Severity of Prior Coronavirus Disease 2019 is Associated With Postoperative Outcomes After Major Inpatient Surgery.

OBJECTIVE: To determine how the severity of prior history (Hx) of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection influences postoperative outcomes after major elective inpatient surgery. BACKGROUND: Surgical guidelines instituted early in the coronavirus disease 2019 (COVID-19) pandemic recommended a delay in surgery of up to 8 weeks after an acute SARS-CoV-2 infection. This was based on the observation of elevated surgical risk after recovery from COVID-19 early in the pandemic. As the pandemic shifts to an endemic phase, it is unclear whether this association remains, especially for those recovering from asymptomatic or mildly symptomatic COVID-19. METHODS: Utilizing the National COVID Cohort Collaborative, we assessed postoperative outcomes for adults with and without a Hx of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from infection to surgery were each used as independent variables in multivariable logistic regression models. RESULTS: This study included 387,030 patients, of whom 37,354 (9.7%) were diagnosed with preoperative COVID-19. Hx of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of respiratory failure. CONCLUSIONS: Impact of COVID-19 on postoperative outcomes is dependent on the severity of illness, with only moderate and severe disease leading to a higher risk of adverse outcomes. Existing perioperative policies should be updated to include consideration of COVID-19 disease severity and vaccination status.

Severity of Prior COVID-19 Infection is Associated with Postoperative Outcomes Following Major Inpatient Surgery.

Objective: To determine the association between severity of prior history of SARS-CoV-2 infection and postoperative outcomes following major elective inpatient surgery. Summary Background Data: Surgical guidelines instituted early in the COVID-19 pandemic recommended delay in surgery up to 8 weeks following an acute SARS-CoV-2 infection. Given that surgical delay can lead to worse medical outcomes, it is unclear if continuation of such stringent policies is necessary and beneficial for all patients, especially those recovering from asymptomatic or mildly symptomatic COVID-19. Methods: Utilizing the National Covid Cohort Collaborative (N3C), we assessed postoperative outcomes for adults with and without a history of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from SARS-CoV-2 infection to surgery were each used as independent variables in multivariable logistic regression models. Results: This study included 387,030 patients, of which 37,354 (9.7%) had a diagnosis of preoperative COVID-19. History of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of mortality and other complications. Conclusions: Impact of COVID-19 on postoperative outcomes is dependent on severity of illness, with only moderate and severe disease leading to higher risk of adverse outcomes. Existing wait time policies should be updated to include consideration of COVID-19 disease severity and vaccination status.

Preoperative Management of Gastrointestinal and Pulmonary Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

Perioperative medication management is integral to preoperative optimization but remains challenging because of a paucity of literature guidance. Published recommendations are based on the expert opinion of a small number of authors without collaboration from multiple specialties. The Society for Perioperative Assessment and Quality Improvement (SPAQI) recognized the need for consensus recommendations in this area as well as the unique opportunity for its multidisciplinary membership to fill this void. In a series of articles within this journal, SPAQI provides preoperative medication management guidance based on available literature and expert multidisciplinary consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of gastrointestinal and pulmonary medications. A panel of experts with anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialty experience was drawn together and identified the common medications in each of these categories. The authors then used a modified Delphi approach to review the literature and to generate consensus recommendations.

Preoperative Management of Endocrine, Hormonal, and Urologic Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

Perioperative medical management is challenging due to the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources utilize the recommendations derived from individual studies and do not include a multidisciplinary focus or formal consensus. The Society for Perioperative Assessment and Quality Improvement (SPAQI) identified a lack of authoritative clinical guidance as an opportunity to utilize its multidisciplinary membership to improve evidence-based perioperative care. SPAQI seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this Consensus Statement is to provide practical guidance on the preoperative management of endocrine, hormonal, and urologic medications. A panel of experts with anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialty experience was drawn together and identified the common medications in each of these categories. The authors then utilized a modified Delphi approach to critically review the literature and generate consensus recommendations.

Using Time-Driven Activity-Based Costing to Demonstrate Value in Perioperative Care: Recommendations and Review from the Society for Perioperative Assessment and Quality Improvement (SPAQI).

A shift in healthcare payment models from volume toward value-based incentives will require deliberate input into systems development from both perioperative clinicians and administrators to ensure appropriate recognition of the value of all services provided-particularly ones that are not reimbursable in current fee-for-service payment models. Time-driven activity-based costing (TDABC) methodology identifies cost drivers and reduces inaccurate costing based on siloed budgets. Inaccurate costing also results from the fact that current costing methods use charges and there has been tremendous cost shifting throughout health care. High cost, high variability processes can be identified for process improvement. As payment models inevitably evolve towards value-based metrics, it will be critical to knowledgably participate in the coordination of these changes. This document provides 8 practical Recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI) aimed at outlining the principles of TDABC, creating process maps for patient workflows, understanding payment structures, establishing physician alignment across service lines to create integrated practice units to facilitate development of evidence-based pathways for specific patient risk groups, establishing consistent care delivery, minimizing variability between physicians and departments, utilizing data analytics and information technology tools to track progress and obtain actionable data, and using TDABC to create costing transparency.

Updates in perioperative medicine.

BACKGROUND: As our surgical population becomes older and more medically complex, knowledge of the most recent perioperative literature is necessary to optimize perioperative care. We aim to summarize and critique literature published over the past year with the highest potential to impact the clinical practice of perioperative medicine. METHODS: We reviewed articles published between January 2014 and April 2015, identified via MEDLINE search. The final 10 articles selected were determined by consensus among all authors, with criteria for inclusion including scientific rigor and relevance to perioperative medicine practice. RESULTS: Key findings include: long term ß-blockade should be continued prior to surgery, routine screening with postoperative troponin is not recommended, initiation/continuation of aspirin or clonidine in the perioperative period is not beneficial and may increase adverse outcomes, preoperative diagnosis and treatment of obstructive sleep apnea may reduce risk of postoperative cardiovascular complications, new pulmonary risk indices are available that accurately estimate postoperative pulmonary complications, postoperative atrial fibrillation is associated with increased long-term stroke risk, risk scores such as the CHADS2 (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes Mellitus, previous stroke or transient ischemic attack) are superior to the Revised Cardiac Risk Index in predicting adverse postoperative outcomes for patients with nonvalvular atrial fibrillation, and utilization of bridging anticoagulation comes with a much higher risk of bleeding compared to patients who are not bridged. CONCLUSIONS: The body of literature reviewed provides important information for clinicians caring for surgical patients across multiple fronts, including preoperative risk assessment, medication management, and postoperative medical care.

Perioperative cardiovascular medicine: an update of the literature 2013-2014.

Perioperative medicine is an important and rapidly expanding area of interest across multiple specialties, including internal medicine, anesthesiology, surgery, cardiology, and hospital medicine. A multispecialty team approach that ensures the best possible patient outcomes has fostered collaborative strategies across the continuum of patient care. Staying current in this multidisciplinary field is difficult, because physicians interested in perioperative medicine would need to review multiple specialty journals on a regular basis. To facilitate this process, the authors performed a focused review of this literature published in 2013 and early 2014. In this update, key articles are reviewed that potentially impact clinical practice in perioperative cardiovascular risk prediction and risk management.

Risk factors for postoperative pulmonary complications: an update of the literature.

Perioperative medicine is a growing area of research that brings together internists, anesthesiologists, surgeons, and hospitalists. A medical team approach to ensure the best possible patient outcomes has fostered collaborative strategies across disciplines. Perioperative pulmonary complications are common and can be associated with significant morbidity and mortality. Effective strategies to identify and reduce risks of pulmonary complications can improve patient outcomes. We review the new literature (2013 to early 2014) in the field of perioperative pulmonary medicine that reports new strategies to improve outcomes in the area of perioperative pulmonary care.

Perioperative anticoagulation and renal disease: an update.

As our surgical population becomes older and increasingly medically complex, knowledge of the most recent perioperative literature can provide guidance for physicians across multiple specialties caring for the surgical patient. Common issues many clinicians encounter in the perioperative period relate to anticoagulation and renal disease. This article identifies gaps in knowledge for the fields of perioperative anticoagulation, acute kidney injury, and chronic kidney disease and highlights recently published studies on these topics that attempt to fill these gaps and help clinicians provide excellent care for their patients.

Vertebral osteomyelitis in a healthy young adult.

A 39-year-old African American man with no significant past medical history presented to our hospital with right hand weakness and pain in both arms. He had no fever, neck pain, headache, dizziness, vision changes, or weakness in his lower extremities. Magnetic resonance imaging of the cervical spine showed extensive abnormal enhancement of the C7-T1 vertebral bodies as well as the prevertebral and epidural spaces. Open biopsy of the lesion showed inflammatory changes consistent with osteomyelitis. Culture of the biopsy specimen grew Group B Streptococcus (GBS). HIV ELISA and blood cultures were negative. The patient was treated with intravenous vancomycin for 6 weeks with complete resolution of symptoms. GBS classically affects newborns and pregnant females. However, the incidence of infection from this pathogen in nonpregnant adults is increasing. Vertebral osteomyelitis due to GBS in nonpregnant adults is exceedingly rare. To our knowledge, this is the first reported case of GBS cervical vertebral osteomyelitis in an adult without risk factors for invasive GBS infection. This case illustrates that GBS should be included in the differential diagnosis of pyogenic vertebral osteomyelitis, irrespective of immune status and predisposing factors.

An Assessment of the Impact of Multimedia, Technology-Based Learning Tools on the Cardiac Auscultation Skills of Third-Year Medical Students.

BACKGROUND: Previous studies have shown that medical students and post-graduate trainees need to improve their proficiency in cardiac auscultation. Technologic advances have created new learner-centered opportunities to enhance proficiency in this important physical examination skill. OBJECTIVES: We sought to determine if technology-based, self-directed learning tools improved the cardiac auscultation skills of third-year medical students. METHODS: Sixteen (16) third-year medical (M3) students were exposed to three educational inter-ventions: a one-hour cardiac auscultation lecture that featured computer-generated heart sounds, a PDA-based heart sounds/murmur form and a web-based cardiac auscultation program. Thirteen (13) internal medicine (IM) residents who served as a comparison group attended a cardiac auscultation lecture identical in content and format to the student lecture. At the end of the study period, we evaluated the ability of both groups to accurately identify heart sounds and cardiac murmurs via a twelve-item performance-based examination utilizing computer-generated heart sounds. RESULTS: Following our teaching interventions, findingsM3 students correctly identified 80% of the computer-simulated heart sounds/murmurs while the comparison group of IM residents accurately detected 60% of the same cardiac findings (p<. 005). CONCLUSIONS: The combination of traditional lecture and multi-media, technology-based, self-directed learning tools appears to be an effective and efficient strategy for teaching and reinforcing cardiac auscultation skills to third year medical students.