Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group.

INTRODUCTION: Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS: Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS: Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS: These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report.

Importance: Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking. Objective: To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH. Evidence Review: With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach. Findings: After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified. Conclusions and Relevance: Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

Identifying Gender-Related Differences in Graduate Medical Education with the Use of a Web-Based Professionalism Monitoring Tool.

OBJECTIVES: Medical education is required to ensure a healthy training and learning environment for resident physicians. Trainees are expected to demonstrate professionalism with patients, faculty, and staff. West Virginia University Graduate Medical Education (GME) initiated a Web-based professionalism and mistreatment form ("button") on our Web site for reporting professionalism breaches, mistreatment, and exemplary behavior events. The purpose of this study was to identify characteristics in resident trainees who had a "button push" activation about their behavior to better understand ways to improve professionalism in GME. METHODS: This West Virginia University institutional review board-approved quality improvement study is a descriptive analysis of GME button push activations from July 2013 through June 2021. We compared characteristics of all of those trainees who had specific button activation(s) about their behavior. Data are reported as frequency and percentage. Nominal data and interval data were analyzed using the χ2 and the t test, respectively. P < 0.05 was significant. Logistic regression was used to analyze those differences that were significant. RESULTS: In the 8-year study period, there were 598 button activations, and 54% (n = 324) of the activations were anonymous. Nearly all of the button reports (n = 586, 98%) were constructively resolved within 14 days. Of the 598 button activations, 95% (n = 569) were identified as involving one sex, with 66.3% (n = 377) identified as men and 33.7% (n = 192) as women. Of the 598 activations, 83.7% (n = 500) involved residents and 16.3% (n = 98) involved attendings. One-time offenders comprised 90% (n = 538), and 10% (n = 60) involved individuals who had previous button pushes about their behavior. CONCLUSIONS: Implementation of a professionalism-monitoring tool, such as our Web-based button push, identified gender differences in the reporting of professionalism breaches, because twice as many men as women were identified as the instigator of a professionalism breech. The tool also facilitated timely interventions and exemplary behavior recognition.

Factors Associated With the Acceptance of Military Applicants to a U.S. Allopathic Medical School.

INTRODUCTION: Service members and veterans applying to medical schools can be a challenging experience. Often, the applicants have difficulty providing descriptions of their experiences. Additionally, their pathway to medical school is significantly different compared to traditional applicants. We sought to determine if there were statistically significant factors within a cohort of U.S. military medical school applications to a U.S.-based allopathic medical school to provide recommendations on how to best advise military applicants. METHODS: Data about social, academic, and military factors were collected and analyzed from the American College Application Service (AMCAS) applications to the West Virginia University School of Medicine (WVU SoM) from the 2017 to 2021 cycles. Eligibility criteria included the applications that indicated that the applicant listed any type of military experience. RESULTS: In the 5-year study period, there were 25,514 applicants to the WVU SoM, and 1.6% (n = 414) self-identified as military applicants. Of the military applicants, 28 (7%) were accepted to the WVU SoM. Statistically significant differences were found in several factors, including but not limited to academic performance, number of total experiences (14.5 vs. 12, P = .01), and number of military experiences (4 vs. 2, P = .003) listed on the AMCAS applications. In the accepted group, 88% of the applications included information about military experiences, which was understandable to the nonmilitary researchers compared to 79% in the nonaccepted group (P = .24). CONCLUSIONS: Premedical advisors can share statistically significant findings with military applicants, so they are informed about the academic and experiential factors associated with medical school acceptance. Applicants should also be advised to provide clear explanations of any military lexicon used in their applications. Although not statistically significant, there were a higher percentage of applications that contained descriptions of military language that was understandable to the civilian researchers in the accepted group vs. the nonaccepted group.

Post-dural puncture headache diagnosis and management.

Epidural analgesia, commonly used to alleviate labor pain, is not without complication. The most common complication associated with labor epidural analgesia (LEA) is Unintentional Dural Puncture (UDP), where many professionals go on to develop a Post Dural Puncture Headache (PDPH). Spinal anesthesia can also result in PDPH. Other complications of dural puncture necessitating further treatment include hospital readmission, persistent headache, persistent backache, cerebral venous thrombosis, subdural hematoma, postpartum depression, post-traumatic stress disorder, and decreased maternal breastfeeding. In this article, we will define and discuss the definition and diagnosis for PDPH, the pathophysiology of PDPH, PDPH treatment options including conservative therapy, pharmacologic therapy, and invasive procedural measures including the therapeutic epidural blood patch, prophylactic epidural blood patch, intrathecal catheter placement after UDP, and potential new therapies.

Virtual interviewing in the COVID-19 era: A survey of graduate program directors.

PURPOSE/OBJECTIVE: Due to the coronavirus pandemic, virtual interviews became a mainstay of graduate dental and medical education selection processes. To gain a handle on how to navigate lingering uncertainties about how interviews should be conducted in the future, this study examined the benefits and pitfalls of the virtual interview process (VIP) and assessed program plans to implement in the next interview cycle. METHODS: An anonymous online survey, for completion by one program representative (director or associate director), was sent to graduate medical education (GME) and advanced dental education programs at West Virginia University (N = 74). RESULTS: Fifty-two (52) of the programs (70%) completed the survey. Zoom was the most frequently used interview platform (78.8%). Approximately two thirds (65.4%) of the interviewers thought VIP allowed the program to promote the university, the school, and their program and also reported experiencing video-conferencing fatigue. About six in 10 perceive VIP can introduce bias in selecting applicants (59.6%) and potentially disadvantage some applicants (67.3%). Compared to the previous in-person cycle, 67.4% of programs invited more applicants, and 73.1% interviewed more applicants. Regarding the 2021-2022 interview cycle, 55.8% of programs plan to offer either an in-person or VIP, while 7.7% plan to keep their process completely virtual. CONCLUSION: Graduate programs in this study demonstrated the indispensability of technology in transitioning from in-person to virtual interviews during COVID-19 pandemic. VIP has several advantages and disadvantages; this style of interview is forecasted to have a presence in applicant selection in the future.

Factors Associated with Acceptance of Repeat MCAT Test Takers into a West Virginian Allopathic Medical School.

OBJECTIVES: A paucity of information exists to advise medical school applicants who have had to retake the Medical College Admission Test (MCAT) to achieve a competitive score. To better advise repeat test takers from West Virginia and other Appalachian and southern areas, MCAT data from West Virginia applicants were analyzed and compared with national data. METHODS: In the application cycles of 2017-2020, the following factors were analyzed in relation to medical school acceptance in West Virginia applicants: MCAT scores, the number of test-taking attempts, biology-chemistry-physics-math grade point average, time between test-taking attempts, and academic major. MCAT data from medical school applicants from West Virginia who took the test more than once also were compared with national data. RESULTS: Of the total repeat test takers from West Virginia (N = 285) in the study timeframe, 57 (20%) were ultimately accepted into medical school. Factors associated with medical school acceptance were as follows: first MCAT test score (odds ratio [OR] 1.3, 95% confidence level [CL] 1.2-1.4, P < 0.001), change in MCAT test score (OR 1.2, 95% CL 1.1-1.3, P = 0.0015), and biology-chemistry-physics-math grade point average (OR 15.1, 95% CL 4.2-54.8, P < 0.0001). The highest benefit for improved scores occurred between the first and second attempts. The highest point gain occurred when the first MCAT score was in the range of 477 to 487 (<1st-12th percentile); this finding was not found in the national data. CONCLUSIONS: Although the study was limited to West Virginia medical school applicants, this information could prove useful in advising premedical applicants from other Appalachian and southern US areas.

A Comparative Study of Braided versus Barbed Suture for Cystotomy Repair.

BACKGROUND: In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 polyglactin, poliglecaprone) versus barbed (V-LocTM 90) suture. As a secondary outcome, we analyzed factors for suture preference between the two groups. METHODS: A retrospective chart review was undertaken for surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson's Chi-square test and interval data by t-test. A p < 0.05 was significant. RESULTS: Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p = 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index (BMI) was significantly higher in patients receiving a barbed suture repair (p = 0.005). CONCLUSION: Barbed suture may be comparable to standard braided suture for cystotomy repair. Barbed suture may offer a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.

Randomized trial of transversus abdominis plane block with liposomal bupivacaine after cesarean delivery with or without intrathecal morphine.

STUDY OBJECTIVE: To investigate efficacy and safety of liposomal bupivacaine (LB) transversus abdominis plane (TAP) block with or without intrathecal morphine (ITM) compared with ITM alone for postsurgical analgesia after cesarean delivery (CD). DESIGN: Multicenter, open-label, randomized trial (NCT03853694). SETTING: Operating room. PATIENTS: Women with term pregnancy of 37 to 42 weeks scheduled for elective CD under spinal anesthesia. INTERVENTION: Patients were randomized 1:1:1 to LB 266 mg TAP block alone (LB group), ITM 50 µg followed by LB 266 mg TAP block (LB + ITM group), or ITM 150 µg alone (ITM group). All groups received the same postsurgical multimodal analgesic regimen. MEASUREMENTS: The LB and LB + ITM groups were compared with the ITM group for all efficacy outcomes. Postsurgical opioid consumption in morphine milligram equivalents (MMEs) through 72 h was compared by assessing noninferiority before testing superiority. Postsurgical pruritus severity was assessed on an 11-point numerical rating scale. MAIN RESULTS: Between March 4, 2019, and January 10, 2020, 153 patients (LB, n = 52; LB + ITM, n = 48; ITM, n = 53) were enrolled. Baseline characteristics were comparable across groups. The LB group had statistically noninferior postsurgical opioid consumption through 72 h compared with the ITM group (least squares mean [LSM], 19.2 vs 16.4 MMEs; LSM treatment ratio, 1.17 [95% confidence interval (CI), 0.74-1.86]; noninferiority P < 0.0034) as did the LB + ITM group (LSM, 14.6 vs 16.4 MMEs; LSM treatment ratio, 0.89 [95% CI, 0.55-1.44]; noninferiority P < 0.0001). The LB and LB + ITM groups had significantly reduced pruritus severity scores through 12, 24, 48, and 72 h compared with the ITM group (P ≤ 0.0121). Adverse events occurred in 58%, 85%, and 81% of the LB, LB + ITM, and ITM groups, respectively. CONCLUSIONS: LB TAP block with or without ITM resulted in statistically noninferior postsurgical opioid consumption through 72 h, reduced pruritus, and favorable safety compared with ITM in women undergoing CD.

The influence of medical insurance on obstetrical care.

Maternal and obstetrical outcomes vary widely within the United States. The impact of insurance type on health care disparities and its influence on obstetrical care and maternal outcome is not clear. We report the impact of health care insurance on obstetrical and maternal outcomes in a tertiary care health care system. Our maternal quality care database (n = 4199) was queried comparing commercial insurance to government sponsored insurance from July 1, 2015 through June 30, 2018. Parturients with commercial insurance were older, weighed more, presented with less gravidity and parity, had more advanced gestation, and had a higher neonatal 5-minute Apgar score than government insured parturients. Additionally, government insured parturients were less likely to be admitted for induction with oxytocin, receive labor epidural analgesia, and have a primary caesarean delivery. Similarly, government insured parturients were more likely to be of African American descent, be a current known smoker, have a positive urine drug screen, and receive a general anesthetic. We conclude obstetrical and maternal health care disparities exist based on medical insurance type.

Independent risk factors for chronic illicit substance use during pregnancy.

OBJECTIVE: We aimed to determine the incidence of chronic illicit substance use during pregnancy and to identify associated risk factors. DESIGN: A 2-year time-matched retrospective maternal quality control database (n = 4,470) analysis of parturients with chronic illicit substance use compared to controls. SETTING: A tertiary academic medical center located in a rural setting. RESULTS: The rate of chronic illicit substance use was 1.95 percent. Demographic factors associated with chronic illicit substance use in pregnancy-included lower body mass index (BMI; OR: 0.93; 95 percent CI: 0.89-0.96, p < 0.0001), higher gravidity (OR: 1.24; 95 percent CI: 1.13-1.36, p < 0.0001), higher parity (OR: 1.38; 95 percent CI: 1.22-1.57, p < 0.0001), and more live births (OR: 1.30; 95 percent CI: 1.16-1.46, p < 0.0001). A history of smoking (OR: 10.51; 95 percent CI: 5.69-19.42, p < 0.0001), alcohol use (OR: 48.98; 95 percent CI: 17.33-138.40, p < 0.0001), anxiety (OR: 1.88; 95 percent CI: 1.16-3.05, p = 0.01), depression (OR: 2.44; 95 percent CI: 1.55-3.85, p = 0.0001), transfer on admission (OR: 2.12; 95 percent CI: 1.16-3.87, p = 0.01), payor insurance (OR: 2.12, 95 percent CI: 2.10-5.04, p < 0.0001), and Apgar scores < 7 at 1 minute (OR: 0.50; 95 percent CI: 0.25-1.00, p = 0.049) were significant. Multiple variable logistic regression-revealed BMI, smoking, alcohol use, and Apgar score <7 at 1 minute as significant factors. CONCLUSIONS: Awareness of these factors can assist in identifying and treating parturients with chronic illicit substance use.

Transversus Abdominis Plane Block With Liposomal Bupivacaine for Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial.

BACKGROUND: In women undergoing cesarean delivery under spinal anesthesia with intrathecal morphine, transversus abdominis plane (TAP) block with bupivacaine hydrochloride (HCl) may not improve postsurgical analgesia. This lack of benefit could be related to the short duration of action of bupivacaine HCl. A retrospective study reported that TAP block with long-acting liposomal bupivacaine (LB) reduced opioid consumption and improved analgesia following cesarean delivery. Therefore, we performed a prospective multicenter, randomized, double-blind trial examining efficacy and safety of TAP block with LB plus bupivacaine HCl versus bupivacaine HCl alone. METHODS: Women (n = 186) with term pregnancies undergoing elective cesarean delivery under spinal anesthesia were randomized (1:1) to TAP block with LB 266 mg plus bupivacaine HCl 50 mg or bupivacaine HCl 50 mg alone. Efficacy was evaluated in a protocol-compliant analysis (PCA) set that was defined a priori. The primary end point was total postsurgical opioid consumption (oral morphine equivalent dosing [MED]) through 72 hours. Pain intensity was measured using a visual analog scale. Adverse events (AEs) after treatment were recorded through day 14. RESULTS: Total opioid consumption through 72 hours was reduced with LB plus bupivacaine HCl versus bupivacaine HCl alone (least squares mean [LSM] [standard error (SE)] MED, 15.5 mg [6.67 mg] vs 32.0 mg [6.25 mg]). This corresponded to an LSM treatment difference of -16.5 mg (95% confidence interval [CI], -30.8 to -2.2 mg; P = .012). The area under the curve of imputed pain intensity scores through 72 hours supported noninferiority of LB plus bupivacaine HCl versus bupivacaine HCl alone (LSM [SE], 147.9 [21.13] vs 178.5 [19.78]; LSM treatment difference, -30.6; 95% CI, -75.9 to 14.7), with a prespecified noninferiority margin of 36 (P = .002). In an analysis of all treated patients, including those not meeting criteria for inclusion in the PCA, there was no difference in postsurgical opioid consumption between groups. In the LB plus bupivacaine HCl group, 63.6% of patients experienced an AE after treatment versus 56.2% in the bupivacaine HCl-alone group. Serious AEs after treatment were rare (≈3% in both groups). CONCLUSIONS: TAP block using LB plus bupivacaine HCl as part of a multimodal analgesia protocol incorporating intrathecal morphine resulted in reduced opioid consumption after cesarean delivery in the PCA set. Results suggest that with correct TAP block placement and adherence to a multimodal postsurgical analgesic regimen, there is an opioid-reducing benefit of adding LB to bupivacaine TAP blocks after cesarean delivery (ClinicalTrials.gov identifier: NCT03176459).

Hospital Spiritual Care Can Complement Graduate Medical Trainee Well-Being.

BACKGROUND: Burnout and depression among physician trainees is increasing at an alarming rate. Promoting well-being is of utmost importance for graduate medical education. The primary objective was to determine if spiritual care staff/chaplaincy can assist in building emotional well-being and resiliency within medical residency education. METHODS: For the academic year of July 2017 through June 2018, all graduate medical trainees in our institution were given the option of attending either an individual or group spiritual care session as part of a universal "Call to Wellness" curriculum. A Post-Wellness Survey was administered to measure perceptions about the program. RESULTS: 49% (N = 258) of residents chose to participate in a spiritual care session. Prior to the session, 51% (N = 132) rated their overall well-being as neutral and 25% (N = 64) rated their overall well-being as slightly positive, positive, or very positive. After their spiritual care session, significant improvement was seen. 25% (N = 64) rated their overall well-being as neutral, and 51% (N = 132) rated their overall well-being as slightly positive, positive, or very positive (p < 0.001). CONCLUSION: Spiritual care staff/chaplaincy can have a positive influence on emotional well-being for physicians during residency training.

Pro-Con Debate: Nitrous Oxide for Labor Analgesia.

This Pro-Con debate will provide the practitioner with an evidence-based knowledge approach to assist the clinician in determining whether to employ (Pro) or not to employ (Con) this technique in the obstetrical suite for labor analgesia. Nitrous oxide has been used safely in dentistry and medicine for many centuries. However, accumulating preclinical and clinical evidence increasingly suggests previously unrecognized adverse maternal and fetal effects of nitrous oxide, which warrants reconsideration of its use in pregnant women and a more detailed informed consent. Nitrous oxide is associated with metabolic, oxidative, genotoxic, and transgenerational epigenetic effects in animals and humans that may warrant limiting its usefulness in labor. This debate will discuss and review the clinical uses, advantages, and disadvantages of nitrous oxide on occupational effects of nitrous oxide exposure, neuroapoptosis, FDA warning on inhalational anesthetics and the developing brain, research limitations, occupational exposure safety limits, effects on global warming, and potential for diversion.

Preeclampsia Induced Liver Dysfunction Complicated by Disseminated Intravascular Coagulopathy and Placental Abruption: A Case Report and Review of the Literature.

A 33-year-old primigravida at 32-week gestation was admitted to labor and delivery complaining of severe right upper quadrant pain and worsening coagulopathy. We report the anesthetic and obstetrical management of a complex case of a parturient with a mixed picture of hemolysis, elevated liver enzymes and low platelets who was delivered under general anesthesia further complicated by Disseminated Intravascular Coagulopathy (DIC) and placental abruption.

Knowledge and Attitudes of Health Care Providers Toward Transgender Patients Within a Rural Tertiary Care Center.

Purpose: Members of the transgender community face significant health disparities within our society, especially within the state of West Virginia, which is primarily rural. We sought to examine and compare existing attitudes and knowledge of resident and faculty physician medical professionals at our institution about treating transgender individuals within a rural tertiary care center. Methods: The Medical Practitioner Attitudes Towards Transgender Patients (MP-ATTS) survey and the Medical Practitioner Beliefs and Knowledge about Treating Transgender Patients (MP-BKTTP) survey were sent to all faculty and resident physicians at West Virginia University Hospitals. Demographics included information about gender, rurality of hometown, race, and description of medical practitioner status (i.e., years out of residency, residency status). Findings: In general, there were positive attitudes and reception of the survey among residents and faculty physicians. 76.45% of providers assumed that their patients were not transgender. More than 40% of respondents believed that they would need further education about transgender patients to provide appropriate health care. Male health care providers had significantly higher negative perceptions of the transgender community (N=85, M=4.46, standard deviation [SD]=0.55, p<0.0001) and perceived fewer barriers due to personnel (N=80, M=3.24, SD=0.96, p<0.0001). Conclusion: A clear need exists for increased training in transgender health care among physicians taking care of this patient population. A gender divide exists among health care providers within West Virginia over attitudes regarding the transgender community. Further studies are needed to fully understand the health care needs and barriers of the transgender population.

Perioperative risk factors for postoperative respiratory failure.

The study aimed to identify the risk factors for respiratory failure after surgery. Postoperative respiratory failure (PRF) was defined as prolonged intubation after surgery or reintubation after unsuccessful extubation. We conducted a retrospective analysis of the following risk factors: age, obesity as reflected by body mass index (BMI), gender, patient admitted to hospital (in-patient status) vs. outpatient surgery, smoking, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, abnormal liver function, anaemia, respiratory infection, physical condition as reflected by ASA class, case type (elective or emergency), anaesthesia type, and surgical duration. The incidence of PRF was found to be 2.4%. Independent risk factors were older age, inpatient status, hypertension, COPD, elective procedure, surgical duration >2 hours, and ASA class ≥3. The study concludes that PRF results in significant postoperative complications. Minimising these risks is essential in improving PRF and subsequently surgical outcomes.