Does eliminating the preoperative history and physical make a difference in low-risk cataract surgery patients? A before and after study of 30-day morbidity and mortality.

OBJECTIVE: To evaluate the safety of omitting the conventional preoperative history and physical examination (H&P) for low-risk cataract surgery patients. DESIGN: Comparison of outcomes before and after the January 1, 2015 system wide implementation of a program that eliminated the conventional preoperative H&P for low-risk patients as identified by a 12-item risk stratification questionnaire. PARTICIPANTS: Two separate groups of Winnipeg residents who had cataract surgery at the city's sole ophthalmological referral centre between July 1 and December 31, 2014 (preimplementation reference group) or between October 1, 2015 and March 31, 2016 (postimplementation intervention group). METHODS: A detailed chart review was completed for cataract surgery patients who experienced a postoperative medical event (a composite of death or hospital admission or emergency department visit, identified within administrative databases) within 30 days of surgery. Nonfatal events were captured for all 7 hospitals and urgent care centres in the city, including the ophthalmological referral centre. RESULTS: Postoperative medical events occurred in 114 of 2981 (3.82%) intervention group surgeries and 125 of 3037 (4.12%) reference group surgeries (Relative risk 0.92, 95% confidence interval 0.72 to 1.19, p = 0.6 Fisher exact test). Subgroup analyses of major medical events and medical events by affected organ system yielded no significant differences between the 2 groups. In the opinion of the physician chart reviewers, none of the events among low-risk patients in the intervention group were related to the omission of a conventional preoperative H&P. CONCLUSIONS: The risk of adverse medical events within 30 days of cataract surgery was not higher after the omission of the conventional preoperative H&P in patients screened to be low risk by a validated preoperative questionnaire.

Risk factors for postoperative cognitive and functional difficulties in abdominal aortic aneurysm patients: a three month follow-up.

BACKGROUND: Cognitive impairment and deficits in functional performance are major concerns following surgery, particularly for older patients. The objective of this study was to examine predictors of postoperative cognitive and functional difficulties and explore the relationship between presurgery and postsurgery cognitive ability and functional performance. METHODS: 89 patients undergoing elective abdominal aortic aneurysm (AAA) surgery were administered a battery of cognitive measures preoperatively, at the time of discharge from hospital and 3 months postoperatively. Functional performance was evaluated by the Portland Adaptability Inventory (PAI), both pre and postsurgery. Symptoms of delirium were assessed during the first six postoperative days. RESULTS: A diagnosis of delirium had a mild effect on functional performance 3 months postoperatively. The strongest predictors of postoperative functional performance were the level of functioning presurgery, a longer length of hospital stay and the total number of days delirious. Cognitive impairment postsurgery was predicted by presurgery cognitive measures of verbal memory and psychomotor speed performance and the total number of days delirious. CONCLUSIONS: Functional performance outcomes for AAA patients 3 months postsurgery revealed no significant loss of functioning relative to presurgery levels, although longer length of hospital stay and greater number of days delirious was associated with somewhat poorer outcome on indicators of social and physical functioning. Cognitive impairment postoperatively was fairly mild but when it was found it was associated with number of days delirious and preoperative deficits in verbal memory and psychomotor speed.

Risk factors and prevalence of perioperative cognitive dysfunction in abdominal aneurysm patients.

BACKGROUND: Perioperative delirium is common in high-risk surgery and is associated with age, education, preoperative cognitive functioning, pre-existing medical conditions, and postoperative complications. We investigated these factors as well as lifestyle and demographic variables by using cognitive measures that were more sensitive than those used in previous studies. METHODS: Extensive medical and demographic data were collected on 102 patients between 41 and 88 years of age to identify comorbidities and lifestyle considerations preoperatively. Elective abdominal aortic aneurysm surgery was performed under combined general/epidural anesthesia with postoperative epidural analgesia. A battery of sensitive, cognitive measures was administered preoperatively, at the time of discharge from hospital, and 3 months postoperatively. Symptoms of delirium were assessed during the first 6 postoperative days using Diagnostic and Statistical Manual of Mental Disorders-4th Edition criteria. Intraoperative and postoperative data, including medications, vital signs, conduct of the surgery and anesthesia, complications, and details of pain control, were collected. RESULTS: Delirium occurred in 33% of the patients during the first 6 days after surgery. Longer duration of delirium was related to lower education, preoperative depression, and greater preoperative psychoactive medication use. Characteristics of the surgery and hospital stay were unrelated to the development of delirium. Patients who were diagnosed with delirium had lower cognitive scores during each of the three assessment periods, even when controlling for age and education. Logistic regression analysis indicated that the most powerful preoperative predictors of delirium were number of pack years smoked (P = .001), mental status scores (P = .003), and number of psychoactive medications (P = .005). CONCLUSION: A significant proportion of patients undergoing elective abdominal aortic aneurysm repair are susceptible to the development of delirium and are at risk for cognitive dysfunction after surgery. Our findings have implications for promoting long-term lifestyle changes, including smoking cessation and improved management of mental health as risk-reduction strategies.