Factors associated with the presence of postoperative headache in elective surgery patients: a prospective single center cohort study

Incidence and factors associated with postoperative headache among adult elective surgical patients at the university of gondar comprehensive specialized hospital, northwest Ethiopia, 2022: a prospective follow-up study

BACKGROUND

Postoperative headache is a medical condition that has a strong association with future recurrence and chronic headache, higher morbidity and mortality, extended hospital stays, poor quality of life and high financial burden. Despite, having these consequences, there are limited studies in the study area.

OBJECTIVE

This study aimed to assess the incidence and associated factors of postoperative headache among adult elective surgical patients at the University of Gondar Comprehensive Specialized Hospital Northwest Ethiopia, April 9 to 20 June 2022.

METHODS

An institution -based follow- up study was conducted from April 9 to June 20, 2022, at the University of Gondar Comprehensive Specialized Hospital, after ethical approval and 424 patients were included. Postoperative headache was assessed with patient interview and the response was dichotomized as present or absent. Data was collected through chart review and patient interviews using a questionnaire. Data was entered into Epidata 4.6.0 and statistical analysis was performed using stata version 14.01. Descriptive statistics was conducted to summarize patient information and determine the outcome's incidence. Binary logistic regression was conducted to identify factors associated with postoperative headache. Variables with P-value < 0.05 were considered statistically significant.

RESULTS

The overall incidence of postoperative headache in the first three postoperative days was 54.3% (228) and the response rate was 99%. Previous history of headache (AOR = 4.83, CI = 2.42 9.73), prolonged fasting (AOR = 2.28, CI = 1.44-3.60), general anesthesia (AOR = 1.96, CI = 1.25-3.07), intraoperative hypotension (AOR = 1.74,CI = 1.06-2.88), being female (AOR = 1.62,CI = 1.06-2.54) and caffeine consumption(AOR = 1.60,CI = 1.02-2.52) were significant factors associated with postoperative headache and most of patients 89(21.2%) had moderate headache.

CONCLUSION AND RECOMMENDATIONS

More than half of patients were suffered from postoperative headache. Use of general anesthesia, having prior history of headache, being female, intraoperative hypotension, caffeine consumption and prolonged preoperative fasting were strongly associated with postoperative headache. The problem needs regular assessment and treatment.

Changes in blood catecholamines during induction of general anesthesia in patients with post-induction hypotension undergoing laparoscopic cholecystectomy: A single-center prospective cohort study

BACKGROUND

Post-induction hypotension (PIH) often occurs during general anesthesia induction. This study aimed to investigate blood catecholamine levels during induction of general anesthesia in patients with PIH undergoing laparoscopic cholecystectomy.

METHODS

This prospective study included 557 adult patients who underwent laparoscopic cholecystectomy under general anesthesia. PIH was defined as a greater than 20% decrease in systolic blood pressure from the pre-induction value, a systolic arterial pressure of less than 90 mmHg, or both. Plasma concentrations of epinephrine and norepinephrine during the induction of general anesthesia were determined using enzyme-linked immunosorbent assay. Multivariate logistic regression analysis evaluated the association between the clinical factors and PIH.

RESULTS

Of the 557 patients, 390 had PIH, and the remaining 167 were allocated to the non-PIH group. Changes in blood adrenaline, noradrenaline levels, or both were more pronounced in the PIH than in the non-PIH group (p<0.05). Age, body mass index, a history of hypertension, preoperative systolic blood pressure, and propofol or sufentanil dose were independent predictors of PIH.

CONCLUSION

The changes of blood catecholamines in patients with more stable hemodynamics during the induction of general anesthesia are smaller than that in patients with post-induction hypotension.

TRIAL REGISTRATION

ChiCTR2200055549, 12/01/2022.

Incidence and Associated Factors of Postoperative Undesirable Anesthetic Outcomes Among Surgical Patients at Referral Hospitals in Amhara Region, Ethiopia: A Multi-Center Study

Background

Patients undergoing surgery frequently experience unfavorable anesthetic outcomes. They may have an impact on body systems and result in more serious postoperative morbidities. This study was conducted to determine the incidence of postoperative undesirable anesthetic outcomes among surgical patients at referral hospitals in Amhara region, Ethiopia.

Methods

A total of 412 patients, who underwent surgical procedures between August 1 and October 30 of 2022, were included in this study. The Leiden Perioperative Care Patient Satisfaction Questionnaire's (LPPSq) dimension "discomfort and needs" was used to collect data on the first postoperative day. Data entry and analysis were performed using SPSS version 20. To assess how risk factors affected the outcome variable, logistic regression analysis was utilized. In multivariable logistic regression analysis, a variable with a P-value of less than 0.05 was statistically considered as significant.

Results

The proportion of those who had "at least a little bit" of unfavorable outcomes was calculated to estimate their overall prevalence, and the prevalence of those who had "more than moderate" levels of unfavorable outcomes was determined to appreciate how severe these outcomes were. The percentages of postoperative pain, the most common undesired result, for "at least a little bit" and "more than moderate" were 87.7% and 32.3%, respectively. In this study, postoperative cold was the least prevalent (51.4%) undesirable anesthetic outcome. The remaining undesirable postoperative outcomes were reported less frequently.

Conclusion and Recommendation

Undesirable postoperative anesthetic outcomes were still common. The most frequent unfavorable result was postoperative pain. Adequate postoperative patient follow-up and quality service are paramount.

Nomogram for Postoperative Headache in Adult Patients Undergoing Elective Cardiac Surgery

Background Postoperative headache (POH) is frequent after cardiac surgery; however, few studies on risk factors for POH exist. The aims of the current study were to explore risk factors related to POH after elective cardiac surgery and to establish a predictive system. Methods and Results Adult patients undergoing elective open-heart surgery under cardiopulmonary bypass from 2016 to 2020 in 4 cardiac centers were retrospectively included. Two thirds of the patients were randomly allocated to a training set and one third to a validation set. Predictors for POH were selected by univariate and multivariate analysis. POH developed in 3154 of the 13 440 included patients (23.5%) and the overall mortality rate was 2.3%. Eight independent risk factors for POH after elective cardiac surgery were identified, including female sex, younger age, smoking history, chronic headache history, hypertension, lower left ventricular ejection fraction, longer cardiopulmonary bypass time, and more intraoperative transfusion of red blood cells. A nomogram based on the multivariate model was constructed, with reasonable calibration and discrimination, and was well validated. Decision curve analysis revealed good clinical utility. Finally, 3 risk intervals were divided to better facilitate clinical application. Conclusions A nomogram model for POH after elective cardiac surgery was developed and validated using 8 predictors, which may have potential application value in clinical risk assessment, decision-making, and individualized treatment associated with POH.

Incidence, Risk Factors and Outcomes of Postoperative Headache After Stanford Type a Acute Aortic Dissection Surgery

Background: Postoperative headache (POH) is common in clinical practice, however, no studies about POH after Stanford type A acute aortic dissection surgery (AADS) exist. This study aims to describe the incidence, risk factors and outcomes of POH after AADS, and to construct two prediction models.

Methods: Adults who underwent AADS from 2016 to 2020 in four tertiary hospitals were enrolled. Training and validation sets were randomly assigned according to a 7:3 ratio. Risk factors were identified by univariate and multivariate logistic regression analysis. Nomograms were constructed and validated on the basis of independent predictors.

Results: POH developed in 380 of the 1,476 included patients (25.7%). Poorer outcomes were observed in patients with POH. Eight independent predictors for POH after AADS were identified when both preoperative and intraoperative variables were analyzed, including younger age, female sex, smoking history, chronic headache history, cerebrovascular disease, use of deep hypothermic circulatory arrest, more blood transfusion, and longer cardiopulmonary bypass time. White blood cell and platelet count were also identified as significant predictors when intraoperative variables were excluded from the multivariate analysis. A full nomogram and a preoperative nomogram were constructed based on these independent predictors, both demonstrating good discrimination, calibration, clinical usefulness, and were well validated. Risk stratification was performed and three risk intervals were defined based on the full nomogram and clinical practice.

Conclusions: POH was common after AADS, portending poorer outcomes. Two nomograms predicting POH were developed and validated, which may have clinical utility in risk evaluation, early prevention, and doctor-patient communication.

Predictors and nomogram models for postoperative headache in patients undergoing heart valve surgery

Background

Headache is a frequent complication after cardiac surgery. However, studies on the risk factors of postoperative headache (POH) are rare. The purpose of this study was to identify independent risk factors for POH in patients undergoing heart valve surgery (HVS) and to develop and validate risk prediction models.

Methods

Consecutive patients undergoing open HVS from 2016 to 2019 were enrolled in this study. Patients were randomly assigned to training and validation sets at a 2:1 ratio. Univariate and multivariate analysis were applied to identify independent predictors for POH in the training set. A nomogram predicting POH was developed based on these factors, and was validated in the independent validation set.

Results

POH developed in 1,061 of the 3,853 patients (27.5%). The overall mortality was 2.9%, and it was significantly higher in patients with POH (4.3% versus 2.4%, P<0.001). In the training set, six independent predictors were identified by multivariate analysis, including female, smoking history, hypertension, headache history, left ventricular ejection fraction, and cardiopulmonary bypass time. The model demonstrated good discrimination in both the training (c-index: 0.811) and validation sets (c-index: 0.814), and calibration was assessed by visual inspection. A second nomogram was also constructed including only preoperative predictors, with good discrimination (c-index: 0.792) and calibration. The decision and clinical impact curves of the models showed good clinical utility.

Conclusions

We developed and validated two risk prediction models for POH in patients undergoing HVS. The models may have clinical utility in individualized risk assessment and preventive interventions.

Robot-assisted Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Management of Endometriosis: A Pilot Study of 33 Cases

STUDY OBJECTIVE

To describe the surgical techniques and short-term outcomes for 33 cases of robot-assisted transvaginal natural orifice transluminal endoscopic surgery (RvNOTES) to treat endometriosis.

DESIGN

Retrospective case series study.

SETTING

Academic tertiary care university hospital in Houston, TX.

PATIENTS

Patients who underwent RvNOTES resection of endometriosis between March 2020 and March 2021.

INTERVENTIONS

RvNOTES.

MEASUREMENTS AND MAIN RESULTS

A total of 33 cases of patients, with pathology-confirmed endometriosis, who underwent RvNOTES total hysterectomy with resection of endometriosis were included in the study. Thirty-two cases were completed successfully by RvNOTES, and 1 case was converted to robotic transumbilical single-incision laparoscopic surgery plus 1 additional port owing to an obliterated posterior cul-de-sac and upper abdominal wall endometriosis. The average operative time was 141.93 ± 40.22 (85-264) minutes, and the mean estimated blood loss was 52.25 ± 33.82 (25-150) mL. The mean preoperative pain score using the visual analog scale (VAS) score was 8.08 ± 2.39 (2-10). The mean VAS pain score 1 week after surgery was 6.73 ± 2.62 (0-10), which was significantly lower than the preoperative scores (p = .059). The mean VAS pain score in the second and third week after surgery was 4.81 ± 2.42 (0-9) and 2.63 ± 2.36 (0-7) respectively, which were both significantly lower than those before surgery (p = .001). There were 4 postoperative complications: urinary tract infection, pneumonia, headache requiring admission, and conversion disorder.

CONCLUSION

RvNOTES is a safe and feasible approach for the treatment of endometriosis, with promising short-term improvements in pain.

Caffeine supplementation as part of enhanced recovery after surgery pathways: a narrative review of the evidence and knowledge gaps

Caffeine is used daily by 85% of United States adults and caffeine withdrawal is a major cause of perioperative headache. Studies have shown that caffeine supplementation in chronic caffeinators reduces the incidence of perioperative headache. This narrative review discusses the perioperative implications of caffeine withdrawal and outlines the benefits of and strategies of caffeine supplementation in the perioperative period. It is time to "wake up and smell the coffee" on integration of caffeine into established enhanced recovery after surgery protocols as a mechanism to consistently provide perioperative caffeine replacement.

Use of therapeutic caffeine in acute care postoperative and critical care settings: a scoping review

BACKGROUND

Caffeine is the most utilised psychoactive drug worldwide. However, caffeine withdrawal and the therapeutic use of caffeine in intensive care and in the perioperative period have not been well summarised. Our objective was to conduct a scoping review of caffeine withdrawal and use in the intensive care unit (ICU) and postoperative patients.

METHODS

PubMed, Embase, CINAHL Complete, Scopus and Web of Science were systematically searched for studies investigating the effects of caffeine withdrawal or administration in ICU patients and in the perioperative period. Areas of recent systematic review such as pain or post-dural puncture headache were not included in this review. Studies were limited to adults.

RESULTS

Of 2268 articles screened, 26 were included and grouped into two themes of caffeine use in in the perioperative period and in the ICU. Caffeine withdrawal in the postoperative period increases the incidence of headache, which can be effectively treated prophylactically with perioperative caffeine. There were no studies investigating caffeine withdrawal or effect on sleep wake cycles, daytime somnolence, or delirium in the intensive care setting. Administration of caffeine results in faster emergence from sedation and anaesthesia, particularly in individuals who are at high risk of post-extubation complications. There has only been one study investigating caffeine administration to facilitate post-anaesthetic emergence in ICU. Caffeine administration appears to be safe in moderate doses in the perioperative period and in the intensive care setting.

CONCLUSIONS

Although caffeine is widely used, there is a paucity of studies investigating withdrawal or therapeutic effects in patients admitted to ICU and further novel studies are a priority.

Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis

Background

Intraoperative hypotension, with varying definitions in literature, may be associated with postoperative complications. The aim of this meta-analysis was to assess the association of intraoperative hypotension with postoperative morbidity and mortality.

Methods

MEDLINE, Embase and Cochrane databases were searched for studies published between January 1990 and August 2018. The primary endpoints were postoperative overall morbidity and mortality. Secondary endpoints were postoperative cardiac outcomes, acute kidney injury, stroke, delirium, surgical outcomes and combined outcomes. Subgroup analyses, sensitivity analyses and a meta-regression were performed to test the robustness of the results and to explore heterogeneity.

Results

The search identified 2931 studies, of which 29 were included in the meta-analysis, consisting of 130 862 patients. Intraoperative hypotension was associated with an increased risk of morbidity (odds ratio (OR) 2.08, 95 per cent confidence interval 1.56 to 2.77) and mortality (OR 1.94, 1.32 to 2.84). In the secondary analyses, intraoperative hypotension was associated with cardiac complications (OR 2.44, 1.52 to 3.93) and acute kidney injury (OR 2.69, 1.31 to 5.55). Overall heterogeneity was high, with an I² value of 88 per cent. When hypotension severity, outcome severity and study population variables were added to the meta-regression, heterogeneity was reduced to 50 per cent.

Conclusion

Intraoperative hypotension during non-cardiac surgery is associated with postoperative cardiac and renal morbidity, and mortality. A universally accepted standard definition of hypotension would facilitate further research into this topic.

Recent Preoperative Concussion and Postoperative Complications: A Retrospective Matched-cohort Study

BACKGROUND

Physiological alterations during the perianesthetic period may contribute to secondary neurocognitive injury after a concussion.

METHODS

Patients exposed to concussion and who received an anesthetic within 90 days were matched to unexposed patients without concussion. Intraoperative and postoperative events were compared. Subgroup analyses assessed relationships among patients with a concussion in the prior 30, 31 to 60, and 61 to 90 days and their respective unexposed matches. To facilitate identification of potential targets for further investigation, statistical comparisons are reported before, as well as after, correction for multiple comparisons.

RESULTS

Sixty concussion patients were matched to 176 unexposed patients. Before correction, 28.3% postconcussion versus 14.8% unexposed patients reported postanesthesia care unit pain score≥7 (P=0.02); 16.7% concussion versus 6.5% unexposed patients reported headache within 90 days of anesthesia (P=0.02) and 23.5% of patients who received surgery and anesthesia within 30 days of concussion experienced headache within 90 days of anesthesia compared with 7.1% in the unexposed group (P=0.01). Patients who experienced concussion and had anesthesia between 31 and 60 days after injury had a postanesthesia care unit Richmond Agitation and Sedation Scale score of -1.61±1.29 versus a score of -0.2±0.45 in unexposed patients (P=0.002). After adjusting the P-value threshold for multiple comparisons, the P-value for significance was instead 0.0016 for the overall cohort. Our study revealed no significant associations with application of adjusted significance thresholds.

CONCLUSIONS

There were no differences in intraoperative and postoperative outcomes in patients with recent concussion compared with unexposed patients. Before correction for multiple comparisons, several potential targets for further investigation are identified. Well-powered studies are warranted.

The association between migraine and hospital readmission due to pain after surgery: A hospital registry study

BACKGROUND

Migraine has been identified as a risk factor of 30-day hospital readmission after surgery. We aimed to further characterize this association examining pain as a potentially migraine-associated, preventable reason for readmission.

HYPOTHESIS

Compared to patients with no migraine, surgical patients with migraine are at increased risk of 30-day hospital readmission with an admitting diagnosis specifying pain.

METHODS

This hospital registry study examined 150,710 patients aged 18 years and above, who underwent surgery with general anesthesia and mechanical ventilation between 2007 and 2015 at a tertiary care center and two affiliated community hospitals in Massachusetts, USA.

RESULTS

Migraine was associated with an increased risk of 30-day pain-related readmission after surgery (adjusted odds ratio 1.42 [95% confidence interval 1.15-1.75]). The association was stronger for migraine with aura (compared to migraine without aura: Adjusted odds ratio 1.69 [95% confidence interval 1.06-2.70]; compared to no migraine: Adjusted odds ratio 2.20 [95% confidence interval 1.44-3.37]). The predicted adjusted risk of pain-related 30-day readmissions was 9.1 [95% confidence interval 5.3-13.0] in 1000 surgical patients with migraine with aura and 5.4 [95% confidence interval 4.2-6.6] in 1000 patients with migraine without aura, compared to 4.2 [95% confidence interval 3.8-4.5] in 1000 patients with no migraine. Furthermore, migraine was associated with an increased risk of postsurgical 30-day readmission due to a priori defined migraine-related pain (headache or abdominal pain) (adjusted odds ratio 1.55 [95% confidence interval 1.20-2.00]).

CONCLUSION

Patients with migraine undergoing surgery are at increased risk of 30-day hospital readmission due to pain.