Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

Association of dysglycemia with post-operative outcomes in pediatric surgery

BackgroundPerioperative dysglycemia is associated with adverse surgical outcomes in adults. We sought to determine the association between perioperative dysglycemia and 30-day adverse surgical events in pediatric patients undergoing non-cardiac surgery.MethodsWe analyzed records from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P) database from 2016 to 2021 at two academic tertiary care hospitals. The primary outcomes were individual 30-day adverse events, composite serious adverse events, composite hospital acquired infections and composite morbidity.ResultsA total of 5410 records were analyzed: the cohort was 52.6% male and 52.6% non-Hispanic White, and 1472 (27.2%) had dysglycemia. Children undergoing procedures in general surgery (48.4%), neurosurgery (25.4%), and orthopedic surgery (16.0%) had higher rates of dysglycemia compared to other surgical specialties. Patients with dysglycemia were more likely to have surgical site infection (4.3% dysglycemic vs. 3.1% normoglycemic, p = 0.028), cardiac arrest (2.6% vs. 0.1%, p < 0.001), and sepsis (3.7% vs. 1.3%, p < 0.001); more likely to undergo reoperation (11.3% vs. 5.8%, p < 0.001); and more likely to remain hospitalized after 30 days (33.0% vs. 6.1%, p < 0.001). After controlling for patient and case demographics, perioperative dysglycemia was associated with more composite serious adverse events (OR 1.85, 95% CI 1.49–2.29, p = 0.000), composite hospital acquired infections (OR 1.42, 95% CI 1.04–1.93, p = 0.026), and composite morbidity (OR 2.52, 95% CI 2.13–2.97, p = 0.000).ConclusionsPerioperative dysglycemia in children undergoing non-cardiac surgery is associated with increased risk of adverse events and outcomes. Interventions that screen and normalize blood glucose in the perioperative period may mitigate risk and improve quality of care.     

Perioperative dexmedetomidine administration to prevent delirium in adults after non-cardiac surgery: A systematic review and meta-analysis

Study objectiveTo evaluate the efficacy of perioperative dexmedetomidine (DEX) administration for preventing delirium in adults after non-cardiac surgery.DesignSystematic review and meta-analysis of randomized controlled trials (RCTs).InterventionsPerioperative administration of DEX to prevent delirium in adults following non-cardiac surgery.MeasurementsThe incidence of postoperative delirium (POD).MethodsThe databases of PubMed, Embase and Cochrane Central Register were searched from inception to Mar 4, 2021 for all available RCTs that assessed DEX for POD in adults after non-cardiac surgery. Risk ratio (RR) with a 95% confidence interval (CI) was calculated for dichotomous data. Standardized mean difference (SMD) was calculated for continuous data. Risk of bias was assessed using the second version of the Cochrane risk-of-bias tool for RCTs (RoB 2.0), and the level of certainty for main outcomes were assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.Main resultsThirteen studies, including the meta-analysis with a total of 4015 patients (DEX group: 2050 patients; placebo group: 1965 patients), showed that DEX significantly reduced the incidence of POD in adults after non-cardiac surgery compared with control group (RR: 0.60; 95%CI: 0.46 to 0.77, P = 0.0001, I² = 55%, GRADE = moderate). Meanwhile, there was a statistical difference by the subgroup analysis between the mean age ≥ 65 years group and the mean age<65 years group. There were no statistical differences in length of hospital stay following surgery (SMD: -0.36; 95%CI: −0.80 to 0.07, P = 0.1, I² = 97%, GRADE = low) and all-cause mortality rate (RR:0.57; 95%CI: 0.25 to 1.28, P < 0.17, I² = 0%, GRADE = moderate) compared with placebo group. However, Meta-analysis showed that DEX administration significantly resulted in intraoperative bradycardia when compared with placebo group (RR: 1.39; 95%CI: 1.14 to 1.69, P = 0.0009, I² = 0%, GRADE = high), and as well as intraoperative hypotension (RR: 1.25; 95%CI: 1.11 to 1.42, P = 0.0004, I² = 0%, GRADE = high).ConclusionThis systematic review and meta-analysis suggests that perioperative administration of DEX could significantly reduce the incidence of POD in patients elder than 65 years following non-cardiac surgery. However, there was no definite evidence that perioperative DEX could reduce the incidence of POD in patients younger than 65 years of age after non-cardiac surgery. In addition, perioperative DEX administration was associated with an elevated risk of bradycardia and hypotension.     

A comparison of four risk models for the prediction of cardiovascular complications in patients with a history of atrial fibrillation undergoing non-cardiac surgery

It is unclear how best to predict peri-operative cardiovascular risk in patients with atrial fibrillation undergoing non-cardiac surgery. This study examined the accuracy of the revised cardiac risk index and three atrial fibrillation thrombo-embolic risk models for predicting 30-day cardiovascular events after non-cardiac surgery in patients with a pre-operative history of atrial fibrillation. We conducted a prospective cohort study in 28 centres from 2007 to 2013 of 40,004 patients ≥ 45 years of age undergoing inpatient non-cardiac surgery who were followed until 30 days after surgery for cardiovascular events (defined as myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death). The 2088 patients with a pre-operative history of atrial fibrillation were at higher risk of peri-operative cardiovascular events compared with the 34,830 patients without a history of atrial fibrillation (29% vs. 13%, respectively, adjusted odds ratio 1.30 (95%CI 1.17–1.45). Compared with the revised cardiac risk index (c-index 0.60), all atrial fibrillation thrombo-embolic risk scores were significantly better at predicting peri-operative cardiovascular events: CHADS₂ (c-index 0.62); CHA₂DS₂-VASc (c-index 0.63); and R₂CHADS₂ (c-index 0.65), respectively. Although the three thrombo-embolic risk prediction models were significantly better than the revised cardiac risk index for prediction of peri-operative cardiovascular events, none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri-operative risk prediction model.     

The effectiveness of positive airway pressure therapy in reducing postoperative adverse outcomes in surgical patients with obstructive sleep apnea: A systematic review and meta-analysis

ImportanceObstructive sleep apnea (OSA) is prevalent in surgical patients and is associated with an increased risk of adverse perioperative events.Study objectiveTo determine the effectiveness of positive airway pressure (PAP) therapy in reducing the risk of postoperative complications in patients with OSA undergoing surgery.DesignSystematic review and meta-analysis searching Medline and other databases from inception to October 17, 2021. The search terms included: “positive airway pressure,” “surgery,” “post-operative,” and “obstructive sleep apnea.” The inclusion criteria were: 1) adult patients with OSA undergoing surgery; (2) patients using preoperative and/or postoperative PAP; (3) at least one postoperative outcome reported; (4) control group (patients with OSA undergoing surgery without preoperative and/or postoperative PAP therapy); and (5) English language articles.PatientsTwenty-seven studies included 30,514 OSA patients undergoing non-cardiac surgery and 837 OSA patients undergoing cardiac surgery.InterventionPAP therapyMain resultsIn patients with OSA undergoing non-cardiac surgery, PAP therapy was associated with a decreased risk of postoperative respiratory complications (2.3% vs 3.6%; RR: 0.72, 95% CI: 0.51–1.00, asymptotic P = 0.05) and unplanned ICU admission (0.12% vs 4.1%; RR: 0.44, 95% CI: 0.19–0.99, asymptotic P = 0.05). No significant differences were found for all-cause complications (11.6% vs 14.4%; RR: 0.89, 95% CI: 0.74–1.06, P = 0.18), postoperative cardiac and neurological complications, in-hospital length of stay, and in-hospital mortality between the two groups. In patients with OSA undergoing cardiac surgery, PAP therapy was associated with decreased postoperative cardiac complications (33.7% vs 50%; RR: 0.63, 95% CI: 0.51–0.77, P < 0.0001), and postoperative atrial fibrillation (40.1% vs 66.7%; RR: 0.59, 95% CI 0.45–0.77, P < 0.0001).ConclusionIn patients with OSA undergoing non-cardiac surgery, PAP therapy was associated with a 28% reduction in the risk of postoperative respiratory complications and 56% reduction in unplanned ICU admission. In patients with OSA undergoing cardiac surgery, PAP therapy decreased the risk of postoperative cardiac complications and atrial fibrillation by 37% and 41%, respectively.     

Increased risk of postoperative wound complications among obesity classes II & III after ALIF in 10-year ACS-NSQIP analysis of 10,934 cases

BACKGROUND CONTEXTAnterior lumbar interbody fusion (ALIF) procedures for lumbar spine disease have been increasing amid a growing obese patient population with limited studies available focusing exclusively on risk-factors for post-operative ALIF complications.PURPOSEThe objective of this study was to compare 30-day post-operative complications among different obesity World Health Organization classes according to body mass index (BMI) in comparison to non-obese patients who underwent an ALIF procedure.STUDY DESIGN/SETTINGRetrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2009 to 2019.PATIENT SAMPLEA total of 10,934 patients undergoing an ALIF.OUTCOME MEASURESPrimary outcome measures include 30 day cardiac, pulmonary, urinary, infectious, and wound complications. Secondary outcomes included rates of blood transfusion, reintubation, deep vein thrombosis, pulmonary embolism, 30-day return to the operating room (OR), and 30 day mortality.METHODSPatients were identified by use of the current procedural terminology codes 22558 and 22585 from 2009 to 2019. Patients were divided into the following groups: non-obese (BMI 18.5–29.9 kg/m²), Obese I (BMI 30–34.9 kg/m²), Obese II (BMI 35–39.9 kg/m²), and Obese III (BMI ≥40 kg/m²). Age, gender, race, American Society of Anesthesiologists status, smoking status, hypertension requiring medication, steroid used, chronic obstructive pulmonary disease, history of a bleeding disorder, and diabetes was identified as risk factors after a univariate analysis conducted for demographic variables and pre-operative comorbidities. A multivariate logistic regression analysis was then performed to adjust for these preoperative risk factors and compare obesity classes I-III to non-obese patients.RESULTSObesity classes II and III had a significant odds ratio (OR) for superficial infection (OR:2.7, 95%CI(1.7–4.5); OR:2.8, 95%CI(1.5–5.2) respectively), organ space infection (OR:3.8, 95%CI(1.6–7.4); OR:3.2, 95%CI(1.1–9.9) respectively), wound disruption (OR:2.8, 95%CI(1.1–7.4); OR:4.6, 95%CI(1.6–13.6) respectively), and total wound complication (OR:2.6, 95%CI(1.8–3.9); OR:3.4, 95%CI(2.2–5.4) respectively) following a multivariate logistic regression analysis.CONCLUSIONSRisk for post-operative wound complications following an ALIF were found to be significantly higher for obesity classes II-III in comparison to non-obese patients. These findings can further support the use of additional wound care in the perioperative setting for certain levels of obesity.     

Preoperative proteinuria may be a risk factor for postoperative acute kidney injury：a meta-analysis

ObjectiveTo investigate the relationship between preoperative proteinuria and postoperative acute kidney injury (AKI).MethodsWe performed a search on databases included PubMed, Embase, the Cochrane Library, and Web of Science, from December 2009 to September 2020. Data extracted from eligible studies were synthesized to calculate the odds ratio (OR) and 95% confidence interval (CI). A fixed or random effects model was applied to calculate the pooled OR based on heterogeneity through the included studies.ResultsThis meta-analysis of 11 observational studies included 203,987 participants, of whom 21,621 patients suffered from postoperative AKI and 182,366 patients did not suffer from postoperative AKI. The combined results demonstrated that preoperative proteinuria is an independent risk factor for postoperative AKI (adjusted OR = 1.65, 95%CI:1.44–1.89, p < 0.001). Subgroup analysis showed that both preoperative mild proteinuria (adjusted OR = 1.30, 95%CI:1.24–1.36, p < 0.001) and preoperative heavy proteinuria (adjusted OR = 1.93, 95%CI:1.65–2.27, p < 0.001) were independent risk factors for postoperative AKI. The heterogeneity was combined because its values were lower. Further subgroup analysis found that preoperative proteinuria measured using dipstick was an independent risk factor for postoperative AKI (adjusted OR = 1.48, 95%CI:1.37–1.60, p < 0.001). Finally, preoperative proteinuria was an independent risk factor for postoperative AKI in the non-cardiac surgery group (adjusted OR = 2.06, 95%CI:1.31–3.24, p = 0.002) and cardiac surgery group (adjusted OR = 1.69, 95%CI:1.39–2.06, p < 0.001)ConclusionPreoperative proteinuria is an independent risk factor for postoperative AKI and in instances when proteinuria is detected using dipsticks.     

Prolonged Postoperative Mechanical Ventilation (PPMV) in children undergoing abdominal operations: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database

BackgroundProlonged postoperative mechanical ventilation (PPMV) increases length of stay, hospitalization costs, and postoperative complications. Independent risk factors associated with PPMV are not well-known for children.MethodWe identified children (<18 years) in the ACS NSQIP-P database who underwent a general surgical abdominal operation. We excluded children with preoperative ventilator dependence and mortality within 48 h of surgery. PPMV was defined as cumulative postoperative mechanical ventilation exceeding 72 h. A multivariable logistic regression model identified independent predictors of PPMV.ResultsWe identified 108,392 children who underwent a general surgical abdominal operation in the ACS NSQIP-P database from 2012 to 2017. We randomly divided the population into a derivation cohort of 75,874(70%) and a validation cohort of 32,518(30%). In the derivation cohort, we identified PPMV in 1,643(2.2%). In the multivariable model, the strongest independent predictor of PPMV was neonatal age (OR:20.66; 95%CI:16.44–25.97). Other independent risk factors for PPMV were preoperative inotropic support (OR:10.56; 95%CI:7.56–14.77), an operative time longer than 150 min (OR:4.30; 95%CI:3.72–4.52), and an American Society of Anesthesiologists classification >3 (OR:12.16; 95%CI:10.75–13.75).ConclusionIndependent preoperative risk factors for PPMV in children undergoing a general surgical operation were neonatal age, preoperative ionotropic support, duration of operation, and ASA classification >3.     

Association between use of enhanced recovery after surgery protocols and postoperative complications in colorectal surgery in Europe: The EuroPOWER international observational study

Study objectiveAssess the relationship between the Enhanced Recovery After Surgery (ERAS®) pathway and routine care and 30-day postoperative outcomes.DesignProspective cohort study.SettingEuropean centers (185 hospitals) across 21 countries.PatientsA total of 2841 adult patients undergoing elective colorectal surgery. Each hospital had a 1-month recruitment period between October 2019 and September 2020.InterventionsRoutine perioperative care.MeasurementsTwenty-four components of the ERAS pathway were assessed in all patients regardless of whether they were treated in a formal ERAS pathway. A multivariable and multilevel logistic regression model was used to adjust for baseline risk factors, ERAS elements and country-based differences.ResultsA total of 1835 patients (65%) received perioperative care at a self-declared ERAS center, 474 (16.7%) developed moderate-to-severe postoperative complications, and 63 patients died (2.2%). There was no difference in the primary outcome between patients who were or were not treated in self-declared ERAS centers (17.1% vs. 16%; OR 1.00; 95%CI, 0.79–1.27; P = 0.986). Hospital stay was shorter among patients treated in self-declared ERAS centers (6 [5–9] vs. 8 [6–10] days; OR 0.82; 95%CI, 0.78–0.87; P < 0.001). Median adherence to 24 ERAS elements was 57% [48%–65%]. Adherence to ERAS-pathway quartiles (≥65% vs. <48%) suggested that patients with the highest adherence rates experienced a lower risk of moderate-to-severe complications (15.9% vs. 17.8%; OR 0.71; 95%CI, 0.53–0.96; P = 0.027), lower risk of death (0.3% vs. 2.9%; OR 0.10; 95%CI, 0.02–0.42; P = 0.002) and shorter hospital stay (6 [4–8] vs. 7 [5–10] days; OR 0.74; 95%CI, 0.69–0.79; P < 0.001).ConclusionsTreatment in a self-declared ERAS center does not improve outcome after colorectal surgery. Increased adherence to the ERAS pathway is associated with a significant reduction in overall postoperative complications, lower risk of moderate-to-severe complications, shorter length of hospital stay and lower 30-day mortality.     

Risk factors for perioperative hypothermia and infectious outcomes in gastroschisis patients

IntroductionPrior data suggest that infants with gastroschisis are at high risk for hypothermia and infectious complications (ICs). This study evaluated the associations between perioperative hypothermia (PH) and ICs in gastroschisis using a multi-institutional cohort.MethodsRetrospective review of infants with gastroschisis who underwent abdominal closure from 2013–2017 was performed at 7 children's hospitals. Any-IC and surgical site infection (SSI) were stratified against the presence or absence of PH, and perioperative characteristics associated with PH and SSI were determined using multivariable logistic regression.ResultsOf 256 gastroschisis neonates, 42% developed PH, with 18% classified as mild hypothermia (35.5–35.9°C), 10.5% as moderate (35.0–35.4°C), and 13% severe (<35°C). There were 82 (32%) ICs with 50 (19.5%) being SSIs. No associations between PH and any-IC (p = 0.7) or SSI (p = 0.98) were found. Pulmonary comorbidities (odds ratio (OR)=3.76, 95%CI:1.42–10, p = 0.008) and primary closure (OR=0.21, 95%CI:0.12–0.39, p<0.001) were associated with PH, while silo placement (OR=2.62, 95%CI:1.1–6.3, p = 0.03) and prosthetic patch (OR=3.42, 95%CI:1.4–8.3, p = 0.007) were associated with SSI on multivariable logistic regression.ConclusionsPrimary abdominal closure and pulmonary comorbidities are associated with PH in gastroschisis, however PH was not associated with increased risk of ICs. Independent risk factors for SSI include silo placement and prosthetic patch closure.     

胃肠外科新生儿围术期凝血功能异常的影响因素分析

目的分析胃肠外科新生儿围术期凝血功能异常的影响因素。方法回顾性分析2012年6月至2016年4月胃肠外科323例新生儿凝血指标,包括血浆凝血酶原时间(PT)、部分活化凝血活酶时间(APTT)、凝血酶时间(TT)和血浆纤维蛋白原(Fib)以及围术期相关临床资料,分析围术期凝血功能异常相关危险因素。结果术后4h内凝血指标异常新生儿158例,其中轻度异常61例,明显异常97例。多元Logistic回归分析显示,术前合并肺炎(OR=2.880,95%CI 1.417~5.852)、围术期低钙(OR=2.381,95%CI 1.167~4.857)、有创穿刺置管(OR=2.490,95%CI 1.299~4.773)是新生儿术后4h内凝血指标异常的独立危险因素(P0.05)。结论在围术期管理时,应积极治疗肺炎、纠正低钙血症及选用浓度低于6.25U/ml的肝素溶液或生理盐水护理动静脉,以减少新生儿术后凝血功能异常的发生。     

Estado nutricional preoperatorio valorado mediante la herramienta CONUT y su relación con la aparición de complicaciones mayores postoperatorias

IntroductionMalnutrition is a risk factor for the appearance of major postoperative complications; therefore, early identification and perioperative optimization of surgical patients may improve postoperative outcomes. The objective of our study was to determine the prevalence of moderate or high under nutrition alerts in patients undergoing major non-cardiac surgery, and their relationship with the appearance of major postoperative complications. Nutritional status was calculated using the CONUT tool.Material and methodsA retrospective observational study in 190 patients who underwent major non-cardiac surgery over two consecutive years. Preoperative nutritional status was calculated using CONUT, and the patients’ medical records were reviewed to determine their epidemiological characteristics and major complications.ResultsThe under nutrition alert was moderate in 17% of patients, and high in 10%. A high under nutrition alert was an independent risk factor for treatment with vasoactive drugs (OR 3.58; 95% CI 1.18-10.89; p = .025), respiratory support (OR 7.63; 95% CI 1.25-46.43; p = .027), renal support (OR 23.29; 95% CI 2.0-271.08; p = .012), prolonged hospital stay (coef. 20.16; 95% CI 2.10-38.22; p = .029) and higher in-hospital mortality (OR 7.15; 95% CI 1.31-39.02; p = .023).ConclusionsIn total, 10% of patients who underwent major non-cardiac surgery presented serious preoperative deterioration in their nutritional status. A high under nutrition alert was an independent risk factor for the appearance of major postoperative complications.     

Outcome analysis for prediction of intraaortic balloon pump support failure and long-term survival in high-risk patients undergoing mitral valve surgery

The outcome predictors of intra-aortic balloon pump (IABP) in patients who undergo mitral valve surgery remain unknown. This study aimed to retrospectively review valvular surgery in patients who received an IABP to identify the predictors of failure of IABP support and anticipate the necessary therapy. This retrospective observational study recruited a total of 157 consecutive patients who underwent open-heart mitral valve surgery with IABP implantation intraoperatively or postoperatively. Univariate and multivariate logistic regression analyses were performed to identify the risk factors attributed to 30-day mortality. Follow-up data of survivors were collected to investigate the effect of IABP support to evaluate long-term outcomes. The overall 30-day mortality was 35.7% (56 patients). The following factors that contributed to 30-day mortality included sepsis (P < .001, OR: 5.627, 95%CI: 2.422-11.683); IABP implantation postoperatively rather than intraoperatively (P = .001, OR: 6.395, 95%CI: 2.085-19.511); right heart failure (P = .042, OR: 3.419, 95%CI: 1.225-12.257); and lack of subvalvular apparatus preservation (P = .033, OR: 3.710, 95%CI: 1.094-13.167). Furthermore, follow-up data of these patients showed an estimation of 5-year and 10-year survival rates of 58.9% and 35.7%, respectively. Patients with intraoperative IABP demonstrated better long-term survival outcomes when compared to those with postoperative IABP (χ² = 4.291, P = .038). In summary, this study distinguished the preoperative predictors of 30-day mortality of IABP-support in mitral valve surgery patients. These results indicated that early intervention with IABP should be taken into consideration in case of hemodynamic instability in critically ill patients undergoing mitral valve surgery.     

Prior bariatric surgery is associated with lower complications,in-hospital mortality,and healthcare utilization after elective spine fusion surgery

BackgroundGrade 3 obesity could potentially increase postoperative complications after spinal fusion surgery. However, the relationship between prior bariatric surgery (BS) and postoperative complications after spinal fusion surgery is not well-established.SettingInpatient hospital admissions from the Nationwide Inpatient Sample.MethodsPatients with a primary procedure of spinal fusion surgery discharged between 2006 and 2014 were identified. In-hospital outcomes included postoperative complications, mortality, cost, and length of stay were compared between patients with prior BS and grade 3 obesity.ResultsA total of 3,132,192 patients who underwent elective spinal fusion surgery were identified. There were 33,936 (1.1%) patients with a diagnosis of prior BS. The prevalence of prior BS increased significantly from .1% in 2006 to 1.5% in 2014. Compared with patients with grade 3 obesity, patients with prior BS were younger, more likely to be female, had less co-morbidities, and higher proportion of cervical surgery. Multivariable analysis indicated that patients with prior BS had lower risk of overall complications (odds ratio [OR]: .44; 95% confidence interval [CI]: .38–.49), neurologic (OR: .55; 95%CI: .35–.84), respiratory (OR: .30; 95%CI: .23–.37), cardiac (OR: .38; 95%CI: .24–.60), gastrointestinal (OR: .61; 95%CI: .44–.84), urinary and renal (OR: .34; 95%CI: .26–.44), venous thromboembolism (OR: .35; 95%CI: .19–.63), wound-related complications (OR: .67; 95%CI: .53–.85), and in-hospital mortality (OR: .12; 95%CI: .02–.88). Prior BS was also related to 13% shorter length of stay and 2% lower cost.ConclusionsAmong patients undergoing spinal fusion surgery, prior BS is associated with lower complications, in-hospital mortality, and healthcare utilization. BS might mitigate risk of worse outcomes associated with grade 3 obesity after spine fusion surgery.     

心肺转流下心脏瓣膜术后急性肾损伤的危险因素分析

目的探讨成人心肺转流(cardiopulmonary bypass,CPB)下心脏瓣膜手术后急性肾损伤(acute kidney injury,AKI)的危险因素。方法回顾性分析1 349例心脏瓣膜手术患者的临床资料,采用多因素Logistic回归分析心脏瓣膜术后AKI的危险因素。结果 1 349例心脏瓣膜手术患者AKI发生率为28.4%,多因素Logistic回归分析显示,每增加1岁(OR=1.05,95%CI 1.03~1.06,P0.001)、糖尿病史(OR=2.11,95%CI 1.22~3.68,P=0.008)、贫血(OR=1.50,95%CI1.05~2.21,P=0.026)、术前血清肌酐(Scr)值每增加1mg/dl(OR=1.01,95%CI 1.01~1.02,P=0.001)、手术时间每增加1h(OR=1.28,95%CI 1.15~1.41,P0.001)、术中输注血浆(OR=1.50,95%CI 1.14~1.97,P=0.004)是心脏瓣膜术后发生AKI的独立危险因素。结论心肺转流下心脏瓣膜术后急性肾损伤的独立危险因素是高龄、糖尿病史、贫血、术前肌酐高、手术时间长以及术中输注血浆。     

Prevalence of preoperative cognitive impairment in older surgical patients.: A systematic review and meta-analysis

Study objectiveOlder surgical patients with cognitive impairment are at an increased risk for adverse perioperative outcomes, however the prevalence of preoperative cognitive impairment is not well-established within this population. The purpose of this review is to determine the pooled prevalence of preoperative cognitive impairment in older surgical patients.DesignSystematic review and meta-analysis.SettingMEDLINE (Ovid), PubMed (non-MEDLINE records only), Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsycINFO, and EMCare Nursing for relevant articles from 1946 to April 2021.PatientsPatients aged ≥60 years old undergoing surgery, and preoperative cognitive impairment assessed by validated cognitive assessment tools.InterventionsPreoperative assessment.MeasurementsPrimary outcomes were the pooled prevalence of preoperative cognitive impairment in older patients undergoing either elective (cardiac or non-cardiac) or emergency surgery.Main resultsForty-eight studies (n = 42,498) were included. In elective non-cardiac surgeries, the pooled prevalence of unrecognized cognitive impairment was 37.0% (95% confidence interval [CI]: 30.0%, 45.0%) among 27,845 patients and diagnosed cognitive impairment was 18.0% (95% CI: 9.0%, 33.0%) among 11,676 patients. Within the elective non-cardiac surgery category, elective orthopedic surgery was analyzed. In this subcategory, the pooled prevalence of unrecognized cognitive impairment was 37.0% (95% CI: 26.0%, 49.0%) among 1117 patients, and diagnosed cognitive impairment was 17.0% (95% CI: 3.0%, 60.0%) among 6871 patients. In cardiac surgeries, the unrecognized cognitive impairment prevalence across 588 patients was 26.0% (95% CI: 15.0%, 42.0%). In emergency surgeries, the unrecognized cognitive impairment prevalence was 50.0% (95% CI: 35.0%, 65.0%) among 2389 patients.ConclusionsA substantial number of surgical patients had unrecognized cognitive impairment. In elective non-cardiac and emergency surgeries, the pooled prevalence of unrecognized cognitive impairment was 37.0% and 50.0%. Preoperative cognitive screening warrants more attention for risk assessment and stratification.     

椎管内阻滞对心脏事件高危患者行非心脏手术后心肌梗死影响的Meta分析

目的采用Meta分析比较椎管内阻滞[包括硬膜外阻滞(epidural anesthesia,EA)和蛛网膜下腔阻滞(spinal anesthesia,SA)]复合全身麻醉(general anesthesia,GA)对非心脏手术后心肌梗死的影响。方法检索中文数据库(中国生物医学文献服务系统、中国知网、万方、维普)和英文数据库(Medline、PubMed、EBSCO、Springer、Ovid、Cochrane Library、Google scholar);收集椎管内阻滞对非心脏手术患者术后心肌梗死及死亡率影响的随机对照试验(RCT),并采用RevMan 5.3软件进行统计分析。结果共纳入10篇RCT(n=21 859)。Meta分析结果显示:EA复合GA与单纯GA非心脏手术术后7d内(OR=0.44,95%CI 0.13~1.46,P=0.18)和30d内(OR=1.49,95%CI 0.89~2.49,P=0.13)内心肌梗死发生率差异无统计学意义;EA复合GA与单纯GA术后30d内(OR=1.26,95%CI 0.84~1.88,P=0.26)全因死亡率差异无统计学意义。SA与GA术后7d内心肌梗死发生率(OR=1.14,95%CI 0.31~4.17,P=0.84)和术后30d内全因死亡率(OR=0.88,95%CI 0.43~1.79,P=0.73)差异无统计学意义。结论椎管内阻滞并未降低心脏事件高危患者行中高危非心脏手术后心肌梗死发生率及死亡率。     

Is preoperative balloon aortic valvuloplasty of interest for severe aortic stenosis in hip fracture surgery?

PurposeIn elderly patients, the discovery and management of a severe aortic stenosis (AS) prior to emergency non-cardiac surgery is a frequent and controversial issue. The objective of this study was to evaluate preoperative balloon aortic valvuloplasty (BAV) for severe AS in hip fracture surgery.MethodsWe conducted an observational, monocentric, retrospective study from 2011 to 2018. Survival (30-day, 90-day and 180-day mortality) and the occurrence of perioperative complications were analyzed and compared between control (i.e. no BAV prior to surgery) and preoperative BAV groups in patients with hip fracture surgery and a formal transthoracic echocardiographic diagnosis of severe AS (aortic valve area < 1 cm²). Patients' allocation to the intervention and control groups was after a discussion between cardiologist, anesthesiologist and the surgeon.ResultsAmong the 8506 patients who underwent hip fracture surgery, 29 patients in the control group and 30 patients in the BAV group were finally included. Kaplan-Meier survival analysis demonstrated a significant decrease in mortality in the BAV group (p=0.014) despite an increase in median time to operation of about 48 hours (p<0.0001). Multivariate analysis (stepwise logistic regression) showed that postoperative delirium (OR [95%CI]: 17.5 [1.8-168]; p=0.013) and postoperative acute congestive heart failure (OR [95%CI]: 59.4 [5.0-711.1]; p=0.0013) were predictive factors of 30-day mortality with an area under ROC curve of 0.90 (95%CI: 0.80-0.97; p<0.0001).Conclusionspreoperative BAV for severe AS could reduce the mortality of hip fracture patients despite an increase in time to operation. This improved survival could be linked to the decrease in cardiologic and neurologic adverse events. A larger prospective randomized study is necessary before generalizing our results.     

Risk factors for estrogen receptor positive ductal carcinoma in situ of the breast in African American women

BackgroundCompared to U.S. white women, African American women are more likely to die from ductal carcinoma in situ (DCIS). Elucidation of risk factors for DCIS in African American women may provide opportunities for risk reduction.MethodsWe used data from three epidemiologic studies in the African American Breast Cancer Epidemiology and Risk Consortium to study risk factors for estrogen receptor (ER) positive DCIS (488 cases; 13,830 controls). Results were compared to associations observed for ER+ invasive breast cancer (n = 2,099).ResultsFirst degree family history of breast cancer was associated with increased risk of ER+ DCIS [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.31, 2.17]. Oral contraceptive use within the past 10 years (vs. never) was also associated with increased risk (OR: 1.43, 95%CI: 1.03, 1.97), as was late age at first birth (≥25 years vs. <20 years) (OR: 1.26, 95%CI: 0.96, 1.67). Risk was reduced in women with older age at menarche (≥15 years vs. <11 years) (OR: 0.62, 95%CI: 0.42, 0.93) and higher body mass index (BMI) in early adulthood (≥25 vs. <20 kg/m² at age 18 or 21) (OR: 0.75, 95%CI: 0.55, 1.01). There was a positive association of recent BMI with risk in postmenopausal women only. In general, associations of risk factors for ER+ DCIS were similar in magnitude and direction to those for invasive ER+ breast cancer.ConclusionsOur findings suggest that most risk factors for invasive ER+ breast cancer are also associated with increased risk of ER+ DCIS among African American women.     

Hiperlactatemia en la ablación quirúrgica de la fibrilación auricular y cirugía cardiaca. ¿Es un factor predictivo de morbimortalidad posoperatoria?

IntroductionIncreased serum lactate in postoperative cardiac surgery is very common and its pathogenesis is due to multiple factors. The elevation of serum lactate is associated with tissue hypoxia (hyperlactatemia type A) and non-hypoxic (hyperlactatemia type B) metabolic disorders. The aim of the study was to assess the evolution of postoperative lactate in surgical atrial fibrillation ablation during cardiac surgery, and to determine whether lactate levels could be predictors of morbimortality.Material and methodsA case-control study was conducted on 32 patients undergoing surgical atrial fibrillation ablation and cardiac surgery (Maze group) and 32 matched patients (Control group), operated on between 2011 and 2012. An analysis was made of the levels of postoperative lactate, perioperative morbimortality and hospital length of stay. A univariate and multivariate study was performed for a composite endpoint of morbimortality, and prolonged length of stay.ResultsLactate levels were significantly higher at 6, 12 and 24 h in the Maze group. The univariate analysis showed that being in the Maze group (OR 3.88; 95% CI 1.3-11.1; P = .01) and an elevated lactate at 12 h (OR 1.33; 95% CI 1.01-1.7; P = .04) were significant predictors of major complications, mortality, and longer hospital stays. In the multivariate analysis, surgical atrial fibrillation ablation (Maze group) was an independent predictor of major complications (OR 4.13; 95% CI 1.312.9; P = .015) for the morbimortality composite endpoint (OR 3.9; 95% CI 1.3-11.6; P = .01), and prolonged length of stay in the Intensive Care Unit (OR 5.7; 95% CI 2.01-15.7; P = .01).ConclusionsThe atrial fibrillation surgical ablation may be a not-yet-described cause of type B hyperlactatemia, with serum peak values being reached between 4-24 h after cardiac surgery. The predictive value of this elevation, its correlation with morbimortality, its sensitivity and specificity to discriminate the significant thresholds needs to be defined.