IntroductionAccurate surgical risk prediction is paramount in clinical shared decision making. Existing risk calculators have limited value in local practice due to lack of validation, complexities and inclusion of non-routine variables.ObjectiveWe aim to develop a simple, locally derived and validated surgical risk calculator predicting 30-day postsurgical mortality and need for intensive care unit (ICU) stay (>24 hours) based on routinely collected preoperative variables. We postulate that accuracy of a clinical history-based scoring tool could be improved by including readily available investigations, such as haemoglobin level and red cell distribution width.MethodologyElectronic medical records of 90 785 patients, who underwent non-cardiac and non-neuro surgery between 1 January 2012 and 31 October 2016 in Singapore General Hospital, were retrospectively analysed. Patient demographics, comorbidities, laboratory results, surgical priority and surgical risk were collected. Outcome measures were death within 30 days after surgery and ICU admission. After excluding patients with missing data, the final data set consisted of 79 914 cases, which was divided randomly into derivation (70%) and validation cohort (30%). Multivariable logistic regression analysis was used to construct a single model predicting both outcomes using Odds Ratio (OR) of the risk variables. The ORs were then assigned ranks, which were subsequently used to construct the calculator.ResultsObserved mortality was 0.6%. The Combined Assessment of Risk Encountered in Surgery (CARES) surgical risk calculator, consisting of nine variables, was constructed. The area under the receiver operating curve (AUROC) in the derivation and validation cohorts for mortality were 0.934 (0.917–0.950) and 0.934 (0.912–0.956), respectively, while the AUROC for ICU admission was 0.863 (0.848–0.878) and 0.837 (0.808–0.868), respectively. CARES also performed better than the American Society of Anaesthesiologists-Physical Status classification in terms of AUROC comparison.ConclusionThe development of the CARES surgical risk calculator allows for a simplified yet accurate prediction of both postoperative mortality and need for ICU admission after surgery.
We describe a postnatally diagnosed case of Walker-Warburg syndrome--a form of congenital muscular dystrophy with lissencephaly and eye abnormalities. We reviewed the literature to highlight its clinico-radiological diagnostic features and discuss the difficulties encountered with prenatal diagnosis, especially in cases with no positive family history. An increased awareness of this rare but lethal condition, and a high index of suspicion during routine antenatal ultrasound, could prompt further advanced fetal ultrasonography and magnetic resonance imaging, and aid in timely prenatal diagnosis, management, and counseling.
INTRODUCTIONThere is strong evidence that epidural analgesia provides good postoperative pain relief in adults, but its use in infants is less established. In this retrospective study, we present our experience with managing infant epidural analgesia for abdominal surgeries in a tertiary paediatric institution. METHODSThe records of 54 infants who had received a thoracic or lumbar epidural as perioperative analgesia for abdominal surgeries were included. The mean age of the infants was 6.1 (standard deviation [SD] 3.8) months and their mean weight was 6.8 kg (SD 1.8). Most (63%) had an ASA (American Society of Anesthesiologists) status of 2 and all underwent elective gastrointestinal, urogenital, hepatobiliary or retroperitoneal surgeries. 20 catheters (37.0%) were inserted in the thoracic region and 33 (61.1%) in the lumbar region.RESULTS A total of 52 (96.3%) catheters provided adequate intraoperative analgesia and 36 (66.7%) provided effective analgesia for the postoperative period. Active management of epidural analgesia, such as through epidural top-ups and infusion rate adjustment, was necessary to optimise analgesia in 22 (44%) of the 50 patients postoperatively. Reasons for premature catheter removal were mainly technical issues such as catheter disconnection, leakage and blockage.CONCLUSION Our data suggests that in experienced hands, specialised settings and active management, the success rate of epidural analgesia in infants undergoing major abdominal surgeries is high and without major incident.
Between 1992 and 1994 the Paediatric Metabolic Centre screened 403 patients for inherited metabolic disease. Seventeen patients were diagnosed, including 7 with organic acidurias, 5 with mucopolysaccharidoses, 2 with amino acid disorders, 2 with carbohydrate disorders and 1 with hyperlipidaemia. The ethnic distribution of disorders in Singapore is compared with incidences reported by others in this part of the world. It is likely that further studies will indicate which diagnostic or screening tests would best serve this community.
BackgroundThe pericapsular nerve group block (PENG) is a novel technique that blocks the articular branches of the hip joint. This study aimed to compare its effectiveness to a sham block in elderly patients with hip fractures.MethodA randomized double-blind controlled trial was conducted in elderly patients with intertrochanteric and neck of femur fractures. Patients were randomized to receive either PENG block or a sham block. Postblock, systemic analgesia was titrated using a standardized protocol of acetaminophen, oral morphine or patient-controlled analgesia. The primary outcome was the dynamic pain score (Numerical Rating Scale 0–10) at 30 min postblock. Secondary outcomes included pain scores at multiple other time points and 24-hour opioid consumption.Results60 patients were randomized and 57 completed the trial (PENG n=28, control n=29). Patients in PENG group had significantly lower dynamic pain scores at 30 min compared with control group (median (IQR) 3 (0.5–5) vs 5 (3–10), p<0.01). For the secondary outcomes, dynamic pain scores were lower in PENG group at 1 hour (median (IQR) 2 (1–3.25) vs 5 (3–8), p<0.01) and 3 hours postblock (median (IQR) 2 (0–5) vs 5 (2–8), p<0.05). Patients in PENG group had lower 24-hour opioid consumption (median (IQR) oral morphine equivalent dose 10 (0–15) vs 15 (10–30) mg, p<0.05).ConclusionPENG block provided effective analgesia for acute traumatic pain following hip fracture. Further studies are required to validate the superiority of PENG blocks over other regional techniques.Trial registration numberNCT04996979.
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