Update on preoperative evaluation and optimisation

Incidence and risk factors of postpartum urinary retention following cesarean section: a retrospective nationwide inpatient sample database study

AIM

To investigate the risk factors associated with postpartum urinary retention after cesarean section (CS) and to determine the associated morbidity rate.

METHODS

This study was a population-based retrospective case-control study analyzed using National Inpatient Sample (NIS) data from 2010 to 2019. The study classified women according to whether they developed postpartum urinary retention after delivery. Predictors of postpartum urinary retention occurring after CS were identified by multivariate logistic regression analysis, and the corresponding incidence rates were examined after adjusting for basic maternal demographic and clinical characteristics.

RESULTS

A total of 2,397,168 CSs were extracted from the NIS database. The overall incidence of urinary retention after CS was 0.20%. Patients who experienced urinary retention after CS demonstrated longer length of stay (LOS), higher total costs, and more postoperative complications. The following variables have been identified as potential risk factors for urinary retention: age between 25 and 34 years (OR = 1.27; 95% CI = 1.17-1.38; P < 0.001), 35 years and older (OR = 1.35; 95% CI = 1.22-1.48; P < 0.001), Asian and Pacific Islander (OR = 1.85; 95% CI = 1.68-2.05; P < 0.001), one comorbidity (OR = 1.51; 95% CI = 1.28-1.79; P < 0.001), two comorbidities (OR = 1.51; 95% CI = 1.09-2.08; P = 0.013), three and more comorbidities (OR = 1.79; 95% CI = 1.06-3.04; P = 0.031), large hospitals (OR = 1.16; 95% CI = 1.07-1.26; P < 0.001), teaching hospitals (OR = 1.93; 95% CI = 1.79-2.07; P < 0.001), eastern hospitals (OR = 1.24; 95% CI = 1.14-1.35; P < 0.001), coagulation disorders (OR = 1.32; 95% CI = 1.08-1.61), fluid and electrolyte disorders (OR = 2.46; 95% CI = 1.94-3.11), other neurological disorders (OR = 1.51; 95% CI = 1.20-1.89), paralysis (OR = 3.24; 95% CI = 1.95-5.38), and weight loss (OR = 2.34;95% CI = 1.26-4.35). In addition, urinary retention was associated with postoperative complications related to bladder or ureteral injury (OR = 6.12; 95% CI = 2.46-15.23), blood transfusion (OR = 1.51; 95% CI = 1.31-1.76), acute renal failure (OR = 4.74; 95% CI = 3.46-6.48), respiratory failure (OR = 2.21; 95% CI = 1.23-3.98), endometritis (OR = 1.32; 95% CI = 1.02-1.71), hemorrhage/hematoma ( OR = 2.52; 95% CI = 1.38-4.62), uterine rupture (OR = 1.75; 95% CI = 1.21-2.54), hysterectomy (OR = 2.30; 95% CI = 1.66-3.18), peritonitis (OR = 2.86; 95% CI = 1.03-7.92), severe puerperal infections (OR = 3.31; 95% CI = 2.60- 4.22), chorioamnionitis (OR = 1.78; 95% CI = 1.59-2.00). Notably, the presence of cephalopelvic disproportion (OR = 1.37; 95% CI = 1.11-1.67), breech or other fetal position abnormalities (OR = 1.10; 95% CI = 1.00-1.20), placenta previa (OR = 1.39; 95% CI = 1.06-1.84), multiple gestation (OR = 1.39; 95% CI = 1.23-1.58), anatomy of the bladder (OR = 3.93; 95% CI = 1.42-10.90), bladder catheter placement (OR = 22.57; 95% CI = 20.24-25.17) and intravenous infusion (OR = 1.22; 95% CI = 1.09-1.36) was associated with a significantly increased risk of urinary retention, while low cervical CS (OR = 0.62; 95% CI = 0.50-0.76), previous CS (OR = 0.87; 95% CI = 0.82-0.93) and prolapsed cord (OR = 0.52; 95% CI = 0.31-0.86) conferred some protective effect against it.

CONCLUSION

In this study, we identified an overall prevalence of 0.20% for urinary retention after CS and several risk factors, including advanced maternal age, Asian and Pacific Islander background, comorbidities, and delivery in large or teaching hospitals, particularly in the Eastern region. Protective factors included hospitals in the southern region, urban hospitals, obesity, and hypertension. Urinary retention was associated with increased postoperative complications, longer LOS, and higher healthcare costs. Several confounders also significantly influenced the incidence of urinary retention. To mitigate these risks, healthcare professionals should prioritize antenatal screening, manage comorbidities, and closely monitor high-risk patients during the postpartum period to reduce adverse outcomes.

Clients' experiences in their first entry to the operating room: a descriptive phenomenological study

BACKGROUND

The unfamiliar atmosphere of the operating room, waiting for anesthesia, and the process of surgery and anesthesia are some of the factors causing fear and anxiety in patients. It leads to physical and psychological pressure on patients. Better understanding of patients' feelings, beliefs, or fears and recording their experiences for optimal care after surgery is helpful. This study explains the experiences of clients in the first entry to the operating room.

METHODS

This qualitative study was conducted using a descriptive phenomenological method. In this study, 17 patients who had the experience of entering the operating room for the first time as an elective surgery under general anesthesia over the last 6 months were purposefully selected as participants. Then, they underwent an in-depth and semi-structured interview. After conducting the interview, the participants' statements were qualitatively analyzed using the seven-step Colaizzi method. During the steps of this study, Lincoln and Guba's four reliable criteria were observed.

RESULTS

By continuous analysis of interviews about patients' experiences, 308 codes, 10 sub-themes, 6 primary themes, and 3 general themes were obtained. Themes included unpleasant emotions experienced, unpleasant atmosphere factors, and the induction of relaxation and hope.

CONCLUSION

Patients' exposure to an unfamiliar place with new and unknown equipment, personnel with different clothing, stress, worry, psychosomatic reactions following stress, and annoying environmental factors can lead to an unpleasant experience for patients, if they are not managed. Also, the effective communication of the surgical team with the patients leads to reducing or removing the stress and complications caused by it.

Clinical Impact of Sarcopenia in the Decision-Making Process for Patients with Acute Diverticulitis

Background: Acute diverticulitis (AD), an inflammatory complication of diverticulosis, affects around 4% of individuals with diverticulosis, with increased incidence in older populations. This study aims to assess the impact of sarcopenia, the age-related loss of muscle mass, on the clinical decision-making and outcomes of patients with AD. Materials and Methods: A retrospective study was conducted on 237 patients admitted to the Emergency Department (ED) between January 2014 and February 2022. Patients diagnosed with AD Hinchey ≥ 2 via contrasted tomography (CT) were included. Sarcopenia was assessed using CT scans at the third lumbar vertebra (L3), with skeletal muscle area (SMA) normalized by height to calculate the skeletal muscle index (SMI). Patients were divided into two groups based on sarcopenia status and analysed for surgical outcomes, non-operative management (NOM) success, and complications. Results: The prevalence of sarcopenia was 46%. Sarcopenic patients were significantly older and had lower BMI and higher frailty scores. A higher proportion of sarcopenic patients underwent Hartmann, while non-sarcopenic patients more often had anastomosis. Sarcopenia did not significantly affect overall morbidity, mortality, or the failure rate of NOM. However, sarcopenic patients with a BMI > 25 had a higher likelihood of requiring redo surgeries. Conclusions: Sarcopenia plays a critical role in the surgical management of AD but does not predict worse clinical outcomes. The decision to perform surgery, particularly Hartmann's procedure, is influenced by sarcopenia, yet morbidity and mortality rates are comparable between sarcopenic and non-sarcopenic patients. These findings highlight the need for sarcopenia to be considered in preoperative assessments.

The impact of comorbidities and functional status on outcomes in the older adult emergency general surgery patient

BACKGROUND

The aim of this study is to quantify the relative contribution of comorbidities and pre-operative functional status on outcomes in geriatric emergency general surgery (EGS) patients.

METHODS

This is a retrospective study of older-adult EGS patients at an academic medical center between 2017 and 2018. Patients ≥65 years were included. The primary outcomes examined were 30-day mortality, 30-day morbidity, and length of stay (LOS).

RESULTS

734 patients were included. The mean age was 76, and 48.9 ​% received non-operative management. The median LOS was 6.8 days; 11.8 ​% of patients died within 30 days, and 40.6 ​% developed morbidities. Lacking capacity to consent on admission was independently associated with 30-day mortality (OR: 2.63, [1.32-5.25], p ​= ​0.006). Comorbidities associated with developing morbidity were CVA with neurologic deficit (OR: 2.29, [1.20-4.36], p ​= ​0.012), CHF (OR: 2.60, [1.64-4.11], p ​< ​0.001), in addition to pre-operative delirium (OR: 3.42, [1.43-8.14], p ​= ​0.006).

CONCLUSIONS

A significant contribution to outcomes is determined by pre-admission comorbidities and cognitive and functional status. Opportunities exist for collaboration between Acute Care Surgery and geriatric medicine teams for the optimization of comorbidities.

Can caloric restriction improve outcomes of elective surgeries?

Energy restriction (ER) is a nutrition method to reduce the amount of energy intake while maintaining adequate nutrition. In clinical medicine, applications of ER have been implicated in longevity, mortality, metabolic, immune, and psychological health. However, there are limited studies showing the clinical benefit of ER within the immediate surgical setting. A specific, clinically oriented summary of the potential applications of ER is needed to optimize surgery outcomes for patients. The purpose of this article is to examine how ER can be used for perioperative optimization to improve outcomes for the patient and surgeon. It will also explore how these outcomes can feasibly fit in with enhanced recovery after surgery protocols and can be used as a method for nutrition optimization in surgery. Despite evidence of caloric restriction improving outcomes in critically ill surgical patients, there is not enough evidence to conclude that ER, perioperatively across noncritically ill cohorts, improves postoperative morbidity and mortality in elective surgeries. Nevertheless, a contemporary account of how ER techniques may have a significant role in reducing risk factors of adverse surgical outcomes in this cohort, for example, by encouraging preoperative weight loss contributing to decreased operating times, is reviewed.

Navigating Post-operative Challenges: A Comprehensive Review of Complications Following Anterior Cruciate Ligament (ACL) Tear Surgery

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating sports-related injuries, often necessitating surgical intervention to restore knee stability and function. ACL reconstruction surgery, which has evolved significantly over the years, aims to enable patients, particularly those who are young and physically active, to return to their pre-injury activity levels. However, despite advancements in surgical techniques and rehabilitation protocols, post-operative complications remain a significant concern that can adversely affect patient outcomes. This comprehensive review explores the spectrum of complications that can arise following ACL tear surgery, ranging from common issues such as infection, graft failure, and knee stiffness to less frequent but clinically significant complications like osteoarthritis and neurological injuries. The review also delves into the various factors influencing the likelihood of these complications, including patient-related variables, surgical techniques, and the effectiveness of rehabilitation protocols. By providing an in-depth analysis of these post-operative challenges, this review aims to enhance the understanding of ACL reconstruction outcomes and guide healthcare professionals in implementing preventive strategies and optimizing patient care. Through a multidisciplinary approach, the goal is to minimize the risk of complications, improve surgical outcomes, and ultimately enhance the quality of life for patients undergoing ACL reconstruction.

Factors Affecting Nursing and Midwifery Students Knowledge Regarding Preoperative Nursing Care

Background

Preoperative competence is a crucial aspect of nursing and midwifery students' education to improve the quality of care and patient safety. It assists nursing and midwifery students in maintaining and enhancing their practice by determining strength and areas that should be developed.

Purpose

This study aims to assess the level of nursing and midwifery students' knowledge regarding preoperative nursing care and determine the most influencing demographic variables.

Methods

A descriptive cross-sectional design using an online self-administered questionnaire was utilised among 202 nursing and midwifery students selected by simple random sampling. The Perceived Preoperative Nursing Care Competence Scale for Nursing students (PPreCC-NS) was used to assess the perceived preoperative nursing care competence of nursing and midwifery students. Descriptive statistics were obtained, and multiple regression was used for data analysis.

Results

The overall level of perceived preoperative nursing care competence was adequate 99.09 (SD = 10.81). The highest mean score was recorded for ability to fulfil legal responsibilities and adherence to ethical principles (M = 23.6, SD = 2.53). The lowest mean score was obtained for research and professional development (M = 17.6, SD = 2.60). The regression analysis showed that place of residency explained significantly about 4.53% of the variance in the nursing and midwifery students' knowledge regarding preoperative nursing care, and it was the strongest predictor (B = 0.218, p = 0.002).

Conclusion

The perceived level of preoperative nursing care among nursing and midwifery students was found to be adequate and associated with place of residence. Future research should be conducted to explore factors affecting nursing and midwifery students' preoperative competence in different cultures and contexts.

The Impact of Preoperative Co-morbidities on Blood Transfusion Requirements Following Reverse Total Shoulder Arthroplasty

Objectives

Reverse total shoulder arthroplasty (RTSA) continues to increase in popularity as a surgical operation in the United States. As indications for this procedure expand, more attention is needed to evaluate perioperative risk factors and patient characteristics. Postoperative anemia requiring blood transfusion (BT) is a well-documented risk factor for increased in-house mortality although little has been studied on the relationship between RTSA and postoperative BT. The purpose of this study was to identify comorbidities and patient characteristics as risk factors for BT in patient's undergoing RTSA.

Methods

Using the Nationwide Inpatient Sample (NIS) database, 59,925 RTSA patients (2016-2019) were analyzed, with 1.96% requiring postoperative BT. Demographics, comorbidities, and preoperative factors were compared between BT and non-BT groups via univariate and multivariate analyses.

Results

Overall prevalence of blood transfusion in all patients was 1.96%. Male sex (OR 1.75, p < 0.001), Asian ethnicity (OR 1.96, p = 0.012), age >80 (OR 1.51, p < 0.001), age >90 (OR 2.26, p < 0.001), CKD (OR 1.94, p < 0.001), and Parkinson's disease (OR 2.08, p < 0.001) were associated with increased BT odds. Cirrhosis exhibited the highest impact (OR 5.7, p < 0.001). Conversely, Caucasian ethnicity (OR 0.76, p = 0.023), uncomplicated DM (OR 0.73, p = 0.002), tobacco-related disorders (OR 0.43, p < 0.001), BMI >30 (OR 0.8, p = 0.011), and elective procedures (OR 0.16, p < 0.001) decreased BT odds.

Conclusion

These results were useful with identifying several risk factors that predispose to a higher risk of postoperative BT in patients undergoing RTSA including male sex, people of Asian descent, age > 80, CKD, Parkinson's disease, and cirrhosis. These findings provide clinicians with information that may be helpful with preoperative planning and perioperative management of complex patient populations.