Factors predicting one-year post-surgical mortality amongst older Asian patients undergoing moderate to major non-cardiac surgery - a retrospective cohort study

BACKGROUND

While short-term perioperative outcomes have been well studied in Western surgical populations, the aim of this study is to look at the one-year perioperative mortality and its associated factors in an Asian surgical population after non-cardiac surgery.

METHODS

A retrospective cohort study of 2163 patients aged above 45 undergoing non-cardiac surgery in a university-affiliated tertiary hospital from January to July 2015 was performed. Relevant demographic, clinical and surgical data were analysed to elicit their relationship to mortality at one year after surgery. A univariate analysis was first performed to identify significant variables with p-values ≤ 0.2, which were then analysed using Firth multiple logistic regression to calculate the adjusted odds ratio.

RESULTS

The one-year mortality in our surgical population was 5.9%. The significant factors that increased one-year mortality include smoking (adjusted OR 2.17 (1.02-4.45), p = 0.044), anaemia (adjusted OR 1.32 (1.16-1.47), p < 0.001, for every 1 g/dL drop in haemoglobin level), lower BMI (adjusted OR 0.93 (0.87-0.98), p = 0.005, for every 1 point increase in BMI), Malay and Indian ethnicity (adjusted OR 2.68 (1.53-4.65), p = 0.001), peripheral vascular disease (adjusted OR 4.21 (1.62-10.38), p = 0.004), advanced age (adjusted OR 1.04 (1.01-1.06), p = 0.004, for every one year increase in age), emergency surgery (adjusted OR 2.26 (1.29-3.15), p = 0.005) and malignancy (adjusted OR 3.20 (1.85-5.52), p < 0.001).

CONCLUSIONS

Our study shows that modifiable risk factors such as malnutrition, anaemia and smoking which affect short term mortality extend beyond the immediate perioperative period into longer term outcomes. Identification and optimization of this subset of patients are therefore vital. Further similar large studies should be done to develop a risk scoring system for post-operative long-term outcomes. This would aid clinicians in risk stratification, counselling and surgical planning, which will help in patients' decision making and care planning.

Perioperative considerations and anesthesia management in patients with obstructive sleep apnea undergoing ophthalmic surgery

Obstructive sleep apnea (OSA) is a disorder characterized by breathing cessation caused by obstruction of the upper airway during sleep. It is associated with multiorgan comorbidities such as obesity, hypertension, heart failure, arrhythmias, diabetes mellitus, and stroke. Patients with OSA have an increased prevalence of ophthalmic disorders such as cataract, glaucoma, central serous retinopathy (detachment of retina, macular hole), eyelid laxity, keratoconus, and nonarteritic anterior ischemic optic neuropathy; and some might require surgery. Given that OSA is associated with a high incidence of perioperative complications and more than 80% of surgical patients with OSA are unrecognized, all surgical patients should be screened for OSA (eg, STOP-Bang questionnaire) with comorbidities identified. Patients suspected or diagnosed with OSA scheduled for ophthalmic surgery should have their comorbid conditions optimized. This article includes a review of the literature and highlights best perioperative anesthesia practices in the management of ophthalmic surgical patients with OSA.

Association of Unrecognized Obstructive Sleep Apnea With Postoperative Cardiovascular Events in Patients Undergoing Major Noncardiac Surgery

Importance

Unrecognized obstructive sleep apnea increases cardiovascular risks in the general population, but whether obstructive sleep apnea poses a similar risk in the perioperative period remains uncertain.

Objectives

To determine the association between obstructive sleep apnea and 30-day risk of cardiovascular complications after major noncardiac surgery.

Design, Setting, and Participants

Prospective cohort study involving adult at-risk patients without prior diagnosis of sleep apnea and undergoing major noncardiac surgery from 8 hospitals in 5 countries between January 2012 and July 2017, with follow-up until August 2017. Postoperative monitoring included nocturnal pulse oximetry and measurement of cardiac troponin concentrations.

Exposures

Obstructive sleep apnea was classified as mild (respiratory event index [REI] 5-14.9 events/h), moderate (REI 15-30), and severe (REI >30), based on preoperative portable sleep monitoring.

Main Outcomes and Measures

The primary outcome was a composite of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, and stroke within 30 days of surgery. Proportional-hazards analysis was used to determine the association between obstructive sleep apnea and postoperative cardiovascular complications.

Results

Among a total of 1364 patients recruited for the study, 1218 patients (mean age, 67 [SD, 9] years; 40.2% women) were included in the analyses. At 30 days after surgery, rates of the primary outcome were 30.1% (41/136) for patients with severe OSA, 22.1% (52/235) for patients with moderate OSA, 19.0% (86/452) for patients with mild OSA, and 14.2% (56/395) for patients with no OSA. OSA was associated with higher risk for the primary outcome (adjusted hazard ratio [HR], 1.49 [95% CI, 1.19-2.01]; P = .01); however, the association was significant only among patients with severe OSA (adjusted HR, 2.23 [95% CI, 1.49-3.34]; P = .001) and not among those with moderate OSA (adjusted HR, 1.47 [95% CI, 0.98-2.09]; P = .07) or mild OSA (adjusted HR, 1.36 [95% CI, 0.97-1.91]; P = .08) (P = .01 for interaction). The mean cumulative duration of oxyhemoglobin desaturation less than 80% during the first 3 postoperative nights in patients with cardiovascular complications (23.1 [95% CI, 15.5-27.7] minutes) was longer than in those without (10.2 [95% CI, 7.8-10.9] minutes) (P < .001). No significant interaction effects on perioperative outcomes were observed with type of anesthesia, use of postoperative opioids, and supplemental oxygen therapy.

Conclusions and Relevance

Among at-risk adults undergoing major noncardiac surgery, unrecognized severe obstructive sleep apnea was significantly associated with increased risk of 30-day postoperative cardiovascular complications. Further research would be needed to assess whether interventions can modify this risk.

Choosing anesthesia options for cataract surgery in patients with dementia

Background and Aims

Not all patients with dementia are the same, and Global Deterioration Scale (GDS) helps in staging dementia. Ophthalmologists usually prefer general anesthesia (GA) for cataract surgery in patients with dementia. We evaluated the impact of "Choosing Wisely" initiative on anesthesia options for cataract surgery in patients with dementia undergoing cataract surgery.

Material and Methods

A retrospective review of electronic perioperative database was performed over a 4-year period of patients with a specific diagnosis of dementia undergoing cataract surgery, after the introduction of the "Choosing Wisely" based on preoperative GDS assessment. Preferred method by the listing ophthalmologist, changes in anesthesia modality based on GDS, and the occurrence of intraoperative events were analyzed.

Results

One hundred and thirty-six patients with dementia underwent cataract surgery over a 4-year period. The mean patient age was 78 years, 73.5% female, and 55% ASA physical status III. GA was administered for GDS stage 6-7, and regional anesthesia (RA) for GDS stages 1-5. Surgery was uneventful under RA in 64% of the patients (87 out of 136), and 2% (3 patients) originally deemed suitable for RA were converted to GA.

Conclusions

The authors found a reduced requirement for GA when "Choosing Wisely' initiative was used based on the GDS stage.

Effectiveness of 3-in-1 Continuous Femoral Block of Differing Concentrations Compared to Patient Controlled Intravenous Morphine for Post Total Knee Arthroplasty Analgesia and Knee Rehabilitation

We assessed the effectiveness of the 3-in-l continuous femoral block as a form of postoperative pain relief for unilateral total knee arthroplasty (TKA). Sixty patients undergoing elective unilateral TKA under subarachnoid block were randomized into three groups. Postoperative analgesia was provided with a continuous 3-in-l femoral nerve catheter with 0.15% ropivacaine in group A, a continuous 3-in-l femoral nerve catheter with 0.2% ropivacaine in group B, or patient controlled intravenous morphine in group C (control group). Groups A and B received patient controlled intravenous morphine pumps for rescue analgesia. Patients in each group were followed for 72 hours postoperatively. Five patients were excluded after randomization. In the remaining 55 patients there was no statistical difference in pain score between the groups. Total morphine use was highest in group C (P< 0.05). No appreciable difference could be found with sensorimotor blockade, morphine usage and satisfaction scores when comparing groups A and B. Femoral catheter dislodgement rate was 7.9%. There was no statistical difference between the groups when comparing the day of first ambulation and the time to discharge from the hospital. Satisfaction scores were higher in group A (P = 0.028) and group B (P = 0.002) compared to group C. We conclude that a continuous 3-in-l femoral nerve block with ropivacaine 0.15% or 0.2% for elective unilateral TKA has an opioid-sparing effect.

Prevailing practices in airway management: a prospective single-centre observational study of endotracheal intubation

INTRODUCTION

Airway management during anaesthesia has potential difficulties and risks. We aimed to investigate the utility of routine airway assessment for predicting difficult tracheal intubation, review the prevailing practice of videolaryngoscope use amongst anaesthetists in a teaching hospital and determine the incidence of intraoperative and postoperative airway-related complications.

METHODS

A prospective observational study of 1,654 patients undergoing general anaesthesia with endotracheal intubation over a seven-month period was performed. Data regarding airway and anaesthetic management was collected and analysed.

RESULTS

Videolaryngoscopes were used as the first-choice equipment in 60.5% of the cohort. The incidence of difficult intubation was 2.1%, of which 45.7% of cases were unanticipated. The sensitivity of airway assessment was 54.3%, with a positive predictive value of 8.1%. When difficult intubation was anticipated, more videolaryngoscopes were used as the first equipment of choice compared to the Macintosh laryngoscope (p < 0.001). In the Macintosh group, more patients required a change of airway equipment (p = 0.015), but the number of intubation attempts was similar (p = 0.293). The incidence of intraoperative (p = 0.920) and postoperative complications (p = 0.380) were similar in both groups.

CONCLUSION

Using the current predictors of difficult intubation, half of the difficult airways we encountered were unanticipated. Videolaryngoscopes were preferred when difficulty was anticipated and were also used in routine tracheal intubation.

Laryngeal Mask Airway Protector™ for intubation and extubation in thyroid surgeries: A case report

The laryngeal mask airway (LMA) Protector™ has recently made its way into clinical practice. As little is reported on this novel supraglottic airway device, we describe our experiences through intubation and Bailey manoeuvre using the LMA Protector™, and the assessment of vocal cord mobility using a flexible bronchoscope through it in three patients undergoing hemithyroidectomies.

Laryngeal mask airway protector™: Advanced uses for laparoscopic cholecystectomies

The laryngeal mask airway (LMA) Protector™ is a second-generation perilaryngeal sealer type supraglottic airway device recently introduced into clinical practice. We describe our initial experiences with the use of the LMA Protector™ in three patients undergoing laparoscopic cholecystectomies. In all patients, we found the LMA Protector™ to have acceptable placements on the first attempt, adequate oropharyngeal leak pressures and ventilation adequacy.