Validation and cross-cultural adaptation of the postoperative quality of recovery 15 (QoR-15) questionnaire for Spanish-speaking patients: A prospective cohort study.

BACKGROUND: The postoperative QoR-15 questionnaire may improve the detection of postoperative complications on an early basis and contribute to optimize treatment and recovery. No validated Spanish QoR-15 questionnaire has been available to date. METHODS: The Spanish QoR-15 questionnaire (QoR-15E), carried out by official bilingual translators, was administered to 242 adult patients undergoing elective surgery before and 24 h after surgery. Patients were asked about their perceived quality of general recovery using a visual analogue scale (VAS). A random subgroup of 36 patients completed a third questionnaire 30-60 min after having completed the first one, and under the same conditions. RESULTS: The Pearson correlation coefficient between QoR-15E and the VAS score was 0.759. Cronbach's alpha was 0.856 in the postoperative period. Reliability by the split-half method was 0.781. Test-retest correlation coefficient was 0.998. Cohen's d was 0.94. The mean time to complete the preoperative questionnaire was 2.9 ± 0.5 min. CONCLUSIONS: The QoR-15E is valid and reliable for assessing postoperative quality of recovery in Spanish-speaking patients, with psychometric and interpretative features similar to those of the original instrument.

Study protocol for an observational cohort evaluating incidence and clinical relevance of perioperative elevation of high-sensitivity troponin I and N-terminal pro-brain natriuretic peptide in patients undergoing lung resection.

INTRODUCTION: Myocardial injury after non-cardiac surgery has been defined as myocardial injury due to ischaemia, with or without additional symptoms or ECG changes occurring during or within 30 days after non-cardiac surgery and mainly diagnosed based on elevated postoperative cardiac troponin (cTn) values. In patients undergoing thoracic surgery for lung resection, only postoperative cTn elevations are seemingly not enough as an independent predictor of cardiovascular complications. After lung resection, troponin elevations may be regulated by mechanisms other than myocardial ischaemia. The combination of perioperative natriuretic peptide measurement together with high-sensitivity cTns may help to identify changes in ventricular function during thoracic surgery. Integrating both cardiac biomarkers may improve the predictive value for cardiovascular complications after lung resection. We designed our cohort study to evaluate perioperative elevation of both high-sensitivity troponin I (hs-TnI) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients undergoing lung resection and to establish a risk score for major cardiovascular postoperative complications. METHODS AND ANALYSIS: We will conduct a prospective, multicentre, observational cohort study, including 345 patients undergoing elective thoracic surgery for lung resection. Cardiac biomarkers such as hs-TnI and NT-proBNP will be measured preoperatively and at postoperatively on days 1 and 2. We will calculate a risk score for major cardiovascular postoperative complications based on both biomarkers' perioperative changes. All patients will be followed up for 30 days after surgery. ETHICS AND DISSEMINATION: All participating centres were approved by the Ethics Research Committee. Written informed consent is required for all patients before inclusion. Results will be disseminated through publication in peer-reviewed journals and presentations at national or international conference meetings. TRIAL REGISTRATION NUMBER: NCT04749212.

Clonidine as an Adjuvant to Bupivacaine for Suprazygomatic Maxillary Nerve Blocks in Cleft lip and Palate Repair: A Randomized, Prospective, Double-Blind Study.

OBJECTIVES: Does clonidine, as adjuvant to bupivacaine for suprazygomatic maxillary nerve blocks, reduce emergence agitation in patients undergoing cleft lip and cleft palate surgery? DESIGN: Randomized, controlled, and double-blind study. SETTING: Guwahati Comprehensive Cleft Care Center, Guwahati (Assam, India). PARTICIPANTS: A total of 124 patients; with a median age of 5 years in the clonidine group (CLG) and 7 years in the control group (CG), who underwent cleft lip or cleft palate surgery were included. Exclusion criteria included lack of consent from patients or their guardians, allergy to local anesthetics, coagulation disorders, local infection at the puncture site before performing the block, and language difficulties or cognitive disorders. INTERVENTIONS: Patients were randomized into 2 groups to receive bilateral suprazygomatic maxillary nerve blocks with either a bupivacaine/clonidine mixture for the CLG or bupivacaine alone in the CG. MAIN OUTCOME MEASURE: The primary end point was the incidence of emergence agitation. RESULTS: There was a statistically significant difference in the incidence of emergence agitation (30.2% in the CG compared to 15.2% in the CLG; difference of incidences: 15%, 95% CI: 0.1-30.1). The percentage of patients requiring intraoperative Fentanyl was lower in the CLG (10.6% compared to 26.4%; difference of incidences: 15.8%, 95% CI: 1.8-29). No other differences were observed. Further research in a more typically aged children population undergoing cleft surgery is needed. CONCLUSIONS: The use of clonidine as an adjuvant to bupivacaine in maxillary nerve block reduces the incidence of emergence agitation and intraoperative opioid consumption without hemodynamic or sedative side effects in patients undergoing cleft lip and palate surgery.

Myocardial Injury After Noncardiac Surgery: Incidence, Predictive Factors, and Outcome in High-Risk Patients Undergoing Thoracic Surgery: An Observational Study.

OBJECTIVE: The authors aimed to evaluate the incidence of myocardial injury after noncardiac surgery (MINS), its relationship with perioperative variables, and its prognostic implications for 30-day mortality in high-risk thoracic surgery patients. DESIGN: Observational study including cardiovascular high-risk patients undergoing routine postoperative troponin monitoring during the first 2 postoperative days. MINS was diagnosed based on at least 1 troponin I determination ≥0.04 ng/mL with no evidence of a nonischemic etiology. SETTING: Tertiary university hospital. PARTICIPANTS: Adult patients with cardiac risk factors, defined as patients ≥65 years old or patients <65 years old with known cardiovascular pathology (history of cardiac, cerebral, or peripheral vascular pathology) who underwent elective thoracic surgery. MEASUREMENT AND MAIN RESULTS: Forty-eight patients (27.3%) (95% confidence interval [CI] 20.8%-34.5%) of 177 had diagnostic criteria for MINS. On univariate analysis, an association was found between MINS and smoking (odds ratio [OR] 2.17, 95% CI 1.26-3.76), lobectomy (OR 1.30, 95% CI 1.03-1.66), pneumonectomy (OR 6.72, 95% CI 1.35-33.9), use of vasoactive drugs (OR 1.94, 95% CI 1.03-3.65), and pericardial incision (OR 6.72, 95% CI 1.35-33.9). On multivariate logistic regression analysis, only smoker status and type of surgery were independent risk factors for MINS. No association was found between MINS and 30-day mortality. CONCLUSIONS: Based on the findings, the elevated incidence of MINS after thoracic surgery, the independent relationship with the extent of lung resection, and the fact that MINS was not associated with greater mortality suggest that nonischemic causes may contribute to troponin elevation after thoracic surgeries.

Audit of transfusion among the oldest old: treading the fine line between undertransfusion and optimum trigger.

BACKGROUND: Recent research has questioned restrictive transfusion policies in vulnerable elderly populations. Our audit assesses the prevalence and postoperative outcomes of extremely elderly patients undergoing the stress of surgery with perioperative hemoglobin (Hb) less than 9 g/dL. STUDY DESIGN AND METHODS: This retrospective analysis of prospectively collected data addressed patients aged 85+ undergoing elective surgery. Demographic data and baseline characteristics were recorded, as well as Hb and transfused red blood cell (RBC) units. The main endpoint was the prevalence of perioperative Hb less than 9 g/dL, that is, patients with baseline Hb <9 g/dL without preoperative transfusions (defined as Group A). Patients with perioperative Hb of 9 g/dL or greater (with or without transfusion) were designated as Group B. Secondary outcomes included morbidity, length of hospital stay, and mortality 30 days and 6 months after surgery. A bivariate analysis was performed followed by logistic regression to determine whether undergoing the stress of surgery with perioperative Hb less than 9 g/dL was an independent risk factor for postoperative outcomes. RESULTS: A total of 148 patients were included. The prevalence of perioperative Hb less than 9 g/dL was 25%. It was associated with increased morbidity and mortality -both 30 days and 6 months after surgery- and a prolonged length of hospital stay. Anemia-associated complications were higher among patients from Group A, whereas transfusion-associated ones were evenly distributed. In all the regression models, perioperative Hb less than 9 g/dL was an independent risk factor for worse postoperative outcomes. CONCLUSION: Perioperative Hb less than 9 g/dL was common among patients aged 85+, and it was associated with increased risk of adverse postoperative outcomes. The tolerance to anemia might decrease perioperatively when Hb is less than 9 g/dL. Thus, less restrictive thresholds deserve further evaluation.

Bilateral suprazygomatic maxillary nerve blocks vs. infraorbital and palatine nerve blocks in cleft lip and palate repair: A double-blind, randomised study.

BACKGROUND: Cleft defects are common craniofacial malformations which require early surgical repair. These patients are at high risk of postoperative airway obstruction and respiratory failure. Cleft surgery may require high doses of opioids which may contribute to these complications. OBJECTIVES: To compare the effectiveness of proximal and distal approaches to blocking the maxillary nerve in patients undergoing cleft lip or cleft palate surgery. DESIGN: Randomised, controlled and double-blind study. SETTING: The current study was carried out in Guwahati (Assam, India) between April 2014 and June 2014. PATIENTS: A total of 114 patients older than 6 months who underwent cleft lip or cleft palate surgery were included. Exclusion criteria included coagulation disorders, peripheral neuropathy or chronic pain syndrome, infection in the puncture site, allergy to local anaesthetics, lack of consent and language problems or other barriers that could impede the assessment of postoperative pain. INTERVENTIONS: Patients were randomly assigned to one of two groups: proximal group (bilateral suprazygomatic maxillary nerve blocks) and distal group (bilateral infraorbital nerve blocks for cleft lip repair and bilateral greater and lesser palatine nerve blocks and nasopalatine nerve block for cleft palate surgery). MAIN OUTCOME MEASURE: The primary endpoint was the percentage of patients requiring extra doses of opioids. Secondary endpoints included pain scores, respiratory and nerve block-related complications during the first 24 h. RESULTS: In the intra-operative period, there was a significant reduction of nalbuphine consumption in the proximal group (9.1 vs. 25.4%, P = 0.02). The percentage of patients requiring intra-operative fentanyl was lower in the proximal group (16.4 vs. 30.5%, P = 0.07). There were no differences in either postoperative pain scores or in postoperative complications. No technical failure or block-related complications were reported. CONCLUSION: Bilateral suprazygomatic maxillary nerve block is an effective and safe alternative to the traditional peripheral nerve blocks for cleft lip and cleft palate surgery, in a mixed paediatric and adult population.

Mortality, Geriatric, and Nongeriatric Surgical Risk Factors Among the Eldest Old: A Prospective Observational Study.

BACKGROUND: Preoperative risk and postoperative outcomes among the elderly are the subject of extensive debate. However, the eldest old, that is, the fastest-growing and most vulnerable group, are insufficiently studied; even their mortality rate is unclear. This prospective observational study was performed with the aim of determining the mortality rate of this population and establishing which preoperative conditions were predictors of which postoperative outcomes. The study was undertaken between 2011 and 2015 in a major tertiary care university hospital. METHODS: All patients aged ≥85 years undergoing any elective procedure during the study period were included. Patients were followed up for 30 days postoperatively.The preoperative conditions studied were demographic data, grade of surgical complexity (1-3), preoperative comorbidities, and some characteristically geriatric conditions (functional reserve, nutrition, cognitive status, polypharmacy, dependency, and frailty). The outcome measures were 30-day all-cause mortality (primary end point), morbidity, prolonged length of stay, and escalation of care in living conditions. RESULTS: Of 139 eligible patients, 127 completed follow-up. The 30-day mortality was 7.9%; 95% confidence interval (CI), 3.2-12.6. It had 3 predictors: malnutrition (odds ratio [OR], 15; 95% CI, 3-89), complexity 3 (OR, 9.1; CI, 2-52), and osteoporosis/osteoporotic fractures (OR, 14.7; CI, 2-126). Significant predictors for morbidity (40%) were ischemic heart disease (OR, 3.9; CI, 1-11) and complexity 3 (OR, 3.6; CI, 2-9), while a nonfrail phenotype (OR, 0.3; CI, 0.1-0.8) was found to be protective. Only 2 factors were found to be predictive of longer admissions, namely complexity 3 (OR, 4.4; CI, 2-10) and frailty (OR, 2.7; CI, 2-7). Finally, risk factors for escalation of care in living conditions were slow gait (a surrogate for frailty, OR, 2.5; CI, 1-6), complexity 3 (OR, 3.2; CI, 1-7), and hypertension (OR, 2.9; CI, 1-9). CONCLUSIONS: The eldest old is a distinct group with a considerable mortality rate and their own particular risk factors. Surgical complexity and certain geriatric variables (malnutrition and frailty), which are overlooked in American Society of Anesthesiologists and most other usual scores, are particularly relevant in this population. Inclusion of these factors along with appropriate comorbidities for risk stratification should guide better decision making for families and doctors alike and encourage preoperative optimization of patients.

Accuracy of transcutaneous laryngeal ultrasound for detecting vocal cord paralysis in the immediate postoperative period after total thyroidectomy.

BACKGROUND: Transcutaneous laryngeal ultrasound (TLUS) has emerged as a promising imaging tool for vocal cord examination in patients undergoing thyroid surgery. The focus of this prospective, double-blind study was to assess the accuracy of TLUS in the diagnosis of vocal cord paralysis in the immediate postoperative period following total thyroidectomy. METHODS: The study included 93 patients undergoing total thyroidectomy and assessed by videostrobolaryngoscopy (VSL) and TLUS. VSL was carried out the day before surgery and was repeated at 4 days postoperatively. TLUS was performed before surgery in the preanesthesia holding area and at completion of the procedure in the postanesthesia care unit. The preoperative and postoperative TLUS results were correlated with those of VSL. The statistical analysis included the sensitivity, specificity, positive predictive value, and negative predictive value (with 95% CI) of TLUS for detecting vocal cord paralysis. RESULTS: The visualization rate associated with TLUS was 93%. The total vocal cord paralysis rate was 16.1%. The performance of TLUS for diagnosing this condition was as follows: sensitivity, 93.3% (95% CI: 77.3-100%); specificity 96.1% (95% CI: 91.2-100%); positive predictive value, 82.3% (95% CI: 61.2-100%); negative predictive value, 98.6% (95% CI, 95.4-100%). CONCLUSIONS: TLUS may be a suitable technique for detecting vocal cord paralysis shortly after total thyroidectomy.

Mortality and surgical risk assessment among the extreme old undergoing emergency surgery.

BACKGROUND: Although longevity is becoming frequent, there are no scores to assess nonagenarians undergoing emergency surgery. The aim of this prospective observational study was to determine 30-day mortality and the individual performance of the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) and other scores in predicting their risk for death. METHODS: A total of 126 patients were included (2006-2011) and followed for 30 days. Patients risk for death was calculated using different scores. The accuracy of each score was assessed with exponential and linear methods and using the area under the receiver operating characteristic curve. RESULTS: Overall mortality was 34.9%. The POSSUM, with a modification in the age category, had an area under the curve of .71 and ratios of observed to predicted deaths of 1.07 and 1.22, respectively, in the linear and exponential analysis. CONCLUSIONS: In a population with as high a risk as nonagenarians, the age-modified POSSUM proved accurate to audit surgery and assess mortality risk.

Centenarians versus patients within the most frequent age range for hip fractures: transfusion practice.

INTRODUCTION: Descriptive retrospective review to compare transfusion among centenarians operated for a hip fracture with a control group within the "typical" age range for that surgery. METHOD: Fractured centenarians admitted between 2001 and 2006 were compared with a randomly selected control group aged 75-83 years, with the same pathology. Main variables recorded: demographic data; pre- and post-operative status; haemoglobin levels and blood use. A comparative statistical analysis was performed. RESULTS: Both groups were similar: each had 17 patients and a majority of females had a pertrochanteric hip fracture. Although there was a trend towards higher comorbidity rates and transfusion indexes among centenarians, a significant difference could only be found in post-operative and trigger haemoglobin levels, and in the incidence of post-operative complications. CONCLUSION: Despite intuitive beliefs, centenarians had results similar to those of the younger population: only a higher complication rate could be proved. Larger samples and prospective studies might be needed to confirm the trends noted.

[Dependency levels and health care services' utilization in psychiatric hospitals in Aragon (Spain)]. / Niveles de dependencia y utilización de servicios en los hospitales psiquiátricos de Aragón.

OBJECTIVES: To determine the characteristics of patients living in psychiatric hospitals in Aragon, to assess their dependency levels, and to analyze health care services' utilization by these patients. METHODS: We performed a cross-sectional study between July 1 and November 31. The questionnaire used was the Resident Assessment Instrument- Mental Health (RAI-MH). The sample consisted of 437 patients living in public psychiatric hospitals in Aragon. These hospitals provide care to chronically mentally ill patients and to patients undergoing rehabilitation. The Resource Utilization Group (RUG-I) system was used to classify patients by their dependency levels for activities of daily life (ADL). RESULTS: Of the 437 patients, 259 (59.3%) were men with a mean age of 62.2 years. A total of 82.1% of the patients were classified as RUG-I group 1. Patients in groups 1 and 2 required more formal health care services. At least one visit by a psychiatrist was required by 25.3% of patients in group 1 and by 15.2% of those in group 2 compared with no visits by the other groups. Nursing interventions were more frequently required by patients in the more dependent groups. All of the of patients in groups 2 to 8 needed daily physical assistance for ADL vs. 26.3% of those in group 1. In the multivariate analysis, predictive variables were the hospital and type of unit. CONCLUSIONS: There is wide variation in health care services' utilization by patients living in psychiatric hospitals, which is related to dependency levels. Many psychiatric patients do not need formal psychiatric care. Health care professionals should assess the real needs of patients to provide each of them with appropriate care.