Risk Factors for Postinduction Hypotension among Elderly Patients Undergoing Elective Non-Cardiac Surgery under General Anesthesia

Objective: We aimed to determine risk factors for hypotension occurring after induction among elderly patients (aged 65 years and older). We hypothesized that the dosage of intravenous anesthesia drugs as well as the type of inhalation agent have an effect on hypotension during post-induction periods. We aimed to test this hypothesis to determine risk factors for hypotension after induction among elderly patients who underwent non-cardiac surgery. Material and Methods: This retrospective cohort study analyzed data from 580 patients between December 2017 and July 2018 at a tertiary university hospital in the south of Thailand. Hypotension is defined as a more than 30.0% decrease in mean arterial pressure from baseline after induction and within 20 minutes of the use of a vasopressor agent to treat hypotension. The intraoperative parameters were blood pressure and heart rate immediately after arrival at the operating room, immediately after intubation, and 5, 10, 15, and 20 minutes after intubation. Results: The median age was 72.5 (68, 78) years. The association of post-induction hypotension was raised with a diuretic drug as preoperative medication (p-value=0.025), and the degree of hypertension immediately after arrival at the operating room (p-value<0.001). Increasing fentanyl dosage during induction was associated with hypotension (p-value<0.010). There was no statistically significant difference in the increase of the propofol dosage. Conclusion: The degree of hypertension immediately after arrival at the operating room coupled with higher fentanyl dosage were significant risk factors for postinduction hypotension in elderly patients

The intensive care unit admission predicting the factors of late complications in trauma patients: A prospective cohort study

Background: Organ failure (OF) and sepsis are important causes of late death in trauma. Previous studies reported the methods that could predict OF at the time of patient arrival. However, most of the evidence is from high-income countries, where health-care systems were different from developing countries. This research aimed to identify the factors to predict late complications in trauma patients in surgical intensive care units (SICUs). Methods: This study was a secondary data analysis from the THAI-SICU study, which was a prospective cohort study in nine university-based-SICUs in Thailand. Late complications were defined as any OF or sepsis that occurred after 48 h of ICU admission. Multivariable logistic regression was conducted to identify the significant factors. Results: Three hundred and fourteen patients were eligible for the analysis. Late complications occurred in 60 patients (19). Patients who had complications had higher Acute Physiology and Chronic Health Enquiry (APACHE II) (15.8 vs. 12.4, P = 0.02) and Sequential OF Assessment (SOFA) scores on admission (6.7 vs. 3.8, P P = 0.04) and SOFA score on admission (OR = 1.2, 95% CI; 1.12-1.29, P P Conclusions: The incidence of late complications in trauma patients in the SICU was 19%. Current smoking and SOFA score might be valuable in future prediction of late complications during admission

Risk Factors for Postinduction Hypotension among Elderly Patients Undergoing Elective Non-Cardiac Surgery under General Anesthesia

Objective: We aimed to determine risk factors for hypotension occurring after induction among elderly patients (aged 65 years and older). We hypothesized that the dosage of intravenous anesthesia drugs as well as the type of inhalation agent have an effect on hypotension during post-induction periods. We aimed to test this hypothesis to determine risk factors for hypotension after induction among elderly patients who underwent non-cardiac surgery.Material and Methods: This retrospective cohort study analyzed data from 580 patients between December 2017 and July 2018 at a tertiary university hospital in the south of Thailand. Hypotension is defined as a more than 30.0% decrease in mean arterial pressure from baseline after induction and within 20 minutes of the use of a vasopressor agent to treat hypotension. The intraoperative parameters were blood pressure and heart rate immediately after arrival at the operating room, immediately after intubation, and 5, 10, 15, and 20 minutes after intubation.Results: The median age was 72.5 (68, 78) years. The association of post-induction hypotension was raised with a diuretic drug as preoperative medication (p-value=0.025), and the degree of hypertension immediately after arrival at the operating room (p-value&lt;0.001). Increasing fentanyl dosage during induction was associated with hypotension (p-value&lt;0.010). There was no statistically significant difference in the increase of the propofol dosage.Conclusion: The degree of hypertension immediately after arrival at the operating room coupled with higher fentanyl dosage were significant risk factors for postinduction hypotension in elderly patients.</jats:p

Supplemental oxygen for caesarean section during regional anaesthesia

BACKGROUND: Supplementary oxygen is routinely administered to low‐risk pregnant women during an elective caesarean section under regional anaesthesia; however, maternal and foetal outcomes have not been well established. This is an update of a review first published in 2013. OBJECTIVES: The primary objective was to determine whether supplementary oxygen given to low‐risk term pregnant women undergoing elective caesarean section under regional anaesthesia can prevent maternal and neonatal desaturation. The secondary objective was to compare the mean values of maternal and neonatal blood gas levels between mothers who received supplementary oxygen and those who did not (control group). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, issue 11), MEDLINE (1948 to November 2014) and EMBASE (1980 to November 2014). The original search was first performed in February 2012. We reran the search in CENTRAL, MEDLINE, EMBASE in February 2016. One potential new study of interest was added to the list of ‘Studies awaiting Classification' and will be incorporated into the formal review findings during the next review update. SELECTION CRITERIA: We included randomized controlled trials (RCTs) of low‐risk pregnant women undergoing an elective caesarean section under regional anaesthesia and compared outcomes with, and without, oxygen supplementation. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data, assessed methodological quality and performed subgroup and sensitivity analyses. MAIN RESULTS: We found one new included study in this updated version. In total, our updated review includes 11 trials (with 753 participants). The low quality of evidence showed no significant differences in average Apgar scores at one minute (N = six trials, 519 participants; 95% confidence (CI) ‐0.16 to 0.31, P = 0.53) and at five minutes (N = six trials, 519 participants; 95% CI ‐0.06 to 0.06, P = 0.98). None of the 11 trials reported maternal desaturation. The very low quality of evidence showed that in comparison to room air, women in labour receiving supplementary oxygen had higher maternal oxygen saturation (N = three trials, 209 participants), maternal PaO(2) (oxygen pressure in the blood; N = six trials, 241 participants), UaPO(2) (foetal umbilical arterial blood; N = eight trials, 504 participants; 95% CI 1.8 to 4.9, P < 0.0001) and UvPO(2) (foetal umbilical venous blood; N = 10 trials, 683 participants). There was high heterogeneity among these outcomes. A subgroup analysis showed no significant difference in UaPO(2) between the two intervention groups in low‐risk studies, whereas the high‐risk studies showed a benefit for the neonatal oxygen group. AUTHORS' CONCLUSIONS: Overall, we found no convincing evidence that giving supplementary oxygen to healthy term pregnant women during elective caesarean section under regional anaesthesia is either beneficial or harmful for either the mother or the foetus' short‐term clinical outcome as assessed by Apgar scores. Although, there were significant higher maternal and neonatal blood gas values and markers of free radicals when extra oxygen was given, the results should be interpreted with caution due to the low grade quality of the evidence

The Trickle-Down Effect of First-Case Tardiness on Last-Case Cancellation Rates and Operating Room Overutilization Involving Scheduled Surgical Patients in a University Hospital

Objective: To observe the frequency and causes of first-case tardiness and its consequences.Material and Methods: Six months of data from scheduled surgical patients from 18 operating rooms (OR), under 13 surgical subspecialties, between September 2014 and February 2015, in a tertiary-care university hospital, were collected. We aimed to identify: (1) the rate and tardy time of first-case tardiness, (2) the time of overutilization caused by first-case tardiness, and (3) the cancellation rate due to first-case tardiness.Results: From a total of 3,965 elective surgical cases, 1,343 qualified as first cases and were included for analysis. Six hundred forty-four cases (48%) started more than 10 minutes later than the scheduled time. The mean (S.D.) tardy time was 25.1 (16.9) minutes. The total tardy time due to first-case tardiness was 16,146 minutes (33.6 8-hour OR days). The late physical presence of surgeons was responsible for most tardy first cases (80.6%). Of a designated OR, in which the first case was delayed, the 419 final cases in the schedule of ORs continued beyond working hours and 65 cases were cancelled. Moreover, of the 52,028 minutes (108.4 8-hour OR days) of OR overutilization, 9,465 minutes (19.7 8-hour OR days) were due to first-case tardiness.Conclusion: First-case tardiness creates substantial futile time and a trickle-down effect on the subsequent cases of a designated OR-either case cancelation or operating room overutilization.</jats:p

Perioperative Risk Factors for Intraoperative Hypothermia in Adult Patients Undergoing Elective Surgery at a National Referral Hospital in Bhutan: A Prospective Observational Study

Objective: Intraoperative hypothermia is commonly encountered in anesthetic practice. It is related to several risk factors and can lead to various adverse events. It is important to detect it early and prevent the complications related to it. This study was done to identify incidence and perioperative risk factors of intraoperative hypothermia at a national referral hospital in Bhutan.Material and Methods: A prospective observational study was conducted in adult patients who underwent elective surgery lasting more than 30 minutes. Patient characteristics, incidence of hypothermia, and any interventions for treatment of hypothermia during the operation were recorded. Intraoperative hypothermia was defined as a core body temperature less than 36 °C measured with an esophageal probe.Results: Data were obtained from 91 patients with a mean (±standard deviation; S.D.) age of 42.3 (17.2) and American Society of Anesthesiologists (ASA) scores of 1 and 2 in 62.6% and 37.4% of the patients, respectively The patients underwent elective surgery with a mean (S.D.) duration of 73.24 (48.1) minutes and a mean (S.D.) duration of anaesthesia of 80.9 (49.2) minutes. The incidence of intraoperative hypothermia was 61.5% (56/91). Preoperative heart rate more than 80 beats per minute [hazard ratio (HR) 0.45, 95% confidence interval (CI), 0.26-0.77] was a protective factor and duration of anesthesia more than 60 minutes (HR 1.82, 95% CI, 0.98–3.38) was a risk factor for intraoperative hypothermia.Conclusion: Patients with a preoperative heart rate less than 80 beats per minute and undergoing duration of anesthesia more than 60 minutes should be assessed from the preoperative period and continuously monitored throughout the intraoperative period.</jats:p

Direct Cost of Anesthesia in Traumatic Patients with Massive Bleeding: a Prospective Micro-Costing Study

Objective:This study aimed to quantify the direct cost as well as cost-to-charge ratio of anesthetic care in traumatic patients with intraoperative massive bleeding.Material and Methods: This study was a prospective observational cost analysis study, conducted in Songklanagarind Hospital, Thailand. Traumatic patients from any mechanisms were recruited. Massive bleeding was defined as estimated blood loss of at least one blood volume in 24 hours or a half of blood volume in 3 hours. The cost components were valued by the bottom-up approach. The direct cost was divided into 4 categories; the labor cost, the capital cost, the material cost and the cost of drugs.Results: From September 2017 to August 2018; 10 eligible patients were included. Seven patients had motorcycle accidents, two patients fell from height and another one was in a minibus accident. Two patients died on the operating table, and another two died within 48 hours. The median direct cost per case was 9,321 Baht (264 United States Dollars), and the cost-to-charge ratio was 0.62. The median Sequential Organ Failure Assessment Score was 8. The median intraoperative blood loss was 3,500 millimeters.Conclusion: Our study provided information on the direct costs of anesthesia in traumatic patients with massive bleeding. The direct cost was 62.0% of the hospital charge. However, this study did not analyze the indirect cost. </jats:p

Association of Frailty with Intraoperative Complications in Older Patients Undergoing Elective Non-Cardiac Surgery

Background: Frailty is increasingly being recognized as a risk factor for adverse outcomes in older surgical patients undergoing surgery. We investigated the association between frailty and intraoperative complications using multiple frailty assessment tools in older patients undergoing elective intermediate- to high-risk non-cardiac surgery. Methods: This retrospective cohort study included 637 older patients scheduled for elective non-cardiac surgery. Frailty was assessed using the Clinical Frailty Scale (CFS), FRAIL scale, and modified Frailty Index-11 (mFI-11). The predictive ability of frailty tools was analyzed and compared using the area under the receiver operating characteristic curve (AUC). Results: Frailty was significantly associated with higher intraoperative complication rates (FRAIL scale: p = 0.01; mFI-11: p = 0.046). Patients considered frail using the mFI-11 were more likely to have unplanned intensive care unit admissions (p &lt; 0.001). Those classified as frail by the FRAIL scale and mFI-11 had significantly higher rates of vasopressor/inotrope use (p = 0.001 and p = 0.005, respectively) and mechanical ventilation (p = 0.033 and p = 0.007, respectively). In the univariate analysis, frailty measured using the FRAIL scale was significantly associated with intraoperative complications (odds ratio [OR], 2.41; 95% confidence interval [CI]: 1.33&ndash;4.38; p = 0.004); this association was not significant in the multivariate analysis (adjusted OR, 1.69; 95% CI: 0.83&ndash;3.43; p = 0.148; AUC = 0.550). Atrial fibrillation, hemoglobin levels, anesthesia type, and surgical subspecialty were stronger predictors of intraoperative complications. Conclusions: Frailty assessments demonstrate the limited predictive ability for intraoperative complications. Specific comorbidities, surgical techniques, and anesthesia types play more critical roles. Comprehensive preoperative evaluations integrating frailty with broader risk stratification methods are necessary to enhance patient outcomes and ensure safety