Preventive Medicine

Complex Surgical Procedures ◽

Overall Mortality ◽

Overall Risk

Mortality associated with anesthesia and surgery has decreased markedly in the past several decades. Today the overall mortality is 1:250,000 even though more complex surgical procedures are performed on sicker patients. The American Society of Anesthesiologists classification, with broadly defined categories, is used to estimate overall risk of mortality within 48 hours postoperatively.

Financial Implications of a Hospital’s Specialization in Rare Physiologically Complex Surgical Procedures

Anesthesiology ◽

10.1097/00000542-200507000-00024 ◽

2005 ◽

Vol 103 (1) ◽

pp. 161-167 ◽

Cited By ~ 27

Author(s):

Ruth E. Wachtel ◽

Franklin Dexter ◽

David A. Lubarsky

Keyword(s):

Surgical Procedures ◽

Age Groups ◽

Surgical Care ◽

Its Region ◽

Large Numbers ◽

Patient Groups ◽

Important Amount ◽

American Society ◽

Complex Surgical Procedures

Background The authors previously identified a hospital that has a unique role in its region for surgical care. In children aged 0-2 yr, the hospital performed 64% of all physiologically complex procedures statewide (>or= 8 American Society of Anesthesiologists Relative Value Guide basic units). For all age groups combined, 48% of the physiologically complex procedures performed at that hospital were rare, defined as < 1/workday statewide. Methods The authors tested the hypothesis that financially important differences can result from performing relatively large numbers of such specialized procedures. Methods were developed to compare contribution margin (revenue from facility and professional fees minus variable costs) per operating room hour (CM/OR hour) between patient groups and different types of surgical procedures. Results CM/OR hour was significantly larger by a financially important amount (> 250 dollars/OR hour) for pediatric versus geriatric patients (P <or= 0.002), primarily because of higher professional reimbursements, with no difference in hospital reimbursements. Unexpectedly, CM/OR hour was also significantly greater by at least 250 dollars when a rare procedure was involved (P < 0.001 for all ages combined), primarily because of greater hospital reimbursements. For cases involving implant charges of 10,000 dollars or greater, overall CM/OR hour was negative because increased revenues did not compensate for the high variable costs. Conclusions Other hospitals can use these methods to perform a similar analysis of the financial impact of those patient populations or surgical procedures that are unique to their own roles in their regional healthcare systems, and to identify the sources of financial losses and gains experienced by the hospital.

Impact of Hospital and Surgeon Volumes in the Management of Complicated Portal Hypertension: Review of a Statewide Database in Florida

The American Surgeon ◽

10.1177/000313481007600304 ◽

2010 ◽

Vol 76 (3) ◽

pp. 263-269

Author(s):

Emmanuel E. Zervos ◽

Dana Osborne ◽

Steven C. Agle ◽

Micheal M. Mcnally ◽

Brian Boe ◽

...

Keyword(s):

Portal Hypertension ◽

Surgical Procedures ◽

Hospital Volume ◽

The State ◽

Healthcare Administration ◽

The Cost ◽

Complex Surgical Procedures ◽

Length Of Hospitalization ◽

Overall Mortality

Mortality after complex surgical procedures has been shown to be inversely related to hospital volume. The purpose of this study was to determine whether these findings are applicable to radiologic and surgical procedures for complicated portal hypertension. The Agency for Healthcare Administration for the State of Florida database was queried to determine outcomes after transjugular intrahepatic stent shunts (TIPS) or surgical shunts from 2000 to 2003. A total of 1486 patients underwent either TIPS (1321) or surgical shunts (165). Natural breakpoints occurred at two and six procedures per year were correlated with survival for surgical shunts but not TIPS. Overall mortality was not different between TIPS and surgical shunts (11.0 vs. 12.7%, P = 0.51); however, the cost of TIPS was significantly lower (62,000 ± 58.5 vs. 107,000 ± 97.8, P < 0.001) as well as the length of hospitalization (9 ± 9.0 days vs. 15 days ± 12.6 days, P < 0.001). Surgical procedures for complicated portal hypertension are rapidly being replaced by TIPS. Like with other complex procedures, outcomes are related to hospital volume.

Letters to the Editor

PEDIATRICS ◽

10.1542/peds.95.3.454 ◽

1995 ◽

Vol 95 (3) ◽

pp. 454-454

Author(s):

Robert K. Williams

Keyword(s):

Laryngeal Mask Airway ◽

General Anesthesia ◽

Pediatric Anesthesia ◽

Letters To The Editor ◽

The Past ◽

Adults And Children ◽

American Society ◽

Spontaneously Breathing ◽

Potential Use

Use of the laryngeal mask airway (LMA) has grown considerably over the past few years in both adults and children.1,2 The LMA may have special benefits in the management of severe airway problems and the American Society of Anesthesiologists have incorporated its potential use into its algorithm on management of the difficult airway.3 Recently, its use in resuscitation of neonates has been advocated.4,5 I have used the LMA in my practice of pediatric anesthesia and have generally been pleased with its performance in spontaneously breathing patients under general anesthesia.

Awareness detection in anaesthesia during otorhino-maxillofacial surgery using bispectral index - monitoring technology

Medicinski pregled ◽

10.2298/mpns1204111r ◽

2012 ◽

Vol 65 (3-4) ◽

pp. 111-114 ◽

Cited By ~ 1

Author(s):

Nadezda Radosic ◽

Dragana Kastratovic ◽

Snjezana Tomic ◽

Milica Terzic ◽

Srdjan Markovic ◽

...

Keyword(s):

General Anaesthesia ◽

Surgical Procedures ◽

Bispectral Index ◽

Maxillofacial Surgery ◽

Depth Of Anaesthesia ◽

Bispectral Index Monitoring ◽

Clinical Centre ◽

American Society ◽

Parameter Values

Introduction. Awareness is characterized by intraoperative presence of consciousness and recollecting of the events occurring during general anaesthesia. The study was aimed at detecting awareness during general anaesthesia in otorhino-maxillofacial procedure. Methods. The study is a part of a prospective, phase IV, academic study carried out at the Department for Otorhinolaringology, Clinical Centre of Serbia, and Maxillofacial Surgery. The study was approved by the Ethics Committee of the Clinical Centre of Serbia and performed in accordance with European Union Clinical Trials Directive. The evaluation included 40 patients (T-propofol and Esevofluran group) subjected to different surgical procedures (American Society of Anesthesiologists I-III). Depth of anaesthesia was monitored during surgical procedures according to the hemodynamic parameters (blood pressure, pulse, oxygen saturation, electrocardiography, capnometry). Bispectral index monitoring was applied; however, the insight into the obtained bispectral index values was possible only after the completion of the surgery when the comparison with hemodynamic values was performed. Modified Brice interview was postoperatively applied to the patients in whom awareness was suspected. Results. Based on the hemodynamic parameter values obtained in 40 anesthetized patients, no cases of awareness were expected. After the completion of the surgical procedures, the recorded graphic and numeric bispectral index values obtained in the course of anaesthesia were analyzed. Higher bispectral index values (BIS > 60) were recorded in 1 T-group patient. Conclusion. It is possible to miss an awareness episode without using bispectral index technology monitoring during general anaesthesia in otorhinolaryngology and maxillofacial surgery. Bispectral index monitoring should be the clinical standard in general anaesthesia.

American Society of Anesthesiologists Physical Status Classification as a reliable predictor of postoperative medical complications and mortality following ambulatory surgery: an analysis of 2,089,830 ACS-NSQIP outpatient cases

BMC Surgery ◽

10.1186/s12893-021-01256-6 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Colin Foley ◽

Mark C. Kendall ◽

Patricia Apruzzese ◽

Gildasio S. De Oliveira

Keyword(s):

Surgical Procedures ◽

Outpatient Surgery ◽

Multivariable Analysis ◽

Outpatient Setting ◽

Ambulatory Setting ◽

Medical Complications ◽

C Statistic ◽

Physical Status Classification ◽

American Society ◽

Abstract Background Seventy percent of surgical procedures are currently performed in the outpatient setting. Although the American Society of Anesthesiologists (ASA) Physical Classification ability to predict risk has been evaluated for in-patient surgeries, an evaluation in outpatient surgeries has yet to be performed. The major goal of the current study is to determine if the ASA classification is an independent predictor for morbidity and mortality for outpatient surgeries. Methods The 2005 through 2016 NSQIP Participant Use Data Files were queried to extract all patients scheduled for outpatient surgery. ASA PS class was the primary independent variable of interest. The primary outcome was 30-day medical complications, defined as having one or more of the following postoperative outcomes: (1) deep vein thrombosis, (2) pulmonary embolism, (3) reintubation, (4) failure to wean from ventilator, (5) renal insufficiency, (6) renal failure, (7) stroke, (8) cardiac arrest, (9) myocardial infarction, (10) pneumonia, (11) urinary tract infection, (12) systemic sepsis or septic shock. Mortality was also evaluated as a separate outcome. Results A total of 2,089,830 cases were included in the study. 24,777 (1.19%) patients had medical complications and 1,701 (0.08%) died within 30 days. ASA PS IV patients had a much greater chance of dying when compared to healthy patients, OR (95%CI) of 89 (55 to 143), P < 0.001. Nonetheless, over 30,000 ASA PS IV patients had surgery in the outpatient setting. Multivariable analysis demonstrated a stepwise independent association between ASA PS class and medical complications (C statistic = 0.70), mortality (C statistic = 0.74) and readmissions (C statistic = 0.67). Risk stratifying ability was maintained across surgical procedures and anesthesia techniques. Conclusions ASA PS class is a simple risk stratification tool for surgeries in the outpatient setting. Patients with higher ASA PS classes subsequently developed medical complications or mortality at a greater frequency than patients with lower ASA PS class after outpatient surgery. Our results suggest that the ambulatory setting may not be able to match the needs of high-risk patients.

Faculty Opinions recommendation of Diversity in the American Society of Anesthesiologists Leadership.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.727383962.793559098 ◽

2019 ◽

Author(s):

Chiara Robba

Keyword(s):

American Society ◽

Faculty Opinions recommendation of Large variability in the diversity of physiologically complex surgical procedures exists nationwide among all hospitals including among large teaching hospitals.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.732234344.793552347 ◽

2018 ◽

Author(s):

Yan Xiao

Keyword(s):

Surgical Procedures ◽

Teaching Hospitals ◽

Large Variability ◽

Complex Surgical Procedures

A Comparison of Colectomy Outcomes Utilizing Open, Laparoscopic, and Robotic Techniques

The American Surgeon ◽

10.1177/0003134820973384 ◽

2020 ◽

pp. 000313482097338

Author(s):

Elizabeth McCarthy ◽

Benjamin L. Gough ◽

Michael S. Johns ◽

Alexandra Hanlon ◽

Sachin Vaid ◽

...

Keyword(s):

Postoperative Recovery ◽

Logistic Regression Models ◽

Community Institution ◽

Physical Status Classification ◽

Estimated Blood Loss ◽

Comparative Review ◽

Significant Difference ◽

American Society ◽

The Individual ◽

Introduction Robotic colectomy could reduce morbidity and postoperative recovery over laparoscopic and open procedures. This comparative review evaluates colectomy outcomes based on surgical approach at a single community institution. Methods A retrospective review of all patients who underwent colectomy by a fellowship-trained colon and rectal surgeon at a single institution from 2015 through 2019 was performed, and a cohort developed for each approach (open, laparoscopic, and robotic). 30-day outcomes were evaluated. For dichotomous outcomes, univariate logistic regression models were used to quantify the individual effect of each predictor of interest on the odds of each outcome. Continuous outcomes received a similar approach; however, linear and Poisson regression modeling were used, as appropriate. Results 115 patients were evaluated: 14% (n = 16) open, 44% (n = 51) laparoscopic, and 42% (n = 48) robotic. Among the cohorts, there was no statistically significant difference in operative time, rate of reoperation, readmission, or major complications. Robotic colectomies resulted in the shortest length of stay (LOS) (Kruskal-Wallis P < .0001) and decreased estimated blood loss (EBL) (Kruskal-Wallis P = .0012). Median age was 63 years (interquartile range [IQR] 53-72). 54% (n = 62) were female. Median American Society of Anesthesiologists physical status classification was 3 (IQR 2-3). Median body mass index was 28.67 (IQR 25.03-33.47). A malignant diagnosis was noted on final pathology in 44% (n = 51). Conclusion Among the 3 approaches, there was no statistically significant difference in 30-day morbidity or mortality. There was a statistically significant decreased LOS and EBL for robotic colectomies.

Predictors of Successful Early Discharge for Total Hip and Knee Arthroplasty in Octogenarians

HSS Journal ® ◽

10.1177/15563316211030631 ◽

2021 ◽

pp. 155633162110306

Author(s):

Andrew B. Kay ◽

Danielle Y. Ponzio ◽

Courtney D. Bell ◽

Fabio Orozco ◽

Zachary D. Post ◽

...

Keyword(s):

Range Of Motion ◽

Knee Arthroplasty ◽

Early Discharge ◽

Readmission Rates ◽

Patients Âgés ◽

Total Hip ◽

Hip And Knee Arthroplasty ◽

Student’S T ◽

American Society ◽

Background: Decreased length of stay after total joint arthroplasty (TJA) is becoming a more common way to contain healthcare costs and increase patient satisfaction. There is little evidence to support “early” discharge in elderly patients. Purpose: We sought to identify preoperative factors that correlated with early discharge (by postoperative day [POD] 1) in comparison to late discharge (after POD2) in octogenarians after TJA. Methods: In a retrospective cohort study from a single institution, we identified 482 patients ages 80 to 89 who underwent primary TJA from January 2014 to December 2017; 319 had total knee arthroplasty (TKA) and 163 had total hip arthroplasty (THA). Data collected included preoperative knee range of motion (ROM), demographics, and comorbidities; 90-day readmission and mortality rates were also evaluated. P values for continuous data were calculated using student’s t test and for categorical data using χ2 testing. Results: Of octogenarian patients, 30.9% were discharged by POD1. Early discharge was associated with being male, married, and nonsmoking, as well as having an American Society of Anesthesiologists (ASA) score of 2, independent preoperative ambulation, and a postoperative caregiver. Type of procedure (TKA vs THA), body mass index, laterality, preoperative range of motion (ROM) for TKA, and single vs multilevel home did not affect the probability of early discharge. Discharge on POD1 was not associated with increased 90-day readmission rates. There were no deaths. Conclusion: Early discharge for octogenarians can be successfully implemented in a select subset of patients without increasing 90-day readmission or death rates. There are multiple factors that predict successful early discharge.

Validation of the Berlin Questionnaire and American Society of Anesthesiologists Checklist as Screening Tools for Obstructive Sleep Apnea in Surgical Patients

Anesthesiology ◽

10.1097/aln.0b013e31816d91b5 ◽

2008 ◽

Vol 108 (5) ◽

pp. 822-830 ◽

Cited By ~ 302

Author(s):

Frances Chung ◽

Balaji Yegneswaran ◽

Pu Liao ◽

Sharon A. Chung ◽

Santhira Vairavanathan ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

High Risk ◽

Screening Tools ◽

Surgical Patients ◽

Apnea Hypopnea Index ◽

Berlin Questionnaire ◽

Obstructive Sleep ◽

American Society ◽

Stop Questionnaire

Background Because of the high prevalence of obstructive sleep apnea (OSA) and its adverse impact on perioperative outcome, a practical screening tool for surgical patients is required. This study was conducted to validate the Berlin questionnaire and the American Society of Anesthesiologists (ASA) checklist in surgical patients and to compare them with the STOP questionnaire. Methods After hospital ethics approval, preoperative patients aged 18 yr or older and without previously diagnosed OSA were recruited. The scores from the Berlin questionnaire, ASA checklist, and STOP questionnaire were evaluated versus the apnea-hypopnea index from in-laboratory polysomnography. The perioperative data were collected through chart review. Results Of 2,467 screened patients, 33, 27, and 28% were respectively classified as being at high risk of OSA by the Berlin questionnaire, ASA checklist, and STOP questionnaire. The performance of the screening tools was evaluated in 177 patients who underwent polysomnography. The sensitivities of the Berlin questionnaire, ASA checklist, and STOP questionnaire were 68.9-87.2, 72.1-87.2, and 65.6-79.5% at different apnea-hypopnea index cutoffs. There was no significant difference between the three screening tools in the predictive parameters. The patients with an apnea-hypopnea index greater than 5 and the patients identified as being at high risk of OSA by the STOP questionnaire or ASA checklist had a significantly increased incidence of postoperative complications. Conclusions Similar to the STOP questionnaire, the Berlin questionnaire and ASA checklist demonstrated a moderately high level of sensitivity for OSA screening. The STOP questionnaire and the ASA checklist were able to identify the patients who were likely to develop postoperative complications.