Pre-operative

Preoperative Opioid and Benzodiazepine Prescription Patterns and Mortality After Noncardiac Surgery

The risks from opioid and benzodiazepines may begin even earlier than the perioperative period. This retrospective analysis examined patients that received prescriptions for either in the year before surgery.

They found “opioid and benzodiazepine prescription fills in the 6 months before surgery are associated with increased short-and long-term mortality and an increased rate of persistent postoperative opioid consumption.”

It is suggested: “These patients should be considered for early referral to preoperative clinic and medication optimization to improve surgical outcomes.”

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Pediatric Risk Stratification: Patient Comorbidities and Intrinsic Surgical Risk

A retrospective study of the Pediatric NSQIP delineated the impact of intrinsic surgical risk with patient co-morbidities, informing how intrinsic surgical risk can add to mortality prediction.

“Surgical procedures identified by specialty are not independent risk factors for perioperative mortality in pediatric patients. However, in multivariable predictive algorithms, the interaction of patient comorbidities with the intrinsic risk of the surgical procedure strongly predicts 30-day mortality.”

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Frailty in Older Patients Undergoing Emergency Laparotomy

Emergency laparotomy has been the subject of many surveys, notably the NELA audit in the UK, which identified areas for improvement.

This current study examined the specific impact of frailty, which should now be routinely and formally scored in older patients.

The conclusion is in line with so much other evidence documented in this blog:

“A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age.”

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Antibiotic Prophylaxis and Dental Procedures

Routine antibiotics before dental procedures are only recommended in select circumstances but continue to be over prescribed. This also seems to be an issue in orthopedics where prosthetic joint prophylaxis is prescribed although it was in most cases considered unnecessary.

This study found “More than 80% of antibiotics prescribed for infection prophylaxis before dental visits were unnecessary”.

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Gabapentinoids and Adverse Postoperative Respiratory Outcomes

This study examined the association between gabapentinoids on the day of surgery and adverse postoperative outcomes in patients undergoing colorectal surgery in the United States.

Their use was associated with only a slightly lower opioid use on the day of surgery but a higher odds of non-invasive ventilation and naloxone use after surgery.

It highlights the fact that before blindly implementing enhanced recovery protocols, a firm evidence base should be established, as opioid-phobia may paradoxically result in unintended adverse events.

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Chronic Post-Surgical Pain after TKR

This was a medical record study that sought to identify the pre-surgical risk factors for chronic post-surgical pain after total knee replacement.

Factors that could predict pain at 5 years in about a third included: fibromyalgia, chronic pain in body parts other than the knee, previous diagnosis of cancer, knee instability, younger age, and presurgical knee pain.

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Preoperative Carbohydrate Loading

Pre-operative carbohydrate loading has been shown to reduce pre-operative discomfort and postoperative nausea and vomiting in general surgical patients, and is a component of enhanced recovery after surgery (ERAS) protocols. This study considered day-case surgery, specifically day case cholecystectomy.

The carbohydrate-rich drink group received oral carbohydrate (200 ml) 2 to 3 h before surgery, and the control (fasting) group fasted from midnight according to standard protocol.

There were no significant differences in any VAS scores between the study groups. No differences in time to mobilisation, need for pain or antiemetic medication or time to discharge were seen between the groups.

The authors conclude: compared with overnight fasting, pre-operative carbohydrate loading did not significantly enhance peri-operative well being or recovery in patients undergoing day-case cholecystectomy.

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Pediatric Temperament and Postoperative Pain

The influence of psychological, psychiatric and emotional factors on pain postoperatively has been well described. Recent studies have shown the negative effects of anxiety, depression, sleep disturbance, and even parental anxiety on postoperative pain in adults as well as children.

This study shows “preoperative temperament characteristics may differentially influence pediatric post‐operative pain experience in children. Specifically, children with high levels of positive and negative emotionality may exhibit more post‐surgical pain behaviors”.

The novel approach looked at broader temperament analysis; positive excitability clusters as well as the more well known negative attitudes are a factor to consider for pain prediction.

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Preoperative Erythropoietin And Transfusion in Surgical Patients

Erythropoietic-stimulating agents such as erythropoietin find wide usage in cancer chemotherapy-related as well as kidney disease anemia, but concerns continue as to their thromboembolic risks.

This systematic review and meta-analysis found a significant reduction in perioperative allogeneic blood transfusions, also confirmed among the subset of patients undergoing cardiac and orthopedic surgery. They found no significant increase in risk of thromboembolic complications with preoperative erythropoietin administration.

Dosing and timeframes in less heterogeneous populations may be needed but the results are encouraging.

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