Brittany N. Burton

Preoperative Functional Status Is Associated With Unplanned Intubations Following Thyroidectomies

BACKGROUND: Unplanned postoperative intubation is an important event that may influence the outcome of thyroid- and parathyroidectomies. We performed a focused study on the association of preoperative functional status with unplanned intubation outcomes in these relatively common surgeries. METHODS: Utilizing data from the National Surgical Quality Improvement Program database from 2007 to 2013, a propensity score-matched retrospective cohort study was performed assessing this outcome in the functionally independent versus dependent groups. Kaplan-Meier survival analysis and a Cox proportional hazards model were performed to assess the difference. RESULTS: There were a total of 98,035 thyroid- and parathyroidectomies identified from the National Surgical Quality Improvement Program from 2007 to 2013. After propensity score matching, there were 1,862 and 931 cases in the independent and dependent group, respectively. There were 11 versus 33 per 1,000 persons in the independent and dependent group, respectively, who experienced an unplanned intubation within 30 d following surgery (P < .001). The dependent group showed worse intubation-free survival over 30 d (P < .001). There were no differences in this outcome during postoperative days 0–1 (P = .17). Dependent functional status was statistically significantly associated with unplanned intubations up to 30 d postoperatively (hazard ratio 2.4, 95% CI 1.4–4.18, P = .002). CONCLUSIONS: Preoperative functional status is a good marker for identifying patients at risk for re-intubation after thyroid- and parathyroidectomy.

Postoperative outcomes with neuraxial versus general anesthesia in bilateral total hip arthroplasty

STUDY OBJECTIVE Current evidence remains limited on the postoperative outcomes of neuraxial (NA) versus general anesthesia (GA) as primary anesthesia type in patients receiving simultaneous bilateral total hip arthroplasty (BTHA). We aimed to evaluate the rates of postoperative outcomes among patients receiving NA versus GA for BTHA. DESIGN Retrospective cohort study. SETTING Multi-institutional. PATIENTS A total of 798 patients undergoing BTHA with 519 and 279 who received GA and NA, respectively. We used the American College of Surgeons - National Surgical Quality Improvement Program database for years 2007 to 2016. INTERVENTIONS Patients undergoing BTHA. MEASUREMENTS We propensity-score matched on demographic factors and comorbid conditions to compare rates of postoperative outcomes among cohorts (NA versus GA). We performed Pearson chi-square and Wilcoxon rank sum test to compare NA versus GA cohorts. MAIN RESULTS The final analysis included 798 BTHA patients, of which 35% received NA as the primary anesthetic. The median age was 58 years old and 50.8% were female. The rate of perioperative transfusion in the NA and GA group were 20.1% and 29.0%, respectively (p = 0.02). There were no significant differences in the rate of postoperative outcomes between patients receiving NA versus GA as their primary anesthesia type (Bonferroni corrected p < 0.006 was considered statistically significant). CONCLUSION Our study showed no significant differences in postoperative outcomes between NA versus GA following BTHA. Further studies are needed to investigate outcomes among this surgical population.

PC188. Epidemiology and Trends of Human Immunodeficiency Virus-Positive Patients Undergoing Noncardiac Vascular Surgery in the United States: 2000 to 2014

Objectives: Given the advantages and disadvantages of competing options for abdominal aortic aneurysm (AAA) repair, it is critical to understand how and patients learn about their options for both open aortic reconstruction and endovascular AAA repair of AAA (EVR). Methods: We performed a multicenter survey of 100 patients facing AAA repair at 20 VA hospitals across the United States as part of the PRreference for Open VErsus Surgical Repair of AAA (PROVE-AAA) study. A validated survey instrument was administered to examine the sources of available information to patients about their repair options. This survey was administered by study personnel before the patient had any interaction with the vascular surgeon, as survey data was collected before the vascular clinic visit. Results: Overall, patients were primarily male (96%) and elderly (mean age 73 years). They commonly had a history of coronary disease (62%), hypertension (71%), diabetes (48%), and COPD (23%). The majority of patients (55%) reported that their primary care physician did not talk with them about their options for AAA treatment (Fig). Only 5% reported having talked to their primary care physician as much as they felt necessary about their AAA (Fig). Nearly half (37%) reported that they did not receive any information at all about the options for open surgical repair or endovascular repair. In terms of other sources of information about their treatment options beyond their primary care provider, few used the internet (12%), family or friends (14%), and more than one-half reported that their views on treatment options had not been influenced at all by anyone (55%; Fig).

Postoperative outcomes in patients with a do-not-resuscitate (DNR) order undergoing elective procedures

STUDY OBJECTIVE Do-not-resuscitate (DNR) status has been shown to be an independent risk factor for mortality in the post-operative period. Patients with DNR orders often undergo elective surgeries to alleviate symptoms and improve quality of life, but there are limited data on outcomes for informed decision making. DESIGN Retrospective cohort study. SETTING A multi-institutional setting including operating room, postoperative recovery area, inpatient wards, and the intensive care unit. PATIENTS A total of 566 patients with a DNR status and 316,431 patients without a DNR status undergoing elective procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2012. INTERVENTIONS Patients undergoing elective surgical procedures. MEASUREMENTS We analyzed the risk-adjusted 30-day morbidity and mortality outcomes for the matched DNR and non-DNR cohorts undergoing elective surgeries. MAIN RESULTS DNR patients had significantly increased odds of 30-day mortality (OR 2.51 [1.55-4.05], p < 0.001) compared with non-DNR patients. In the DNR versus non-DNR cohort there was no significant difference in the occurrence of a number of 30-day complications, the rate of resuscitative measures undertaken, including cardiac arrest requiring CPR, reintubation, or return to the OR. The most common complications in both DNR and non-DNR patients undergoing elective procedures were transfusion, urinary tract infection, reoperation, and sepsis. Finally, the DNR patients had a significantly increased total length of hospital stay (7.65 ± 9.55 vs. 6.87 ± 9.21 days, p = 0.002). CONCLUSIONS DNR patients, as compared with non-DNR patients, have increased post-operative mortality but not morbidity, which may arise from unmeasured severity of illness or transition to comfort care in accordance with a patients wishes. The informed consent process for elective surgeries in this patient population should include a discussion of acceptable operative risk.

An Update of Racial Disparities with Thirty-day Outcomes Following Coronary Artery Bypass Graft Under the Affordable Care Act

OBJECTIVE The impact of race on outcomes after coronary artery bypass graft (CABG) has been reported before the enactment of the Patient Protection and Affordable Care Act. However, the impact of race on outcomes post-Affordable Care Act enactment remains unclear. The authors evaluated the association of race with outcomes after enactment of the Affordable Care Act in CABG patients. DESIGN Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016. SETTING Multi-institutional. PARTICIPANTS The authors identified 9,698 CABG patients. INTERVENTIONS CABG. MEASUREMENTS AND MAIN RESULTS Compared with the white population, the black/African American population had higher rates of congestive heart failure, blood transfusion, bleeding disorder, insulin-dependent diabetes mellitus, active smoking, renal dialysis, and hypertension (all p < 0.05). Compared with whites, Asians tended to have a higher prevalence of blood transfusion, American Society of Anesthesiologists class ≥4, diabetes mellitus, and renal dialysis (all p < 0.05). Postoperative red blood cell transfusion (56.5%) and prolonged hospital length of stay ≥12 days (27.7%) were the most prevalent adverse outcomes. Compared with whites, the adjusted odds of postoperative overall morbidity were higher among blacks/African Americans (odds ratio [OR]: 1.42, 95% confidence interval [CI]: 1.15-1.76, p < 0.001) and Asians (OR: 1.43, 95% CI: 1.06-1.91, p = 0.001). Compared with blacks/African Americans, Asians had higher odds of infection complications (OR: 2.07, 95% CI: 1.10-3.88, p = 0.023). CONCLUSION Differential outcomes were observed for morbidity and mortality outcome measures. The persistence of racial disparities beyond the Affordable Care Act calls for multidisciplinary action.

Perioperative Risk Factors Associated with Postoperative Unplanned Intubation Following Lung Resection

OBJECTIVE Postoperative respiratory failure requiring reintubation is associated with a significant increase in mortality. However, perioperative risk factors and their effects on unplanned 30-day reintubation and postoperative outcomes after unplanned reintubation following lung resection are not described well. The aim of this study was to determine whether certain comorbidities, demographic factors, and postoperative outcomes are associated with 30-day reintubation after thoracic surgery. DESIGN This was a retrospective observational study using multivariable logistic regression to identify preoperative risk factors and consequences of unplanned 30-day reintubation. SETTING Multi-institutional, prospective, surgical outcome-oriented database study. PARTICIPANTS Using the American College of Surgeons National Surgical Quality Improvement Program database, video-assisted thorascopic surgery and thoracotomy lung resections (lobectomy, wedge resection, segmentectomy, bilobectomy, pneumonectomy) were analyzed by Common Procedural Terminology codes from the years 2007 to 2016 in 16,696 patients undergoing thoracic surgery. INTERVENTION None. MEASUREMENT AND MAIN RESULTS The final analysis included 16,696 patients, of who 593 (3.5%) underwent unplanned reintubation. Among the final study population, 137 (23%) of unplanned intubations occurred within 24 hours postoperatively and the median (25%, 75% quartile) day of reintubation was day 3 (2, 8 days). The final multivariable logistic regression analysis suggested that age, American Society of Anesthesiologists physical status classification score ≥4, dyspnea with moderate exertion and at rest, history of chronic obstructive pulmonary disease, male sex, smoking, functional dependence, steroid use, open thoracotomies, increased operation time, and preoperative laboratory results (albumin and hematocrit) were associated with unplanned intubation after lung resection (p < 0.05). Unplanned intubation was associated significantly with 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay (p < 0.05). CONCLUSIONS Nonmodifiable and modifiable preoperative risk factors were associated with increased odds of unplanned reintubation. Patients who experienced unplanned intubation were at considerable risk for 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay.

An updated assessment of morbidity and mortality following skull base surgical approaches

OBJECTIVES Updated multi-institutional database studies assessing perioperative risk factors on 30-day morbidity and mortality after skull base surgeries are limited. We aim to identify perioperative risk factors and report the incidence of 30-day morbidity and mortality in adult patients after skull base surgery. PATIENTS AND METHODS We queried the 2007-2016 American College of Surgeons National Surgical Quality Improvement program database to identify patients who underwent anterior, middle, or posterior skull base surgery. We performed multivariable logistic regression to identify risk factors associated with 30-day morbidity and mortality. Postoperative events were compared between propensity score matched cohorts (no morbidity versus 30-day morbidity). RESULTS The final analysis included 1028 adult (≥18 years old) patients. The incidence of 30-morbidity and mortality was 14.6% and 1.6%, respectively. Postoperative ventilator dependence (52.9%) followed by pneumonia (23.5%) and unplanned intubation (23.5%) had the highest prevalence among those with 30-day mortality. The adjusted odds of 30-day morbidity was significantly higher among patients with functional dependency, American Society of Anesthesiologists Physical Status ≥4, hyponatremia, and anemia (p < 0.05). The adjusted odds of 30-day mortality was significantly increased among patients with sepsis, bleeding disorder, disseminated cancer, and older age (p < 0.05). CONCLUSION Clinical perioperative factors are significantly associated with 30-day morbidity and mortality after skull base surgery. The reported rate of 30-day morbidity and mortality was similar to earlier studies and therefore highlights the need for continued quality improvement.

Perioperative Risk Factors Associated With Morbidity and Mortality Following Pediatric Inpatient Sinus Surgery

Objectives: Pediatric sinus surgery is indicated for a wide range of sinonasal and skull base pathologies, but it is most commonly performed for recalcitrant chronic rhinosinusitis or complicated acute sinusitis. The authors aim to report medical risk factors of morbidity and mortality following inpatient sinus surgery in the pediatric population. Methods: Using data from the Kids’ Inpatient Database from 2003 to 2012, patients with International Classification of Diseases, Ninth Revision, procedure codes for primary sinus surgery were identified. Mixed-effect multivariable logistic regression was used to identify risk factors of inpatient postoperative morbidity and mortality. Results: The final sample included a weighted estimate of 4965 pediatric patients. The rates of inpatient morbidity and mortality were 6% and 1%, respectively. Respiratory complications (2.5%) were the most prevalent postoperative adverse events. The most prevalent comorbidities were chronic sinusitis (59.8%), acute sinusitis (27.8%), and cystic fibrosis (26.4%). Compared with patients who did not experience any morbidity, patients with inpatient morbidity had higher rates of pneumonia, mycoses, and nasal or paranasal benign neoplasm (P < .05). The odds of inpatient morbidity and mortality were highest for patients with leukemia (odds ratio, 2.74; 95% confidence interval, 1.59-4.72; P < .001) and mycoses (odds ratio, 15.84; 95% confidence interval, 6.45-38.89; P < .001), respectively. Conclusions: This study is the first to report the national comorbidity burden and risk factors for postoperative adverse events following inpatient sinus surgery. Knowledge of the comorbidities and independent factors associated with morbidity and mortality will help in directing preoperative optimization and counseling. Level of Evidence: 2c

Factors Predictive of Postoperative Acute Respiratory Failure Following Inpatient Sinus Surgery

Objective: The impact of perioperative risk factors on outcomes following outpatient sinus surgery is well defined; however, risk factors and outcomes following inpatient surgery remain poorly understood. We aimed to define risk factors of postoperative acute respiratory failure following inpatient sinus surgery. Methods: Utilizing data from the Nationwide Inpatient Sample Database from the years 2010 to 2014, we identified patients (≥18 years of age) with an Internal Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code of sinus surgery. We used multivariable logistic regression to identify risk factors of postoperative acute respiratory failure. Results: We identified 4919 patients with a median age of 53 years. The rate of inpatient postoperative acute respiratory failure was 3.35%. Chronic sinusitis (57.7%) was the most common discharge diagnosis. The final multivariable logistic regression analysis suggested that pneumonia, bleeding disorder, alcohol dependence, nutritional deficiency, heart failure, paranasal fungal infections, and chronic kidney disease were associated with increased odds of acute respiratory failure (all P < .05). Conclusion: To our knowledge, this represents the first study to evaluate potential risk factors of acute respiratory failure following inpatient sinus surgery. Knowledge of these risk factors may be used for risk stratification.

Optimizing Preoperative Anemia to Improve Patient Outcomes

Anemia is a decrease in red blood cell mass, which hinders oxygen delivery to tissues. Preoperative anemia has been shown to be associated with mortality and morbidity following major surgery. The preoperative care clinic is an ideal place to start screening for anemia and discussing potential interventions in order to optimize patients for surgery. This article (1) reviews the relevant literature and highlights consequences of preoperative anemia in the surgical setting, and (2) suggests strategies for screening and optimizing anemia in the preoperative setting.