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Patients undergoing colectomy are at risk of numerous major complications. However, existing binary risk stratification models do not predict when a patient may be at highest risks of each complication. Accurate prediction of the timing of complications facilitates targeted, resource-efficient monitoring. We sought to develop and internally validate Cox proportional hazards models to predict time-to-complication of major complications within 30 days after elective colectomy. We studied a retrospective cohort from the multicentered American College of Surgeons National Surgical Quality Improvement Program procedure-targeted colectomy dataset. Patients aged 18 years or above, who underwent elective colectomy between January 1, 2014 and December 31, 2019 were included. A priori candidate predictors were selected based on variable availability, literature review, and multidisciplinary team consensus. Outcomes were mortality, hospital readmission, myocardial infarction, cerebral vascular events, pneumonia, venous thromboembolism, acute renal failure, and sepsis or septic shock within 30 days after surgery. The cohort consisted of 132145 patients (mean ± SD age, 61 ± 15 years; 52% females). Complication rates ranged between 0.3% (n = 383) for cardiac arrest and acute renal failure to 5.3% (n = 6986) for bleeding requiring transfusion, with readmission rate of 8.6% (n = 11415). We observed distinct temporal patterns for each complication: the median [quartiles] postoperative day of complication diagnosis ranged from 1 [0, 2] days for bleeding requiring transfusion to 12 [6, 18] days for venous thromboembolism. Models for mortality, myocardial infarction, pneumonia, and renal failure showed good discrimination with a concordance > 0.8, while models for readmission, venous thromboembolism, and sepsis performed poorly with a concordance of 0.6 to 0.7. Models exhibited good calibration but ranges were limited to low probability areas. We developed and internally validated time-to-event prediction models for complications after elective colectomy. Once further validated, the models can facilitate tailored monitoring of high risk patients during high risk periods. Clinicaltrials.gov (NCT05150548; Principal Investigator: Janny Xue Chen Ke, M.D., M.Sc., F.R.C.P.C.; initial posting: November 25, 2021).

Approximately 320 million surgeries occur annually worldwide, increasingly performed on an ageing, comorbid population in whom postoperative complications contribute significantly to mortality. While anesthesiologists have led advances in perioperative care, the optimal structure of the provision of postoperative care has lacked discourse. In this article, we describe the implementation, structure, role, and benefits of an Anesthesiology Perioperative Outreach Service (APOS) at a Canadian tertiary hospital, providing proactive daily review and management of high-risk surgical patients. The APOS involves routine reviews and care on surgical wards, emphasizing collaboration among anesthesiology, internal medicine, surgery, and geriatric medicine teams, with a specific screening pathway to identify patients experiencing myocardial injury after noncardiac surgery. We discuss case vignettes to illustrate common examples of how the APOS enabled early detection and treatment escalation for deteriorating patients and provide a focused narrative literature review. The anesthesiology-led perioperative outreach model described herein could provide an implementable framework for institutions seeking to enhance their quality of postoperative care-particularly among complex, comorbid patients at risk of postoperative morbidity.

BackgroundSingle-injection superficial parasternal intercostal plane (SPIP) blockade provides an effective and low-risk analgesic option for patients undergoing cardiac surgery with sternotomy, but their duration is limited. We sought to evaluate whether continuous SPIP blockade, compared with single-injection SPIP blockade, reduces acute sternal pain on coughing at 24 hours after cardiac surgery.MethodsWe conducted a randomized controlled parallel-arm superiority trial at a tertiary care center in Vancouver, BC, Canada. We included English-speaking adult patients undergoing scheduled cardiac surgery with full median sternotomy. We randomized participants in a 1:1 ratio to intervention or control groups, stratified by sex, using permuted block randomization with variable block sizes of 4 or 6. Patients in both study groups received bilateral SPIP catheters, with a 20 mL bolus of ropivacaine 0.2% through each catheter followed by a 3 mL/hour infusion of study solution (ropivacaine 0.2% in the intervention group and normal saline in the control group) for 48 hours. All patients received standardized multimodal analgesia. The primary outcome was the numeric rating scale (NRS) sternal pain score on standardized coughing at 24 hours. Secondary outcomes included sternal pain within 48 hours, opioid use, quality of recovery, postoperative nausea or vomiting and chronic sternal pain. Patients, healthcare providers, outcome collectors and data analysts were blinded to group allocation.ResultsEighty patients were randomized (n=40 per group). Mean (SD) sternal pain (NRS) scores on coughing at 24 hours were 4.0 (2.2) in the intervention group versus 3.9 (2.2) in the control group. The adjusted mean difference was −0.2 (95% CI −1.7 to 1.3; p=0.79). There were no differences between the groups in secondary outcomes. One patient in the intervention group experienced suspected local anesthetic systemic toxicity requiring unblinding. No other major complications were noted.ConclusionsContinuous SPIP blockade did not demonstrate superiority over single-injection SPIP blockade in reducing acute sternal pain on coughing at 24 hours after cardiac surgery.Trial registration number NCT05054179.