Imaging characteristics of hip joint microinstability: a case-control study of hip arthroscopy patients.

OBJECTIVES: Hip microinstability is a clinical entity increasingly recognized and treated but challenging to diagnose with a lack of objective criteria. This study assessed the prevalence and diagnostic accuracy of different imaging findings for hip microinstability on radiograph and MR. METHODS: A retrospective case-control study of 224 hips treated with arthroscopic surgery by a single orthopedic surgeon, 112 hips with clinical microinstability and 112 controls without. Pre-operative radiograph and MRI/MRA imaging were evaluated by two musculoskeletal radiologists to assess morphological parameters and imaging signs reportedly associated with hip microinstability. RESULTS: Four imaging features reached significance as predictors of microinstability via three-step logistic regression: labral hyperplasia and decreased lateral center edge angle on MR (OR 2.45 and 0.93, respectively) and the absence of positive ischial spine sign and absence of osteophytes on radiographs (OR 0.47 and 0.28, respectively). Increased acetabular anteversion and absence of cam lesions were more likely in the microinstability group (p = 0.02 and 0.04, respectively), but not independent predictors. Labral tears, chondral loss, abnormal ligamentum teres, anterior capsule thinning, iliocapsularis to rectus femoris ratio, posterior crescent sign, cliff sign, and femoro-epiphyseal acetabular roof (FEAR) index were not associated with microinstabillity. CONCLUSION: Imaging features may be predictive of hip microinstability in some cases. Decreased LCEA, increased acetabular anteversion, and labral hyperplasia were associated with microinstability in this study, while many other published imaging findings were not. Imaging remains complementary, but not definitive, in the diagnosis of hip microinstability.

Intravenous Local Anesthetic Compared With Intraperitoneal Local Anesthetic in Laparoscopic Colectomy: A Double-blind Randomized Controlled Trial.

INTRODUCTION: Controlling perioperative pain is essential to improving patient experience and satisfaction following surgery. Traditionally opioids have been frequently utilized for postoperative analgesia. Although they are effective at controlling pain, they are associated with adverse effects, including postoperative nausea, vomiting, ileus, and long-term opioid dependency.Following laparoscopic colectomy, the use of intravenous or intraperitoneal infusions of lidocaine (IVL, IPL) are promising emerging analgesic options. Although both techniques are promising, there have been no direct, prospective randomized comparisons in patients undergoing laparoscopic colon resection. The purpose of this study was to compare IPL with IVL. METHODS: Double-blinded, randomized controlled trial of patients undergoing laparoscopic colonic resection. The 2 groups received equal doses of either IPL or IVL which commenced intra-operatively with a bolus followed by a continuous infusion for 3 days postoperatively. Patients were cared for through a standardized enhanced recovery after surgery program. The primary outcome was total postoperative opioid consumption over the first 3 postoperative days. Patients were followed for 60 days. RESULTS: Fifty-six patients were randomized in a 1:1 fashion to the IVL or IPL groups. Total opioid consumption over the first 3 postoperative days was significantly lower in the IPL group (70.9 mg vs 157.8 mg P < 0.05) and overall opioid consumption during the total length of stay was also significantly lower (80.3 mg vs 187.36 mg P < 0.05. Pain scores were significantly lower at 2 hours postoperatively in the IPL group, however, all other time points were not significant. There were no differences in complications between the 2 groups. CONCLUSION: Perioperative use of IPL results in a significant reduction in opioid consumption following laparoscopic colon surgery when compared to IVL. This suggests that the peritoneal cavity/compartment is a strategic target for local anesthetic administration. Future enhanced recovery after surgery recommendations should consider IPL as an important component of a multimodal pain strategy following colectomy.

Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process.

In many countries, liberalisation of the legislation regulating the use of cannabis has outpaced rigorous scientific studies, and a growing number of patients presenting for surgery consume cannabis regularly. Research to date suggests that cannabis can impact perioperative outcomes. We present recommendations obtained using a modified Delphi method for the perioperative care of cannabis-using patients. A steering committee was formed and a review of medical literature with respect to perioperative cannabis use was conducted. This was followed by the recruitment of a panel of 17 experts on the care of cannabis-consuming patients. Panellists were blinded to each other's participation and were provided with rater forms exploring the appropriateness of specific perioperative care elements. The completed rater forms were analysed for consensus. The expert panel was then unblinded and met to discuss the rater form analyses. Draft recommendations were then created and returned to the expert panel for further comment. The draft recommendations were also sent to four independent reviewers (a surgeon, a nurse practitioner, and two patients). The collected feedback was used to finalise the recommendations. The major recommendations obtained included emphasising the importance of eliciting a history of cannabis use, quantifying it, and ensuring contact with a cannabis authoriser (if one exists). Recommendations also included the consideration of perioperative cannabis weaning, additional postoperative nausea and vomiting prophylaxis, and additional attention to monitoring and maintaining anaesthetic depth. Postoperative recommendations included anticipating increased postoperative analgesic requirements and maintaining vigilance for cannabis withdrawal syndrome.

Incidence and predictors of iron deficiency anaemia in parturients undergoing elective caesarean section at a tertiary hospital in New Zealand: a retrospective, observational cohort study.

BACKGROUND: Worldwide, iron deficiency anaemia in pregnancy is a significant problem which can be especially problematic when delivery is by caesarean section, a procedure associated with significant blood loss. Optimising iron stores pre-delivery remains an overarching goal. We aim to measure the incidence of iron deficiency anaemia in patients undergoing elective caesarean section at our institution and determine any associated predictors, as well as adverse outcomes. METHODS: A retrospective, observational cohort study of patients presenting for elective caesarean section over a two-year period. Patient data was collected from hospital electronic records. Iron deficiency anaemia was defined a haemoglobin < 110 g/L and a ferritin < 30 µg/L in the three-month period prior to delivery. The primary aim was to establish the incidence of iron deficiency anaemia at the time of delivery and any associated predictors. Secondary outcomes included any association between the primary outcome and complications defined by the hospital discharge complication coding system, as well as an evaluation of the number of blood tests carried out antenatally per trimester. RESULTS: One thousand and ninety-three women underwent caesarean section over the study period and 16.2% had iron deficiency anaemia. Patients with iron deficiency anaemia were more likely to be of Maori and Pacific Island ethnicity, have a greater booking body mass index, be younger and have a greater parity. Pre-operative anaemia was associated with a greater likelihood of post-operative blood transfusion. CONCLUSIONS: There remains potential for optimisation of iron deficiency anaemia in our local population undergoing elective caesarean section.

Safety and Efficacy of Volatile Anesthetic Agents Compared With Standard Intravenous Midazolam/Propofol Sedation in Ventilated Critical Care Patients: A Meta-analysis and Systematic Review of Prospective Trials.

BACKGROUND: Inhalation agents are being used in place of intravenous agents to provide sedation in some intensive care units. We performed a systematic review and meta-analysis of prospective randomized controlled trials, which compared the use of volatile agents versus intravenous midazolam or propofol in critical care units. METHODS: A search was conducted using MEDLINE (1946-2015), EMBASE (1947-2015), Web of Science index (1900-2015), and Cochrane Central Register of Controlled Trials. Eligible studies included randomized controlled trials comparing inhaled volatile (desflurane, sevoflurane, and isoflurane) sedation to intravenous midazolam or propofol. Primary outcome assessed the effect of volatile-based sedation on extubation times (time between discontinuing sedation and tracheal extubation). Secondary outcomes included time to obey verbal commands, proportion of time spent in target sedation, nausea and vomiting, mortality, length of intensive care unit, and length of hospital stay. Heterogeneity was assessed using the I statistic. Outcomes were assessed using a random or fixed-effects model depending on heterogeneity. RESULTS: Eight trials with 523 patients comparing all volatile agents with intravenous midazolam or propofol showed a reduction in extubation times using volatile agents (difference in means, -52.7 minutes; 95% confidence interval [CI], -75.1 to -30.3; P < .00001). Reductions in extubation time were greater when comparing volatiles with midazolam (difference in means, -292.2 minutes; 95% CI, -384.4 to -200.1; P < .00001) than propofol (difference in means, -29.1 minutes; 95% CI, -46.7 to -11.4; P = .001). There was no significant difference in time to obey verbal commands, proportion of time spent in target sedation, adverse events, death, or length of hospital stay. CONCLUSIONS: Volatile-based sedation demonstrates a reduction in time to extubation, with no increase in short-term adverse outcomes. Marked study heterogeneity was present, and the results show marked positive publication bias. However, a reduction in extubation time was still evident after statistical correction of publication bias. Larger clinical trials are needed to further evaluate the role of these agents as sedatives for critically ill patients.

Validity of Thromboelastometry for Rapid Assessment of Fibrinogen Levels in Heparinized Samples During Cardiac Surgery: A Retrospective, Single-center, Observational Study.

OBJECTIVE: To assess the validity of fibrinogen assay of rotational thromboelastometry (FIBTEM)-derived estimates of fibrinogen in samples collected during cardiopulmonary bypass in cardiac surgical patients by comparison to Clauss method fibrinogen concentration. DESIGN: Retrospective observational study. SETTING: Single university hospital center. PARTICIPANTS: Human participants. INTERVENTIONS: Retrospectively obtained laboratory assays including rotational thromboelastometry (ROTEM) and Clauss fibrinogen assay. MEASUREMENTS AND MAIN RESULTS: A retrospective review was performed of anesthesia records at a single university teaching hospital during a 1-year period. From paired samples taken near the end of cardiopulmonary bypass, fibrinogen concentrations (Clauss method) were compared with FIBTEM-derived measures of maximal clot firmness (MCF) and clot amplitude at 10 minutes (A10) using Spearman's rank correlation, linear regression, and receiver operating characteristic curve analysis. The study included 1,077 patients. Clauss fibrinogen was correlated strongly with FIBTEM amplitudes (r = 0.78 for MCF and A10; p<0.01). The correlation was related inversely to hemoglobin concentration (p<0.01). The area under the receiver operating characteristic curve was 0.95; the optimal FIBTEM A10 cutoff for diagnosis of a fibrinogen concentration of<1.5 g/L was ≤8 mm. CONCLUSIONS: The FIBTEM was a valid point-of-care method for estimating the fibrinogen concentration during cardiopulmonary bypass and may be used for prediction of hypofibrinogenemia before separation from the extracorporeal circuit.

Reliability of a point-of-care device for international normalized ratio testing during the three surgical phases of orthotopic liver transplantation: a retrospective observational study.

PURPOSE: To investigate the reliability of a point-of-care device, the HEMOCHRON(®) Jr. Signature, for measuring the international normalized ratio (INR) during the three surgical phases of liver transplantation. METHODS: A retrospective review was performed on patients undergoing liver transplantation during July to December 2013. Thirty-one patients who had simultaneous laboratory and point-of-care INR readings from each phase of liver transplant surgery (paleohepatic, anhepatic, and neohepatic) were eligible for inclusion. Bland-Altman analysis, Spearman's rank correlation, and four quadrant plots were used to compare INR results from the point-of-care device (pocINR) with those from the laboratory (labINR). RESULTS: Based on the Bland-Altman analysis, mean biases (95% prediction interval) were 0.10 (0.03 to 0.17), 0.19 (0.12 to 0.27), and 0.21 (0.01 to 0.43) for the paleohepatic, anhepatic, and neohepatic phases, respectively. The pocINR device showed a systematic underestimation of the labINR. The Spearman's rank correlation coefficients (95% confidence interval [CI]) were: Ρ = 0.90 (95% CI 0.80 to 0.95); Ρ = 0.92 (95% CI 0.71 to 0.93); and Ρ = 0.71 (95% CI 0.46 to 0.85), respectively. Direction-of-change analysis between the paleohepatic to anhepatic and the anhepatic to neohepatic phases showed strong concordance of 84% and, also considering the small bias between the measurements, supports the use of the pocINR device in the clinical management of liver transplant surgery. CONCLUSION: Point-of-care INR was accurate prior to hepatic reperfusion, but reliability decreased in the neohepatic phase.

Hip dysplasia hiding in plain sight: A retrospective analysis of radiology reports.

INTRODUCTION: Timely recognition of dysplastic hip morphology is critical to facilitate appropriate management before significant joint damage has developed. It is likely that radiologist under reporting contributes to delays in diagnosis. This study aimed to assess how often adult hip dysplasia goes undetected in radiological reports and to identify clinical and radiological variables that impact the likelihood of detection of dysplasia by radiologists. METHODS: Referral details and radiology reports of patients who underwent periacetabular osteotomy by a single surgeon for symptomatic hip dysplasia between 1 January 2016 and 30 June 2020 were reviewed. Four assessors measured the lateral centre edge angle from the pelvic radiograph performed at time of referral. Film quality and other radiographic parameters were also assessed. RESULTS: Sixty-eight patients were included, 84% were female and the median age was 28.1 years. Dysplasia was not documented in the radiology report in 49% of cases. Dysplasia was more likely to be reported with no history of injury, an aspherical femoral head, lower lateral centre edge angle, higher acetabular index, increased femoral head shaft angle, higher femoro-epiphyseal acetabular roof index, or if there was disruption of Shenton's line, with the first three variables being independent predictors of radiologist detection. CONCLUSION: Hip dysplasia should be considered in all adolescents/young adults presenting with hip pain. Causes of radiologist under reporting are likely multifactorial. Clinical information can cause cognitive biases and result in selective looking. A systematic approach to pelvis radiographs should include assessment of acetabular coverage and active search for evidence of femoral head migration.

Tranexamic Acid Use During Surgery Associated with Extension of Acute Perioperative Type 1 Myocardial Infarction: A Case Report.

CASE PRESENTATION: A 70-year-old women presented to a regional hospital after a fall, resulting in a periprosthetic femoral fracture. Preoperative echocardiogram was ordered to investigate a cardiac murmur, and unexpectedly, a significant regional wall abnormality was found. Further repeat electrocardiograph and troponin blood biomarker analysis demonstrated the patient had suffered an acute type 1 myocardial infarction after admission to the ward, without exhibiting classical ischemic cardiac symptoms. A multidisciplinary decision was made for the patient to proceed to surgery, and at that time, she received tranexamic acid (TXA). Postoperatively, there was notable echocardiographic extension of the infarction, which required transfer to a tertiary center for management with complex coronary artery stenting. The patient once discharged was followed up by cardiology at the 3-month interval. CONCLUSION: The use of TXA in arterial thromboembolic disease requires thorough consideration because it may contribute to further myocardial damage. A patient-specific approach should be adopted with the risk of thrombosis extension being considered.

Impact of a prescriber and patient educational intervention on discharge analgesia prescribing and hospital readmission rates following elective unilateral total hip and knee arthroplasty.

INTRODUCTION: Pain management after elective, unilateral total hip and knee arthroplasty (THA and TKA) should use a multimodal approach. At discharge, challenges include ensuring correct prescribing practices to optimise analgesia and rationalise opioid use as well as ensuring patients are adequately educated to take these medications safely and effectively in the community. This audit cycle reports on a prescriber and patient education intervention using printed guidelines, educational outreach and prescription standardisation along with a patient information sheet to address the high unplanned readmission rate following THA and TKA at our institution. METHODS: Two cohorts of patients were identified before (2016) and after (2019) the introduction of the educational package. The primary outcome was the unplanned hospital readmission rate in the 42 days following discharge. Secondary outcomes were the compliance with the set prescribing standards and the prescription of strong opioid medications (morphine or oxycodone) on discharge. RESULTS: There was a reduction in the readmission rate from 20.4% to 10.0% (p=0.004). Readmission rates for pain and constipation were also reduced. The prescribing of tramadol (p<0.001) and non-steroidal anti-inflammatory drugs (p<0.001) both increased while the number of patients who received a strong opioid at discharge decreased (p<0.001) as did the number of patients who received a sustained release strong opioid (p<0.001). CONCLUSION: We have observed significant improvement in discharge prescribing which coincided with a reduction in unplanned readmissions after elective TKA and THA. Our approach used prescriber guidelines, education and standardisation with printed information for patients to enhance understanding and recall.

Paediatric forearm fractures manipulated in the emergency department: incidence and risk factors for re-manipulation under general anaesthesia.

AIM: Re-manipulation of paediatric forearm fractures under general anaesthetic may be required following inadequate closed reduction under conscious sedation. Manipulation under general anaesthetic carries significant inherent risks and is preferably avoided. We assessed one institution's experience with paediatric forearm fracture reduction and investigate the incidence of re-manipulation under general anaesthetic of fractures initially managed under conscious sedation without fluoroscopy. METHOD: All paediatric forearm fractures presenting to the children's emergency department of our national children's hospital between 1 January 2019 and 30 June 2019 were studied. Radius and ulna fractures were categorised according to fracture location (distal third, middle third, proximal third), any associated injury, and any plan to proceed to the operating room that was documented prior to manipulation in the emergency department. Univariate and multivariate statistical analysis was carried out to test for differences between discrete and continuous data and odds ratios were calculated. RESULTS: Three-hundred and nine patients presented during the study period with 267 being eligible for analysis. Fifteen point seven percent (42/267) required fracture manipulation in the operating theatre following initial reduction in the children's emergency department. Independent risk factors associated with significantly higher rates of failed reduction under conscious sedation (p<0.001-0004) were patients who had a delay in presentation to hospital, were older, or had a non-distal fracture site. CONCLUSION: There are higher rates of re-manipulation under general anaesthetic in children presenting to the emergency department of our national children's hospital with forearm fractures than seen in comparative international studies. Risk factors which predict an inadequate initial reduction and interventions to improve this are discussed.

The effect of perioperative sustained-release opioid use on long-term opioid dispensing following total knee arthroplasty: a retrospective cohort study.

AIMS: To determine the impact of perioperative sustained-release (SR) opioid use on total inpatient opioid consumption and longer-term outpatient dispensing for three months following elective total knee arthroplasty (TKA). METHODS: Patients who underwent primary unilateral TKA between 1 January and 31 December 2018 at Counties Manukau Health were retrospectively identified. Participants were stratified into two groups by inpatient use or avoidance of strong SR opioids (OxyContin or M-Eslon). The primary outcome was the percentage of patients receiving prescriptions for opioid medications at thirty-day intervals for three months after discharge. RESULTS: Two hundred and thirty-two patients were eligible for inclusion. The baseline demographics of both groups were similar. In the SR opioid use group, the majority (79%) received OxyContin. Overall, inpatient opioid use between postoperative days (POD) zero and three was lower in the SR opioid avoidance group, although this was not statistically significant (157.5 [IQR 110.0-220.0] vs 167.5mg OME [110.0-290.0], p=0.14). Outpatient postoperative opioid dispensing between 0-30 days was significantly greater in patients who received inpatient SR opioids (p=0.01). Dispensing of oxycodone was significantly higher in the SR opioid use group at one- and two- months (p=0.01 and 0.03 respectively). CONCLUSION: The postoperative use of SR opioids is not routinely recommended following TKA. Their use is associated with greater overall inpatient opioid use, sustained opioid dispensing during and after the expected recovery period, and the potential for significant harm.

The prognostic implication of perioperative cardiac enzyme elevation in patients with fractured neck of femur: A systematic review and meta-analysis.

BACKGROUND: Neck of Femur (NOF) fractures are a common injury in comorbid elderly patients which are associated with increased rates of morbidity and mortality following fracture. Because of their injury, patients can experience reductions in quality of life and independent living leading to transfer to nursing home or dependent levels of care. Numerous factors are associated with either complications or reductions in survival following fractured NOF. From the VISION cohort there is evidence that troponin elevation in the post-operative period following a diverse range of non-cardiac surgical procedures may lead to an increased risk of mortality in the absence of classical ischaemic or cardiac symptoms. The aim of this systematic review and meta-analysis is to validate the utility of perioperative troponin elevation as a prognostic indicator for mortality and cardiac morbidity in those with fractured NOF. METHODS: The PRISMA guidelines for the conduct of meta-analyses were followed. An electronic search was conducted of the EMBASE, MEDLINE (Ovid) and Biosis databases. Studies were included for analysis if they stratified outcomes by perioperative troponin elevation in surgically managed fractured NOF and reported sufficient data on troponin elevation and mortality following surgery. Primary and secondary outcomes assessed were all-cause post-operative mortality and a composite measure of cardiac complications (myocardial infarction, cardiac failure and arrhythmia) respectively. RESULTS: Eleven studies met inclusion criteria giving a total of 1363 patients. Overall, 497 patients (36.5%) experienced an elevation in troponin levels following surgery. Perioperative troponin elevation was significantly associated with all-cause mortality (OR 2.6; 95% CI 1.5 - 4.6; p <0.001) and cardiac complications (OR 7.4; 95% CI 3.5 - 15.8; p <0.001). Patient factors significantly associated with troponin elevation included pre-existing coronary artery disease, cardiac failure, hypertension, previous stroke and previous myocardial infarction. CONCLUSION: Perioperative troponin elevation is significantly associated with increased mortality and post-operative cardiac complications following fractured NOF and may be a useful prognostic indicator in these patients. Future research should further stratify patients by the magnitude of troponin elevation and further refine the risk factors.

Predictors of hyponatremia following elective primary unilateral knee arthroplasty at a tertiary centre: A retrospective observational cohort and predictive model.

INTRODUCTION: Hyponatremia is a common electrolyte disorder. This can be associated with nausea, disorientation and in more serious cases a decreased level of consciousness or neurological deficits. These symptoms may lead to increases in the cost of hospital care and significant morbidity. The purpose of this retrospective, observational cohort study is to investigate the impact of hyponatremia on patient and systems specific outcome measures in those undergoing elective, unilateral total knee arthroplasty (TKA) at two hospitals in Auckland, New Zealand over a twelve-month period. MATERIALS AND METHODS: Patients were stratified into two groups based on the presence or absence of post-operative hyponatremia (defined as a blood sodium of <135 mmol/L with a concurrent decrease of ≥5 mmol/L between the pre- and post-operative recordings). Outcomes collected included Quality of Recovery - 15 (QOR) scores, time to assisted mobilisation, discharge ICD-10 complication codes and hospital length of stay. RESULTS: During the study period 236 patients underwent surgery. Eighty-six (36.4%) patients met criteria for post-operative hyponatremia. This finding was associated with prolongation of the hospital length of stay (4.17 (3.26-5.18) versus 4.28 (3.31-5.45) days, p = 0.031) and a reduction in the QOR score on the second post-operative day (113.0 (99.5-126.5) versus 105.0 (94.0-118.0), p = 0.039). There was no difference in the time to assisted mobilisation. CONCLUSIONS: Hyponatremia is a common finding following TKA. This abnormality is associated with small changes in patient specific outcome measures. These implications of these findings may become more significant in settings where same day or rapid discharge from hospital is targeted.

Multidisciplinary survey of current and future use of emergency laparotomy risk assessment scores in New Zealand.

Risk prediction is an important part of the management of emergency laparotomy (EL) patients. This study aims to investigate the current use of and future directions for EL risk prediction scores. New Zealand members of the Royal Australasian College of Surgery (RACS), Australian and New Zealand College of Anaesthetists (ANZCA) and College of Intensive Care Medicine (CICM) were invited to participate in an anonymous online survey. Responses were received from 316 clinicians (45 RACS, 253 ANZCA and 19 CICM), with 73% of them having >10 years' experience as a consultant. Risk assessment scores were utilised by respondents for approximately 30% of EL cases. The most common EL risk scores used were Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality (P-POSSUM) and American College of Surgeons National Surgical Quality Improvement Programs (ACS-NSQIP). When used, respondents used risk assessment mostly preoperatively (RACS 100%, ANZCA 98% and CICM 78%), although P-POSSUM and ACS-NSQIP scores require intraoperative data (which can only be estimated crudely preoperatively by the clinician). Respondents on average 'somewhat agreed' that risk assessment scores should only include preoperative variables. The most common reasons for using P-POSSUM and ACS-NSQIP scores were familiarity and ease of use and availability of online/app calculators. The most important outcomes that the respondents would like to predict were quality of life and 30-day mortality rather than long-term impact from EL. These findings suggest that developing a new score may be required to improve utilisation and help in decision-making. This may require tailoring risk scores specifically for EL, and designing them to predict what is preferred by the clinicians making the decisions.

Association between perioperative intraperitoneal local anaesthetic infusion and long-term survival and cancer recurrence after colectomy: follow-up analysis of a previous randomized controlled trial.

BACKGROUND: High concentrations of local anaesthetic have an anti-proliferative effect on colonic cancer in vitro. Intraperitoneal local anaesthetic (IPLA) has shown analgesic benefit and improved recovery in the perioperative setting. The long-term effects of IPLA in colon cancer resection have not been examined. This study aims to review the survival and oncological outcomes of a previously conducted trial that compared perioperative IPLA with placebo. METHODS: Sixty patients underwent colonic resection for benign and malignant disease as part of a double-blinded, randomized, placebo-controlled study between September 2008 and November 2009. The IPLA group received instillation of intraperitoneal ropivacaine before dissection followed by a 3-day infusion. The placebo group was treated identically but with 0.9% saline solution. A follow-up analysis was conducted to evaluate overall survival, disease-free survival and recurrence specifically for patients undergoing resection for stages I-III colon cancer. Kaplan-Meier analysis was performed, and the log-rank test was used to evaluate difference in survival between groups. RESULTS: Thirty-seven of the 60 patients had stages I-III colon cancer and were included in this analysis. Nineteen patients were in the placebo group. There was no significant difference in overall survival or all-cause mortality. There was a higher incidence of cancer-specific mortality in the local anaesthetic group (P < 0.046). CONCLUSION: It does not appear that IPLA is associated with a significant survival benefit in patients with colonic malignancy undergoing colectomy. Other studies are needed to analyse the long-term outcomes.

The interaction between pre-operative anaemia and peri-operative blood transfusion on patient outcomes following general surgical procedure: a retrospective review.

AIM: To assess the incidence of pre-operative anaemia in patients presenting for general surgery and determine the relationship between pre-operative anaemia, transfusion and post-operative metrics including length of stay (LOS) and infectious complications. METHOD: A retrospective cohort of 1,186 patients. Stratification into two groups with and without pre-operative anaemia through propensity score matching. Logistic regression was used to determine the relationship between pre-operative anaemia, blood transfusion and infectious complications. RESULTS: The incidence of pre-operative anaemia was 17.4%. Red blood cell (RBC) transfusion was greater in those with PA than those without, 13.1% versus 0.7% (OR 21.7 (2.9-166.7, p<0.001)). In the propensity matched cohort, pre-operative anaemia was associated with an increase in LOS from 2.1 to 3.0 days (p=0.006) and increased infectious complications from 6.4% to 18.4%, (OR 3.3 (1.4-7.7), p=0.004). The risk of infectious complications was amplified in the patients receiving RBC transfusion. After adjustment for transfusion, in patients with pre-operative anaemia the OR for infectious complications became 2.3 (0.95-5.7, p=0.06) for those not transfused and 5.5 (2.0-15.3, p=0.001) for those transfused. CONCLUSION: Pre-operative anaemia is associated with an increase in hospital LOS and infectious complications. When adjusted for transfusion the effect of pre-operative anaemia alone on hospital LOS and infectious complications is not statistically significant. Expeditious investigation and treatment of PA could reduce complications and save resources.

Intraoperative cell salvage use reduces the rate of perioperative allogenic blood transfusion in patients undergoing periacetabular osteotomy.

Blood loss during periacetabular osteotomy (PAO) is variable, with losses ranging from 100 to 3900 ml in published series. Perioperative allogenic blood transfusion is frequently utilized although is associated with significant risk of morbidity. Cell salvage (CS) is a common blood conservation tool; however, evidence supporting its use with PAO is lacking. Our aim was to assess whether CS affects perioperative allogenic blood transfusion rate in patients undergoing PAO. The clinical records of 58 consecutive PAOs in 54 patients (median age 24.7 years, interquartile range 17.8-29.4 years) performed by a single surgeon between 1 January 2016 and 30 April 2018 were reviewed. Autologous blood pre-donation and surgical drains were not used. Due to variable technician availability, CS was intermittently used during the study period. PAOs were allocated into a CS group or no cell salvage group (NCS group), according to whether an intraoperative CS system was used. There was no significant difference in patient age, gender, body mass index, dysplasia severity, regional anesthetic technique, tranexamic acid administration, surgical duration or estimated blood loss (all P > 0.05) between the two groups. The CS group had a lower preoperative hemoglobin compared to the NCS group (median, 13.4 g/dl versus 14.4 g/dl, P = 0.006). The incidence of allogenic blood transfusion was significantly lower in the CS group compared to the NCS group (2.5% versus 33.3% patients transfused, P = 0.003). Multivariate modeling showed CS use to be protective against allogenic blood transfusion (P = 0.003), with an associated 80-fold reduction in the odds of transfusion (odds ratio, 0.01; 95th% CI, 0-0.57). To our knowledge, this is the first study to assess the effect of CS use on allogenic transfusion rate in patients undergoing PAO. Our results demonstrate CS to be a mandatory component of blood conservation for all patients undergoing PAO.

Restrictive Versus Liberal Fluid Regimens in Patients Undergoing Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis.

BACKGROUND: Pancreaticoduodenectomy is associated with significant morbidity and mortality which may be influenced by perioperative fluid management. It remains unclear whether liberal and restrictive fluid regimens impact mortality and morbidity in patients undergoing pancreaticoduodenectomy. METHODS: Medline, EMBASE, Cochrane Library and clinicaltrials.gov were searched for studies comparing restrictive and liberal perioperative fluids in patients undergoing pancreaticoduodenectomy. Both prospective and retrospective studies in those undergoing pancreaticoduodenectomy were eligible for inclusion where the patient outcomes were stratified to restrictive and liberal perioperative fluid management regimens, with mortality as the primary outcome. Following study identification, a systematic review and meta-analysis with trial sequential analysis was completed. RESULTS: Thirteen studies including five prospective trials and eight retrospective analyses totalling 3062 patients were included. Restrictive fluid regimens were associated with a significant reduction in mortality compared to liberal fluid regimens for the overall cohort (odds ratio 0.54; 95% CI 0.31-0.94, p = 0.03). There were no significant differences in complication profile. Subgroup analysis revealed this result was contributed to significantly by retrospective studies. The results of the trial sequential analysis suggest this mortality benefit may be due to a type I statistical error and that further patient numbers are required for definitive conclusions. CONCLUSIONS: Restrictive fluid regimens are associated with a reduction in mortality following pancreaticoduodenectomy. The clinical relevance of this finding needs to be interpreted pragmatically given the lack of association with significant causes of morbidity and in considering the results of the recently published RELIEF study.

Penetrating head injury from nailguns: a case series from New Zealand.

Penetrating head injury from nailguns has become increasingly recognised due to their frequent use in the construction industry and home. We report a New Zealand case series of 12 penetrating nailgun head injuries, the largest of its type, detailing presentation, management, risk factors and outcomes. Recommendations based on these factors are provided, suggesting a minimal surgical approach and an individually case-assessed need for antibiotic prophylaxis and anti-epileptic drugs. Prognostic factors on initial imaging are discussed. The majority of injuries, despite being visually impressive, are associated with minimal neurological impairment.