Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study.

Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.

[Late results after lumbar vertebrae fracture with Lorenz Böhler conservative treatment]. / Spätergebnisse nach Lendenwirbelfraktur mit konservativer Behandlung nach Lorenz Böhler.

We report on a clinical and radiological follow-up of patients who had sustained a fracture of their lumbar spine between 1982 and 1989 and were treated at our department by the method of Lorenz Böhler. 244 patients left our clinic with a plaster bodice after fracture reposition, 153 came to the follow-up (most of the cases are documented radiologically from the first to the follow-up x-ray). Our results are similar to the outcomes which are published after early functional treatment. We could not find a relationship between the radiological and clinical results and we saw, that it is impossible to fix the spine sufficiently in a plaster bodice without fracture redislocation.

[Follow-up analysis of total hip endoprosthesis after femoral neck fracture with and without previous operation]. / Verlaufsanalyse von Hüfttotalendoprothesen bei Zustand nach Schenkelhalsfraktur mit und ohne Voroperation.

Damage occurring after joint-preserving surgical treatment of femoral neck--mostly femoral head necrosis of pseudoarthrosis-necessitates endoprosthetic joint replacement. In the case of inferior bone quality and unfavorable fracture forms as well as after failed conservative therapy, surgical treatment consists of implanting a total hip endoprosthesis. Between 1971 and 1989, 120 patients received total hip replacement after suffering fractures of the femoral neck: 61 patients did not have previous surgery, 59 patients had had joint-preserving surgery. Statistical analysis of the results showed that the primary stabilizing operation to preserve the joint did not have a negative influence on the survival probability of the total hip replacement in comparison with primary implantation. If the joint-preserving primary intervention fails, total hip replacement is a good choice for secondary surgery. In the case of complications such as femoral head necrosis or pseudoarthrosis the indication for total hip replacement should therefore be made early on.