Evaluating the Association of Preoperative Functional Status and Postoperative Functional Decline in Older Patients Undergoing Major Surgery

This prospective cohort study sought to identify predictors of functional decline in patients aged 65 years or older who underwent major, nonemergent abdominal or thoracic surgery in our tertiary hospital from 2006 to 2008. We used the Stanford Health Assessment Questionnaire–Disability Index (HAQ-DI) to evaluate functional decline; a 0.1 or greater increase was used to indicate a clinically significant decline. The preoperative Duke Activity Status Index (DASI) and a physical function score (PFS), assessing gait speed, grip strength, balance, and standing speed, were evaluated as predictors of decline. We enrolled 215 patients (71.2 ± 5.2 years; 56.7% female); 204 completed follow-up HAQ assessments (71.1 ± 5.3 years; 57.8% female). A significant number of patients had functional decline out to 1 year. Postoperative HAQ-DI increases of 0.1 or greater occurred in 45.3 per cent at 1 month, 30.1 per cent at 3 months, and 28.3 per cent at 1 year. Pre-operative DASI and PFS scores were not predictors of functional decline. Male sex at 1 month (odds ratio [OR], 3.05; 95% confidence interval [CI], 1.41 to 6.85); American Society of Anesthesiologists class (OR, 3.41; 95% CI, 1.31 to 8.86), smoking (OR, 3.15; 95% CI, 1.27 to 7.85), and length of stay (OR, 1.09; 95% CI, 1.01 to 1.16) at 3 months; and cancer diagnosis at 1 year (OR, 2.6; 95% CI, 1.14 to 5.96) were associated with functional decline.

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Effect of Intraoperative Fluid Management on Outcome after Intraabdominal Surgery

Anesthesiology ◽

10.1097/00000542-200507000-00008 ◽

2005 ◽

Vol 103 (1) ◽

pp. 25-32 ◽

Cited By ~ 570

Author(s):

Vadim Nisanevich ◽

Itamar Felsenstein ◽

Gidon Almogy ◽

Charles Weissman ◽

Sharon Einav ◽

...

Keyword(s):

Body Weight ◽

Hospital Stay ◽

Fluid Management ◽

Postoperative Outcome ◽

Protocol Group ◽

Number Of Patients ◽

Secondary Endpoints ◽

American Society ◽

American Society Of Anesthesiologists ◽

The Impact

Background The debate over the correct perioperative fluid management is unresolved. Methods The impact of two intraoperative fluid regimes on postoperative outcome was prospectively evaluated in 152 patients with an American Society of Anesthesiologists physical status of I-III who were undergoing elective intraabdominal surgery. Patients were randomly assigned to receive intraoperatively either liberal (liberal protocol group [LPG], n = 75; bolus of 10 ml/kg followed by 12 ml x kg(-1) x h(-1)) or restrictive (restrictive protocol group [RPG], n = 77; 4 ml x kg(-1) x h(-1)) amounts of lactated Ringer's solution. The primary endpoint was the number of patients who died or experienced complications. The secondary endpoints included time to initial passage of flatus and feces, duration of hospital stay, and changes in body weight, hematocrit, and albumin serum concentration in the first 3 postoperative days. Results The number of patients with complications was lower in the RPG (P = 0.046). Patients in the LPG passed flatus and feces significantly later (flatus, median [range]: 4 [3-7] days in the LPG vs. 3 [2-7] days in the RPG; P < 0.001; feces: 6 [4-9] days in the LPG vs. 4 [3-9] days in the RPG; P < 0.001), and their postoperative hospital stay was significantly longer (9 [7-24] days in the LPG vs. 8 [6-21] days in the RPG; P = 0.01). Significantly larger increases in body weight were observed in the LPG compared with the RPG (P < 0.01). In the first 3 postoperative days, hematocrit and albumin concentrations were significantly higher in the RPG compared with the LPG. Conclusions In patients undergoing elective intraabdominal surgery, intraoperative use of restrictive fluid management may be advantageous because it reduces postoperative morbidity and shortens hospital stay.

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A Method to Compare Costs of Drugs and Supplies among Anesthesia Providers

Anesthesiology ◽

10.1097/00000542-199805000-00027 ◽

1998 ◽

Vol 88 (5) ◽

pp. 1350-1356 ◽

Cited By ~ 19

Author(s):

Franklin Dexter ◽

David A. Lubarsky ◽

Bill C. Gilbert ◽

Christine Thompson

Keyword(s):

Tertiary Hospital ◽

Demographic Variables ◽

Drug Supply ◽

Anesthetic Drugs ◽

Anesthesia Providers ◽

Relative Value ◽

American Society ◽

The Cost ◽

American Society Of Anesthesiologists ◽

Pearson Correlations

Background Comparison of costs among anesthesia providers using "cost per case" does not adjust for variations in casemix (such as the type of procedure and patient condition). The authors propose an alternative method for comparing costs using the American Society of Anesthesiologists' Relative Value Scale (ASARVS) system, which incorporates basic units (for the procedure), modifier units (for the patient's physical condition), "other" units (such as for the placement of invasive monitors), and time units (proportional to the case duration). Methods Data were obtained from a series of 3,340 anesthetics performed at a tertiary hospital. Administered and discarded drug, supply, and fluid costs were used. Results Costs expressed as dollars per ASARVS unit had 54% less variability than costs expressed as dollars per case (P < 0.0001). Pearson correlations between demographic variables and cost per ASARVS unit ranged from -0.10 to 0.13. Total (e.g., quarterly) costs for simulated sets of cases were predicted within 0.0 +/- 2.3% by multiplying (1) their sum of units and (2) a like set of case's sum of costs divided by sum of units. Conclusions Costs of anesthetic supplies and drugs of a case were more accurately reported as "cost per unit" than as "cost per case." This method of calculating the cost of anesthetic drugs and supplies has several applications, including (1) comparison of costs among anesthesia providers and (2) benchmarking costs among hospitals and anesthesia groups. By design, anesthesia providers' time is quantified by their ASARVS units. Together anesthesia costs (personnel, supplies, and drugs) are better reported as "cost per unit" than as "cost per case."

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Assessing the completeness of perioperative anesthetic record documentation in a tertiary hospital

Anaesthesia, Pain & Intensive Care ◽

10.35975/apic.v24i6.1401 ◽

2020 ◽

Vol 24 (6) ◽

Author(s):

Hayatul Akma Bolhan ◽

Nurlia Yahya ◽

Azarinah Izaham ◽

Wan Rahiza Wan Mat ◽

Raha Abdul Rahman ◽

...

Keyword(s):

Prospective Observational Study ◽

Tertiary Care ◽

Tertiary Hospital ◽

Policy Statement ◽

Anesthetic Record ◽

Standard Guideline ◽

Tertiary Care Institution ◽

American Society ◽

American Society Of Anesthesiologists

Background and Objective: Many previous studies assessing the completeness of perioperative documentation of surgical patients were reported to be inadequate and unsatisfactory. The aim of this study was to compare the perioperative anesthetic record (PAR) at our tertiary care institution to a standard guideline and have an audit of its completeness. Methodology: It was a prospective, observational study, done in the general operating theater of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). We compared our PAR to the American Society of Anesthesiologists (ASA) policy statement on documentation of anesthesia care. We audited the completeness of PAR documentation of 358 patients by using a self-generated checklist which was created in accordance to the PAR parameters. A total of 44 parameters were studied covering three phases; preoperative, peroperative and post-operative phases. Results: Although the UKMMC PAR varied from the ASA guidelines, various salient parameters were identical in both. None of the perioperative forms were completely filled throughout the three perioperative phases. Out of 44 parameters studied, only 2 parameters were completely filled, which were medications administered and fluid therapy. Conclusion: Parameters given in the UKMMC PAR varied with the ASA guidelines and the documentation was found to be only partially complete. Hence, necessary modification of the current PAR in our institution, and the stress on filling it completely is needed to improve the quality of perioperative anesthetic documentation. Keywords: Audit; Completeness; Perioperative; Anesthetic record; Documentation Citation: Bolhan HA, Yahya N, Izaham A, Mat WRW, Rahman RA, Musthafa QA. Anaesth. pain intensive care 2020;24(6):--- Received: 23 April 2020, Reviewed: 17 August 2020, Revised: 18 October 2020, Accepted: 27 October 2020

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IMPACT-Scot report on COVID-19 and hip fractures

The Bone & Joint Journal ◽

10.1302/0301-620x.102b9.bjj-2020-1100.r1 ◽

2020 ◽

Vol 102-B (9) ◽

pp. 1219-1228 ◽

Cited By ~ 16

Author(s):

Andrew J. Hall ◽

Nicholas D. Clement ◽

Luke Farrow ◽

Alasdair M. J. MacLullich ◽

Graham F. Dall ◽

...

Keyword(s):

Platelet Count ◽

Hip Fracture ◽

Hip Fractures ◽

Area Under The Curve ◽

Clinical Predictors ◽

Time To Surgery ◽

Patient Demographics ◽

Number Of Patients ◽

American Society ◽

American Society Of Anesthesiologists

Aims The primary aim was to assess the independent influence of coronavirus disease (COVID-19) on 30-day mortality for patients with a hip fracture. The secondary aims were to determine whether: 1) there were clinical predictors of COVID-19 status; and 2) whether social lockdown influenced the incidence and epidemiology of hip fractures. Methods A national multicentre retrospective study was conducted of all patients presenting to six trauma centres or units with a hip fracture over a 46-day period (23 days pre- and 23 days post-lockdown). Patient demographics, type of residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, American Society of Anesthesiologists (ASA) grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded. Results Of 317 patients with acute hip fracture, 27 (8.5%) had a positive COVID-19 test. Only seven (26%) had suggestive symptoms on admission. COVID-19-positive patients had a significantly lower 30-day survival compared to those without COVID-19 (64.5%, 95% confidence interval (CI) 45.7 to 83.3 vs 91.7%, 95% CI 88.2 to 94.8; p < 0.001). COVID-19 was independently associated with increased 30-day mortality risk adjusting for: 1) age, sex, type of residence (hazard ratio (HR) 2.93; p = 0.008); 2) Nottingham Hip Fracture Score (HR 3.52; p = 0.001); and 3) ASA (HR 3.45; p = 0.004). Presentation platelet count predicted subsequent COVID-19 status; a value of < 217 × 109/l was associated with 68% area under the curve (95% CI 58 to 77; p = 0.002) and a sensitivity and specificity of 63%. A similar number of patients presented with hip fracture in the 23 days pre-lockdown (n = 160) and 23 days post-lockdown (n = 157) with no significant (all p ≥ 0.130) difference in patient demographics, residence, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management. Conclusion COVID-19 was independently associated with an increased 30-day mortality rate for patients with a hip fracture. Notably, most patients with hip fracture and COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have implications for the management of hip fractures, in particular the need for COVID-19 testing. Cite this article: Bone Joint J 2020;102-B(9):1219–1228.

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Surgeon’s physical and mental stress while performing laparoscopic cholecystectomy

Journal of Kathmandu Medical College ◽

10.3126/jkmc.v4i4.18251 ◽

2017 ◽

Vol 4 (4) ◽

pp. 111-117

Author(s):

Mukund Raj Joshi ◽

Tanka P Bohara ◽

Anuj Parajuli ◽

Shail Rupakheti

Keyword(s):

Patient Outcome ◽

Laparoscopic Cholecystectomy ◽

Mental Stress ◽

Analogue Scale ◽

Laparoscopic Cholecystectomy Group ◽

The Difference ◽

Clinically Significant ◽

American Society ◽

American Society Of Anesthesiologists ◽

Additional Port

Background: Laparoscopic cholecystectomy is performed either by four port or three port. Although the overall patient outcome has been studied with comparable results, surgeon’s stress level has not been addressed commonly.Objective: To compare the difference in surgeon’s physical and mental stress between three port and four port laparoscopic cholecystectomy.Methods: This prospective randomized comparative study was carried out from January 2014 to August 2014 in patients undergoing laparoscopic cholecystectomy with American technique. Patients were randomized into four port laparoscopic cholecystectomy group and three port laparoscopic cholecystectomy group. Surgery was performed by experienced laparoscopic surgeons. At the end of procedure, surgeons were given questionnaire to evaluate physical and mental stress faced by them based on Visual Analogue Scale. The results obtained were compared.Results: Total 60 cases were evaluated, 30 in each group. Mean age of patients and American society of Anesthesiologists score were not different. Surgeon’s perception regarding physical and mental stress while performing in two different groups was analyzed. The difference is not statistically significant. Neither any of the three port group needed to add additional port nor any of the patients were converted to open surgery. None of the patient in either group developed clinically significant complication.Conclusion: Both the four and three port laparoscopic cholecystectomy techniques are comparable in regards to patient outcome as well as to the physical and mental stress experienced by the surgeons.

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Effectiveness of Acute Normovolemic Hemodilution to Minimize Allogeneic Blood Transfusion in Major Liver Resections

Anesthesiology ◽

10.1097/00000542-200210000-00008 ◽

2002 ◽

Vol 97 (4) ◽

pp. 794-800 ◽

Cited By ~ 107

Author(s):

Idit Matot ◽

Olga Scheinin ◽

Oded Jurim ◽

Ahmed Eid

Keyword(s):

Liver Resection ◽

Blood Transfusion ◽

Allogeneic Blood Transfusion ◽

Allogeneic Blood ◽

Major Liver Resection ◽

Acute Normovolemic Hemodilution ◽

Number Of Patients ◽

Normovolemic Hemodilution ◽

American Society ◽

American Society Of Anesthesiologists

Background Liver resection is a major operation for which, even with the improvements in surgical and anesthetic techniques, the reported rate of blood transfusion was rarely less than 30%. About 60% of transfused patients require only 1 or 2 units of blood, a blood requirement that may be accommodated by the use of acute normovolemic hemodilution (ANH). Methods The efficacy, hemodynamic effects, and safety of ANH were investigated in a randomized, active-control study in patients with American Society of Anesthesiologists status I-II who were undergoing major liver resection with fentanyl-nitrous oxide-isoflurane anesthesia. Patients were randomized to the ANH (n = 39) or control group (n = 39). Patients in the ANH group underwent hemodilution to a target hematocrit of 24%. The indication for blood transfusion was standardized. In both groups transfusion was started at a hematocrit of 20%. The primary efficacy endpoint was the avoidance of allogeneic blood transfusion in the intraoperative period and first 72 h after surgery. Various laboratory and hemodynamic parameters as well as postoperative morbidity were monitored to define the safety of ANH in this patient population. Results During the perioperative period, 14 control patients (36%) received at least one unit of allogeneic blood compared with 4 patients (10%) in the ANH group ( < 0.05). The hemodilution process was not associated with significant changes in patients' hemodynamics. Morbidity was similar between the control and the ANH groups. Postoperative hematocrit levels and biochemical liver, renal, and standard coagulation test results were similar in both groups. Conclusions Acute normovolemic hemodilution in patients with American Society of Anesthesiologists status I-II undergoing major liver resection may allow a significant number of patients to avoid exposure to allogeneic blood.

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Efficacy of prophylactic intravenous ondansetron for attenuation of pain on propofol injection

Journal of Patan Academy of Health Sciences ◽

10.3126/jpahs.v6i1.27074 ◽

2019 ◽

Vol 6 (1) ◽

pp. 31-36

Author(s):

Sujita Manandhar ◽

Kishor Manandhar

Keyword(s):

Placebo Group ◽

Venous Drainage ◽

Controlled Study ◽

Simple Method ◽

Mild Pain ◽

Number Of Patients ◽

Calculated Dose ◽

American Society ◽

Double Blinded ◽

American Society Of Anesthesiologists

Introductions: Propofol is a popular intravenous anesthetic agent. One disadvantage of propofol is pain on its injection which can be excruciating at times. Various agents and methods have been tried to attenuate this unpleasant effect. Ondansetron, primarily used as an antiemetic has also been studied to reduce it. Methods: This randomized, prospective, double-blinded, placebo-controlled study was conducted on patients of either sex, American Society of Anesthesiologists (ASA) physical status I & II, undergoing elective surgeries requiring general anesthesia. The patients were randomly divided into ondansetron (A, received intravenous ondansetron 4 mg) and placebo (B, received equivalent volume of normal saline) groups. Manual occlusion of venous drainage was done at mid-arm by an assistant for 1 minute after which 25% of the calculated dose (2 mg/kg) of propofol (1% w/v in lipid base) was injected. Patients were asked by a blinded investigator to score the pain on injection of propofol on 4-point scale: 0=no pain, 1=mild pain, 2=moderate pain, 3=severe pain and compared in between two groups. The p<0.05 was considered significant. Results: There were 96 adult patients, 48 in each group of Ondansetron placebo. Pain on propofol injection was found significantly higher in the placebo group compared to the ondansetron group. (62.5% vs 35.4%). Most of the patients in the ondansetron group had mild pain only, whereas, a significant number of patients in the placebo group had higher degrees of pain on propofol injection. Conclusions: Prophylactic intravenous 4 mg ondansetron is a safe and simple method of attenuating pain on propofol injection.

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Anti-Emetic Efficacy of Tropisetron and Metoclopramide

Journal of International Medical Research ◽

10.1177/030006059602400305 ◽

1996 ◽

Vol 24 (3) ◽

pp. 266-270 ◽

Cited By ~ 9

Author(s):

A Yilmazlar ◽

T Yilmazlar ◽

E Gürpinar ◽

N Korun ◽

O Kutlay

Keyword(s):

Rescue Medication ◽

Surgical Patients ◽

Saline Control ◽

Double Blind ◽

Number Of Patients ◽

Post Operation ◽

Group 2 ◽

American Society ◽

American Society Of Anesthesiologists ◽

Group 1

Post-operative vomiting, especially in ambulatory surgical patients, remains a troublesome problem. This placebo-controlled, randomized, prospective double-blind trial was designed to evaluate the efficacy of two prophylactic anti-emetic regimens on post-operative vomiting in 1-day thyroid surgery. Altogether 60 elective surgical patients were followed for 4 h post-operatively. All patients were American Society of Anesthesiologists physical status of I or II and aged between 22 and 60 years: group 1 was saline control; in groups 2 and 3, metoclopramide (0.2 mg/kg) or tropisetron (5 mg) was administered, respectively, as an intravenous single dose during induction. Patients were pre-medicated. A standardized anaesthetic technique consisting of thiopentone-succinylcholine for induction and fentanyl-nitrous oxide-halothane-pancuronium for maintenance of anaesthesia was used. A ‘rescue’ anti-emetic was provided in case of continued vomiting or at the patient's request. Anti-emetic inefficacy was defined as request for rescue anti-emetic and/or vomiting episode during the first 4 h post-operation. The number of patients vomiting was 12/20 (60%), 10/20 (50%) and 1/20 (5%) within the first 2 h post-operation in groups 1, 2 and 3, respectively ( P > 0.05 for groups 1 and 2; P < 0.01 for groups 2 and 3; P < 0.001 for groups 1 and 3). In group 2, three patients required rescue medication during the first 2 h post operation, but no signiñcant difference was observed between groups 2 and 3 ( P > 0.05). None of the cases in any of the groups needed any rescue medication during post-operative 2 – 4 h. It is concluded that tropisetron is a highly effective anti-emetic drug in the prophylaxis of post-operative vomiting.

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Predictors of Clinically Significant Postoperative Events after Open Craniosynostosis Surgery

Anesthesiology ◽

10.1097/aln.0000000000000612 ◽

2015 ◽

Vol 122 (5) ◽

pp. 1021-1032 ◽

Cited By ~ 31

Author(s):

Susan M. Goobie ◽

David Zurakowski ◽

Mark R. Proctor ◽

John G. Meara ◽

Petra M. Meier ◽

...

Keyword(s):

Body Weight ◽

Tranexamic Acid ◽

Primary Outcome Measure ◽

Physical Status ◽

Intraoperative Complication ◽

Icu Admission ◽

Increased Risk ◽

Clinically Significant ◽

American Society ◽

American Society Of Anesthesiologists

Abstract Background: Craniosynostosis surgery is associated with clinically significant postoperative events requiring intensive care unit (ICU) admission. The authors investigate specific variables, which might influence the risk for these events, and thereby make recommendations regarding the need for postoperative ICU admission. Methods: A retrospective review of 225 children undergoing open craniosynostosis repair at a single center during a 10-yr period is reported. The primary outcome measure was the incidence of predefined clinically relevant postoperative cardiorespiratory and hematological events requiring ICU admission. Results: The incidences of postoperative cardiorespiratory and hematological events requiring ICU care were 14.7% (95% CI, 10.5 to 20.1%) and 29.7% (95% CI, 24.0 to 36.3%), respectively. Independent predictors of cardiorespiratory events were body weight less than 10 kg, American Society of Anesthesiologists physical status 3 or 4, intraoperative transfusion of greater than 60 ml/kg packed erythrocytes, and the occurrence of an intraoperative complication. The independent predictors of hematological events were body weight less than 10 kg, American Society of Anesthesiologists physical status 3 or 4, intraoperative transfusion of greater than 60 ml/kg packed erythrocytes, transfusion of hemostatic products (fresh-frozen plasma, platelets, and/or cryoprecipitate), and tranexamic acid not administered. Conclusions: Children undergoing craniosynostosis surgery are at increased risk for clinically significant postoperative events requiring ICU admission if they are less than 10 kg body weight, American Society of Anesthesiologists physical status 3 or 4, require intraoperative transfusion of greater than 60 ml/kg of packed erythrocytes, receive hemostatic blood products, or if they develop a significant intraoperative complication. Tranexamic acid administration was associated with fewer postoperative events. A predictive clinical algorithm for pediatric patients having major craniosynostosis surgery was developed and validated to risk stratify these patients.

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Resuming elective orthopaedic services during the COVID-19 pandemic

Bone & Joint Open ◽

10.1302/2633-1462.211.bjo-2021-0080.r1 ◽

2021 ◽

Vol 2 (11) ◽

pp. 951-957

Author(s):

Rongkagorn Chuntamongkol ◽

Rebekah Meen ◽

Sophie Nash ◽

Nicholas E. Ohly ◽

Jon Clarke ◽

...

Keyword(s):

Patient Selection ◽

Orthopaedic Surgery ◽

Selection Criteria ◽

Standard Operating Procedure ◽

Orthopaedic Patients ◽

Number Of Patients ◽

Patient Selection Criteria ◽

American Society ◽

A Prospective Study ◽

American Society Of Anesthesiologists

Aims The aim of this study was to surveil whether the standard operating procedure created for the NHS Golden Jubilee sufficiently managed COVID-19 risk to allow safe resumption of elective orthopaedic surgery. Methods This was a prospective study of all elective orthopaedic patients within an elective unit running a green pathway at a COVID-19 light site. Rates of preoperative and 30-day postoperative COVID-19 symptoms or infection were examined for a period of 40 weeks. The unit resumed elective orthopaedic services on 29 June 2020 at a reduced capacity for a limited number of day-case procedures with strict patient selection criteria, increasing to full service on 29 August 2020 with no patient selection criteria. Results A total of 2,373 cases were planned in the 40-week study period. Surgery was cancelled in 59 cases, six (10.2%) of which were due to having a positive preoperative COVID-19 screening test result. Of the remaining 2,314, 996 (43%) were male and 1,318 (57%) were female. The median age was 67 years (interquartile range 59.2 to 74.6). The median American Society of Anesthesiologists grade was 2. Hip and knee arthroplasties accounted for the majority of the operations (76%). Six patients tested positive for COVID-19 preoperatively (0.25%) and 39 patients were tested for COVID-19 within 30 days after discharge, with only five patients testing positive (0.22%). Conclusion Through strict application of a COVID-19 green pathway, elective orthopaedic surgery could be safely delivered to a large number of patients with no selection criteria. Cite this article: Bone Jt Open 2021;2(11):951–957.

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