Acute Postoperative Pain Is Associated With Myocardial Injury After Noncardiac Surgery.

BACKGROUND: Uncontrolled pain after noncardiac surgery activates the sympathetic nervous system, which causes tachycardia, hypertension, and increased cardiac contractility-all of which may increase myocardial oxygen demand. We therefore determined whether time-weighted average pain scores over the initial 72 postoperative hours are associated with myocardial injury after noncardiac surgery (MINS). METHODS: We conducted a retrospective cohort analysis of adults with routine postoperative troponin monitoring after noncardiac surgery under general, regional, or combined anesthesia at tertiary level centers in Cleveland from January 2012 to December 2015. Time-weighted average pain scores were calculated from all the available pain scores, typically at 4-hour intervals, until a troponin elevation was detected. MINS was defined as peak troponin T concentrations exceeding 0.03 ng/mL within 72 hours after surgery. We used a generalized linear mixed model to assess the association between pain and MINS with 3 hospitals as clusters, adjusting for potential confounders. RESULTS: Among 2892 eligible patients, 4.5% had myocardial injury within 72 hours after surgery. Higher time-weighted average pain scores were associated with increased hazard of myocardial injury. The estimated hazard ratio for a 1-unit increase in pain score was 1.12 (95% confidence interval [CI], 1.02-1.22; P = .013), adjusting for confounding variables. CONCLUSIONS: Among patients undergoing noncardiac surgery, time-weighted average pain scores within 72 hours after surgery were significantly associated with myocardial injury.

Real-time Ultrasound-Guided Lumbar Epidural with Transverse Interlaminar View: Evaluation of an In-Plane Technique.

OBJECTIVE: The anatomical landmarks method is currently the most widely used technique for epidural needle insertion and is faced with multiple difficulties in certain patient populations. Real-time ultrasound guidance has been recently used to aid in epidural needle insertion, with promising results. Our aim was to test the feasibility, success rate, and satisfaction associated with a novel real-time ultrasound-guided lumbar epidural needle insertion in the transverse interlaminar view. DESIGN: Prospective descriptive trial on a novel approach. SETTING: Operating room and preoperative holding area at a tertiary care hospital. SUBJECTS: Adult patients presenting for elective open prostatectomy and planned for surgical epidural anesthesia. METHODS: Consented adult patients aged 30-80 years scheduled for open prostatectomy under epidural anesthesia were enrolled. Exclusion criteria included allergy to local anesthetics, infection at the needle insertion site, coagulopathy, and patient refusal. A curvilinear low-frequency (2-5 MHz) ultrasound probe and echogenic 17-G Tuohy needles were used by one of three attending anesthesiologists. Feasibility of epidural insertion was defined as a 90% success rate within 10 minutes. RESULTS: Twenty-two patients were enrolled into the trial, 14 (63.6%) of whom found the process to be satisfactory or very satisfactory. The median time to perform the block was around 4.5 minutes, with an estimated success rate of 95%. No complications related to the epidural block were observed over the 48 hours after the procedure. CONCLUSIONS: We demonstrate the feasibility of a novel real-time ultrasound-guided epidural with transverse interlaminar view.

Multimodal Pain Management for Cesarean Delivery: A Double-Blinded, Placebo-Controlled, Randomized Clinical Trial.

OBJECTIVE: Our objective was to evaluate the efficacy of perioperative multimodal pain management in reducing opioid use after elective cesarean delivery (CD). STUDY DESIGN: A single-center, double-blinded, placebo-controlled randomized trial of women undergoing elective CD. Participants were allocated 1:1 to receive the multimodal protocol or matching placebos. The multimodal protocol consisted of a preoperative dose of intravenous acetaminophen, preincision injection of subcutaneous bupivacaine, and intraoperative injection of intramuscular ketorolac. Primary outcome was total opioid intake at 48 hours postoperatively. Secondary outcomes were pain scores, time to first opioid intake, neonatal outcomes, and total outpatient opioid intake on postoperative day (POD) 7. Data were analyzed using parametric and nonparametric tests and quantile regression as appropriate. RESULTS: A total of 242 women were screened with 120 randomized, 60 to the multimodal group and 60 to control group. There was no significant difference in the primary outcome of opioid use nor in the secondary outcomes. Smokers and patients with a history of drug use had higher median postoperative opiate use and earlier administration. On POD 7, only 40% of prescribed opioids had been used, and there was no difference between the groups. CONCLUSION: This perioperative multimodal pain regimen did not reduce opioid use in 48 hours after CD. Patients who smoke or with a history of drug use required more opioids in the postoperative period. Providers significantly overprescribed opioids after CD.

Postoperative Hypotension and Surgical Site Infections After Colorectal Surgery: A Retrospective Cohort Study.

BACKGROUND: Hypotension compromises local tissue perfusion, thereby reducing tissue oxygenation. Hypotension might thus be expected to promote infection. Hypotension on surgical wards, while usually less severe than intraoperative hypotension, is common and often prolonged. In this retrospective cohort study, we tested the hypotheses that there is an association between surgical site infections and low postoperative time-weighted average mean arterial pressure and/or postoperative minimum mean arterial pressure. METHODS: We considered patients who had colorectal surgery lasting ≥1 hour at the Cleveland Clinic between 2009 and 2013. We defined blood pressure exposures as time-weighted average (primary) and minimum mean arterial pressure (secondary) within 72 hours after surgery. We assessed associations between continuous blood pressure exposures with a composite of deep and superficial surgical site infection using separate severity-weighted average relative effect generalized estimating equations models, each using an unstructured correlation structure and adjusting for potentially confounding variables. RESULTS: A total of 5896 patients were eligible for analysis. Time-weighted mean arterial pressure and surgical site infection were not significantly associated, with an estimated odds ratio (95% CI) of 1.03 (0.99-1.08) for a 5-mm Hg decrease (P = .16). However, there was a significant inverse association between minimum postoperative mean arterial pressure and infection, with an estimated odds ratio of 1.08 (1.03-1.12) per 5-mm Hg decrease (P = .001). CONCLUSIONS: Postoperative time-weighted mean arterial pressure was not associated with surgical site infection, but lowest postoperative mean arterial pressure was. Whether the relationship is causal remains to be determined.

Systemic Lupus Erythematosus Is Associated With Increased Adverse Postoperative Renal Outcomes and Mortality: A Historical Cohort Study Using Administrative Health Data.

BACKGROUND: Systemic lupus erythematosus (SLE) is a common autoimmune connective tissue disease that mainly harms kidneys, heart, lungs, and nervous system. Effects of surgical stimulus and anesthesia combined with SLE-related pathologies may increase morbidity and mortality. Therefore, we aimed to evaluate the association between SLE (versus none) and postoperative renal, cardiac, and in-hospital mortality complications among patients undergoing major surgeries. METHODS: We obtained censuses of 2009 to 2011 inpatient hospital discharges across 7 states and conducted a retrospective cohort study by using International Classification of Diseases and Injuries, Version 9, diagnosis codes, procedure codes, and present-on-admission indicators. We included patients who had major surgery and matched each SLE discharge up to 4 control discharges for potential confounders. We assessed the association between matched SLE patients and controls on in-hospital renal complications, cardiovascular complications, and in-hospital mortality using separate logistic regression models. RESULTS: Among 8 million qualifying discharges, our sample contained 28,269 SLE patients matched with 13,269 controls. SLE was associated with a significantly higher risk of postoperative renal complications, with an estimated odds ratio (99% CI) of 1.33 (1.21, 1.46); P < .001. In addition, SLE was significantly associated with a higher risk of in-hospital mortality, with an estimated odds ratio (99% CI) of 1.27 (1.11, 1.47); P < .001. However, we found no significant association between SLE and cardiac complications, with an estimated odds ratio (99% CI) of 0.98 (0.83, 1.16), P = .79. CONCLUSIONS: This is, by far, the largest clinical study for postoperative outcomes of SLE patients with adequately powered statistical analyses. We concluded that SLE was associated with a higher risk of renal complications and in-hospital mortality but not cardiac events after major surgery. In SLE patients, more aggressive measures should be taken to prevent renal injury in the perioperative period.

Novel needle guide reduces time to perform ultrasound-guided femoral nerve catheter placement: A randomised controlled trial.

BACKGROUND: Ultrasound-guided nerve blocks have become the standard when performing regional nerve blocks in anaesthesia. Infiniti Plus (CIVCO Medical Solutions, Kalona, Iowa, USA) is a needle guide that has been recently developed to help clinicians in performing ultrasound-guided nerve blocks. OBJECTIVES: We tested the hypothesis that femoral nerve catheter placement carried out with the Infiniti Plus needle guide will be quicker to perform than without the Infiniti Plus. Secondary aims were to assess whether the Infiniti Plus needle guide decreased the number of block attempts and also whether it improved needle visibility. DESIGN: A randomised, controlled trial. SETTING: Cleveland Clinic, Cleveland, Ohio, USA. PATIENTS: We enrolled adult patients having elective total knee arthroplasty with a femoral nerve block and femoral nerve catheter. Patients, who were pregnant or those who had preexisting neuropathy involving the surgical limb, coagulopathy, infection at the block site or allergy to local anaesthetics were excluded. INTERVENTIONS: Patients were randomised into two groups to receive the ultrasound-guided femoral nerve catheter placement with or without the Infiniti Plus needle guide. MAIN OUTCOME MEASURES: The time taken to place the femoral nerve catheter, the number of attempts, the success rate and needle visibility were recorded. We used an overall α of 0.05 for both the primary and secondary analyses; the secondary analyses were Bonferroni corrected to control for multiple comparisons. RESULT: The median (interquartile range Q1 to Q3) time to perform the femoral nerve catheter placement was 118 (100 to 150) s with Infiniti Plus and 177 (130 to 236) s without Infiniti Plus. Infiniti Plus significantly reduced the time spent performing femoral nerve catheterisation, with estimated ratio of means [(95% confidence interval), P value] of 0.67 [(0.60 to 0.75), P < 0.001] with Infiniti Plus compared with no Infiniti Plus. However, Infiniti Plus had no effect on the odds of a successful femoral nerve catheter placement, number of attempts or percentage of perfect needle visibility. CONCLUSION: We found that the use of Infiniti Plus decreased the median time to successfully place a femoral nerve catheter by 33% compared with not using Infiniti Plus. This difference may be more apparent to clinicians undertaking this procedure less often or by those in training as our team was very experienced, had been trained in the technique and was working in a hospital with a large caseload. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02080481.

Association Between Intraoperative Low Blood Pressure and Development of Surgical Site Infection After Colorectal Surgery: A Retrospective Cohort Study.

OBJECTIVE: We tested the primary hypothesis that surgical site infections (SSIs) are more common in patients who had longer periods of intraoperative low blood pressure. Our secondary hypothesis was that hospitalization is prolonged in patients experiencing longer periods of critically low systolic blood pressure (SBP) and/or mean arterial pressure (MAP). BACKGROUND: Hypotension compromises local tissue perfusion, thereby reducing tissue oxygenation. Hypotension might thus be expected to promote infection, but the extent to which low blood pressure contributes remains unclear. METHODS: We considered patients who had colorectal surgery lasting at least 1 hour at the Cleveland Clinic between 2009 and 2013. The duration of hypotensive exposure and development of SSI was assessed with logistic regression; the association between hypotensive exposure and duration of hospitalization was assessed with Cox proportional hazard regression. RESULTS: A total of 2521 patients were eligible for analysis. There was no adjusted association between SBP hypotension < 80 mm Hg and SSI, with an estimated odds ratio (95% confidence interval) of 0.97 (0.81, 1.17) per 5-minute increase in SBP hypotension (P = 0.54). There was also no adjusted association between MAP hypotension time and SSI, with estimated odds ratio of 0.97 (0.81, 1.17) for a 5-minute increase in MAP hypotension < 55 mm Hg time (P = 0.71). There was no association between duration of hypotension and time to discharge. CONCLUSIONS: Intraoperative hypotension does not seem to be a clinically important predictor of SSI after colorectal surgery, probably because the outcomes are overwhelmingly determined by other baseline and surgical factors-and perhaps postoperative hypotension.

Clonidine Does Not Reduce Pain or Opioid Consumption After Noncardiac Surgery.

BACKGROUND: Clonidine is an α2-adrenoceptor agonist, which has analgesic properties. However, the analgesic efficacy of perioperative clonidine remains unclear. We, therefore, tested the hypothesis that clonidine reduces both pain scores and cumulative opioid consumption during the initial 72 hours after noncardiac surgery. METHODS: Six hundred twenty-four patients undergoing elective noncardiac surgery under general and spinal anesthesia were included in this substudy of the PeriOperative ISchemia Evaluation-2 trial. Patients were randomly assigned to 0.2 mg oral clonidine or placebo 2 to 4 hours before surgery, followed by 0.2 mg/d transdermal clonidine patch or placebo patch, which was maintained until 72 hours after surgery. Postoperative pain scores and opioid consumption were assessed for 72 hours after surgery. RESULTS: Clonidine had no effect on opioid consumption compared with placebo, with an estimated ratio of means of 0.98 (95% confidence interval, 0.70-1.38); P = 0.92. Median (Q1, Q3) opioid consumption was 63 (30, 154) mg morphine equivalents in the clonidine group, which was similar to 60 (30, 128) mg morphine equivalents in the placebo group. Furthermore, there was no significant effect on pain scores, with an estimated difference in means of 0.12 (95% confidence interval, -0.02 to 0.26); 11-point scale; P = 0.10. Mean pain scores per patient were 3.6 ± 1.8 for clonidine patients and 3.6 ± 1.8 for placebo patients. CONCLUSIONS: Clonidine does not reduce opioid consumption or pain scores in patients recovering from noncardiac surgery.

A nomogram for predicting the need for sciatic nerve block after total knee arthroplasty.

PURPOSE: Sciatic nerve block (SNB) is commonly performed in combination with femoral nerve block (FNB) for postoperative analgesia following total knee arthroplasty (TKA). Despite the fact that 10-20 % of TKA patients require SNB for postoperative posterior knee pain, there are no existing studies that suggest a model to predict the need for SNB. The aim of our study was to develop a prediction tool to measure the likelihood of patients undergoing TKA surgery requiring a postoperative SNB. METHODS: With institutional review board approval, we obtained data from the electronic medical record of patients who underwent TKA at the Cleveland Clinic. A multivariable logistic regression was used to estimate the probability of requiring a postoperative SNB. Clinicians selected potential predictors to create a model, and the potential nonlinear association between continuous predictors and SNB was assessed using the restricted cubic spline model. RESULTS: In total 6279 TKA cases involving 2329 patients with complete datasets were used for building the prediction model, including 276 (12 %) patients who received a postoperative SNB and 2053 (88 %) patients who did not. The estimated C statistic of the prediction model was 0.64. The nomogram is used by first locating the patient position on each predictor variable scale, which has corresponding prognostic points. The cut-off of 11.6 % jointly maximizes the sensitivity and specificity. CONCLUSION: This is the first study to be published on SNB prediction after TKA. Our nomogram may prove to be a useful tool for guiding physicians in terms of their decisions regarding SNB.

The Association Between Sjögren Syndrome and Adverse Postoperative Outcomes: A Historical Cohort Study Using Administrative Health Data.

BACKGROUND: Sjögren syndrome is a chronic autoimmune disorder of the exocrine glands associated with cardiovascular events. We aimed to evaluate postoperative complications in patients with Sjögren syndrome undergoing noncardiac surgery. Specifically, we tested the primary hypothesis that patients with Sjögren syndrome have a greater risk of postoperative cardiovascular complications than those without the disease. Our secondary hypotheses were that patients with Sjögren syndrome are at greater risk of thromboembolic complications, microcirculatory complications, and mortality. METHODS: We obtained censuses of 2009 to 2010 inpatient hospital discharges across 7 states. Sjögren syndrome was identified by the present-on-admission diagnosis code 710.2. Each Sjögren n syndrome discharge was propensity matched to 4 control discharges. A generalized linear model was used to compare matched Sjögren syndrome patients and controls on risk of in-hospital cardiovascular complications, thromboembolic complications, microcirculatory complications, and mortality. RESULTS: Among 5.5 million qualifying discharges, our final matched sample contained 22,785 matched discharges, including 4557 with Sjögren syndrome. Sixty-six (1.45%) of the matched discharges with Sjögren syndrome and 213 (1.17%) of the matched controls had associated in-hospital cardiovascular complications. The adjusted odds ratio (99% confidence interval) was estimated at 1.14 (0.79-1.64), which was not statistically significant (P = 0.35). There were no significant differences in the odds of in-hospital thromboembolic complications (1.12 [0.82-1.53]; P = 0.36), in the odds of in-hospital microcirculatory complications (0.98 [0.77-1.26]; P = 0.86), or in the odds of in-hospital mortality (1.11 [0.76-1.61]; P = 0.49). CONCLUSIONS: The presence of Sjögren syndrome does not place patients at an increased risk for postoperative complications or in-hospital mortality.

Effects of sevoflurane and desflurane on otoacoustic emissions in humans.

Otoacoustic emissions (OAEs) are non-invasive, easy to apply and objective test methods which are widely used to determine the presence of hearing in audiology clinics. Under certain circumstances, the study should be applied under general anesthesia. The aim of this study was to determine the influence of new short-acting inhalation agents, desflurane and sevoflurane, on OAE in humans. These short-acting agents are widely used in general anesthesia. Thirty-one healthy patients who underwent septoplasty and turbinoplasty surgery were included in this study. Unpremedicated patients were anesthetized and monitored by a standard protocol except the inhalation agents. Desflurane and sevoflurane were added to the inhaled gas mixture at ~1MAC, 5-6 % and 1.5-2 %, respectively. Transient evoked otoacoustic emissions and distortion product otoacoustic emissions measured in both ears of each patient preoperatively in the operating room before induction, 5 min after induction, after the completion of surgical procedure while the anesthetic agents are still given and 1 h after surgery in the ward. Between-group and within-group comparisons and correlations with hemodynamic parameters were performed for statistical analysis. The measurements of 26 ears in desflurane group and 28 ears in sevoflurane group were evaluated. There were no differences in initial measurements between groups (p > 0.05). Both groups presented significant decrease in intraoperative measurements and changes in time were statistically significant (p < 0.05). The changes in OAEs were similar to changes in systemic blood pressures. Correlation between OAEs and systemic blood pressures were significant (p < 0.05). In conclusion, sevoflurane and desflurane decreased OAEs around 2-3 dB; OAEs are still measurable under inhalation agents. This provides some findings about the OAE status of patient, but the evaluations should be done with the impact of anesthetic agents in mind.

It.ÇÖs not always postdural puncture headache: a case report and note to the astute anesthesiologist.

Dural puncture is either diagnosed by unexpectedly profound response to medication test dose or development of a postpartum postural headache. Epidural blood patch is the gold standard for treatment of PDPH when conservative management fails. However, postpartum headaches can be resistant to multiple epidural blood patches. In such cases, preexisting intracranial processes should be considered and ruled out. We report here the unique case of a pregnant patient who developed a resistant headache in the postpartum period related to an incidental intracranial aneurysm. Subsequent treatment with endovascular embolization adequately relieved her symptoms. Early surgical consultation and a multidisciplinary team approach involving neurology and neuroimaging is required for successful management of patients such as the one described here.

Transversus abdominis plane block with liposomal bupivacaine versus continuous epidural analgesia for major abdominal surgery: The EXPLANE randomized trial.

OBJECTIVE: Compare transversus abdominis plane (TAP) blocks with liposomal bupivacaine were to epidural analgesia for pain at rest and opioid consumption in patients recovering from abdominal surgery. BACKGROUND: ERAS pathways suggest TAP blocks in preference to epidural analgesia for abdominal surgery. However, the relative efficacies of TAP blocks and epidural analgesia remains unknown. METHODS: Patients having major abdominal surgery were enrolled at six sites and randomly assigned 1:1 to thoracic epidural analgesia or bilateral/4-quadrant TAP blocks with liposomal bupivacaine. Intravenous opioids were used as needed. Non-inferiority margins were a priori set at 1 point on an 11-point pain numeric rating scale for pain at rest and at a 25% increase in postoperative opioid consumption. RESULTS: Enrollment was stopped per protocol at 3rd interim analysis after crossing an a priori futility boundary. 498 patients were analyzed (255 had TAP blocks and 243 had epidurals). Pain scores at rest in patients assigned to TAP blocks were significantly non-inferior to those given epidurals, with an estimated difference of 0.09 points (CI: -0.12, 0.30; noninferiority P < 0.001). Opioid consumption during the initial 3 postoperative days in TAP patients was not non-inferior to epidurals, with an estimated ratio of geometric means of 1.37 (CI: 1.05, 1.79; non-inferiority P = 0.754). However, the absolute difference was only 21 mg morphine equivalents over the 3 days. Patients with epidurals were more likely to experience mean arterial pressures <65 mmHg than those given TAP blocks: 48% versus 31%, P = 0.006. CONCLUSION: Pain scores at rest during the initial three days after major abdominal surgery were similar. Patients assigned to TAP blocks required more opioid then epidural patients but had less hypotension. Clinicians should reconsider epidural analgesia in patients at risk from hypotension. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02996227.

Comparison of the Effectiveness of Different Barrier Enclosure Techniques in Protection of Healthcare Workers During Tracheal Intubation and Extubation.

The coronavirus disease 2019 (COVID-19; SARS-CoV-2) pandemic has created serious challenges to anesthesiologists. As hospitalized patients' respiratory function deteriorates, many will require endotracheal intubation. Airway management of infected patients risks aerosolization of viral-loaded droplets that pose serious hazards to the anesthesiologist and all health care personnel present. The addition of an enclosure barrier during airway management minimizes the hazard by entrapping the droplets and possibly the aerosols within an enclosed space adding additional protection for health care workers. The aim of this study was to compare the effectiveness of different barrier enclosure techniques during tracheal intubation and extubation.

Anesthetic Management and 30-Day Outcomes After Renal Autotransplantation.

Background: Renal autotransplantation is a complex procedure performed for various indications such as treatment of renal vascular and urologic lesions and loin pain hematuria syndrome (LPHS). Because of the rarity of the procedure, few reports have been published, and little is known about anesthetic management and postoperative outcomes of patients with LPHS. The goal of this study was to review and describe all cases of renal autotransplantation performed at Cleveland Clinic during a specified period, focusing on anesthetic management and postoperative 30-day outcomes. Methods: We performed a retrospective review of the records of all patients who underwent renal autotransplantation from 2005 to 2014 at the Cleveland Clinic and collected demographic, anesthetic, surgical, and postoperative data. Results: A total of 64 patients underwent renal autotransplantation from 2005 to 2014. The most frequent indications were nephrolithiasis and LPHS. General endotracheal anesthesia with epidural for pain control was used in 47% of cases. Median duration of anesthesia was 528 minutes. Most patients were sent to a regular nursing floor postoperatively, but 28% of patients required intensive care unit admission. Two patients developed graft ischemia, and 1 patient developed graft failure requiring nephrectomy. No anesthetic-related complications and no mortality were associated with this procedure during the study. Conclusion: Renal autotransplantation is a safe option for patients with LPHS. Additional studies are needed to assess the effect of intraoperative anesthetic management on outcomes in this patient population.

Acute postcesarean pain is associated with in-hospital exclusive breastfeeding, length of stay and post-partum depression.

STUDY OBJECTIVE: The primary aim of the proposed study was to determine the association between postoperative pain and breastfeeding after cesarean delivery during hospital stay. DESIGN: Retrospective cohort study. SETTING: Postoperative recovery area and operating room. PATIENTS: Data was obtained on singleton pregnancies undergoing scheduled cesarean deliveries under spinal anesthesia between 2013 and 2016. INTERVENTIONS: Determine the association between postoperative pain and breastfeeding after cesarean delivery. MEASUREMENTS: Postoperative pain score, breastfeeding, LATCH score post-partum depression and length of stay values collected. MAIN RESULTS: The dataset consisted of electronic medical records from 5350 patients. We found that the pain score is negatively associated with the LATCH score; higher pain was associated with lower LATCH scores, -0.01 [-0.01,-0.00], p < .0402. Every one-point increase in average pain score was associated with a 21% reduction in the odds of in-hospital exclusive breast-feeding relative to exclusive formula-feeding, OR = 0.79 [0.70-0.90], p < .0002. We observed that the post-partum depression status was associated with the average postoperative pain score, F (1, 5347) = 41.51, p < .0001. We also found a significant positive association between the average pain score and the duration of hospital stay (p < .0001); every one-point increase in the average pain-score was associated with a 7.98 [6.28, 9.68] hour increase in length of stay. CONCLUSIONS: Our results demonstrate significant association between the increase in post-cesarean pain scores and deterioration of breastfeeding initiation while also exposing slight reductions in the quality of breastfeeding. Additionally, we found that increases in post-cesarean pain scores also positively associate with postpartum depression and duration of stay, with each increase in pain score resulted in an almost one-day increase in the length of stay.

Is the Neutrophil-to-Lymphocyte Ratio Associated With Increased Morbidity After Colorectal Surgery?

PURPOSE: We aimed to evaluate the association between preoperative and postoperative neutrophil-to-lymphocyte ratio (NLR) and 30-day postoperative complications after colorectal surgery. METHODS: Patients undergoing elective colorectal surgery between January, 2010 and December, 2014 were identified. Patients who had preoperative and postoperative days 1 and 2 (Postoperative day [POD]-1, POD-2) NLR were included in the study. Primary study outcomes were optimal NLR cutoff values at preop, POD-1, and POD-2. RESULTS: A total of 1328 patients met the inclusion criteria. Of those, 518 (39%) patients experienced at least one postoperative complication. Sex (P<0.001), diabetes mellitus (DM) (P<0.001), diagnosis (P=0.001), operation type (P=0.03), and open surgery (P<0.001) were statistically associated with higher NLR (POD-1, P=0.02; POD2, P=0.01). DM (OR, 1.97; 95%CI, 1.27-3.08; P=0.003] and NLR on POD-2≥9.2 (OR, 1.43; 95%CI, 1.03-1.98; P=0.02) were significantly related to postoperative complications. CONCLUSIONS: NLR may provide clinicians with an additional tool for identifying patients at high risk for postoperative complications after elective colorectal surgery. Routine use of NLR may lead to early intervention and potentially improve the management of complications after colorectal surgery.