Implementing Preoperative Penicillin Allergy Testing in Surgical Patients.

Penicillin allergy is the most reported immunoglobulin E (IgE)-mediated reaction. About 10% of the general population and 20% of hospitalized patients have a history of penicillin allergy. Unconfirmed penicillin allergy with subsequent administration of second-line antibiotics has been associated with increased morbidity. However, when penicillin allergy testing is performed, the incidence of IgE-mediated reactions is extremely low; in fact, the negative predictive value of penicillin allergy testing exceeds 99%. This article aims to briefly describe implementing safe penicillin allergy testing as a routine test during the preoperative evaluation of surgical patients.

Limited English Proficiency and Perioperative Patient-Centered Outcomes: A Systematic Review.

This systematic review assesses whether limited-English proficiency (LEP) increases risk of having poor perioperative care and outcomes. This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 99 articles were identified in Embase and PubMed and screened by 2 independent reviewers. Ten studies, which included 3 prospective cohort studies, 6 retrospective cohort studies, and 1 cross-sectional study, met inclusion and exclusion criteria. All studies were of high-quality rating according to the Newcastle-Ottawa scale. Subsequently, the Levels of Evidence Rating Scale for Prognostic/Risk Studies and Grade Practice Recommendations from the American Society of Plastic Surgeons were used to assess the quality of evidence of each study and the strength of the body of evidence, respectively. There is strong evidence that professional medical interpreter (PMI) use or having a language-concordant provider for LEP patients improves understanding of the procedural consent. The evidence also highly suggests that LEP patients are at risk of poorer postoperative pain control and poorer understanding of discharge instructions compared with English-speaking patients. Further studies are needed to discern whether consistent PMI use can minimize the disparities in pain control and discharge planning between LEP and English-proficient (EP) patients. There is some evidence that LEP status is not associated with differences in having adequate access to and receiving surgical preoperative evaluation. However, the evidence is weak given the small number of studies available. There are currently no studies on whether LEP status impacts access to preoperative evaluation by an anesthesiology-led team to optimize the patient for surgery. There is some evidence to suggest that LEP patients, especially when PMI services are not used consistently, are at risk for increased length of stay, more complications, and worse clinical outcomes. The available outcomes research is limited by the relative infrequency of complications. Additionally, only 4 studies validated whether LEP patients utilized a PMI. Future studies should use larger sample sizes and ascertain whether LEP patients utilized a PMI, and the effect of PMI use on outcomes.

Preoperative Anemia and Risk for Perioperative Neurocognitive Dysfunction in Cardiac Surgery Patients: A Retrospective Analysis.

OBJECTIVES: To evaluate whether there is a relationship between preoperative anemia and domain-specific cognitive performance in patients undergoing cardiac surgery. DESIGN: Retrospective analysis of data collected from a randomized study. SETTING: Tertiary care university hospital. PARTICIPANTS: A total of 436 patients age ≥55 years undergoing cardiac surgery. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Neuropsychological testing was performed before and one month after surgery, using a standard battery. Individual Z-scores calculated from the mean and standard deviation of tests at baseline were combined into domain-specific scores. Anemia (hemoglobin <130 g/L for men, <120 g/L for women) was present in 41% of patients. Preoperative anemia had little impact on preoperative cognition. There were no differences in the change in cognitive performance one month after surgery from baseline between patients with and without preoperative anemia. However, in a sensitivity analysis using multiple imputation for missing cognitive test scores, significant associations were observed between preoperative anemia and change in postoperative processing speed (p = 0.016), change in executive function (p = 0.049), and change in fine motor speed (p = 0.016). Nadir hemoglobin during cardiopulmonary bypass, which was lower in anemic than nonanemic patients, was associated with decrements in performance on tests of verbal fluency (p = 0.007), processing speed (p = 0.042), and executive function (p = 0.10) one month after surgery but not delayed neurocognitive recovery (p = 0.06). CONCLUSIONS: Preoperative anemia may be associated with impairment of selective cognitive domains after surgery. Any effect of preoperative anemia may have on cognition after surgery might be related to lower nadir hemoglobin during cardiopulmonary bypass.

Risk assessment and risk stratification for perioperative complications and mitigation: Where should the focus be? How are we doing?

Various risk stratification tools are used to predict patients' risk of adverse outcomes. Most of these tools are based on type of surgery and patient comorbidities. Accuracy of risk prediction is improved when additional factors such as functional capacity are included. However, these tools are limited because data are obtained from specific patient populations, are simplified to aid ease of use, and do not account for improved treatment modalities that occur over time. Risk estimation allows for shared decision-making among the perioperative care team and the patient, for perioperative planning, and for opportunity for risk mitigation. Technological advancement in data collection will likely improve existing risk assessment and allow development of new options. Future research should focus on establishing and standardizing perioperative outcomes that include meaningful patient-centric considerations such as quality of life. We review available stratification tools and important risk assessment biomarkers that address the most common causes of adverse outcomes.

Preoperative considerations for Jehovah's Witness patients: a clinical guide.

PURPOSE OF REVIEW: Jehovah's Witnesses have religious beliefs that preclude transfusion of blood products and certain medical interventions. This presents a unique dilemma and ethical challenge to healthcare providers, especially in a surgical setting. RECENT FINDINGS: The growing number of followers of this faith warrants a deeper look at the ethical, legal, and clinical implications of their beliefs. Advances in patient blood management now allow timely optimization before surgery. SUMMARY: Anticipating the challenges associated with managing and optimizing patients who refuse blood products allows for more favorable outcomes in the preoperative period.

An Effective and Efficient Testing Protocol for Diagnosing Iron-deficiency Anemia Preoperatively.

BACKGROUND: Iron-deficiency anemia is a common perioperative condition and increases perioperative morbidity and mortality. Timely diagnosis and treatment are important. This retrospective cohort study tested the hypothesis that a newly developed preprocedure evaluation protocol diagnoses more patients with iron-deficiency anemia than the traditional practice of obtaining a complete blood count followed by iron studies. METHODS: The preprocedure anemia evaluation is an order for a complete blood count and reflex anemia testing, which can be completed with a single patient visit. A hemoglobin concentration of 12 g/dl or less with serum ferritin concentration less than 30 ng/ml or transferrin saturation less than 20% defined iron-deficiency anemia. Northwestern Medicine's database was queried for preoperative clinic patients, age 16 to 89 yr, before (2015 to 2016) and after (2017 to 2018) protocol implementation. The proportion of patients diagnosed with iron-deficiency anemia before and after the preprocedure anemia evaluation implementation was compared. RESULTS: Before implementing the protocol, 8,816 patients were screened with a traditional complete blood count. Subsequent iron studies at the providers' discretion diagnosed 107 (1.2%) patients with iron-deficiency anemia. Some patients were still screened with a complete blood count after implementing the protocol; 154 of 4,629 (3.3%) patients screened with a complete blood count and 738 of 2,828 (26.1%) patients screened with the preprocedure anemia evaluation were diagnosed with iron-deficiency anemia. The preprocedure anemia evaluation identified a far larger proportion of patients with iron-deficiency anemia than did the traditional complete blood count when compared both before (relative risk [95% CI], 21.5 (17.6 to 26.2); P < 0.0001) and after (7.8 [6.6 to 9.3]; P < 0.0001) its implementation. CONCLUSIONS: The preprocedure anemia evaluation improved identification of iron-deficiency anemia preoperatively. It is more effective and efficient, allowing anemia evaluation with a single patient visit.

Preoperative Evaluation for Ambulatory Anesthesia: What, When, and How?

Most surgery in the United States occurs in offices, free-standing surgicenters, and hospital-based outpatient facilities. Patients are frequently elderly with comorbidities, and procedures are increasingly complex. Traditionally, patients have been evaluated on the day of surgery by anesthesia providers. Obtaining information on patients' health histories, establishing criteria for appropriateness, and communicating medication instructions streamline throughput, lower cancellations and delays, and improve provider and patient satisfaction. Routine testing does not lower risk or improve outcomes. Evaluating and optimizing patients with significant diseases, especially those with suboptimal management, has positive impact on ambulatory surgery and anesthesia.

Bilateral Prone Percutaneous Nephrolithotomy Under Epidural in Candidate for Lung Transplant: Case Report and Review of Literature.

Background: Percutaneous nephrolithotomy (PCNL) is a procedure typically performed under general anesthesia (GA); however, many patients might be considered unfit for GA and locoregional anesthesia is their only chance to have the procedure done. Case Presentation: A 60-year-old Middle-Eastern female with end-stage lung disease underwent evaluation for lung transplant; she was found to have severe restrictive pattern on steroid and continuous oxygen therapy, pulmonary hypertension with dilated right ventricle, chronic anemia, and asthma. She had kidney stones for 10 years, having spontaneously passed several in the past. During work-up for a lung transplant, she was found to have bilateral staghorn calculi and was referred to urology for stone management before lung transplant. After insertion of a Double-J stent for management of worsening right hydronephrosis, antibiotic therapy for extended spectrum beta-lactamases Klebsiella pneumoniae, and optimization after two procedure cancellations because of new onset of cardiovascular issues, she had a simultaneous bilateral PCNL under thoracic epidural anesthesia in two stages within 48 hours without significant complications. She was rendered stone-free and a candidate to be added to the lung transplant list. Conclusion: Bilateral prone PCNL under epidural is a safe and effective option in high anesthetic risk patients.