The effect of intraoperative dexmedetomidine administration on length of stay in the post-anesthesia care unit in ambulatory surgery: A hospital registry study

Study objectiveDexmedetomidine, which is commonly used for procedural sedation and as adjunct to general anesthesia for ambulatory procedures, may affect patient discharge from the post-anesthesia care unit (PACU). We hypothesized that intraoperative dexmedetomidine use in ambulatory surgery is associated with delayed discharge from the PACU and that this is modified by surgical duration and anesthesia type.DesignRetrospective cohort study.SettingAcademic medical center.Patients130,854 adult patients undergoing ambulatory surgery between 2008 and 2018.InterventionsIntraoperative administration of dexmedetomidine.MeasurementsThe primary outcome was PACU length of stay. In secondary and exploratory analyses, we examined dose-dependency, effect modification by duration of surgery and anesthesia type, effects of timing of dexmedetomidine administration, and PACU discharge delays.Main resultsDexmedetomidine was associated with a prolonged PACU length of stay (adjusted absolute difference [AD_adj] 15.0 min; 95%CI 12.7–17.3; p < 0.001). This effect was dose-dependent (p-for-trend < 0.001), magnified in surgeries of less than one hour (AD_adj 20.7 min; 95%CI 16.7–24.7; p < 0.001) and in patients undergoing monitored anesthesia care compared to general anesthesia (AD_adj 16.8 min; 95%CI 14.1–19.6; p < 0.001). The effect was more pronounced if dexmedetomidine was administered within the last 60 min of surgery (AD_adj 18.7 min; 95%CI 15.7–21.7; p < 0.001). Dexmedetomidine was associated with discharge delays due to cardiovascular complications (OR_adj 2.27; 95%CI 1.59–3.24; p < 0.001) and over-sedation (OR_adj 1.28; 95%CI 1.11–1.48; p < 0.001). In patients who received dexmedetomidine (n = 2901), the use of bolus doses only versus the combination of bolus and infusions, magnified the effects on PACU length of stay (AD_adj 29.5 min per μg/kg; 95%CI 17.3–41.8 versus 18.1 min per μg/kg; 95%CI 11.4–24.8; p < 0.001).ConclusionsThe intraoperative administration of dexmedetomidine was dose-dependently associated with a prolonged PACU length of stay. Clinicians should judiciously titrate dexmedetomidine, especially when using this long-acting drug for monitored anesthesia care for shorter procedures.     

Changes in pediatric trauma during COVID-19 stay-at-home epoch at a tertiary pediatric hospital

BackgroundTrauma is the leading cause of morbidity and mortality in the pediatric population. However, during the societal disruptions secondary to the coronavirus (COVID-19) stay-at-home regulations, there have been reported changes to the pattern and severity of pediatric trauma. We review our two-institution experience.MethodsPediatric trauma emergency department (ED) encounters from the National Trauma Registry for a large, tertiary, metropolitan level 1 pediatric trauma center and pediatric burn admission at the regional burn center were extracted for children less than 19 years from March 15th thru May 15th during the years 2015–2020. The primary outcome was the difference in encounters during the COVID-19 (2020) epoch versus the pre-COVID-19 epoch (2015–2019).ResultsThere were 392 pediatric trauma encounters during the COVID-19 epoch as compared to 451, 475, 520, 460, 432 (mean 467.6) during the pre-COVID-19 epoch. Overall trauma admissions and ED trauma encounters were significantly lower (p < 0.001) during COVID-19. Burn injury admissions (p < 0.001) and penetrating trauma encounters (p = 0.002) increased during the COVID-19 epoch while blunt trauma encounters decreased (p < 0.001). Trauma occurred among more white (p = 0.01) and privately insured (p < 0.001) children, but no difference in suspected abuse, injury severity, mortality, age, or gender were detected. Sub-analysis showed significant decreases in motor vehicle crashes (p < 0.001), pedestrians struck by automobile (p < 0.001), all-terrain vehicle (ATV)/motorcross/bicycle/skateboard involved injuries (p = 0.02), falls (p < 0.001), and sports related injuries (p < 0.001). Fewer injuries occurring in the playground or home play equipment such as trampolines neared significance (p = 0.05). Interpersonal violence (assault, NAT, self-harm) was lower during the COVID-19 era (p = 0.04). For burn admissions, there was a significant increase in flame burns (p < 0.001).ConclusionsStay-at-home regulations alter societal patterns, leading to decreased overall and blunt traumas. However, the proportion of penetrating and burn injuries increased. Owing to increased stressors and time spent at home, healthcare professionals should keep a high suspicion for abuse and neglect.     

Effect of preoperative pregabalin on post-caesarean delivery analgesia: a dose-response study

IntroductionWe hypothesised that preoperative administration of a single-dose of pregabalin would be associated with lower morphine consumption after uncomplicated caesarean delivery.MethodsAfter Institutional Ethics Committee approval, 135 parturients scheduled for elective caesarean delivery under spinal anaesthesia were randomly allocated to receive either placebo, or oral pregabalin 150 mg or 300 mg, one hour before induction of anaesthesia. Maternal cumulative morphine requirement at 24 h, pain scores, sedation scores, nausea and vomiting, pruritus, pregabalin-related adverse effects, Apgar scores, Neurologic and Adaptive Capacity scores and umbilical cord acid-base status were recorded.ResultsCompared with placebo or pregabalin 150 mg, the use of a preoperative dose of pregabalin 300 mg resulted in significantly lower cumulative morphine consumption at 24 h (mean dose: placebo 12.9 mg [95% CI 11.6 to 14.2]; pregabalin 150 mg 11.9 mg; [95% CI 10.7 to 13.1]; pregabalin 300 mg 6 mg [95% CI 5.4 to 7.3]; P<0.001). Pregabalin 300 mg resulted in lower pain scores at 4 h and 6 h after delivery (P<0.001), and fewer instances of nausea, vomiting and pruritus (P<0.009). Dizziness and abnormal vision were observed most frequently in the pregabalin 300 mg group (P<0.05 and P<0.009, respectively). The three groups were similar in terms of maternal sedation, Apgar scores, Neurologic and Adaptive Capacity scores and umbilical cord acid-base status. Three babies in the pregabalin 300 mg group (6.7%) experienced short-term poor latching-on for breastfeeding.ConclusionIn our study, preoperative administration of pregabalin 300 mg reduced postoperative morphine consumption and early postoperative pain in parturients undergoing elective caesarean delivery, although maternal side effects were more common.     

Comparison of the effects of gabapentin and pregabalin on wound healing in rats

Gabapentinoids are effective adjunct drugs for reducing postoperative pain. However, the effects of gabapentinoids on wound healing have not been evaluated yet. In this study we evaluated their effects on wound healing. A total of 17 male Wistar‐Albino rats, 250–350 g, were divided into three groups randomly: control group (n = 5, 2 ml saline), gabapentin group (n = 6, 20 mg/kg gabapentin) and pregabalin group (n = 6, 20 mg/kg pregabalin). Until day 13 inflammation scores were significantly lower (P < 0·05) and wound healing was significantly better in the control group when compared with gabapentin and pregabalin groups (P < 0·001). Inflammation scores were significantly lower in pregabalin group when compared with gabapentin group until day 13. But wound healing was significantly better in gabapentin group than in pregabalin group between days 13 and 21. In conclusion when gabapentin and pregabalin were compared, although pregabalin decreases inflammation scores, gabapentin has better results in wound healing.     

Association of pre-admission opioid abuse and/or dependence on major complications in traumatic brain injury (TBI) patients

SettingIn the last few decades, an opioid related health crisis has been a challenging problem in many countries around the world, especially the United States. Better understanding of the association of pre-admission opioid abuse and/or dependence (POAD) on specific major complications in traumatic brain injury (TBI) patients can aid the medical team in improving patient care management and outcomes.Study objectiveOur goal is to assess and quantify the risk of POAD on in-hospital mortality and major complications in TBI patients.DesignWe conducted a retrospective study and used the National Inpatient Sample (NIS) database from 2004 to 2015 to investigate the impact of POAD on in-hospital mortality and major complications in TBI patients. We utilized propensity score matching and conditional logistic regression models, adjusted with injury severity score (ISS) and comorbidities, to obtain the adjusted odds ratios (OR).Main resultsPOAD TBI patients had lower risks of in-hospital mortality (OR 0.58; p < 0.001) and acute myocardial infarction (OR 0.53; p = 0.045), while a higher risk of respiratory (OR 1.59; p < 0.001) and neurologic complications (OR 2.54; p < 0.001), compared to non-POAD TBI patients. Additionally, POAD patients were significantly more likely to have sepsis (OR 2.16, p < 0.001), malnutrition (OR 1.56, p < 0.001), delirium (OR 2.81, p < 0.001), respiratory failure (OR 1.79, p < 0.001), and acute renal failure (OR 1.83, p < 0.001). POAD TBI patients had shorter length of hospital stay compared to non-POAD TBI patients (mean 8.0 vs 9.2 days, p < 0.001).ConclusionsPOAD TBI patients have a lower in-hospital mortality, shorter duration of hospitalization and a lower risk of acute myocardial infarction, while they are more likely to have respiratory failure, delirium, sepsis, malnutrition, and acute renal failure compared to TBI patients without POAD. Prospective study is warranted to further confirm these findings.     

Clinical and Budget Impact of Treating Preoperative Anemia in Major Orthopedic Surgery—A Retrospective Observational Study

BackgroundPreoperative anemia (POA) in elective surgery is associated with worse outcome. In this retrospective study, in elective hip and knee arthroplasties, the prevalence of POA and its associations with outcome were analyzed, followed by a model estimating the budget impact of screening and treatment of POA.MethodsAll elective hip/knee arthroplasties performed during the period 2016-2018 were included. Patients with normal hemoglobin and patients with POA (hemoglobin < 13.0 g/dL in men and <12.0 g/dL in women) were compared. Outcome measures were allogeneic blood transfusion (ABT), length of stay (LOS), complications, mortality, and costs. The budget impact of screening for POA and treatment with intravenous iron when relevant was modeled based on the results of the costs related to POA.ResultsIn 881 procedures, the prevalence of POA was 21.5%. POA independently predicted increased risks of ABT (odds ratio [OR]_adj, 9.5 [confidence interval—CI, 6.4-13.9]), prolonged LOS (OR_adj, 2.8 [CI, 1.8-4.2]), and was associated with increased complications (OR_adj, 1.9 [CI, 0.7-4.9]) and mortality (OR_adj, 3.2 [CI, 0.8-13.5]). POA resulted in increased costs per patient (P < .001). The budget impact model showed a cost reduction of 254 euros per patient based on the assumption that patients screened and treated for iron-deficient anemia would have the same outcome as non-POA.ConclusionThe prevalence of POA in elective orthopedic surgery in Sweden is at the same level as previously reported by others. Screening and treatment of POA would reduce costs based on less ABT and decreased LOS and may reduce complications in elective major orthopedic surgery.     

Emergency readmissions following geriatric ground-level falls: How does frailty factor in?

BackgroundGround-level falls (GLFs) in older adults are increasing as life expectancy increases, and more patients are being discharged to skilled nursing facilities (SNFs) for continuity of care. However, GLF patients are not a homogenous cohort, and the role of frailty remains to be assessed. Thus, the aim of this study is to examine the impact of frailty on the in-hospital and 30-day outcomes of GLF patients.Materials and MethodsThis is a cohort analysis from the Nationwide Readmissions Database 2017. Geriatric (age ≥65 years) trauma patients presenting following GLFs were identified and grouped based on their frailty status. The associations between frailty and 30-day mortality and emergency readmission were examined by multivariate regression analyses adjusting for patient demographics and injury characteristics.ResultsA total of 100,850 geriatric GLF patients were identified (frail: 41% vs. non-frail: 59%). Frail GLF patients were younger (81[74–87] vs. 83[76–89] years; p<0.001) and less severely injured–Injury Severity Score [ISS] (4[1–9] vs. 5[2–9]; p<0.001). Frail patients had a higher index mortality (2.9% vs. 1.9%; p<0.001) and higher 30-day readmissions (14.0% vs. 9.8%; p<0.001). Readmission mortality was also higher in the frail group (15.2% vs. 10.9%; p<0.001), with 75.2% of those patients readmitted from an SNF. On multivariate analysis, frailty was associated with 30-day mortality (OR 1.75; p<0.001) and 30-day readmission (OR 1.49; p<0.001).ConclusionFrail geriatric patients are at 75% higher odds of mortality and 49% higher odds of readmission following GLFs. Of those readmitted on an emergency basis, more than one in seven patients died, 75% of whom were readmitted from an SNF. This underscores the need for optimization plans that extend to the post-discharge period to reduce readmissions and subsequent high-impact consequences.     

Perioperative mortality and morbidity of hip fractures among COVID-19 infected and non-infected patients: A systematic review and meta-analysis

PurposeHip fractures among elderly patients are surgical emergencies. During COVID-19 pandemic time, many such patients could not be operated at early time because of the limitation of the medical resources, the risk of infection and redirection of medical attention to a severe infective health problem.MethodsA search of electronic databases (PubMed, Medline, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials) with the keywords “COVID”, “COVID-19″, “SARS-COV-2”, “Corona”, “pandemic”, “hip fracture”, “trochanteric fracture” and “neck femur fracture” revealed 64 studies evaluating treatment of hip fracture in elderly patients during COVID-19 pandemic time. The 30-day mortality rate, inpatient mortality rate, critical care/special care need, readmission rate and complications rate in both groups were evaluated. Data were analyzed using Review Manager (RevMan) V.5.3.ResultsAfter screening, 7 studies were identified that described the mortality and morbidity in hip fractures in both COVID-19 infected (COVID-19 +) and non-infected (COVID-19 −) patients. There were significantly increased risks of 30-day mortality (32.23% COVID-19 + death vs. 8.85% COVID-19 − death) and inpatient mortality (29.33% vs. 2.62%) among COVID-19 + patients with odds ratio (OR) of 4.84 (95% CI: 3.13 – 7.47, p < 0.001) and 15.12 (95% CI: 6.12 – 37.37, p < 0.001), respectively. The COVID-19 + patients needed more critical care admission (OR = 5.08, 95% CI: 1.49 – 17.30, p < 0.009) and they remain admitted for a longer time in hospital (mean difference = 3.6, 95% CI: 1.74 – 5.45, p < 0.001); but there was no difference in readmission rate between these 2 groups. The risks of overall complications (OR = 17.22), development of pneumonia (OR = 22.25), and acute respiratory distress syndrome/acute respiratory failure (OR = 32.96) were significantly high among COVID-19 + patients compared to COVID-19 − patients.ConclusionsThere are increased risks of the 30-day mortality, inpatient mortality and critical care admission among hip fracture patients who are COVID-19 +. The chances of developing pneumonia and acute respiratory failure are more in COVID-19 + patients than in COVID-19 ‒ patients.     

Effect of spinal versus general anesthesia on thirty-day outcomes following total hip arthroplasty: A matched-pair cohort analysis

Study objectiveIt has not yet been established whether total hip arthroplasty complications are associated with anesthetic technique (spinal versus general). This study assessed the effect of spinal versus general anesthesia on health care resource utilization and secondary endpoints following total hip arthroplasty.DesignPropensity-matched cohort analysis.SettingAmerican College of Surgeons National Surgical Quality Improvement Program participating hospitals from 2015 to 2021.PatientsPatients undergoing elective total hip arthroplasty (n = 223,060).InterventionsNone.MeasurementsThe a priori study duration was 2015 to 2018 (n = 109,830). The primary endpoint was 30-day unplanned resource utilization, namely readmission and reoperation. Secondary endpoints included 30-day wound complications, systemic complications, bleeding events, and mortality. The impact of anesthetic technique was investigated with univariate analyses, multivariable analyses, and survival analyses.Main resultsThe 1:1 propensity-matched cohort included 96,880 total patients (48,440 in each anesthesia group) from 2015 to 2018. On univariate analysis, spinal anesthesia was associated with a lower incidence of unplanned resource utilization (3.1% [1486/48440] vs 3.7% [1770/48440]; odds ratio [OR], 0.83 [95% CI, 0.78 to 0.90]; P < .001), systemic complications (1.1% [520/48440] vs 1.5% [723/48440]; OR, 0.72 [95% CI, 0.64 to 0.80]; P < .001), and bleeding events requiring transfusion (2.3% [1120/48440] vs 4.9% [2390/48440]; OR, 0.46 [95% CI, 0.42 to 0.49]; P < .001). On multivariable analysis, spinal anesthesia remained an independent predictor of unplanned resource utilization (adjusted odds ratio [AOR], 0.84 [95% CI, 0.78 to 0.90]; c = 0.646), systemic complications (AOR, 0.72 [95% CI, 0.64 to 0.81]; c = 0.676), and bleeding events (AOR, 0.46 [95% CI, 0.42 to 0.49]; c = 0.686). Hospital length of stay was also shorter in the spinal anesthesia cohort (2.15 vs 2.24 days; mean difference, −0.09 [95% CI, −0.12 to −0.07]; P < .001). Similar findings were observed in the cohort from 2019 to 2021.ConclusionsTotal hip arthroplasty patients receiving spinal anesthesia experience favorable outcomes compared to propensity-matched general anesthesia patients.     

The direct anterior approach is safe and shortens hospital length of stay following hemiarthroplasty for neck of femur fracture

ObjectiveTo investigate the safety of using the anterior approach (AA), compared to the lateral approach (LA), in hemiarthroplasty for the treatment of displaced neck of femur fractures.DesignRetrospective case-control match cohort study.SettingLevel 1 trauma center.PatientsRetrospective review of prospectively collected data for 39 consecutive intracapsular hip fractures treated with hemiarthroplasty using an AA between 2017 and 2021. Patients operated with the AA were matched in 1:2 ratio with patients that had hemiarthroplasty via a LA.Main Outcome MeasuresDischarge destination, 90-day emergency room (ER) visit or readmission rate, inpatient and 90-day mortality rate, inpatient medical complications, 90-day mechanical complications, 90-day reoperation, and length of hospital stay (LOS).ResultsDischarge destination (p = 0.695), 90-day ER visit or readmission rate (p = 0.315), inpatient (p = 0.719) and 90-day mortality rate (p = 0.815), medical complications (p = 0.524), mechanical complications (p = 0.150) were similar between cohorts. Five patients, all in the LA-group, required re-operations within 90-days (p = 0.106). Patients in AA-group had shorter LOS (9.3 days, 95% CI [7.6–11.1] vs. 14.7 days [95% CI 12.2–17.3], p = 0.002).ConclusionsThe AA can be safely introduced for the treatment of hip fractures. Similar short-term outcomes relative to the LA were identified. The shorter LOS may reflect the improved early functional recovery offered from the muscle-sparing AA technique. Future, level-1 data should include early- and longer term functional outcome along with cost-effectiveness.     

Socioeconomic and clinical factors associated with prolonged hospital length of stay after traumatic brain injury

BackgroundHospital length of stay (HLOS) after traumatic brain injury (TBI) is a metric of injury severity, resource utilization, and access to services. This study aimed to evaluate socioeconomic and clinical factors associated with prolonged HLOS after TBI.MethodsRetrospective data from adult hospitalized patients diagnosed with acute TBI at a US Level 1 trauma center between August 1, 2019 - April 1, 2022 were extracted from the electronic health record. HLOS was stratified by Tier (1: 1–74th percentile; 2: 75–84th; 3: 85–94th; 4: 95–99th). Demographic, socioeconomic, injury severity, and level-of-care factors were compared by HLOS. Multivariable logistic regressions evaluated associations between socioeconomic and clinical variables and prolonged HLOS, using multivariable odds ratios (mOR) and [95% confidence intervals]. Estimated daily charges were calculated for a subset of medically-stable inpatients awaiting placement. Statistical significance was assessed at p < 0.05.ResultsIn 1443 patients, median HLOS was 4 days (interquartile range 2–8; range 0–145). HLOS Tiers were 0–7, 8–13, 14–27, and ≥28 days (Tiers 1–4, respectively). Patients with Tier 4 HLOS differed significantly from others, with increased Medicaid insurance (53.4% vs. 30.3–33.1%, p = 0.003), severe TBI (Glasgow Coma Scale 3–8: 38.4% vs. 8.7–18.2%, p < 0.001), younger age (mean 52.3-years vs. 61.1–63.7-years, p = 0.003), low socioeconomic status (53.4% vs. 32.0–33.9%, p = 0.003), and need for post-acute care (60.3% vs. 11.2–39.7%, p < 0.001). Independent factors associated with prolonged (Tier 4) HLOS were Medicaid (mOR = 1.99 [1.08–3.68], vs. Medicare/commercial), moderate and severe TBI (mOR = 3.48 [1.61–7.56]; mOR = 4.43 [2.18–8.99], respectively, vs. mild TBI), and need for post-acute placement (mOR = 10.68 [5.74–19.89], while age was protective (per-year mOR = 0.98 [0.97–0.99]). Estimated daily charges for a medically-stable inpatient was $17126.ConclusionsMedicaid insurance, moderate/severe TBI, and need for post-acute care were independently associated with prolonged HLOS ≥28 days. Medically-stable inpatients awaiting placement accrue immense daily healthcare costs. At-risk patients should be identified early, receive care transitions resources, and be prioritized for discharge coordination pathways.     

Association of positive pre-transplant angiotensin II type 1 receptor antibodies with clinical outcomes in lung transplant recipients

IntroductionAutoantibodies against the angiotensin II type 1 receptor (AT1R-Ab) have been previously associated with de novo donor-specific antibody (DSA) formation in lung transplantation. However, data regarding the clinical significance of AT1R-Ab in long-term graft function after lung transplantation are lacking.MethodsSeventy-one patients who underwent lung transplantation between July 2016 and January 2020 were enrolled in this study. We examined the relationship between pre-transplant AT1R-Ab levels and graft function, clinical outcomes, and human leukocyte antigen (HLA) DSA levels during the first 3 years post-transplantation.ResultsSeventeen (23.9%) patients were AT1R-Ab-positive, and 54 (76.1%) were AT1R-Ab-negative. The median antibody value of the AT1R-Ab-positive group was 18 [18–22.5] U/mL, while that of the AT1R-Ab-negative group was 5.1 [3.5–8.0] U/mL (p < 0.001). There was no significant difference in the median acute cellular rejection (ACR) scores between the two groups (median [interquartile range] 1 [0.8–3] vs. 0.7 [0–1]; p = 0.145). However, there was a significant difference in the distribution of the ACR scores between the two groups (p = 0.015). Most (41.2%) patients in the pre-transplant AT1R-positive group scored above 1. The incidence of de novo DSA was also higher in AT1R-Ab-positive than in AT1R-Ab-negative patients (52.9% vs. 20.4%, p = 0.009). The incidence of chronic lung allograft dysfunction (CLAD) within 3 years was significantly higher in AT1R-Ab-positive than in AT1R-Ab-negative patients (58.3% vs. 11.8%; p < 0.001). In the multivariate Cox regression analysis, AT1R-Ab positivity (hazard ratio, 9.46; 95% confidence interval, 2.89–30.94; p < 0.001) was significantly associated with early CLAD. Furthermore, Kaplan-Meier analysis showed that AT1R-Ab-positive patients had a shorter survival time (χ² = 39.62, p < 0.001).ConclusionHigh AT1R-Ab levels in the pre-transplant serum of lung recipients were associated with the development of de novo HLA-DSA, ACR, early CLAD, and short survival.     

Factors in childhood associated with lung function decline to adolescence in cystic fibrosis

BackgroundDespite improvements in general health and life expectancy in people with cystic fibrosis (CF), lung function decline continues unabated during adolescence and early adult life.MethodsWe examined factors present at age 5-years that predicted lung function decline from childhood to adolescence in a longitudinal study of Australasian children with CF followed from 1999 to 2017.ResultsLung function trajectories were calculated for 119 children with CF from childhood (median 5.0 [25%-75%=5.0–5.1]) years) to early adolescence (median 12.5 [25%-75%=11.4–13.8] years). Lung function fell progressively, with mean (standard deviation) annual change -0.105 (0.049) for forced vital capacity (FVC) Z-score (p<0.001), -0.135 (0.048) for forced expiratory volume in 1-second (FEV₁) Z-score (p<0.001), -1.277 (0.221) for FEV₁/FVC% (p<0.001), and -0.136 (0.052) for forced expiratory flow between 25% and 75% of FVC Z-score (p<0.001). Factors present in childhood predicting lung function decline to adolescence, in multivariable analyses, were hospitalisation for respiratory exacerbations in the first 5-years of life (FEV₁/FVC p = 0.001, FEF_25–75 p = 0.01) and bronchoalveolar lavage neutrophil elastase activity (FEV₁/FVC% p = 0.001, FEV₁ p = 0.05, FEF_25–75 p = 0.02). No examined factor predicted a decline in the FVC Z-score.ConclusionsAction in the first 5-years of life to prevent and/or treat respiratory exacerbations and counteract neutrophilic inflammation in the lower airways may reduce lung function decline in children with CF, and these should be targets of future research.     

Primary laparoscopic sleeve gastrectomy versus gastric bypass: a propensity-matched comparison of 30-day outcomes

BackgroundBariatric surgery is the most effective treatment for obesity. There is uncertainty regarding rates of adverse outcomes between the most common methods: laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG).ObjectivesTo compare rates of readmission, reoperation, intervention, unplanned intensive care unit (ICU) admission, all-cause and procedure-related mortality, and postoperative complications at 30 days between LRYGB and LSG.SettingRetrospective, observational, multicenter registry.MethodsWe identified 611,619 patients from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry between January 1, 2015, and December 31, 2018 (447,326 [73.1%] LSG; 164,293 [26.9%] LRYGB).ResultsAdverse events were more common after LRYGB (readmission: 3% with LSG versus 5.9% with LRYGB [P < .001; odds ratio {OR}, LSG/LRYGB = .489]; intervention: .9% with LSG versus 2.4% with LRYGB [P < .001; OR, LSG/LRYGB = .357]; reoperation: .8% with LSG versus 2.3% with LRYGB [P < .001; OR, LSG/LRYGB = .363]; unplanned ICU admission: .52% with LSG versus 1.1% with LRYGB [P < .001; OR, LSG/LRYGB = .454]; all-cause mortality: .07% with LSG versus .15% with LRYGB [P < .001; OR, LSG/LRYGB = .489]; procedure-related mortality: .04% with LSG versus .08% with LRYGB [P < .001; OR, LSG/LRYGB = .446]; Clavien-Dindo I: .20% with LSG versus .63% with LRYGB [P < .001; OR, LSG/LRYGB = .317]; Clavien-Dindo II: .70% with LSG versus 1.3% with LRYGB [P < .001; OR, LSG/LRYGB = .527]; Clavien-Dindo III: 3.3% with LSG versus 6.6% with LRYGB [P < .001; OR, LSG/LRYGB = .481]; Clavien-Dindo IV: .36% with LSG versus .76% with LRYGB [P < .001; OR, LSG/LRYGB = .466]; and Clavien-Dindo V: .07% with LSG versus .15% with LRYGB [P < .001; OR, LSG/LRYGB = .488]). Surgery type was among the strongest independent predictors of adverse events, and LRYGB conferred higher adjusted odds of all adverse outcomes (all-cause mortality: OR, LRYGB/LSG = 1.791 [P < .001]; procedure-related mortality: OR, LRYGB/LSG = 1.979 [P < .001]; readmission: OR, LRYGB/LSG = 1.921 [P < .001]; unplanned ICU admission: OR, LRYGB/LSG = 1.870 [P < .001]; intervention: OR, LRYGB/LSG = 2.662 [P < .001]; reoperation: OR, LRYGB/LSG = 2.646 [P < .001]; and Clavien-Dindo grade: OR, LRYGB/LSG = 2.007 [P < .001]).ConclusionThe rates of 30-day adverse outcomes are lower after LSG compared with after LRYGB. LRYGB independently conferred increased odds of adverse outcomes compared with LSG, and surgery type was among the strongest predictors of adverse outcomes.     

Does surgical approach matter in the treatment of pediatric ulcerative colitis?

BackgroundThis study aims to compare the morbidity of open versus laparoscopic colectomy or proctocolectomy for pediatric patients with ulcerative colitis (UC) using national readmission outcomes.Materials and methodsThe 2010–2014 Nationwide Readmissions Database was used to identify patients < 18 years (excluding newborns) who underwent colectomy or proctocolectomy for UC. Patients with planned readmissions for staged procedures were excluded from readmission analysis. Demographics, hospital factors, and outcomes were compared by operative approach (open vs. laparoscopic) using standard statistical analysis. Results were weighted for national estimates.ResultsThere were 1922 patients (51% female, age 13 ± 3 years) with UC who underwent colectomy or proctocolectomy during index admission. Most cases were performed open (54%) and as elective admissions (64%). Compared to open approach, laparoscopy was associated with shorter index hospital length of stay (8 [5-17] days vs. 9 [6-18] days, p = 0.015), fewer surgical site infections (< 2% vs. 2%, p = 0.022), and less post-operative gastrointestinal dysfunction (5% vs. 8%, p = 0.008). After stratifying to control for elective and unplanned index admissions, laparoscopic approach was associated with fewer small bowel obstructions during index hospitalizations in both elective (9% vs. 15%, p = 0.003) and unplanned (5% vs. 16%, p<0.001) settings. Readmission for surgical site infection was also less common following laparoscopic approach in both elective (0% vs. 7%, p = 0.008) and unplanned (0% vs. < 7%, p = 0.017) settings.ConclusionsIn pediatric patients with ulcerative colitis, laparoscopic colectomy or proctocolectomy is associated with shorter hospital length of stay, less post-operative complications, and improved readmission outcomes.     

Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial

Study objectiveTo assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation.DesignsParallel-group, randomized trial.SettingOperating room of a university hospital, Italy.PatientsMorbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery.InterventionsParticipants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH₂O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH₂O, recruitment maneuvers) ventilation during anesthesia.MeasurementsPrimary outcome was PaO₂/FiO₂ one hour after extubation. Secondary outcomes included day-1 PaO₂/FiO₂, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves.Main resultsSixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300–360] in PV group and 525 [500–575] in SV group. Median PaO₂/FiO₂ one hour after extubation was 280 mmHg [246–364] in PV group vs. 298 [250–343] in SV group (p = 0.64). Day-1 PaO₂/FiO_2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH₂O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH₂O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO₂ and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001).ConclusionsIn obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results.Trial registrationProspectively registered on http://clinicaltrials.gov NCT03157479 on May 17th, 2017.     

Delayed versus early repair of inguinal hernia in preterm infants: A systematic review and meta-analysis

ObjectivesTo evaluate the clinical outcomes of herniotomy in preterm infants undergoing early versus delayed repair, the risk factors for complications, and to identify best timing of surgery.MethodsMedline, Embase and Central databases were searched from inception until 25 Jan 2021 to identify publications comparing the timing of neonatal inguinal hernia repair between early intervention (before discharge from first hospitalization) and delayed (after first hospitalisation discharge) intervention. Inclusion criteria was preterm infants diagnosed with inguinal hernia during neonatal intensive care unit admission. Results were analyzed using fixed and random effects meta-analysis (RevManv5.4).ResultsOut of 721 articles found, six studies were included in the meta-analysis. Patients in the early group had lower odds of developing incarceration [odds ratio (OR) 0.43, 95% confidence interval (CI) 0.34–0.55, I² = 0%, p < 0.001]; but higher risk of post-operative respiratory complications (OR 4.36, 95% CI 2.13–8.94, I² = 40%, p < 0.001). No significant differences were reported in recurrence rate (OR 3.10, 95% CI 0.90–10.64, I² = 0%, p = 0.07) and surgical complication rate (OR 0.94, 95% CI 0.18–4.83, I² = 0%, p = 0.94) between early and delayed groups.ConclusionWhile early inguinal hernia repair in preterm infants reduces the risk of incarceration, it increases the risk of post-operative respiratory complications compared to delayed repair. Surgeons should discuss the risks and benefits of delaying inguinal hernia repair with the caregivers to make an informed decision best suited to the patient physiology and circumstances.Level of evidenceTreatment study, level 3.     

Variability in the management of adhesive small bowel obstruction in children

BackgroundThis study assessed inter-hospital variability in operative-vs-nonoperative management of pediatric adhesive small bowel obstruction (ASBO).MethodsA multi-institutional retrospective study was performed examining patients 1–21 years-of-age presenting with ASBO from 2010 to 2019 utilizing the Pediatric Health Information System. Multivariable mixed-effects logistic regression was performed assessing inter-hospital variability in operative-vs-nonoperative management of ASBO.ResultsAmong 6410 pediatric ASBO admissions identified at 46 hospitals, 3,239 (50.5%) underwent surgery during that admission. The hospital-specific rate of surgery ranged from 35.3% (95%CI: 28.5–42.6%) to 74.7% (66.3–81.6%) in the unadjusted model (p < 0.001), and from 35.1% (26.3–45.1%) to 73.9% (66.7–79.9%) in the adjusted model (p < 0.001). Factors associated with operative management for ASBO included admission to a surgical service (OR 2.8 [95%CI: 2.4–3.2], p < 0.001), congenital intestinal and/or rotational anomaly (OR 2.5 [2.1–3.1], p < 0.001), diagnostic workup including advanced abdominal imaging (OR 1.7 [1.5–1.9], p < 0.001), non-emergent admission status (OR 1.5 [1.3–1.8], p < 0.001), and increasing number of complex chronic comorbidities (OR 1.3 [1.2–1.4], p < 0.001). Factors associated with nonoperative management for ASBO included increased hospital-specific annual ASBO volume (OR 0.98 [95%CI: 0.97–0.99], p = 0.002), older age (OR 0.97 [0.96–0.98], p < 0.001), public insurance (OR 0.87 [0.78–0.96], p = 0.008), and presence of coinciding non-intestinal congenital anomalies, neurologic/neuromuscular disease, and/or medical technology dependence (OR 0.57 [95%CI: 0.47–0.68], p < 0.001).ConclusionsRates of surgical intervention for ASBO vary significantly across tertiary children's hospitals in the United States. The variability was independent of patient and hospital characteristics and is likely due to practice variation.Level of evidenceIII     

Antipsychotic use and the risk of hip/femur fracture: a population-based case–control study

Summary  This case–control study showed that current use of conventional antipsychotics, but not atypical antipsychotics, seems to be associated with an increased risk of a hip/femur fracture, possibly related to the pharmacological properties of conventional antipsychotics. Furthermore, no evidence for a dose effect was found. Introduction  The aim of this study was to assess the risk of hip/femur fracture associated with antipsychotic use, with particular reference to any difference in risk with conventional versus atypical antipsychotics, dose, and pharmacological properties. Methods  A case–control study was conducted using data from the PHARMO Record Linkage System among individuals aged 18 years and older between 1991 and 2002. Cases had a record of a hip or femur fracture, while controls had no evidence of ever having sustained any fracture. Results  Most cases were elderly (77.6% aged ≥70 years). We found an increased risk for hip/femur fracture associated with the use of antipsychotic drugs. The risk for current users (OR_adj 1.68 [1.43, 1.99]) was significantly greater than with past use (OR_adj 1.33 [1.14, 1.56]; p = 0.036). Current use of conventional antipsychotics (OR_adj 1.76 [1.48, 2.08]) but not atypical antipsychotics (OR_adj 0.83 [0.42, 1.65]) was associated with an increased risk. We did not find evidence for a dose effect. Conclusion  The use of conventional, but not atypical antipsychotics, seems to be associated with an increased risk of hip/femur fracture, possibly related to the pharmacological properties of conventional antipsychotics. However, the numbers of atypical antipsychotic users were small, and therefore this observation needs further attention in other study populations.     

Preoperative opioid use is associated with increased readmission,revision surgery and cost after total shoulder arthroplasty

BackgroundPreoperative opioid use has been associated with higher pain scores and lower functional outcomes after total shoulder arthroplasty (TSA), but the association between preoperative opioid use and readmission, revision surgery and cost following TSA is less well-known. The purpose of this study is to determine the association between preoperative opioid use and readmission, revision surgery and cost after total shoulder arthroplasty.MethodsUsing the Marketscan© administrative claims database, we identified patients from 2010–2015 who underwent primary TSA using Current Procedural Terminology codes. 5,621 patients aged 18–64 were identified who had 6-months of continuous coverage preoperatively and one year of continuous coverage postoperatively. Patients who were using opioids up until the 30-day period prior to surgery were classified as preoperative opioid users. Our primary outcomes were rates of 90-day all-cause hospital readmission, 1-year rates of revision surgery, and 1-year healthcare payments. Logistic regression and a generalized linear model were used to analyze binomial and payment data, respectively. All models were controlled for age, gender and Charlson comorbidity index.ResultsMean age of patients was 57 ± 5.6 years, 42% were females. Average length of stay was 1.7 ± 1.2 days. 28% of patients were using opioids preoperatively. Preoperative opioid use was associated with significantly increased odds of 90-day readmission (OR 2.6, p<0.001), having a revision TSA within 1-year (OR 2.35, p<0.001), and higher total postoperative 1-year healthcare payments (+$10,034, p<0.001). Preoperative opioid use was also associated with a small, but significant increased length of stay (+0.13 days, p = 0.001).ConclusionsPreoperative opioid use is associated with increased rates of readmission and revision surgery following TSA. Patients undergoing TSA have significantly higher total healthcare costs and a modest increase in length of hospital stay.Level of evidenceLevel II