Objectives: Multiple limb amputations are an uncommon complication from inotrope-induced peripheral gangrene. Case Presentation: A 20-year-old lady with valvular heart disease had septic shock secondary to infective endocarditis and required prolonged cardiopulmonary resuscitation. Despite aggressive fluid resuscitation, the patient had triple strength intravenous noradrenaline to maintain hemodynamic stability. On day 5 of post-shock, dry gangrene occurred in distal parts of all limbs, and inotrope was stopped. Although the gangrenous changes were non-progressive, she required a significant degree of assistance with mobility and daily function performance. The patient was counseled for multiple limb amputations to promote walking and hand function through prosthetic restoration. Five months after the event, she had a right transtibial amputation, left Chopart amputation, left wrist disarticulation, and right second, third, fourth, and fifth fingers amputation. Three specific goals for inpatient rehabilitation were independent short-distance ambulation with prostheses, performing basic activities of daily living with adaptive devices, and independent wheelchair propulsion for long-distance mobility using a right-sided transtibial prosthesis, left-sided Syme's prosthesis with Kingsley's foot, right-sided silicone-based cosmetic glove and left-sided body-powered transradial prosthesis. Discussion: Although an uncommon complication, inotrope may lead to multiple limb amputations secondary to peripheral gangrene. Following amputation, the ultimate rehabilitative goal is to restore the mobility and capacity to perform daily functions through prosthetic restoration, whether walking for lower amputees or functioning hand for upper limb amputees. Prescribing prosthesis in a single limb loss is relatively straightforward, but restoring multiple limb amputations bears many challenges toward successful recovery of walking and functions.
Abstract Introduction Unplanned hospital readmissions after surgery contribute significantly to healthcare costs and potential complications. Identifying predictors of readmission is inherently complex and involves an intricate interplay between medical factors, healthcare system factors and sociocultural factors. Therefore, the aim of this study was to elucidate the predictors of readmissions in an Asian surgical patient population. Methods A two-year single-institution retrospective cohort study of 2744 patients was performed in a university-affiliated tertiary hospital in Singapore, including patients aged 45 and above undergoing intermediate or high-risk non-cardiac surgery. Unadjusted analysis was first performed, followed by multivariable logistic regression. Results Two hundred forty-nine patients (9.1%) had unplanned 30-day readmissions. Significant predictors identified from multivariable analysis include: American Society of Anaesthesiologists (ASA) Classification grades 3 to 5 (adjusted OR 1.51, 95% CI 1.10–2.08, p = 0.01), obesity (adjusted OR 1.66, 95% CI 1.18–2.34, p = 0.04), asthma (OR 1.70, 95% CI 1.03–2.81, p = 0.04), renal disease (OR 2.03, 95% CI 1.41–2.92, p < 0.001), malignancy (OR 1.68, 95% CI 1.29–2.37, p < 0.001), chronic obstructive pulmonary disease (OR 2.46, 95% CI 1.19–5.11, p = 0.02), cerebrovascular disease (OR 1.73, 95% CI 1.17–2.58, p < 0.001) and anaemia (OR 1.45, 95% CI 1.07–1.96, p = 0.02). Conclusion Several significant predictors of unplanned readmissions identified in this Asian surgical population corroborate well with findings from Western studies. Further research will require future prospective studies and development of predictive risk modelling to further address and mitigate this phenomenon.
Post-anaesthesia care unit (PACU) delirium is a potentially preventable condition that results in a significant long-term effect. In a multicentre prospective cohort study, we investigate the incidence and risk factors of postoperative delirium in elderly patients undergoing major non-cardiac surgery.Patients were consented and recruited from 4 major hospitals in Singapore. Research ethics approval was obtained. Patients older than 65 years undergoing non-cardiac surgery >2 hours were recruited. Baseline perioperative data were collected. Preoperative baseline cognition was obtained. Patients were assessed in the post-anaesthesia care unit for delirium 30-60 minutes after arrival using the Nursing Delirium Screening Scale (Nu-DESC).Ninety-eight patients completed the study. Eleven patients (11.2%) had postoperative delirium. Patients who had PACU delirium were older (74.6±3.2 versus 70.6±4.4 years, P=0.005). Univariate analysis showed those who had PACU delirium are more likely to be ASA 3 (63.6% vs 31.0%, P=0.019), had estimated glomerular filtration rate (eGFR) of >60mL/min/1.73m2 (36.4% vs 10.6%, P=0.013), higher HbA1C value (7.8±1.2 vs 6.6±0.9, P=0.011), raised random blood glucose (10.0±5.0mmol/L vs 6.5±2.4mmol/L, P=0.0066), and moderate-severe depression (18.2% vs 1.1%, P=0.033). They are more likely to stay longer in hospital (median 8 days [range 4-18] vs 4 days [range 2-8], P=0.049). Raised random blood glucose is independently associated with increased PACU delirium on multivariate analysis.
Introduction: Post-anaesthesia care unit (PACU) delirium affects 5%–45% of patients after surgery and is associated with postoperative delirium and increased mortality. Up to 40% of PACU delirium is preventable, but it remains under-recognised due to a lack of awareness of its diagnosis. The nursing delirium screening scale (Nu-DESC) has been validated for diagnosing PACU delirium, but is not routinely used locally. This study aimed to use Nu-DESC to establish the incidence and risk factors of PACU delirium in patients undergoing non-cardiac surgery in the surgical population. Methods: We conducted an audit of eligible patients undergoing major surgery in three public hospitals in Singapore over 1 week. Patients were assessed for delirium 30–60 min following their arrival in PACU using Nu-DESC, with a total score of ≥2 indicative of delirium. Results: A total of 478 patients were assessed. The overall incidence rate of PACU delirium was 18/478 (3.8%), and the incidence was 9/146 (6.2%) in patients aged > 65 years. Post-anaesthesia care unit delirium was more common in females, patients with malignancy and those who underwent longer operations. Logistic regression analysis showed that the use of bispectral index ( P < 0.001) and the presence of malignancy ( P < 0.001) were significantly associated with a higher incidence of PACU delirium. Conclusion: In this first local study, the incidence of PACU delirium was 3.8%, increasing to 6.2% in those aged > 65 years. Understanding these risk factors will form the basis for which protocols can be established to optimise resource management and prevent long-term morbidities and mortality in PACU delirium.
Abstract Background Diabetes is known to increase morbidity and 30-day mortality in adults undergoing non-cardiac surgery, but longer term outcomes are less studied. This study was done to explore how undiagnosed and known diabetes affect 30-day and one-year morbidity and mortality outcomes. The secondary aim was to study the prevalence of undiagnosed diabetics in our perioperative Asian surgical population. Methods A retrospective cohort study of 2106 patients aged > 45 years undergoing non-cardiac surgery in a single tertiary hospital was performed. Undiagnosed diabetics were identified (HbA1c ≥6.5% or fasting blood glucose ≥126 mg/dL) and relevant demographic, clinical and surgical data were analyzed to elicit the relationship to adverse outcomes. Univariate analysis was first performed to identify significant variables with p -values ≤0.1, which were then analyzed using multiple logistic regression to calculate the adjusted odds ratio. Results The prevalence of undiagnosed diabetes was 7.4%. The mean and median HbA1c of known diabetics were 7.9 and 7.5%, while the mean and median HbA1c for undiagnosed diabetics were 7.2 and 6.8% respectively. 36.4% of known diabetics and 20.5% of undiagnosed diabetics respectively had a random blood glucose > 200 mg/dL. Undiagnosed diabetics had a three-fold increase in 1-year mortality compared to non-diabetics (adjusted OR 3.46(1.80–6.49) p < 0.001) but this relationship was not significant between known and non-diabetics. Compared to non-diabetics, known diabetics were at increased risks of new-onset atrial fibrillation (aOR 2.48(1.01–6.25) p = 0.047), infection (aOR 1.49(1.07–2.07) p = 0.017), 30-day readmission (aOR 1.62(1.17–2.25) p = 0.004) and 30-day mortality (aOR 3.11(1.16–8.56) p = 0.025). Conclusions Although undiagnosed diabetics have biochemically less severe disease compared to known diabetics at the point of testing, they are at a one-year mortality disadvantage which is not seen among known diabetics. This worrying trend highlights the importance of identifying and treating diabetes. Congruent to previous studies, known diabetics have higher morbidity and 30-day mortality compared to non-diabetics.
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