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Background: Chronic postoperative pain following total joint replacement (TJA) is a substantial clinical problem, and poor sleep may affect predictive factors for postoperative pain, such as pain catastrophizing. However, the magnitude of these associations is currently unknown. This exploratory study investigated (1) the relationship between preoperative sleep quality, clinical pain intensity, pain catastrophizing, anxiety, and depression and (2) their associations with chronic postoperative pain following TJA. Methods: This secondary analysis from a larger randomized controlled trial included rest pain intensity (preoperative and 12 months postoperative; visual analogue scale, VAS), preoperative Pittsburgh Sleep Quality Index (PSQI), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS) data from 74 knee and 89 hip osteoarthritis (OA) patients scheduled for TJA. Poor sleepers were identified based on preoperative PSQI scores higher than 5. Results: Poor sleepers demonstrated higher preoperative VAS, pain catastrophizing, anxiety, and depression compared with good sleepers (all p < 0.003). Preoperative PSQI (β = 0.23, p = 0.006), PCS (β = 0.44, p < 0.005), and anxiety (β = 0.18, p = 0.036) were independent factors for preoperative VAS. Preoperative VAS (β = 0.32, p < 0.005), but not preoperative sleep quality (β = −0.06, p = 0.5), was an independent factor for postoperative VAS. Conclusion: The OA patients reporting poor preoperative sleep quality show higher preoperative pain, pain catastrophizing, anxiety, and depression. High preoperative pain intensity, but not poor sleep quality, was associated with higher chronic postoperative pain intensity. Future studies are encouraged to explore associations between sleep and chronic postoperative pain.

Background Proximal interphalangeal joint (PIPJ) arthrodesis can provide reliable pain relief and restore hand function in patients with PIPJ arthritis. However, there is a paucity of literature on patient-specific preoperative risk factors that are associated with adverse outcomes after PIPJ arthrodeses. Therefore, the primary purpose of this study was to assess preoperative predictors of nonunion and reoperation after PIPJ arthrodesis. Methods This study identified all patients who underwent PIPJ arthrodesis at a single community practice between 1987 and 2013. The final analysis included 415 PIPJs treated with arthrodesis. The mean follow-up was 1.3 years. Data on preoperative diagnosis, demographics, comorbidities, and operative techniques were recorded, as well as the occurrence of nonunions and reoperations. Logistic regression models were used to identify independent risk factors of nonunion and reoperation. Results There were 40 nonunions (10%) and 62 reoperations (15%). Of the reoperations, there were 39 incidences of isolated hardware removal, 9 irrigation and debridement, 8 amputations, 5 revision arthrodeses, and 1 corrective osteotomy. The highest number of nonunions occurred in the traumatic diagnosis group (37%), followed by the rheumatoid group (23%) and the scleroderma group (15%). The highest number of reoperations occurred within the traumatic joint disorder group (40%), followed by the rheumatoid group (24%) and the scleroderma group (11%). Multivariate analysis revealed that male sex ( P < .01) and hepatic disease ( P = .03) were significant risk factors of nonunion. Male sex was also significantly associated with increased reoperation risk ( P < .01). Conclusion Risks of nonunions and reoperations after PIPJ arthrodeses are low; however, these findings may guide clinicians and patients in the preoperative decision-making process and help with targeted postoperative surveillance to mitigate these risks.

Objectives Type II endoleak is a problem after endovascular abdominal aneurysm repair. Preoperative risk factors for Type II endoleak include anatomical factors in the lumbar artery and inferior mesenteric artery; however, preventable postoperative risk factors are unknown. Postimplantation syndrome is associated with lower incidence of Type II endoleak. Therefore, we focused on inflammation, and our aim was to investigate nonsteroidal anti-inflammatory drugs as a postoperative risk factor for Type II endoleak. Methods This was a retrospective study of patients with aortic aneurysm who underwent endovascular aneurism repair at the Department of Cardiovascular Surgery, Beppu Medical Center, Oita, Japan, from January 2011 to August 2018. Clinical characteristics were retrieved from patients’ medical records and included age, sex, body mass index, smoking history, comorbidities, treatment devices, medications, and perioperative information, including postimplantation syndrome. Postimplantation syndrome was defined as body temperature >38.5°C with 12,000/dL white blood cells or >10.0 mg/dL C-reactive protein. The primary outcome was the presence or absence of Type II endoleak assessed on the first postoperative enhanced computed tomography scan. Risk factors for Type II endoleak were assessed. Results and conclusions: Of the eligible 84 patients, 20 (24%) had Type II endoleak identified in the first enhanced computed tomographic scans after endovascular aneurism repair. Nonsteroidal anti-inflammatory drug use (odds ratio (OR): 21.2; 95% confidence interval (95% CI): 1.5–308.4; P = 0.026), cerebrovascular disease (OR: 7.27; 95% CI: 1.06–49.99; P = 0.044), and body mass index 2 (OR: 17.3; 95% CI: 2.1–141.8; P = 0.008) were independent risk factors for Type II endoleak after endovascular aneurism repair. Comparing the rate of Type II endoleak among patients who did not receive nonsteroidal anti-inflammatory drugs within 24 h after endovascular aneurism repair, patients who first used nonsteroidal anti-inflammatory drugs 12–24 h after endovascular aneurism repair, and those who received nonsteroidal anti-inflammatory drugs within 12 h after endovascular aneurism repair, we found a significant difference among the groups (4%, 18%, 45%, respectively; P = 0.001). Nonsteroidal anti-inflammatory drug use within 24 h after endovascular aneurism repair is a risk factor for Type II endoleak. We should know nonsteroidal anti-inflammatory drugs within 24 h after endovascular aneurism repair can be a risk of Type II endoleak.

This study examined the effects of pain and opioid intakes on subsyndromal delirium in older adults who had joint replacement surgery. Delirium assessments of 53 older adults were completed on the first, second, and third days following joint replacement surgery using the Confusion Assessment Method (CAM). Statistical relationships were analyzed using correlations and multiple regressions. Subsyndromal delirium developed in 68% ( n = 36) of participants. Pain was significantly related ( p < .05) to increased delirium symptoms after accounting for preoperative risk factors of comorbidity, cognitive status, fall history, and preoperative fasting times, whereas opioid intake was not significantly associated with increased delirium symptoms. Findings suggest older adults with increased pain levels are at higher risk for subsyndromal delirium as well as delirium after joint replacement surgery.

Preoperative risk factors, intraoperative fluid shifts, and transfusions place patients at increased risk for right ventricular failure during left ventricular assist device implantation. Despite aggressive use of inotropes and pulmonary vasodilators, in severe cases of RV failure, a right ventricular assist device may be required. For the past several years, we have been implanting right ventricular assist devices in the presented configuration, allowing less invasive removal without sternotomy. The method is presented herein.

Objective The increasing number of spinal surgeries being performed in the elderly has increased the incidence of postoperative delirium. The prediction of delirium is complex, and few studies have been performed to examine the preoperative risk factors for delirium after spinal surgery in the elderly. This study was performed to clarify such risk factors in patients aged ≥75 years undergoing spinal surgery. Method This retrospective observational study included 299 patients aged ≥75 years. Comorbidities, medication history, preoperative examination findings, surgery-related characteristics, and health scale assessments, including the 36-Item Short-Form Survey (SF-36) score and prognostic nutritional index (PNI), were examined as potential risk factors for delirium. Results Delirium occurred in 53 patients (17.7%). The preoperative risk factors for delirium were a history of stroke and mental disorders, hypnotic drug use, malnutrition, hyponatremia, anemia, respiratory dysfunction, and cervical surgery. Logistic regression analysis demonstrated that the independent predictors of delirium were a history of stroke, non-benzodiazepine hypnotic drug use, preoperative hyponatremia, the PNI, and the SF-36 physical component summary (PCS) score. Conclusions Independent preoperative predictors of delirium in elderly patients undergoing spinal surgery included a history of stroke, non-benzodiazepine hypnotic drug use, preoperative hyponatremia, the PNI, and the SF-36 PCS score.

The aim of this study is to evaluate the validity of the Glasgow aneurysm score (GAS) and Hardman index in patients operated on because of ruptured abdominal aortic aneurysm (rAAA), and determining preoperative risk factors that affect in-hospital mortality. One hundred one patients operated on to repair a rAAA within the last 10 years were included. The GAS and Hardman index were calculated for each patient separately. The relation between in-hospital mortality and the Hardman index and GAS was analyzed by means of the receiver-operator characteristic (ROC) curve. Univariate and multivariate methods of analyses were used to determine preoperative risk factors. Average age was 69 ± 8, and in-hospital mortality rate was 51.5%. Analysis of the ROC curve showed that the Hardman index had an area under the curve (AUC) = 0.71 (95% confidence interval [CI], 0.593–0.800, P = 0.0002) for predicting in-hospital mortality. The GAS had an AUC = 0.77 (95% CI, 0.680–0.851, P < 0.0001). The results of multivariate analysis revealed the presence of the following preoperative risk factors: age more than 63 years (odds ratio [OR], 4.4; 95% CI, 1.17–16.49, P = 0.028); loss of consciousness (OR, 9.33; 95% CI, 1.94–44.86, P = 0.005); creatinine higher than 1.7 mg/dL (OR, 5.52; 95% CI, 1.92–15.85, P = 0.001); and pH lower than 7.31 (OR, 3.77; 95% CI, 1.18–11.99, P = 0.024). In conclusion, the Hardman index and GAS have a significant correlation with in-hospital mortality rates. Nevertheless, a high score does not necessarily correspond with a definite mortality. This is why scoring systems could not be considered as the sole criterion for choosing patients for this study. Clinical experience was still the leading factor in deciding against or in favor of surgery.

We sought to describe outcome of surgical repair in patients presenting with orbital blowout fractures. This noncomparative, retrospective, consecutive case series reviewed the case notes of 63 consecutive patients who underwent surgery for a blowout fracture between November 1992 and March 2005. Risk factors for motility outcome as well as presence of enophthalmos after surgery were analyzed. Children had earlier surgery than adults ( p < 001) and tended to have better motility outcome than adults. Surgery performed within the first week showed a trend for better outcome, but this was not statistically significant ( p = 0.231). Assault had the best motility outcome, compared with other modes of trauma. Patients with worse preoperative motility had better outcome ( p < 0.001). Enophthalmos improved significantly after surgery ( p < 001). Children as compared with adults and surgery performed within the first week tended to have better motility outcome, but this was not statistically significant.

Introduction: Perioperative delirium in elderly hip fracture patients has been correlated with significant morbidity. The purpose of this study was to determine the preoperative risk factors for and short-term sequelae of postoperative delirium in geriatric hip fracture patients. Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained operative hip fractures in 2016. Cohorts of patients with and without documented postoperative delirium were identified. Primary data on patient demographics and comorbidities were collected and correlated with postoperative complications and hip fracture outcome measures. Multivariate regression was used to compute risk-adjusted odds ratios (OR) of risk factors and sequelae of delirium. Results: In total, 8,439 geriatric hip fracture patients were identified of whom 2,569 patients (30.4%) had postoperative delirium. Age (OR 1.03 [1.02-1.04, p < 0.001), white race (OR 1.54 [1.19-2.00], p = 0.001), American Society of Anesthesiologists classification (OR 1.20 [1.07-1.36], p = 0.003), baseline dementia (OR 2.46 [2.11-2.86], p < 0.001), and preoperative delirium (OR 10.06 [8.12-12.45], p < 0.001) were independent risk factors for postoperative delirium in multivariate analysis. Patients with postoperative delirium had a significantly higher risk-adjusted 30-day mortality (12.0% vs. 4.8%, OR 2.22 [1.74-2.84], p < 0.001) and morbidity profile. Postoperative delirium was also independently associated with higher rates of discharge to (OR 1.65 [1.32-2.06], p < 0.001) and prolonged stay in (OR 1.79 [1.53-2.09], p < 0.001) an inpatient facility, hospital readmission (OR 1.94 [1.58-2.38], p < 0.001) and hospital length of stay (7.6 ± 5.0 vs. 6.1 ± 4.1 days, p < 0.001), as well as lower rates of immediate postoperative weight bearing (OR 0.73 [0.63-0.86], p < 0.001). Discussion: Postoperative delirium is a common occurrence in geriatric hip fractures with multiple risk factors. Delirium portends higher mortality and worse perioperative hospital-based outcomes. Conclusions: Multidisciplinary foreknowledge and management efforts are warranted to mitigate the risk of developing delirium, which strongly predicts perioperative morbidity, mortality, and hip fracture outcomes.

Most performance assessments of cardiac surgery programs use models based on preoperative risk factors. Models that were primarily developed to assess performance in general intensive care unit (ICU) populations have also been used to evaluate the quality of surgical, anesthetic, and ICU management after cardiac surgery. Although there are currently 5 models for evaluating general ICU populations, only the Acute Physiology and Chronic Health Evaluation (APACHE) system has been independently validated for cardiac surgery patients. This review describes the evolution, rationale, and accuracy of APACHE models that are specific for cardiac surgery patients as well as for patients who have had vascular and thoracic procedures. In addition to performance comparisons based on observed and predicted mortality, APACHE provides similar comparisons of ICU and hospital lengths of stay and duration of mechanical ventilation. However, the low mortality incidence of many cardiac outcomes means that very large numbers of patients must be obtained to get good predictive models. Thus, the equations are not designed for predicting individual patients' outcome but have proven useful in performance comparisons and for quality improvement initiatives.

Serious pulmonary failure may be treated with extracorporeal membrane oxygenation (ECMO) when other treatment has failed. The aim of this study was to analyze pre-operative risk factors of early mortality in patients who underwent either veno-arterial (VA) ECMO or veno-venous (VV) ECMO for pulmonary failure. We studied a total of 26 risk factors in 72 patients with severe pulmonary insufficiency treated with ECMO. All consecutive cases treated at our institution between Sept 1990 and Aug 2007 were included. Univariate analysis and multiple logistic regression analysis were performed on 26 risk factors. The end point was early mortality (any death within 30 days of ECMO treatment). Thirty-six (50%) of the patients died within 30 days of treatment. Age, gender, body mass index(BMI)(adults), cause of pulmonary failure, pre-ECMO treatment with nitric oxide(NO), intra-aortic balloon pump(IABP), and type of ventilation did not significantly influence early mortality. Neither pre-operative blood gas results, oxygenation index or pre-operative PaO2/FiO2ratio, nor mean ventilator days prior to ECMO gave any indications on early mortality. Liver function did not predict early mortality, but pre-ECMO serum creatinine levels were significantly lower in patients who survived. Treatment with ECMO in patients with severe pulmonary failure may save lives. It is, however, difficult to predict outcome when initiating ECMO. In this analysis, only pre-operative serum creatinine levels correlated with survival. None of the other parameters, including those which were used to select patients for ECMO treatment, could significantly predict the outcome.

Ciaglia Blue Rhino percutaneous dilatational tracheostomy is used as an aid to ventilatory weaning. It carries an immediate complication rate previously reported in 100 consecutive patients by Fikkers et al at 6% for “major” complications and 30% for “minor” complications. Mortality has been associated with the procedure. Our institution has performed dilatational percutaneous tracheostomy since 1998 and used the Blue Rhino technique since 2002. Consensus guidelines were developed following initial experiences. They focus on preoperative risk assessment including levels of ventilatory support and anatomical considerations, seniority of staff, use of bronchoscopy and capnography and correction of coagulopathies. Following introduction of the guidelines we conducted an audit of the first 200 Ciaglia Blue Rhino tracheostomies performed. There was an immediate major complication rate of 3% and minor complication rate of 18%. No deaths occurred within 24 hours of the procedure. We conclude that applying our consensus guidelines produced an immediate complication rate for Ciaglia Blue Rhino percutaneous dilatational tracheostomy below published audits.

Peer review of surgical cases resulting in death or potentially avoidable complications is a longstanding tradition, but intensive reviews of individual cases rarely produces tangible improvements in clinical outcomes. The systematic comparison of care received by patients who experienced adverse outcomes to care received by patients who had uneventful surgical courses is a promising alternative to intensive case review. However, the results of these studies may be misleading because physicians often choose interventions based on their perceptions of patients’ preoperative risks, and higher adverse outcome rates among patients with higher preoperative risk may distort comparisons of alternative interventions. The creation of a control sample by carefully matching each patient who experienced an adverse outcome to a patient who had a similar preoperative risk but did not experience an adverse outcome can overcome this problem and provide excellent insight into how to improve clinical performance most effectively and efficiently. By using currently available electronic data to compute each patient's risk of an adverse outcome, a series of cases with adverse outcomes can be matched to an equal number of controls. Peer review committees can then direct focused data collection and analyses of potentially critical processes of care to determine which, if any, are associated with significantly poorer clinical results. A simulated scenario is analyzed in detail to illustrate the ability of this technique to correctly determine best practices when other approaches fail to do so.

Statistical analysis of data collected prospectively from all patients undergoing surgery under cardiopulmonary bypass from September 1994 to November 1998 (group 1) was performed to identify preoperative risk factors for reopening for bleeding. Multiple logistic regression analysis of 19 preoperative variables was carried out with reoperation for bleeding as the endpoint. The protocol for intraoperative use of aprotinin was then changed to include high-risk patients. Data collected from all subsequent patients from May 1999 to March 2002 (group 2) were analyzed. Subgroup analyses on primary isolated coronary artery surgery were also performed. Data were obtained from 1,946 patients aged 22 to 88 years (mean, 62.5 years). Older age, severe left ventricular impairment, redo surgery, and chronic renal failure were the independent predictors of reopening for bleeding in group 1. There were no independent predictors of reopening in group 2. Older age and chronic renal failure were the predictors of reexploration for bleeding in patients undergoing primary isolated coronary artery grafting. Prophylactic measures to prevent excessive bleeding should be used in elderly patients and those with severe left ventricular impairment, redo surgery, and chronic renal failure.

Performing laparoscopic cholecystectomy (LC) always carries the risk of having to convert from laparoscopic to open cholecystectomy (LOC). Being able to identify these patients preoperatively may allow better preoperative planning and lowering operative cost. All LC and LOC were performed by the Eastern Virginia Medical School Department of Surgery retrospectively identified between January 2008 and December 2009. Preoperative risk factors identified in both groups included: age, gender, body mass index greater than 30 kg/m2, diabetes mellitus, previous upper abdominal surgery, previous abdominal surgery, presence of pericholecystic fluid, gallbladder wall thickness greater than 3 mm, preoperative diagnosis of acute cholecystitis, and pancreatitis. Reasons for conversion in the LOC group were identified from the operative note. A total of 346 LC and LOC were identified. The LOC group had 41 identified with a conversion rate of 11.9 per cent. The LOC group was compared with 100 randomly chosen LC. Risk factors that reached statistical significance for conversion included advanced age, male gender, previous upper abdominal surgery, preoperative diagnosis of acute cholecystitis, and gallbladder wall thickness greater than 3 mm ( P = 0.0009). Average operative time was higher in LOC compared with open cholecystectomy (123 minutes average vs 109 minutes average). Of the reasons for conversion, the degree of inflammation was the most common (51.2%). Preoperative risk factors that were associated with need for conversion were advanced age, male gender, previous upper abdominal surgery, preoperative diagnosis of acute cholecystitis, and pericholecystitic fluid. In patients who have all of these risk factors, we recommend starting with an open cholecystectomy. This will save operative time and overall cost.

From 1982 to 1986, 27 of 34 consecutive patients with squamous cell carcinoma of the distal esophagus had resection by the transthoracic approach. From 1987 to 1990, 39 of 48 consecutive patients underwent transhiatal esophagectomy. The two groups were comparable in terms of demographics, preoperative risk factors, and tumor stage. All patients had received one cycle of anterior chemotherapy. The incidence of pneumonia and wound infection was significantly higher following transthoracic compared to transhiatal resection (44% versus 18%). Transhiatal esophagectomy required markedly less operating time (137 versus 327 min) but had a higher incidence of recurrent laryngeal nerve palsy (20% versus 0%). Anastomotic leaks occurred with similar frequency in both groups (23% versus 19%) and intrathoracic disruption carried a very high mortality (80%). Transhiatal resection had lower mortality (10% versus 26%) and both groups had similar survival. These results suggest that compared to transthoracic esophagectomy, the transhiatal approach had fewer complications, a lower mortality rate, and comparable survival, and thus remains an acceptable procedure for resection of squamous cell carcinoma of the distal esophagus.

A retrospective review of a community experience with ruptured abdominal aortic aneurysm (AAA) identified 117 cases from five community hospitals over a 12-year period. There were 90 men (77%) and 27 women (23%), ranging in age from 49 to 87 years. In the initial 6 years, the majority of operations were performed by general surgeons, with a survival rate of 35%. In the latter 6 years, most operations were performed by vascular surgeons, with a survival rate of 61%. For the entire period, patient survival with vascular surgeons was significantly greater than that with general surgeons ( P< 0.05). Preoperative risk factors assessed in terms of their impact on survival were similar to those of previously reported series. Patients in the latter half of the study were older (72.8 versus 69.9 years), with survivors requiring a longer length of hospital stay than those in the initial 6-year period (34.5 versus 22.5 days), indicative of the changing patient population and having diagnostic-related group implications. There was also increased reliance by emergency room physicians on computed tomography for diagnosis, with increased survival rates. Misdiagnosis (patient sent home or admitted with incorrect diagnosis) occurred in 12 patients with no deleterious impact on survival. Some 15 patients with known AAA who either refused surgery for medical reasons or were considered to be at excessive risk for elective resection had a survival rate of 33%, indicating a definite potential for survival. It is concluded that there is continuing evolution of care for patients with ruptured AAA in the community setting. Prompt computed tomography in uncertain cases and management by vascular surgeons have had a positive impact on survival. A survival rate > 60% can be achieved in a community hospital.

Introduction Surgery for lumbar disc degeneration has been shown to yield poor results in 10 to 45% of the patients. Evidence-based clinical tools for preoperative risk estimation would be very important to identify the “at-risk” patients. Several factors referring on the patients' symptoms, psychosocial issues, and medical history were previously published as significant individual risk factors on outcome, but there is low number of reports on integrative models with advanced statistics. The aim of this study was to identify significant outcome predictors and clinically different subgroups in patients surgically treated because of lumbar degenerative disc disease. Patients and Methods A total of 750 consecutive patients indicated for one- or two-level lumbar decompression/microdiscectomy or fusion surgery (TLIF) were recruited into the study. Patients with previous lumbar surgery or nondisc degeneration-related phenotype were not included into the analysis. Patients completed a questionnaire booklet containing the Oswestry disability index (ODI), visual analogue scales on low back (LBP), and leg pain (LP), Zung depression scale (ZDS), and the Modified Somatic Perception Questionnaire (MSPQ) before the surgery and 2 years after the surgery. Five-point Likert scale on self-reported outcome of the surgery was classified into two categories (“good” and “poor” outcome) and effect of preoperative parameters on that was determined applying uni- and multivariate logistic regression models. Two-step agglomerative cluster analysis was used to determine the best fit cluster structure of the cohort entering the significant outcome predictors into the model. Multivariate analysis of variance (MANOVA) and Fischer test were used to analyze the clinical clusters and their canonical discriminant functions. Chi-square tests were applied to investigate the clinical outcome in the different clusters. Results Four different preoperative parameters; number of spinal levels treated, severity of low back pain, duration of pain, and distress (calculated from ZDS and MSPQ scores) were proved to be significant predictors on surgical outcome in the final multivariate regression model ( p Conclusion Preoperative parameters of the patients with lumbar disc degeneration have got significant influence on the midterm surgical outcome. Outcome predictors determine different patient clusters with different risk for poor outcome. Advanced statistical approaches are advised to use in the future for patient stratification and risk estimation.

Nasogastric decompression following abdominal aortic aneurysmectomy or bypass, for 3–4 days, is a routine part of postoperative care in many centers. A prospective randomized study of 80 patients undergoing abdominal aortic surgery was performed in order to determine the necessity of prolonged nasogastric decompression. Patients were divided evenly between removal of the nasogastric tube upon tracheal extubation and retention of the tube until the passage of flatus. Preoperative risk factors, aortic cross-clamp time, estimated blood loss, length of procedure, length of intensive care unit stay, numbers of days with nasogastric tube, number of days until clear liquid and regular diets commenced, and the length of hospital stay were recorded for all patients. There were no significant differences in any of the measured variables between the two groups. The length of hospital stay was similar in both groups and three patients in each group required a nasogastric tube or reinsertion of one. In conclusion, the routine postoperative use of nasogastric tubes for abdominal aortic procedures is unnecessary. Copyright © 1996 The International Society for Cardiovascular Surgery.