BackgroundThere is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications.MethodsThis was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4‐month interval (October–December 2014) were eligible for inclusion. The primary outcome was the 30‐day major complication rate (Clavien–Dindo grade III–V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital‐level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.).ResultsOf 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30‐day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147).ConclusionOverweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.
SummaryIncreasing numbers of patients presenting for surgery are receiving concurrent medication with low-dose aspirin. We surveyed the opinions and working practices of consultant members of the Neuroanaesthesia Society regarding patients who present for elective intracranial surgery whilst taking this form of medication. Identical questionnaires were sent to 140 members of the society and proffered four main questions: (1) the adherence to any policy of stopping aspirin preoperatively, (2) the preferred method of treatment for excessive bleeding in this context, (3) personal knowledge of haemorrhagic complications in this group of patients, (4) the neurosurgical unit concerned. There were 121 responses (86.4%) of which 116 (82.9%) were valid. Of the respondents, 78 (67.2%) were unaware of a written departmental policy for the discontinuation of pre-operative aspirin treatment and had no personal policy. Thirty-two respondents (27.6%) had a personal policy but were unaware of a written departmental policy; only six respondents (5.2%) stated that a written departmental policy was in place. The mean time suggested for discontinuation of aspirin pre-operatively was 11.3 days (range: 1-42 days). Fifty-one respondents (44.0%) considered that patients taking low-dose aspirin were at increased risk of excessive perioperative haemorrhage and 15 (12.9%) anaesthetists reported having personal experience of such problems. Fifty-seven respondents (49.1%) would use a platelet infusion, alone or in association with other blood products or prohaemostatic agents, if haemorrhagic complications developed. The majority of neuroanaesthetists felt that aspirin was a risk factor for haemorrhagic complications associated with intracranial procedures, but most adopt no policy regarding its preoperative discontinuation.Keywords Surgery; neurosurgical. Analgesics; salicylates, aspirin. ...................................................................................... Correspondence to: D. N. James, Department of Anaesthesia, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, UK. Accepted: 18 October 1996 Aspirin is increasingly prescribed for its antithrombotic properties [1][2][3][4][5] and more patients are therefore presenting for surgery with dysfunctional circulating platelets. Aspirin is also a common constituent of many 'over the counter ' medications [6].The contribution of low-dose aspirin to increased perioperative blood loss is a contentious issue with conflicting published results from different surgical groups. Data from neurosurgical patients are sparse [7] but aspirin has been identified as an important risk factor in the development of postoperative haematomata following intracranial surgery [8].This survey examined the opinions and working practices of consultant neuroanaesthetists with regard to patients taking low-dose aspirin medication who present for elective intracranial surgery. MethodsIdentical questionnaires with stamped addressed return envelopes were sent to practising consultant members o...
SummaryWe speculated that asymptomatic patients undergoing routine surgery might be at higher risk of subsequent cardiac events. We studied 183 534 patients with no prior admission for heart disease, aged 50-75 years, admitted electively for one of five operations considered medium to low risk of peri-operative cardiac morbidity, between January 1997 and December 2005. Controls were generated from linked records. Within 3 years 3444 (1.9%) patients undergoing operations had subsequent myocardial infarction ⁄ acute coronary syndrome (MI ⁄ ACS) compared with 3708 (2.0%) controls (p < 0.001). Overall 8406 (4.6%) patients undergoing surgery had MI ⁄ ACS compared with 9306 (5.1%) controls (p < 0.001). Of patients undergoing surgery, 20.2% died compared with 25
Background: Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery. Methods: This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and intercentre variation in critical care admission after emergency laparotomy. Results: Of 4529 patients included, 37.8% (n¼1713) underwent planned critical care admissions from theatre. Some 3.1% (n¼86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n¼133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51e19.97) than planned admissions (OR: 2.32, 95% CI: 1.43e3.85). Some 26.7% of patients (n¼1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8e51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n¼10/145) of centres outside the 95% CI. Conclusions: After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.
SummaryThe new generation nionoaniine oxidase inhibitors are short acting and specific for nionoaniine osidase A . Evidence to date aggests that there is little potential for significant interaction with niost drugs used in anaesthesia. Key wordsPharmacology; moclobemide, reversible inhibitors of monoamine oxidase A. Interactions.Historically, monoamine oxidase inhibitors (MAOIs) have been a bite noir for anaesthetists because of the potential for unpredictable and serious interactions with some drugs used in anaesthesia. A review in 1988 [ 1 ] clarified the nature of these interactions and the drugs to be avoided, but a general decline in usage of MAOIs despite their undoubted efficacy, means that anaesthetists are now only rarely confronted with the problem.Moclobemide (Manerix) is the first available member of a new generation of short acting MAOIs, that are specific for one type of receptor, the reversible inhibitors of monoamine oxidase type A (RIMAs) [2]. This new drug is virtually devoid of the serious side effects that are associated with first generation MAOIs, and is likely to become increasingly used for a wide spectrum of psychiatric illness [3]. The known pharmacological profile of this drug suggests that interaction with drugs used in anaesthesia jhould be minimal [4]. Case report.A woman of 38 years weighing 70 kg, with no important past medical history, presented with stress incontinence and, following investigation, was scheduled for operation to support her bladder neck outlet (colposuspension). She was physically fit and healthy but had suffered severe depression for more than 2 years. She had been maintained successfully on MAOIs and lithium but 8 months before surgery, her MA01 had been changed to moclobemide with good effect.She declined night sedation and on the morning of surgery moclobemide and lithium were omitted and temazepam 20 mg was given 2 h before operation. In the anaesthetic room she was relaxed but not drowsy. Anaesthesia was induced with propofol 160 mg to which lignocaine 10 mg had been added, followed by atracurium 35 mg. Anaesthesia was maintained with isoflurane in nitrous oxide and oxygen. and morphine 10 mg and droperidal 2.5 mg were given in divided doses during the operation. Blood pressure and heart rate remained stable (the highest pressure was 125,'80 and the lowest 90160) throughout the 50 min procedure. Muscle relaxation was reversed without incident and she awoke promptly.In the recovery room she received morphine 3 mg and was established on a morphine Patient Controlled Analgesia System (PCAS) to receive a 1 mg bolus dose with a 6 min lockout time. Over the next 32 h she received a total of 35 mg of morphine, remained comfortable and with stable blood pressure and heart rate. Moclobemide and lithium were restarted on the first postoperative day and analgesia was maintained over the next few days with oral mefenamic acid. Her stay in hospital was prolonged by 48 h because of an initial failure to retain bladder tone, for which she received ubretid.
SummaryThe Scottish Audit of Surgical Mortality is a voluntary, peer reviewed, critical event analysis of patients who die under the care of consultant surgeons in acute hospitals in Scotland. The anaesthetic contribution to surgical mortality over a 10-year period from 1996 was reviewed. The total number of deaths was 44 230 or 1.5% of all admissions. Forty thousand, eight hundred and ninety-six deaths (92%) were audited. Deaths after elective surgery declined over 10 years. Over 80% of deaths followed emergency admission. The number of deaths where an anaesthetist was present was 16 981 or 0.6% of all admissions. Anaesthetic areas of concern were identified in 8% of deaths. Of these, 43% were related to pre-operative assessment. Anaesthesia also played a part in a further 18% of deaths where decision making was shared with the surgical team. Of these, 41% were related to access to critical care. A further 24% related to communication failures, principally when the operation should not have been done or was unnecessary.
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