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BMJ Open Quality Jun 2022Despite a clear association between cognitive impairment and physical frailty and poor postoperative outcomes in older adults, preoperative rates are rarely assessed. We...
INTRODUCTION
Despite a clear association between cognitive impairment and physical frailty and poor postoperative outcomes in older adults, preoperative rates are rarely assessed. We sought to implement a preoperative cognitive impairment and frailty screening programme to meet the unique needs of our rural academic centre.
METHODS
Through stakeholder interviews, we identified five primary drivers underlying screening implementation: staff education, technology infrastructure, workload impact, screening value and patient-provider communication. Based on these findings, we implemented cognitive dysfunction (AD8, Mini-Cog) and frailty (Clinical Frailty Scale) screening in our preoperative care clinic and select surgical clinics.
RESULTS
In the preoperative care clinic, many of our patients scored positive for clinical frailty (428 of 1231, 35%) and for cognitive impairment (264 of 1781, 14.8%). In our surgical clinics, 27% (35 of 131) and 9% (12 of 131) scored positive for clinical frailty and cognitive impairment, respectively. Compliance to screening improved from 48% to 86% 1 year later.
CONCLUSION
We qualitatively analysed stakeholder feedback to drive the successful implementation of a preoperative cognitive impairment and frailty screening programme in our rural tertiary care centre. Preliminary data suggest that a clinically significant proportion of older adults screen positive for preoperative cognitive impairment and frailty and would benefit from tailored inpatient care.
Topics: Aged; Cognitive Dysfunction; Frailty; Geriatric Assessment; Humans; Preoperative Care; Tertiary Care Centers
PubMed: 35728865
DOI: 10.1136/bmjoq-2022-001873 -
Cardiology in the Young Jan 2020Preoperative mechanical ventilation is associated with morbidity and mortality following CHD surgery, but prior studies lack a comprehensive analysis of how preoperative...
BACKGROUND
Preoperative mechanical ventilation is associated with morbidity and mortality following CHD surgery, but prior studies lack a comprehensive analysis of how preoperative respiratory support mode and timing affects outcomes.
METHODS
We retrospectively collected data on children <18 years of age undergoing cardiac surgery at an academic tertiary care medical centre. Using multivariable regression, we examined the association between modes of preoperative respiratory support (nasal cannula, high-flow nasal cannula/noninvasive ventilation, or invasive mechanical ventilation), escalation of preoperative respiratory support, and invasive mechanical ventilation on the day of surgery for three outcomes: operative mortality, postoperative length of stay, and postoperative complications. We repeated our analysis in a subcohort of neonates.
RESULTS
A total of 701 children underwent 800 surgical procedures, and 40% received preoperative respiratory support. Among neonates, 243 patients underwent 253 surgical procedures, and 79% received preoperative respiratory support. In multivariable analysis, all modes of preoperative respiratory support, escalation in preoperative respiratory support, and invasive mechanical ventilation on the day of surgery were associated with increased odds of prolonged length of stay in children and neonates. Children (odds ratio = 3.69, 95% CI 1.2-11.4) and neonates (odds ratio = 8.97, 95% CI 1.31-61.14) on high-flow nasal cannula/noninvasive ventilation had increased odds of operative mortality compared to those on room air.
CONCLUSION
Preoperative respiratory support is associated with prolonged length of stay and mortality following CHD surgery. Knowing how preoperative respiratory support affects outcomes may help guide surgical timing, inform prognostic conversations, and improve risk stratification models.
Topics: Adolescent; Cardiac Surgical Procedures; Child; Child, Preschool; Female; Heart Defects, Congenital; Humans; Infant; Infant, Newborn; Intensive Care Units, Pediatric; Length of Stay; Logistic Models; Male; Multivariate Analysis; Noninvasive Ventilation; North Carolina; Postoperative Complications; Preoperative Care; Respiration, Artificial; Retrospective Studies; Risk Factors; Tertiary Care Centers; Time Factors
PubMed: 31771666
DOI: 10.1017/S1047951119002786 -
Frontiers in Endocrinology 2021
Topics: Adrenal Gland Neoplasms; Carcinogenesis; Combined Modality Therapy; Endocrinology; Humans; Molecular Targeted Therapy; Mutation; Pheochromocytoma; Preoperative Care; Prognosis; Receptors, G-Protein-Coupled; Risk Assessment; Succinate Dehydrogenase; Tumor Hypoxia
PubMed: 34497588
DOI: 10.3389/fendo.2021.720983 -
The Journal of Surgical Research Oct 2021Preoperative optimization is increasingly emphasized for high-risk surgical patients. One critical component of this includes preoperative advanced care planning to...
BACKGROUND
Preoperative optimization is increasingly emphasized for high-risk surgical patients. One critical component of this includes preoperative advanced care planning to promote goal-concordant care. We aimed to define a subset of patients that might benefit from preoperative palliative care consult for advanced care planning.
MATERIALS AND METHODS
We examined adult patients admitted from January 2016 to December 2018 to a university health system for elective surgery. Multivariate logistic regression was used to identify variables associated with death within 1 y, and presence of palliative care consults preoperatively. Chi-square analysis evaluated the impact of a palliative care consult on advanced care planning variables.
RESULTS
Of the 29,132 inpatient elective procedures performed, there was a 2.0% mortality rate at 6 mo and 3.5% at 1 y. Those who died were more likely to be older, male, underweight (BMI <18), or have undergone an otolaryngology, neurosurgery or thoracic procedure type (all P-values < 0.05). At the time of admission, 29% had an advance directive, 90% had a documented code status, and 0.3% had a preoperative palliative care consult. Patients were more likely to have an advanced directive, a power of attorney, a documented code status, and have a do not resuscitate order if they had a palliative care consult (all P-values <0.05). The mortality rates and preoperative palliative care rates per procedure type did not follow similar trends.
CONCLUSIONS
Preoperative palliative care consultation before elective admissions for surgery had a significant impact on advanced care planning.
Topics: Adult; Advance Care Planning; Aged; Aged, 80 and over; Elective Surgical Procedures; Female; Humans; Logistic Models; Male; Middle Aged; Palliative Care; Preoperative Care; Retrospective Studies
PubMed: 33984730
DOI: 10.1016/j.jss.2021.04.003 -
Nutrients Dec 2021Despite the increasing array of medications available for the treatment of Crohn's disease and a focus on mucosal healing, approximately 35% of patients with Crohn's... (Review)
Review
Despite the increasing array of medications available for the treatment of Crohn's disease and a focus on mucosal healing, approximately 35% of patients with Crohn's disease undergo bowel surgery at some stage. The importance of nutritional optimisation before Crohn's surgery is well-highlighted by surgical, nutritional, and gastroenterological societies with the aim of reducing complications and enhancing recovery. Surgical procedures are frequently undertaken when other treatment options have been unsuccessful, and, thus, patients may have lost weight and/or required steroids, and are therefore at higher risk of post-operative complications. EEN is used extensively in the paediatric population to induce remission, but is not routinely used in the induction of remission of adult Crohn's disease or in pre-operative optimisation. Large prospective studies regarding the role of pre-operative EEN are lacking. In this review, we evaluate the current literature on the use of EEN in pre-operative settings and its impact on patient outcomes.
Topics: Crohn Disease; Enhanced Recovery After Surgery; Enteral Nutrition; Humans; Postoperative Complications; Preoperative Care; Remission Induction; Risk; Treatment Outcome
PubMed: 34959941
DOI: 10.3390/nu13124389 -
American Journal of Surgery Jul 2020• Telehealth has become a medical necessity during the COVID-19 pandemic. • Surgeons must integrate this new technology into surgical practice. • Effective for...
• Telehealth has become a medical necessity during the COVID-19 pandemic. • Surgeons must integrate this new technology into surgical practice. • Effective for detecting post-operative complications and preoperative counseling.
Topics: Betacoronavirus; COVID-19; Coronavirus Infections; Counseling; Humans; Pandemics; Pneumonia, Viral; Postoperative Complications; Preoperative Care; SARS-CoV-2; Surgical Procedures, Operative; Telemedicine
PubMed: 32336519
DOI: 10.1016/j.amjsurg.2020.04.026 -
Seizure Feb 2020Investigation of possible candidates for epilepsy surgery will usually require inpatient EEG to capture seizures and allow full operative planning. Withdrawal of... (Review)
Review
Investigation of possible candidates for epilepsy surgery will usually require inpatient EEG to capture seizures and allow full operative planning. Withdrawal of antiepileptic drugs increases the yield of this valuable diagnostic information and the benefits of this should justify any increase in the risk of harm associated with these seizures This paper outlines our opinion on what would constitute proposed best practice for management of antiepileptic drug (AED) dosing when patients are admitted for monitoring of seizures to an epilepsy monitoring unit (EMU). In the vast majority of cases EMU admissions are safe and, even if seizures occur, will pass off without complication. Previous guidance has concentrated on ensuring practice around technical aspects of EEG monitoring itself and staffing within the unit. In this guidance we aim to outline optimally safe ways of ensuring that EMUs ensure the minimisation of risk to the patients admitted under their care. We propose an algorithm for enhancing the safety of AED withdrawal in VT admissions while ensuring adequate seizure yields. Risk minimisation requires planned management of drug dosing (with reduction if appropriate), provision of adequate rescue medication, and adequate supervision to allow rapid response to generalised seizures. This algorithm is accompanied by a table which uses knowledge of the clinical and pharmacological properties of each AED to ensure dose withdrawal and reduction is timely and safe taking into account the severity and frequency of the individual's seizures.
Topics: Anticonvulsants; Electroencephalography; Epilepsy; Humans; Monitoring, Physiologic; Preoperative Care; Substance Withdrawal Syndrome
PubMed: 31896534
DOI: 10.1016/j.seizure.2019.12.010 -
Journal of Orthopaedic Surgery and... Apr 2022Templating is a preoperative planning procedure that improves the efficiency of the surgical process and reduces postoperative complications of total hip arthroplasty... (Observational Study)
Observational Study
BACKGROUND
Templating is a preoperative planning procedure that improves the efficiency of the surgical process and reduces postoperative complications of total hip arthroplasty (THA) by improving the precision of prediction of prosthetic implant size. This study aimed to evaluate the accuracy of the preoperative cup and stem size digital 2D templating of THA with mediCAD software and find the factors that influence the accuracy, such as indication for surgery, patients' demographics, implant brand, and the assessors' grade of education.
METHODS
We retrospectively retrieved 420 patient template images of all patients who underwent THA between March 2018 and March 2021. Templating of all included images was processed using mediCAD software a day before surgery by a newcomer physician to hip arthroplasty course (PGY-2 orthopedic resident or hip surgery fellow). Preoperative templating cup and stem sizes were compared with the actual inserted implant sizes.
RESULT
After excluding ineligible patients, this study included 391 patients, 193 (49.4%) males and 198 (50.6%) females with a mean age of 43.3 ± 14.9. The average cup sizes predicted before and after surgery were 52.12 ± 14.28 and 52.21 ± 15.05 respectively, and the mean delta cup size (before and after surgery) was 2.79 ± 2.94. The delta stem size before and after surgery has a mean value of 1.53 ± 1.49. The acetabular cup components, measured within ± 0, ± 1, and ± 2 sizes, were 28.9%, 63.9%, 83.1% accurate, respectively. The femoral stem design component measured within ± 0, ± 1, and ± 2 sizes were 27.2%, 61.0%, 78.6% accurate, respectively. Wagner Cone stem brand, DDH patients, and females showed significantly higher accuracy of stem size templating. Revision THA has the lowest accuracy in terms of cup size templating. The compression of accuracy rate between resident and fellow revealed no significant differences. Also, no significant difference was detected between the accuracy of templating performed in the first months with the second months of the arthroplasty course period.
CONCLUSION
Our study showed that under mentioned condition, templating using mediCAD has acceptable accuracy in predicting the sizes of femoral and acetabular components in THA patients. Digital software like mediCAD remains favorable because of the short learning curve, user-friendly features, and low-cost maintenance, leading to level-up patient care and THA efficacy. Further studies are necessary for clarifying the role of the assessor's experience and expertise in THA preoperative templating.
LEVEL OF EVIDENCE
Level III (retrospective observational study).
Topics: Acetabulum; Adult; Arthroplasty, Replacement, Hip; Female; Hip Joint; Hip Prosthesis; Humans; Male; Middle Aged; Preoperative Care; Retrospective Studies; Software
PubMed: 35399090
DOI: 10.1186/s13018-022-03086-5 -
British Journal of Anaesthesia Mar 2023Perioperative frailty is prevalent and requires complex management, which could be guided by clinical practice guidelines (CPGs). The objective of this systematic review... (Review)
Review
BACKGROUND
Perioperative frailty is prevalent and requires complex management, which could be guided by clinical practice guidelines (CPGs). The objective of this systematic review was to identify and synthesise CPGs that provide perioperative recommendations specific to older adults living with frailty.
METHODS
After protocol registration, we performed a systematic review of CPGs. MEDLINE, Embase, CINAHL, and 14 grey literature databases were searched (January 1, 2000 until December 22, 2021). We included all CPGs that contained at least one frailty-specific recommendation related to any phase of the perioperative period. We compiled all relevant recommendations, extracted underlying strength of evidence, and categorised them by perioperative phase of care. Within each phase, recommendations were synthesised inductively into themes. Quality of CPGs was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.
RESULTS
From 4707 citations, 13 guidelines were included; 8/13 were focused on the perioperative care of older surgical patients in general. Among 110 recommendations extracted, 37 themes were generated, with the majority pertaining to preoperative care. Four themes were supported by strong evidence: performing preoperative frailty assessments, using multidimensional frailty instruments, reducing urinary catheter use, and following multidisciplinary care and communication throughout the perioperative period. Per AGREE II, most guidelines (8/13; 62%) were recommended for use with modifications.
CONCLUSIONS
Despite increasing numbers of patients living with frailty, few guidelines exist that address frailty-specific perioperative care. Given the lack of strong evidence-based recommendations, particularly outside the preoperative period, high-quality primary research is required to underpin future guidelines and better inform the care of older surgical patients with frailty.
SYSTEMATIC REVIEW PROTOCOL
PROSPERO CRD42022320149.
Topics: Humans; Aged; Frailty; Preoperative Care; Databases, Factual
PubMed: 36707368
DOI: 10.1016/j.bja.2022.12.010 -
Surgery Dec 2019Ensuring timely and high-quality surgery must be a key element of breast cancer control efforts in sub-Saharan Africa. We investigated delays in preoperative care and...
BACKGROUND
Ensuring timely and high-quality surgery must be a key element of breast cancer control efforts in sub-Saharan Africa. We investigated delays in preoperative care and the impact of on-site versus off-site operation on time to operative treatment of patients with breast cancer at Butaro Cancer Center of Excellence in Rwanda.
METHODS
We used a standardized data abstraction form to collect demographic data, clinical characteristics, treatments received, and disease status as of November 2017 for all patients diagnosed with breast cancer at Butaro Cancer Center of Excellence in 2014 to 2015.
RESULTS
From 2014 to 2015, 89 patients were diagnosed with stage I to III breast cancer and treated with curative intent. Of those, 68 (76%) underwent curative breast operations, 12 (14%) were lost to follow-up, 7 (8%) progressed, and 2 declined the recommended operation. Only 32% of patients who underwent operative treatment had the operation within 60 days from diagnosis or last neoadjuvant chemotherapy. Median time to operation was 122 days from biopsy if no neoadjuvant treatments were given and 51 days from last cycle of neoadjuvant chemotherapy. Patients who received no neoadjuvant chemotherapy experienced greater median times to operation at Butaro Cancer Center of Excellence (180 days) than at a referral hospital in Kigali (93 days, P = .04). Most patients (60%) experienced a disruption in preoperative care, frequently at the point of surgical referral. Documented reasons for disruptions and delays included patient factors, clinically indicated treatment modifications, and system factors.
CONCLUSION
We observed frequent delays to operative treatment, disruptions in preoperative care, and loss to follow-up, particularly at the point of surgical referral. There are opportunities to improve breast cancer survival in Rwanda and other low- and middle-income countries through interventions that facilitate more timely surgical care.
Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Chemotherapy, Adjuvant; Continuity of Patient Care; Delivery of Health Care; Female; Humans; Middle Aged; Neoadjuvant Therapy; Neoplasm Staging; Preoperative Care; Referral and Consultation; Retrospective Studies; Rwanda; Time-to-Treatment
PubMed: 31466858
DOI: 10.1016/j.surg.2019.06.021