The importance of perioperative optimisation to facilitate safe regional anaesthesia and their improved outcomes in fracture neck of femur patients

Background: Hip fractures are common presentations to orthopaedic departments, and their surgical management often results in blood transfusions. Compared with general anaesthesia, regional anaesthesia reduces the need for transfusions and mortality in the wider surgical population. Aims: In hip fracture patients, our primary outcome measure was to examine any relationship between anaesthetic modality and transfusion rates. The secondary outcome measure was to assess the relationship between anaesthetic modality and one-year mortality. Methods: A retrospective cohort study of 280 patients was carried out in 2017 and 2018. Data were collected from patient records, local transfusion laboratory and the national hip fracture database. Results: A total of 59.6% had regional and 40.4% general anaesthesia. Regional anaesthesia patients were younger with fewer comorbidities (p < .05). About 19.8% regional and 34.5% general anaesthesia patients received transfusions (odds ratio (OR) = 0.47, p < .05); 13.6% were taking anticoagulants and were less likely to receive a regional anaesthetic (31.6% versus 64%, OR = 0.26, p < .05). One-year mortality was 27% for regional and 37% for general anaesthetic patients (OR = 0.64, p = .09). Conclusion: Regional anaesthesia halved the risk of blood transfusion. Anticoagulated patients were 74% less likely to receive regional anaesthetics, but had no additional transfusion risk. With optimisation, a larger proportion of patients could have regional anaesthesia.

The effect of intraoperative dexmedetomidine on cognitive dysfunction after surgery: a updated meta-analysis

Background Postoperative cognitive dysfunction (POCD) is one of the most common. Neuroprotective effects of dexmedetomidine (DEX) are reported in previous studies but evidence regarding the POCD is still unclear. In order to gain latest evidence, the present study analyzes the outcomes of randomized controlled trials (RCTs) which utilized DEX with general anaesthesia perioperatively. Method Four online databases (PubMed, Embase, the Cochrane Library, and CNKI) were used to find relevant RCTs to conduct systematic analysis. All studies comparing the incidence of POCD or MMSE score between the DEX group and the placebo or comparator group in patients undergoing general anaesthetic surgery were eligible for inclusion. Based on the inclusion and exclusion criteria, the studies were selected. This meta-analysis was performed using odds ratios (ORs) with 95% confidence intervals (CIs) for dichotomous data and standardized mean difference (SMD) and 95% CIs for continuous data as effective measures. Results In total of 21 studies were included in this meta-analysis. The results showed that the incidence of POCD in DEX group was significantly lower than the control group on the first (OR = 0.36, 95% CI 0.24–0.54),third (OR = 0.45,95% CI 0.33–0.61) and seventh (OR = 0.40,95% CI 0.26–0.60) postoperative days; the MMSE scores in DEX group were higher than the control group on the first (SMD = 1.24, 95% CI 1.08–1.41), third(SMD = 1.09, 95%CI 0.94–1.24) and seventh (SMD = 3.28, 95% CI 1.51–5.04) postoperative days. Conclusions Intraoperative DEX use can ameliorate the POCD of patients who received surgical operations under general anesthesia, and effectively reduce the incidence of POCD and improve MMSE score.

Kidney Biopsy Adequacy and Complications in Children – Does Technique Matter?

Background Kidney biopsy is part of the diagnostic workup of many children with renal disease. Traditionally a perpendicular approach to the biopsy has been used but more recently some proceduralists have favoured a tangential approach. It is not clear if one technique is superior with regards to tissue adequacy or complication rates. In our centre interventional radiologists (IR) use general anaesthetic and a tangential approach whereas paediatric nephrologists (PN) use sedation and a perpendicular approach. Methods We examined consecutive kidney biopsies performed between January 2008 and December 2017 for adequacy (sufficient tissue for light and electron microscopy and immunofluorescence) and examined the electronic medical records for data regarding technique and complications. Results IR performed 72 (29.4%) of the 245 native kidney biopsies, obtaining more total glomeruli (median 39 vs 16, p<0.001) and more glomeruli per tissue core (median 13.2 vs 8.0, p<0.001) than PN. No differences in specimen adequacy were observed between the two groups (79.2% IR vs 80.9% PN, p=0.75) and a diagnosis could be made in 98.6% and 93.6% respectively (p=0.1). A statistically lower rate of peri-nephric haematoma (27.8% vs 41.6%, p=0.04) was detected in the IR group, but there were no significant differences in other complications. One patient required a blood transfusion (PN) and another required surgical intervention for a perinephric haematoma (IR). Conclusion IR obtained larger samples and number of glomeruli, but the overall adequacy for native kidney biopsies was good using both perpendicular and tangential techniques, with similar low rates of significant complications.

Advanced equine diagnostics – developments in computed tomography

Advancement in veterinary imaging technologies to assess pathology in the horses has been greatly improved since the development of computed tomography in the 1970s. These technical innovations have enabled faster acquisition times, lower patient doses of radiation and easier care of the patient during scanning. A wide range of computed tomography scanners are now available to the veterinary market, from companies providing second hand refurbished scanners, to those tailoring computed tomography scanners to the veterinary market. In turn, this makes the price of purchase, or rental, much more feasible to the industry. The financial implications of purchasing a scanner need to be reviewed to ensure viability, as well as identifying maintenance costs, space, specialist staffing and case load. However, even with access to advanced imaging devices such as computed tomography, imaging the equine patient comes with its own complexities and limitations. Owing to their size and anatomy, passing the relevant structures through the gantry can be difficult in itself, often requiring the administration of general anaesthetic to acquire suitable images, which comes with its own set of risks and additional costs. Therefore, there is an ongoing need to further develop the skills and abilities needed for standing computed tomography.

SP8.1.2 The Effect of Ginger Oil on Postoperative Nausea and Vomiting (PONV) After Breast Augmentation Surgery

Aim Postoperative nausea and vomiting (PONV) is one of the commonest complaints following general anaesthetic. Poorly controlled due to its multifactorial nature most current antiemetics are not effective and have an undesirable side effect profile. As such we have studied the effect of Ginger (Zingiber Officinale), a relatively inert yet powerful antiemetic and its properties in managing PONV. Methods A double-blind (surgeon/anaesthetist), randomised, placebo-controlled, single-centre study was carried out in a homogenous 30 female patient cohort undergoing breast augmentation surgery. Participants were randomly allocated to have 3 drops of either Ginger oil (110mg Zingiber officinale) or a simple control oil on the laryngeal mask before insertion. PONV and visual analogue scales (VAS) were used as outcome measures and were plotted against the dose of morphine used in the patient. Results Multivariate analysis of variance (MANOVA) was conducted on the data. Using Pillai’s trace, there was a significant effect of ginger on PONV/VAS, V = 0.87, F(3,16)=34.78, P &lt; 0.001. Separate univariate ANOVAs showed: PONV Mean=1.70, PONVSD=0.48 compared with no ginger treatment plan group; PONV Mean=4.20, PONVSD=0.79. VAS Mean= 5.0, VASSD=1.63 for the ginger treatment plan group; and VAS Mean=5.9, VASSD=2.33 for the no ginger treatment plan group. Conclusion This study has found that ginger has an important role in preventing postoperative vomiting, reducing postoperative nausea, and is useful in breast augmentation. We have demonstrated a novel application of ginger oil during induction of anaesthesia and have provided evidence of its use in opioid-induced PONV.

EP.TU.693A rare case of anal melanoma: An entity to be aware of

Aims Anal melanoma is a rare but aggressive malignancy representing a small percentage anorectal cancers. We report a rare case incidentally detected during bowel screening. Methods A 74-year-old female presented for endoscopy after a positive qFIT. She was asymptomatic. During endoscopy, perianal examination revealed a jet black naevus of approximately 3x3cm from 9 to 12’O clock position, overlying the perianal body, involving anal margin to the posterior vagina. General physical, abdominal and rectal examinations were unremarkable. During colonoscopy, a benign polyp was removed from the sigmoid colon. She underwent examination of rectum and vagina under general anaesthetic, and incisional biopsies were obtained. Histopathology confirmed an invasive, superficial spreading malignant melanoma, with a Breslow thickness of 1.5mm and Clark Level IV invasion. Staging CT scans did not reveal metastasis. Following loco-regional MDT discussion, a combined colorectal and plastic surgery was offered. She underwent wide local excision from the posterior vaginal fourchette to the anal canal, bilateral perforator flap reconstruction, and defunctioning sigmoid loop colostomy. Results There were no intraoperative complications. She recovered well post-operatively. After histopathology, her tumour was staged as pT2b, N0, M0. She did not require further treatment post-operatively as per MDTdiscussion. No disease recurrence has been detected yet with 30 months follow up, and she is awaiting reversal of colostomy. Conclusions Prognosis is generally poor in anal melanoma. This case report adds to the limited literature and emphasizs that despite no consensus on management, early detection and surgical resection offers the best chance for favorable outcomes.

EP.FRI.596 A Tale of Two Ultrasounds

Background Testicular torsion is a common cause of acute testicular pain, which requires immediate investigation and treatment. We describe a unique presentation of testicular torsion, which required the operating surgeon to assess the viability of a clinically dead testis through surgical manipulation, 16 hours after onset of pain. Case Report A 19 year old male presented with a 12 hour history of pain and swelling in the left scrotum. Examination revealed the left testes was hard, swollen and tender with a palpable spermatic cord. Clinical diagnosis of testicular mass or epididymo-orchitis was suggested and scrotal ultrasound was organised. This reported no blood flow in the left testis, and so torsion was suspected. Patient was taken immediately to theatre. Examination was performed under general anaesthetic, which revealed a hard, swollen testis, with no torsion clinically. Midline scrotal incision was made. On visual examination, left testis was black and hard, but there was no obvious torsion in the cord. However, during manipulation, the testis softened and started to change colour, eventually becoming dusky. A small incision into the testis showed bright red blood, and the decision was made to replace the testis and fix both testes. The patient made an excellent recovery post-operatively. Repeat ultrasound showed return of testicular vascularity. Conclusion This case showcases the importance of considering salvage in patients who have presented even after the generally accepted 6-8 hour time window. It also highlights the value of an experienced surgeon’s judgement in unusual presentations and with unexpected events intraoperatively.

SP4.2.4 Single centre experience of ‘Green Zone’ elective general surgery after the first wave of COVID-19

Introduction Elective surgery came to a halt during the first wave of COVID-19. The safe resumption of elective surgery with COVID-19 prevalent in the community, remains a significant challenge. The aim of this study was to look into the outcomes of elective general surgery in a dedicated ‘Green Zone’ following the first wave of COVID-19. Methods A ‘Green Zone’ pathway was drafted which was meant to provide a COVID-free environment for patients. Prospective data was collected on consecutive patients who underwent elective general surgical procedure at a single NHS trust over a 10-week period (1st Sept 2020 - 10th Nov 2020). The primary outcome was 30-day COVID-19 mortality. Secondary outcomes included 30-day nonCOVID-19 mortality, readmissions and complications. Results The study included 185 patients with a median age 55 years (IQR 41-67); 96 (52%) were females. Majority of the patients were ASA 2 (n = 98, 53%) followed by equal number of ASA 1 and ASA 3 (n = 42, 23%). 33 patients (18%) had been shielding earlier in the year. 96% underwent general anaesthetic. Most of the cases were day cases (n = 131, 71%). There was no 30-day COVID-19 or nonCOVID-19 mortality. One patient developed COVID-19 three weeks after the index operation. 30-day readmission and complication rate were 5% (n = 10) and 10% (n = 18). Most of the complications were Clavien-Dindo grade 1(n = 8, 4%) and 2(n = 8, 4%). Conclusion This study has shown that dedicated ‘Green Zone’ elective operating pathway is safe provided a balanced risk assessment approach is adopted.

SP3.2.7 Surgical techniques in emergency hernia repair - what are we doing? Findings from the MASH study

Aims There is limited evidence to guide the emergency management of acutely symptomatic abdominal wall and groin hernias (ASH) and there is a lack of consensus on optimal surgical technique. This study aimed to explore surgical techniques used to repair ASH. Methods A prospective 12-week cohort study (NCT04197271) recruited adult patients with ASH across 23 UK sites. Baseline characteristics, quality of life, management strategy and 30/90-day outcomes were collected. For those undergoing surgery, detailed information was recorded on: time to surgery, anaesthetic technique, grade of surgeon, intraoperative findings, antibiotic use, operative approach, repair technique (mesh vs suture), mesh/suture type and position and whether bowel resection/stoma formation was required. Results Of the 264 patients recruited, 214 (82%) underwent acute repair within 48 hours of admission. 95% underwent open repair, with 93% under general anaesthetic. 5% of inguinal and femoral hernias had laparoscopic repair. Mesh was used in 89% of inguinal hernias vs 29% of umbilical hernias. The majority (86%) used a synthetic non-absorbable mesh (94% inguinal, 84% umbilical). Mesh placement varied widely for epigastric and umbilical hernia, with onlay used most commonly (24%). Similar variation was seen in suture choice. 8% developed an SSI by 30 days, the majority of which were in umbilical repairs. One patient developed early hernia recurrence (umbilical) requiring surgery. Conclusions This data demonstrates variation in the surgical management of ASH, especially with the use of mesh. Laparoscopic surgery was uncommon. Further studies are required to clarify optimal technique strategies in the emergency setting.