Complications In High-risk Patients Research Articles

Effectiveness and Safety of Ultrasound Guided Lower Extremity Nerve Blockade in Infragenicular Bypass Grafting for High Risk Patients With Chronic Limb Threatening Ischaemia

Surgical revascularisation to accomplish limb salvage remains preferable in some patients with chronic limb threatening ischaemia (CLTI). The aim of this study was to evaluate the effectiveness and safety of ultrasound guided lower extremity nerve blockade (UGNB) in infragenicular bypass surgery (IGBS). This was a single centre, retrospective clinical study. Fifty-nine patients with CLTI (67 limbs) who underwent IGBS under UGNB (femoral and sciatic nerve blockade) at Asahikawa Medical University between January 2012 and December 2017 were compared with patients with CLTI (137 limbs) who underwent IGBS under general anaesthesia (GA) over the same period. Propensity score matching based on pre-operative comorbidities was used to minimise background differences of the two groups. Fifty-six pairs of CLTIs were matched and analysed (55% dialysis dependent). Procedure duration was similar between the two groups, but intraoperative catecholamine index and intravenous fluid volume were lower with UGNB compared with GA (2.9 ± 4.6 vs. 5.9 ± 6.5; p < .01 and 1831 ± 990 vs. 2335 ± 931 mL; p < .01, respectively). The mean arterial blood pressure during induction of anaesthesia was significantly decreased with GA. Post-operatively, the time period to resume a clear liquid and solid food diet was significantly shorter with UGNB (P < 0.01 for both outcome measures). Intravenous fluid volume was significanlty lower, while cardiac complications and delirium, based on the NEECHAM confusion scale, occurred significantly less often with UGNB than GA. These significant differences show advantages of UGNB compared to GA. No mortality or major amputations were observed in either group. Early graft thrombosis was observed in five limbs (8.9%) with UGNB and in four limbs with GA (7.1%) (p = .73). UGNB has advantages for intra- and post-operative management and could be a useful method to prevent peri-operative complications for high risk patients with CLTI. To ensure the effectiveness of UGNB for IGBS for future indications, a randomised study is required.

Tranexamic Acid Administration Is Not Associated With an Increase in Complications in High-Risk Patients Undergoing Primary Total Knee or Total Hip Arthroplasty: A Retrospective Case-Control Study of 38,220 Patients

BackgroundTranexamic acid (TXA) administration to reduce postoperative blood loss and transfusion is a well-established practice for total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, clinical concerns remain about the safety of TXA in patients with a history of a prothrombotic condition. We sought to determine the risk of complications between high-risk and low-risk TKA and THA patients receiving TXA. MethodsWe retrospectively reviewed 38,220 patients (8877 high-risk cases) who underwent primary TKA and THA between 2011 and 2017 at our institution. Intravenous TXA was administered in 20,501 (54%) of cases. The rates of thrombotic complications (deep vein thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], and cerebrovascular accident [CVA]) as well as mortality and readmission were assessed at 90 days postoperatively. Additionally, we evaluated 90-day postoperative occurrence of DVT and PE separate from occurrence of MI and CVA. Patients were categorized as high risk if they had a past medical history of a prothrombotic condition prior to surgery. ResultsThere was no significant difference in the odds of these adverse outcomes between high-risk patients who received TXA and high-risk patients who did not receive TXA (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.85-1.18). There were also no differences when evaluating the odds of 90-day postoperative DVT and PE (OR 0.84, 95% CI 0.59-1.19) nor MI and CVA (OR 0.91, 95% CI 0.56-1.49) for high-risk patients receiving TXA vs high-risk patients who did not receive TXA. ConclusionTXA administration to high-risk TKA and THA patients is not associated with a statistically significant difference in adverse outcomes. We present incremental evidence in support of TXA administration for high-risk patients undergoing primary arthroplasties.

Incidence, Prevalence, and Analysis of Risk Factors for Surgical Site Infection After Lumbar Fusion Surgery: ≥2-Year Follow-Up Retrospective Study

Surgical site infection (SSI) in spine surgery remains a significant cause of morbidity and prolonged hospitalization. We intended to document our experience in our center and to highlight possible factors influencing SSI in posterior lumbar fusion surgery. Between June 2015 and March 2017, 448 consecutive patients with lumbar degenerative disease who underwent classic open transforaminal lumbar interbody fusion were enrolled in the study. We divided the patients into the SSI group and the non-SSI group and compared their patient-specific and procedure-specific factors. Univariate and multiple logistic regression analyses were performed to determine risk factors. There was a significant difference between groups in age (P= 0.001), body mass index (P < 0.001), subcutaneous fat thickness (P < 0.001), preoperative American Society of Anesthesiologists (ASA) score (P < 0.001), postoperative hemoglobin (P= 0.003), preoperative serum albumin (P < 0.001), operative time (P < 0.001), operated levels (P < 0.001), postoperative drainage (P= 0.004), time of draining (P < 0.001) and late-presenting dural tear (P= 0.008). Logistic regression analysis of these differences showed that thicker subcutaneous fat thickness, higher preoperative ASA score, lower preoperative serum albumin, and longer time of draining were significantly related to SSI (P < 0.05). The risk factors for SSI after lumbar fusion surgery are multifactorial. These data should provide a step toward the development of quality improvement measures aimed at reducing complications in high-risk patients. These factors may prove useful for patient counseling and for surgical planning.

Effectiveness and Safety of Ultrasound Guided Lower Extremity Nerve Blockade in Infragenicular Bypass Grafting for High Risk Patients With Chronic Limb Threatening Ischaemia

Surgical revascularisation to accomplish limb salvage remains preferable in some patients with chronic limb threatening ischaemia (CLTI). The aim of this study was to evaluate the effectiveness and safety of ultrasound guided lower extremity nerve blockade (UGNB) in infragenicular bypass surgery (IGBS). This was a single centre, retrospective clinical study. Fifty-nine patients with CLTI (67 limbs) who underwent IGBS under UGNB (femoral and sciatic nerve blockade) at Asahikawa Medical University between January 2012 and December 2017 were compared with patients with CLTI (137 limbs) who underwent IGBS under general anaesthesia (GA) over the same period. Propensity score matching based on pre-operative comorbidities was used to minimise background differences of the two groups. Fifty-six pairs of CLTIs were matched and analysed (55% dialysis dependent). Procedure duration was similar between the two groups, but intraoperative catecholamine index and intravenous fluid volume were lower with UGNB compared with GA (2.9±4.6 vs. 5.9±6.5; p<.01 and 1831±990 vs. 2335±931mL; p<.01, respectively). The mean arterial blood pressure during induction of anaesthesia was significantly decreased with GA. Post-operatively, the time period to resume a clear liquid and solid food diet was significantly shorter with UGNB (P<0.01 for both outcome measures). Intravenous fluid volume was significanlty lower, while cardiac complications and delirium, based on the NEECHAM confusion scale, occurred significantly less often with UGNB than GA. These significant differences show advantages of UGNB compared to GA. No mortality or major amputations were observed in either group. Early graft thrombosis was observed in five limbs (8.9%) with UGNB and in four limbs with GA (7.1%) (p=.73). UGNB has advantages for intra- and post-operative management and could be a useful method to prevent peri-operative complications for high risk patients with CLTI. To ensure the effectiveness of UGNB for IGBS for future indications, a randomised study is required.

134P - The negative pressure therapy with PICO as a prevention of surgical site infection in high risk patients undergoing breast surgery

Background: The negative pressure therapy (NPWT) is usually used to treat difficult and chronic wounds. Among NPWT devices, some of them, like PICO, have a proven utility as a prophylaxis against surgical wound complications in high risk patients. PICO is a fixed intensity instrument, working with a continuous -80mmHg pressure over the wound. Methods: In the MARIPI study 100 high risk patients have been enrolled, 50 of them received a PICO plaster directly in the surgical room. We have then evaluated the difference in incidence of surgical wound complications between the case and control groups.Patients have been considered eligible to our study in the period 01.01.2016 to 01.01.2017 due to one or more of these following risk factors: diabetes, heavy smoke (more than 10 cigarettes per day), previous radiotherapy in the thoracic fields, skin diseases, vascular or cardiac alterations. Results: After a deep results analysis, significant difference in the wound infection rate comes out: 1(4.3% ) in the PICO group vs 3 (13,0%) in control group. The same consideration can be made concerning the wound dehiscences: 2 (8.7%) in the PICO group, 6 in the control one (26,1%). (p = 0.093) The whole number of patients’ clinical checks was 113 in the PICO group and 150 in the control one (p < 0.001) Medications with negative pressure reduce the wound infection rate down to about 50 and the dehiscence rate of about 66%, and this can lead to a costs reduction even considering the cost of 200$ (about 130 €) for any PICO medication. Conclusions: In our opinion, similarly to what may be found in the literature concerning other kinds of surgery, the use of PICO for risk reduction is justified in high risk patients. Further and broader randomized studies are in any case needed to better clarify the role of the therapies with negative pressure in breast cancer patients. Legal entity responsible for the study: AUSL Romagna. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

Surgical treatment of high-risk patients with severe ulcerative colitis

Introduction . Ulcerative colitis (UC) is an idiopathic autoimmune disease of the colon of unknown etiology, which is characterized by recurrent and intermittent inflammation with ulceration of the mucous membrane. In severe course often, a life-threatening condition requires a multidisciplinary approach with the participation of a gastroenterologist and surgeon. In approximately 25–30% of patients with UC, surgical treatment plays a key role. The timing of the operation depends on the effectiveness of conservative therapy and definitely affect the overall outcome of treatment. Postponing surgery, especially in severe, «critical» patients, is associated with an increased risk of postoperative complications and mortality. Purpose of the study is to analyze the results of surgical treatment of patients with ulcerative colitis and undifferentiated severe colitis. Materials and methods . The data of 15 patients aged from 19 to 83 operated in the period from January 2013 to May 2017 about severe ulcerative colitis. Results . The majority of patients (11 patients) underwent surgery on a planned and urgent basis, and the main indications were the ineffectiveness of conservative treatment. Mainly performed radical operations of large volume, usually with the imposition of ileostomy. In the early postoperative period, two patients died, urgently operated for toxic dilation and perforation of the intestine. Conclusions . Timely implementation of radical surgery for severe ulcerative colitis can avoid severe intestinal complications. Compliance with the optimal volume and technique of interventions can improve immediate results; reduce the incidence of perioperative complications in high-risk patients.

КОРРЕКЦИЯ ЦЕРЕБРАЛЬНОЙ ОКСИГЕНАЦИИ С ЦЕЛЬЮ СНИЖЕНИЯ РАЗВИТИЯ ПОСЛЕОПЕРАЦИОННЫХ ОСЛОЖНЕНИЙ У КАРДИОХИРУРГИЧЕСКИХ ПАЦИЕНТОВ ВЫСОКОГО РИСКА

The imbalance between oxygen delivery and consumption in the brain can lead to unfavorable post-operative outcomes of cardiac surgery. The authors evaluated the effect of the protocol on management of cerebral oxygenation episodes during the post-operative period in the patients undergoing cardiac surgery and facing a high risk of complications. Subjects : Patients who underwent coronary bypass surgery and/or cardiac valve surgery with cardiopulmonary bypass, were randomly divided into two groups: the interventional group (n = 60), where a special protocol was used to manage desaturation episodes, and the control group (n = 60) where only blinded monitoring of cerebral oximetry was used. Within 30 days after surgery, the development of desaturation episodes during surgery was assessed as well as the occurrence of complications (myocardial infarction, brain damage of the 1st and 2nd types, infectious complications, prolonged artificial ventilation of the lungs, arrhythmia, repeated thoracotomy, acute renal damage) in both groups. Results . The duration and intensity of desaturation did not significantly differ between the groups. The composite outcome was observed in 41 (68.3%) patients in the intervention group and in 38 (63.3%) of them in the control group (p = 0.70), and no significant difference was found in the frequency of individual components of the composite outcome. It was found out that desaturation significantly affected the development of delirium (odds ratio 1.03, 95% confidence interval 1.01–1.05, p = 0.03, to reduce % of the area under saturation curve for the less than 60% of the absolute value per every 5 minutes). Conclusion . The cerebral oximetry correction protocol provided no effect on prevention of complications in high-risk patients undergoing cardiac surgery. However, the reduction of cerebral oximetry turned out to be significant to predict the development of post-operative delirium, and it noted the need to search for ways to manage oxygen imbalance during surgery.

Value of preoperative spirometry test in predicting postoperative pulmonary complications in high-risk patients after laparoscopic abdominal surgery.

Whether preoperative spirometry in non-thoracic surgery can predict postoperative pulmonary complications (PPCs) is controversial. We investigated whether preoperative spirometry results can predict the occurrence of PPCs in patients who had undergone laparoscopic abdominal surgery. This retrospective observational study analyzed the records of patients who underwent inpatient laparoscopic gastric or colorectal cancer surgery at Seoul National University Bundang Hospital between January 2010 and June 2017. Preoperative spirometry was performed for patients at a high risk of PPCs, such as elderly patients (age >60 years), patients aged <60 years with chronic pulmonary disease, and current smokers. The main outcome was the association between the results of spirometry tests performed within 1 month prior to surgery and the occurrence of PPCs, as determined by multivariable logistic regression analysis. Of the 898 included patients who underwent laparoscopic gastric (372 patients) or colorectal cancer surgery (526 patients), PPC occurred in 117 patients (gastric cancer: 74, colorectal cancer: 43). A 1% greater preoperative forced vital capacity (FVC) was associated with a 2% lower incidence of PPCs after laparoscopic gastric or colorectal cancer surgery (odds ratio: 0.98, 95% confidence interval: 0.97–0.99, P = 0.018). However, the preoperative forced expiratory volume in 1 second (FEV1) (%) and FEV1/FVC (%) were not significantly associated with PPCs (P = 0.059 and P = 0.147, respectively). In conclusion, lower preoperative spirometry FVC, but not FEV1 or FEV1/FVC, may predict PPCs in high-risk patients undergoing laparoscopic abdominal surgery.

Physiotherapist administered, non-invasive ventilation to reduce postoperative pulmonary complications in high-risk patients following elective upper abdominal surgery; a before-and-after cohort implementation study

ObjectivesTo (1) determine whether short, 30-minute sessions of non-invasive ventilation (NIV) is associated with fewer postoperative pulmonary complications (PPC) following elective high-risk upper abdominal surgery and (2) measure feasibility and safety of this intervention when delivered by physiotherapists. DesignProspective, pre post cohort, observational, single-centre study. SettingPrimary referral hospital in Australia. ParticipantsA total of 182 consecutive high-risk elective upper abdominal surgery patients consisting of 101 pre cohort participants compared to 81 post cohort participants. InterventionsBoth groups received standardised preoperative physiotherapy and early postoperative mobilisation. The post cohort group received five additional 30-minute NIV sessions in the first two postoperative days. Main outcome measurePrimary outcome measure was PPC incidence within the first seven postoperative days. Secondary outcomes included feasibility and safety of physiotherapy-led NIV. ResultsIncidence of PPC (7% vs 18%, adjusted relative risk 0.24; 95% CI 0.10 to 0.59, p=0.002) was less in the NIV group compared to those who received no NIV. Mean time to first NIV session was 18.6 (SD 11.0) hours with 74% of participants receiving NIV within 24-hours of surgery. There were no major adverse events. ConclusionThese findings suggest PPC reduction may be possible with postoperative NIV following high-risk elective upper abdominal surgery. Results should be seen as hypothesis-generating associations only considering the significant limitations to this study. Physiotherapy-led NIV was delivered safely to ICU and ward patients. However, the planned protocol was not feasible and appropriate physiotherapy staffing and/or a multidisciplinary approach may be required to provide this service successfully. Trial registrationLIPPSMAck POP (Lung Infection Prevention Post Surgery – Major Abdominal – with Pre Operative Physiotherapy) ANZCTR-12613000664741 (for pre cohort group only).

Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial

ObjectiveTo assess whether laparoscopic cholecystectomy is superior to percutaneous catheter drainage in high risk patients with acute calculous cholecystitis.DesignMulticentre, randomised controlled, superiority trial.Setting11 hospitals in the Netherlands, February 2011 to...

Hybrid repair of thoracoabdominal aneurysm: An alternative strategy for preventing major complications in high risk patients

BackgroundNowadays, less invasive endovascular procedures have been employed in high risk patients for thoracoabdominal aortic aneurysm (TAAA) in order to try to reduce the risk of major complications. The aim of the study was to analyze the results of our hybrid 2-stage approach for TAAA repair. MethodsBetween July 2011 and September 2016, 17 consecutive high-risk patients received a hybrid 2-stage procedure for TAAA repair. Mean age of the population was 58.9 ± 9.0 years and 16 (94.1%) were male. Of them, 7 (41.2%) suffered of chronic obstructive pulmonary disease and 15 (88.2%) had a previous history of aortic operation. Three patients had Marfan syndrome (17.6%). The preoperative anatomy of the aneurysms was classified according to “Crawford classification” in type II (n = 6, 35.3%), type III (n = 10, 58.8%) and type IV (n = 1, 5.9%). All patients were followed up with an angio CT-scan at 1, 3 months and yearly thereafter. ResultsIn-hospital mortality was 11.8% (2 patient). None of the patients experienced paraplegia and paraparesis. Major post-operative complications were pancreatitis 17.6% (3/17). At follow-up (mean time of 23.3 ± 21.7 months) 2 patient died (12.5%) waiting for the second stage endovascular completion. Median interval time between the 2 steps was 35 days. Overall survival at 1- and 3-years was 75.6 ± 1.0. One type Ib and 1 type III endoleak were noted and successfully treated with an additional stent graft. ConclusionsThe results of hybrid 2-stage TAAA repair on high-risk patients are satisfactory and therefore encouraging. The extremely low incidence of spinal cord injury could make this technique the technique of choice for this type of pathology in selected high-risk patients. At follow-up, residual endoleaks occur although surgical reoperations are not often needed.

Accuracy of Daily Foot Temperature Monitoring for Patients with Recently Healed Diabetic Foot Ulcers or History of Amputation

Diabetic foot ulcers (DFU) result in significant morbidity, mortality, and healthcare costs. Fortunately, recent data suggest as many as 75% of DFU and 60% of lower extremity amputations (LEA) may be preventable. Clinical practice guidelines recommend evidence-based foot temperature monitoring (thermometry) for preventing DFU and its complications in high-risk patients. Despite this, several authors have noted that thermometry is not commonly practiced. This is potentially due to lack of evidence on the accuracy of thermometry in some of the highest-risk cohorts, including those with a recently-healed DFU or with history of LEA. The former may present with ipsilateral inflammation as part of normal healing, while the latter may lack the anatomy required for direct contralateral comparison of temperatures. Whether these concerns affect the accuracy of thermometry needs to be assessed. A recent study suggests that a novel thermometric mat may address some barriers to adoption. The mat was found to predict as many as 97% of non-traumatic plantar DFU with an average lead time of five weeks in a cohort with history of DFU. In the current investigation, we hypothesized no difference in the predictive accuracy of thermometry in two subgroups: those who healed from a DFU fewer than three months before enrolling, and those with a history of partial LEA (Syme amputation or more distal). Of the 129 subjects studied, 31% had recently-healed DFU and 56% had history of LEA. Although no difference in DFU incidence was found in the LEA subgroup, we found significantly higher incidence in those with recently-healed DFU (0.88 vs. 0.63 DFU/subject/year). Importantly, we found no differences in accuracy or lead time in either cohort. These data suggest thermometry is appropriate for monitoring both recently-healed DFU or partial LEA patients. Utilization of thermometry in these high-risk patients may significantly reduce morbidity, mortality, and resource utilization. Disclosure I.L. Gordon: None. A. Nouvong: None. B. Najafi: None. G.M. Rothenberg: Consultant; Self; Podimetrics. B. Petersen: Employee; Self; Podimetrics, Inc.. Stock/Shareholder; Self; Podimetrics, Inc. J.D. Bloom: Employee; Self; Podimetrics, Inc. Board Member; Self; Podimetrics, Inc. Stock/Shareholder; Self; Podimetrics, Inc. R. Frykberg: None.

PIN17 - Global Burden of Seasonal Influenza Disease: A Structured Literature Review

To review published data on the global burden of seasonal influenza in terms of epidemiology, economics, and impact on health-related quality of life (HRQoL). The overall incidence of seasonal influenza was estimated from the incidence rates of infected cases in the placebo groups of clinical trials on vaccines and prophylactic antivirals identified in systematic literature reviews. Targeted searches were performed on Medline to assess: the overall economic burden of influenza from observational studies, HRQoL associated with influenza and excess mortality/hospitalization rates during influenza outbreaks based on statistical regression analyses. Geographical scope covered the US, EU5 and Japan. Average incidence of laboratory-confirmed influenza was estimated between 3.71% in adults and 35.39% in children over 6 and up to 16 years old (yo). Large variability, related to different factors including season, country and target population, was observed between studies. The incidence rate of hospitalization appeared relatively high in <5 yo children, declined in 5-17 yo children and increased progressively after 18 yo. Patients aged >65 yo had the highest mortality rates. Type A influenza caused more hospitalizations and deaths than type B. Influenza resulted in a significant economic burden, including office visits, laboratory tests, emergency department visits, hospital stays with possible ICU admission, and medications. Major cost components were the productivity costs (absenteeism of infected adults or parents of infected children), the physician visit costs and the hospitalization costs related to influenza or its complications. Although the HRQoL impact of influenza on the infected population is often highlighted in evaluations of influenza vaccines and treatments, data on the HRQoL impact of influenza are scarce. Despite efforts to vaccinate high-risk individuals, influenza remains associated with a substantial public health and economic burden in developed countries, mostly related to complications in high-risk patients, and absenteeism in otherwise healthy patients.

Routine pre- and post-neoadjuvant chemotherapy fitness testing is not indicated for oesophagogastric cancer surgery.

Introduction There is a known correlation between anaerobic threshold (AT) during cardiopulmonary exercise testing and development of cardiopulmonary complications in high-risk patients undergoing oesophagogastric cancer surgery. This study aimed to assess the value of routine retesting following neoadjuvant chemotherapy. Methods Patients undergoing neoadjuvant chemotherapy with subsequent oesophagogastric cancer surgery with pre- and post-neoadjuvant chemotherapy cardiopulmonary exercise data were identified from a prospectively maintained database. Measured cardiopulmonary exercise variables included AT and maximum oxygen uptake at peak exercise (VO2 peak). Anaerobic threshold values within 1 ml/kg/minute were considered static. Patients were grouped into AT ranges of less than 9 ml/kg/minute, 9-11 ml/kg/minute and greater than 11 ml/kg/minute. Outcome measures were unplanned intensive care stay, postoperative cardiovascular morbidity and mortality. Results Between May 2008 and August 2017, 42 patients from 675 total resections were identified, with a mean age of 65 years (range 49-84 years). Mean pre-neoadjuvant chemotherapy AT was 11.07 ml/kg/minute (standard deviation, SD, 3.24 ml/kg/minute, range 4.6-19.3 ml/kg/minute) while post-neoadjuvant chemotherapy AT was 11.19 ml/kg/minute (SD 3.05 ml/kg/minute, range 5.2-18.1 ml/kg/minute). Mean pre-neoadjuvant chemotherapy VO2 peak was 17.13 ml/kg/minute, while post-chemotherapy this mean fell to 16.59 ml/kg/minute. Some 44.4% of patients with a pre-chemotherapy AT less than 9 ml/kg/minute developed cardiorespiratory complications compared with 42.2% of those whose AT was greater than 9 ml/kg/minute (P = 0.914); 63.6% of patients in the post-neoadjuvant chemotherapy group with an AT less than 9 ml/kg/minute developed cardiorespiratory complications. There was no correlation between direction of change in AT and outcome. Conclusion In our patient population, neoadjuvant chemotherapy does not appear to result in a significant mean reduction in cardiorespiratory fitness. Routine pre- and post-neoadjuvant chemotherapy cardiopulmonary exercise testing is currently not indicated; however, larger studies are required to demonstrate this conclusively.

What are the optimum components in a care bundle aimed at reducing post-operative pulmonary complications in high-risk patients?

BackgroundPost-operative pulmonary complications (POPC) are common, predictable and associated with increased morbidity and mortality, independent of pre-operative risk. Interventions to reduce the incidence of POPC have been studied individually, but the use of a care bundle has not been widely investigated. The purpose of our work was to use Delphi consensus methodology and an independently chosen expert panel to formulate a care bundle for patients identified as being at high of POPC, as preparation towards an evaluation of its effectiveness at reducing POPC.MethodsWe performed a survey of members of the ESICM POIC section to inform a Delphi consensus and to share their opinions on a care bundle to reduce POPC, the POPC-CB. We formed a team of 36 experts to participate in and complete an email-based Delphi consensus over three rounds, leading to the formulation of the POPC-CB.ResultsThe survey had 362 respondents and informed the design of the Delphi consensus. The Delphi consensus resulted in a proposed POPC-CB that incorporates components before surgery-supervised exercise programmes and inspiratory muscle training, during surgery, low tidal volume ventilation with individualised PEEP (positive end-expiratory pressure), use of routine monitoring to avoid hyperoxia and efforts made to limit neuromuscular blockade, and post-operatively, deep breathing exercises and elevation of the head of the bed.ConclusionA care bundle has been suggested for evaluation in surgical patients at high risk of POPC. Evaluation of feasibility of both implementation and effectiveness is now indicated.

Combined Fluoroscopy and Ultrasound-Guided Transjugular Kidney Biopsy in Cirrhotic Patients

PurposeTo evaluate the safety and diagnostic yield of combined fluoroscopy and ultrasound-guided transjugular kidney biopsy (TJKB) in cirrhotic patients with suspected renal parenchymal disease. Materials and MethodsA retrospective review was made of 27 patients (21 men; overall mean age 44.7 y) who underwent TJKB from June 2013 to June 2016; 21 patients had coagulopathy and/or thrombocytopenia, 4 underwent simultaneous TJKB with transjugular liver biopsy, and 1 patient each had severe obesity and gross ascites. All procedures were performed with the use of fluoroscopy and simultaneous transabdominal ultrasound guidance. The data were analyzed for number of passes taken, number of glomeruli in the tissue cores, adequacy of tissue core for histopathologic diagnosis, and incidence and severity of complications. ResultsThe average number of passes per case was 3.6 (range 2–6). The total length of tissue cores ranged from 0.4 cm to 2.5 cm. The mean numbers of glomeruli per procedure on light microscopy were 6.7 (range 0–17). Diagnostic biopsy specimens were obtained in 23 out of 27 patients (85%). Eleven patients had minor complications. One patient had major complication in the form of hemoglobin drop of 2.1 mg/dL which required embolization and blood transfusion. ConclusionsCombined use of fluoroscopy and ultrasound guidance for TJKB yielded adequate tissue samples with fewer passes and a low rate of complications in high-risk patients with cirrhosis.

MICROWAVE ABLATION IN COMBINED TREATMENT OF PRIMARY AND METASTATIC LIVER TUMORS

Aim. To increase the effectiveness of treatment of patients with primary and metastatic liver cancer. Material and Methods. Microwave ablation was performed in 29 patients including 13 cases of hepatocellular carcinoma stage 0-A (byBarcelona classification and TNM) and 16 patients with colorectal cancer and liver metastases stage I (by Gennari). For microwave ablation of liver tumors AveCure MWG881 (MedWaves) device was used. Procedure was performed via percutaneous transhepatic approach (25), under ultrasonic guidance and intraoperatively simultaneously with liver resection in 4 cases. Effectiveness was estimated using CT and sonography. Results. There were no deaths. We observed following complications: moderate bleeding from the point of needle catheter entry that has stopped independently in 1 case; residual cavity formed in one case that did not require additional surgery. Intrahepatic hematoma was diagnosed in 1 case. Burns of the skin were revealed in 2 cases. The average hospital stay was 7 days. Local recurrences after ablation were not observed. 1- and 2-year survival was 78.5% and 63.3% respectively. Conclusion. Microwave ablation in patients with primary and secondary liver cancer and concomitant cirrhosis increases 1- and 2-year survival. Percutaneous microwave ablation reduces the incidence of complications in high risk patients due to low invasiveness and less trauma.

The effects of prehabilitation versus usual care to reduce postoperative complications in high-risk patients with colorectal cancer or dysplasia scheduled for elective colorectal resection: study protocol of a randomized controlled trial

Of all older patients that opt for elective colorectal surgery, approximately one-third has one or more postoperative complications, particularly those patients with a low cardiorespiratory fitness (ventilatory anaerobic threshold (VAT) < 11 mL/kg/min). A physical exercise training program prior to surgery (prehabilitation) can improve their cardiorespiratory fitness. It remains to be seen whether prehabilitation also reduces postoperative complications, as most of the studies so far were rather underpowered, heterogeneous, and biased toward selection of patients with a lower risk of postoperative complications. The primary objective of this study is to evaluate the effects of a three-week prehabilitation program on 30-day postoperative complications in patients with a VAT < 11 mL/kg/min planned for elective colorectal resection for colorectal cancer or dysplasia. In this multicenter prospective randomized controlled trial, patients ≥ 60 years with colorectal cancer or dysplasia grade I, II, or III, planned for elective colorectal resection in two hospitals in the Netherlands, will be recruited. Eligible patients must have a score ≤ 7 metabolic equivalents on the veterans-specific activity questionnaire, and should be able to perform a cardiopulmonary exercise test. A total of 86 patients will be randomized (block-stratified randomization) to prehabilitation (intervention group) or usual care (control group). For final inclusion, VAT should be < 11 mL/kg/min. Three times a week for 3 weeks, a 60-min supervised prehabilitation session will be completed in community physical therapy practices by the 43 patients in the prehabilitation group, consisting of moderate-to-high intensity interval training to improve cardiorespiratory fitness, and resistance training to improve peripheral muscle strength. Additionally, patients perform home exercises twice a week on a moderate intensity level. The 43 patients in the usual care group will receive usual care. Optimizing preoperative physical fitness may decrease the postoperative complication rate, may lead to fewer reoperations, less intense clinical care, a shorter length of stay, a more effective surgical planning (process-optimization), fewer readmissions, less intense rehabilitation, shorter rehabilitation period, earlier resumption of work, enhance patient perceived health-related quality of life, and promote performance in daily life. Cost-effectiveness should therefore be expected and evaluated. Medical Ethics Committee Twente, Enschede, the Netherlands (NL45001.044.13, September 3, 2013); Netherlands Trial Register (NTR; NTR4032 , June 14, 2013).

Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial.

The aim of this study was to assess the impact of personalized prehabilitation on postoperative complications in high-risk patients undergoing elective major abdominal surgery. Prehabilitation, including endurance exercise training and promotion of physical activity, in patients undergoing major abdominal surgery has been postulated as an effective preventive intervention to reduce postoperative complications. However, the existing studies provide controversial results and show a clear bias toward low-risk patients. This was a randomized blinded controlled trial. Eligible candidates accepting to participate were blindly randomized (1:1 ratio) to control (standard care) or intervention (standard care + prehabilitation) groups. Inclusion criteria were: i) age >70 years; and/or, ii) American Society of Anesthesiologists score III/IV. Prehabilitation covered 3 actions: i) motivational interview; ii) high-intensity endurance training; and promotion of physical activity. The main study outcome was the proportion of patients suffering postoperative complications. Secondary outcomes included the endurance time (ET) during cycle-ergometer exercise. We randomized 71 patients to the control arm and 73 to intervention. After excluding 19 patients because of changes in the surgical plan, 63 controls and 62 intervention patients were included in the intention-to-treat analysis. The intervention group enhanced aerobic capacity [ΔET 135 (218) %; P < 0.001), reduced the number of patients with postoperative complications by 51% (relative risk 0.5; 95% confidence interval, 0.3-0.8; P = 0.001) and the rate of complications [1.4 (1.6) and 0.5 (1.0) (P = 0.001)] as compared with controls. Prehabilitation enhanced postoperative clinical outcomes in high-risk candidates for elective major abdominal surgery, which can be explained by the increased aerobic capacity.

Lenalidomide-Related Spinal Cord Infarction in Primary Amyloidosis

Spinal cord infarction is a rare but often devastating disorder caused by disruption in the vascular spinal supply. We report a patient with spinal cord infarction associated with lenalidomide therapy for primary amyloidosis, in the background of other predisposing factors. We describe the clinical case and discuss the possible explanation for this rare complication. As spinal cord infarction is not a known complication of lenalidomide therapy or amyloidosis, this description raises the potential of such a side effect in some certain conditions and discusses the role of the old and new anticoagulant agents in prevention of thromboembolic complications in high-risk patients.