was found using Fisher Exact test. The trends in intraoperative hemodynamics were analysed using 2 way repeated measure Anova test. T-test was used for comparing two group means for various parameters.

Results:

A total of 15 patients were included in the study. One patient underwent surgery twice on two different occasions. Thirteen patients belonged to paediatric age group (<18 years). The type of anaesthetics used for induction and maintenance had no effect on patient outcome. Mean duration of anaesthesia was 2.45 (1.3-4.0) hours. The mean duration of hospital stay was 5.13 (3-10) days. Most of the parameters did not have significant effect on postoperative hospital stay. Patients with mean value of intraoperative end tidal carbon dioxide (EtCO₂) either less than 31 mmHg or more than 35 mmHg had statistically significant prolongation of hospital stay.

Conclusion:

Maintaining the intraoperative EtCO₂ between 31-35 mmHg may be associated with short hospital stay when compared to those who have intraoperative EtCO₂ either less than 31 mmHg or more than 35 mmHg.