The SingHealth Perioperative and Anesthesia Subject Area Registry (PASAR), a large-scale perioperative data mart and registry.

BACKGROUND: To enhance perioperative outcomes, a perioperative registry that integrates high-quality real-world data throughout the perioperative period is essential. Singapore General Hospital established the Perioperative and Anesthesia Subject Area Registry (PASAR) to unify data from the preoperative, intraoperative, and postoperative stages. This study presents the methodology employed to create this database. METHODS: Since 2016, data from surgical patients have been collected from the hospital electronic medical record systems, de-identified, and stored securely in compliance with privacy and data protection laws. As a representative sample, data from initiation in 2016 to December 2022 were collected. RESULTS: As of December 2022, PASAR data comprise 26 tables, encompassing 153,312 patient admissions and 168,977 operation sessions. For this period, the median age of the patients was 60.0 years, sex distribution was balanced, and the majority were Chinese. Hypertension and cardiovascular comorbidities were also prevalent. Information including operation type and time, intensive care unit (ICU) length of stay, and 30-day and 1-year mortality rates were collected. Emergency surgeries resulted in longer ICU stays, but shorter operation times than elective surgeries. CONCLUSIONS: The PASAR provides a comprehensive and automated approach to gathering high-quality perioperative patient data.

Prehabilitation programs - a systematic review of the economic evidence.

Introduction: Prehabilitation, which involves improving a patient's physical and psychological condition before surgery, has shown potential benefits but has yet to be extensively studied from an economic perspective. To address this gap, a systematic review was conducted to summarize existing economic evaluations of prehabilitation interventions. Methods: The PRISMA Protocols 2015 checklist was followed. Over 16,000 manuscripts were reviewed, and 99 reports on preoperative interventions and screening tests were identified, of which 12 studies were included in this analysis. The costs are expressed in Pounds (GBP, £) and adjusted for inflation to December 2022. Results: The studies were conducted in Western countries, focusing on specific surgical subspecialties. While the interventions and study designs varied, most studies demonstrated cost savings in the intervention group compared to the control group. Additionally, all cost-effectiveness analysis studies favored the intervention group. However, the review also identified several limitations. Many studies had a moderate or high risk of bias, and critical information such as time horizons and discount rates were often missing. Important components like heterogeneity, distributional effects, and uncertainty were frequently lacking as well. The misclassification of economic evaluation types highlighted a lack of knowledge among physicians in prehabilitation research. Conclusion: This review reveals a lack of robust evidence regarding the economics of prehabilitation programs for surgical patients. This suggests a need for further research with rigorous methods and accurate definitions.

Cost-savings of short stay sleeve gastrectomy and walk-in hydration clinic versus conventional inpatient care.

OBJECTIVE: We aim to evaluate the cost-saving of the short stay ward (SSW) versus conventional inpatient care following sleeve gastrectomy (LSG). We also compared the readmission rates pre- and post-inception of the intravenous hydration clinic and analyzed the cost-savings. METHODS: Patients who underwent LSG between December 2021 to March 2022 with SSW care were compared with standard inpatient care. Total costs were analyzed using univariate analysis. With a separate cohort of patients, 30-day readmission rates in the 12-months preceding and following implementation of the IV hydration clinic and associated cost-savings were evaluated. RESULTS: After matching on the propensity score to within ± 0.1, 20-subjects pairs were retained. The total cost per SSW-subject was significantly lower at $13,647.81 compared to $15,565.27 for conventional inpatient care (p = 0.0302). Lower average ward charges ($667.76 vs $1371.34, p < 0.0001), lower average daily treatment fee per case ($235.68 vs $836.54, p < 0.0001), and lower average laboratory investigation fee ($612.31 vs $797.21, p < 0.0001) accounted for the difference in costs between the groups. Thirty-day readmission rate reduced from 8.9 to 1.8% after implementation of the hydration clinic (p < 0.01) with decreased 30-day readmission cost (S$96,955.57 vs. S$5910.27, p < 0.01). CONCLUSION: SSW for LSG is cost-effective and should be preferred to inpatient management. Walk-in hydration clinics significantly reduced readmission rates and result in tremendous cost-savings.

Improving the accuracy of revised cardiac risk index with HbA1C: Hemoglobin ratio (HH ratio) - A retrospective cohort study.

Background: The current Lee's Revised cardiac risk index (RCRI) was created in 1999. Validation studies have found RCRI to be only moderately discriminant. The "Diabetes Mellitus on insulin" component of the score does not accurately reflect the severity of the disease. A previously studied HbA1C:Hemoglobin ratio shows an improved association with outcomes than individual components alone. Study design: A retrospective cohort study was performed in diabetic patients undergoing non-cardiac surgery. Ethics approval was obtained. The study compares the predictive value of RCRI and substitution of the "DM on insulin" component with HH ratio for 30- and 90-day mortality, and postoperative acute myocardial injury (AMI) and acute kidney injury (AKI). Results: A total of 20,099 adult patients were included in the final analysis. The incidence of 30- and 90-day mortality was at 4.2 and 6.5%, respectively. Substitution of HH ratio in RCRI resulted in 687 more patients being in the moderate to high-risk category. The substituted HH-RCRI score had better prediction for 30-day (AUC 0.66 vs. 0.69, p < 0.001) and 90-day mortality (AUC 0.67 vs. 0.70, p < 0.001), and postoperative AMI (AUC 0.69 vs. 0.71, p < 0.001) and AKI (AUC 0.57 vs. 0.62, p < 0.001). Conclusion: Although currently not an universal practice, substitution of "DM on insulin" with HbA1C:Hemoglobin ratio in RCRI score improves the accuracy of the RCRI risk prediction model in diabetic patients going for non-cardiac surgery.

Outcomes after natural orifice extraction vs conventional specimen extraction surgery for colorectal cancer: A propensity score-matched analysis.

BACKGROUND: Natural orifice specimen extraction (NOSE) via the anus or vagina replaces conventional transabdominal specimen retrieval via the transabdominal route through a limited mid-line laparotomy or Pfannenstiel incision. Reducing the number of laparoscopic ports further decreases operative abdominal wall trauma. These techniques reduce the surgical wound size as well as the risk of incision-related morbidity. AIM: To compare short-term outcomes following 3-port NOSE surgery with a matched cohort of conventional non-NOSE colorectal cancer surgery. METHODS: Patients who underwent elective 3-port laparoscopic colorectal NOSE surgery between February to October 2021 were identified. Selection criteria for NOSE surgery was adapted from the 2019 International Consensus on Natural Orifice Specimen Extraction Surgery for colorectal cancer. Patients with clinical T4 or N2 tumors on staging computed tomography were also excluded. The propensity score-matched cohort was identified amongst patients who underwent conventional laparoscopic colorectal surgery from January 2019 to December 2020. Matching was performed in the ratio of 1:4 based on age, gender, type of resection, and p - tumor node metastasis staging. RESULTS: Over the eight-month study duration, 14 consecutive cases (nine female, five male) of elective 3-port laparoscopic surgery with NOSE were performed for colorectal cancer. Median age and body mass index were 70 (range 43-82) years and 24.1 (range 20.0-31.7) kg/m2 respectively. Six patients underwent transanal NOSE and eight had transvaginal NOSE. Median operative time, intraoperative blood loss and postoperative length of stay were 208 (range 165-365) min, 30 (range 10-150) mL and 3 (range 2-6) d respectively. Two (14%) suffered minor postoperative compilations not attributable to the NOSE procedure. Median follow-up duration was 12 (range 8-15) mo. No instances of mortality, local or distant disease recurrence were recorded in this cohort. Compared to the conventional surgery cohort of 56 patients, the 3-port NOSE cohort had significantly quicker mean return of bowel function (2.6 vs 1.2 d, P < 0.001), reduced postoperative pain and patient-controlled analgesia use, and decreased length of hospital stay (6.4 vs 3.4 d, P < 0.001). There were no statistical differences in surgical duration and perioperative complication rates between the NOSE and non-NOSE cohorts. CONCLUSION: 3-port laparoscopic colorectal surgery with NOSE is a feasible technique, augmenting the minimally invasive nature of surgery and producing good outcomes. Appropriate patient selection and expertise in conventional laparoscopy are required.

An Agile Systems Modeling Framework for Bed Resource Planning During COVID-19 Pandemic in Singapore.

Background: The COVID-19 pandemic has had a major impact on health systems globally. The sufficiency of hospitals' bed resource is a cornerstone for access to care which can significantly impact the public health outcomes. Objective: We describe the development of a dynamic simulation framework to support agile resource planning during the COVID-19 pandemic in Singapore. Materials and Methods: The study data were derived from the Singapore General Hospital and public domain sources over the period from 1 January 2020 till 31 May 2020 covering the period when the initial outbreak and surge of COVID-19 cases in Singapore happened. The simulation models and its variants take into consideration the dynamic evolution of the pandemic and the rapidly evolving policies and processes in Singapore. Results: The models were calibrated against historical data for the Singapore COVID-19 situation. Several variants of the resource planning model were rapidly developed to adapt to the fast-changing COVID-19 situation in Singapore. Conclusion: The agility in adaptable models and robust collaborative management structure enabled the quick deployment of human and capital resources to sustain the high level of health services delivery during the COVID-19 surge.

Discordant American Society of Anesthesiologists Physical Status Classification between anesthesiologists and surgeons and its correlation with adverse patient outcomes.

The American Society of Anesthesiologists Physical Status Classification (ASA) is used for communication of patient health status, risk scoring, benchmarking and financial claims. Prior studies using hypothetical scenarios have shown poor concordance of ASA classification among healthcare providers. There is a paucity of studies using clinical data, and of clinical factors or patient outcomes associated with discordant classification. The study aims to assess ASA classification concordance between surgeons and anesthesiologists, factors surrounding discordance and its impact on patient outcomes. This retrospective cohort study was conducted in a tertiary medical center on 46,284 consecutive patients undergoing elective surgery between January 2017 and December 2019. The ASA class showed moderate concordance (weighted Cohen's κ 0.53) between surgeons and anesthesiologists. We found significant associations between discordant classification and patient comorbidities, age and race. Patients with discordant classification had a higher risk of 30-day mortality (odds ratio (OR) 2.00, 95% confidence interval (CI) = 1.52-2.62, p < 0.0001), 1-year mortality (OR 1.53, 95% CI = 1.38-1.69, p < 0.0001), and Intensive Care Unit admission > 24 h (OR 1.69, 95% CI = 1.47-1.94, p < 0.0001). Hence, there is a need for improved standardization of ASA scoring and cross-specialty review in ASA-discordant cases.

AutoScore-Imbalance: An interpretable machine learning tool for development of clinical scores with rare events data.

BACKGROUND: Medical decision-making impacts both individual and public health. Clinical scores are commonly used among various decision-making models to determine the degree of disease deterioration at the bedside. AutoScore was proposed as a useful clinical score generator based on machine learning and a generalized linear model. However, its current framework still leaves room for improvement when addressing unbalanced data of rare events. METHODS: Using machine intelligence approaches, we developed AutoScore-Imbalance, which comprises three components: training dataset optimization, sample weight optimization, and adjusted AutoScore. Baseline techniques for performance comparison included the original AutoScore, full logistic regression, stepwise logistic regression, least absolute shrinkage and selection operator (LASSO), full random forest, and random forest with a reduced number of variables. These models were evaluated based on their area under the curve (AUC) in the receiver operating characteristic analysis and balanced accuracy (i.e., mean value of sensitivity and specificity). By utilizing a publicly accessible dataset from Beth Israel Deaconess Medical Center, we assessed the proposed model and baseline approaches to predict inpatient mortality. RESULTS: AutoScore-Imbalance outperformed baselines in terms of AUC and balanced accuracy. The nine-variable AutoScore-Imbalance sub-model achieved the highest AUC of 0.786 (0.732-0.839), while the eleven-variable original AutoScore obtained an AUC of 0.723 (0.663-0.783), and the logistic regression with 21 variables obtained an AUC of 0.743 (0.685-0.801). The AutoScore-Imbalance sub-model (using a down-sampling algorithm) yielded an AUC of 0.771 (0.718-0.823) with only five variables, demonstrating a good balance between performance and variable sparsity. Furthermore, AutoScore-Imbalance obtained the highest balanced accuracy of 0.757 (0.702-0.805), compared to 0.698 (0.643-0.753) by the original AutoScore and the maximum of 0.720 (0.664-0.769) by other baseline models. CONCLUSIONS: We have developed an interpretable tool to handle clinical data imbalance, presented its structure, and demonstrated its superiority over baselines. The AutoScore-Imbalance tool can be applied to highly unbalanced datasets to gain further insight into rare medical events and facilitate real-world clinical decision-making.

Impact of introduction of an enhanced recovery protocol on the outcomes of laparoscopic liver resections: A propensity-score matched study.

BACKGROUND: Presently, data on the impact of enhanced recovery protocols on the outcomes of laparoscopic liver resection remain limited. We performed propensity matched analysis comparing the outcomes between patients undergoing laparoscopic liver resection before and after the introduction of an enhanced recovery protocol. METHODS: Between 2013 and 2019, 462 consecutive patients underwent laparoscopic liver resection by 3 surgeons of which 360 met the study inclusion criteria. There were 89 patients who underwent surgery under an enhanced recovery protocol and 271 without an enhanced recovery protocol. One-to-one propensity matched analysis was performed for 84 enhanced recovery protocol patients and 84 nonenhanced recovery protocol patients. RESULTS: Comparisons between propensity matched cohorts revealed that patients who received laparoscopic liver resection with enhanced recovery protocol had reduced median blood loss (200 vs 300 mL, P = .013), postoperative stay (3 vs 4 days, P = .003), and lower open conversion rates (0% vs 8.3%, P = .008). There was no difference in other key perioperative outcomes such as operation time, postoperative morbidity, postoperative major morbidity, and 30-day readmission rates. CONCLUSION: A combined approach of enhanced recovery protocol and laparoscopic liver resection was associated with improved perioperative outcomes as opposed to laparoscopic liver resection alone.

The impact of preoperative glycated hemoglobin (HbA1c) on postoperative complications after elective major abdominal surgery: a meta-analysis.

BACKGROUND: Diabetes is a risk factor for postoperative complications. Previous meta-analyses have shown that elevated glycated hemoglobin (HbA1c) levels are associated with postoperative complications in various surgical populations. However, this is the first meta-analysis to investigate the association between preoperative HbA1c levels and postoperative complications in patients undergoing elective major abdominal surgery. METHODS: PRISMA guidelines were adhered to for this study. Six databases were searched up to April 1, 2020. Primary studies investigating the effect of HbA1c levels on postoperative complications after elective major abdominal surgery were included. Risk of bias and quality of evidence assessments were performed. Data were pooled using a random effects model. Meta-regression was performed to evaluate different HbA1c cut-off values. RESULTS: Twelve observational studies (25,036 patients) were included. Most studies received a 'good' and 'moderate quality' score using the NOS and GRADE, respectively. Patients with a high HbA1c had a greater risk of anastomotic leaks (odds ratio [OR]: 2.80, 95% CI [1.63, 4.83], P < 0.001), wound infections (OR: 1.21, 95% CI [1.08, 1.36], P = 0.001), major complications defined as Clavien-Dindo [CD] 3-5 (OR: 2.16, 95% CI [1.54, 3.01], P < 0.001), and overall complications defined as CD 1-5 (OR: 2.12, 95% CI [1.48, 3.04], P < 0.001). CONCLUSIONS: An HbA1c between 6% and 7% is associated with higher risks of anastomotic leaks, wound infections, major complications, and overall postoperative complications. Therefore, guidelines with an HbA1c threshold > 7% may be putting pre-optimized patients at risk. Future randomized controlled trials are needed to explore causation before policy changes are made.

Resuming elective surgery after COVID-19: A simulation modelling framework for guiding the phased opening of operating rooms.

OBJECTIVE: To develop a 2-stage discrete events simulation (DES) based framework for the evaluation of elective surgery cancellation strategies and resumption scenarios across multiple operational outcomes. MATERIALS AND METHODS: Study data was derived from the data warehouse and domain knowledge on the operational process of the largest tertiary hospital in Singapore. 34,025 unique cases over 43 operating rooms (ORs) and 18 surgical disciplines performed from 1 January 2019 to 31 May 2020 were extracted for the study. A clustering approach was used in stage 1 of the modelling framework to develop the groups of surgeries that followed distinctive postponement patterns. These clusters were then used as inputs for stage 2 where the DES model was used to evaluate alternative phased resumption strategies considering the outcomes of OR utilization, waiting times to surgeries and the time to clear the backlogs. RESULTS: The tool enabled us to understand the elective postponement patterns during the COVID-19 partial lockdown period, and evaluate the best phased resumption strategy. Differences in the performance measures were evaluated based on 95% confidence intervals. The results indicate that two of the gradual phased resumption strategies provided lower peak OR and bed utilizations but required a longer time to return to BAU levels. Minimum peak bed demands could also be reduced by approximately 14 beds daily with the gradual resumption strategy, whilst the maximum peak bed demands by approximately 8.2 beds. Peak OR utilization could be reduced to 92% for gradual resumption as compared to a minimum peak of 94.2% with the full resumption strategy. CONCLUSIONS: The 2-stage modelling framework coupled with a user-friendly visualization interface were key enablers for understanding the elective surgery postponement patterns during a partial lockdown phase. The DES model enabled the identification and evaluation of optimal phased resumption policies across multiple important operational outcome measures. LAY ABSTRACT: During the height of the COVID-19 pandemic, most healthcare systems suspended their non-urgent elective surgery services. This strategy was undertaken as a means to expand surge capacity, through the preservation of structural resources (such as operating theaters, ICU beds, and ventilators), consumables (such as personal protective equipment and medications), and critical healthcare manpower. As a result, some patients had less-essential surgeries postponed due to the pandemic. As the first wave of the pandemic waned, there was an urgent need to quickly develop optimal strategies for the resumption of these surgeries. We developed a 2-stage discrete events simulation (DES) framework based on 34,025 unique cases over 43 operating rooms (ORs) and 18 surgical disciplines performed from 1 January 2019 to 31 May 2020 captured in the Singapore General Hospital (SGH) enterprise data warehouse. The outcomes evaluated were OR utilization, waiting times to surgeries and time to clear the backlogs. A user-friendly visualization interface was developed to enable decision makers to determine the most promising surgery resumption strategy across these outcomes. Hospitals globally can make use of the modelling framework to adapt to their own surgical systems to evaluate strategies for postponement and resumption of elective surgeries.

Time to intubation with McGrath™ videolaryngoscope versus direct laryngoscope in powered air-purifying respirator: a randomised controlled trial.

INTRODUCTION: During the COVID-19 pandemic, multiple guidelines have recommended the videolaryngoscope for tracheal intubation. However, there is no evidence that videolaryngoscope reduces time to tracheal intubation, which is important for COVID-19 patients with respiratory failure. METHODS: To simulate intubation of COVID-19 patients, we randomised 28 elective surgical patients to be intubated with either the McGrath™ MAC videolaryngoscope or the direct laryngoscope by specialist anaesthetists donning 3M™ Jupiter™ powered air-purifying respirators (PAPR) and N95 masks. Primary outcome was time to intubation. RESULTS: The median (IQR) times to intubation were 61s (37-63 s) and 41.5s (37-56 s) in the videolaryngoscope and direct laryngoscope groups respectively (p = 0.35). The closest mean (SD) distances between the anaesthetist and the patient during intubation were 21.6 cm (4.8 cm) and 17.6 cm (5.3 cm) in the videolaryngoscope and direct laryngoscope groups, respectively (p = 0.045). There were no significant differences in the median intubation difficulty scale scores, proportion of successful intubation at first laryngoscopic attempt and proportion of intubations requiring adjuncts. Intubations for all the patients were successful with no adverse event. CONCLUSION: There was no significant difference in the time to intubation by specialist anaesthetists who were donned in PAPR and N95 masks on elective surgical patients with either the McGrath™ videolaryngoscope or direct laryngoscope. The distance between the anaesthetist and patient was significantly further with the videolaryngoscope. The direct laryngoscope could be an equal alternative to videolaryngoscope for specialist anaesthetists when resources are limited or disrupted due to the pandemic.

Developing a Simpler Prognosticating Tool: Comparing the Combined Assessment of Risk Encountered in Surgery Score with Deyo-Charlson Comorbidity Index and The American Society of Anesthesiologists Physical Status Score in Predicting 2 years Mortality after Hip Fracture Surgery.

Background: The use of risk stratification tools in identifying high-risk hip fracture patients plays an important role during treatment. The aim of this study was to compare our locally derived Combined Assessment of Risk Encountered in Surgery (CARES) score with the the American Society of Anesthesiologists physical status (ASA-PS) score and the Deyo-Charlson Comorbidity Index (D-CCI) in predicting 2-year mortality after hip fracture surgery. Methods and Material: A retrospective study was conducted on surgically treated hip fracture patients in a large tertiary hospital from Jan 2013 through Dec 2015. Age, gender, time to surgery, ASA-PS score, D-CCI, and CARES score were obtained. Univariate and multivariable logistic regression analyses were used to assess statistical significance of scores and risk factors, and area under the receiver operating characteristic (ROC) curve (AUC) was used to compare ASA-PS, D-CCI, and CARES as predictors of mortality at 2 years. Results: 763 surgically treated hip fracture patients were included in this study. The 2-year mortality rate was 13.1% (n = 100), and the mean ± SD CARES score of surviving and demised patients was 21.2 ± 5.98 and 25.9 ± 5.59, respectively. Using AUC, CARES was shown to be a better predictor of 2-year mortality than ASA-PS, but we found no statistical difference between CARES and D-CCI. A CARES score of 23, attributable primarily to pre-surgical morbidities and poor health of the patient, was identified as the statistical threshold for "high" risk of 2-year mortality. Conclusion: The CARES score is a viable risk predictor for 2-year mortality following hip fracture surgery and is comparable to the D-CCI in predictive capability. Our results support the use of a simpler yet clinically relevant CARES in prognosticating mortality following hip fracture surgery, particularly when information on the pre-existing comorbidities of the patient is not immediately available.

Preoperative Single-Dose Intravenous Iron Formulation to Reduce Postsurgical Complications in Patients Undergoing Major Abdominal Surgery: A Randomized Control Trial Feasibility Study (PIRCAS Trial Pilot).

Background Preoperative anemia is associated with an increased need for blood transfusion, complications, and prolonged hospital stay. Iron deficiency anemia (IDA) may be treated with oral or intravenous (IV) iron. IV iron repletes iron stores more rapidly. Its impact on perioperative blood transfusion, postoperative complications, patients' recovery, and long-term quality of life is unclear. Newer agents, such as ferric carboxymaltose (FCM), are costly but have higher maximum approved doses and a very low incidence of anaphylactic-type reactions. This study aims to explore the feasibility of a randomized control trial to compare the preoperative treatment of IDA with IV FCM versus oral ferrous fumarate, in patients undergoing elective major abdominal surgery. Experimental design This is an open-label pilot randomized controlled trial. A total of 30 adults with IDA scheduled for elective major abdominal surgery were recruited for the study. They were randomized into two groups to receive either oral iron or IV FCM. Primary outcomes are defined as the time from enrollment to study drug administration, recruitment rate, and follow-up rate up to three months. Secondary outcomes are hemoglobin rise from recruitment to surgery, perioperative blood transfusion, postoperative complications, EQ-5D-3L scores at baseline, and three months and adverse events related to IV FCM therapy. Results All patients received study drugs within five days of enrollment; 30 patients were recruited within four months, 15 patients in each group. Two in each group were withdrawn for surgery postponement. All patients were followed up for three months and there was no crossover of patients. Per protocol, analysis was performed. No severe adverse events related to IV FCM therapy occurred. Both groups had similar baseline characteristics, similar hemoglobin rise from enrollment to the day of surgery [0.2 (+1.6) g/dL in the FCM group and 0.8 (+0.7) g/dL in the Oral Iron group, p=0.3] and similar mean units of perioperative blood transfused (recruitment to discharge) per patient [1.3 (+ 2.1) in the FCM group and 0.9 (+1.3) in the Oral Iron group, p=0.6]. Postoperatively, there was a similar hospital length of stay [11.5 (+13.6 days) in the FCM group and 9.0 (+9.8 days) in the Oral Iron group, p=0.6]; there were similar postoperative complications as reflected by the average Comprehensive Complication Index [12.8 (+19.6) in the FCM group and 22.6 (+30.7) in the Oral Iron group, p=0.3]; similar postoperative health-related quality of life as reflected by mean EQ-5D-3L scores at one month [70.4 (+21.8) in the FCM group and 84.5 (+12.1) in the Oral Iron group] and three months [80.0 (+18.4) in the FCM group and 85.9 (+10.7) in the Oral Iron group]. Conclusions A full-scale randomized controlled trial to evaluate the effectiveness of preoperative IV FCM compared to oral iron in patients with IDA undergoing major abdominal surgery is feasible.

Postoperative delirium following total joint arthroplasties in a multi-ethnic population - A prospective observational study.

BACKGROUND: Postoperative delirium (POD) is a cause of poorer patient outcomes following total joint arthroplasties (TJA). However, it often goes undiagnosed. Although various risk factors have been documented, study heterogeneity leads to poor understanding within a South East Asian population. This study aims to evaluate POD within this demographic and elucidate its risk factors. METHODS: This was a single-centre prospective observational study comprising 462 patients. Inclusion criteria was patients 65-90 years old undergoing elective TJA. Exclusion criteria was patients unable to personally provide consent for TJA. Preoperative, intraoperative, and postoperative data was recorded to analyse treatment pathway factors. Patients were assessed for POD twice daily for 3 days after TJA using the Confusion Assessment Method (CAM). RESULTS: Mean age of the study cohort was 72 ± 5 years; 70.1% were female; and mean MMSE score preoperatively was 27.3 ± 3.3. 419 patients underwent total knee arthroplasty (TKA) and 43 patients underwent total hip arthroplasty (THA). 164 patients received general anaesthesia, and 298 patients received regional anaesthesia. Overall, 0% (0/462) of patients tested positive for POD at any postoperative timepoint. While various CAM components were met, no patients were positive for the complete requisite criteria for POD diagnosis. CONCLUSION: We report zero incidence of POD in 462 patients who underwent elective TJA in our institution. We believe that our streamlined care process including pre-operative assessment, patient-specific anaesthesia regime as well as a strictly administered inpatient clinical care pathway with opioid-reducing strategy and early mobilization are protective factors against POD.

Smoking Characteristics and Readiness-to-Quit Status Among Smokers Attending Preoperative Assessment Clinic - A Prospective Cohort Study.

BACKGROUND: Perioperative smoking is associated with an increased incidence of general postoperative morbidity and mortality. The perioperative period is recognized as an important "teachable moment" that can motivate patients to adopt health changing behaviors. OBJECTIVE: In this study, we aimed to determine the prevalence of smokers among elective surgical patients in an Asian tertiary hospital. We also investigated their smoking characteristics, previous quitting attempts, readiness-to-quit status as well as knowledge of smoking-related postoperative complications. METHODS: We conducted a single-center prospective cohort study among all patients who attended a preoperative assessment clinic within a 2-month period (August to September 2020) using a preoperative smoking questionnaire. RESULTS: A total of 3362 patients participated in the study, of which 348 (10.4%) were current smokers. More than half (65.6%) of the smokers had previously attempted to quit smoking, with most (78%) having made more than one attempt. Forty-nine percent of current smokers were in the pre-contemplation stage of quitting and thirty-one percent were in the contemplation stage. Only twenty-one percent were in the preparation stage of quitting. Thirty-eight percent of patients recognized the importance of smoking cessation perioperatively but only twenty-eight percent were confident of quitting perioperatively. Less than sixty percent of smokers were aware of at least one type of smoking-related postoperative complication. Less than half of the patients (45%) had ever received advice on perioperative smoking cessation from the surgeons. CONCLUSION: A thorough understanding of smokers' smoking characteristics, barriers to quit and readiness-to-quit status are crucial to establishing a successful multidisciplinary perioperative smoking cessation program. Counselling should address knowledge deficits and be tailored to a patient's stage-of-change in order to seize this precious perioperative "teachable moment".

Association of Multimorbidity With Frailty in Older Adults for Elective Non-Cardiac Surgery.

Introduction Frailty is associated with adverse surgical outcomes. While existing studies describe the prevalence of multimorbidity and frailty in the community, the surgical population may have more severe disease and significant surgical stress. This study aims to describe the distribution of frailty and multimorbidity in the older surgical population and examine if specific comorbidities are more strongly associated with frailty. Methods This is a single-centre retrospective cohort study using an electronic database in the preoperative evaluation clinic, conducted in Singapore General Hospital, Singapore. All patients above 70 years old going for elective non-cardiac surgery were included. Demographics and comorbidities were analysed for their association with frailty according to the Edmonton Frail Scale. Results A total of 1396 out of 1398 patients were analyzed. The overall incidence of frailty was 27.8% and multimorbidity was 63.4%. Factors independently associated with frailty were age (adjusted Odds Ratio [aOR] = 1.07), female gender (aOR = 1.67), type 2 diabetes mellitus (aOR = 1.69), chronic kidney disease (aOR = 1.47), end-stage renal failure (aOR = 3.58), history of cerebrovascular accident or transient ischemic attack (aOR = 1.87), moderate anaemia (aOR = 2.11), dementia (aOR = 6.38), depression (aOR = 3.82), and peptic ulcer disease (aOR = 1.98). The presence of multi-morbidity was significantly associated with frailty, with overall increasing strength of association. Conclusion As the number of comorbidities increases, the odds of frailty increase. Only a small proportion of those with multimorbidity accumulate enough biological deficits to develop frailty, putting them at higher risk than with solely multimorbidity or frailty. Dementia and depression are comorbidities with strong associations that have yet to see coordinated interventional efforts in the preoperative setting.

Prevalence and risk factors of preoperative malnutrition risk in older patients and its impact on surgical outcomes: a retrospective observational study.

PURPOSE: Elderly patients are vulnerable to malnutrition and we have started systematic screening for preoperative malnutrition risk in our institution. This study aims to determine the prevalence and risk factors of preoperative malnutrition risk among elderly surgical patients, and its impact on surgical outcomes. METHODS: In this retrospective cohort study of patients ≥ 65 yr old undergoing elective surgery, we recorded demographics, medications, preoperative effort tolerance, Malnutrition Universal Screening Tool (MUST) score, American Society of Anesthesiologists physical status (ASA), Charlson Comorbidity Index (CCI), and Edmonton Frailty Score (EFS). Postoperative complications based on the Clavien-Dindo (CD) classification and hospital length of stay (LOS) were also recorded. RESULTS: Of the 1,033 patients studied, 123 (11.9%) were at risk of malnutrition (MUST ≥ 1), with 48 (4.6%) at high risk (MUST ≥ 2). Unadjusted predictors for high malnutrition risk included ASA ≥ III, higher EFS, higher CCI, polypharmacy (≥ ten medications), poor effort tolerance (metabolic equivalent of tasks < 3), malignancy, general surgery patients, and lower hemoglobin. These patients had higher odds of CD grade ≥ 1 complications compared with those without risk (adjusted odds ratio, 2.30; 95% confidence interval [CI], 1.11 to 4.78; P = 0.025) and 22% longer hospital LOS (adjusted incidence rate ratio,1.22; 95% CI, 1.00 to 1.49; P = 0.049) after multivariate adjustment for sex, severity of surgery, comorbidities, frailty, malignancy, and anemia. CONCLUSION: Preoperative malnutrition risk is prevalent among the elderly. Patients at high malnutrition risk have increased risk of postoperative complications and longer hospital LOS. Patients with high comorbidity burden and frailty should be screened for malnutrition so that nutritional optimization can be sought.

RéSUMé: OBJECTIF: Les patients âgés sont vulnérables à la malnutrition, c'est pourquoi nous avons commencé un dépistage systématique du risque de malnutrition préopératoire dans notre établissement. Cette étude vise à déterminer la prévalence et les facteurs de risque du risque de la malnutrition préopératoire chez les patients chirurgicaux âgés, ainsi que l'impact de la malnutrition sur les devenirs chirurgicaux. MéTHODE: Dans cette étude de cohorte rétrospective portant sur des patients âgés de ≥ 65 ans subissant une chirurgie non urgente, nous avons enregistré les données démographiques, les médicaments, la tolérance préopératoire à l'effort, le score sur l'Outil de dépistage universel de la malnutrition (MUST), le statut physique selon l'American Society of Anesthesiologists (ASA), l'indice de comorbidité de Charlson (ICC) et le score sur l'Échelle de fragilité d'Edmonton (EFS). Les complications postopératoires basées sur la classification de Clavien-Dindo (CD) et la durée de séjour à l'hôpital ont également été enregistrées. RéSULTATS: Parmi les 1033 patients étudiés, 123 (11,9 %) étaient à risque de malnutrition (MUST ≥ 1), et 48 (4,6 %) à haut risque (MUST ≥ 2). Les prédicteurs non ajustés d'un risque élevé de malnutrition comprenaient un statut ASA ≥ III, un score plus élevé à l'EFS, un ICC plus élevé, la polypharmacie (≥ dix médicaments), une tolérance faible à l'effort (équivalent métabolique des tâches < 3), la malignité, les patients de chirurgie générale, et un taux d'hémoglobine plus bas. Ces patients couraient un risque plus élevé de complications de catégorie CD ≥ 1 comparés aux patients sans risque (rapport de cotes ajusté, 2,30; intervalle de confiance [IC] 95 %, 1,11 à 4,78; P = 0,025) et des durées de séjour hospitalier 22 % plus longues (taux d'incidence ajusté,1,22; IC 95 %, 1,00 à 1,49; P = 0,049) après ajustement multivarié pour tenir compte du sexe, de la sévérité de la chirurgie, des comorbidités, de la fragilité, de la malignité et de l'anémie. CONCLUSION: Le risque de malnutrition préopératoire est répandu chez les personnes âgées. Les patients présentant un risque élevé de malnutrition courent un risque accru de complications postopératoires et d'hospitalisation prolongée. Les patients présentant un fardeau de comorbidité et de fragilité élevé devraient être dépistés pour la malnutrition afin de pouvoir optimiser leur nutrition.

Preoperative hypoalbuminemia: Poor functional outcomes and quality of life after hip fracture surgery.

AIMS: Hip fracture patients have severe deterioration of their quality of life and function after their injury. Markers of malnutrition such as low albumin and low body mass index (BMI) have been shown to increase mortality and complication rates but their effect on recovery of quality of life and function after hip fracture surgery is unclear. The main aim of this paper is to further investigate if low albumin affects recovery after hip fracture surgery, while additionally studying low BMI as a possible risk factor for poor recovery. PATIENTS AND METHODS: Retrospective analysis of 971 patients who underwent surgery for fragility hip fractures between January 2012 and December 2016 was performed. Demographic data, preoperative serum albumin and haemoglobin levels, BMI, Charlson Comorbidity Index (CCI), type of surgery (fixation vs replacement) and site of surgery were obtained. Patients were assessed using the Parker Mobility Scale (PMS), Harris Hip Score(HHS), Medical Outcomes Study 36-item Short-Form Health Survey (SF36) at pre-fracture, 6 weeks and 6 months after surgery. HHS was not available pre-operatively. Patients were grouped according to their albumin levels (low ≤35 g/L or normal) and BMI (underweight <18.5 or normal). Univariate and multivariate analyses were performed to examine the association between albumin and BMI and 6-month scores. RESULTS: On univariate analysis, patients with low albumin ≤35 g/L had lower baseline PMS and SF36 Physical Functioning (PF) score. On multivariate analysis, preoperative hypoalbuminemia was associated with lower 6-month HHS, PMS and SF36 PF scores even after accounting for baseline scores and other confounders. BMI had no effect on 6-month scores. CONCLUSION: Low albumin (≤35 g/L) is prevalent in elderly hip fracture patients and is associated with slower recovery of function and quality of life after surgery. Low albumin can be a useful prognostic tool to identify patients with poor recovery for further intervention or rehabilitation after hip fracture surgery.