Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology

Prohibiting Babel-A call for professional remote interpreting services in pre-operation anaesthesia information

INTRODUCTION

Language barriers within clinical settings pose a threat to patient safety. As a potential impediment to understanding, they hinder the process of obtaining informed consent and uptake of critical medical information. This study investigates the impact of the current use of interpreters, with a particular focus on of engaging laypersons as interpreters, rather than professional interpreters potentially affecting patient safety. A further objective is to explore the reliability of phone-based telemedicine in terms of the retention of important medical facts.

METHODS

In three groups (N per group = 30), we compared how using lay or professional interpreters affected non-German speaking patients' subjectively perceived understanding (understood vs. not understood) and recollection (recollected vs. not recollected) of information about general anaesthesia. Proficient German speaking patients served as the control group. Statistical analyses (χ2 tests and binomial) were calculated to show differences between and within the groups.

RESULTS

All three groups indicated similar, high self-reported levels of having understood the medical information provided. This was in stark contrast to the assessed objective recollection data. In the lay interpreter group, recollection of anaesthesia facts was low; only around half of participants recalled specific facts. For patients supported by professional interpreters, their recollection of facts about anaesthesia was significantly enhanced and elevated to the same level of the control group (fluent in German). Moreover, for these patients, providing information by means of phone-based telemedicine before anaesthesia yielded high levels of understanding and recollection of anaesthesia facts.

CONCLUSION

Phone-based telemedicine is a safe and reliable method of communication in the professional interpreter group and German speaking control group, but not in the lay interpreter group. Compared to lay interpreters, professional interpreters significantly improve patients' uptake of critical information about general anaesthesia, thus highlighting the importance of professional interpreters for patient safety and informed consent.

Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care

BACKGROUND

When considering whether a patient is fit for surgery, a comprehensive patient assessment represents the first step for an anaesthetist to evaluate the risks associated with the procedure and the patient's underlying diseases, and to optimise (whenever possible) the perioperative surgical journey. These guidelines from the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) update previous guidelines to provide new evidence on existing and emerging topics that consider the different aspects of the patient's surgical path.

DESIGN

A comprehensive literature review focused on organisation, clinical facets, optimisation and planning. The methodological quality of the studies included was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. A Delphi process agreed on the wording of recommendations, and clinical practice statements (CPS) supported by minimal evidence. A draft version of the guidelines was published on the ESAIC website for 4 weeks, and the link was distributed to all ESAIC members, both individual and national, encompassing most European national anaesthesia societies. Feedback was gathered and incorporated into the guidelines accordingly. Following the finalisation of the draft, the Guidelines Committee and ESAIC Board officially approved the guidelines.

RESULTS

In the first phase of the guidelines update, 17 668 titles were initially identified. After removing duplicates and restricting the search period from 1 January 2018 to 3 May 2023, the number of titles was reduced to 16 774, which were then screened, yielding 414 abstracts. Among these, 267 relevant abstracts were identified from which 204 appropriate titles were selected for a comprehensive GRADE analysis. Additionally, the study considered 4 reviews, 16 meta-analyses, 9 previously published guidelines, 58 prospective cohort studies and 83 retrospective studies. The guideline provides 55 evidence-based recommendations that were voted on by a Delphi process, reaching a solid consensus (>90% agreement).

DISCUSSION

This update of the previous guidelines has covered new organisational and clinical aspects of the preoperative anaesthesia assessment to provide a more objective evaluation of patients with a high risk of postoperative complications requiring intensive care. Telemedicine and more predictive preoperative scores and biomarkers should guide the anaesthetist in selecting the appropriate preoperative blood tests, x-rays, and so forth for each patient, allowing the anaesthetist to assess the risks and suggest the most appropriate anaesthetic plan.

CONCLUSION

Each patient should have a tailored assessment of their fitness to undergo procedures requiring the involvement of an anaesthetist. The anaesthetist's role is essential in this phase to obtain a broad vision of the patient's clinical conditions, to coordinate care and to help the patient reach an informed decision.

Preoperative coagulation tests: A narrative review of current guidelines

INTRODUCTION

Hemostasis tests are traditionally requested for all patients requiring any surgical act or invasive diagnostic-therapeutic procedure to prevent hemorrhagic complications. The aim of this study is to assess the necessity of requesting standard pre-procedure hemostasis tests.

METHODOLOGY

A narrative literature review was conducted using the PubMed data-base. Search terms included «Hemostasis» or «Blood coagulation» in combination with «Preoperative care», «Preoperative period», or «Preoperative procedure». Additionally, a targeted search was performed to find recommendations from international societies related to the topic.

RESULTS

A total of 233 articles were found, 17 were pre-selected, and after full-text evaluation, 14 relevant articles were identified. The targeted search yielded an additional 12 articles. The request for tests should be individualized according to the clinical history. Standardized screening questionnaires for hemostasis disorders are useful and complement the aforementioned approach. Factors such as age, ASA classification, bleeding potential-complexity of the procedure, and anesthetic technique may influence their request.

DISCUSSION

The incidence of hemostasis disorders in the general population is very low, and these can mostly be detected through clinical history. Thus, it is the clinical history that should guide the need for laboratory test requests.

CONCLUSIONS

Preoperative hemostasis tests should not be indiscriminately requested for all patients needing an intervention or invasive diagnostic-therapeutic procedure, but rather when there are doubts about their hemostatic competence or as advised by the nature of the procedure they are undergoing.

Economic Indicators, Quantity and Quality of Health Care Resources Affecting Post-surgical Mortality

OBJECTIVE

to identify correlations between quality and quantity of health care resources, national economic indicators, and postoperative in-hospital mortality as reported in the EUSOS study.

METHODS

Different variables were identified from a series of publicly available database. Postoperative in-hospital mortality was identified as reported by EUSOS study. Spearman non-parametric and Coefficients of non-linear regression were calculated.

RESULTS

Quality of health care resources was strongly and negatively correlated to postoperative in-hospital mortality. Quantity of health care resources were negatively and moderately correlated to postoperative in-hospital mortality. National economic indicators were moderately and negatively correlated to postoperative in-hospital mortality. General mortality, as reported by WHO, was positively but very moderately correlated with postoperative in-hospital mortality.

CONCLUSIONS

Postoperative in-hospital mortality is strongly determined by quality of health care instead of quantity of health resources and health expenditures. We suggest that improving the quality of health care system might reduce postoperative in-hospital mortality.

Anaesthesiologists' guideline adherence in pre-operative evaluation: a retrospective observational study

BACKGROUND

Surveys suggest a low level of implementation of clinical guidelines, although they are intended to improve the quality of treatment and patient safety. Which guideline recommendations are not followed and why has yet to be analysed. In this study, we investigate the proportion of European and national guidelines followed in the area of pre-operative anaesthetic evaluation prior to non-cardiac surgery.

METHODS

We conducted this monocentric retrospective observational study at a German university hospital with the help of software that logically links guidelines in such a way that individualised recommendations can be derived from a patient's data. We included routine logs of 2003 patients who visited our pre-anaesthesia outpatient clinic between June 2018 and June 2020 and compared the actual conducted pre-operative examinations with the recommendations issued by the software. We descriptively analysed the data for examinations not performed that would have been recommended by the guidelines and examinations that were performed even though they were not covered by a guideline recommendation. The guidelines examined in this study are the 2018 ESAIC guidelines for pre-operative evaluation of adults undergoing elective non-cardiac surgery, the 2014 ESC/ESA guidelines on non-cardiac surgery and the German recommendations on pre-operative evaluation on non-cardiothoracic surgery from the year 2017.

RESULTS

Performed ECG (78.1%) and cardiac stress imaging tests (86.1%) indicated the highest guideline adherence. Greater adherence rates were associated with a higher ASA score (ASA I: 23.7%, ASA II: 41.1%, ASA III: 51.8%, ASA IV: 65.8%, P < 0.001), lower BMI and age > 65 years. Adherence rates in high-risk surgery (60.5%) were greater than in intermediate (46.5%) or low-risk (44.6%) surgery (P < 0.001). 67.2% of technical and laboratory tests performed preoperatively were not covered by a guideline recommendation.

CONCLUSIONS

Guideline adherence in pre-operative evaluation leaves room for improvement. Many performed pre-operative examinations, especially laboratory tests, are not recommended by the guidelines and may cause unnecessary costs. The reasons for guidelines not being followed may be the complexity of guidelines and organisational issues. A software-based decision support tool may be helpful.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT04843202.

The value of preoperative diagnostic testing and geriatric assessment in frail institutionalized elderly with a hip fracture; a secondary analysis of the FRAIL-HIP study

PURPOSE

The aim of this study was to provide a comprehensive overview of (preoperative and geriatric) diagnostic testing, abnormal diagnostic tests and their subsequent interventions, and clinical relevance in frail older adults with a hip fracture.

METHODS

Data on clinical consultations, radiological, laboratory, and microbiological diagnostics were extracted from the medical files of all patients included in the FRAIL-HIP study (inclusion criteria: hip fracture, > 70 years, living in a nursing home with malnourishment/cachexia and/or impaired mobility and/or severe co-morbidity). Data were evaluated until hospital discharge in nonoperatively treated patients and until surgery in operatively treated patients.

RESULTS

A total of 172 patients (88 nonoperative and 84 operative) were included, of whom 156 (91%) underwent laboratory diagnostics, 126 (73%) chest X-rays, and 23 (13%) CT-scans. In 153/156 (98%) patients at least one abnormal result was found in laboratory diagnostics. In 82/153 (50%) patients this did not result in any additional diagnostics or (pharmacological) intervention. Abnormal test results were mentioned as one of the deciding arguments for operative delay (> 24 h) for 10/84 (12%) patients and as a factor in the decision between nonoperative and operative treatment in 7/172 (4%) patients.

CONCLUSION

A large number and variety of diagnostics were performed in this patient population. Abnormal test results in laboratory diagnostics were found for almost all patients and, in majority, appear to have no direct clinical consequences. To prevent unnecessary diagnostics, prospective research is required to evaluate the clinical consequences and added value of the separate elements of preoperative diagnostic testing and geriatric assessment in frail hip fracture patients.

Intraoperative monitoring of the central and peripheral nervous systems: a narrative review

The central and peripheral nervous systems are the primary target organs during anaesthesia. At the time of the inception of the British Journal of Anaesthesia, monitoring of the central nervous system comprised clinical observation, which provided only limited information. During the 100 yr since then, and particularly in the past few decades, significant progress has been made, providing anaesthetists with tools to obtain real-time assessments of cerebral neurophysiology during surgical procedures. In this narrative review article, we discuss the rationale and uses of electroencephalography, evoked potentials, near-infrared spectroscopy, and transcranial Doppler ultrasonography for intraoperative monitoring of the central and peripheral nervous systems.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Anaesthetic management of people with multiple sclerosis

There is a lack of published guidelines on the management of patients with multiple sclerosis (MS) undergoing procedures that require anaesthesia and respective advice is largely based on retrospective studies or case reports. The aim of this paper is to provide recommendations for anaesthetists and neurologists for the management of patients with MS requiring anaesthesia. This review covers issues related to the anaesthetic management of patients with MS, with a focus on preoperative assessment, choice of anaesthetic techniques and agents, side-effects of drugs used during anaesthesia and their potential impact on the disease evolution, drug interactions that may occur, and the need to use monitoring devices. A systematic PubMed research was performed to retrieve relevant articles.

Venous thromboembolism and major adverse cardiovascular events in patients with hip fractures suffering from SARS-CoV-2 infection: a systematic review

INTRODUCTION

Hip fractures represent 1 of the most common injuries in older adults. They are associated with increased perioperative morbidity and mortality. Additionally, current research suggests that SARS-COV-2 infection may worsen the prognosis of the hip fracture patients who undergo hip fixation. The aims of the present study were: (1) to determine the rate of specific adverse events including VTE (venous thromboembolism) and major adverse cardiovascular events (MACEs) in patients with hip fracture and concomitant SARS-CoV-2 infection undergoing surgery; and (2) to examine if the aforementioned population is at increased risk for VTE and MACEs, when compared to SARS-CoV-2 free patients with hip fracture.

METHODS

PubMed, EMBASE, Cochrane, Web of Science, Google scholar and medRxiv were searched from March 2020 to January 2021 for English language studies with patients suffering from hip fractures and SARS-COV-2 -CoV-2. 2 researchers were involved in the data extraction and the quality assessment of the studies respectively.

RESULTS

The literature search yielded a total of 1256 articles of which 14 were included in the systematic review and 7 in the meta-analysis respectively. The estimated pooled rate for VTE and MACE were 4.3% and 6.3% respectively. Patients with hip fracture and concomitant SARS-CoV-2 infection who undergo surgery are at increased risk for VTE, when compared to SARS-CoV-2 free patients (odds ratio 2.8 [95% CI, 1.1-7.1]). These patients are also at increased risk for MACE postoperatively as indicated by the odds ratio 2.4 (95% CI, 1.0-5.8). The quality of the studies was moderate.

CONCLUSIONS

Although there is a lack of high-quality data it seems that patients with hip fractures and concomitant SARS-CoV-2 infection are facing a 2.8 and 2.4 times increased risk for VTE and MACE.

Perioperative Arrhythmias

BACKGROUND

Perioperative arrhythmias are common depending on the type of the operation and can increase morbidity and mortality.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, as well as the relevant European guidelines.

RESULTS

Arrhythmias are seen in more than 90% of cardiac operations; they are usually transient and often asymptomatic. The risk factors for arrhythmia include ion channel diseases, old age, structural heart disease, cardiac surgery, noncardiac surgery with major fluid shifts, and pulmonary resection. The full spectrum of supraventricular and ventricular arrhythmias can arise perioperatively. Correct ECG interpretation, consideration of the arrhythmia in the overall clinical context, and an understanding of its causes, pathophysiology, and options for effective treatment are critically important. According to a meta-analysis, betablockers lower the risk of perioperative atrial fibrillation (OR = 0.56; 95% confidence interval: [0.35; 0.91]). If anticoagulant treatment is not interrupted for surgery, there is less bleeding with direct oral anticoagulants than with vitamin K antagonists (relative risk: 0.62 [0.47; 0.82]). Moreover, clinical follow-up is important, especially for patients with new-onset atrial fibrillation or heart failure.

CONCLUSION

The identification of high-risk patients and the provision of individualized perioperative monitoring are essential aspects of patient safety. Outpatient cardiological follow-up can improve outcomes.

Obesity Is Associated With Increased Risk for Adverse Postoperative Outcomes After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

INTRODUCTION

Conflicting reports exist about the effect obesity has on adverse postoperative surgical outcomes after distal pancreatectomy (DP). The aim of this study is to explore the role of obesity in terms of morbidity and pancreas-specific complications following DP for pancreatic ductal adenocarcinoma (PDAC).

METHODS

All patients who underwent DP at a single institution over 10 y were analyzed (2009-2020). Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). Independent predictors of adverse postoperative outcomes were calculated using multivariate logistic regression models. Overall survival was assessed using Kaplan-Meier survival analysis.

RESULTS

Of the 178 patients included, 58 (32.5%) were obese. Clinically relevant postoperative pancreatic fistula (CR-POPF) formation rate was significantly higher in the obese group (20.6% versus 7.5%, P value = 0.011). We did not identify any significant difference between obese and nonobese patients in median overall survival (30.2 mon versus 28.9 mon, P value = 0.811). On multivariate binary logistic regression analysis, BMI ≥ 30 was an independent predictor of morbidity (any complication) and CR-POPF formation after DP for PDAC.

CONCLUSIONS

Obesity is associated with a significantly increased risk for CR-POPF in patients undergoing DP for PDAC. Obesity should be considered as a variable in fistula risk calculators for DP.

Methodological transparency of preoperative clinical practice guidelines for elective surgery. Systematic review

BACKGROUND

Clinical practice guidelines (CPG) are statements that provide recommendations regarding the approach to different diseases and aim to increase quality while decreasing the risk of complications in health care. Numerous guidelines in the field of perioperative care have been published in the previous decade but their methodological quality and transparency are relatively unknown.

OBJECTIVE

To critically evaluate the transparency and methodological quality of published CPG in the preoperative assessment and management of adult patients undergoing elective surgery.

DESIGN

Systematic review and methodological appraisal study.

DATA SOURCES

We searched for eligible CPG published in English or Spanish between January 1, 2010, and June 30, 2022, in Pubmed MEDLINE, TRIP Database, Embase, the Cochrane Library, as well as in representatives' medical societies of Anaesthesiology and developers of CPG.

ELIGIBILITY CRITERIA

CPG dedicated on preoperative fasting, cardiac assessment for non-cardiac surgery, and the use of routine preoperative tests were included. Methodological quality and transparency of CPG were assessed by 3 evaluators using the 6 domains of the AGREE-II tool.

RESULTS

We included 20 CPG of which 14 were classified as recommended guidelines. The domain of "applicability" scored the lowest (44%), while the domains "scope and objective" and "editorial interdependence" received the highest median scores of 93% and 97% respectively. The remaining domains received scores ranging from 44% to 84%. The top mean scored CPG in preoperative fasting was ASA 2017 (93%); among cardiac evaluation, CPG for non-cardiac surgery were CCS 2017 (91%), ESC-ESA 2014 (90%), and AHA-ACC 2014 (89%); in preoperative testing ICSI 2020 (97%).

CONCLUSIONS

In the last ten years, most published CPG in the preoperative assessment or management of adult patients undergoing elective surgery focused on preoperative fasting, cardiac assessment for non-cardiac surgery, and use of routine preoperative tests, present moderate to high methodological quality and can be recommended for their use or adaptation. Applicability and stakeholder involvement domains must be improved in the development of future guidelines.

A comparison of face-to-face, brochure- and video-assisted anesthesia interviews: a qualitative randomized survey study

BACKGROUND

Previous studies showed mixed results for patient satisfaction by supplementing the pre-anesthetic assessment with written or audio-visual materials. We hypothesize that an audio-visual aid or a brochure in addition to face-to-face interview, leads to improved patient satisfaction and shortens the pre-anesthetic assessment duration.

METHODS

We randomly assigned 1051 patients scheduled for pre-anesthetic assessment to three different groups: face-to-face pre-anesthetic interview alone (Group 1), videos before the interview (Group 2), and brochure before the interview (Group 3). All patients were asked to complete a post-interview questionnaire assessing patient satisfaction, knowledge gain, prior experience with anesthesia, and quality of supplementary media.

RESULTS

The use of additional materials immediately before the pre-anesthetic interview did increase the overall patient satisfaction (F(2, 1003) = 3.10, p <0 .05, ƞ² = 0.006) but not the interview satisfaction (F(2, 1011) = 0.756, p >0 .05) nor information gain (procedure explanations F(2, 987) = 0.400, p > 0.05) or quality of answered questions (F(2, 1029) = 0.769, p > 0.05). A statistically significant effect on interview satisfaction (F(13,996) = 5.15, p < 0.01., ƞ² = 0.063), overall satisfaction (F(13,988) = 4.25, p < 0.01., ƞ² = 0.053) and given explanations (F(13, 972) = 3.132, p < 0.001, ƞ² = 0.04) was associated with the explanation of different anesthetic techniques by the provider. No differences of response quality between the anesthesiologists was found (F(13, 1014) = 1.494, p > 0.05).

CONCLUSIONS

Additional information imparted in the form of an educational brochure or videos immediately before the pre-anesthetic assessment and interview does not lead to higher patient satisfaction.

Digital Online Anaesthesia Patient Informed Consent before Elective Diagnostic Procedures or Surgery: Recent Practice in Children—An Exploratory ESAIC Survey (2021)

Background: One undisputed benefit of digital support is the possibility of contact reduction, which has become particularly important in the context of the COVID-19 pandemic. However, to the best of our knowledge, there is currently no study assessing the Europe-wide use of digital online pre-operative patient information or evaluation in the health sector. The aim of this study was to give an overview of the current status in Europe. Methods: A web-based questionnaire covering the informed consent process was sent to members of the European Society of Anaesthesia and Intensive Care Medicine (ESAIC) in 47 European countries (42,433 recipients/930 responses). Six questions related specifically to the practice in paediatrics. Results: A total of 70.2% of the respondents indicated that it was not possible to obtain informed consent via the Internet in a routine setting, and 67.3% expressed that they did not know whether it is in line with the legal regulations. In paediatric anaesthesia, the informed consent of only one parent was reported to be sufficient by 77.6% of the respondents for simple interventions and by 63.8% for complex interventions. Just over 50% of the respondents judged that proof of identity of the parents was necessary, but only 29.9% stated that they ask for it in clinical routine. In the current situation, 77.9% would favour informed consent in person, whereas 60.2% could imagine using online or telephone interviews as an alternative to a face-to-face meeting if regulations were changed. Only 18.7% participants reported a change in the regulations due to the current pandemic situation. Conclusion: Whether informed consent is obtained either online or on the telephone in the paediatric population varies widely across Europe and is not currently implemented as standard practice. For high-risk patients, such as the specific cohort of children with congenital heart defects, wider use of telemedicine might provide a benefit in the future in terms of reduced contact and reduced exposure to health risks through additional hospital stays.

Teleconsultation for preoperative evaluation during the coronavirus disease 2019 pandemic: A technical and medical feasibility study

BACKGROUND

During the surge in coronavirus disease 2019 (COVID-19) infections in early 2020, many medical organisations began developing strategies for implementing teleconsultation to maintain medical services during lockdown and to limit physical contact. Therefore, we developed a teleconsultation preoperative evaluation platform to replace on-site preoperative meetings.

OBJECTIVE

This study assessed the feasibility of a teleconsultation for preoperative evaluation and procedure-associated adverse events.

DESIGN

Implementation study.

SETTING

A tertiary care university hospital in Germany from April 2020 to October 2020.

PATIENTS

One hundred and eleven patients scheduled for elective surgery.

INTERVENTION

Patients were assigned to receive teleconsultation for preoperative evaluation and to complete a subsequent survey.

MAIN OUTCOME MEASURES

Primary endpoints were medical and technical feasibility, user satisfaction and time savings.

RESULTS

For 100 out of 111 patients, telepreoperative consultations allowed for adequate perioperative risk assessment, patient education and also for effective collection of legal signatures. For six patients (5.4%), consultations could not be started because of technical issues, whereas for five patients (4.8%), clearance for surgery could not be granted because of medical reasons. A clear majority of anaesthetists (93.7%) rated the telepreoperative evaluations as equivalent to on-site meetings. The majority of the patients considered teleconsultation for preoperative evaluation as convenient as an on-site meeting (98.2%) and would choose a teleconsultation again (97.9%). Median travel time saved by patients was 60 min (Q1 40, Q3 80). We registered one adverse event: we detected atrial fibrillation in one patient only immediately prior to surgery.

CONCLUSION

Telepreoperative evaluations are medically and technically feasible, yielding high satisfaction rates on both sides. However, regarding patient safety, not every patient is equally well suited. Overall, implementation of teleconsultation for preoperative evaluation into clinical routine could help maintain medical care during the COVID-19 pandemic.

TRIAL REGISTRATION

NCT04518514, ClinicalTrials.gov.

Surgical Trainee Supervision During Non-Trauma Emergency Laparotomy in Rwanda and South Africa

OBJECTIVE

The primary objective was to describe the level of surgical trainee autonomy during non-trauma emergency laparotomy (NTEL) operations in Rwanda and South Africa. The secondary objective was to identify potential associations between trainee autonomy, and patient mortality and reoperation.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective, observational study of NTEL operations at 3 teaching hospitals in South Africa and Rwanda over a 1-year period from September 1, 2017 to August 31, 2018. The study included 543 NTEL operations performed by the acute care and general surgery services on adults over the age of 18 years.

RESULTS

Surgical trainees led 3-quarters of NTEL operations and, of these, 72% were performed autonomously in Rwanda and South Africa. Notably, trainee autonomy was not significantly associated with reoperation or mortality.

CONCLUSIONS

Trainees were able to gain autonomous surgical experience without impacting mortality or reoperation outcomes, while still providing surgical support in a high-demand setting.

Exploration of a quality improvement process to standardised preoperative tests for a surgical procedure to reduce waste

BACKGROUND

Preoperative tests are done to determine a patient's fitness for anaesthesia and surgery.

LOCAL PROBLEM

Although routine tests before surgery in the absence of specific clinical indications are not recommended, we observed high volumes of routine preoperative tests were performed in our institution. We describe a process to implement a standardised preoperative investigational approach to reduce unnecessary testing before surgeries.

METHODS

A series of six Plan-Do-Study-Act (PDSA) cycles was conducted for root cause analysis and process mapping, development of standardised tool (GRID), collection of baseline data, education and feedback, pilot testing and implementation and uptake of GRID.Root cause analysis revealed a lack of awareness of guidelines and a lack of a standardised tool to guide preoperative testing. We undertook a pilot quality improvement project to reduce unnecessary testing before knee and hip arthroplasty by developing and implementing a standardised tool (GRID) and engaging all stakeholders.

INTERVENTIONS

A clinical development team (CDT) was formed, including all the stakeholders. Our CDT focused on a continuous rapid cycle improvement strategy.

RESULTS

After implementation of the tool in a subgroup of patients undergoing elective hip or knee arthroplasty, unnecessary coagulation tests (activated partial thromboplastin time and the international normalised ratio), electrolyte/renal panel tests and electrocardiograms were reduced by 81% (91%-17%), 81% (41%-7%) and 68% (35%-11%), respectively. No surgery was delayed or cancelled due to tests not performed before surgery.

CONCLUSIONS

A standardised preoperative investigational approach based on patients' medical conditions rather than routine testing can reduce unnecessary tests before surgery. Further, implementing guidelines is more complex than developing guidelines. Hence, continuous PDSA cycles are essential to evaluate the processes in a quality improvement project. It can take time to build teams and have shared goals; however, once this is achieved, the success of a quality improvement project is certain.

The inductor role of cardiac consultation in the pre-anesthetic evaluation of asymptomatic patients submitted to non-cardiac minor and intermediate-risk surgery: a cross-sectional study

INTRODUCTION

Asymptomatic patients with moderate functional capacity do not require Coronary Artery Disease (CAD) workup in the preoperative period of non-cardiac surgeries, especially when scheduled for minor and intermediate-risk surgeries. The workup is inappropriate because it promotes over diagnosing and pointless treatments. Moreover, those patients usually undergo cardiology assessment, in addition to pre-anesthetic evaluation.

OBJECTIVE

Investigate the role of cardiology consultation as mediator in inappropriate assessment of CAD for preoperative of non-cardiac surgeries.

METHOD

Retrospective study performed in a private anesthesia service using medical charts of asymptomatic patients with a history of controlled systemic disease and moderate functional capacity, submitted to pre-anesthetic consultation for minor and intermediate risk surgeries. Cardiology consultations were identified by the presence of a consultation report by a cardiologist. CAD workup was defined as undergoing cardiac stress tests.

RESULTS

We included 390 medical charts of patients with mean age of 48.6 ± 15.4 years, 67% women and 69% intermediate risk surgeries. CAD workup was infrequent and performed in 3.9% of patients. Besides, pre-anesthetic evaluation, 93 (24%) patients had a cardiology consultation. Among those patients, 15.1% were submitted to CAD workup, compared to 0.34% of patients without cardiology assessment (p < 0.001; RR = 4.4; 95% CI: 3.5-5.6).

CONCLUSIONS

Inappropriate testing for CAD investigation is infrequent for asymptomatic individuals submitted to minor and intermediate risk surgeries. However, cardiology consultation increases substantially the likelihood of a patient undergoing CAD workup, suggesting that, unlike the anesthesiologist, the cardiologist is a major mediator of this kind of management.

[Noninvasive evaluation of airways prior to sedation or anesthesia : An update within the framework of the revision of the German S1 guidelines on airway management 2015 of the German Society for Anesthesiology and Intensive Care Medicine]

As a single and reliable parameter for prediction of the difficult airway is missing, the specialist societies for anesthesiology recommend the use of scores that combine the individual parameters. Contemporary scores include head-neck mobility, mouth opening and anatomical distances. Their training and correct performance are essential. For a broad acceptance the performance has to be easy and fast. In addition, before anesthesia a check must be made for pathological alterations (e.g. tumors) in the head and neck region and the patient history must be thoroughly determined. If the patient reports difficulties with securing the airway in the past, these are likely to occur again if they have not been surgically resolved. This includes an accurate documentation of the airway and knowledge of the in-house standard operating procedure on unexpected difficult airways as well as local equipment. Preparation causes work but may save lives.

Estimation of the Overuse of Preoperative Chest X-rays According to "Choosing Wisely", "No Hacer", and "Essencial" Initiatives: Are They Equally Applicable and Comparable?

BACKGROUND

Overuse reduces the efficiency of healthcare systems and compromises patient safety. Different institutions have issued recommendations on the indication of preoperative chest X-rays, but the degree of compliance with these recommendations is unknown. This study investigates the frequency and characteristics of the inappropriateness of this practice.

METHODS

This is a descriptive observational study with analytical components, performed in a tertiary hospital in the Community of Madrid (Spain) between July 2018 and June 2019. The inappropriateness of preoperative chest X-ray tests was analyzed according to "Choosing Wisely", "No Hacer" and "Essencial" initiatives and the cost associated with this practice was estimated in Relative Value and Monetary Units.

RESULTS

A total of 3449 preoperative chest X-ray tests were performed during the period of study. In total, 5.4% of them were unjustified according to the "No Hacer" recommendation and 73.3% according to "Choosing Wisely" and "Essencial" criteria, which would be equivalent to 5.6% and 11.8% of the interventions in which this test was unnecessary, respectively. One or more preoperative chest X-ray(s) were indicated in more than 20% of the interventions in which another chest X-ray had already been performed in the previous 3 months. A higher inappropriateness score was also recorded for interventions with an American Society of Anesthesiologists (ASA) grade ≥ III (16.5%). The Anesthesiology service obtained a lower inappropriateness score than other Petitioning Surgical Services (57.5% according to "Choosing Wisely" and "Essencial"; 4.1% according to "No Hacer"). Inappropriate indication of chest X-rays represents an annual cost of EUR 52,122.69 (170.1 Relative Value Units) according to "No Hacer" and EUR 3895.29 (2276.1 Relative Value Units) according to "Choosing Wisely" or "Essencial" criteria.

CONCLUSIONS

There was wide variability between the recommendations that directly affected the degree of inappropriateness found, with the main reasons for inappropriateness being duplication of preoperative chest X-rays and the lack of consideration of the particularities of thoracic interventions. This inappropriateness implies a significant expense according to the applicable recommendations and therefore a high opportunity cost.

Preoperative anaesthesia triage with a patient-centred system-A prospective clinical study

BACKGROUND

Increase in day surgery has challenged preoperative anaesthesia with need to identify a few high-risk patients requiring detailed preoperative intervention. We aimed to assess if a nurse-administered Preoperative Patient-centred Anaesthesia System (Pre-PAS) could identify high-risk patients, defined as ASA score III-IV, before surgery and allow triage in standard preanaesthesia care. We hypothesized that Pre-PAS ≥ 1 would identify ASA III-IV patients with high specificity.

METHODS

We conducted a prospective study, where twelve preoperative risk factors were recorded before surgery with the Pre-PAS questionnaire along with a score from zero to twelve based on the number of positive criteria. Only patients with a Pre-PAS score ≥ 1 were followed by mandatory preoperative anaesthetists' assessment visit. Medical records were reviewed to ensure accurate ASA score evaluation, surgical cancellations and airway difficulties. Association between Pre-PAS score and ASA score was evaluated by Fisher's exact test.

RESULTS

In a total of 487 included patients, 92% of high-risk patients (ASA III-IV) and 54% of low-risk patients (ASA I-II) had Pre-PAS score ≥ 1 (P ≤ .001). Nine out of 12 Pre-PAS criteria were significantly associated with higher frequency in ASA III-IV. Pre-PAS reduced number of preanaesthetic visits by 39%. Pre-PAS ≥ 1 had a sensitivity of 0.92 and a specificity of 0.46 for ASA III-IV.

CONCLUSIONS

A patient-centred preoperative triage system had high sensitivity for identifying ASA III-IV, and multiple Pre-PAS variables were associated with ASA III-IV, but the model had low specificity. Pre-PAS may guide triage of relevant patients to preanaesthetic visit.

Sternomental Distance Ratio as a Predictor of Difficult Laryngoscopy: A Prospective, Double-Blind Pilot Study

Background:

No single test has shown to be an accurate predictor of difficult laryngoscopy.

Aims:

This study aims to evaluate the effectiveness of the ratio of the sternomental distance (SMD) in neutral and full neck extension position SMD ratio (SMDR) as a predictor of difficult laryngoscopy and any need of assisted intubation.

Settings and Design:

Prospective, double-blind pilot study.

Materials and Methods:

This study included 221 consecutive adult patients scheduled to undergo elective surgery under general anesthesia. Physical and airway characteristics, SMDR, difficult laryngoscopy (using Cormack/Lehane [C/L] scale), and any kind of assisted intubation were assessed.

Statistical Analysis:

The optimal cutoff point for SMDR was identified using receiver operating characteristic (ROC) analysis. The association between SMDR and the intubation method was evaluated through multiple logistic regression analysis.

Results:

A SMDR below 1.55 led in 33% of the cases to assisted intubation and 33%–53% of C/L III–IV glottic views for McCoy and Macintosh blades, respectively. On the other hand, SMDR above 1.9 led to no C/L IV glottic views for both blades and 4% and 11% C/L III views glottic views for McCoy and Macintosh, respectively. The best sensitivity and specificity cutoff point as defined by the ROC curve was identified for an SMDR value of 1.7 (area[s] under the curve: 0.815; 95% confidence interval: 0.743–0.887). Assisted intubation rates were significantly higher in patients with an SMDR inferior to 1.7 (30.5% compared to 3.5%, P < 0.001).

Conclusions:

SMDR is a simple, objective, and easy to perform test. The present study indicates that SMDR may be helpful in predicting difficult laryngoscopy and assisted intubation.

Association of preoperative spirometry with cardiopulmonary fitness and postoperative outcomes in surgical patients: A multicentre prospective cohort study

BACKGROUND

Preoperative spirometry and cardiopulmonary exercise testing (CPET) may stratify risk for respiratory complications. This secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study examined whether CPET performance (i.e., cardiopulmonary fitness) confounds associations of spirometry with outcomes.

METHODS

The analysis included 1200 participants having major non-cardiac surgery at 25 hospitals in Canada, Australia, New Zealand and UK. Forced expiratory volume in 1 s (FEV₁), and ratio of FEV₁ to forced vital capacity (FVC) were measured during preoperative spirometry, and peak oxygen consumption and ventilatory efficiency during preoperative CPET. Outcomes were respiratory morbidity (Postoperative Morbidity Survey) and pulmonary complications (pneumonia or respiratory failure). We used multivariable logistic regression models to estimate associations of FEV₁ with outcomes after adjustment for risk factors and either peak oxygen consumption or ventilatory efficiency.

FINDINGS

128 participants (11%) developed respiratory morbidity, and 48 (4%) developed pulmonary complications. There was no strong evidence that FEV₁ predicted respiratory morbidity after adjustment for peak oxygen consumption (p = 0·80) or ventilatory efficiency (p = 0·76), or FEV₁ predicted pulmonary complications after adjustment for ventilatory efficiency (p = 0·37). Peak oxygen consumption (odds ratio 0·66 per 5 mL/kg/min increase; 95% CI, 0·54-0·82) was associated with respiratory morbidity. Ventilatory efficiency was associated with respiratory morbidity (p = 0·04) and pulmonary complications (p = 0·02). Peak oxygen consumption also confounded the association between FEV₁ and respiratory morbidity.

INTERPRETATION

After accounting for fitness and clinical factors, FEV₁ was not strongly predictive of respiratory complications. Prior associations between FEV₁ and respiratory morbidity may be explained by confounding by peak oxygen consumption.

FUNDING

Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.

Variables associated with survival in patients with invasive bladder cancer with and without surgery

We recorded the survival of 141 patients assessed for radical cystectomy, which included cardiopulmonary exercise testing. The median Kaplan-Meier survival estimates were: 1540 days for the whole cohort; 2200 days after cystectomy scheduled (n = 108); and 843 days without surgery. The mortality hazard remained double that expected for a matched general population, but survival was better in patients scheduled for surgery than those who were not: the mortality hazard ratio (95%CI) after cystectomy was 0.43 (0.26-0.73) the mortality hazard without surgery, p = 0.001. The mortality hazard ratios for the three-variable Bayesian Model Averaging survival model for all 141 patients were: referral for surgery (0.5); haemoglobin concentration (0.98); and efficiency of carbon dioxide output (1.05). Efficiency of carbon dioxide output was the single variable in the postoperative model (n = 108), mortality hazard 1.08 (per unit increase). The ratio of observed to expected peak oxygen consumption associated best with mortality in 33 patients not referred for surgery, hazard ratio 0.001. Our results can inform consultations with patients with invasive bladder cancer and suggest that interventions to increase fitness and haemoglobin may improve survival in patients who do and who do not undergo radical cystectomy.

[Patient blood management : Medical concept for increasing patient safety]

Patient blood management (PBM) is a multidisciplinary evidence-based treatment model. Aims are to provide treatment of pre-existing or recently occureed deficits in blood volume and of substances that are important for erythropoiesis in patients, as well as the targeted administration of cellular and non-cellular blood products within reasonable and scientifically proven limits. The overall goal is therefore a safe therapy and complication-free course of the disease. PBM follows a strategy based on three pillars, which encompasses the aspects of optimization of anemia and hemoglobin, the handling of bleeding and the use of patient-related resources.

Over-ordering of ultrasound and pre-operative investigations for inguinal hernia repair at Northern Health: a Choosing Wisely audit

BACKGROUND

Choosing Wisely Australia is an initiative aimed at reducing the incidence of unnecessary investigations. This study is an audit of Northern Health's adherence to two Choosing Wisely recommendations in the context of inguinal hernia repair. Recommendation 1: Avoid routinely performing pre-operative investigations in patients, but instead order in response to patient factors, signs and symptoms, disease or planned surgery. Recommendation 2: Do not order ultrasound for clinically apparent inguinal hernias.

METHODS

Records of 264 patients who underwent elective inguinal hernia repair at Northern Health in 2016 were reviewed.

RESULTS

Recommendation 1: Results demonstrated over-ordering of coagulation studies. Thirty-four percent of patients received coagulation studies, 86% of which were unindicated. There was better adherence to Choosing Wisely guidelines for other investigations: 38% of patients received a full blood examination (42% unindicated), 38% received a urea, electrolytes and creatinine (14% unindicated), 7% received a glycated haemaglobin (0% unindicated) and 38% received an electrocardiogram (11% unindicated). Recommendation 2: Seventy percent (n = 186) of patients received an ultrasound of which 25% (n = 46) had a documented indication. Correlation with surgical findings showed a positive predictive value of 95.6% and sensitivity of 97.8% for ultrasound.

CONCLUSION

Recommendation 1: Most pre-operative coagulation studies were unindicated, while adherence to Choosing Wisely guidelines was better for pre-operative full blood examination, urea, electrolytes and creatinine, glycated haemaglobin and electrocardiogram. Recommendation 2: The majority of patients received an inguinal hernia ultrasound, most of which had no documented indication.

Impact of Obesity on Surgical Outcomes Following Laminectomy for Spinal Metastases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To determine the effect of obesity (body mass index >30 kg/m²) on perioperative morbidity and mortality after surgical decompression of spinal metastases.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database is a large multicenter clinical registry that collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent decompression with laminectomy for treatment of metastatic spinal lesions between 2010 and 2014. Patients were separated into 2 cohorts based on the presence of absence of obesity. Univariate analysis and multivariate logistic regression analysis were used to analyze the effect of obesity on perioperative morbidity and mortality.

RESULTS

There was a significantly higher rate of venous thromboembolism (VTE; obese 6.6% vs nonobese 4.2%; P = .01) and pulmonary complications (obese 2.6% vs nonobese 2.2%; P = .046) in the obese group compared with the nonobese group. The nonobese group had prolonged hospitalization (obese 62.0% vs nonobese 69.0%; P = .001) and a higher incidence of blood transfusions (obese 26.8% vs nonobese 34.2%; P < .001). On multivariate analysis, obesity was found to be an independent risk factor for VTE (odds ratio = 1.75, confidence interval = 1.17-2.63, P = .007).

CONCLUSIONS

Obese patients were predisposed to an elevated risk of VTE following laminectomy for spinal metastases. Early postoperative mobilization and a low threshold to evaluate for perioperative VTE are important in these patients in order to appropriately diagnose and treat these complications and minimize morbidity.

Clinical standards for patient blood management and perioperative hemostasis and coagulation management. Position Paper of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new "standard of care" so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period.

The Effectiveness of Full-body EOS Compared With Conventional Chest X-ray in Preoperative Evaluation of the Chest for Patients Undergoing Spine Operations: A Preliminary Study

STUDY DESIGN

A prospective radiographic comparative study.

OBJECTIVE

The aim of this study was to compare full-body EOS with conventional chest X-ray (CXR) for use in the preoperative evaluation of the chest in patients undergoing spine operations.

SUMMARY OF BACKGROUND DATA

The full-body EOS reproduces an image of the chest similar to a routine CXR. The potential for the former replacing the latter is plausible. This is especially applicable in spine patients who would routinely have a preoperative full-body EOS performed.

METHODS

A radiographic comparative study of 266 patients was conducted at a single tertiary center from January 2013 to July 2016. Each patient had EOS and CXR done in random order <2 weeks apart. Two radiologists reported the image findings using a checklist. A third radiologist was consulted in cases of discrepancy. Interobserver agreement was calculated using Gwet AC1 and a comparison between EOS and CXR findings was analyzed using paired Chi-squared test. Multivariate analysis was performed to identify predictors for abnormal radiological findings. The institutional ethics committee approved this prospective study and waiver of informed consent was obtained.

RESULTS

There were 84 males (31.6%) and 182 females (68.4%). The mean age was 38.9 years (SD = 25.0 years). High interobserver agreement was found for EOS and CXR (Gwet AC1 0.993 and 0.988, respectively). There were no significant differences between both imaging modalities. Rare diagnoses precluded comparison of certain conditions. Age >18 years [odds ratio (OR) 7.69; P = 0.009] and American Society of Anesthesiologists physical status 3 (OR 6.64; P = 0.018) were independent predictors of abnormal radiological findings.

CONCLUSION

EOS is not inferior to, and may be used to replace CXR in preoperative radiological screening of thoracic conditions especially in low-risk patients ≤18 years old and patients with ASA <3. Preoperative assessment should never rely on a single modality. High-risk patients should be sent for a thorough work-up before spine surgery.

LEVEL OF EVIDENCE

4.

Joint consensus on abdominal robotic surgery and anesthesia from a task force of the SIAARTI and SIC

Minimally invasive surgical procedures have revolutionized the world of surgery in the past decades. While laparoscopy, the first minimally invasive surgical technique to be developed, is widely used and has been addressed by several guidelines and recommendations, the implementation of robotic-assisted surgery is still hindered by the lack of consensus documents that support healthcare professionals in the management of this novel surgical procedure. Here we summarize the available evidence and provide expert opinion aimed at improving the implementation and resolution of issues derived from robotic abdominal surgery procedures. A joint task force of Italian surgeons, anesthesiologists and clinical epidemiologists reviewed the available evidence on robotic abdominal surgery. Recommendations were graded according to the strength of evidence. Statements and recommendations are provided for general issues regarding robotic abdominal surgery, operating theatre organization, preoperative patient assessment and preparation, intraoperative management, and postoperative procedures and discharge. The consensus document provides evidence-based recommendations and expert statements aimed at improving the implementation and management of robotic abdominal surgery.

[Update Mallampati : Theoretical and practical knowledge of European anesthetists on basic evaluation of airways]

In 1985 Mallampati et al. published a non-invasive score for the evaluation of airways (Mallampati grading scale, MGS), which originally consisted of only three different classes and has been modified several times. At present it is mostly used in the version of Samsoon and Young consisting of four different classes. Class I: soft palate, fauces, uvula, palatopharyngeal arch visible, class II: soft palate, fauces, uvula visible, class III: soft palate, base of the uvula visible and class IV: soft palate not visible. Nevertheless, other versions of MGS still exist, each having different values for sensitivity and specification. The current opinion is therefore that MGS is no longer useful as a stand-alone predictor but in combination with others it is still part of today's most relevant guidelines, such as those of the American Society of Anesthesiologists (ASA), the UK's Difficult Airway Society (DAS), the European Society of Anaesthesiology (ESA) and the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and must therefore be known by anesthetists. Even in times of sophisticated tools for airway management, the procedure remains a high risk, so every anesthetist has to be prepared for and well trained in management of known and unexpected difficult airways. Evaluation of the patient's airway is a part of modern airway management to prevent problems and reduce risk of hypoxia during the procedure. The theoretical knowledge and practical skills of European anesthetists were evaluated at two international congresses, the German Anesthesia Congress (DAC) and Euroanaesthesia 2014. The DAC is an annual meeting of German speaking anesthetists, hosted by the DGAI. The Euroanaesthesia is the annual European pendant hosted by the ESA. Participation was voluntary and only physicians were allowed to take part. Theory was evaluated by a questionnaire containing open and closed questions for MGS that had to be answered by every participant alone. Apart from theory, a practical evaluation was performed. Every participant had to classify the MGS of a human airway model. The model was identical on both congresses. According to the original publication a checklist containing the factors essential for the correct performance was filled out by a supervising experienced anesthetist. During DAC 2014 n = 267 physicians participated in the study, 22 participants were excluded due to inconsistent answers, incomplete questionnaires or missing practical part. A total of 245 data sets were evaluated. During Euroanaesthesia 2014 n = 298 physicians participated in the study, 68 participants were excluded due to inconsistent answers, incomplete questionnaires or missing practical part and 230 data sets were evaluated. At the DAC the mean age (± SD) was 44.5 ± 9.5 years, 157 (64.1%) were male and 88 (35.9%) were female. Working experience was trainee anesthetist in 16.7% and other participants were experienced anesthetists. At the ESA the mean age (± SD) was 42.4 ± 9.5 years, 133 (57.8%) were male and 97 (42.2%) female. Trainee anesthetists were 15.2%, the rest were experienced anesthetists. The DAC participants knew Mallampati classes 1 (65%) and 4 (45%) better than 2 and 3 and there was no relevant differences to the ESA (close to 30% knew the classes 1-4 here). Classification of the airway model was correct in 62% and 67% at DAC and ESA, respectively. Most participants performed the practical evaluation correctly except the sitting position of the model. In agreement with earlier studies, these results show the lack of knowledge in evaluation of airways according to current guidelines of all relevant societies. This is likely to increase preventable risks for patients as unexpected difficult airway management increases the risk for hypoxia and intubation damage.

Respiratory evaluation of the risk for postoperative pulmonary complications in patients who preoperatively consulted pulmonologists: Studying both patients who underwent and who precluded planned surgery

BACKGROUND

Due to advances in medicine, patients with pulmonary diseases have become candidates for surgery under general anesthesia. They often consult pulmonologists to assess their tolerability for surgery. The purpose of this study was to evaluate the significant characteristics responsible for postoperative pulmonary complications (PPCs) and the preclusion of the planned surgery.

METHODS

The clinical data of 462 consecutive patients who consulted at the Department of Respiratory Medicine before surgery under general anesthesia were used in this study. The relationship between the patient׳s characteristics and their outcomes were analyzed. The patients who were scheduled for lung resection were excluded.

RESULTS

Of the 386 patients who underwent planned surgery, 353 had no PPCs (Group A) and 33 developed PPCs (Group B). Planned surgery under general anesthesia was precluded in 31 patients due to respiratory problems (Group C). The significant predictors for PPCs consisted of a higher age, male gender, asthma, gastrointestinal surgery, cardiovascular surgery and a lower percentage of the predicted forced expiratory volume in 1 second (% predicted FEV₁). The significant factors associated with the preclusion of planned surgery included interstitial pneumonia (IP), dermatologic surgery and a lower % predicted FEV₁. The predicted probability of PPCs in Group C was significantly higher than that in Group A and lower than that in Group B (all p-values < 0.05).

CONCLUSION

The common clinical finding for predicting PPCs and encouraging the preclusion of the planned surgery under general anesthesia was a lower % predicted FEV₁.

Enhancing the quality and safety of the perioperative patient

PURPOSE OF REVIEW

Many possible hazards bedevil the perioperative patient. This review focuses on a number of aspects of perioperative management where the patient's quality and safety can be enhanced.

RECENT FINDINGS

Our understanding of the relationship between preoperative preparation and postoperative outcomes has improved. There have also been recent developments in our understanding of how to construct useful cognitive aids and make the best use of checklists by understanding the cultural environment supporting their use. Postoperatively, the concept of 'failure to rescue' in the surgical patients has been explored.

SUMMARY

A clear vision of what postoperative recovery should mean for practitioner and patients; careful risk stratification and prophylactic measures to avoid postoperative complications; the judicious use of checklists and other cognitive aids to complement clinical expertise in promoting safety within each local context; and the prompt recognition and rescue of postoperative problems when they occur are all important aspects of a safe perioperative care.

Value of Routine Preoperative Tests for Coagulation Before Elective Cranial Surgery. Results of an Institutional Audit and a Nationwide Survey of Neurosurgical Centers in Pakistan

BACKGROUND

Routine preoperative blood testing has become a dogma. The general practice is to order preoperative workup as a knee-jerk response rather than individualize it for each patient. The fact that the bleeding brain tends to swell, which coupled with limited options for proximal control, packing, and overall hemostasis, leads to an overemphasis on the preoperative coagulation profile.

MATERIAL AND METHODS

This is a retrospective review of the medical records of patients admitted at Aga Khan University Hospital from January 2010 to December 2015 for an elective craniotomy. The hospital registry was used to identify files for review. Data were collected on a predefined proforma. A nationwide survey was performed, and 30 neurosurgery centers were contacted across Pakistan to confirm the practice of preoperative workup.

RESULTS

The survey revealed that all centers had a similar practice of preoperative workup. This included complete blood count, serum electrolytes, and coagulation profile, including prothrombin time, activated partial thromboplastin time (aPTT), and international normalized ratio (INR). A total of 1800 files were reviewed. Nine (0.5%) patients were found to have deranged clotting profile without any predictive history of clotting derangement; 56% were male and 44% were female. Median age was 32 years with an interquartile range of 27 years. Median aPTT was (40.8 with 20.8 IQR). Median INR was (1.59 with 0.48 IQR). Median blood loss was (400 with 50 IQR). No significant association between coagulation profile (aPTT, INR) and blood loss was found (P = 0.85, r = -0.07).

CONCLUSIONS

We conclude that patients without a history of coagulopathy and normal physical examination do not require routine coagulation screening before elective craniotomy.

Enhanced Recovery After Surgery Protocols in Major Urologic Surgery

The purpose of the review

The analysis of the components of enhanced recovery after surgery (ERAS) protocols in urologic surgery.

Recent findings

ERAS protocols has been studied for over 20 years in different surgical procedures, mostly in colorectal surgery. The concept of improving patient care and reducing postoperative complications was also applied to major urologic surgery and especially procedure of radical cystectomy. This procedure is technically challenging, due to a major surgical resection and high postoperative complication rate that may reach 65%. Several clinical pathways were introduced to improve perioperative course and reduce the length of hospital stay. These protocols differ from ERAS modalities in other surgeries. The reasons for this are longer operative time, increased risk of perioperative transfusion and infection, and urinary diversion achieved using transposed intestinal segments. Previous studies in this area analyzed the need for mechanical bowel preparation, postoperative nasogastric tube decompression, as well as the duration of urinary drainage. Furthermore, the attention has also been drawn to perioperative fluid optimization, pain management, and bowel function.

Summary

Notwithstanding partial resemblance between the pathways in major urologic surgery and other pelvic surgeries, there are still scarce guidelines for ERAS protocols in urology, which is why further studies should assess the importance of preoperative medical optimization, implementation of thoracic epidural anesthesia and analgesia, and perioperative nutritional management.

Thyromental distance ("Patil") revisited : Knowledge and performance of a basic airway screening tool among European anesthetists

Predicting and managing the difficult airway is a lifesaving and vital basic task for the anesthetist. Current guidelines of all important societies include thyromental distance (TMD, "Patil") as a possible predictor for a difficult airway and includes two important aspects for airway management: the mandibular space and the flexibility of the cervical spine. We evaluated knowledge and execution regarding TMD for predicting a difficult airway on participants at the Euroanaesthesia (ESA) congress and German Anaesthesia Congress (DAC) in 2014. Our evaluation consisted of a theoretical part with questions regarding general knowledge and a practical evaluation with anesthetists performing on a human airway model. Practical evaluations were performed separately from other participants. During the DAC 245 (ESA 230) physicians participated, of which 64% were male (ESA 58%). At the DAC 182 (74.3%) and ESA 82 (35.6%) participants knew about Patil/TMD. Its use as a predictive score for a difficult airway was known by 122 (49.8%; DAC) and 79 (34.4%; ESA) participants. The correct definition for intubation was given by 45 (25.7%) at the DAC and 56 (24.3%) at ESA. Only 40-41% of the participants measured the correct distance for TMD. Only 6.1-6.5% completed both the theoretical and practical parts correctly. As non-invasive TMD includes two different aspects of patient airways and is part of current guidelines, education and training must be extended to assure adequate evaluation in the future.