High-risk Elective Surgery Research Articles

Impact of Enhanced PeriOperative Care in restoring high-risk surgery at an acute tertiary hospital during the COVID-19 pandemic

Background: The COVID-19 pandemic led to an exceptional demand on critical care services and dramatic reduction in elective surgical capacity within our hospital, a large acute tertiary centre. To facilitate high-risk elective surgery and to ease pressure on our critical care unit (CCU), an Enhanced PeriOperative Care (EPOC) unit was established in June 2020. The EPOC service was set up within the framework and guidance offered by the Faculty of Intensive Care Medicine (FICM).1 We evaluated the impact of EPOC on restoring high-risk elective surgery.

PCO2 gap, its ratio to arteriovenous oxygen content, ScvO2 and lactate in high-risk abdominal surgery patients: An observational study

BackgroundThe difference between arterial and central venous carbon dioxide partial pressure (PCO2 gap), a marker of oxygen delivery (DO2) and oxygen consumption (VO2) adequacy, has been evaluated as a promising prognostic tool in intensive care unit (ICU) patients. We therefore sought to study the association between intraoperative PCO2 gap and postoperative complications (POC) in the perioperative setting of elective major abdominal surgery. MethodsWe conducted a single-centre prospective observational study. All adult patients who underwent major planned abdominal surgery were eligible. PCO2 gap was measured every 2 h during surgery, at ICU admission and repeated 12 h and 24 h later. Severe POC within 28 days after surgery were defined as complications graded 3 or more according to Clavien-Dindo classification. Following a univariate analysis, a multivariable analysis using a logistic regression model was performed. ResultsNinety patients were included and divided into two groups according to the occurrence of POC. No significant difference was found between groups regarding baseline characteristics at inclusion. Thirty-nine (43%) patients developed postoperative complications. The median [IQR] intraoperative PCO2 gap was significantly higher in patients who had complications (6.5 [5.5−7.3] mmHg) compared to those who did not (5.0 [3.9–5.8] mmHg; p < 0.001). The area under the receiver operating characteristic curve for occurrence of POC was 0.78 for the PCO2 gap. After multivariable analysis, PCO2 gap was found independently associated with POC (OR: 14.9, 95% CI [4.68–60.1], p < 0.001) with a threshold value of 6.2 mmHg. The duration of surgery (OR: 1.01, 95% CI [1.00; 1.01], p = 0.04) and the need for vasoactive support during surgery (OR: 5.76, 95% CI [1.72; 24.1], p = 0.006) were also independently associated with POC. ConclusionIntraoperative PCO2 gap is a relevant predictive factor of severe postoperative complications in high-risk elective surgery patients. Trial registrationClinicalTrials.gov, NCT03914976.

Outcomes and associated factors among patients undergone emergency laparotomy: A retrospective study

IntroductionEmergency laparotomy patients are different in pathology and surgical urgency. Mortality rates following emergency laparotomy ranges from 13% to 18% which is five times greater than high-risk elective surgery. In addition, major complication rates are as high as 50%. Limited data is available in our country regarding outcomes of emergency laparotomy. This study aimed to assess outcome of emergency laparotomy. ObjectiveTo determine outcomes and associated factors among patients undergone emergency laparotomy. MethodsA four years institutional based retrospective observational study was conducted for patients who undergone emergency laparotomy from January 2016 to January 2020.A total of 518 patient charts were enrolled in this study. All consecutive patient charts during the study period were included. Data was entered and analyzed using SPSS version 20. Descriptive statistics, cross-tabs and logistic regression analysis were performed to identify the association between dependant and independent variables. The strength of the association was presented using adjusted odds ratio with 95% confidence interval and p-value≤0.05 was considered as statistically significant with mortality. ResultsMortality rate was 42 (8.1%) and 70(13.5%) patients were developed complication which needed surgical intervention under general anesthesia. The mean length of hospital stay was 8 ± 5.9 days. Patients age ≥65 (AOR = 9.6, CI = 3.4–27.1), ASA status of ≥III (AOR = 7.4, CI = 1.9–29.3), presence of preoperative sepsis (AOR = 6.7,(95% CI: 2.0–22.6) and intraoperative use of vasopressor (AOR = 10.5,(95% CI: 3.8–29.5) were significantly associated with mortality of emergency laparotomy patients. ConclusionEmergency laparotomy possesses high mortality. Preoperative resuscitation and sepsis management may improve outcome following emergency laparotomy.

P-035. Behavioral risk factors of cardiovascular diseases in pregnant women. Prevalence and socioeconomic predictors in Burkina Faso: a cross-sectional study

Emergency laparotomy patients are different in pathology and surgical urgency. Mortality rates following emergency laparotomy ranges from 13% to 18% which is five times greater than high-risk elective surgery. In addition, major complication rates are as high as 50%. Limited data is available in our country regarding outcomes of emergency laparotomy. This study aimed to assess outcome of emergency laparotomy.To determine outcomes and associated factors among patients undergone emergency laparotomy.A four years institutional based retrospective observational study was conducted for patients who undergone emergency laparotomy from January 2016 to January 2020.A total of 518 patient charts were enrolled in this study. All consecutive patient charts during the study period were included. Data was entered and analyzed using SPSS version 20. Descriptive statistics, cross-tabs and logistic regression analysis were performed to identify the association between dependant and independent variables. The strength of the association was presented using adjusted odds ratio with 95% confidence interval and p-value≤0.05 was considered as statistically significant with mortality.Mortality rate was 42 (8.1%) and 70(13.5%) patients were developed complication which needed surgical intervention under general anesthesia. The mean length of hospital stay was 8 ± 5.9 days. Patients age ≥65 (AOR = 9.6, CI = 3.4–27.1), ASA status of ≥III (AOR = 7.4, CI = 1.9–29.3), presence of preoperative sepsis (AOR = 6.7,(95% CI: 2.0–22.6) and intraoperative use of vasopressor (AOR = 10.5,(95% CI: 3.8–29.5) were significantly associated with mortality of emergency laparotomy patients.Emergency laparotomy possesses high mortality. Preoperative resuscitation and sepsis management may improve outcome following emergency laparotomy.

The effect of compliance with a perioperative goal-directed therapy protocol on outcomes after high-risk surgery: a before-after study

Perioperative goal-directed therapy is considered to improve patient outcomes after high-risk surgery. The association of compliance with perioperative goal-directed therapy protocols and postoperative outcomes is unclear. The purpose of this study is to determine the effect of protocol compliance on postoperative outcomes following high-risk surgery, after implementation of a perioperative goal-directed therapy protocol. Through a before-after study design, patients undergoing elective high-risk surgery before (before-group) and after implementation of a perioperative goal-directed therapy protocol (after-group) were included. Perioperative goal-directed therapy in the after-group consisted of optimized stroke volume variation or stroke volume index and optimized cardiac index. Additionally, the association of protocol compliance with postoperative complications when using perioperative goal-directed therapy was assessed. High protocol compliance was defined as ≥ 85% of the procedure time spent within the individual targets. The difference in complications during the first 30 postoperative days before and after implementation of the protocol was assessed. In the before-group, 214 patients were included and 193 patients in the after-group. The number of complications was higher in the before-group compared to the after-group (n = 414 vs. 282; p = 0.031). In the after-group, patients with high protocol compliance for stroke volume variation or stroke volume index had less complications compared to patients with low protocol compliance for stroke volume variation or stroke volume index (n = 187 vs. 90; p = 0.01). Protocol compliance by the attending clinicians is essential and should be monitored to facilitate an improvement in postoperative outcomes desired by the implementation of perioperative goal-directed therapy protocols.

Considering self-reported baseline function and cognition in predicting post-operative complications among older adults.

Older adults experience high rates of postoperative complications and poorer outcomes. Current perioperative risk assessments lack specific measures and are too time-consuming for busy surgeons. Using data from the Health and Retirement Study Survey linked with Medicare data, we performed a cross-sectional study, evaluating all adults ≥65 years old who underwent high-risk elective surgery between 1992-2012. Primary exposure variables included self-reported preoperative functional and cognitive abilities using activities of daily living (ADLs), instrumental activities of daily living (IADLs), and a 27-point self-administered test of memory and mental processing. Primary outcome was the development of a serious postoperative complication within 30-days following index operation. Overall, 42% (n=501) developed at least one serious postoperative complication. Patients with moderate (aOR 1.52, 95% CI: 1.14-2.04) and severe (aOR 1.55, 95% CI: 1.00-2.46) baseline functional limitations were at higher risk of serious postoperative complications compared to those with no functional limitation. Cognitive impairment was not associated with serious postoperative complications. Self-reported functional measures may help to quickly identify patients at high-risk for surgical complications and better inform pre-operative discussions including earlier initiation of palliative care services.

Continuous Noninvasive Haemoglobin Monitoring in Vascular Surgery within the Goal-Directed Therapy Protocol

The optimisation of DO2, within the Goal-Direct Therapy Protocol (GDTP) in high-risk surgical patients, improves their outcome. Haemodynamic and haemoglobin monitoring become crucial to achieve optimal DO2. Our study compared Hb as measured by three methods: Coulter Counter (standard laboratory method) and CO-Oximetry (Masimo rainbow SET Radical 7 Pulse CO-Oximetry (SpHb) and Blood Gas Analysis) to establish the utility of the Hb continuous intraoperative monitoring, within the GDTP, in high-risk bleeding surgery. We studied 72 patients undergoing open abdominal aortic aneurysm repair. We compared the accuracy and the trending ability in measuring the haemoglobin concentration between the three methods (Coulter Counter, BGA and Masimo). We collected three simultaneous haemoglobin measurements: after induction of anaesthesia, pre- and post-aortic cross-clamping and at the end of the surgery. SpHb showed an excellent r-value for all samples (0.952, CI-95% (0.939, 0.961), p-value &lt; 0.0001) compared to laboratory measurements. The results of the linear regression between SpHb and laboratory, for each time considered, demonstrated that SpHb showed excellent r and R2 value. All data were statistically significant, with a p-value &lt;0.0001. A Bland-Altmann analysis for SpHb vs. laboratory showed a bias of −1.45 g/dL (CI-95% −1.51 and −1.39 g/dL, LOA from −2.42 to −0.48 g/dL) with a precision of 0.49 g/dL. Four-quadrant plot trend analyses showed a high concordance rate ≥90%. During elective high-risk surgery, Masimo Pulse CO-Oximetry is not enough sufficiently accurate to assess the current value of haemoglobin but may be useful for the trend value ensuring DO2 within intraoperative GDTP.

Early risk factors and the role of fluid administration in developing acute respiratory distress syndrome in septic patients

Background Sepsis is a major risk factor for acute respiratory distress syndrome (ARDS). However, there remains a paucity of literature examining risk factors for ARDS in septic patients early in their course. This study examined the role of early fluid administration and identified other risk factors within the first 6 h of hospital presentation associated with developing ARDS in septic patients.MethodsThis was a secondary analysis of septic adult patients presenting to the Emergency Department or being admitted for high-risk elective surgery from the multicenter observational cohort study, US Critical Injury and Illness trial Group-Lung Injury Prevention Study 1 (USCIITG-LIPS 1, NCT00889772). Multivariable logistic regression was performed to identify potential early risk factors for ARDS. Stratified analysis by shock status was performed to examine the association between early fluid administration and ARDS.ResultsOf the 5584 patients in the original study cohort, 2534 (45.4%) met our criteria for sepsis. One hundred and fifty-six (6.2%) of these patients developed ARDS during the hospital stay. In multivariable analyses, Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR 1.10, 95% CI 1.07–1.13), age (OR 0.97, 95% CI 0.96–0.98), total fluid infused in the first 6 h (in liters) (OR 1.15, 95% CI 1.03–1.29), shock (OR 2.57, 95% CI 1.62–4.08), pneumonia as a site of infection (OR 2.31, 95% CI 1.59–3.36), pancreatitis (OR 3.86, 95% CI 1.33–11.24), and acute abdomen (OR 3.77, 95% CI 1.37–10.41) were associated with developing ARDS. In the stratified analysis, total fluid infused in the first 6 h (in liters) (OR 1.05, 95% CI 0.87–1.28) was not associated with the development of ARDS in the shock group, while there was an association in the non-shock group (OR 1.21, 95% CI 1.05–1.38).ConclusionsIn septic patients, the following risk factors identified within the first 6 h of hospital presentation were associated with ARDS: APACHE II score, presence of shock, pulmonary source of infection, pancreatitis, and presence of an acute abdomen. In septic patients without shock, the amount of fluid infused during the first 6 h of hospital presentation was associated with developing ARDS.

Scarcity

Clinicians' perceptions of scarcity influence rationing of critical care resources, which may lead to serious adverse outcomes for patients who are denied access. We sought to better understand the phenomenon of scarcity in the critical care setting. Qualitative research methods. We used purposeful sampling to recruit ICU clinicians who were frequently involved in decisions to allocate ICU resources. Thematic analysis was performed to identify concepts related to the phenomenon of scarcity. An ICU of a university-affiliated hospital in Toronto, Canada, between October and December 2007. We conducted 22 interviews with 12 ICU physicians, 4 ICU fellows, 2 ICU nursing team leaders, and 4 ICU resource nurses. The perception of scarcity arose from a complex interaction of factors within the institution including: 1) practices of non-ICU physicians (e.g., failure to specify end-of-life treatment plans or to secure an ICU bed prior to elective high-risk surgery), 2) family demands for life support and clinicians' perception of a lack of legal support if they opposed these, and 3) inability to transfer patients to non-ICU care settings in a timely manner. Implications of scarcity included: 1) diversions of critically ill patients, 2) premature patient transfers, 3) temporary delivery of critical care in non-ICU locations (e.g., emergency department, postanesthesia care unit), and 4) interprofessional conflicts. ICU clinicians' perceptions of scarcity may lead to rationing of critical care resources. We found that nonmedical factors strongly influenced prioritization activity, both for admission and discharge. Although scarcity of ICU beds might be mitigated by process improvements such as patient flow or proactive communication, our findings highlight the importance of a fair process for inevitable limit setting at the bedside.

Cardiovascular assessment for noncardiac surgery

Cardiac complications such as myocardial infarction and cardiac death are a common cause of morbidity and mortality in patients undergoing noncardiac surgery. Risk stratifying these patients by evaluating their clinical history, risk factors, functional capacity and surgery-specific risk in conjunction with noninvasive and invasive tests, is essential to optimize patients for surgery. Patients with low clinical risk and good functional status, undergoing low- or intermediate-risk surgery, have an excellent prognosis and may proceed straight to surgery. Stable patients with previous coronary revascularization may also safely undergo surgery. Patients requiring emergency surgery should proceed immediately as the benefits will outweigh the delay associated with cardiac risk assessment. However, worse peri-operative outcomes are associated with previous or current cardiac disease, diabetes, renal dysfunction, poor exercise tolerance and high-risk surgery. Controversy surrounds patients with high clinical risk undergoing elective high-risk surgery. In this case, noninvasive testing may be of value, with best evidence favouring dobutamine stress echocardiography. Coronary revascularization in risk limitation is unproven and peri-operative β -blockade is best indicated. Coronary revascularization should be reserved for patients with unstable angina or stable angina refractory to medical therapy. We review the issues surrounding peri-operative risk stratification and the therapies that exist to prevent complications.

Recently published papers: of head injuries, high frequencies and haemodynamic optimization.

Recently published papers: of head injuries, high frequencies and haemodynamic optimization.

Early continuous noninvasive haemodynamic monitoring after severe blunt trauma

Background: invasive haemodynamic parameters obtained by pulmonary artery (PA) catheterization from survivors' patterns were reported to provide criteria for therapeutic goals in high-risk elective surgery and accidental injuries. This approach is limited because PA catheterization requires critical care conditions; however, noninvasive methods can provide early information anywhere in the hospital. Objectives: to evaluate the feasibility of using noninvasive haemodynamic monitoring of patients with severe blunt trauma immediately after emergency department (ED) admission and to describe the early time course of haemodynamic events in survivors and nonsurvivors of blunt trauma. Setting: a large, academic, level-I trauma centre. Design: prospective, descriptive haemodynamic study. Patients and methods: 38 severely injured patients, 22 (58%) survivors and 16 (42%) nonsurvivors, with ISS>15 were monitored by: (a) an improved thoracic bioelectric impedance device that estimated cardiac output noninvasively and continuously, (b) simultaneous arterial oxygen saturation by pulse oximetry, (c) noninvasive blood pressure measurement and (d) transcutaneous oxygen and carbon dioxide sensors. The patients were monitored as soon as possible upon arrival at the ED and continued during the first 24 h or more after admission. When the patient reached the ICU, monitoring by PA catheterization was undertaken to validate the noninvasive methods and for continued diagnostic evaluations. Results: cardiac output estimations by thermodilution and bioimpedance were well correlated; r=0.91. Survivors started with high cardiac index (CI) values that subsequently rose to over 4 L/min/m 2; arterial oxygen saturation (SaO 2), transcutaneous oxygen tension and transcutaneous-oxygen-tension-to-inspired-fraction-of-oxygen-concentration (PtcO 2/FiO 2) values were normal in survivors and higher than those of the nonsurvivors. In the 1st h after admission, nonsurvivors' blood pressures were higher than normal and higher than that of the survivors, but in the 2nd and 3rd h, both groups were in the normal range; thereafter, nonsurvivors' values were lower than survivors' and often lower than normal. Conclusions: the noninvasive haemodynamic monitoring system provides reasonably accurate, continuous, on-line, real-time display of haemodynamic data that show marked differences in the early patterns of survivors and nonsurvivors. The study suggests noninvasive monitoring may be used for early detection and correction of posttraumatic circulatory deficits.

Advance directive use among patients undergoing selected high-risk surgical procedures.

Since 1991, the Patient Self-Determination Act has required that all patients entering Medicare-reimbursed institutions be asked if they have an advance directive (AD) and be given information about advance directives if they do not have one. Patients undergoing elective high-risk surgery for diseases with a poor prognosis were identified as being most likely to benefit from an AD. The charts of patients being explored for possible pancreaticoduodenectomy or esophagectomy at a tertiary referral hospital in 1996 were retrospectively reviewed. Few patients had an AD, and there was little evidence that the presence of an AD affected patient care.