American Society of Anesthesiologists

Background/Aim. Incarcerated inguinal hernias surgical treatment represents one of the most frequent surgical treatments in elderly patients. The percentage of incarcerated inguinal hernias urgent surgical treatments is growing exponentially with the age in patients over 50. The aim of the study was to investigate some of the factors that may have impact on the incarcerated inguinal hernias surgical treatment outcome in elderly patients. Methods. The study included 180 patients classified in two groups: the study group (> 65 years of age) and the control group (? 65), managed in the period from January 2005 till March 2009 at the General Surgery Clinic, Clinical Center Nis. Results. Most of the patients had right inguinal hernia (52.6%, the study group; 59.1%, the control group). All the study group patients suffered from some of accompanying chronic diseases (100%), opposite to 39 (59%) patients of the control group. Synthetic material was implanted in 124 (68.9%) patients, whil...

The aim of this study is to evaluate the impact of concurrent mesh herniorrhaphy on short-term outcomes of colorectal surgery by using a large, nationwide database. METHODS: Patients who underwent simultaneous ventral hernia repair (VHR) and colorectal surgery between 2005 and 2010 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Patients who underwent VHR with mesh repair were case matched with patients who underwent VHR without mesh based on the type of colorectal procedure, diagnosis, and American Society of Anesthesiologists score. RESULTS: Two hundred sixty-two patients who underwent VHR with mesh were case matched with 524 patients who underwent VHR without mesh. Mean operating time was significantly longer in patients who underwent VHR with mesh (195.8 6 98.7 vs 164.3 6 84.4 minutes, P , .001). Postoperative morbidity (P 5 .58), mortality (P 5 .27), superficial surgical site infection (SSI) (P 5 .14), deep SSI (P 5 .38), organ space SSI (P 5 .17), wound disruption (P . .99), reoperation (P 5 .48), and length of hospital stay (P 5 .71) were comparable between the groups. CONCLUSION: The American College of Surgeons National Surgical Quality Improvement Program data suggest that VHR with mesh does not increase 30-day mortality, medical or surgical morbidity in colorectal surgery setting.

Computer-assisted propofol sedation (CAPS) allows non-anesthesiologists to administer propofol for gastrointestinal procedures in relatively healthy patients. As the first US medical center to adopt CAPS technology for routine clinical use, we report our 1-year experience with CAPS for esophagogastroduodenoscopy (EGD). Methods Between September 2014 and August 2015, 926 outpatients underwent elective EGDs with CAPS at our center. All EGDs were performed by 1 of 17 gastroenterologists certified in the use of CAPS. Procedural success rates, procedure times, and recovery times were compared against corresponding historical controls done with midazolam and fentanyl sedation from September 2013 to August 2014. Adverse events in CAPS patients were recorded. The mean age of the CAPS cohort was 56.7 years (45% male); 16.2% of the EGDs were for variceal screening or Barrett's surveillance and 83.8% for symptoms. The procedural success rates were similar to that of historical controls (99.0% vs. 99.3%; p = 0.532); procedure times were also similar (6.6 vs. 7.4 min; p = 0.280), but recovery time was markedly shorter (31.7 vs. 52.4 min; p < 0.001). There were 11 (1.2%) cases of mild transient oxygen desaturation (< 90%), 15 (1.6%) cases of marked agitation due to undersedation, and 1 case of asymptomatic hypotension. In addition, there were six (0.6%) patients with more pronounced desaturation episodes that required brief (< 1 min) mask ventilation. There were no other serious adverse events. Conclusions CAPS appears to be a safe, effective, and efficient means of providing sedation for EGD in healthy patients. Recovery times were much shorter than historical controls.

Purpose: The emergency intervention for acute malignant left-sided colonic obstruction remains controversial. Conflicting reports exist regarding the efficacy and safety of endoscopic placement of self-expandable metallic stents (SEMS) vs. primary surgery. Most reports focus on SEMS insertion as a bridge to surgery. Methods: An observational nonrandomized study at a single center in Cairo, Egypt included 65 high-risk patients (American Society of Anesthesiologists physical status classification ≥ III, age > 60 years) with acute malignant metastatic (stage IV) colonic obstruction. Twenty-nine patients underwent primary surgery (Hartmann's procedure, HP), and 35 patients underwent SEMS insertion. Results: All cases that underwent SEMS insertion were technically successful. The 2 procedures were comparable in clinical success rates but a statistically significant difference existed between them regarding the duration of postoperative hospital stay in the HP and SEMS group (7.7 ± 3.1 days vs. 3.5 ± 0.6 days, retrospectively; P < 0.001), the interval before regaining oral feeding (41.8 ± 26.8 hours vs. 27.6 ± 18.5 hours, retrospectively; P = 0.015), and the duration of intensive care unit (ICU) admission (5.0 ± 1.7 days vs. 1.5 ± 0.7 days, retrospectively; P = 0.035). Six patients (20.7%) in the HP group and 2 patients (5.7%) in the SEMS group required postoperative ICU admission. Conclusion: SEMS placement provides comparable efficacy and safety to HP in managing acute malignant obstruction of the rectosigmoid region in high-risk individuals, with faster recovery and less hospital and ICU admission time.

Purpose: The emergency intervention for acute malignant left-sided colonic obstruction remains controversial. Conflicting reports exist regarding the efficacy and safety of endoscopic placement of self-expandable metallic stents (SEMS) vs. primary surgery. Most reports focus on SEMS insertion as a bridge to surgery.Methods: An observational nonrandomized study at a single center in Cairo, Egypt included 65 high-risk patients (American Society of Anesthesiologists physical status classification ≥ III, age &gt; 60 years) with acute malignant metastatic (stage IV) colonic obstruction. Twenty-nine patients underwent primary surgery (Hartmann’s procedure, HP), and 35 patients underwent SEMS insertion.Results: All cases that underwent SEMS insertion were technically successful. The 2 procedures were comparable in clinical success rates but a statistically significant difference existed between them regarding the duration of postoperative hospital stay in the HP and SEMS group (7.7 ± 3.1 d...

Introduction Development of acute kidney injury (AKI) during the perioperative period is associated with increases in morbidity and mortality. Our aim was to evaluate the incidence and determinants of postoperative AKI after major noncardiac surgery in patients with previously normal renal function. This retrospective cohort study was carried out in the multidisciplinary Post-Anaesthesia Care Unit (PACU) with five intensive care beds. The study population consisted of 1166 patients with no previous renal insufficiency who were admitted to these intensive care unit (ICU) beds over 2 years. After admission patients were followed for the development of AKI, defined as proposed by The Acute Kidney Injury Network (increment of serum creatinine [greater than or equal to] 0.3 mg/ dL or 50% from baseline within 48 hours or urine output < 0.5 mL/kg/hr for > 6 hours despite fluid resuscitation when applicable). Patient preoperative characteristics, intraoperative management and outcome were evaluated for associations with acute kidney injury using an univariate and multiple logistic regression model. A total of 1597 patients were admitted to the PACU and of these, 1166 met the inclusion criteria. Eighty-seven patients (7.5%) met AKI criteria. Univariate analysis identified age, American Society of Anesthesiologists (ASA) physical status, emergency surgery, high risk surgery, ischemic heart disease, congestive heart disease and Revised Cardiac Risk Index (RCRI) score as independent preoperative determinants for AKI in the postoperative period. Multivariate analysis identified ASA physical status, RCRI score, high risk surgery and congestive heart disease as preoperative determinants for AKI in the postoperative period. Patients that developed AKI had higher Simplified Acute Physiology Score (SAPS) II and Acute Physiology and Chronic Health Evaluation (APACHE) II, higher PACU length of stay (LOS), higher PACU mortality, higher hospital mortality and higher mortality at 6 months follow-up. AKI was an independent risk factor for hospital mortality (OR 3.12, 95% CI 1.41 to 6.93, P = 0.005). This study shows that age, emergency and high risk surgery, ischemic heart disease, congestive heart disease, ASA physical status and RCRI score were considered risk factors for the development of AKI, in patients needing intensive care after surgery. AKI has serious impact on PACU length of stay and mortality. AKI was an independent risk factor for hospital mortality.

Background and study aims: Propofol is increasingly being used for sedation purposes during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to evaluate the safety of nonanaesthesiologist administration of propofol (NAAP) during therapeutic ERCP. Patients and methods: Patients, who underwent ERCP at Centre for Liver and Digestive Diseases, Holy Family Hospital, Rawalpindi, were included in the study. Propofol sedation was administered by a physician who was a non-anaesthesiologist certified in basic and advanced cardiac life support. The total study duration was 6 months. The primary outcome variable was the frequency of any sedation-related complication. Results: A total of 156 patients (41% males and 59% females) were enrolled in the study. The mean propofol dose used during the procedure was 201 ± 132 mg. The mean propofol dose, when adjusted to weight and duration of procedure, was 0.05 ± 0.04 mg kg À1 min À1 . According to the American Society of Anesthesiologists (ASA) classification, 136 (87%) patients were placed in ASA class I and II and 20 (13%) patients were of ASA class III. Only two patients developed sedation-related complication: one minor requiring bag-mask ventilation and other major requiring mechanical ventilation via endotracheal intubation. Both were managed by the trained non-anaesthesiologist and gastroenterologist at the place of procedure. No patients required cardiopulmonary resuscitation and admission to the intensive care unit. There were no sedation-related deaths. Conclusion: NAAP sedation can be considered safe for low-risk patients (ASA class I and II) undergoing ERCP. The presence of a trained anaesthetist is advisable in high-risk patients (ASA class III and higher) with significant co-morbidities.

Aims The COVID-19 pandemic drastically affected elective orthopaedic services globally as routine orthopaedic activity was largely halted to combat this global threat. Our institution (University College London Hospital, UK) previously showed that during the first peak, a large proportion of patients were hesitant to be listed for their elective lower limb procedure. The aim of this study is to assess if there is a patient perception change towards having elective surgery now that we have passed the peak of the second wave of the pandemic. Methods This is a prospective study of 100 patients who were on the waiting list of a single surgeon for an elective hip or knee procedure. Baseline characteristics including age, American Society of Anesthesiologists (ASA) grade, COVID-19 risk, procedure type, and admission type were recorded. The primary outcome was patient consent to continue with their scheduled surgical procedure. Subgroup analysis was also conducted to define if any specific...

1. In adult cardiac surgery with cardiopulmonary bypass (CPB), avoiding hyperthermic perfusion (.37 C) is recommended to reduce the risk of cardiac surgeryassociated acute kidney injury (CSA-AKI). (Class of Recommendation: I, Level of Evidence: B-R) 2. In adult cardiac surgery with CPB, a goal-directed oxygen delivery strategy is recommended to reduce the

This trial was designed to study the correlation between peri‐operative mortality in patients undergoing elective surgery and the physical status classification of the American Society of Anesthesiologists, the Goldman multifactorial cardiac risk index or the two indices combined. All patients scheduled for elective surgery over a 5‐year period were evaluated pre‐operatively and were scored according to both indices. Of 16 227 patients studied, 215 died within 4 weeks of operation. Both indices correlated significantly with peri‐operative mortality, the ASA grade showing a closer correlation. A regression tree analysis divided the combination groups into five subgroups where the mortality was lowest (0.4%) in ASA grade ≤2 and cardiac risk index group I (score 0–5 points) and increased up to 7.3% in ASA grade = 4 and cardiac risk index group ≥3 (score &gt;13 points). We conclude that for this large number of patients peri‐operative mortality can be predicted with the ASA grade and, t...

BACKGROUND: The proportion of women medical school graduates in the United States has grown substantially; however, representation of women in anesthesiology lags behind. We sought to investigate factors associated with women recommending against a career in anesthesiology due to obstacles related to motherhood. METHODS: We surveyed 9525 women anesthesiologist members of the American Society of Anesthesiologists (ASA) with a web-based survey distributed via e-mail. Associations between whether women would counsel against anesthesiology due to obstacles related to motherhood and 34 related categorical variables were estimated. Fisher exact test was used for categorical binary variables, and Wilcoxon-Mann-Whitney test was used for ranked variables. RESULTS: The response rate for the primary question was 19.2%. Among the 1827 respondents to the primary question, 11.6% would counsel a female medical student against a career in anesthesiology due to obstacles pertaining to motherhood. Co...

on . Preoperative identification of high-risk patients should be performed, and all available preoperative and perioperative measures of blood conservation should be undertaken in this group as they account for most blood products transfused. It is reasonable to discontinue low-intensity antiplatelet drugs (e.g., aspirin) only in purely elective patients without ACS before operation with the expectation that blood transfusion will be reduced. Class IIA, Level A Minimization of phlebotomy through reduction in blood sampling volumes and frequencies is a reasonable means of blood conservation. Class IIA, Level B-NR (nonrandomized) The addition of a P2Y12 inhibitor to aspirin therapy, if indicated, in the immediate postoperative care of CABG patients before ensuring surgical hemostasis may increase bleeding and the need for surgical reexploration, and is not recommended until the risk of bleeding has abated. Class III: No benefit, Level C-LD (limited data) Use of 1-deamino-8-D-arginine vasopressin (DDAVP) may be reasonable to attenuate excessive bleeding and transfusion in certain patients with demonstrable and specific platelet dysfunction known to respond to this agent (e.g., uremic or CPB-induced platelet dysfunction, type I von Willebrand disease). Class IIB, Level B-NR Plasma transfusion is reasonable in patients with serious bleeding in the context of multiple or single coagulation factor deficiencies when safer fractionated products are not available. Class IIA, Level B-NR Prophylactic use of plasma in cardiac operations in the absence of coagulopathy is not indicated, does not reduce blood loss, and exposes patients to unnecessary risks and complications of allogeneic blood component transfusion. When allogeneic blood transfusion is needed, it is reasonable to use leukoreduced donor blood, if available. Class IIA, Level B-R (randomized) Use of recombinant factor VIIa concentrate may be considered for the management of intractable nonsurgical bleeding that is unresponsive to routine hemostatic therapy after cardiac procedures using CPB. Class IIB, Level B-NR Antithrombin III concentrates are indicated to reduce plasma transfusion in patients with antithrombinmediated heparin resistance immediately before CPB. In high-risk patients with known malignancy who require CPB, blood salvage using centrifugation of salvaged blood from the operative field may be considered when allogeneic transfusion is required. Class IIB, Level B-NR Centrifugation of pump-salvaged blood is reasonable for minimizing post-CPB allogeneic RBC transfusion. Class IIA, Level A Use of modified ultrafiltration may be reasonable for blood conservation and reducing postoperative blood loss in adult cardiac operations using CPB. Class IIB, Level B-R Routine use of red cell salvage using centrifugation is helpful for blood conservation in cardiac operations using CPB. Class I, Level A Direct reinfusion of shed mediastinal blood from postoperative chest tube drainage is not recommended as a means of blood conservation and may cause harm. Class III: Harm, Level B-NR A comprehensive multimodality blood conservation program led by a multidisciplinary team of healthcare providers should be part of any patient blood management program to limit utilization of blood resources and decrease the risk of bleeding. Class I, Level B-R

Study Objectives: To determine 1) which proportion of academic departments have policies concerning older anesthesiologists, 2) whether departments with such policies, particularly those related to call, had characteristics such as departmental size and proportions of older anesthesiologists that differed from departments without these policies, 3) if departments routinely screened their older members for problem behaviors, and 4) if departments provided nonclinical roles for older anesthesiologists. Design: Survey instrument. Setting: Academic medical centers. Measurements: An anonymous, web-based questionnaire that included questions on demographics and specific policy-related issues was sent to chairpersons of all academic anesthesia departments in the ASA database. Main Results: No department directly addressed every issue listed in the survey. Department size and the number of anesthesiologists over 60 years of age were unrelated to whether that department had one or more policies for older anesthesiologists. Twenty percent of programs stopped night call at age 60 years. Most departments did not exempt older anesthesiologists of any age from call responsibilities. Almost all departments tracked critical incidents and errors in technique and/or judgment. Almost three quarters tracked substance abuse, and over half of the responding departments tracked physical and emotional impairment and fixation errors. A third of departments tracked all 6 types of problem behavior. Only 12% had specific assessment tools for tracking problem behaviors in the clinic, and no

BACKGROUND: During a war, many civilians are severely injured by firearms, bombs, and shrapnel. The triage of war injuries involves difficult and complicated processes requiring surgical procedures and patient monitoring in the Intensive Care Unit (ICU) of hospitals. In this study, we examine the demographic, traumatic, and critical care characteristics of cases injured during the civil war in Syria and requiring emergency surgery. METHODS: Electronic data of the traumatic, surgical, and ICU monitoring features of 707 patients admitted to Kilis Public Hospital between March 2012 and January 2013 were analyzed retrospectively RESULTS: Most of the patients reported having been injured due to firearms (83.75%). Of the 707 cases studied in this work, 93.2% was male. Male patients reported a mean age of 26.1±12.1 years, while pediatric cases reported a mean age of 11.7±3.41 years. The most frequently injured region of the body was the head-neck region (52.7%). The New Injury Severity Score (NISS) of the cases was 42.5±11.2 and their American Society of Anesthesiologists (ASA) score was 3.2±0.7. The number of cases with intraoperative exitus was 7, while the number of cases who had undergone damage control surgery was 204. The number of cases hospitalized in the ICU during the postoperative period was 233, and the average hospitalization duration in the ICU was 4.67±1.32 days. Among survivor patients, the first 24-hour invasive measurements (i.e., pH, hemoglobin, body temperature, and mean arterial blood pressure) and international normalized ratio were found to be high. The number of blood products used for surviving patients was fewer relative to that used for non-surviving patients, and these NISS of these patients was 29.7±10.1. The mortality rate of all patients followed up in the ICU after emergency surgery was 45%, and neurosurgical cases showed the lowest level of survival (24.1%). The results of this study indicated that head-neck, chest-abdomen, and multiple body injuries are the most widely seen among civilians brought to Turkey because of gunshot injuries sustained during the Civil War in Syria. The number of emergency operations performed in the study sample was high, and critical care follow-up durations were long. In addition, the NISS and ASA scores of mortal cases were fairly high.

Amaç: Kalça kırıkları tedavisinde uygulanan hemiartroplasti ile erken mobilizasyon ve iyi fonksiyonel sonuçlar elde edilmektedir. Güncel literatürde, kalça kırığı olan geriatrik hastalarda hemiartroplasti sonrası 30 günlük mortaliteye etki eden risk faktörlerini araştıran az sayıda çalışma bulunmaktadır. Bu çalışmamızda, geriatrik femur boyun kırıklarında hemiartroplasti uygulaması sonrası 30 günlük mortaliteye etki eden hasta ile ilişkili faktörler, ucuz, rutin olarak kullanılan ve kolayca ulaşılabilen biyokimyasal belirteçlerin incelenmesi amaçlanmıştır. Yöntemler: Çalışmamızda 169 hasta retrospektif olarak incelenmiştir. Yaş, vücut kitle indeksi, başvuru -ameliyat arası geçen süre, toplam yatış süreleri, komorbid hastalıklar, Amerikan Anestezi Derneği Skorları, kan transfüzyonu, antikoagülan ilaç kullanımı, albumin ve plazma replasmanları, ameliyat öncesi ve sonrası hemogram ve biyokimya testlerinin 30 günlük mortaliteye etkisi incelenmiştir. Bulgular: 30 günlük mortalite oranı %14,2 olarak bulunmuştur. Çoklu değişkenler analizi sonucunda; yaş (>80 yaş) (1.095 odds ratio, p = 0.029), Amerikan Anestezi Derneği Skoru (3.584 odds ratio, p = 0.007) ve ameliyat sonrası kreatinin değerleri (2.845 odds ratio, p = 0.001), geriatrik femur boyun kırıkları için uygulanan hemiartroplasti sonrası 30 günlük mortalitenin ana belirleyicileri olarak bulunmuştur. Sonuç: İleri yaş (>80 yaş), yüksek Amerikan Anestezi Derneği skorları (ASA skoru 3 veya 4) ve artmış ameliyat sonrası kreatinin değerleri, artmış 30 günlük mortalite riski ile ilişkili bulunmuştur.

Objectives: Hip surgeries performed in elderly patients are important in terms of both the physiological features of geriatric patients and the risks of surgery. The aim of this study was to evaluate the effects of age and the anesthesia method used on morbidity and mortality in geriatric patients who had hip surgery. Methods: Patients who were aged 65 and older who also had hip surgery and had American Society of Anesthesiologists (ASA) Physical Status Scale scores were included in the study. The patients were classified as aged (Group AG) for those ≥65 years of age, and very aged (Group VAG) for those ≥75 years of age. Details obtained from the hospital electronic records system of the patients' age, sex, ASA score, anesthesia method used, intraoperative and postoperative blood transfusion requirements, respiratory and cardiovascular complications, postoperative intensive care requirements, duration of hospital treatment, period of development of any postoperative complications, morbidity, and mortality were evaluated by age group. Results: A total of 258 patients between the ages of 65 and 95 who had hip surgery and available ASA scores were included in the study. In Group VAG, the rate of morbidity and mortality of ASA III and IV patients was high in the postoperative period. Regional anesthesia methods were used more often in Group VAG patients, and there were more cardiovascular complications developing in the intraoperative period in the general anesthesia patients, although there was no difference between anesthesia methods in terms of postoperative morbidity and mortality. In this study of elderly patients who had hip surgery, there was no correlation between the anesthesia method used and morbidity and mortality. Advanced age (≥75 years) and a high ASA score were the most important risk factors for mortality.

PURPOSE The aim of this study is to evaluate the effects of anesthesia methods on the surgical results of spinal, epidural, and general anesthesia procedures and the success of urethral access and stone access achievement. MATERIALS AND METHODS In this prospective randomized study, 105 patients who underwent primary URS procedure for ureteral stones were evaluated. The patients were randomized into three groups by permuted block randomization according to the applied anesthesia method: General anesthesia (GA): 33 patients, Spinal anesthesia (SA): 31 patients, and Epidural anesthesia (EA): 31 patients. Ten patients, whose ureteral access was not successful, were dropped out. The success of the three anesthesia methods on the success of the ureter access and its effects on surgical outcomes were compared. RESULTS There was no statistically significant difference among the three groups in terms of the demographic values and preoperative features except the American Society of Anesthesi...

rain arteriovenous malformations (AVMs) are among the most formidable challenges within neurosurgery, primarily due to their intricate vascular architecture and the potential morbidity associated with their resection. [1] With significant heterogeneity in presentation, location, and hemodynamic properties, AVM surgeries necessitate a combination of meticulous preoperative planning and precise intraoperative execution. Mixed reality (MxR), a combination of virtual reality (VR) planning and augmented reality (AR) intraoperative guidance, offers a new dimension in the surgical management of AVMs. After rendering catheter-based and CT angiograms into 3D models in VR, 360° inspection of the model and the 3D angioarchitecture allow for clear identification of deep arterial feeders. In turn, these can be segmented or marked in VR, and during surgery, they can be made visible AR targets through a navigation-tracked microscope. The surgeon can thus hone in on the feeders efficiently and eliminate them early in surgery without diverting attention to probe-and-monitor-based navigation.

Purpose. Restoration of gastrointestinal continuity following Hartmann's procedure is a challenging task associated with signifi cant morbidity and mortality. New strategies to avoid a stoma are not readily available in general hospitals. Knowledge of the factors related to reversal is required to develop treatment strategies and counsel patients realistically. The present study was conducted to determine the reversal rate and factors affecting Hartmann's reversal in our practice. Methods. This study retrospectively reviewed the medical records of patients who underwent Hartmann's procedure and its reversal in two United Kingdom District Hospitals between January 1996 and December 2005. Results. Case notes from 184 patients were reviewed. Hartmann's procedure was reversed in 51 (34.7%) of the surviving patients, with a complication rate of 37.3% and no mortality. Reversal of Hartmann's procedure was signifi cantly related to patient age (P < 0.001), mode of admission (P = 0.003), American Society of Anesthesiologists grading (P = 0.003), Dukes' staging (P = 0.003), benign pathology (P = 0.001), and extracolonic cancer (P = 0.023). Conclusions. Despite the challenging nature of Hartmann's reversal, colostomy closure can be achieved without mortality in a district general hospital. Familiarity with the factors associated with reversal should enable a genuine discussion with patients regarding reversal.

Determining the type of anesthesia is a complex medical decision that depends on many factors including co-morbidity, age, type of surgery performed, and the risk of the anesthetic techniques. This study evaluated the effects of anesthesia type on postoperative mortality and morbidity in hip fractures. M Ma at te er ri ia al l a an nd d M Me et th ho od ds s: : One hundred eighty-five patients older than 60 years who were operated for hip fracture between 2005-2009 were retrospectively analyzed. Patients received general anesthesia (n=67), spinal anesthesia (n=67), or epidural anesthesia (n=51). The clinical features of the patients were obtained from the hospital records. Morbidity outcomes were assessed on postoperative day 7. Mortality rates were calculated on postoperative day 7 and postoperative day 30. R Re es su ul lt ts s: : There were no significant differences between the three groups with regard to intraoperative blood loss, intraoperative blood transfusion, smoking status, length of stay in hospital, American Society of Anesthesiology (ASA) physical status, and Charlson Comorbidity Index (CCI) (p=0. 393, p=0.088, p=0.369, p=0.228, p=0.491, p=0.371 respectively). Similarly, no difference was detected between the three groups regarding patient mortality rates for day 7 and 30 (p=0.738, p=0.805 respectively). C Co on nc cl lu us si io on n: : No technique was superior to the others. Due to the similar mortality rates among the groups, we suggest that the proper anesthetic technique selected according to the clinical features of the patient combined with adequate monitorization would yield successful results with all three techniques. K Ke ey y W Wo or rd ds s: : Hip fractures; mortality; anesthesia Ö ÖZ ZE ET T A Am ma aç ç: : Anestezi tipinin belirlenmesi, yaş, uygulanacak cerrahi tipi ve anestezi tekniklerinin riski gibi birçok faktörün göz önüne alınmasını gerektiren, kompleks bir tıbbi karardır. Bu çalışmada, kalça kırıklarında anestezi tipinin cerrahi sonrası mortalite ve morbidite üzerindeki etkileri değerlendirilmiştir. G Ge er re eç ç v ve e Y Yö ön nt te em ml le er r: : Çalışmada, 2005-2009 yılları arasında kalça kırığı operasyonu geçiren 60 yaş üzeri 185 hasta retrospektif olarak analiz edilmiştir. Hastalara genel anestezi (n=67), spinal anestezi (n=67) ve epidural anestezi (n=51) yöntemlerinden biri uygulanmıştır. Hastalara ait klinik bilgiler hastane kayıtlarından elde edilmiştir. Morbidite sonuçları operasyon sonrası yedinci günde değerlendirilmiştir. Mortalite oranı ise operasyon sonrası 7. ve 30. günlerde hesaplanmıştır. B Bu ul lg gu ul la ar r: : Her üç grupta cerrahi sırasındaki kan kaybı ve kan transfüzyonu, sigara içme durumu, hastanede kalış süresi, American Society of Anesthesiology (ASA) skoru ve Charlson morbidite indeksi skoru açısından anlamlı bir fark bulunmamıştır (sırasıyla p=0,393, p=0,088, p=0,369, p=0,228, p=0,491, p=0,371). Hastaların 7. ve 30. günlerdeki mortalite oranları açısından gruplar arasında anlamlı bir fark saptanmamıştır (sırasıyla p=0,738, p=0,805). S So on nu uç ç: : Benzer mortalite oranları nedeniyle hiçbir anestezi tekniği diğerinden üstün değildir. Bu nedenle, perioperatif takibi iyi yapılan hastalarda, anestezi tekniği hastanın klinik özellikleri dikkate alınarak seçildiği müddetçe, her üç anestezi tekniği ile başarılı sonuçlar elde etmek mümkündür. A An na ah ht ta ar r K Ke el li im me el le er r: : Kalça kırığı; ölüm oranı; anestezi T Tu ur rk ki iy ye e K Kl li in ni ik kl le er ri i J J M Me ed d S Sc ci i 2 20 01 12 2; ;3 32 2( (3 3

In order to improve our understanding of the evidence-based literature supporting temperature management during adult cardiopulmonary bypass, The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiology and the American Society of ExtraCorporeal Technology tasked the authors to conduct a review of the peerreviewed literature, including: 1) optimal site for temperature monitoring, 2) avoidance of hyperthermia, 3) peak cooling temperature gradient and cooling rate, and 4) peak warming temperature gradient and rewarming rate. Authors adopted the American College of Cardiology/American Heart Association method for development clinical practice guidelines, and arrived at the following recommendations: Class I Recommendations:

on . Preoperative identification of high-risk patients should be performed, and all available preoperative and perioperative measures of blood conservation should be undertaken in this group as they account for most blood products transfused. It is reasonable to discontinue low-intensity antiplatelet drugs (e.g., aspirin) only in purely elective patients without ACS before operation with the expectation that blood transfusion will be reduced. Class IIA, Level A Minimization of phlebotomy through reduction in blood sampling volumes and frequencies is a reasonable means of blood conservation. Class IIA, Level B-NR (nonrandomized) The addition of a P2Y12 inhibitor to aspirin therapy, if indicated, in the immediate postoperative care of CABG patients before ensuring surgical hemostasis may increase bleeding and the need for surgical reexploration, and is not recommended until the risk of bleeding has abated. Class III: No benefit, Level C-LD (limited data) Use of 1-deamino-8-D-arginine vasopressin (DDAVP) may be reasonable to attenuate excessive bleeding and transfusion in certain patients with demonstrable and specific platelet dysfunction known to respond to this agent (e.g., uremic or CPB-induced platelet dysfunction, type I von Willebrand disease). Class IIB, Level B-NR Plasma transfusion is reasonable in patients with serious bleeding in the context of multiple or single coagulation factor deficiencies when safer fractionated products are not available. Class IIA, Level B-NR Prophylactic use of plasma in cardiac operations in the absence of coagulopathy is not indicated, does not reduce blood loss, and exposes patients to unnecessary risks and complications of allogeneic blood component transfusion. When allogeneic blood transfusion is needed, it is reasonable to use leukoreduced donor blood, if available. Class IIA, Level B-R (randomized) Use of recombinant factor VIIa concentrate may be considered for the management of intractable nonsurgical bleeding that is unresponsive to routine hemostatic therapy after cardiac procedures using CPB. Class IIB, Level B-NR Antithrombin III concentrates are indicated to reduce plasma transfusion in patients with antithrombinmediated heparin resistance immediately before CPB. In high-risk patients with known malignancy who require CPB, blood salvage using centrifugation of salvaged blood from the operative field may be considered when allogeneic transfusion is required. Class IIB, Level B-NR Centrifugation of pump-salvaged blood is reasonable for minimizing post-CPB allogeneic RBC transfusion. Class IIA, Level A Use of modified ultrafiltration may be reasonable for blood conservation and reducing postoperative blood loss in adult cardiac operations using CPB. Class IIB, Level B-R Routine use of red cell salvage using centrifugation is helpful for blood conservation in cardiac operations using CPB. Class I, Level A Direct reinfusion of shed mediastinal blood from postoperative chest tube drainage is not recommended as a means of blood conservation and may cause harm. Class III: Harm, Level B-NR A comprehensive multimodality blood conservation program led by a multidisciplinary team of healthcare providers should be part of any patient blood management program to limit utilization of blood resources and decrease the risk of bleeding. Class I, Level B-R

To the Editor:-We read with interest the article by Ripart et al. 1 that provides clinical evidence to conclude that single-injection, high-volume medial canthus episcleral anesthesia is an efficient and safer alternative to peribulbar anesthesia. The salient features of their method are the injection of a relatively high volume (8 -10 ml) of anesthetic solution and the use of adjuncts, such as clonidine premed-

To investigate national trends in admission status after thyroidectomy in the United States and to evaluate the factors associated with 30-day unplanned readmission and reoperation. Retrospective review of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) METHODS: The ACS-NSQIP database was queried for patients who underwent a partial or total thyroidectomy between 2005 and 2014. Outpatient surgery was defined as discharge on the day of surgery. Patient demographic information, unplanned hospital readmission, and reoperation were reviewed. Risk factors were identified using logistic regression modeling. A total of 76,604 cases met inclusion criteria as described above. There were 1,473 (1.9%) patients who underwent reoperation and 477 unplanned 30-day readmissions (1.4%) for procedures performed since 2012. There was a significant positive trend in the percentage of thyroidectomy (partial and total) patients who underwent outpatient procedures by...

The American Society of Anesthesiologists Physical Status (ASA-PS) grade better risk stratifies geriatric trauma patients, but it is only reported in patients scheduled for surgery. The Charlson Comorbidity Index (CCI), however, is available for all patients. This study aims to create a crosswalk from the CCI to ASA-PS. Geriatric trauma cases, aged 55 years and older with both ASA-PS and CCI values (N = 4223), were used for the analysis. We assessed the relationship between CCI and ASA-PS, adjusting for age, sex, marital status, and body mass index. We reported the predicted probabilities and the receiver operating characteristics. A CCI of zero was highly predictive of ASA-PS grade 1 or 2, and a CCI of 1 or higher was highly predictive of ASA-PS grade 3 or 4. Additionally, while a CCI of 3 predicted ASA-PS grade 4, a CCI of 4 and higher exhibited greater accuracy in predicting ASA-PS grade 4. We created a formula that may accurately situate a geriatric trauma patient in the appropriate ASA-PS grade after adjusting for age, sex, marital status, and body mass index. In conclusion, ASA-PS grades can be predicted from CCI, and this may aid in generating more predictive trauma models.

Background: Stimulation of various sites, from the nasal mucosa to the diaphragm, can evoke laryngospasm. To reduce airway reflexes, tracheal extubation should be performed while the patient is deeply anesthetized or with drugs that do not depress ventilation. However, tracheal extubation during rhinoplasty may be difficult because of the aspiration of blood and the possibility of laryngospasm. Dexmedetomidine and fentanyl both have sedative and analgesic effects, but dexmedetomidine has been reported to induce sedation without affecting respiratory status.

The American Society of Anesthesiologists Physical Status (ASA PS) classification has long been used as a ranking system that quantifies patient health before anaesthesia and surgery. When initially developed, the ASA PS intended application was purely statistical. However, nowadays it is commonly used by surgical specialties to determine a patient's likelihood of developing postoperative complications, despite studies reporting scoring method subjectivity and inconsistencies among anaesthesiologists in assigning these scores. Over the years, the ASA PS classifications have undergone many changes and modifications to address its limitations. There are a few points to be discussed if all shortcomings are to be treated and interobserver variability is to be limited.

Objectives: We compared the outcome of elective laparoscopic cholecystectomy (LC) in a teaching hospital and a private communityhospital to assess the impact of the involvement of residents. Materials and methods: The following parameters were studied prospectively in patients who underwent elective LC during the period from September 2014 to February 2016 in a teaching university hospital (group A) and in a private community hospital (group B): age, sex, body mass index (BMI), comorbidities, American Society of Anaesthesiologists (ASA) score, length of surgery from skin incision to skin closure, use of drain, 30-day perioperative morbidity and mortality, and length of postoperative hospital stay. Results: The group A consisted of 93 elective LC and the group B of 167 elective LC. Operative time was significantly longer in group A. Intraoperative complications were similar and no conversion was necessary in both groups. An increased rate of postoperative complications was observed in group A. All postoperative complications were managed with conservative therapy. No mortality occurred. At logistic regression analysis, the only factor favouring the occurrence of complications was the hospital type. Conclusions: Our study shows that elective LC can be performed in a teaching hospital with comparable intraoperative morbidity and increased postoperative complications. The greater rate of morbidity found in the teaching hospital may be due to an increased vigilance linked to the presence of residents and not to the lack of expertise.

Patients with gastrointestinal bleeding admitted out of hours or at the weekends may have an excess mortality rate. The literature reports around this are conflicting. We aimed to analyze the outcomes of emergency endoscopies performed out of hours and over the weekends in our center. We retrospectively analyzed data from April 2008 to June 2012. A total of 507 &#39;high risk&#39; emergency gastroscopies were carried out over the study period for various indications. Patients who died within 30 days of the index procedure [22 % (114 /510)] had a significantly higher Rockall score (7.6 vs. 6.0, P &lt; 0.0001), a higher American Society of Anesthesiologists (ASA) status (3.5 vs. 2.7, P &lt; 0.001), and a lower systolic blood pressure (BP) at the time of the examination (94.8 vs 103, P = 0.025). These patients were significantly older (77.7 vs. 67.5 years, P = 0.006), and required more blood transfusion (5.9 versus 3.8 units). Emergency out-of-hours endoscopy was not associated with an...

The impact of surgeons and anesthesiologists, both individually and paired, on the length of operative procedures was studied. Methods: Five general surgeons, six neurosurgeons, and 21 anesthesiologists all completed two personality assessments. A retrospective review of OR records of six procedure types performed by those in the study (2,087 neurosurgical and 2,107 general surgery) was conducted. Statistical analysis was employed to estimate various effects on OR times and to identify the importance of each factor. Results: Surgeon effect on OR time varies with procedure type but was greater in neurosurgical cases: LMD (16%), ACDF (14.5%), cranioplasties (6.6%). The combination of surgeon and anesthesiologist had a significant effect on length of the operation: ACDF (7.6%) and LMD (12.5%). Conclusion: In some procedures types a significant part of the variability in operative time is due to the interaction between the surgeon and anesthesiologist. Reviewing operative records should allow identification of efficient/ inefficient combinations.

BACKGROUND: Many patients experience pain on injection of propofol. The use of lidocaine to prevent propofol injection pain is common. The analgesic effect of preinjected lidocaine has been found to increase when a tourniquet is used. OBJECTIVE: The aim of this study was to compare the effectiveness of various venous occlusion times with lidocaine analgesia to prevent pain during propofol injection. METHODS: In this prospective, randomized, double-blind, controlled study, women aged 18 to 45 years, classifed as American Society of Anesthesiologists physical status I or II, who were scheduled to undergo elective surgery under general anesthesia induced with propofol, were randomly assigned to 1 of 5 groups: group 1, 2% lidocaine 20 mg in saline in a total volume of 10 mL and no venous occlusion; group 2, 2% lidocaine 20 mg in saline in a total volume of 10 mL plus venous occlusion for 15 seconds; group 3, 2% lidocaine plus venous occlusion for 30 seconds; group 4, 2% lidocaine plus venous occlusion for 60 seconds; and group 5, saline 10 mL and no venous occlusion. When the first 25% of the calculated propofol dose was administered, patients were asked about propofol-induced pain using a verbal pain scale (0 no pain; 1 mild pain; 2 moderate pain; and 3 severe pain). All patients and the anesthesiologist who evaluated pain severity were blinded to the study preparation being used. RESULTS: The study comprised 100 women who were randomly divided into 5 groups of 20 patients each. Significantly more patients in group 5 (18 [90%] patients; P < 0.05) reported pain compared with the other treatment groups. In groups 2, 3, and 4, in which venous occlusion was applied, pain was reported during propofol injection in 6 (30%), 7 (35%), and 2 (10%) patients, respectively. The incidence of reported pain was significantly greater in group 1 (lidocaine without venous occlusion) than in group 4 (P < 0.05); however, the incidence of pain was similar in group 1 compared with groups 2 and 3.

Background: Surgical site infection (SSI) is the most prevalent in developing countries where 61-90% of cases develop in-hospital. The study aimed to assess the correctness of antibiotic prophylaxis (AP) use, the incidence of in-hospital SSI, and its determinants. Patients and Methods: A 3-month hospital-based prospective observational study design was used on general surgery patients. The criteria for identification of SSI were performed based on the Center for Disease Control and Prevention's (CDC's) definition of SSI. The correctness of AP was performed based on the American Society of Health System Pharmacist 2013 guideline (ASHP). Multiple stepwise backward logistic regression analysis was used at p-value <0.05 to predict SSI. Results: Of 269 adult patients, the type of admission was almost equal between emergency and elective surgery. The mean (± SD) age of the study participants was 41.95±17.764. Only 19.7% of the study participants used AP correctly. The incidence rate of in-hospital SSI was 16.7% (45/269), which corresponds to 45/4736 or 9.5/1000 person-days. Independent predictors for SSI were American Society of Anesthesiology (ASA) class III-IV (p-value <0.0001), patients with age-adjusted Charlson co-morbidity index (CCI) of ≥1 score (p value=0.008), and incorrect use of AP (p-value =0.025). Conclusion: Incorrect antibiotic prophylaxis use contributed to an increased risk of SSI, which needs urgent attention in the present study area.

Our aim is to present our experience with laparoscopic cholecystectomy (LC) and percutaneous cholecystostomy (PC) in high-risk patients with acute cholecystitis (AC). The guidelines for AC are still debatable for high-risk patients. We aimed to emphasize the role of LC as a primary treatment method in patients with severe AC instead of a treatment after PC according to the Tokyo Guidelines (TG). AC patients with high surgical risk [American Society of Anesthesiologists (ASA) III-IV] who were admitted to our department between March 2008 and November 2014 were retrospectively evaluated. Disease severity in all patients was assessed according to the 2007 TG for AC. Patients were either treated by emergency LC (group LC) or PC (group PC). Demographic data, ASA scores, treatment methods, rates of conversion to open surgery, duration of drainage, length of hospital stay, and morbidity and mortality rates were compared among groups. Age, ASA score, and TG07 severity scores in the PC group...

Background: Surgical complications occur more frequently, are more often preventable, and their consequences can be more severe than other types of complications. Controversy exists how best to identify and predict surgical complications. Several studies on predictive factors for surgical complications focussed on a specific predictor for a specific outcome. In order to develop a reliable tool to identify patients with surgical complications, insight in predictive factors for surgical complications is required. Methods: We searched all publications addressing predictive factors for the development of surgical complications in adult patients admitted to the gastrointestinal, vascular or general surgery departments. Data were extracted regarding study design, patient characteristics, surgical specialty, types of surgical procedures, types of complications, possible predictors, and associated complication risk increase (expressed as an odds ratio; OR). Results: The final set of 30 articles yielded a total of 53 predictive factors studied in various settings, surgical specialties, and disorders. To focus our analysis we selected the 25 most robust and clinically applicable factors (i.e. appearing in 3 or more studies). These factors were then categorized into 4 different groups: Patient-related factors, Comorbidities, Laboratory values, and Surgery-related factors. The most predictive factors for morbidity in these groups were BMI (ORs from 1.80 to 6.30), age (1.02-4.62), ASA classification (1.77-7.10), dyspnea (1.23-1.30), serum creatinine (1.39-2.14), emergency surgery (1.50-2.54) and functional status (1.36-4.07). Conclusion: This review presents a set of factors predictive of surgical complications for general surgical departments. These easily retrievable factors can and should be validated in the specific patient populations of each hospital.

Background The Charlson Comorbidity Index (CCI) has been validated as a predictor of overall survival and post-surgical mortality. CCI is adopted by Tokyo Guidelines as one of the main criteria in the management of acute cholecystitis. Our study evaluates the role of CCI in predicting difficult cholecystectomy. Methods All patients who underwent cholecystectomy for acute cholecystitis between January 2017 and September 2019 were included. CCI, Emergency Surgery Score (ESS), and American Society of Anesthesiologists (ASA) score were calculated and analyzed to assess their predictive value for difficult cholecystectomy. Results A total of 96 patients were included and allocated to difficult and non-difficult cholecystectomy groups. CCI was found to be a significant predictor of difficult cholecystectomy (OR 1.59; 59% CI, 1.04. 2.42; p= 0.031). Similarly, ESS was found to be a predictor tool of difficult cholecystectomy (OR 1.42; 59% CI, 1.05. 1.93; p= 0.024). There was no significant difference in adverse outcomes between the two groups. Conclusion CCI was able to predict a difficult cholecystectomy in our study population. However further studies are required to evaluate if it can be used as a predictor of adverse outcomes in the context of acute cholecystitis.

Background The Charlson Comorbidity Index (CCI) has been validated as a predictor of overall survival and post-surgical mortality. CCI is adopted by Tokyo Guidelines as one of the main criteria in the management of acute cholecystitis. Our study evaluates the role of CCI in predicting difficult cholecystectomy. Methods All patients who underwent cholecystectomy for acute cholecystitis between January 2017 and September 2019 were included. CCI, Emergency Surgery Score (ESS), and American Society of Anesthesiologists (ASA) score were calculated and analyzed to assess their predictive value for difficult cholecystectomy. Results A total of 96 patients were included and allocated to difficult and non-difficult cholecystectomy groups. CCI was found to be a significant predictor of difficult cholecystectomy (OR 1.59; 59% CI, 1.04. 2.42; p= 0.031). Similarly, ESS was found to be a predictor tool of difficult cholecystectomy (OR 1.42; 59% CI, 1.05. 1.93; p= 0.024). There was no significant difference in adverse outcomes between the two groups. Conclusion CCI was able to predict a difficult cholecystectomy in our study population. However further studies are required to evaluate if it can be used as a predictor of adverse outcomes in the context of acute cholecystitis.

Introduction: High mobility group box 1 (HMGB1) is a key mediator of inflammation that is actively secreted by macrophages and/or passively released from damaged cells. The proinflammatory role of HMGB1 has been demonstrated in both animal models and humans, since the severity of inflammatory response is strictly related to serum HMGB1 levels in patients suffering from traumatic insult, including operative trauma. This study was undertaken to investigate HMGB1 production kinetics in patients undergoing major elective surgery and to address how circulating mononuclear cells are implicated in this setting. Moreover, we explored the possible relationship between HMGB1 and the proinflammatory cytokine interleukin-6 (IL-6). Methods: Forty-seven subjects, American Society of Anesthesiologists physical status I and II, scheduled for major abdominal procedures, were enrolled. After intravenous medication with midazolam (0.025 mg/Kg), all patients received a standard general anesthesia protocol, by thiopentone sodium (5 mg/Kg) and fentanyl (1.4 μg/Kg), plus injected Vecuronium (0.08 mg/Kg). Venous peripheral blood was drawn from patients at three different times, t 0 : before surgery, t 1 : immediately after surgical procedure; t 2 : at 24 hours following intervention. Monocytes were purified by incubation with anti-CD14-coated microbeads, followed by sorting with a magnetic device. Cellular localization of HMGB1 was investigated by flow cytometry assay; HMGB1 release in the serum by Western blot. Serum samples were tested for IL-6 levels by ELISA. A one-way repeated-measures analysis ANOVA was performed to assess differences in HMGB1 concentration over time, in monocytes and serum. Results: We show that: a) cellular expression of HMGB1 in monocytes at t 1 was significantly higher as compared to t 0 ; b) at t 2 , a significant increase of HMGB1 levels was found in the sera of patients. Such an increase was concomitant to a significant down-regulation of cellular HMGB1, suggesting that the release of HMGB1 might partially derive from mononuclear cells; c) treatment of monocytes with HMGB1 induced in vitro the release of IL-6; d) at t 2 , high amounts of circulating IL-6 were detected as compared to t 0. Conclusions: This study demonstrates for the first time that surgical/anesthesia trauma is able to induce an early intracellular upregulation of HMGB1 in monocytes of surgical patients, suggesting that HMGB1 derives, at least partially, from monocytes.

Both ketamine and priming may shorten the onset time of rocuronium. This study investigates the effects of ketamine and priming as components of a propofol induction on intubating conditions and onset of neuromuscular block. Methods This prospective randomized double-blind study was performed in 120 American Society of Anesthesiologists (ASA) I-II patients who were assigned to one of four groups of 30 patients each: control, priming, ketamine, and ketamine-priming. Ketamine 0.5 mg Á kg-1 or saline was given before priming and induction. Rocuronium 0.06 mg Á kg-1 or saline was injected 2 min before propofol 2.5 mg Á kg-1. This was followed by rocuronium 0.6 mg Á kg-1 or by rocuronium 0.54 mg Á kg-1 if priming was given. Intubation was performed one minute later. Intubating conditions were graded as excellent, good, or poor. Heart rate, noninvasive blood pressure, and train-offour (TOF) response were monitored. Results Intubating conditions were graded excellent in 20% of the control group, 30% of the priming group, 47% of the ketamine group, and 57% of the ketamine-priming group. Analysis using forward stepwise regression indicated that ketamine improved intubating conditions (P = 0.001) but priming did not (P = 0.35). Time to reach a TOF count of zero was shortened by ketamine (P = 0.001) but not by priming (P = 0.94): 216 ± 20 s in the control group, 212 ± 27 s in the priming group,

Aims The COVID-19 pandemic drastically affected elective orthopaedic services globally as routine orthopaedic activity was largely halted to combat this global threat. Our institution (University College London Hospital, UK) previously showed that during the first peak, a large proportion of patients were hesitant to be listed for their elective lower limb procedure. The aim of this study is to assess if there is a patient perception change towards having elective surgery now that we have passed the peak of the second wave of the pandemic. Methods This is a prospective study of 100 patients who were on the waiting list of a single surgeon for an elective hip or knee procedure. Baseline characteristics including age, American Society of Anesthesiologists (ASA) grade, COVID-19 risk, procedure type, and admission type were recorded. The primary outcome was patient consent to continue with their scheduled surgical procedure. Subgroup analysis was also conducted to define if any specific...

Peritonitis is inflammation of the peritoneum and is most commonly due to a localized or generalized infection. It can be primary, secondary, or tertiary based on the source and nature of microbial contamination. Secondary peritonitis which is due to perforation of the hollow viscus continues to be one of the most common surgical emergencies. Risk factors among the general population include among others, Helicobacter pylori infection, indiscriminate use of steroids and nonsteroidal anti-inflammatory agents, and enteric fever in addition to several other less common causes. This condition most of the times needs an emergency surgical intervention. Since there is lack of data in India regarding its prognostic indicators, morbidity, and mortality patterns, [1] application of a scoring system, is needed to stratify the patients to assess the type and level of care required for a particular patient. Background: Perforation peritonitis continues to be one of the most common surgical emergencies that need a surgical intervention most of the times. Anesthesiologists are invariably involved in managing such cases efficiently in perioperative period. Aims: The assessment and evaluation of Acute Physiology and Chronic Health Evaluation II (APACHE II) score at presentation and 24 h after goal-directed optimization, administration of empirical broad-spectrum antibiotics, and definitive source control postoperatively. Outcome assessment in terms of duration of hospital stay and mortality in with or without optimization was also measured. Settings/Design: It is a prospective, randomized, double-blind controlled study in hospital setting. Materials and Methods: One hundred and one patients aged ≥18 years, of the American Society of Anesthesiologists physical Status I and II (E) with clinical diagnosis of perforation peritonitis posted for surgery were enrolled. Enrolled patients were randomly divided into two groups. Group A is optimized by goal-directed optimization protocol in the preoperative holding room by anesthesiology residents whereas in Group S, managed by surgery residents in the surgical wards without any fixed algorithm. The assessment of APACHE II score was done as a first step on admission and 24 h postoperatively. Duration of hospital stay and mortality in both the groups were also measured and compared. Statistical Analysis: Categorical data are presented as frequency counts (percent) and compared using the Chi-square or Fisher's exact test. The statistical significance for categorical variables was determined by Chi-square analysis. For continuous variables, a two-sample t-test was applied. Results: The mean APACHE II score on admission in case and control groups was comparable. Significant lowering of serial scores in case group was observed as compared to control group (P = 0.02). There was a significant lowering of mean duration of hospital stay seen in case group (9.8 ± 1.7 days) as compared to control group (P = 0.007). Furthermore, a significant decline in death rate was noted in case group as compared to control group (P = 0.03). Conclusion: Goal-directed optimized patients with perforation peritonitis were discharged early as compared to control group with significantly lesser mortality as compared with randomly optimized patients in the perioperative period.

Pregnancy is associated with anatomical and physiological changes leading to potential difficult airway management. Some pregnant women have known difficult airways and cannot be intubated even with a hyperangulated videolaryngoscope. If neuraxial techniques are also impossible, awake tracheal intubation with a flexible bronchoscope may be one of the few available options to avoid more invasive techniques. The Infrared Red Intubation System (IRRIS) may help nonexpert anesthesiologists in such situations and may enhance the chance of successful intubation increasing safety for the mother and the fetus, especially in hospitals without the ear, nose, and throat surgical backup.