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Importance: Overlapping surgery, in which more than 1 procedure performed by the same primary surgeon is scheduled so the start time of one procedure overlaps with the end time of another, is of concern because of potential adverse outcomes. Objective: To determine the association between overlapping surgery and mortality, complications, and length of surgery. Design, Setting, and Participants: Retrospective cohort study of 66430 operations in patients aged 18 to 90 years undergoing total knee or hip arthroplasty; spine surgery; coronary artery bypass graft (CABG) surgery; and craniotomy at 8 centers between January 1, 2010, and May 31, 2018. Patients were followed up until discharge. Exposures: Overlapping surgery (≥2 operations performed by the same surgeon in which ≥1 hour of 1 case, or the entire case for those

BACKGROUND:: Thrombocytopenia has been considered a relative or even absolute contraindication to neuraxial techniques due to the risk of epidural hematoma. There is limited literature to estimate the risk of epidural hematoma in thrombocytopenic parturients. The authors reviewed a large perioperative database and performed a systematic review to further define the risk of epidural hematoma requiring surgical decompression in this population. METHODS:: The authors performed a retrospective cohort study using the Multicenter Perioperative Outcomes Group database to identify thrombocytopenic parturients who received a neuraxial technique and to estimate the risk of epidural hematoma. Patients were stratified by platelet count, and those requiring surgical decompression were identified. A systematic review was performed, and risk estimates were combined with those from the existing literature. RESULTS:: A total of 573 parturients with a platelet count less than 100,000 mm who received a neuraxial technique across 14 institutions were identified in the Multicenter Perioperative Outcomes Group database, and a total of 1,524 parturients were identified after combining the data from the systematic review. No cases of epidural hematoma requiring surgical decompression were observed. The upper bound of the 95% CI for the risk of epidural hematoma for a platelet count of 0 to 49,000 mm is 11%, for 50,000 to 69,000 mm is 3%, and for 70,000 to 100,000 mm is 0.2%. CONCLUSIONS:: The number of thrombocytopenic parturients in the literature who received neuraxial techniques without complication has been significantly increased. The risk of epidural hematoma associated with neuraxial techniques in parturients at a platelet count less than 70,000 mm remains poorly defined due to limited observations.

BACKGROUND AND PURPOSE: Preoperative embolization of arteriovenous malformations (AVMs) is thought to improve outcome following surgical resection of these lesions. The purpose of this study was to examine the cost associated with preoperative embolization and different surgical risk categories in the surgical treatment of brain AVMs. METHODS: In a review of 126 patients treated surgically for resection of AVMs, we noted the total days spent in the hospital and calculated the associated costs (from hospital and estimated professional fees). Surgical risk category was determined using the Spetzler-Martin grading system. We examined the effect of risk category, preoperative embolization, and outcome (Rankin score) on cost and inpatient days. RESULTS: Preoperative embolization and greater surgical risk were independently associated with higher total costs. Average adjusted cost for embolization and surgery was $78,400 ± $4,900 versus $49,300 ± $5,800 for surgery alone. Patients ranged in preoperative risk category from Spetzler-Martin grades II through V, with an average increase of $20,100 in total cost per Spetzler-Martin grade (95% CI, $13,500 to $28,100). Higher surgical risk category was also associated with more days spent in hospital, with an average increase of 6 days per increment in Spetzler-Martin grade (95% CI, 4 to 8). After surgical resection of an AVM, new neurologic deficits were associated with large differences in cost: $68,500 ± $6,100 and 15 ± 2 days in hospital for patients who were neurologically worse after surgery, versus $44,700 ± $3,900 and 10 ± 1 days for patients who were unchanged. CONCLUSION: Preoperative embolization in the treatment of AVMs is associated with higher cost but not more days in the hospital. Patients with higher Spetzler-Martin grade AVMs utilize more hospital resources, in part because they have poorer neurologic outcome, and postoperative deficits are associated with higher costs and more days in the hospital.

During placement of implantable cardioverter-defibrillators, ventricular arrhythmias are induced to test the function of the devices. Although cerebral hypoperfusion and ischemic electroencephalographic changes occur in patients while implantable cardioverter-defibrillators are being tested, no investigation has assessed neurologic outcome in these patients. Nine patients having either implantation or change of an implantable cardioverter-defibrillator underwent neurologic examination and neuropsychometric tests before and after the operation. After induction of general anesthesia and insertion of implantable cardioverter-defibrillator leads (when needed), ventricular fibrillation, ventricular flutter, or ventricular tachycardia, was induced by means of programmed electrical stimulation. Implantable cardioverter-defibrillator testing continued until satisfactory lead placement was confirmed. The intraoperative electroencephalographic recording was analyzed for evidence of ischemic change. In all, an electroencephalogram was recorded during 50 periods of circulatory arrest. Mean duration of the arrest periods was 13.6 seconds. By means of conventional visual inspection of the raw electroencephalogram, high-amplitude rhythmic delta or theta, voltage attenuation, or loss of fast frequency activity was observed in 30 of the arrests. By means of an automated technique of electroencephalographic interpretation based on power spectral analysis, electroencephalographic changes were correctly identified in 26 of the arrests. The incidence of these electroencephalographic changes was dependent on the arrest duration. The mean interval from arrest onset to electroencephalographic change was 7.5 seconds (standard deviation ± 1.8 seconds). In patients with electroencephalographic changes during multiple arrests, no downward trend in this interval was detected in later arrests and no evidence of persistent ischemic change was observed in electroencephalograms recorded after the conclusion of implantable cardioverter-defibrillator testing. Postoperative neurologic and neuropsychometric testing was completed in eight patients, none of whom exhibited a new neurologic deficit, exacerbation of a preexisting neurologic condition, or significant deterioration in neuropsychometric performance. We conclude that the brief arrest of cerebral circulation induced during insertion of an implantable cardioverter-defibrillator is not associated with permanent neurologic injury. (J THORAC CARDIOVASC SURG 1995; 109: 565-73)