In this large retrospective database analysis, researchers found that composite measure adherence to SCIP measures was associated with lower rates of postoperative infections, but not with the individual measures. This is consistent with “bundling” theory, whereby outcomes can be affected by a number of processes, which need to be combined to successfully improve the outcome of interest (abstract)

In this prospective cohort 1005 patients scheduled for elective vascular surgery, all had an echo performed. Of all the patients, 21% had asymptomatic diastolic dysfunction, and 19% had asymptomatic systolic dysfunction. After multivariate adjustment, LV dysfunction independently predicted risk of 30 day cardiovascular events (OR 2.3 and 1.8 for systolic and diastolic dysfunction, respectively) and long term cardiovascular mortality (HR 4.6 and 3.0 for systolic and diastolic dysfunction, respectively) in patients undergoing open vascular surgery. Although the authors recommend routine pre-operative echo for patients undergoing vascular surgery, as of now it is unclear what interventions would be performed to reduce the risk of events (abstract)

In this large trial, >2500 patients with carotid stenosis were randomized to either stenting or endarterectomy. There were no differences at 2.5 years in the rate of the primary outcome between the groups (composite of stroke, MI, or death), but at 4 years follow-up, the stent group had significantly higher rates of stroke/death (6% vs 5%). Carotid endarterectomy remains the procedure of choice for most patients requiring carotid revascularization (abstract)

In this multi-center trial of >1200 patients with large (>5.5cm) AAAs, they were randomized to elective repair by open or endovascular techniques. 30 day death was significantly lower in the endovascular group (1.8% vs 4.3%) but there was no difference in all-cause mortality by the end of follow-up between the groups. The endovascular group had higher rates of complications and re-interventions, and higher overall cost (abstract). This study is consistent with the recently published EVAR-1 Trial (link) which found in patients ineligible for open repair, endovascular repair was associated with lower aneurysm-related death, but there was no benefit to all-cause mortality. Type of AAA repair will likely be driven by patient-specific and physician preferences, and life expectancy.

In this Cochrane meta-analysis, researchers analyzed the overall efficacy and safety of direct thrombin inhibitors, compared to warfarin or LMWH, in preventing VTE after orthopedic surgeries (hip and knee arthroplasty). In14 studies involving over 20,000 participants, they found no difference in efficacy between direct thrombin inhibitors, warfarin, or LMWH, but did find higher mortality and bleeding in the thrombin group compared to LMWH (but no difference between the thrombin group and warfarin) (abstract). The timing of the thrombin inhibitors also matters, as pre-operative dosing results in fewer VTE’s but likely higher bleeding. Dabigatran is the oral direct thrombin inhibitor that is currently approved in Canada and throughout Europe, but US FDA approval is pending.

The long term benefit of open versus endovascular repair of AAA is undetermined. In this trial of 1252 patients with large AAA’s (>5.5cm), they were randomized to open or endovascular repair (EVAR-1 Trial link). Short term mortality was significantly lower in the endovascular group (2% vs 4%), but long term mortality was the same between the groups. In addition, the endovascular group had higher rates of endovascular graft complications, re-interventions, and overall cost. A related trial (EVAR-2 trial link) randomized 404 patients ineligible for surgery, to endovascular repair versus no procedure. They found long-term overall mortality was the same between the groups, with the endovascular repair group costing significantly more than the no procedure group. Although initially appealing, endovascular repair of AAA’s does not reduce long term mortality, and increases long term cost of care.

In this trial of 114 elderly patients (>age 65) undergoing spinal anesthesia for hip fracture repair, they were randomized to heavy or light sedation (with propofol). They found those in the light sedation group were significantly less likely to experience post-operative delirium (19% vs 40%) (abstract). This is a feasible way (if working closely with the surgeon and anesthesiologist) to reduce the risk of post-op delirium in high risk elders.

The ACCP guidelines recommend mechanical prophylaxis of DVT for patients who can not take anti-thrombotic drugs, but do not state a preference for intermittent pneumatic compression (IPC) versus graduated compression stockings (GCS). This systematic review of 10 studies (9 surgical) found slightly lower risk of DVT with the use of IPC (3% versus 6%). IPC may be more effective for mechanical DVT prophylaxis than GCS in surgical patients (abstract)

In this trial of 300 patients s/p surgery for hip fracture, they were randomized to 1 month of iron or no iron. At 6 week f/u, mean Hb levels were not significantly different between the groups (increased 2.1 g/dL in the iron group and 1.8 g/dL in the no iron group), but 17% of the iron group reported GI side effects. Given an absence of clinical benefit, routine iron after hip fracture surgery is probably not necessary (abstract).

In this large statewide retrospective database analysis, adjusted ICU mortality was lowest in units which had daily multi-disciplinary rounds. When stratified by intensivist staffing, those with daily rounds and high staffing had the lowest mortality, followed by those with daily rounds and low staffing. Multi-disciplinary rounds are vital to good patient outcomes (abstract)