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Anesthesiology Feb 2022Frailty is increasingly being recognized as a public health issue, straining healthcare resources and increasing costs to care for these patients. Frailty is the decline...
BACKGROUND
Frailty is increasingly being recognized as a public health issue, straining healthcare resources and increasing costs to care for these patients. Frailty is the decline in physical and cognitive reserves leading to increased vulnerability to stressors such as surgery or disease states. The goal of this pilot diagnostic accuracy study was to identify whether point-of-care ultrasound measurements of the quadriceps and rectus femoris muscles can be used to discriminate between frail and not-frail patients and predict postoperative outcomes. This study hypothesized that ultrasound could discriminate between frail and not-frail patients before surgery.
METHODS
Preoperative ultrasound measurements of the quadriceps and rectus femoris were obtained in patients with previous computed tomography scans. Using the computed tomography scans, psoas muscle area was measured in all patients for comparative purposes. Frailty was identified using the Fried phenotype assessment. Postoperative outcomes included unplanned intensive care unit admission, delirium, intensive care unit length of stay, hospital length of stay, unplanned skilled nursing facility admission, rehospitalization, falls within 30 days, and all-cause 30-day and 1-yr mortality.
RESULTS
A total of 32 patients and 20 healthy volunteers were included. Frailty was identified in 18 of the 32 patients. Receiver operating characteristic curve analysis showed that quadriceps depth and psoas muscle area are able to identify frailty (area under the curve-receiver operating characteristic, 0.80 [95% CI, 0.64 to 0.97] and 0.88 [95% CI, 0.76 to 1.00], respectively), whereas the cross-sectional area of the rectus femoris is less promising (area under the curve-receiver operating characteristic, 0.70 [95% CI, 0.49 to 0.91]). Quadriceps depth was also associated with unplanned postoperative skilled nursing facility discharge disposition (area under the curve 0.81 [95% CI, 0.61 to 1.00]) and delirium (area under the curve 0.89 [95% CI, 0.77 to 1.00]).
CONCLUSIONS
Similar to computed tomography measurements of psoas muscle area, preoperative ultrasound measurements of quadriceps depth shows promise in discriminating between frail and not-frail patients before surgery. It was also associated with skilled nursing facility admission and postoperative delirium.
Topics: Aged; Female; Frailty; Hand Strength; Humans; Male; Middle Aged; Point-of-Care Systems; Postoperative Complications; Predictive Value of Tests; Preoperative Care; Prospective Studies; Ultrasonography, Interventional
PubMed: 34851395
DOI: 10.1097/ALN.0000000000004064 -
JNMA; Journal of the Nepal Medical... Oct 2022The overall outcome of the patient after any surgery is determined not only by the fineness of the surgical procedure but also by preoperative conditioning and... (Review)
Review
UNLABELLED
The overall outcome of the patient after any surgery is determined not only by the fineness of the surgical procedure but also by preoperative conditioning and postoperative care. Prehabilitation decreases the surgical stress response and increases the preparedness of the patient to undergo planned surgical insult. Preoperatively structured inspiratory muscle exercises, cardiopulmonary fitness program, and planned exercise program for muscles of limbs, back, abdomen, head, and neck allow an overall upliftment of the physiological capacity of the patient to better cope with the surgical stress. Optimization of dietary status by macronutrients, micronutrients, and the nutrients has an impact on augmenting postoperative recovery and shortening the overall hospital stay. Preparing patients for the scheduled surgery and initiating alcohol and smoking cessation programs overhaul the patient's mental health and boost the healing process. This concept of prehabilitation a few weeks before surgery is equally beneficial compared to enhancing operative procedures and postsurgical care.
KEYWORDS
length of stay; mental health; nutrients; preoperative exercise; smoking cessation.
Topics: Humans; Preoperative Exercise; Preoperative Care; Exercise; Postoperative Care; Delivery of Health Care; Postoperative Complications
PubMed: 36705159
DOI: 10.31729/jnma.7545 -
ANZ Journal of Surgery Oct 2020Preoperative screening for coronavirus disease 2019 (COVID-19) aims to preserve surgical safety for both patients and surgical teams. This rapid review provides an... (Review)
Review
BACKGROUND
Preoperative screening for coronavirus disease 2019 (COVID-19) aims to preserve surgical safety for both patients and surgical teams. This rapid review provides an evaluation of current evidence with input from clinical experts to produce guidance for screening for active COVID-19 in a low prevalence setting.
METHODS
An initial search of PubMed (until 6 May 2020) was combined with targeted searches of both PubMed and Google Scholar until 1 July 2020. Findings were streamlined for clinical relevance through the advice of an expert working group that included seven senior surgeons and a senior medical virologist.
RESULTS
Patient history should be examined for potential exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Hyposmia and hypogeusia may present as early symptoms of COVID-19, and can potentially discriminate from other influenza-like illnesses. Reverse transcription-polymerase chain reaction is the gold standard diagnostic test to confirm SARS-CoV-2 infection, and although sensitivity can be improved with repeated testing, the decision to retest should incorporate clinical history and the local supply of diagnostic resources. At present, routine serological testing has little utility for diagnosing acute infection. To appropriately conduct preoperative testing, the temporal dynamics of SARS-CoV-2 must be considered. Relative to other thoracic imaging modalities, computed tomography has the greatest utility for characterizing pulmonary involvement in COVID-19 patients who have been diagnosed by reverse transcription-polymerase chain reaction.
CONCLUSION
Through a rapid review of the literature and advice from a clinical expert working group, evidence-based recommendations have been produced for the preoperative screening of surgical patients with suspected COVID-19.
Topics: COVID-19; COVID-19 Testing; Humans; Mass Screening; Practice Guidelines as Topic; Preoperative Care
PubMed: 32770653
DOI: 10.1111/ans.16260 -
Current Opinion in Anaesthesiology Dec 2022Ambulatory surgery is increasingly performed in medically complex patients. This dynamic environment requires new approaches to ensure cost-effective, efficient, and... (Review)
Review
PURPOSE OF REVIEW
Ambulatory surgery is increasingly performed in medically complex patients. This dynamic environment requires new approaches to ensure cost-effective, efficient, and ultimately safe preoperative evaluation of the patient. This review investigates recent advances in the assessment of ambulatory patients, with a special focus on patient screening, digital communication, and multidisciplinary team evaluation.
RECENT FINDINGS
Identifying suitable candidates for ambulatory surgery relies on a variety of medical, surgical, and institutional factors. Identification of high-risk patients and optimization of their treatment can be achieved through multidisciplinary protocols specific to the local institution and in line with current guidelines. Virtual assessment may be sufficient for most patients and provide an efficient evaluation strategy and high patient satisfaction. Prescreening can be supported by preoperative nursing teams.
SUMMARY
The increasing complexity of treatment provided in day surgery offers a unique opportunity to highlight the importance of anesthesiology staff as perioperative caregivers. Preoperative evaluation serves as a central junction to integrate a variety of surgical, medical, and institutional factors to provide safe, satisfactory, and efficient care for patients. Implementing technological innovation to streamline and facilitate this process is paramount.
Topics: Humans; Ambulatory Surgical Procedures; Preoperative Care; Anesthesiology; Patient Satisfaction
PubMed: 36194141
DOI: 10.1097/ACO.0000000000001192 -
British Journal of Anaesthesia Jul 2021In the general adult population, lymphopaenia is associated with an increased risk for hospitalisation with infection and infection-related death. The quality of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In the general adult population, lymphopaenia is associated with an increased risk for hospitalisation with infection and infection-related death. The quality of evidence and strength of association between perioperative lymphopaenia across different surgical procedures and mortality/morbidity has not been examined by systematic review or meta-analysis.
METHODS
We searched MEDLINE, Embase, Web of Science, Google Scholar, and Cochrane databases from their inception to June 29, 2020 for observational studies reporting lymphocyte count and in-hospital mortality rate in adults. We defined preoperative lymphopaenia as a lymphocyte count 1.0-1.5×10 L. Meta-analysis was performed using either fixed or random effects models. Quality was assessed using the Newcastle-Ottawa Scale. The I index was used to quantify heterogeneity. The primary outcome was in-hospital mortality rate and mortality rate at 30 days.
RESULTS
Eight studies met the inclusion criteria for meta-analysis, comprising 4811 patients (age range, 46-91 yr; female, 20-79%). These studies examined preoperative lymphocyte count exclusively. Studies were of moderate to high quality overall, ranking >7 using the Newcastle-Ottawa Scale. Preoperative lymphopaenia was associated with a threefold increase in mortality rate (risk ratio [RR]=3.22; 95% confidence interval [CI], 2.19-4.72; P<0.01, I=0%) and more frequent major postoperative complications (RR=1.33; 95% CI, 1.21-1.45; P<0.01, I=6%), including cardiovascular morbidity (RR=1.77; 95% CI, 1.45-2.15; P<0.01, I=0%), infections (RR=1.45; 95% CI, 1.19-1.76; P<0.01, I=0%), and acute renal dysfunction (RR=2.66; 95% CI, 1.49-4.77; P<0.01, I=1%).
CONCLUSION
Preoperative lymphopaenia is associated with death and complications more frequently, independent of the type of surgery.
PROSPERO REGISTRY NUMBER
CRD42020190702.
Topics: Elective Surgical Procedures; Hospital Mortality; Humans; Lymphopenia; Morbidity; Postoperative Complications; Preoperative Care; Prospective Studies
PubMed: 33795133
DOI: 10.1016/j.bja.2021.02.023 -
BJS Open May 2023The use of intravenous antibiotics at anaesthetic induction in colorectal surgery is the standard of care. However, the role of mechanical bowel preparation, enemas, and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The use of intravenous antibiotics at anaesthetic induction in colorectal surgery is the standard of care. However, the role of mechanical bowel preparation, enemas, and oral antibiotics in surgical site infection, anastomotic leak, and other perioperative outcomes remains controversial. The aim of this study was to determine the optimal preoperative bowel preparation strategy in elective colorectal surgery.
METHODS
A systematic review and network meta-analysis of RCTs was performed with searches from PubMed/MEDLINE, Scopus, Embase, and the Cochrane Central Register of Controlled Trials from inception to December 2022. Primary outcomes included surgical site infection and anastomotic leak. Secondary outcomes included 30-day mortality rate, ileus, length of stay, return to theatre, other infections, and side effects of antibiotic therapy or bowel preparation.
RESULTS
Sixty RCTs involving 16 314 patients were included in the final analysis: 3465 (21.2 per cent) had intravenous antibiotics alone, 5268 (32.3 per cent) had intravenous antibiotics + mechanical bowel preparation, 1710 (10.5 per cent) had intravenous antibiotics + oral antibiotics, 4183 (25.6 per cent) had intravenous antibiotics + oral antibiotics + mechanical bowel preparation, 262 (1.6 per cent) had intravenous antibiotics + enemas, and 1426 (8.7 per cent) had oral antibiotics + mechanical bowel preparation. With intravenous antibiotics as a baseline comparator, network meta-analysis demonstrated a significant reduction in total surgical site infection risk with intravenous antibiotics + oral antibiotics (OR 0.47 (95 per cent c.i. 0.32 to 0.68)) and intravenous antibiotics + oral antibiotics + mechanical bowel preparation (OR 0.55 (95 per cent c.i. 0.40 to 0.76)), whereas oral antibiotics + mechanical bowel preparation resulted in a higher surgical site infection rate compared with intravenous antibiotics alone (OR 1.84 (95 per cent c.i. 1.20 to 2.81)). Anastomotic leak rates were lower with intravenous antibiotics + oral antibiotics (OR 0.63 (95 per cent c.i. 0.44 to 0.90)) and intravenous antibiotics + oral antibiotics + mechanical bowel preparation (OR 0.62 (95 per cent c.i. 0.41 to 0.94)) compared with intravenous antibiotics alone. There was no significant difference in outcomes with mechanical bowel preparation in the absence of intravenous antibiotics and oral antibiotics in the main analysis.
CONCLUSION
A bowel preparation strategy with intravenous antibiotics + oral antibiotics, with or without mechanical bowel preparation, should represent the standard of care for patients undergoing elective colorectal surgery.
Topics: Humans; Anti-Bacterial Agents; Surgical Wound Infection; Anastomotic Leak; Colorectal Surgery; Network Meta-Analysis; Preoperative Care
PubMed: 37257059
DOI: 10.1093/bjsopen/zrad040 -
British Journal of Anaesthesia Jul 2019Frailty is a syndrome of cumulative decline across multiple physiological systems, which predisposes vulnerable adults to adverse events. Assessing vulnerable patients... (Review)
Review
Frailty is a syndrome of cumulative decline across multiple physiological systems, which predisposes vulnerable adults to adverse events. Assessing vulnerable patients can potentially lead to interventions that improve surgical outcomes. Anaesthesiologists who care for older patients can identify frailty to improve preoperative risk stratification and subsequent perioperative planning. Numerous clinical tools to diagnose frailty exist, but none has emerged as the standard tool to be used in clinical practice. Radiological modalities, such as computed tomography and ultrasonography, are widely performed before surgery, and are therefore available to be used opportunistically to objectively evaluate surrogate markers of frailty. This review presents the importance of frailty assessment by anaesthesiologists; lists common clinical tools that have been applied; and proposes that utilising radiological imaging as an objective surrogate measure of frailty is a novel, expanding approach for which anaesthesiologists can significantly contribute to broad implementation.
Topics: Aged; Aged, 80 and over; Frail Elderly; Geriatric Assessment; Humans; Postoperative Complications; Preoperative Care; Risk Assessment; Risk Factors
PubMed: 31056240
DOI: 10.1016/j.bja.2019.03.034 -
Vascular Medicine (London, England) Oct 2022Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of... (Review)
Review
Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients' risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.
Topics: Humans; Postoperative Complications; Preoperative Care; Risk Assessment; Risk Factors; Vascular Surgical Procedures
PubMed: 36214163
DOI: 10.1177/1358863X221122552 -
Der Unfallchirurg Oct 2021The success of a surgical procedure is significantly influenced by several critical factors. The safety of the patient is the primary goal. To this end, the term...
The success of a surgical procedure is significantly influenced by several critical factors. The safety of the patient is the primary goal. To this end, the term surgical preparation covers a number of procedures aiming to ensure the safety for the patient and a successful surgical intervention: verifying the indications, planning the intervention, identification of potential harmful factors, risks and countermeasures, patient education and documentation. Trauma surgery poses a particular challenge to preoperative preparation, especially due to urgent surgical interventions. Here, a standardized and evidence-based preoperative evaluation ensures a successful treatment of the patient.
Topics: Documentation; Humans; Preoperative Care
PubMed: 34292350
DOI: 10.1007/s00113-021-01037-z -
JAMA Network Open Oct 2020The association between preoperative benzodiazepine use and long-term postoperative outcomes is not well understood. (Comparative Study)
Comparative Study
IMPORTANCE
The association between preoperative benzodiazepine use and long-term postoperative outcomes is not well understood.
OBJECTIVE
To characterize the association between preoperative benzodiazepine use and postoperative opioid use and health care costs.
DESIGN, SETTING, AND PARTICIPANTS
In this cohort study, retrospective analysis of private health insurance claims data on 946 561 opioid-naive patients (no opioid prescriptions filled in the year before surgery) throughout the US was conducted. Patients underwent 1 of 11 common surgical procedures between January 1, 2004, and December 31, 2016; data analysis was performed January 9, 2020.
EXPOSURES
Benzodiazepine use, defined as long term (≥10 prescriptions filled or ≥120 days supplied in the year before surgery) or intermittent (any use not meeting the criteria for long term).
MAIN OUTCOMES AND MEASURES
The primary outcome was opioid use 91 to 365 days after surgery. Secondary outcomes included opioid use 0 to 90 days after surgery and health care costs 0 to 30 days after surgery.
RESULTS
In this sample of 946 561 patients, the mean age was 59.8 years (range, 18-89 years); 615 065 were women (65.0%). Of these, 23 484 patients (2.5%) met the criteria for long-term preoperative benzodiazepine use and 47 669 patients (5.0%) met the criteria for intermittent use. After adjusting for confounders, long-term (odds ratio [OR], 1.59; 95% CI, 1.54-1.65; P < .001) and intermittent (OR, 1.47; 95% CI, 1.44-1.51; P < .001) benzodiazepine use were associated with an increased probability of any opioid use during postoperative days 91 to 365. For patients who used opioids in postoperative days 91 to 365, long-term benzodiazepine use was associated with a 44% increase in opioid dose (additional 0.6 mean daily morphine milligram equivalents [MMEs]; 95% CI, 0.3-0.8 MMEs; P < .001), although intermittent benzodiazepine use was not significantly different (0.0 average daily MMEs; 95% CI, -0.2 to 0.2 MMEs; P = .65). Preoperative benzodiazepine use was also associated with increased opioid use in postoperative days 0 to 90 for both long-term (32% increase, additional 1.9 average daily MMEs; 95% CI, 1.6-2.1 MMEs; P < .001) and intermittent (9% increase, additional 0.5 average daily MMEs; 95% CI, 0.4-0.6 MMEs; P < .001) users. Intermittent benzodiazepine use was associated with an increase in 30-day health care costs ($1155; 95% CI, $938-$1372; P < .001), while no significant difference was observed for long-term benzodiazepine use.
CONCLUSIONS AND RELEVANCE
The findings of this study suggest that, among opioid-naive patients, preoperative benzodiazepine use may be associated with an increased risk of developing long-term opioid use and increased opioid dosages postoperatively, and also may be associated with increased health care costs.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Benzodiazepines; Cohort Studies; Female; Health Care Costs; Humans; Male; Middle Aged; Pain, Postoperative; Preoperative Care; Retrospective Studies; United States; Young Adult
PubMed: 33107919
DOI: 10.1001/jamanetworkopen.2020.18761