Surgical site infection and transfusion rates are higher in underweight total knee arthroplasty patients.

BACKGROUND: Underweight (UW) patients undergoing total hip arthroplasty have exhibited higher complication rates, including infection and transfusion. No study to our knowledge has evaluated UW total knee arthroplasty (TKA) patients. We, therefore, conducted a study to investigate if these patients are at increased risk for complications, including infection and transfusion. METHODS: A case-control study was conducted using a prospectively collected institutional database. Twenty-seven TKA patients were identified as UW (body mass index [BMI] \u3c 18.5 kg/m RESULTS: The average BMI was 17.1 kg/m CONCLUSIONS: Our study demonstrates that UW TKA patients have a higher likelihood of developing SSI and requiring blood transfusions. The specific reasons are unclear, but we conjecture that it may be related to decreased wound healing capabilities and low preoperative hemoglobin. Investigation of local tissue coverage and hematologic status may be beneficial in this patient population to prevent SSI. Based on the results of this study, a prospective evaluation of these factors should be undertaken

Reducing Preoperative Anxiety in Adolescents Facing Spinal Fusion Surgery

Reducing preoperative anxiety for adolescents facing spinal fusion surgery for the treatment of scoliosis has significant implications for clinical practice and patient outcomes for this specific population. The reality of a pending surgery creates a difficult, uncomfortable, and exhausting state of being that can lead to increased postoperative pain, sleep disturbances, and maladaptive behaviors. This final capstone project inquiry report presents three manuscripts which focus on the reduction of preoperative anxiety in adolescents facing spinal fusion surgery. The first manuscript is a literature review examining current evidence related to preoperative anxiety, adolescents undergoing spinal fusion surgery, and teaching programs aimed at decreasing preoperative anxiety. The second manuscript is an account of the development of a formalized, comprehensive, multidisciplinary preoperative teaching protocol. The goal of this protocol is to provide optimal preparation for adolescents undergoing spinal fusion surgery in order to reduce preoperative anxiety and to increase basic knowledge of scoliosis and spinal fusion surgery. This research led to the implementation of the Spinal Fusion Care Protocol (SFCP). The third manuscript is a report of the one-group pretest-posttest study conducted to evaluate the SFCP. The study seeks to determine if the SFTP significantly reduces preoperative anxiety for adolescents facing spinal fusion surgery. Practical implications for clinical practice are presented to improve preoperative teaching for adolescents in order to reduce preoperative anxiety and increase basic knowledge of scoliosis and spinal fusion surgery

Nutrition and Neurosurgery: Designing a Perioperative Pathway for Elective Spine Fusion Patients

Each additional hospital day related to a surgical complication costs an estimated $1,000 (Grusky et al., 2015). Due to the rising costs of healthcare, European professors designed Enhanced Recovery After Surgery pathways to mitigate potential adverse surgical outcomes and associated costs. A primary focus of these pathways emphasizes the importance of pre-procedure nutritional optimization. Literature increasingly supports malnutrition as an independent predictor of postoperative complications and increased length of stay (LOS) (Adogwa et al., 2014). The neurosurgical population has a wide variety of comorbidities that place them at increased risk for nutritional compromise. Thus, a perioperative nutrition pathway was implemented at a Midwest neurosurgery office for elective spinal fusion patients. The pathway incorporated twenty-nine (n=29) patients who were screened and provided with Ensure Pre-Surgery drinks preoperatively. Result yielded no statistically significant difference in hospital LOS or 30-day readmission rates among patients in the pathway and those in a historical comparison group. However, the pathway did highlight the importance of a standardized process to identify patients at risk of nutritional compromise. A total of three (n=3) patients received nutrition consults postoperatively due to screening answers and body mass index (BMI) results. Additionally, the pathway identified the need for future guidelines addressing diabetic preoperative clearance. Future recommendations from the pathway highlight the importance of a nutritional algorithm for diabetic patients, utilization of information technology and comprehensive nutritional screening tools

The Role of Nutrition in Degenerative Cervical Myelopathy: A Systematic Review.

INTRODUCTION: Degenerative cervical myelopathy (DCM) is the commonest cause of adult spinal cord impairment worldwide, encompassing chronic compression of the spinal cord, neurological disability and diminished quality of life. Evidence on the contribution of environmental factors is sparse; in particular, the role of nutrition in DCM is unknown. The objective of this review was to assess the effect of nutrition on DCM susceptibility, severity and surgical outcome. METHODS: A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English papers, focussing on cervical myelopathy and nutrition, published before January 2020 were considered eligible. Quality assessments were performed using the GRADE assessment tool. Patient demographics, nutritional factor and DCM outcomes measures were recorded. Relationships between nutritional factors, interventions and disease prognosis were assessed. RESULTS: In total, 5835 papers were identified of which 44 were included in the final analysis. DCM patients with pathological weight pre-operatively were more likely to see poorer improvements post-surgically. These patients experienced poorer physical and mental health improvements from surgery compared to normal weight patients and were more likely to suffer from post-operative complications such as infection, DVT, PE and hospital readmissions. Two trials reporting benefits of nutritional supplements were identified, with 1 suggesting Cerebrolysin to be significant in functional improvement. An unbalanced diet, history of alcohol abuse and malnourishment were associated with poorer post-operative outcome. CONCLUSION: Although the overall strength of recommendation is low, current evidence suggests nutrition may have a significant role in optimising surgical outcome in DCM patients. Although it may have a role in onset and severity of DCM, this is a preliminary suggestion. Further work needs to be done on how nutrition is defined and measured, however, the beneficial results from studies with nutritional interventions suggest nutrition could be a treatment target in DCM.Funding: Dr Benjamin M. Davies is supported by an NIHR Clinical Doctoral Research Fellowship. This report is independent research arising from a Clinician Scientist Award, CS-2015-15-023, supported by the National Institute for Health Research

Preoperative Narcotic Use, Impaired Ambulation Status, and Increased Intraoperative Blood Loss Are Independent Risk Factors for Complications Following Posterior Cervical Laminectomy and Fusion Surgery.

ObjectiveThis retrospective cohort study seeks to identify risk factors associated with complications following posterior cervical laminectomy and fusion (PCLF) surgery.MethodsAdults undergoing PCLF from 2012 through 2018 at a single center were identified. Demographic and radiographic data, surgical characteristics, and complication rates were compared. Multivariate logistic regression models identified independent predictors of complications following surgery.ResultsA total of 196 patients met the inclusion criteria and were included in the study. The medical, surgical, and overall complication rates were 10.2%, 23.0%, and 29.1% respectively. Risk factors associated with medical complications in multivariate analysis included impaired ambulation status (odds ratio [OR], 2.27; p=0.02) and estimated blood loss over 500 mL (OR, 3.67; p=0.02). Multivariate analysis revealed preoperative narcotic use (OR, 2.43; p=0.02) and operative time (OR, 1.005; p=0.03) as risk factors for surgical complication, whereas antidepressant use was a protective factor (OR, 0.21; p=0.01). Overall complication was associated with preoperative narcotic use (OR, 1.97; p=0.04) and higher intraoperative blood loss (OR, 1.0007; p=0.03).ConclusionPreoperative narcotic use and estimated blood loss predicted the incidence of complications following PCLF for CSM. Ambulation status was a significant predictor of the development of a medical complication specifically. These results may help surgeons in counseling patients who may be at increased risk of complication following surgery

Perioperative management and anaesthetic considerations in pelvic exenterations using Delphi methodology: Results from the PelvEx Collaborative

Background: The multidisciplinary perioperative and anaesthetic management of patients undergoing pelvic exenteration is essential for good surgical outcomes. No clear guidelines have been established, and there is wide variation in clinical practice internationally. This consensus statement consolidates clinical experience and best practice collectively, and systematically addresses key domains in the perioperative and anaesthetic management. Methods: The modified Delphi methodology was used to achieve consensus from the PelvEx Collaborative. The process included one round of online questionnaire involving controlled feedback and structured participant response, two rounds of editing, and one round of web-based voting. It was held from December 2019 to February 2020. Consensus was defined as more than 80 per cent agreement, whereas less than 80 per cent agreement indicated low consensus. Results: The final consensus document contained 47 voted statements, across six key domains of perioperative and anaesthetic management in pelvic exenteration, comprising preoperative assessment and preparation, anaesthetic considerations, perioperative management, anticipating possible massive haemorrhage, stress response and postoperative critical care, and pain management. Consensus recommendations were developed, based on consensus agreement achieved on 34 statements. Conclusion: The perioperative and anaesthetic management of patients undergoing pelvic exenteration is best accomplished by a dedicated multidisciplinary team with relevant domain expertise in the setting of a specialized tertiary unit. This consensus statement has addressed key domains within the framework of current perioperative and anaesthetic management among patients undergoing pelvic exenteration, with an international perspective, to guide clinical practice, and has outlined areas for future clinical research

An investigation of the relationship between perioperative characteristics and perioperative anaesthesia on the postoperative systemic inflammatory response and clinical outcome in patients undergoing surgery for colorectal cancer

In UK, colorectal cancer (CRC) is the fourth most common cancer and the second most common cause of cancer death. Until now, surgical resection remains the cornerstone for the management of CRC in all stages, however, stress response elicit from surgery may cause different changes through multiple systems in human body including neural, endocrine, metabolic, inflammatory, and immunological changes. In addition, other perioperative factors such as volatile anaesthetic and opioids may induce the immunosuppression. There is a proportional correlation between the stress response and the magnitude of the inflammatory immune response, invasiveness, and duration of surgery. The pre-operative and post-operative status of patients are important when considering the prognosis. The systemic inflammatory response (SIR) has been recognised to correlate with tumour progression and the prognosis of CRC. An exaggerated postoperative SIR is associated with postoperative infective complications and poor survival. Several predictive markers of the SIR have been used, such as the neutrophil to lymphocyte ratio (NLR), serum C-reactive protein (CRP) level, and Glasgow prognostic score (GPS). Some evidence reported that general anaesthesia (GA) combined with regional anaesthesia (RA) are better than the single use of general anaesthesia in reducing the post-operative immuno-suppression in some degrees. Furthermore, the peri-operative inflammatory process may be affected by the choice of anaesthetic technique, with propofol reported to have anti-inflammatory effect by targeting neutrophil activity. Up to now, there is insufficient evidence to recommend any specific anaesthetic or analgesic technique for patients undergoing surgery for tumour resection based on inflammatory response, recurrence, and metastasis. The work presented in this thesis further examines the relationship between the perioperative characteristics, perioperative anaesthesia, and the postoperative systemic inflammatory response following surgery for colorectal cancer. Several preoperative medications along with anaesthesia might influence the postoperative systemic inflammatory response but the question is whether the post-operative systemic inflammatory response affected by the administration of different types of anaesthesia or not following surgery for colorectal cancer. Chapter 1 discusses the epidemiology, aetiology, carcinogenesis, risk factors of colorectal cancer, pro-carcinogenic factors, anti-carcinogenic agents, inflammation and cancer, the post-operative systemic inflammatory response, tumour staging, screening, and diagnosis of colorectal cancer. Chapter 2 discusses the treatment of colorectal cancer. Chapter 3 discusses different anaesthetic techniques and agents. Chapter 4 provides summary and aims of the thesis. Chapter 5 represents findings from a systematic review and meta-analysis about the effect of anaesthesia on the postoperative systemic inflammatory response in patients undergoing surgery. The results conclude that there was some evidence that anaesthetic regimens may reduce the magnitude of the post-operative SIR. However, the studies identified in this systematic review were heterogeneous and generally of low quality. Chapter 6 represents a retrospective cohort study about the relationship between anaesthetic technique, clinicopathological characteristics and the magnitude of the postoperative systemic inflammatory response in patients undergoing elective surgery for colon cancer. The results show that the type of anaesthesia varied over time and appears to influence the magnitude of the postoperative SIR on post-operative day 2 for those patients who underwent for open surgery but not laparoscopic surgery. Chapter 7 represents a prospective cohort study about the effect of anaesthesia on the magnitude of the postoperative systemic inflammatory response in patients undergoing elective surgery for colorectal cancer in the context of an enhanced recovery pathway. The results show that there was a modest but an independent association between regional anaesthesia (RA) and a lower magnitude of the postoperative SIR. Chapter 8 represents the relationship between pre-operative medications, the type of anaesthesia and post-operative sequelae in patients undergoing surgery for colorectal cancer. The results show that there was no association between the preoperative administration of aspirin, statins and ACE inhibitors and anaesthesia. Chapter 9 represents the relationship between nutritional status, anaesthetic approach, and peri-operative characteristics of patients undergoing surgery for colorectal cancer. The results show that there was no significant association between measures of nutritional status and anaesthetic approach. Chapter 10 represents the relationship between opioid administration, type of anaesthesia and clinicopathological characteristics in patients undergoing surgery for colorectal cancer. The results show that opioid administration was independently associated with both anaesthetic and operative factors. Chapter 11 represents the main findings of the thesis and some recommendation for a future work

Predicting Surgical Site Infection in Pediatric Patients Undergoing Spinal Deformity Surgery

The incidence of surgical site infection (SSI) in pediatric spinal deformity has been reported to remain high in the United States in spite of efforts made to reduce SSI. The risk of SSI is associated with multiple factors. For example, the heterogeneity of patients with different clinical and surgical characteristics in this population imposes challenges to identify the most beneficial preventive strategies for individual patients. This dissertation sought to advance understanding of risk factors and preventive strategies for SSI in individual pediatric patients undergoing spinal deformity surgery. Although the literature reports various risk factors and preventive strategies associated with SSI, there are no reliable review papers using formal methodology to aggregate evidence. The first aim of the dissertation was to conduct a systematic review and a meta-analysis to assess published literature investigating associations between various risk factors and SSI in pediatric patients undergoing spine surgery. The systematic review and the meta-analysis were conducted among peer-reviewed journals published in English between January 2000 - April 2019 using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA-P). Studies included pediatric patients with spinal deformity undergoing surgical procedures in North America and were assessed for risk factors of SSI. Of 763 articles identified, thirteen met inclusion criteria after abstract or full manuscript review, and seven studies were rated as average and six as poor based on the quality checklist. The meta-analysis identified obesity/overweight, neuromuscular etiology, gastrostomy tube, non-ambulatory status, pelvic instrumentation, and high estimated blood as significant risk factors for SSI. Because the published literature does not identify which individual patients are at high risk for SSI, the second aim of this dissertation was to create a calculator using prediction modeling including patient, surgical and hospital characteristics to quantify the risk of SSI in individual patients. A retrospective cohort study was conducted using a database from seven centers that included 3,092 pediatric patients (0-21 years of age) with spinal deformity who underwent primary, revision, or definitive spinal fusion from 2004 to 2018. A total of 132 SSI (4.5%) within 90 days after surgery were identified. Candidate risk factors in this study included 31 patient, 12 surgical and 4 hospital factors that were present or determined before the surgery and unlikely to be modifiable. The final prediction model achieved adequate predictive ability (area under the curve [AUC]: 0.76) and included 10 risk factors: overweight/obese, neuromuscular etiology, American Society of Anesthesiologist Physical Status Classification System (ASA) >1, non-ambulatory status, abnormal hemoglobin (HGB) level, high white blood cell (WBC) count, revision surgery, presence of pelvic instrumentation, procedure time for ≥7 hours, and <100 spine surgical case per year per institution. Based on these findings, a risk probability calculator to predict the risk of SSI in individual patients was developed. There are a number of preventive strategies that have been recommended in consensus-based guidelines in the United States. The third aim of this dissertation was to investigate the association between preventive care measures and SSI and predict the reduction of SSI probability in individual patients by these preventive strategies. The database used in Aim 2 was also utilized to investigate the association between preventive care measures and the risk of SSI. Examined preventive strategies were the use of topical vancomycin, povidone-iodine irrigations, multilayered closure, impermeable dressing, the enrollment in Children’s Hospitals’ Solutions for Patient Safety (SPS) program or in the Comprehensive Unit-based Safety Program (CUSP), and adherence to the institutional perioperative antibiotic prophylaxis guideline. None of these preventive strategies were included in the risk model from Aim 2. When the CUSP/SPS enrollment alone was in the model, patients whose procedures were performed when sites were enrolled in the programs had 49.4% decrease in SSI (odds ratio [OR]:0.51, [95% CI: 0.32; 0.81], p=0.005) and AUC of 0.56. When CUSP/SPS enrollment was added to the risk model from Aim 2, the model revealed that patients whose procedures were performed when sites were enrolled in the CUSP/SPS had an average 48.9% decrease in SSI (odds ratio: 0.51, [95% CI: 0.29; 0.82]). The final prediction model demonstrated adequate predictive ability (AUC: 0.77). This dissertation highlighted factors associated with an increased risk of SSI and preventive strategies related to a reduced risk of SSI in pediatric patients undergoing spinal deformity surgery. The results of this study will enable healthcare providers to calculate the risk of SSI and effects of preventive strategies in reducing the risk of SSI in individual patients. In the long term, the information from this study could be used to enhance personalized care in clinical practice to prevent SSI in individual patients as well as to facilitate patient education and shared decision-making

Resting-state prefrontal EEG biomarker in correlation with postoperative delirium in elderly patients

Postoperative delirium (POD) is associated with adverse outcomes in elderly patients after surgery. Electroencephalography (EEG) can be used to develop a potential biomarker for degenerative cerebral dysfunctions, including mild cognitive impairment and dementia. This study aimed to explore the relationship between preoperative EEG and POD. We included 257 patients aged &gt;70 years who underwent spinal surgery. We measured the median dominant frequency (MDF), which is a resting-state EEG biomarker involving intrinsic alpha oscillations that reflect an idle cortical state, from the prefrontal regions. Additionally, the mini-mental state examination and Montreal cognitive assessment (MoCA) were performed before surgery as well as 5 days after surgery. For long-term cognitive function follow up, the telephone interview for cognitive status™ (TICS) was performed 1 month and 1 year after surgery. Fifty-two (20.2%) patients were diagnosed with POD. A multivariable logistic regression analysis that included age, MoCA score, Charlson comorbidity index score, Mini Nutritional Assessment, and the MDF as variables revealed that the MDF had a significant odds ratio of 0.48 (95% confidence interval 0.27–0.85). Among the patients with POD, the postoperative neurocognitive disorders could last up to 1 year. Low MDF on preoperative EEG was associated with POD in elderly patients undergoing surgery. EEG could be a novel potential tool for identifying patients at a high risk of POD

Perioperative management and anaesthetic considerations in pelvic exenterations using Delphi methodology: results from the PelvEx Collaborative

Background: The multidisciplinary perioperative and anaesthetic management of patients undergoing pelvic exenteration (PE) is essential for good surgical outcomes. No clear guidelines have been established, and there is wide variation in clinical practice internationally. This consensus statement consolidates clinical experience and best practice collectively, and systematically addresses key domains in the perioperative and anaesthetic management. Methods: The modified Delphi methodology was used to achieve consensus from the PelvEx Collaborative. The process included one round of online questionnaire involving controlled feedback and structured participant response, two rounds of editing, and one round of web-based voting. It was held from December 2019 to February 2020. Consensus was defined as more than 80 per cent agreement; whereas less than 80 per cent agreement indicated low consensus. Results: The final consensus document contained 47 voted statements, across six key domains of perioperative and anaesthetic management in PEs comprising preoperative assessment and preparation, anaesthetic considerations, perioperative management, anticipating possible massive haemorrhage, stress response and postoperative critical care, and pain management. Consensus recommendations were developed based on consensus agreement achieved on 34 statements. Conclusion: The perioperative and anaesthetic management of PE patients is best accomplished by a dedicated multidisciplinary team with relevant domain expertise in the setting of a specialized tertiary unit. This consensus statement has addressed key domains within the framework of current perioperative and anaesthetic management among PE patients, with an international perspective, to guide clinical practice, and has outlined areas for future clinical research