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1.  Is ASA classification useful in risk stratification for endoscopic procedures? 
Gastrointestinal endoscopy  2013;77(3):10.1016/j.gie.2012.11.039.
The American Society of Anesthesiologists’ (ASA) physical status classification is a measurement of co-morbidity and is a predictor of peri-operative morbidity and mortality.
To assess the predictive ability of the ASA class for peri-endoscopic adverse events
retrospective cohort analysis
74 sites in the USA comprised of academic, community/HMO and VA/Military practices affiliated with the Clinical Outcomes Research Initiative (CORI) database
≥ 18 years who underwent an endoscopic procedure between 2000–2008
EGD, colonoscopy, flexible sigmoidoscopy, ERCP
Main outcome measurements
immediate adverse event requiring an unplanned intervention
A total of 1,590,648 endoscopic procedures were performed on 1,318,495 unique patients. The majority of patients were designated as ASA class I or II (I: 27%, II: 63%). An immediate adverse events occurred in 0.35% of all endoscopic procedures (n=5,596) and was proportionally highest for ERCPs (1.84%). Increasing ASA class was associated with higher prevalence and a stepwise increase in the odds ratio of serious adverse events for EGD (II: 1.54 [95% CI 1.31–1.82]; III: 3.90 [95% CI 3.27–4.64]; IV/V: 12.02 [95% CI 9.62–15.01]); and colonoscopy COL (II: 0.92 [95% CI 0.85–1.01]; III: 1.66 [95% CI 1.46–1.87]; IV/V: 4.93 [95% CI 3.66–66.3]). This trend was not significant for FS and ERCP.
retrospective, end point is a surrogate for peri-procedure morbidity
ASA class is associated with increased risk of adverse events at endoscopy, particularly for EGD and colonoscopy. It is useful in endoscopic risk stratification and is an important quality indicator for endoscopy.
PMCID: PMC3816502  PMID: 23410699
ASA class; endoscopy; adverse events; complications; risk stratification; CORI
2.  “Timed Up & Go”: A Screening Tool for Predicting 30-Day Morbidity in Onco-Geriatric Surgical Patients? A Multicenter Cohort Study 
PLoS ONE  2014;9(1):e86863.
To determine the predictive value of the “Timed Up & Go” (TUG), a validated assessment tool, on a prospective cohort study and to compare these findings to the ASA classification, an instrument commonly used for quantifying patients’ physical status and anesthetic risk.
In the onco-geriatric surgical population it is important to identify patients at increased risk of adverse post-operative outcome to minimize the risk of over- and under-treatment and improve outcome in this population.
280 patients ≥70 years undergoing elective surgery for solid tumors were prospectively recruited. Primary endpoint was 30-day morbidity. Pre-operatively TUG was administered and ASA-classification was registered. Data were analyzed using multivariable logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (95%-CI). Absolute risks and area under the receiver operating characteristic curves (AUC’s) were calculated.
180 (64.3%) patients (median age: 76) underwent major surgery. 55 (20.1%) patients experienced major complications. 50.0% of patients with high TUG and 25.6% of patients with ASA≥3 experienced major complications (absolute risks). TUG and ASA were independent predictors of the occurrence of major complications (TUG:OR 3.43; 95%-CI = 1.14–10.35. ASA1 vs. 2:OR 5.91; 95%-CI = 0.93–37.77. ASA1 vs. 3&4:OR 12.77; 95%-CI = 1.84–88.74). AUCTUG was 0.64 (95%-CI = 0.55–0.73, p = 0.001) and AUCASA was 0.59 (95%-CI = 0.51–0.67, p = 0.04).
Twice as many onco-geriatric patients at risk of post-operative complications, who might benefit from pre-operative interventions, are identified using TUG than when using ASA.
PMCID: PMC3901725  PMID: 24475186
3.  Risk factors for intraoperative hypotension during thyroid surgery 
Hypotension is a common adverse effect of IV anaesthetics, especially during the induction of anaesthesia. The aim of our study was to determine the incidence and risk factors for intraoperative hypotension (IOH) in thyroid surgery, as well as to determine whether and to what extent IOH affects the occurrence of postoperative hypotension.
The study included 1252 euthyroid patients, ASA 2 and ASA 3 status (American Society of Anesthesiologists physical status classification), who had thyroid surgery between 2007 and 2011. IOH was defined as a decrease in systolic blood pressure of >20% of baseline values. We studied the influence of demographic characteristics (sex, age, body mass index-BMI), comorbidity, type and duration of surgery, and anaesthesia on the occurrence of IOH. Univariate and multivariate logistic regression were used to determine predictors of occurrence of IOH.
IOH was registered in 6.5% of patients. The most common operation was thyroidectomy. Patients with IOH were younger, had lower BMI, and significantly less often had hypertension as a coexisting disease. The multivariate regression model identified BMI and the absence of hypertension as a coexisting disease, and as independent predictors of occurrence of IOH. Significantly more patients with IOH had postoperative hypotension (9.9% vs. 2.4%, p=0.000).
IOH is common, even during operations of short duration and with minimal bleeding. It is necessary to pay special attention to these patients, given that many of these patients remained hypotensive during the postoperative period.
PMCID: PMC3659157  PMID: 23548975
predictors; intraoperative; hypotension; thyroid gland; surgery
4.  Postresectional lung injury in thoracic surgery pre and intraoperative risk factors: a retrospective clinical study of a hundred forty-three cases 
Acute respiratory dysfunction syndrome (ARDS), defined as acute hypoxemia accompanied by radiographic pulmonary infiltrates without a clearly identifiable cause, is a major cause of morbidity and mortality after pulmonary resection. The aim of the study was to determine the pre and intraoperative factors associated with ARDS after pulmonary resection retrospectively.
Patients undergoing elective pulmonary resection at Adnan Menderes University Medical Faculty Thoracic Surgery Department from January 2005 to February 2010 were included in this retrospective study. The authors collected data on demographics, relevant co-morbidities, the American Society of Anesthesiologists (ASA) Physical Status classification score, pulmonary function tests, type of operation, duration of surgery and intraoperative fluid administration (fluid therapy and blood products). The primary outcome measure was postoperative ARDS, defined as the need for continuation of mechanical ventilation for greater than 48-hours postoperatively or the need for reinstitution of mechanical ventilation after extubation. Statistical analysis was performed with Fisher exact test for categorical variables and logistic regression analysis for continuous variables.
Of one hundred forty-three pulmonary resection patients, 11 (7.5%) developed postoperative ARDS. Alcohol abuse (p = 0.01, OR = 39.6), ASA score (p = 0.001, OR: 1257.3), resection type (p = 0.032, OR = 28.6) and fresh frozen plasma (FFP)(p = 0.027, OR = 1.4) were the factors found to be statistically significant.
In the light of the current study, lung injury after lung resection has a high mortality. Preoperative and postoperative risk factor were significant predictors of postoperative lung injury.
PMCID: PMC2936288  PMID: 20716368
5.  Decisions to operate: the ASA grade 5 dilemma 
Deciding to operate on high risk patients suffering catastrophic surgical emergencies can be problematic. Patients are frequently classed as American Society of Anesthesiologists (ASA) grade 5 and, as a result, aggressive but potentially lifesaving intervention is withheld. The aim of our study was to review the short-term outcomes in patients who were classed as ASA grade 5 but subsequently underwent surgery despite this and to compare the ASA scoring model to other predictors of surgical outcome.
All patients undergoing emergency surgery with an ASA grade of 5 were identified. Patient demographics, indications for surgery, intraoperative findings and outcomes were recorded. In addition to the ASA scores, retrospective Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P POSSUM) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated and compared to the observed outcomes.
Nine patients (39%) survived to discharge. ASA grade was a poor predictor of outcome. P POSSUM and APACHE II scores correlated significantly with each other and with observed outcomes when predicting surgical mortality. The median stay for survivors in the intensive care unit was nine days.
In times of an ageing population, the number of patients suffering catastrophic surgical events will increase. Intervention, with little hope of a cure, a return to independent living or an acceptable quality of life, leads to unnecessary end-of-life suffering for patients and their relatives, and consumes sparse resources. The accuracy and reliability of ASA grade 5 as an outcome predictor has been questioned. P POSSUM and APACHE II scoring systems are significantly better predictors of outcome and should be used more frequently to aid surgical decision-making in high risk patients.
PMCID: PMC3365453  PMID: 21943459
ASA 5; Outcome prediction scores; P POSSUM
6.  Evaluation of Four Risk-Scoring Methods to Predict Long-Term Outcomes in Patients Undergoing Aorto-Bifemoral Bypass for Aorto-Iliac Occlusive Disease 
This study was done to determine the usefulness of the American Society of Anesthesiologists (ASA) classification, the comorbidity Charlson index unadjusted (CCIu),the comorbidity Charlson index adjusted by age (CCIa), and the Glasgow aneurysm score (GAS) for postoperative morbimortality and survival in patients treated with aorto-bifemoral bypass (AFB) for aorto-iliac occlusive disease (AIOD). A series of 278 patients who underwent AFB were restrospectively studied. For the CCIu, CCIa, ASA, and GAS, receiver operating characteristics curve analysis for prediction of morbidity showed area under the curves of 0.61 (p = 0.004), 0.59 (p = 0.026), 0.569 (p = 0.087), and 0.63 (p = 0.001), respectively. Additionally, univariate analysis showed that CCIa (p = 0.016) and GAS (p = 0.006) were associated significantly with an increased risk of developing complications. Furthermore, CCIa (p < 0.001) and GAS (p = 0.001) showed a significant association with survival. Finally, the variable age was related to morbidity (p = 0.004), mortality (p = 0.038), and survival (p < 0.001). The comorbididity and the age should be taken in account in clinical treatment decisions for patients with AIOD. The CCIa and GAS may play a role as predictive factors for postoperative morbidity and survival after AFB.
PMCID: PMC3444032  PMID: 23450270
atherosclerosis; peripheral arterial disease; risk factors; risk-scoring methods
7.  Comparative evaluation of ASA classification and ACE-27 index as morbidity scoring systems in oncosurgeries 
Indian Journal of Anaesthesia  2010;54(3):219-225.
The primary intention of the study was to find out whether Adult Comorbidity Evaluation Index (ACE-27) was better than the American Society of Anaesthesiologists’ (ASA) risk classification system in predicting postoperative morbidity in head and neck oncosurgery. Another goal was to identify other risk factors for complications which are not included in these indexes. Univariate and multivariate analyses were performed on 250 patients to determine the impact of seven variables on morbidity-ACE-27 grade, ASA class, age, sex, duration of anaesthesia, chemotherapy and radiotherapy. In univariate analysis ACE-27 index, ASA score, duration of anaesthesia, radiotherapy and chemotherapy were significant. As both comorbidity scales were significant in univariate analysis they were analyzed together and separately in multivariate analysis to illustrate their individual strength. In the first multivariate analysis (excluding ACE-27 grade) ASA class, duration of anaesthesia, radiotherapy and chemotherapy were significant. The positive predictive value (PPV) of this model to predict morbidity was 60.86% and negative predictive value (NPV) was 77.9%. The sensitivity was 75% and specificity 62.2%. In the second multivariate analysis (excluding ASA class) ACE-27 grade, duration of anaesthesia and radiotherapy were significant. The PPV of this model to predict morbidity was 62.1% and NPV was 76.5%. The sensitivity was 61.6% and specificity 70.9%. In the third multivariate analysis which included both ACE-27 grade and ASA class only ASA class, duration of anaesthesia, radiotherapy and chemotherapy remained significant. In conclusion, ACE-27 grade and ASA class were reliable predictors of major complications but ASA class had more impact on complications than ACE-27 grade.
PMCID: PMC2933480  PMID: 20885868
Morbidity prediction; perioperative complications; surgery
8.  Safety and effectiveness of outpatient laparoscopic cholecystectomy in a teaching hospital: a prospective study of 110 consecutive patients 
BMC Research Notes  2010;3:207.
The aim of this study was to evaluate the safety and efficacy of outpatient laparoscopic cholecystectomy (OLC) in a day surgery unit in a teaching hospital. OLC was offered to patients with symptomatic cholelithiasis who met the following established inclusion criteria: ASA (American Society of Anesthesiology) physical status classification class I and II; age: 18 - 70 years; body mass index (BMI) < 30 kg/m2; patient acceptance and cooperation (informed consent); presence of a responsible adult to accompany the patient to his residency; patient residency in Athens. The primary study end-point was to evaluate success rates (patient discharge on the day of surgery), postoperative outcome (complications, re-admissions, morbidity and mortality) and patient satisfaction. A secondary endpoint was to evaluate its safe performance under appropriate supervision by higher surgical trainees (HSTs).
110 consecutive patients, predominantly female (71%) and ASA I (89%) with a mean age 40.6 ± 8.1 years underwent an OLC. Surgery was performed by a HST in 90 patients (81.8%). A mean postoperative pain score 3.3 (range 0-6) occurred in the majority of patients and no patient presented postoperative nausea or vomiting. Discharge on the day of surgery occurred in 95 cases (86%), while an overnight admission was required for 15 patients (14%). Re-admission following hospital discharge was necessary for 2 patients (1.8%) on day 2, due to persistent pain in the umbilical trocar site. The overall rate of major (trocar site bleeding) and minor morbidity was 15.5% (17 patients). At 1 week follow-up, 94 patients (85%) were satisfied with their experience undergoing OLC, with no difference between grades of operating surgeons.
This study confirmed that OLC is clinical effective and can be performed safely in a teaching hospital by supervised HSTs.
PMCID: PMC2914656  PMID: 20649998
9.  Hypothermia in a surgical intensive care unit 
BMC Anesthesiology  2005;5:7.
Inadvertent hypothermia is not uncommon in the immediate postoperative period and it is associated with impairment and abnormalities in various organs and systems that can lead to adverse outcomes. The aim of this study was to estimate the prevalence, the predictive factors and outcome of core hypothermia on admission to a surgical ICU.
All consecutive 185 adult patients who underwent scheduled or emergency noncardiac surgery admitted to a surgical ICU between April and July 2004 were admitted to the study. Tympanic membrane core temperature (Tc) was measured before surgery, on arrival at ICU and every two hours until 6 hours after admission. The following variables were also recorded: age, sex, body weight and height, ASA physical status, type of surgery, magnitude of surgical procedure, anesthesia technique, amount of intravenous fluids administered during anesthesia, use of temperature monitoring and warming techniques, duration of the anesthesia, ICU length of stay, hospital length of stay and SAPS II score. Patients were classified as either hypothermic (Tc ≤ 35°C) or normothermic (Tc> 35°C). Univariate analysis and multiple regression binary logistic with an odds ratio (OR) and its 95% Confidence Interval (95%CI) were used to compare the two groups of patients and assess the relationship between each clinical predictor and hypothermia. Outcome measured as ICU length of stay and mortality was also assessed.
Prevalence of hypothermia on ICU admission was 57.8%. In univariate analysis temperature monitoring, use of warming techniques and higher previous body temperature were significant protective factors against core hypothermia. In this analysis independent predictors of hypothermia on admission to ICU were: magnitude of surgery, use of general anesthesia or combined epidural and general anesthesia, total intravenous crystalloids administrated and total packed erythrocytes administrated, anesthesia longer than 3 hours and SAPS II scores. In multiple logistic regression analysis significant predictors of hypothermia on admission to the ICU were magnitude of surgery (OR 3.9, 95% CI, 1.4–10.6, p = 0.008 for major surgery; OR 3.6, 95% CI, 1.5–9.0, p = 0.005 for medium surgery), intravenous administration of crystalloids (in litres) (OR 1.4, 95% CI, 1.1–1.7, p = 0.012) and SAPS score (OR 1.0, 95% CI 1.0–1.7, p = 0.014); higher previous temperature in ward was a significant protective factor (OR 0.3, 95% CI 0.1–0.7, p = 0.003). Hypothermia was neither a risk factor for hospital mortality nor a predictive factor for staying longer in ICU.
The prevalence of patient hypothermia on ICU arrival was high. Hypothermia at time of admission to the ICU was not an independent factor for mortality or for staying longer in ICU.
PMCID: PMC1180426  PMID: 15938757
10.  Comparative utility of centrally versus peripherally transduced venous pressure monitoring in the perioperative period in spine surgery patients 
Journal of clinical anesthesia  2012;24(7):542-548.
Study Objective
To compare central venous pressure (CVP) with peripheral venous pressure (PVP) monitoring during the intraoperative and postoperative periods in patients undergoing spine surgery.
Prospective observational study.
University-affiliated teaching hospital.
35 ASA physical status 1, 2, and 3 patients.
A peripheral catheter in the forearm or hand and a central catheter into the internal jugular vein were placed for PVP and CVP monitoring, respectively.
CVP and PVP values were collected simultaneously and recorded electronically at 5-minute intervals throughout surgery and in the recovey room. The number of attempts for catheter placement, ease of use, maintenance, and interpretation were recorded. Patient comfort, frequency of complications, and cost were analyzed.
Main results
The correlation coefficient between CVP and PVP was 0.650 in the operating room (P < 0.0001) and 0.388 in the recovery room (P < 0.0001). There was no difference between groups in number of attempts to place either catheter, maintenance, and interpretation with respect to PVP and CVP monitoring in the operating room. In the recovery room, the nurses reported a higher level of difficulty in interpretation of PVP than CVP, but no differences were noted in ease of maintenance. There were no complications related to either central or peripheral catheter placement. Patient comfort and cost efficiency were higher with a peripheral than a central catheter.
During clinically relevant conditions, there was limited correlation between PVP and CVP in the prone position during surgery and postoperatively in the recovery room.
PMCID: PMC3483409  PMID: 22999983
Central venous pressure; correlation study; peripheral venous pressure
11.  Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study 
BMJ : British Medical Journal  2003;327(7425):1192-1197.
Objective To evaluate the effect of comorbidity and other risk factors on postoperative mortality and morbidity in patients undergoing major oesophageal and gastric surgery.
Design Multicentre cohort study with data on postoperative mortality and morbidity in hospital.
Data source and methods The ASCOT prospective database, comprising 2087 patients with newly diagnosed oesophageal and gastric cancer in 24 hospitals in England and Wales between 1 January 1999 and 31 December 2002. Multivariate logistic regression analysis was used to model the risk of death and postoperative complications.
Results 955 patients underwent oesophagectomy or gastrectomy. Of these, 253 (27%) were graded ASA III or IV, and 187 (20%) had a high physiological POSSUM score (≥ 20). Operative mortality was 12% (111/955). Physiological POSSUM score, surgeon's assessment, type of operation, hospital case volume, and tumour stage independently predicted operative mortality. Medical complications were associated with higher physiological POSSUM scores and ASA grade, oesophagectomy or total gastrectomy, thoracotomy, and radical nodal dissection. Stage and additional organ resection predicted surgical (technical) complications.
Conclusions Many patients undergoing surgery for gastro-oesophageal cancer have major comorbid disease, which strongly influences their risk of postoperative death. Technical complications do not seem to be influenced by preoperative factors but reflect the extent of surgery and perhaps surgical judgment. Detailed prospective multicentre cooperative audit, with appropriate risk adjustment, is fundamental in the evaluation of cancer care and must be properly resourced.
PMCID: PMC274052  PMID: 14630753
12.  Management of postoperative pain: experience of the Niamey National Hospital, Niger 
Journal of Pain Research  2012;5:591-595.
The aim of this study was to evaluate the management of postoperative pain at the Niamey National Hospital.
A prospective study was conducted in the Department of Anesthesiology and Intensive Care at the Niamey National Hospital from March to June, 2009. Data collected included age, sex, literacy, American Society of Anesthesiologists (ASA) physical status classification, type of anesthesia, type of surgery, postoperative analgesics used, and the cost of analgesics. Three types of pain assessment scale were used depending on the patient’s ability to describe his or her pain: the verbal rating scale (VRS), the numerical rating scale (NRS), or the visual analog scale (VAS). Patients were evaluated during the first 48 hours following surgery.
The sample included 553 patients. The VRS was used for the evaluation of 72% of patients, the NRS for 14.4%, and the VAS for 13.6%. Of the VRS group, 33.9%, 8.3%, and 2.1% rated their pain as 3 or 4 out of 4 at 12, 24, and 48 hours postoperatively, respectively. For the NRS group, 33.8%, 8.8%, and 2.5% rated their pain as greater than 7 out of 10 at 12, 24, and 48 hours postoperatively, respectively. For the VAS group, 29.3%, 5.4%, and 0% rated their pain as greater than 7 out of 10 at 12, 24, and 48 hours postoperatively, respectively.
Postoperative pain assessment and management in developing countries has not been well described. Poverty, illiteracy, and inadequate training of physicians and other health personnel contribute to the underutilization of postoperative analgesia. Analysis of the results gathered at the Niamey National Hospital gives baseline data that can be the impetus to increase training in pain management and to establish standardized protocols.
PMCID: PMC3526868  PMID: 23271923
postoperative pain; pain scales; Niamey National Hospital
13.  Chronic pain after lower abdominal surgery: do catechol-O-methyl transferase/opioid receptor μ-1 polymorphisms contribute? 
Molecular Pain  2013;9:19.
Preoperative pain, type of operation and anesthesia, severity of acute postoperative pain, and psychosocial factors have been identified as risk factors for chronic postsurgical pain (CPP). Recently, it has been suggested that genetic factors also contribute to CPP. In this study, we aimed to determine whether the catechol-O-methyl transferase (COMT) and opioid receptor μ-1 (OPRM1) common functional polymorphisms rs4680 and rs1799971 were associated with the incidence, intensity, or duration of CPP in patients after lower abdominal surgery.
One hundred and two patients with American Society of Anesthesiologists (ASA) physical status I/II underwent either abdominal radical prostatectomy (n = 45) or hysterectomy (n = 57). The incidences of CPP in the pelvic and scar areas were evaluated in all patients three months after surgery.
Thirty-five (34.3%) patients experienced CPP after lower abdominal surgery. Within this group, six (17.1%) patients demonstrated symptoms of neuropathic pain. For COMT rs4680, 22 (21.6%) patients had Met158Met, 55 (53.9%) patients had Val158Met, and 25 (24.5%) patients had Val158Val. No association was found between CPP phenotypes (incidence, intensity, and duration) and different rs4680 genotypes. For OPRM1 rs1799971, only CPP patients carrying at least one copy of the G allele had higher pain intensity than A118A carriers (p=0.02). No associations with other phenotypes were found. No combined effect of COMT/OPRM1 polymorphisms on CPP phenotypes was observed.
OPRM1 genotype influences CPP following lower abdominal surgery. COMT didn’t affect CPP, suggesting its potential modality-specific effects on human pain.
PMCID: PMC3623849  PMID: 23566343
Chronic postsurgical pain; Lower abdominal surgery; COMT; OPRM1; Gene; Polymorphism
14.  A comparison of the upper lip bite test with hyomental/thyrosternal distances and mandible length in predicting difficulty in intubation: A prospective study 
Indian Journal of Anaesthesia  2011;55(1):43-46.
The incidence of difficulty in tracheal intubation has been reported to range from 0.5 to 18% in patients undergoing surgery. We aimed to elucidate the role of upper lip bite test (ULBT) with other prevailing tests, hyomental/thyrosternal distances (HMD/TSD), and the mandible length (ML) and their possible correlation in predicting difficulty in intubation. After institutional approval and informed consent were obtained, 300 consecutive patients aged 20–60 years of ASA physical status I and II, scheduled for elective surgical procedures requiring tracheal intubation and meeting the inclusion criteria, were enrolled in this study. Each patient was evaluated regarding ULBT, HMD, TSD and ML. Laryngoscopy was assessed by an attending anaesthesiologist blinded to the measurements. The laryngoscopic result was graded according to Cormack and Lehane’s Grading system. The negative predictive value (NPV) and positive predictive value (PPV) of ULBT were found to be 94 and 100%, respectively. These corresponding figures for TSD were 88.5 and 0%, respectively. Specificities for ULBT, HMD, ML and TSD were 100, 98.9, 98.9 and 98.1%, respectively. ULBT class and laryngoscopic grading showed the greatest agreement (kappa = 0.61, P < 0.001). An agreement between laryngoscopic grading and HMD and ML also existed (0.003 and <0.001, respectively), but was comparatively weaker. The high specificity, NPV, PPV and accuracy of ULBT as revealed in this study could be a good rationale for its application in the prediction of difficulty or easiness in intubation. ML > 9 cm and HMD > 3.5 cm were good predictors of negative difficult intubation.
PMCID: PMC3057244  PMID: 21431052
Difficult intubation; difficult laryngoscopy; endotracheal intubation; predictive airway tests
15.  Italian Version of Corah's Dental Anxiety Scale: Normative Data in Patients Undergoing Oral Surgery and Relationship With the ASA Physical Status Classification 
Anesthesia Progress  2008;55(4):109-115.
To test the Italian translation of Corah's Dental Anxiety Scale (DAS) and to check the relationship between dental anxiety and the American Society of Anesthesiologists (ASA) physical status classification (ASA-PS), the DAS was translated into Italian and administered to 1072 Italian patients (620 male and 452 female patients, ages 14–85 years) undergoing oral surgery. Patients' conditions were checked and rated according to the ASA-PS. The DAS ranged from 4 to 20 (modus  =  8, median  =  10); 59.5% of patients had a DAS of 7–12, 26.1% had a DAS >12, and 10.3% had a DAS >15. The mean DAS was 10.29 (95% confidence limit  =  0.19); female patients were more anxious than male patients (P < .001), while patients older than 60 years showed a significant decrease in the level of anxiety. Five hundred two patients were rated as ASA-PS class P1, 502 as ASA-PS class P2, and 68 as ASA-PS class P3, with a mean DAS score of 9.69, 10.78, and 11.09, respectively: the DAS difference between groups was significant (P < .001).
PMCID: PMC2614648  PMID: 19108594
Anxiety; Dentistry; Dental anxiety scale; Visual analogue scale; Psychological tests; Methods; Dental phobia; Physical status
16.  Preoperative drug dispensing as predictor of surgical site infection. 
Emerging Infectious Diseases  2001;7(1):57-65.
The system used by the National Nosocomial Infection Surveillance (NNIS) program to measure risk of surgical site infection uses a score of 3 on the American Society of Anesthesiologists (ASA)-physical status scale as a measure of underlying illness. The chronic disease score measures health status as a function of age, sex, and 29 chronic diseases, inferred from dispensing of prescription drugs. We studied the relationship between the chronic disease score and surgical site infection and whether the score can supplement the NNIS risk index. In a retrospective comparison of 191 patients with surgical site infection and 378 uninfected controls, the chronic disease score and ASA score were highly correlated. The chronic disease score improved prediction of infection by the NNIS risk index and augmented the ASA score for risk adjustment.
PMCID: PMC2631693  PMID: 11266295
17.  Perioperative predictors of morbidity and mortality following cardiac surgery under cardiopulmonary bypass 
Saudi Journal of Anaesthesia  2012;6(3):242-247.
Prediction of outcome after cardiac surgery is difficult despite a number of models using pre-, intra- and post-operative factors. Ideally, risk factors operating in all three phases of the patients’ stay in the hospital should be incorporated into any outcome prediction model. The aim of the present study was to identify the perioperative risk factors associated with morbidity, mortality and length of stay in the recovery room (LOSR) and length of stay in the hospital (LOSH).
Eighty-eight adults of either sex, patients undergoing elective open cardiac surgery were studied prospectively. The ability of a number of pre-, intra- and post-operative factors to predict outcome in the form of mortality, immediate morbidity (LOSR) and intermediate morbidity (LOSH) was assessed.
Factors associated with higher mortality were preoperative prothrombin index (PTI), American Society of Anesthesiology-Physical Status (ASA-PS) grade, Cardiac Anaesthesia Risk Evaluation (CARE) score and New York Heart Association (NYHA) class, intraoperative duration of cardiopulmonary bypass (DCPB), number of inotropes used while coming off cardiopulmonary bypass and postoperatively, Acute Physiology and Chronic Health Evaluation (APACHE) II excluding the Glassgow Comma Scale (GCS) component and the number of inotropes used. Immediate morbidity was associated with preoperative PTI, inotrope usage intra- and post-operatively and the APACHE score. Intermediate morbidity was associated with DCPB and intra- and post-operative inotrope usage. Individual surgeon influenced the LOSR and the LOSH.
APACHE score, a general purpose severity of illness score, was relatively ineffective in the postoperative period because of sedation, neuromuscular blockade and elective ventilation used in a number of these patients. The preoperative and intraoperative factors like CARE, ASA-PS grade, NYHA, DCPB and number of inotropes used influencing morbidity and mortality are consistent with the literature, despite the small size of our sample.
PMCID: PMC3498662  PMID: 23162397
Cardiac surgery; outcome prediction; prognostication; risk stratification
18.  Analgesic efficacy of peritubal infiltration of ropivacaine versus ropivacaine and morphine in percutaneous nephrolithotomy under ultrasonic guidance 
Saudi Journal of Anaesthesia  2013;7(2):118-121.
Background and Purpose:
Percutaneous nephrolithotomy is a safe and effective endourologic procedure which is less morbid than open surgery. However, pain around a nephrostomy tube requires good post-operative analgesia. We hypothesize that infiltration of local anesthetic with opioid from the renal capsule to the skin around the nephrostomy tract under ultrasonic guidance would alleviate the postoperative pain for a long period.
A total of 60 ASA physical status I to II patients were selected for a prospective randomized double-blind controlled study in percutaneous nephrolithotomy surgeries. Patients were divided into group R (n=30) and group RM (n=30). Balanced general anesthesia was given. After completion of the surgical procedure, a 23-gauze spinal needle was inserted at 6 and 12 O’clock position under ultrasonic guidance up to renal capsule along the nephrostomy tube. A 10 ml drug solution was infiltrated in each tract while withdrawing from renal capsule to the skin. After extubation, the patient was shifted to the post-anesthesia care unit for 24 hours. Post-operative pain was assessed using the visual analog scale (VAS) and dynamic visual analog scale (DVAS) (during deep breathing and coughing) rating 0-10 for initial 24 hours. Rescue analgesia was given in the form of injection tramadol 1.0 mg/kg intravenously when VAS ≥4 and maximum up to 400 mg in 24 hours. Time to 1st rescue analgesic, number of doses of tramadol and total consumption of tramadol required in initial 24 hours were noted. Patients were observed for any side effect and treated accordingly.
Time to 1st rescue analgesic, i.e., duration of analgesia in group RM is more prolonged than group R (P=0.0004). The number of doses of tramadol in 24 hours in group R were higher as compared to group RM (P=0.0003). The total amount of tramadol in 24 hours in group R was more than in group RM (P=0.0013). Side effects like nausea and vomiting and sedation were comparable in both the groups.
Addition of morphine to ropivacaine for nephrostomy tract infiltration significantly prolonged the duration of post-operative analgesia and reduced the number of doses and total consumption of rescue analgesic in initial 24 hours in percutaneous nephrolithotomy surgery.
PMCID: PMC3737683  PMID: 23956707
Morphine; percutaneous nephrolithotomy; ropivacaine; ultrasound
19.  The Old and Ill: Influence and Impact on the Reconstructive Effort 
Seminars in Plastic Surgery  2010;24(3):319-324.
Head and neck reconstruction is often mandatory in elderly and ill patients, especially after tumor ablation. Even complex reconstructive procedures can be done in the elderly population after careful evaluation. The morbidity and mortality rates increase with age, thus the risks and benefits of surgical intervention must be weighed precisely. The functional capacities of the vital organs and the limitations should be assessed. The only significant preoperative guide for the risk of the operation is the American Society of Anesthesiologists (ASA) score. According to this scoring system, ASA 3 and 4 patients are more prone to complications. For a successful reconstructive procedure in old and ill patients, detailed preoperative evaluation is mandatory. Based on this evaluation, the type and duration of the surgery can be properly selected, and postoperative monitoring can be handled individually.
PMCID: PMC3324227  PMID: 22550453
ASA score; elderly patients; operative risk; preoperative assessment
20.  Pulmonary circulatory changes after bilateral total knee arthroplasty during regional anesthesia 
Study Objective
To monitor the pulmonary hemodynamics of patients undergoing bilateral total knee arthroplasty (BTKA) intraoperatively and up to 24 hours following surgery.
Prospective observational study.
University-affiliated teaching hospital.
30 ASA physical status 2 and 3 patients scheduled for single-stage, cemented, BTKA during epidural anesthesia.
Pulmonary artery catheters attached to all patients.
Systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), the ratio of PVR to SVR at baseline, at the beginning of surgery, and after each knee implantation were recorded and compared with measurements taken one day postoperatively (POD 1).
Main Results
On POD 1, PVR/SVR was increased by 30% compared with baseline (P < 0.0001) and by 20% versus the end of surgery (P < 0.0001). Systemic vascular resistance decreased during surgery and was significantly lower than baseline at 24 hours after surgery (P < 0.0001). No significant change in PVR was noted during surgery.
The PVR/SVR ratio on the day following BTKA was increased. This change may represent the different effects of inflammatory perioperative stresses on the pulmonary and systemic vasculature.
PMCID: PMC4009487  PMID: 23391339
Bilateral knee arthroplasty; epidural anesthesia; pulmonary hemodynamics
21.  The value of short and simple measures to assess outcomes for patients of total hip replacement surgery 
Quality in Health Care : QHC  2000;9(3):146-150.
Objectives—To evaluate the performance of a patient assessed outcome measure, the Oxford Hip Score, in a national study of primary hip replacement surgery.
Design—A survey of patients' health status before undergoing primary hip replacement surgery and three months and one year after surgery.
Setting—143 hospitals in three NHS English regions.
Patients—7151 patients admitted for primary total hip replacement surgery over a period of 13 months from September 1996.
Main measures—For patients, Oxford Hip Score and satisfaction with hip replacement and, for surgeons, American Anesthiologists' Society (ASA) classification of physical status.
Results—The response rates to the postal questionnaire at three and 12 months follow up were 85.2% and 80.7%, respectively. Including all three administrations of the questionnaire, all except two items of the Oxford Hip Score were completed by 97% or more respondents and only one item at one administration appeared marginally to reduce the reliability of the score. The effect sizes for changes in the score from baseline to three months was 2.50 and to 12 months was 3.05. Patients rated by surgeons as being healthy preoperatively by the ASA classification were somewhat more likely to return a completed questionnaire at three months (79.4% versus 75.3%) and 12 months (72.4% versus 70.3%) than those rated as having poorer health.
Conclusions—Overall there was little evidence of difficulties for patients in completing the Oxford Hip Score or of unreliable data, except in relation to one questionnaire item. The instrument was very responsive to change over time and score changes for the Oxford Hip Score related well to patients' satisfaction with their surgery. The instrument is an appropriate measure in terms of validity, responsiveness, and feasibility for evaluating total hip replacement from the perspective of the patient.
Key Words: total hip replacement surgery; Oxford Hip Score; questionnaire; assessment
PMCID: PMC1743526  PMID: 10980074
22.  Prediction of early postoperative major cardiac events after elective orthopedic surgery: the role of B-type natriuretic peptide, the revised cardiac risk index, and ASA class 
BMC Anesthesiology  2014;14:20.
The aim of this study was to evaluate pre- and post-operative brain natriuretic peptide (BNP) levels and compare the power of this test in predicting in-hospital major adverse cardiac events (MACE: atrial fibrillation, flutter, acute heart failure or non-fatal/fatal myocardial infarction) in patients undergoing elective prosthesis orthopedic surgery to that of the Revised Cardiac Risk Index (RCRI) and American Society of Anesthesiology (ASA) class, the most useful scores identified to date.
The study was an observational study of consecutive patients undergoing elective prosthesis orthopedic surgery. Surgical risk was established using RCRI score and ASA class criteria. Venous blood was sampled before surgery and on postoperative day 1 for the measurement of BNP. The intraoperative data collected included details of the surgery and anesthesia and any MACE experienced up until hospital discharge.
MACE occurred in 14 of the 227 patients treated (6.2%). Age was statistical associated with MACE (p < 0.004). Preoperative BNP levels were higher (p < 0.0007) in patients who experienced MACE than in event-free patients (median values: 92 and 35 pg/mL, respectively). Postoperative BNP levels were also greater (p < 0.0001) in patients sustaining MACE than in event-free patients (median values: 165 and 45 pg/mL, respectively). ROC curve analysis demonstrated that for a cut-off point ≥ 39 pg/mL, the area under the curve for preoperative BNP was equal to 0.77, while a postoperative BNP cut-off point ≥ 69 pg/mL gave an AUC of 0.82.
Both pre- and post-operative BNP concentrations are predictors of MACE in patients undergoing elective prosthesis orthopedic surgery.
PMCID: PMC3998048  PMID: 24655733
Brain natriuretic peptide; Orthopedic surgery; Preoperative care
23.  Risk factors of morbidity and mortality following hip fracture surgery 
Korean Journal of Anesthesiology  2013;64(6):505-510.
The preoperative coexisting chronic systemic illness, delay in surgery, gender, and age were considered as risk factors for the complications after hip fracture surgery. The wider range of surgical delay and immobility-related pulmonary morbidity may affect postoperative complications and mortality. This study examined the risk factors for morbidity and mortality following the hip fracture surgery.
The patient data was collected retrospectively. The consecutive 506 patients with hip fracture surgery, aged 60 years or older, were included. The patients' age, gender, preexisting diseases, American Society of Anesthesiologists (ASA) classification, delay in surgical repair, duration of surgical procedure, and methods of anesthesia were noted. The thirty-day postoperative complications were reviewed, and cardiac complications, pulmonary complications, delirium, and death were recorded. The data was analyzed for postoperative complications and risk factors.
Atelectasis was associated with postoperative pulmonary complications. Male gender and age ≥ 80 years were associated with an increased incidence of postoperative delirium. ASA classification 3 was associated with death. A delay in surgery was not associated with any complications. Preexisting diseases and methods of anesthesia did not affect mortality and postoperative complications.
The results suggest that a delay in surgery did not affect the postoperative complications and morbidity.
PMCID: PMC3695247  PMID: 23814650
Hip fractures; Morbidity; Mortality
24.  Lung Function before and Two Days after Open-Heart Surgery 
Reduced lung volumes and atelectasis are common after open-heart surgery, and pronounced restrictive lung volume impairment has been found. The aim of this study was to investigate factors influencing lung volumes on the second postoperative day. Open-heart surgery patients (n = 107, 68 yrs, 80% male) performed spirometry both before surgery and on the second postoperative day. The factors influencing postoperative lung volumes and decrease in lung volumes were investigated with univariate and multivariate analyses. Associations between pain (measured by numeric rating scale) and decrease in postoperative lung volumes were calculated with Spearman rank correlation test. Lung volumes decreased by 50% and were less than 40% of the predictive values postoperatively. Patients with BMI >25 had lower postoperative inspiratory capacity (IC) (33 ± 14% pred.) than normal-weight patients (39 ± 15% pred.), (P = 0.04). More pain during mobilisation was associated with higher decreases in postoperative lung volumes (VC: r = 0.33, P = 0.001; FEV1: r = 0.35, P ≤ 0.0001; IC: r = 0.25, P = 0.01). Patients with high BMI are a risk group for decreased postoperative lung volumes and should therefore receive extra attention during postoperative care. As pain is related to a larger decrease in postoperative lung volumes, optimal pain relief for the patients should be identified.
PMCID: PMC3423658  PMID: 22924127
25.  Hidden in plain sight: bias towards sick patients when sampling patients with sufficient electronic health record data for research 
To demonstrate that subject selection based on sufficient laboratory results and medication orders in electronic health records can be biased towards sick patients.
Using electronic health record data from 10,000 patients who received anesthetic services at a major metropolitan tertiary care academic medical center, an affiliated hospital for women and children, and an affiliated urban primary care hospital, the correlation between patient health status and counts of days with laboratory results or medication orders, as indicated by the American Society of Anesthesiologists Physical Status Classification (ASA Class), was assessed with a Negative Binomial Regression model.
Higher ASA Class was associated with more points of data: compared to ASA Class 1 patients, ASA Class 4 patients had 5.05 times the number of days with laboratory results and 6.85 times the number of days with medication orders, controlling for age, sex, emergency status, admission type, primary diagnosis, and procedure.
Imposing data sufficiency requirements for subject selection allows researchers to minimize missing data when reusing electronic health records for research, but introduces a bias towards the selection of sicker patients. We demonstrated the relationship between patient health and quantity of data, which may result in a systematic bias towards the selection of sicker patients for research studies and limit the external validity of research conducted using electronic health record data. Additionally, we discovered other variables (i.e., admission status, age, emergency classification, procedure, and diagnosis) that independently affect data sufficiency.
PMCID: PMC4062889  PMID: 24916006

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