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Background Preoperative frailty has been associated with adverse postoperative outcomes. Additionally, low testosterone has been associated with physical frailty and cognitive decline. However, the impact of simultaneous frailty and low testosterone on surgical outcomes is understudied. Methods Preoperative frailty status and testosterone levels were obtained in patients undergoing a diverse range of surgical procedures. Preoperative frailty was evaluated independently and in combination with testosterone through the creation of composite risk groups. Relationships between preoperative frailty and composite risk groups with overall survival were determined using Kaplan–Meier and logistic regression analyses. Bivariate analysis was used to determine the associations between frailty and testosterone status on postoperative complications, length of hospital stay, and readmission rates. Results Median age of the cohort was 63 years, and the median follow-up time was 105 weeks. Thirty-one patients (23%) were frail, and 36 (27%) had low free testosterone. Bivariate analysis demonstrated a statistically significant relationship between preoperative frailty and overall survival (P = .044). In multivariate analysis, coexisting frailty and low free testosterone were significantly associated with decreased overall survival (hazard ratio 4.93, 95% confidence interval, 1.68–14.46, P = .004). Conclusion We observed preoperative frailty, both independently and in combination with low free testosterone levels, to be significantly associated with decreased overall survival across various surgical procedures. Personalizing the surgical risk assessment through the incorporation of preoperative frailty and testosterone status may serve to improve the prognostication of patients undergoing major surgery., Highlights • Both frailty (P = .015) and low free testosterone (P = .005) were independently associated with 1-year mortality. • After stratifying our cohort into 4 composite groups based on frailty and testosterone status, frail patients with low free T had the shortest overall survival when compared to the reference group, with nearly a 5-fold higher risk of death.

Made available in DSpace on 2022-04-28T16:56:17Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-08-09. Added 1 bitstream(s) on 2022-04-28T17:11:34Z : No. of bitstreams: 1 S2352-22912021000600649.pdf: 745498 bytes, checksum: 57cb064d535f8c0582912fbc4dff37a1 (MD5) Fundação de Amparo a Pesquisa do Estado de São Paulo Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) The International Association for the Study of Pain chose pain prevention as the theme for the 2020 Global Year. Chronic postoperative pain is one the many types of pain that can be potentially prevented. It develops or increases in severity after a surgery, persists for at least three months, even after ruling out all other possible causes of pain. To perform the present narrative review, the authors searched the PubMed database using the following keywords “postoperative pain” OR “postsurgical pain” AND “chronic” OR “persistent”. The present review focused on the incidence, pain development and chronification, and predisposing factors. It also discusses prevention, diagnosis, and treatment of chronic postoperative pain. Awareness of occurrence of chronic postoperative pain and recognizing risk factors is crucial for the day-to-day practice of the anesthesiologist. Hence, numerous surgical patients can have their outcome improved by preventing chronic postoperative pain, a condition scarcely identified and without a well-established treatment. Universidade Estadual Paulista, Departamento de Especialidades Cirúrgicas e Anestesiologia Universidade Federal de Santa Maria, Departamento de Cirurgia Universidade Estadual Paulista, Departamento de Especialidades Cirúrgicas e Anestesiologia Fundação de Amparo a Pesquisa do Estado de São Paulo: 2016/16158-0 CAPES: 001

Background: Current intensive care unit physician-staffing (IPS) models for postoperative cardiac surgery have not been previously investigated in Canada. The purpose of this study was to determine current IPS models at 2 time points and describe the evolution of Canadian cardiac surgery IPS models. Methods: A survey of 32 Canadian cardiovascular intensive care units (CVICUs) was undertaken in 2012 and 2017 to determine IPS models of care during “daytime” and “after-hours” in each unit. Data were collected regarding surgical volume, base specialties, and style of IPS management (“open”; “semi-open”; “closed”). In addition, we collected the overnight experience level of the bedside healthcare provider for in-house intensive care units. Results: Survey responses were received from 27 of 32 CVICUs (87%). As of 2017, the style of 1 (4%) was open, 7 (26%) were semi-open, and 19 (70%) were closed in their unit IPS strategy. Base specialties of CVICU physicians varied. A medical doctor provided after-hours coverage in 81% of CVICUs. Senior residents (37%) or critical care certified attending staff (25%) typically provided after-hours coverage for in-house CVICUs. Linked Canadian Institute for Health Information data did not indicate a difference among CVICU models in mortality or rehospitalization for coronary artery bypass graft or valve procedures. Conclusions: Considerable heterogeneity is demonstrated in CVICU staffing patterns. No consensus was identified regarding the appropriate level of training for “after-hours” coverage. In-house overnight physician staffing in CVICUs varies widely. Finally, semi-open and closed style models did not demonstrate differences compared to Canadian Institute for Health Information data. Variability among CVICUs does exist; however, benefits of one model over another have not been identified. Résumé: Introduction: Les modèles actuels de dotation en médecins aux soins intensifs (DMSI) postopératoires de chirurgie cardiaque n’ont pas fait l’objet d’études antérieures au Canada. L’objectif de la présente étude était de déterminer les modèles actuels de DMSI à deux points temporels et de décrire l’évolution des modèles de DMSI de chirurgie cardiaque au Canada. Méthodes: Nous avons entrepris une enquête auprès de 32 unités de soins intensifs cardiovasculaires du Canada (USICC) en 2012 et en 2017 pour déterminer les modèles de soins DMSI « pendant la journée » et « après les heures normales » dans chaque unité. Nous avons collecté les données relatives au volume d’interventions chi- rurgicales, aux spécialités de base et au style de gestion de la DMSI (« ouvert », « semi-ouvert », « fermé »). De plus, nous avons collecté les données sur le niveau d’expérience de nuit des prestataires de soins au chevet des patients des unités intégrées de soins intensifs. Résultats: Nous avons reçu les réponses à l’enquête de 27 des 32 USICC (87 %). Depuis 2017, le style de 1 (4 %) USICC était ouvert, de 7 (26 %) était semi-ouvert et de 19 (70 %) était fermé dans leur stra- tégie de DMSI à l’unité. Les spécialités de base des médecins de l’USICC variaient. Un docteur en médecine offrait ses services après les heures normales dans 81 % des USICC. Les résidents chevronnés (37 %) ou les médecins titulaires agréés en soins aux patients en phase critique (25 %) offraient habituellement leurs services après les heures normales aux USICC intégrées. Les données liées de l’Institut canadien d’information sur la santé n’indiquaient pas de différence entre les modèles des USICC en ce qui a trait à la mortalité ou à la réhospitalisation en raison de pontages aortocoronariens ou d’interventions valvulaires. Conclusions: Les modèles de dotation en personnel aux USICC démontrent une importante hétérogénéité. Aucun consensus n’a été établi quant au niveau approprié de formation pour les services offerts « après les heures normales ». Le personnel médical de nuit à l’interne des USICC varie grandement. Finalement, les modèles de styles semi-ouverts et fermés ne démontraient pas de différence par rapport aux données de l’Institut canadien d’information sur la santé. Une variabilité existe entre les USICC. Toutefois, les avantages d’un modèle par rapport à un autre n’ont pas été définis.

Background: We hypothesised that in acute high-risk surgical patients, a lower intraoperative peripheral perfusion index (PPI) would indicate a higher risk of postoperative complications and mortality. Methods: This retrospective observational study included 1338 acute high-risk surgical patients from November 2017 until October 2018 at two University Hospitals in Denmark. Intraoperative PPI was the primary exposure variable and the primary outcome was severe postoperative complications defined as a Clavien–Dindo Class ≥III or death, within 30 days. Results: intraoperative PPI was associated with severe postoperative complications or death: odds ratio (OR) 1.12 (95% confidence interval [CI] 1.05–1.19; P0.5, P=0.003. If PPI was ≤1.5, 30-day mortality was 16% vs 8% in patients with a PPI >1.5 (PConclusions: Low intraoperative PPI was associated with severe postoperative complications or death in acute high-risk surgical patients. To guide intraoperative haemodynamic management, the PPI should be further investigated.

Background Operation notes often have omissions and are difficult to locate in patients notes despite clear guidance from the Royal College of Surgeons (RCS) 'Good Surgical Practice' 2014 outlining what should be included in operation notes. Procedure-specific proformas are rarely used by Plastic surgeons despite being utilised by other specialities. With an alarming rise of incidence of skin malignancies there has been an increase in the number of skin lesions referred to Plastic surgeons for excision. The need for reliable, reproducible, accurate and easily accessible operating notes for skin lesion excision is pivotal for continuity of care and treatment planning. This study aimed at comparing the quality of skin lesion operation notes prior-to and after implementation of a procedure-specific proforma in relation to RCS recommendations. Methods Fourteen parameters from the recommendations by the RCS ‘Good Surgical Practice’ 2014 guidelines were used to audit skin lesion operation notes. The study consisted of a retrospective audit of 80 operation notes and a prospective audit of 80 operation notes following the development and implementation of a skin lesion procedure-specific proforma. We assessed and compared the operation notes overall compliance with the RCS guidelines. Statistical analysis highlighting the difference between both groups was performed using the independent sample t-test. Results After implementation of the skin lesion procedure-specific proforma, the average compliance with the RCS recommendations increased significantly from 87.5% retrospectively to 98.8% prospectively (p-value 0.0414). In 6 of the 14 parameters assessed significant improvements with regards compliance to the guidelines was demonstrated. Conclusion The development and implementation of a skin lesion procedure-specific proforma has demonstrated a significant improvement in the quality of operation notes within a Plastic surgery department which has the potential to minimise omissions and improve continuity of surgical patient care.

Background Early intraoperative hypotension (eIOH) is a common complication of general anesthesia and is significantly associated with postoperative morbidity and mortality. The incidence of eIOH was high, especially in resource-limited settings. Identifying the factors associated with the occurrence of eIOH might allow avoidance and planning of a timely treatment of it. Objective To assess the incidence of early intraoperative hypotension and its associated factors among surgical patients undergoing Surgical procedures under general anesthesia at XX Comprehensive Specialized Hospital, North-central Ethiopia, 2021. Methods A total of 424 surgical patients under general anesthesia were included in this prospective observational study. The data were collected by a structured questionnaire. Variables with p-values of less than 0.2 in the bivariable logistic regression were fitted to multivariable logistic regression. Data was presented in odds ratios with a 95% confidence interval. Descriptive statistics were used to summarize data. Results The incidence of early intra-operative hypotension (eIOH) was 21.2%. In this study older age (age≥ 60 years) (AOR: 2.063 (95% CI;1.194, 3.563)), ASA physical status (AOR: (II2.259 (95% CI;1.229, 4.153)), III(AOR: 2.810 (95% CI;1.319, 5.986)), a BMI of 25–29.9 kg/m2 (AOR: 2.098 (1.128, 3.901), a BMI of ≥30 kg/m2 (AOR: 3.090 (95% CI;1.324, 7.210)), emergency surgical procedures (AOR: 2.215 (95% CI;1.287, 3.810)), the estimated blood loss greater than 500 ml (AOR: 2.510 (95% CI;1.478, 4.261)) were found to be independent factors of eIOH. Conclusion This study revealed that the incidence of eIOH was high (21.2%). Older age, ASA II and III, BMI ≥25, emergency surgical procedures, and a significant amount of blood loss (EBL ≥500 ml) were the main predictors of an increased occurrence of eIOH., Highlights • Early intraoperative hypotension is associated with postoperative morbidity and mortality. • Emergency surgical procedures, and a significant amount of blood loss are the main predictors of an increased occurrence of eIOH. • Thyroidectomy has a relatively short duration and less amount of estimated blood loss when compared to major surgical procedures. • The occurrence of eIOH after general anesthesia for general surgery is a common problem. • Arterial hypotension in patients undergoing surgery under general anesthesia usually described by the very general term intraoperative hypotension.

BACKGROUND: It is unclear how preoperative neurodegeneration and postoperative changes in EEG delta power relate to postoperative delirium severity. We sought to understand the relative relationships between neurodegeneration and delta power as predictors of delirium severity. METHODS: We undertook a prospective cohort study of high-risk surgical patients (>65 yr old) to identify predictors of peak delirium severity (Delirium Rating Scale-98) with twice-daily delirium assessments (NCT 03124303). Participants (n=86) underwent preoperative MRI; 54 had both an MRI and a postoperative EEG. Cortical thickness was calculated from the MRI and delta power from the EEG. RESULTS: In a linear regression model, the interaction between delirium status and preoperative mean cortical thickness (suggesting neurodegeneration) across the entire cortex was a significant predictor of delirium severity (P

Background Several devices record and interpret patient brain activity via electroencephalogram (EEG) to aid physician assessment of anaesthetic effect. Few studies have compared EEG monitors on data from the same patient. Here, we describe a set-up to simultaneously compare the performance of three processed EEG monitors using pre-recorded EEG signals from older surgical patients. Methods A playback system was designed to replay EEG signals into three different commercially available EEG monitors. We could then simultaneously calculate indices from the SedLine® Root (Masimo Inc., Irvine, CA, USA; patient state index [PSI]), bilateral BIS VISTA™ (Medtronic Inc., Minneapolis, MN, USA; bispectral index [BIS]), and Datex Ohmeda S/5 monitor with the Entropy™ Module (GE Healthcare, Chicago, IL, USA; E-entropy index [Entropy]). We tested the ability of each system to distinguish activity before anaesthesia administration (pre-med) and before/after loss of responsiveness (LOR), and to detect suppression incidences in EEG recorded from older surgical patients receiving beta-adrenergic blockers. We show examples of processed EEG monitor output tested on 29 EEG recordings from older surgical patients. Results All monitors showed significantly different indices and high effect sizes between comparisons pre-med to after LOR and before/after LOR. Both PSI and BIS showed the highest percentage of deeply anaesthetised indices during periods with suppression ratios (SRs) > 25%. We observed significant negative correlations between percentage of suppression and indices for all monitors (at SR >5%). Conclusions All monitors distinguished EEG changes occurring before anaesthesia administration and during LOR. The PSI and BIS best detected suppressed periods. Our results suggest that the PSI and BIS monitors might be preferable for older patients with risk factors for intraoperative awareness or increased sensitivity to anaesthesia.

Oral anticoagulants (OACs) are a class of medications commonly used in the long-term management of patients at risk of thrombosis. They include warfarin and direct oral anticoagulants (DOACs). The aging of the population and improvements in perioperative care have led to an increase in the number of patients on OACs and presenting for different types of elective and emergency surgery. Perioperative management of OACs constitutes a unique challenge. It is based on the quantification of a patient's individual hemorrhagic and thrombotic risk together with the intrinsic surgical bleeding risk. We reviewed current guidelines to define effective discontinuation of OACs, the need for bridging with different anticoagulants, and post-surgery OACs re-initiation. We also discussed the option for acute reversal of anticoagulation.

Background Patient-reported outcome measures (PROMs) have become increasingly important in assessing clinical outcomes. However, acquisition of data at routine time intervals can be challenging. The ability of e-mail reminders to save follow-up intervals when office visits are missed is unknown. Materials and Methods A retrospective review of a consecutive series of 186 shoulder surgical patients who underwent surgery between October 2, 2012, and July 2, 2013, was conducted. Simple Shoulder Test and 12-Item Short Form Health Survey scores were completed at preoperative visits using office-based tablet surveys. Patients were observed for completeness of PROMs at expected routine follow-up of 1 year and 2 years. When office visits were missed, e-mail reminders with links to online surveys were sent to patients without further incentives. Improvement in data acquisition achieved using e-mail reminders when patient follow-up was missed was assessed. The influence of the procedure performed was further analyzed to determine whether patients treated with different surgical procedures would be more compliant with PROM completion. Results Use of e-mail reminders significantly increased the number of patients for whom complete follow-up data were obtained. Compared with tablet surveys completed during office visits alone, the addition of e-mail reminders increased the collection of complete PROM data (both 1- and 2-year follow-up) by 25.8% (P

Surgical multimodal strategies encompass a bundle of attitudes that should be carried out to improve patients' outcomes after the operation, while promoting a better recovery and quality of life (Wilmore, 2002; Fearon et al., 2005). It has also been shown that the adoption of multimodal strategies leads to health care savings (Gramlich et al., 2017) ( Chapter 22 ). The fundamental foundation for these initiatives is to reach the adequate balance after injury by ameliorating the organic response to stress. Throughout this book, many of these strategies have been discussed in separate chapters due to its relevant direct impact on metabolism, inflammation, immune response, and nutrition status. However, the integral approach of the surgical patient would not be complete if the topics covered in the current chapter were not discussed as well because they also impact the metabolic milieu of the patients. Multimodal strategies aim at enhancing the patients' recovery phase, by decreasing the risk for postoperative complications related to the individual's overall clinical status (Wilmore, 2002). The adoption of such initiatives should be tackled before the surgical act, but many of them can also be applied in urgent/emergent cases. The more the steps of the bundle adopted, the higher the probability of better results. The interdisciplinary team approach certainly facilitates the adoption of more steps of these initiatives (Herbert et al., 2017; Kahokehr et al., 2017).

Most surgical patients are able to resume oral diets in a short period of time after the operation, thus nutritional therapy might not be needed, in particular, if the patients are well-nourished and the nutritional intake fulfills the requirements or are at least 70% (for no longer than 7 days). However, malnutrition in surgical patients is approximately 50% (Correia et al., 2001; Ferreira et al., 2013; Mauricio et al., 2017), and in this regard, not only preoperative nutrition care is important but also postoperative care because nutritional deficiencies increase the risk of adverse events and mortality (Tobert et al., 2017; van der Kroft et al., 2018; Vashi et al., 2013). Furthermore, it is currently known that providing early oral or enteral diet to patients undergoing major procedures, independently of the nutritional status, may modulate the inflammatory/organic response to trauma, leading to better outcomes (Binkowska et al., 2015).

Surgery impacts patients not only physically but also emotionally. In this regard, anxiety and fear are dominant feelings, especially preoperatively, and the waiting period for the procedure further imposes stressful stimulus which triggers the organic response to trauma even before the surgical act is performed ( Chapter 2 ). Furthermore, the fear of temporary disability, pain, and death causes significant psychological stress. Stress responses compromise the ability for the patient to cooperate and may lead to sleep disruption, delayed gastric emptying with the concomitantly higher risk of aspiration, and a negative quality of life. Therefore, attitudes that may ameliorate or decrease surgical anxiety should be adopted to minimize the exacerbated organic response to stress that negatively interferes with postoperative outcomes. Considering that more than 51 million operative procedures are carried out every year in the United States of America and that 4.6 million hospital admissions per year, in England, lead to surgical care, it's essential to identify potential ways of decreasing anxiety and fear, which trigger stress responses and negatively impact surgical outcomes. Music was first described in surgical patients by Evan Kane, in 1914 (Hole et al., 2015), but despite the number of studies reporting its advantages in the hospital setting, in particular, for the surgical patient (Hole et al., 2015; Gallagher et al., 2018; Yaman Aktas, 2016; Hutter et al., 2015; Jimenez-Jimenez et al., 2013) as ways of decreasing pain, anxiety, and fear, music has not been implemented as a routine practice to help patients overcome the psychological distress of surgery. It is an inexpensive technique and easy to be implemented; however, few centers and health care professionals have adopted it as an integral part of surgical care.

Probiotics (live microorganisms that when administered in adequate amounts, confer a health benefit on the host) have been considered the good bugs (Guarino et al., 2013) because of their favorable role under various stressful situations. In surgery, they have also been used as a way to potentially decrease postoperative infections. A combination of probiotics with prebiotics (a substrate that is selectively utilized by host microorganisms conferring a health benefit) constitutes the symbiotics (Gibson et al., 2017), which have also been reported to decrease infection complications in surgical patients (Fujita, 2008; Bengmark, 2005). Patients undergoing major operations are at a high risk of surgical site infections, in particular, if they are malnourished, immunosuppressed, related to other comorbidities (diabetes, in use of steroids, etc.), and mainly when undergoing procedures that are clean-contaminated, contaminated, or infected. Infections may affect up to 50% of those individuals with infected procedures, or 30% of those undergoing gastrointestinal procedures, and up to 60% of patients with pancreatic resections (Rammohan et al., 2015; Bohl et al, 2016; Kamath et al., 2016). Despite the important advances in surgical care, sepsis secondary to postoperative complications is still a serious problem accounting for one-third of the sepsis cases in the United States of America (Hadley, 2014; Moore et al., 2011; Wafaisade et al., 2011). Patients with infections have twice higher mortality rates, and data have indicated that there are 39% death rates among emergent operations and 30% for elective surgical patients (Arumugam et al., 2016). Length of hospital stay is longer, altogether representing extra costs for the health care system (Schweizer et al., 2014).

The nutritional status of surgical patients has been shown to impact outcomes since the classical study by Studley (Studley, 1936), in which he showed that patients who had lost more than 20% of the usual body weight before peptic ulcer surgery presented with increased mortality. Several studies enrolling patients who undergo different surgical procedures have corroborated this observation, and although no clinical randomized study has been carried out, which would be absolutely unethical, the relationship between the nutritional status and morbidity, mortality, costs, and length of hospital stay has been well shown. Therefore, it is highly recommended that patients who will undergo surgery, in particular, complex procedures, should be nutritional screened and assessed. If the patient is malnourished, nutrition therapy, while preparing the patient for the surgical act, should be carried out. The goal of nutrition therapy in surgical patients is specially directed to the provision of substrates for the body to be able to adequately face the organic response and also to improve wound healing. In this regard, it is not expected to have the patient fully recover his/her previous nutritional status and also to gain weight by recovering body compartments. This happens late in the course of nutritional replenishment with updated assessment of the requirements. In this regard, it is noteworthy to point out that the nutritional requirements should be individually tailored according to the nutritional and metabolic status of the patient.

Introduction: Venous thromboembolism (VTE) is a disease manifested as deep vein thrombosis and pulmonary embolism. General surgical procedures are associated with significant risk of precipitating VTE, and despite the surging evidences, it is often overlooked. The study attempted at estimating the prevalence of VTE and bleeding risk factors coupled with the adequacy of thromboprophylaxis administered. Methodology: The study spanning 1-year duration was executed through collection of data from patients older than 18 years, admitted to the general surgery department of a tertiary care hospital. The data were collected using internally validated data collection form and the appraisal of data was done using SPSS 18. Results: Among the 400 subjects enrolled, number of patients in low, moderate, and high risk, as per the Caprini score, was 24%, 35%, and 41%, respectively, with the difference being significant with p

This chapter addresses the preoperative assessment of surgical patients in terms of relevant history, including medication history and examination, as well as preoperative testing in order to assess risk of bleeding as well as take steps to minimize bleeding during the intraoperative and postoperative periods. Among preoperative testing, coagulation-based testing, blood bank testing and tests for liver and renal function are also discussed. Appropriate steps, such as holding various medications prior to surgery and administration of various blood products and other pharmacotherapeutic agents, are also addressed.

Pulmonary artery catheter is an invasive monitor usually placed in high-risk cardiac surgical patients to optimize the cardiac functions. We present this case of blood oozing from the oximetry connection port of the pulmonary artery catheter that resulted in the inability to monitor continuous cardiac output requiring replacement of the catheter. The cause of this abnormal bleeding was later confirmed to be due to a manufacturing defect. Resumo: O cateter de artéria pulmonar é um monitor invasivo geralmente usado durante cirurgias cardíacas em pacientes de alto risco para otimizar as funções cardíacas. Apresentamos o caso de escoamento de sangue pela porta de conexão do cateter de artéria pulmonar para oximetria que resultou na impossibilidade de monitorar o débito cardíaco contínuo e na substituição do cateter. A causa do sangramento anormal foi posteriormente confirmada como um defeito de fabricação. Keywords: Pulmonary artery catheter, Bleeding, Oximetry port, Palavras-chave: Cateter de artéria pulmonar, Sangramento, Porta oximétrica

Most people think of hospitals as places for healing. But the threat of violence—which can take many forms—can be a daily reality for nurses and other healthcare workers. The issue of violence in healthcare gained national attention in September 2010 when a doctor at Johns Hopkins Hospital was shot by the distraught son of a surgical patient. The event was a stark reminder to security professionals and hospital administrators that healthcare facilities are increasingly treating sicker and poorer patients and are rife with all sorts of emotions, both obvious and hidden that support what healthcare professionals have been concerned about for years. Acts of patient-generated violence are an industry-wide problem and can happen anywhere in the healthcare delivery system. This chapter focuses on the problem of violence in healthcare, the behaviors that undermine a culture of safety and discusses what healthcare facilities can do to combat the intimidating and disruptive behaviors that need to change the culture of tolerance prevalent in many healthcare facilities.

Background The escalation of care process has not been explored in surgery, despite the role of communication failures in adverse events. This study aimed to develop a conceptual framework of the influences on escalation of care in surgery allowing solutions to facilitate management of sick patients to be developed. Methods A multicenter qualitative study was conducted in three hospitals in London, UK. A total of 41 participants were recruited, including 16 surgeons, 11 surgical PGY1s, six surgical nurses, four intensivists, and four critical care outreach team members. Participants were submitted to semistructured interviews that were analyzed using grounded theory methodology. Results A decision to escalate was based upon five key themes: patient, individual, team, environmental, and organizational factors. Most participants felt that supervision and escalation of care were problematic in their hospital, with unclear escalation protocols and poor availability of senior surgical staff the most common concerns. Mobile phones and direct conversation were identified to be more effective when escalating care than hospital pager systems. Transparent escalation protocols, increased senior clinician supervision, and communication skills training were highlighted as strategies to improve escalation of care. Conclusion This is the first study to describe escalation of care in surgery, a key process for protecting the safety of deteriorating surgical patients. Factors affecting the decision to escalate are complex, involving clinical and professional aspects of care. An understanding of this process could pave the way for interventions to facilitate escalation in order to improve patient outcome.

Within the spectrum of intra-abdominal infection, secondary peritonitis is the most common condition confronted by surgeons. The scores available to assess severity of illness are unable to reconcile the needs of the individual surgeon and the demands of clinical researchers studying these patients. Considering their aim, the medical scenarios and conditions for which they were devised, the manner in which the variables of interest were selected, and their applicability, this chapter discusses 11 of the scores most frequently cited in the MEDLINE data base. Considering the diversity of conditions, the moment and place of the evaluation, and the limitations of each score, the chapter makes suggestions for their use and invites further discussion in this changing field.

Although numerous studies exist about infection risk stratification of surgical patients, a comprehensive assessment of the postoperative infection risk of patients seems to be lacking. A microbiological assessment of the surgical patient before surgery, performed to identify infection risks and take adequate and appropriate steps to minimize those risks, is not possible without a holistic assessment of numerous medical, surgical, microbiological and organizational factors. In the present chapter an extensive list of patient and organizational factors which may directly or indirectly lead to postoperative infections have been highlighted, drawing on facts and figures from a wide range of references. It is emphasized that infection prevention in surgical patients requires a multi-disciplinary team approach, in which the contributions of a wide spectrum of resources and systems come into play, ranging from the cleanliness of the hospital environment to the competence of surgeons. Common infection control tools such as hand hygiene, skin disinfection, or adequate antibiotic prophylaxis are necessary but not sufficient conditions for prevention of surgical site infections.

New noninvasive MR imaging techniques are currently deeply changing the exploration of epileptic and functional networks in childhood epilepsies, as well as of the normally developing brain. While DTI can be used to look at the anatomical connectivity and at the microstructural changes that reflect the organization of an epileptic network, in addition to other techniques such as SPECT and PET, functional MRI is nowadays used routinely in the presurgical planning of focal epilepsies to assess the cortical organization of motor and language networks, helping to select surgical patients and plan the resection. Precise and robust motor mapping can be obtained in children comparably to adults. The assessment of language dominance by fMRI has reduced the need for invasive techniques such as the Wada test, provided age-related paradigms are being used in cooperating children (from 5 to 6 years of developmental age, with IQs of at least 60, and without behavioral disorders). Recent data indicate that the localizing value of language fMRI might be good when compared to cortical stimulation, and memory fMRI is emerging in children. However, invasive techniques are still necessary in difficult cases with high risk of postoperative deficit.