Factors For Postoperative Morbidity Research Articles

Ventricular Fibrillation Following Synchronized Cardioversion in Junctional Ectopic Tachycardia: A Pediatric Case Report

Junctional ectopic tachycardia (JET) has been observed in up to 11.4% of pediatric patients after cardiac surgery and is the most common tachyarrhythmia during the early postoperative period. 1 Following surgery, the heart is vulnerable to the negative effects of a high heart rate and atrioventriular (AV) asynchrony, which can lead to hemodynamic instability, decreasing cardiac output. Accurate identification of JET is critical because it is not amenable to synchronized cardioversion and is an important factor in postoperative morbidity. 1 The following case is an example of the cardioversion attempt of a perfusing tachyarrhythmia mistakenly identified as supraventricular tachycardia (SVT).A 5-month-old, 8.7-kg, female infant underwent surgical treatment of complete atrialventricular septal defect with a common atrium, left-looped ventricles, pulmonary atresia with confluent pulmonary arteries, and dextrocardia. A Glenn shunt and AV valvuloplasty was performed with a cardiopulmonary bypass time of 225 minutes and aortic cross-clamp time of 47 minutes.Adenosine was successfully used in the operating room for SVT after cardiopulmonary bypass was discontinued. Intermittent tachycardia continued throughout the first postoperative night. The morning of postoperative day 1, the patient was tachycardiac (>200/min) with a variable arterial blood pressure. Supraventricular tachycardia was suspected, and the child was cardioverted using 0.5 J/kg of body weight (Figure 1). Immediately afterward ventricular fibrillation occurred without measurable blood pressure or detectable pulse. Defibrillation using 2 J/kg of body weight was immediately performed with restoration of tachyarrhythmia (220/min) with variable blood pressure present (Figure 2). Cardiologists were contacted and consultation identified the rhythm as JET, not SVT. The patient was cooled to a temperature of 35.5°C via environmental exposure. Potassium and magnesium levels were normalized and the child was given amiodarone 5 mg/kg body weight over 1 hour, with eventual restoration of sinus rhythm.Junctional ectopic tachycardia is associated with AV asynchrony, which may lead to hypotension. The rhythm does not respond to electrical cardioversion. 2 The dysrhythmia has been commonly observed following cardiac surgery, and its presence may be a marker of an untoward effect of the surgical procedure. 3 Risk factors for the development of JET include young age (<30 days), weight less than 4 kg, aortic cross-clamp time more than 60 minutes, cardiopulmonary bypass time more than 100 minutes, and postoperative magnesium and potassium levels that are lower than normal levels.4, 5 Identification of JET is crucial for proper treatment. When AV dissociation is present, cannon A waves will be apparent in the waveforms of central venous pressure monitoring, such as right- and left-atrial lines, and P waves will not be apparent on continuous electrocardiographic monitoring.Treatment of JET primarily involves support and restoration of hemodynamics. If the rhythm is slow and blood pressure is acceptable, then not treating the arrhythmia may be entertained. In cases of hemodynamic instability, treatment of JET includes overdrive pacing, avoidance of hyperthermia, optimization of sedation, pacer control, and administration of amiodarone.2–7 Optimizing electrolytes and decreasing inotropic therapy may also be indicated.4–7Interdisciplinary teams caring for critically ill pediatric cardiac surgery patients in the postoperative period should be aware that JET is a common rhythm for patients undergoing repairs near the AV node. Supraventricular tachycardia also can occur during this same timeframe and had been successfully treated in the patient with chemical cardioversion (adenosine) in the immediate postbypass period. Although suspecting SVT as the tachyarrhythmia in the patient was reasonable, on reflection, seeking expert consultation before proceeding to cardioversion would have been preferable. The patient had a perfusing rhythm at the time that may have allowed time for a cardiology consult, assessment, and development of a treatment plan. A 12-lead electrocardiogram also could have aided the assessment.Differences between SVT and JET could have served as cues to which rhythm was present. P waves are absent in both rhythms, and the rates are often more than 200/min in children younger than 1 year. Supraventricular tachycardia, however, usually has a fixed rate that is not changed by stimulation, temperature, or pain medications. The JET rate, on the contrary, can vary up and down on the basis of the patient’s condition. Therefore, JET is treated with cooling, sedative agents, and interventions that decrease metabolic demands.6,7 Those who care for pediatric patients at risk of these arrhythmias can use this knowledge to help inform the collaborative decision-making process for interventions.Proper and timely identification of JET is necessary to avoid morbidity and mortality of postoperative cardiac pediatric patients. Anticipating potential changes in the patient’s condition is critical so that evidence-based interventions can be initiated. Interdisciplinary team members caring for this population of patients need expert assessment skills and collaborative processes in place when complexities arise to ensure excellent care for pediatric patients and positive patient outcomes.

Chirurgia Cancerului Gastric–Analiza A 110 Cazuri

Introduction: The current trend for the modern treatment of gastric cancer it is represented by radical surgery with extended lymphadenectomy. The lymphadenectomy, as defined by the Japanese surgeons, is an important, already proved, marker for the overall and disease free survival, but is associated with a risk of postoperative morbidity and mortality. Aim: The aim of the study was to analyze the gastric cancer surgery evaluating the postoperative morbidity and mortality. Material and Method: We performed an observational study, on 110 patients with gastric cancer operated in the Emergency Clinical Hospital BucureE™ti. We also included in our study the tumors located at the gastro-oesophageal junction (that proved by histopathology exam to be of gastric origin) and the tumors of the remnant stomach. RESULTS: The men to women ratio was 1.5 and the mean age was 65.02 ± 11.04 years old. The gastric cancer is located in the 1/3rd upper part in 20.90% cases, and on the distal 2/3rd in 68.17%. Almost half of the patients (48.18%) were admitted with complications (bleeding, stenosis and/or perforation). 25.54% from the patients had distant metastasis (liver, peritoneum, pulmonary, or/and lymphnodes). All the cases were advanced or locally advanced gastric cancer and no case of early gastric cancer has been noted. Most of our surgical interventions were standard resections: total or distal gastrectomy associated with D1 lymphadenectomy in 64 cases and D2 in 32 cases. The mean operative time was 182.3 ± 99 minutes. The overall mortality rate was of 4.5%. The type of lymphadenectomy wasn’t a risk factor for postoperative mortality. Conclusions: The gastric cancer is diagnosed, most commonly, in an advance stage. However, the trend is to perform radical or potentially radical gastrectomies associated with D1 or D2 lymphadenectomy. The type of lymphadenectomy is not a risk factor for postoperative morbidity and mortality.

A New Score to Predict Post Operative Complications after Endovascular Treatment of Thoraco Abdominal Aortic Aneurysms

Background: The endovascular treatment of thoraco abdominal aortic aneurysms (TAAA) is a minimally invasive solution. However, patient selection remains a major problem. We have analysed our experience to identify the risk factors for post-operative morbidity and mortality and to construct a scoring system to identify those patients likely to benefit from this treatment.Methods : We have analysed a consecutive cohort of patients treated electively for TAAA using endovascular techniques between 2006 and October 2012. All data were collected prospectively. The risk factors associated with spinal cord ischemia (SCI), the need for post-operative dialysis and 30 day mortality were determined using multivariate statistical techniques and a logistic regression model including all variables that were significant on univariate analysis (p < 0.05). A predictive score was calculated using a Received Operating Characteristic (ROC) curve, defining best specificity and sensibility.Results : We analysed the data from 113 patients (median age 70 years). The 30 day mortality rate was 8% (10 patients). The SCI rate was 6% (7 patients). One patient (1%) required long-term dialysis after the aortic procedure. The cumulative early mortality, SCI and permanent dialysis rate was 14% (17 patients). In multivariate analysis, adverse outcome was associated with advanced age (OR = 1.110; p = 0.011), and Crawford type I or II or III (OR = 9.191; p = 0.002) as compared with Crawford type IV. Pre-operative beta blocker (BB) treatment was a protective factor (OR = 0.099; p = 0.005). A predictive score was then constructed: Score = -10.060 + 0.104x(A) +2.229x(B) -1.315x(C)(A = patient age; B = 1 if TAAA Crawford type 1, 2 or 3, 0 if TAAA type 4; C = 1 if on-going BB treatment (30 days pre-surgery minimum), 0 if none). Its sensitivity and specificity were 88% and 89% respectively. Conclusion : We propose a simple predictive scoring system. This tool is useful in predicting the most feared complications after endovascular TAAA repair and has potential use in the identification and counselling of vulnerable patients being considered for surgery. More data are needed to refine the prediction of individual operative risks.

Anaemia is a predictor of mortality in patients undergoing aortic valve surgery

We read the article ‘Preoperative anaemia is a risk factor for mortality and morbidity following aortic valve surgery (AVS)’ by Elmistekawy et al. [1] with interest. They aimed to investigate the incidence of preoperative anaemia in patients undergoing nonemergency AVS and its association with postoperative outcomes. They concluded that preoperative anaemia is a common finding in patients undergoing AVS and is an important and potentially modifiable risk factor for postoperative morbidity and mortality. We believe that these findings will pave the way for further studies about the relationships between preoperative anaemia and AVS. Thanks to the authors for their contribution. It is actually believed that patients undergoing heart surgery have a lower margin of safety for tolerance of low haemoglobin (Hg) levels. A significant association between anaemia with adverse outcomes (death, stroke and renal impairment) in patients undergoing cardiac and non-cardiac surgery has been demonstrated in previous studies [2]. Blood transfusion is dangerous with regard to in-hospital mortality, morbidity and long-term survival. Blood transfusion is frequently used as a volume expander while simultaneously increasing the haematocrit. Transfusions have been independently associated with increased mortality after cardiac surgery. Transfusion is also dose-dependent risk factor for early mortality after revascularization. Blood transfusions have been linked to postoperative renal dysfunction, pneumonia, wound infections, severe sepsis and hospital mortality [3]. Based on this point of view, because anaemia and need for blood transfusions lead to very significant adverse effects after cardiopulmonary bypass surgery, it is necessary to research the effective methods of anaemia correction to reduce the need for blood transfusions. Nowadays, although anaemia is a predictor of postoperative complications and is a risk factor for mortality in patients after cardiac surgery treatment, red distribution width (RDW) is known as an independent early marker of Hg evolution and independently identified risk of new onset anaemia, providing predictive information for haematological abnormalities beyond Hg concentrations and other known risk factors. RDW has recently been identified as an independent predictor of all-cause long-term mortality in patients with coronary artery disease [4]. So, if the authors had mentioned RDW, the results of the study might be different. Reduced glomerular filtration rate (GFR) may also be associated with adverse outcomes in patients with cardiovascular disease. In previous study, preoperative GFR was predictive of all-cause mortality, cardiovascular mortality and combined cardiovascular mortality and morbidity. GFR may be useful to identify those patients undergoing cardiovascular surgery with subclinical chronic kidney disease [5]. For this reason, it would be better, if the authors mentioned any of these possible conditions. Finally, it would be better if the authors might define how much time they specified on measuring Hg levels, because it can be associated with haemodilutional anaemia [6]. Following cardiac surgery, some factors including longer hospital stays, increased risk of infection, higher rate of pulmonary complications, prolonged ventilation, stroke, renal failure, atrial fibrillation, myocardial infarction, pneumonia, prolonged ventilation and operation time are associated with increased morbidity and mortality rates in patients undergoing AVS [3]. So, the further studies should evaluated these factors in patients with AVS.

Preoperative anaemia is a negative factor in aortic valve surgery

The impact of anaemia on patients undergoing aortic valve surgery is poorly understood. Anaemia is associated with aortic valve surgery. A recent article by Elmistekawy et al. [1] demonstrated that preoperative anaemia is a common finding in patients undergoing aortic valve surgery and is an important and potentially modifiable risk factor for postoperative morbidity and mortality. This analysis suggests that anaemia may serve as a negative factor in aortic valve surgery. Other studies have been carried out on this topic. Major surgery in a patient with pancytopenia might be associated with increased surgical risks, particularly for bleeding and infection. Halliday et al. [2] demonstrated that, in a logistic regression model, coexisting vascular disease, diabetes and preprocedural anaemia significantly affected the incidence of life-threatening or major bleeding. Furthermore, Kitamura et al. [3] have shown that postoperatively, a patient developed paravalvular leak and haemolytic anaemia, subsequently undergoing reoperation. Also, Van Mieghem et al. [4] found that baseline anaemia is common in patients undergoing transcatheter aortic valve implantation, forecasts a need for more red blood cell transfusions and is associated with increased 1-year mortality. Moreover, hypercoagulative states have been observed in patients with alpha-thalassaemia as beta-thalassaemia; therefore, special attention should be taken in perioperative anticoagulation therapy. Kawase et al. [5] indicated that haemolytic anaemia with aortic stenosis resolved by urgent aortic valve replacement. However, Lee and Lee [6] reported a successful cardiac surgery with extracorporeal cardiopulmonary bypass in a patient with severe aortic valve insufficiency and concomitant idiopathic aplastic anaemia. In summary, these findings suggest that anaemia may be a negative factor in aortic valve surgery. Therapeutic agents targeting anaemia might result in innovative new therapies for aortic valve surgery. Finally, we greatly enjoyed reading the article by Elmistekawy et al. and believe that the prevention and treatment of anaemia may be useful in aortic valve surgery.

A predictive model of risk and outcomes in tissue expander reconstruction: A multivariate analysis of 9786 patients

Outcomes of tissue expander breast reconstruction show variability based on presurgical risk factors. Few comprehensive, multi-institutional risk analyses exist. Patients who underwent tissue expander reconstruction were identified in a multi-institutional registry that spans over 240 institutions with over 200 variables per patient. Bivariate analysis of preoperative variables was performed across outcomes. Multivariate logistic regression was used to adjust for confounders and identify risk factors for complications. In 9786 total tissue expander patients, 526 (5.38%) patients experienced one or more complications. Wound infection and reoperations occurred in 3.45% and 6.76% of patients, respectively. Body mass index (BMI) was found to be a significant independent risk factor for overall morbidity, reoperation, prosthesis failure, and wound infection. Overweight, obese, and morbidly obese patients were at 1.7-, 2.6-, and 5.1-times greater risk of morbidity, respectively (p < 0.001 for all). Reconstructive timing, combined surgical procedures, and neoadjuvant chemotherapy were not found to be significant predictors of morbidity. The odds of developing complications were 1.5- and 1.3-times greater in smokers and patients over the age of 50, respectively (p = 0.001 and p = 0.015). For each additional hour of surgery, the odds of morbidity increased 1.26-times (p < 0.001). Precise risk profiles garnered from multi-institutional studies can help improve patient selection and education. Overall, tissue expander reconstruction was found to be safe, with relatively few complications. Operative time, BMI, and smoking were consistently found to be independent risk factors for postoperative morbidity.

Human Acellular Dermis versus Submuscular Tissue Expander Breast Reconstruction: A Multivariate Analysis of Short-Term Complications

BackgroundAcellular dermal matrix (ADM) allografts and their putative benefits have been increasingly described in prosthesis based breast reconstruction. There have been a myriad of analyses outlining ADM complication profiles, but few large-scale, multi-institutional studies exploring these outcomes. In this study, complication rates of acellular dermis-assisted tissue expander breast reconstruction were compared with traditional submuscular methods by evaluation of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) registry.MethodsPatients who underwent immediate tissue expander breast reconstruction from 2006-2010 were identified using surgical procedure codes. Two hundred forty tracked variables from over 250 participating sites were extracted for patients undergoing acellular dermis-assisted versus submuscular tissue expander reconstruction. Thirty-day postoperative outcomes and captured risk factors for complications were compared between the two groups.ResultsA total of 9,159 patients underwent tissue expander breast reconstruction; 1,717 using acellular dermis and 7,442 with submuscular expander placement. Total complications and reconstruction related complications were similar in both cohorts (5.5% vs. 5.3%, P=0.68 and 4.7% vs. 4.3%, P=0.39, respectively). Multivariate logistic regression revealed body mass index and smoking as independent risk factors for reconstructive complications in both cohorts (P<0.01).ConclusionsThe NSQIP database provides large-scale, multi-institutional, independent outcomes for acellular dermis and submuscular breast reconstruction. Both thirty-day complication profiles and risk factors for post operative morbidity are similar between these two reconstructive approaches.

Thoracic epidural anesthesia for modified radical mastectomy in carcinoma of breast patient with chronic obstructive pulmonary disease: A case report

Introduction: Modified radical mastectomy, the standard surgical procedure in the management of carcinoma of breast is routinely performed under general anesthesia. But the patients of chronic obstructive pulmonary disease with other comorbidites are at increased risk of perioperative morbidity and mortality especially because of pulmonary complications. We report successful perioperative management of modified radical mastectomy only with thoracic epidural anesthesia in a diagnosed case of carcinoma of breast with hypertension, type 2 diabetes mellitus and severely compromised pulmonary function. Case Report: A 66-year-old female, a known case of chronic obstructive pulmonary disease since seven years with comorbidites (ASA grade III), presented with carcinoma of breast was scheduled for modified radical resection. Continuous thoracic epidural anesthesia was administered at T4-5 level. Local anesthetic titrated as per the demands of surgery and postoperative analgesia. Chromic obstructive pulmonary disease has been considered as independent risk factor for postoperative morbidity and mortality because of cardiopulmonary complications. But Thoracic epidural anesthesia, one of the regional anesthesia techniques, with use of low dose of local anesthetic helps preserving respiratory function. The procedure was well tolerated without cardiopulmonary complications which lead to prompt recovery with additional effect of prolonged postoperative analgesia. Conclusion: Thoracic epidural anesthesia provided not only hemodynamic, cardiopulmonary stability but also adequate anesthesia, analgesia and satisfaction to patient in postoperative phase. It proved to be an excellent anesthesia technique for modified radical mastectomy in patient with chronic obstructive pulmonary disease.

Metadona e morfina na indução da anestesia em cirurgia cardíaca: repercussão na analgesia pós-operatória e prevalência de náuseas e vômitos

BACKGROUND AND OBJECTIVES: Pain is an aggravating factor in postoperative morbidity and mortality especially in large size surgeries. Methods to effectively fend pain collide with elevated costs and for this reason they are not accessible in every service. The option would be the use of an opioid with long half-life, such as methadone. The objective of the present study was to compare the requirements of postoperative analgesia in patients who received methadone, morphine, or placebo during anesthetic induction, besides the prevalence of postoperative nausea and vomiting. METHODS: Fifty-five patients scheduled for cardiac surgery were divided into three groups and they received during anesthetic induction 20 mg of methadone, 20 mg of morphine, or placebo. At the end of surgery, patients were transferred to the ICU where the following parameters were evaluated: duration of anesthesia, time until extubation, time until the need of the first analgesic, number of doses required in 24 hours, assessment of analgesia by the patient, and prevalence of nausea/vomiting. RESULTS: Differences in the duration of anesthesia and time until extubation were not observed. The first dose of analgesic in patients who received methadone was administered later than in patients in the other two groups. The need of analgesics in the methadone group was lower, quality of analgesia was better, and prevalence of nausea and vomiting was also lower. CONCLUSIONS: Methadone during anesthetic induction was effective for analgesia in large size surgeries. Lower incidence of nausea and vomiting was observed in the methadone group and therefore it is a low cost option available among us that should be stimulated.

Methadone and Morphine during Anesthesia Induction for Cardiac Surgery. Repercussion in Postoperative Analgesia and Prevalence of Nausea and Vomiting

Pain is an aggravating factor in postoperative morbidity and mortality especially in large size surgeries. Methods to effectively fend pain collide with elevated costs and for this reason they are not accessible in every service. The option would be the use of an opioid with long half-life, such as methadone. The objective of the present study was to compare the requirements of postoperative analgesia in patients who received methadone, morphine, or placebo during anesthetic induction, besides the prevalence of postoperative nausea and vomiting. Fifty-five patients scheduled for cardiac surgery were divided into three groups and they received during anesthetic induction 20mg of methadone, 20mg of morphine, or placebo. At the end of surgery, patients were transferred to the ICU where the following parameters were evaluated: duration of anesthesia, time until extubation, time until the need of the first analgesic, number of doses required in 24 hours, assessment of analgesia by the patient, and prevalence of nausea/vomiting. Differences in the duration of anesthesia and time until extubation were not observed. The first dose of analgesic in patients who received methadone was administered later than in patients in the other two groups. The need of analgesics in the methadone group was lower, quality of analgesia was better, and prevalence of nausea and vomiting was also lower. Methadone during anesthetic induction was effective for analgesia in large size surgeries. Lower incidence of nausea and vomiting was observed in the methadone group and therefore it is a low cost option available among us that should be stimulated.

Effects of an immuno-enhanced diet containing antioxidants in esophageal cancer surgery following neoadjuvant therapy

Neoadjuvant therapy-induced immunological deterioration may be a key factor in postoperative morbidity in patients with esophageal cancer. This study aimed to determine the effects of perioperative feeding with an immuno-enhanced diet on immune competence in patients treated with neoadjuvant therapy followed by surgery. Because an immuno-enhanced diet that contained several antioxidants was used, perioperative oxidative stress and the effects of the immuno-enhanced diet on this stress were also investigated. Of 39 patients with esophageal cancer who underwent similar surgical procedures, 26 patients who received chemotherapy or chemoradiation therapy before surgery were randomly divided into two groups: group 1 (n= 14) was given an immuno-enhanced diet for 5 days before surgery, and group 2 (n= 12) received no enteral feeding products before surgery. Group 3 (n= 13) consisted of patients that did not receive neoadjuvant therapy and received no enteral feeding products before surgery. Several markers for coagulation and fibrinolysis were determined and immunological assessments were performed for each patient. To measure reactive oxygen metabolites and the total antioxidant capacity, diacron-reactive oxygen metabolites (d-ROMs) and OXY-adsorbent tests were performed using a free radical elective evaluator. Significant depression in lymphocyte numbers was observed in groups 1 and 2 before and early after surgery as compared to group 3. Numbers of B cells, CD4/CD8 ratio, and phytohemagglutinin-induced lymphocyte transformation tests were also significantly decreased in groups 1 and 2 on postoperative day 1. Fibrin and fibrinogen degradation products were significantly elevated in group 2 compared to group 1. d-ROMs and OXY-adsorbent test values were elevated before surgery and were decreased transiently early after surgery. Compared to groups 2 and 3, d-ROMs values were significantly lower in group 1 patients throughout the postoperative period, while OXY-adsorbent test values were significantly higher in group 2 patients. Oxidative index was significantly suppressed in group 1 compared to group 3. No significant intergroup differences were observed with regard to morbidity after surgery. Although the baseline levels of immunological function might have been different because of less-advanced cancer stages in group 3, neoadjuvant therapy significantly affected several immunological parameters. Preoperative administration of an immuno-enhanced diet did not significantly prevent neoadjuvant therapy-induced immunological deterioration prior to esophageal cancer surgery. Patients with esophageal cancer had elevated levels of oxidant and antioxidant activities before surgery, which were transiently decreased early after surgery. Although the underlying mechanisms for these perioperative changes are unclear, this study showed that an immuno-enhanced diet containing several antioxidants may reduce oxidative stress following esophageal cancer surgery. After these mechanisms are studied further, oxidative stress control may become another tool for perioperative management to reduce morbidity after esophageal cancer surgery.

Is TNM classification related to early postoperative morbidity and mortality after colorectal cancer resections?

To examine the role of TNM staging system as a predictive factor for postoperative morbidity and mortality, after colorectal cancer resections. During the last ten years, 368 patients with colorectal cancer were referred to our institution. All patients, who underwent primary treatment elsewhere or defunctioning colostomy only, or who did not undergo surgical therapy were excluded from the analysis. The early postoperative outcomes registration of the remaining 351 patients (197 men, median age 66.2 years) was retrospectively linked to TNM stage. TNM stage had a poor prognostic value for the early postoperative morbidity rate. In addition, according to the statistical analysis, the proportion of early postoperative mortality proved to be higher in patients with TNM stage III or IV colorectal cancer. TNM classification could be considered as a reliable predictor of early postoperative mortality, but has no role in the prediction of early postoperative morbidity after colorectal resections.

The Effect of PaCO2 on Cerebral Perfusion: An Experimental Swine Model

Adequate cerebral perfusion is of particular concern to the clinician and is a major factor in postoperative morbidity. Cerebral circulation has the ability to autoregulate blood flow in order to maintain nutrient delivery and prevent high intravascular pressures. The focus of this study was to characterize the impact of gradually changing arterial CO2 levels on cerebral perfusion. A total of eight porcine subjects were placed into either a normothermic group (NG, N = 4, rectal temperature = 35.4 ± 1.2° C) or a hypothermic group (HG, N = 4, 30.6 ± 0.6° C). After initiation of cardiopulmonary bypass, the PaCO2 values sequentially varied between 24 and 56 mmHg. Arterial, venous, and internal jugular blood gas data were collected at 4 mmHg increments, and relative cerebral blood flow was calculated as CBF = 1 (CarterialO2–CjugularO2)−1 Physiological parameters were similar in both groups across all test conditions: mean arterial pressure— NG 81.6 ± 11.9 mmHg versus HG 73.4 ± 7.0 mmHg, p = NS, and systemic oxygen consumption—HG 110.6 ± 30.0 mL min−1 versus NG 136.4 ± 37.9 mL min−1, p = NS. No significant differences were found in CBF in the NG (21.8 ± 4.4 mL min−1 100 gL at PaCO2= 56 mmHg versus 20.5 ± 5.0 mL min−1 100 g−1 at PaCO2 = 24 mmHg) or the HG (24.3 ± 9.5 mL min−1 100 g−1 at PaCO2 = 56 mmHg versus 25.6 ± 12.0 mL min−1 100 g−1 at PaCO2 = 24 mmHg). In conclusion, the alteration of PaCO2 under both hypothermic and normothermic conditions resulted in no significant differences in 1 (CarterialO2 – CjugularO2)−1 in this model.

Perioperative factors influencing surgical morbidity: what the anesthesiologist needs to know.

S URGERY is accompanied by widespread changes in organ function. These functional changes are mediated by an alteration in the endocrine-metabolic milieu and activation of several biological cascade systems known as inflammatory mediators. These responses presumably evolved because they confer an advantage with respect to survival. In fact, it seems indisputable that when an individual organism acquires an enhanced ability to recover from an injury, the species is benefitted. However, the metabolic response can also be debilitaring and can lead to organ dysfunction. If amplified and prolonged, the body cell mass becomes eroded. Despite advances in anesthesia care and surgical techniques, major surgery is still beset with undesirable consequences amongst which the most important are infection, thrombo-embolic and cardio-respiratory complications, cerebral dysfunction, gastrointestinal paralysis, pain, fatigue and prolonged convalescence. Although postoperative morbidity can be related to some imperfections of surgery and anesthesia, complications do occur regardless of surgical skill and drug regimens. One could ask the simple question: why a successful operation is followed by an unsuccessful postoperative period? Clearly, the key pathogenic factor in postoperative morbidity is the surgical stress response with subsequent increased demands on organ function. The object of this review is to discuss postoperative pathophysiology and to propose a rationale for controlling the undesirable sequelae of surgical injury.

Multimodal Approach to Control Postoperative Pathophysiology and Rehabilitation

Major surgery is still associated with undesirable sequelae such as pain, cardiopulmonary, infective and thromboembolic complications, cerebral dysfunction, nausea and gastrointestinal paralysis, fatigue and prolonged convalescence. The key pathogenic factor in postoperative morbidity, excluding failures of surgical and anaesthetic technique, is the surgical stress response with subsequent increased demands on organ function. These changes in organ function are thought to be mediated by trauma-induced endocrine metabolic changes and activation of several biological cascade systems (cytokines, complement, arachidonic acid metabolites, nitric oxide, free oxygen radicals, etc). To understand postoperative morbidity it is therefore necessary to understand the pathophysiological role of the various components of the surgical stress response and to determine if modification of such responses may improve surgical outcome. While no single technique or drug regimen has been shown to eliminate postoperative morbidity and mortality, multimodal interventions may lead to a major reduction in the undesirable sequelae of surgical injury with improved recovery and reduction in postoperative morbidity and overall costs.

Peri-Operative Care: Management of the Diabetic Patient. A Novel Controversy About Tight Glycemic Control.

SummaryThe peri-operative tight control of glycaemia for the diabetic patient is a matter of controversy. Diabetes per se is not a risk factor for post-operative morbidity or mortality, after adjustment for co-morbidities like atherosclerosis.Controlled studies have shown the advantages of tight control of glycaemia in two acute complications of atherosclerosis, i.e. myocardial infarction and cerebro-vasculair accident. As these diseases have high prevalence in diabetes, and constitute the majority of post-operative problems of diabetic patients, when metabolic or infections are mastered, peri-operative tight control of glycaemia (6–10 mmol/1; 100–180 mg/dl) is presented as a probable necessity, when the pre-operative probability of macroangiopathy is high.This objective is best reached by a team associating anaesthesiologist and diabetologist, organising rules adapted to each hospital, including frequent capillary glycaemia controls and IV perfusions of glucose and insulin. Controlled clinical studies have to be done in this field.

Stacked Inspiratory Spirometry Reduces Pulmonary Shunt in Patients After Coronary Artery Bypass

Atelectasis is a major factor in postoperative morbidity for patients undergoing cardiopulmonary surgery. We evaluated the effectiveness of stacked inspiratory spirometry (STIS) in 17 patients status postcoronary artery bypass graft in a nonrandomized fashion. We measured pulmonary shunt as an endpoint, and compared the magnitudes before and after the STIS maneuver. Our results showed an 8.66 percent reduction in pulmonary shunt (p < 0.05). The reduction in shunt was modest; however, repetitive maneuvers might result in greater improvement.

Preservation of renal function in juxtarenal and suprarenal abdominal aortic aneurysm repair

Deterioration in renal function is a common cause of morbidity in patients treated surgically for juxtarenal and suprarenal abdominal aortic aneurysms. We reviewed our experience over the last 8 years with 65 consecutive patients undergoing juxtarenal (n = 31) or suprarenal (n = 34) abdominal aortic aneurysm repair. The aneurysms were repaired with a transabdominal (n = 8), thoracoabdominal (n = 4), retroperitoneal (n = 22), or thoracoretroperitoneal (n = 31) approach. Proximal aortic clamps were placed at the suprarenal, supra-superior mesenteric artery, or supraceliac level. Renal hypothermia with cold heparinized saline solution renal artery perfusion was used to protect renal function in 38 patients with either preoperative renal insufficiency or with anticipated prolonged renal ischemia (> 30 minutes). Concomitant renal artery reconstruction was required in 30 patients. Significant operative morbidity developed in 23 (35.3%) patients. There was one (1.53%) perioperative death (0 to 90 days). Temporary dialysis was necessary in two patients. Preoperative renal insufficiency was a significant risk factor on multivariate analysis for a decline in renal function during the first postoperative week. However, serum creatinine concentration had returned to baseline or improved in all patients but two (3.1%) at the time of discharge. In spite of significantly longer renal ischemia, discharge creatinine levels were, on univariate analysis, statistically less than baseline creatinine levels in patients with suprarenal aneurysms, patients requiring renal reconstruction, and patients treated with renal hypothermia. The location of the proximal aortic clamp was not a factor in postoperative morbidity. There was no significant difference between juxtarenal and suprarenal aneurysms with respect to operating room time, transfusion requirements, days intubated, resumption of oral diet, or the length of hospitalization. Careful consideration of the route of exposure, location of the proximal aortic clamp, and the preservation of renal function with renal hypothermia and with the repair of significant renal artery lesions will result in minimal morbidity and mortality in patients requiring surgery for juxtarenal or suprarenal abdominal aortic aneurysms.

Preservation of renal function in juxtarenal and suprarenal abdominal aortic aneurysm repair

Purpose: Deterioration in renal function is a common cause of morbidity in patients treated surgically for juxtarenal and suprarenal abdominal aortic aneurysms. We reviewed our experience over the last 8 years with 65 consecutive patients undergoing juxtarenal (n = 31) or suprarenal (n = 34) abdominal aortic aneurysm repair.Methods: The aneurysms were repaired with a transabdominal (n = 8), thoracoabdominal (n = 4), retroperitoneal (n = 22), or thoracoretroperitoneal (n = 31) approach. Proximal aortic clamps were placed at the suprarenal, supra-superior mesenteric artery, or supraceliac level. Renal hypothermia with cold heparinized saline solution renal artery perfusion was used to protect renal function in 38 patients with either preoperative renal insufficiency or with anticipated prolonged renal ischemia (> 30 minutes). Concomitant renal artery reconstruction was required in 30 patients.Results: Significant operative morbidity developed in 23 (35.3%) patients. There was one (1.53%) perioperative death (0 to 90 days). Temporary dialysis was necessary in two patients. Preoperative renal insufficiency was a significant risk factor on multivariate analysis for a decline in renal function during the first postoperative week. However, serum creatinine concentration had returned to baseline or improved in all patients but two (3.1%) at the time of discharge. In spite of significantly longer renal ischemia, discharge creatinine levels were, on univariate analysis, statistically less than baseline creatinine levels in patients with suprarenal aneurysms, patients requiring renal reconstruction, and patients treated with renal hypothermia. The location of the proximal aortic clamp was not a factor in postoperative morbidity. There was no significant difference between juxtarenal and suprarenal aneurysms with respect to operating room time, transfusion requirements, days intubated, resumption of oral diet, or the length of hospitalization.Conclusions: Careful consideration of the route of exposure, location of the proximal aortic clamp, and the preservation of renal function with renal hypothermia and with the repair of significant renal artery lesions will result in minimal morbidity and mortality in patients requiring surgery for juxtarenal or suprarenal abdominal aortic aneurysms.