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Share Video Embed. That is consistent with multiple other studies, which generally show overlapping surgery cases to be about a half hour longer than non-overlapping cases.


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  • We often cite the statistic that infection rates increase by 2. One previous Canadian study Ravi on hip fracture patients and patients undergoing total hip replacement did find a higher rate of infectious complications in those undergoing overlapping surgery. After matching, overlapping hip fracture procedures had a statistically significant greater risk for a complication hazard ratio 1. Moreover, for the overlapping hip fracture operations, increasing duration of operative overlap was associated with increasing risk for complications adjusted odds ratio, 1.

    For hip fracture patients the complications in the overlapping group were primarily infections and revisions. We suspect the lack of more infectious complications in the Sun study and most of the other studies may reflect that most of the excess duration in overlapping cases is related simply to wound closure the prior studies assessed total surgical length without breaking down individual components contributing to duration. Nevertheless, the longer case duration of overlapping surgery should catch the interest of those interested in optimizing OR efficiency.

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    Overlapping procedure patients had an average case length of 2. Hyder et al. Hyder compared their experience with overlapping surgery vs. They used various methods to match patients in the non-overlapping cases to those in the overlapping cases. They found no significant difference in mortality between the two groups nor significant differences in length of stay LOS. They do note that, because mortality rates were very low, that mortality may not be a good parameter to assess.

    Rather, LOS or intraoperative measures may be more appropriate. Orthopedics is probably the area in which overlapping surgery is most often practiced. There have been several studies comparing orthopedic procedures done in overlapping vs. Goldfarb et al. Complications were logged into a database monthly by surgeons. The median duration of surgery overlap was 8 minutes. After propensity score weighting, there were only minor differences between groups in operative time, anesthesia time, and tourniquet time and no significant differences in surgical site infection, noninfectious surgical complications, hospitalization, or morbidity.

    Dy et al. Dy looked at all inpatient orthopedic surgical procedures performed at 5 academic institutions over a one year period. Overlapping surgery was defined as 2 skin incisions open simultaneously for 1 surgeon. There was no difference in mortality and the overlapping group had reduced odds of perioperative complications OR, 0.

    So, there are now multiple retrospective cohort studies supporting the safety of overlapping surgery and very few noting an increased risk of complications with overlapping surgery. First, untoward events related to overlapping surgery, particularly serious ones, are not common.

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    In fact, the vast majority of overlapping surgeries are accomplished without any problems. In fact, the bigger the series, the less likely we are to identify cases in which the overlap contributed to an adverse outcome. Given that a randomized controlled trial is not likely to ever take place, the only real way to determine whether overlapping surgery caused or contributed to such events is to perform root cause analysis of all cases with adverse events, a time- and resource-intensive process.

    A second problem is that, even in those studies that used propensity score adjustments to minimize bias, there is likely an element of selection bias.

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    There is really no way from administrative data or even chart review to fully understand why non-overlapping surgery was chosen over overlapping surgery or vice versa. It is quite likely that surgeons may avoid overlapping surgery in patients they consider to be at more risk. Note that the subgroup analysis in the Sun study does indicate that complications may be more common with overlapping surgery in more complex cases. So, when we see a retrospective cohort study that says patients undergoing overlapping surgery do better than those with non-overlapping surgery, we are not at all surprised.

    If they are less at risk, they should have fewer complications. Most of the studies come from venues in which the practice of overlapping surgery has been well ingrained. Those of us involved in patient safety have all seen instances in which overlapping surgery was a contributing factor to or root cause of an adverse event. Wrong-site surgery and retained surgical items are also relatively rare events.

    Yet we strive to prevent all such cases of those. Why should events related to overlapping surgery be treated differently? The one thing that is reassuring from these studies is that, with the exception of the Ontario study, there does not seem to be an increased rate of surgical site infections in cases of overlapping surgery.

    That is somewhat surprising to us, given that virtually all the studies have shown that procedure durations are longer in overlapping surgery. Many of the above studies showed mean surgical durations on the order of 30 minutes longer in overlapping cases. But note that those are mean durations. Quite likely there are many cases with prolonged durations of, say, 10 minutes and then other cases with more prolonged durations that raise the mean. Perhaps the latter ones are associated with increased infection rates. That cannot be determined from the currently published studies. It is interesting that in the Canadian study the complication rate did increase incrementally as the duration of overlap increased.

    We noted studies showing the perception of overlapping surgery differed between surgeons and patients. Another recent pediatric study Choe found a significant mismatch between parents' expectations and those of pediatric surgeons about the role of the surgeon on the day of operation, with parents consistently expecting more direct involvement by the attending surgeon. JAMA ; 8 : March 19, Updated Beers Criteria. There are a variety of medications that are particularly prone to be problematic in older adults.

    With the last several updates, Beers Criteria have become much more evidence-based. The last update had been in The AGS notes that a panel of 13 experts reviewed more than 1, clinical trials and research studies published between and the last update in The Beers Criteria update was developed by a consensus expert panel who reviewed the evidence base developed since the last update and used a Delphi process to arrive at the current recommendations. Recommendations are grouped into several tables which include with each drug a rationale for the recommendation, the recommendation itself, and the quality of the evidence and strength of recommendation.

    Sound clinical judgement must be used in weighing potential benefits of any drug against potential adverse effects. High on the list of drugs to avoid in the elderly are those with strong anticholinergic properties. The update has added two such drugs to that list, pyrilamine and methscopolamine. Changes to criteria on cardiovascular drugs include minor updates to the rationale and a minor change to clarify the recommendation for avoiding digoxin as first-line therapy for atrial fibrillation and heart failure.

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    The rationale to avoid sliding scale insulin was revised to clarify its meaning and intent and glimepiride was added to the list of sulfonylureas with a greater risk of severe prolonged hypoglycemia. Serotonin-norepinephrine reuptake inhibitors SNRIs have been added to the list of drugs to avoid in patients with a history of falls or fractures.

    After reviewing and discussing the evidence on antipsychotics to treat psychosis in patients with Parkinson disease, the panel decided to remove aripiprazole as preferred and add pimavanserin. Thus, the Beers Criteria recognize quetiapine, clozapine, and pimavanserin as exceptions to the general recommendation to avoid all antipsychotics in older adults with Parkinson disease. The Beers Criteria has a nice table with recommendations on PIM use in older adults due to drug-disease or drug-syndrome interactions that may exacerbate the disease or syndrome.

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    The list also notes that trimethoprim-sulfamethoxazole should be used with caution when used concurrently with an ACEI or ARB in the presence of decreased creatinine clearance because of an increased risk for hyperkalemia. So, what do you do when you come across a PIM or a drug to be used with caution on Beers List in an elderly patient? As pointed out in the companion article Steinman , presence of a drug on Beers List is not an absolute contraindication to using that drug in a specific patient. You need to assess both the risks and potential benefits of the drug and consider whether safer alternatives are available.

    So, you need a system in place to alert you at the time of initial prescribing. If your patient is already taking a medication on Beers List, you need to consider deprescribing. See our numerous columns, listed below, on deprescribing. Endsley Endsley notes that deprescribing can be accomplished in four steps:. Farrell Farrell notes five steps to individualize deprescribing practices to each patient:. Years ago, we set up an alert for prescribers about avoiding use of amitriptyline in the elderly amitriptyline has both anticholinergic side effects and may cause orthostatic hypotension and may cause drowsiness and increase the risk of falling in the elderly.

    New starts of amitriptyline dropped substantially. But we found that the prescribers almost never stopped the drug in patients for whom they had already prescribed it. Why is it so difficult to get healthcare professionals to deprescribe? One is an inherent cognitive bias to continue doing something one started. In human factors research, continuation bias is the unconscious cognitive bias to continue with the original plan in spite of changing conditions.