High Perioperative Risk Research Articles

Establishment and validation of clinical prediction model and prognosis of perioperative pneumonia in elderly patients with hip fracture complicated with preoperative acute heart failure

BackgroundElderly hip fracture was a common orthopedic emergency with high perioperative complication risks. Combined with preoperative acute heart failure, the risk increases further, with pneumonia being a common complication. The aim of this study was to construct and evaluate risk factor prediction models for perioperative pneumonia in these patients and to explore prognostic factors.MethodsA retrospective study design was used to collect data on elderly patients with hip fracture combined with preoperative acute heart failure at the Third Hospital of Hebei Medical University from January 2020 to December 2022. The feature variables were screened by logistic regression and nomogram was constructed. The receiver operating characteristics curve (ROC), decision curve analysis (DCA), and calibration curve were employed to assess the predictive power of the model. Correlation heatmaps and shapley additive explanation (SHAP) were employed to assess key variables and their impact. Employing the Kaplan-Meier curve and Cox regression, the patients’ prognosis was ultimately evaluated.Results535 elderly patients with hip fracture combined with preoperative acute heart failure were included in this study. Logistic regression analysis was used to identify combined respiratory disease, hemoglobin, albumin, neutrophils, and blood glucose as independent danger factors for perioperative pneumonia (p < 0.05). The nomogram was designed to display the outcomes instinctively, with an AUC of 0.819. The model was internally validated by initiating self-sampling 1000 times. The calibration curve indicated that the model had excellent treaty. The DCA curve showed that the model had good validity and clinical practicability. Correlation heatmaps and SHAP were visualized and analyzed. The K-M curves indicated that the prognosis of the non-pneumonia group was better than that of the pneumonia group (p = 0.014). COX regression analysis found that the major risk factors for all-cause mortality in patients with acute heart failure(AHF) were age, brain natriuretic peptide, platelet count, and combined respiratory failure (p < 0.05).ConclusionThe prediction model, established in this study, was highly accurate and proved a potent instrument for clinical evaluation of the perioperative pneumonia risk of elderly hip fracture patients with preoperative acute heart failure. We hope that this study can reduce the occurrence of perioperative pneumonia in patients and improve the prognosis of patients.

Efficacy and safety of the ultraslow low-dose thrombolytic regimen for mechanical prosthetic valve thrombosis: a prospective cohort study

Abstract Background Mechanical prosthetic valve thrombosis (MPVT) remains a significant and life-threatening complication. While surgery is here considered the gold standard therapy, it has a high perioperative risk in the acute setting. Preliminary evidence suggests that an ultraslow low-dose thrombolytic regimen may offer a safer and equally effective alternative compared to both conventional fast-infusion thrombolytic approaches or surgical options. Purpose We aimed at evaluating efficacy and safety of a previously described ultraslow low-dose thrombolytic regimen for treating acute MPVT in hospitalized adult patients. Methods This prospective single-center cohort study included all consecutive adult patients with acute MPVT treated with our ultraslow low-dose thrombolytic regimen. Patients with contraindication to thrombolytic therapy or left-sided MPVT with a minimum thrombus size of 0.8 cm2 or severe dyspnea with NYHA FC IV were excluded, and considered candidate to surgery. The regimen here used consisted of 25 mg rtPA infused over 25 hours. If initially failed, a repeat 6-hour infusion of 25 mg rtPA was administered up to a maximum total cumulative dose of 150 mg or until an adverse event occurred. The primary objective was the rate of complete MPVT resolution, defined as &amp;gt;75% reduction in the obstructive gradient by transthoracic echocardiography, less than 10 degrees residual constraint in opening and closing valve motion angles as quantified by fluoroscopy, and alleviation of patients’ thrombosis-associated symptoms or signs. Results From April 2018 to November 2023, 135 infusions of thrombolytic therapy were administered in 118 patients (median age: 35 years (IQR, 25-49); 59 [50%] women) (Table 1). 12 patients had more than one episode of MPVT during the study period. Obstructive prosthetic valve thrombosis occurred in 89.6% (121/135) of cases. Pulmonary valves were most frequently affected (n = 84, 62.2%), followed by tricuspid (n = 34, 25.2%), mitral (n = 10, 7.4%), and aortic (n = 7, 5.2%) valves. A complete thrombolysis success was achieved in 119/135 episodes of thrombolytic therapy (88.1%); of these, 47/119 patients (39.5%) responded after the first thrombolytic dose. The median total dose administered was 50 mg (IQR, 25-75) over a median infusion duration of 30 hours (IQR, 25-36). Four patients responded partially to the regimen, six patients were candidates for bailout surgery, and only one fatal intracranial bleeding occurred. No other thromboembolic or bleeding adverse events were observed. Conclusion This is the largest prospective evaluation on the safety and efficacy of the ultraslow low-dose thrombolytic regimen, which proved highly effective - in this prospective cohort - in achieving prosthetic valve thrombosis resolution with minimal complications. Further larger clinical trials are warranted.Table 1- baseline CharacteristicsStudy Outcomes

Propensity score-based comparison of high-risk coronary artery bypass grafting vs. left ventricular assist device implantation in patients with coronary artery disease and advanced heart failure.

Revascularization in patients with severely reduced left ventricular function and coronary artery disease (CAD) is associated with a high perioperative risk. In this setting, implantation of a durable left ventricular assist device (LVAD) might be an alternative. We retrospectively compared the outcomes of adult patients with CAD and a left ventricular ejection fraction (LVEF) ≤ 25% who underwent coronary artery bypass grafting (CABG) vs. LVAD implantation. Propensity score (PS) matching was performed for statistical analysis, resulting in 168 pairs. In the PS-matched cohorts, the mean age was 62 years; one third had a history of myocardial infarction, 11% were resuscitated, half of the patients were on inotropic support, and 20% received preoperative mechanical circulatory support. LVAD patients required significantly longer ventilation (58 h [21, 256] vs. 16 h [9, 73], p < 0.001) and had a longer ICU stay (11d [7, 24] vs. 4d [2, 10], p ≤ 0.001) compared to CABG patients The incidence of postoperative renal replacement therapy (2 [1.2%] vs.15 [8.9%], p = 0.002) and temporary mechanical circulatory support was lower in the LVAD group (1 [0.6%] vs. 51 [30.4%], p ≤ 0.001). The in-hospital stroke rate was similar (LVAD 7 [5.4%] vs. CABG 8 [6.2%], p = 0.9). In-hospital survival, 1-year survival, and 3-year survival were 90.5% vs. 85.5% (p = 0.18), 77.4% vs. 68.9% (p = 0.10) and 69.6% vs. 45.9% (p < 0.001), for CABG and LVAD patients respectively. Patients with CAD and advanced HF demonstrate better mid-term survival if they undergo CABG rather than LVAD implantation.

Effectiveness and Safety of Cholecystectomy Versus Percutaneous Cholecystostomy for Acute Cholecystitis in Older and High-Risk Surgical Patients: A Systematic Review.

Acute cholecystitis (AC) is a prevalent surgical emergency, particularly among elderly individuals who present with high perioperative risks. While early cholecystectomy (CCY) is the standard treatment, percutaneous cholecystostomy (PC) isproposedas an alternative for high-risk patients. This systematic review aims to evaluate the comparative safety and efficacy of CCY versus PC in managing AC among elderly and high-risk surgical patients. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted across multiple electronic databases, including PubMed/Medline, Cochrane Central Register of Controlled Trials (CENTRAL), ScienceDirect, Europe PMC, ClinicalTrials.gov, and EBSCO Open Dissertations, from July 1to 15, 2024. Studies published from January 2019 to July 15, 2024, were included if they focused on patients aged 65 and older or those classified as high-risk surgical candidates. The review encompassed 72,366 participants across 22 studies, predominantly observational. Key outcomes assessed included postoperative complications, readmission rates, recurrence of cholecystitis, and mortality rates. This study highlights the need for individualized treatment strategies for managing AC in elderly populations. While CCY remains the preferred approach when feasible, PC offers a critical alternative for high-risk patients. Future research is necessary to optimize outcomes for this vulnerable population.

Conservative fluid resuscitation protocol does not reduce the incidence of reoperation for bleeding after emergency CABG

Reoperation for bleeding (ROB) after emergency coronary artery bypass grafting (eCABG) has been identified as an independent risk factor for mortality. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. This retrospective single-center study included 265 patients undergoing eCABG between 2011 and 2020. From 2018, postoperative hemodynamic management was performed with lower volume administration and higher vasoactive support. The primary outcome measure was the incidence of ROB within 48 h according to altered fluid resuscitation strategy. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. Incidence of ROB was independent from the volume resuscitation protocol (P = .3). The ROB group had a higher perioperative risk, which was observed in EuroSCORE II. Fluid intake (P = .021), fluid balance (P = .001), and norepinephrine administration (P = .004) were associated with ROB. Fluid output and blood loss were not associated with ROB (P = .22). Post-test probability was low among all variables. Although fluid management might have an impact on specific postoperative complications, different fluid resuscitation protocols did not alter the incidence of ROB after emergency CABG.Trial registration: www.clinicaltrials.gov registration number NCT04533698; date of registration: August 31, 2020 (retrospectively registered due to nature of the study); URL: https://classic.clinicaltrials.gov/ct2/show/NCT04533698

Significant Preoperative Anxiety Associated with Perceived Risk and Gender in Cataract Surgery.

Background/Objectives: Cataract surgery is an often-sought solution to the universal problem of lens opacification. Studies of perioperative anxiety have yielded conflicting results, reporting a high prevalence but low clinical significance. The objective of this study was to ascertain anxiety levels immediately after the scheduling of surgery, controlling for trait anxiety and other related factors. Methods: This is an observational comparative study of two patient populations assessed for receiving cataract surgery, with one group of seventy patients scheduled for operation and receiving an assessment of the potential perioperative risk and the other group of seventy patients deemed ineligible for operation since their opacification was not advanced. The patients were assessed for state and trait anxiety while controlling for cognitive status. Results: The findings indicate a clinically significant burden of state anxiety in the group of patients scheduled for operation, with 34 out of 70 meeting the threshold for clinically significant levels of state anxiety compared to 9 out of the 70 patients who were not assigned for surgery (p < 0.001). Those patients who were assigned for surgery were assessed for perioperative risk factors, and state anxiety differed statistically significantly between the preoperative risk factor groups, (p = 0.003) with those assessed as having at least low perioperative risk presenting with more anxiety than those without any risk factors. Male patients exhibited lower state anxiety compared to female patients in the group assigned to surgery (p = 0.028). Cognitive status did not affect the results. Conclusions: These findings point to the importance of prevention against perioperative anxiety early on, especially in patients with a higher perioperative risk and female gender.

National survey on peritonsillar abscess treatment and attitudes toward quinsy tonsillectomy

ABSTRACT Objectives Peritonsillar abscess (PTA) is a common deep neck infection traditionally managed with conservative measures. Quinsy Tonsillectomy (QT) is recognized as a definitive treatment but remains variably utilized. We aimed to investigate PTA management strategies and attitudes toward QT among otolaryngologists. Methods An anonymous questionnaire was distributed to members of the local national Society of Otolaryngology, evaluating treatment strategies based on patient characteristics and clinical scenario. Results A total of 108 otolaryngologists responded (response rate: 30.8%). Participants preferred to treat PTA patients as inpatients (89%) and predominantly offered incision and drainage (I&D) as the first (90.7%) and subsequent (98.1%) treatment plan. QT was favored as a primary treatment only in 1.9% of responders. QT adoption increased with multiple I&D failures, reaching 95.3% after four attempts. In patients with recurrent PTA or tonsillitis, 84.2% preferred I&D follows by interval elective tonsillectomy, while 15% considered QT. The most common reason (72.2%) to avoid QT was the perception of a high perioperative risk. Conclusion I&D was favored for initial PTA treatment. QT is considered after multiple failed I&D attempts, and its use is limited as a primary treatment, mainly due to concerns regarding perioperative risk.

THE CHOICE OF ANESTHESIA METHOD FOR HYBRID ANGIOPLASTY. CLINICAL OBSERVATION

Many patients presenting for surgical revascularization of the lower extremities have progressive systemic atherosclerotic disease affecting not only the peripheral extremities, but also the coronary, cerebral, and renal vessels. Vascular patients are therefore considered high perioperative risk patients, making them a real challenge even for experienced anesthesiologists. This article analyzes a clinical case of hybrid angioplasty of lower extremity vessels in a patient with generalized atherosclerotic lesions under regional anesthesia with ultrasound navigation. Analysis of the clinical case and its analysis shows that regional anesthesia provides reliable protection against surgical stress with minimal impact on the body and should be used in patients with concomitant cardiac and pulmonary pathologies.

A decade's summary of transcatheter tricuspid valve repair.

Tricuspid regurgitation (TR) is the most common pathology for the tricuspid valve. Moderate to severe TR is associated with morbidity and adverse outcomes. The concept that TR resolves on its own if the underlying disease is successfully treated has proven to be false. Only a few patients with significant TR are deemed suitable for surgery. Given the late presentation of patients with high perioperative risks and substantial perioperative mortality, the development of transcatheter therapies and the experience gained with transcatheter aortic valve implantation operations have turned attention towards treating this challenging group of patients. In this article, we review the treatment options and highlight the role of transcatheter valve therapies in patients with severe TR.

Urinary diversion in old patients(80+ years)

With increasing life expectancy there is also an increased need for the management of older (≥ 80years) patients with the diagnosis of muscle-invasive bladder cancer. Radical cystectomy with urinary diversion is the state of the art treatment (with neoadjuvant chemotherapy, as long as the patient is fit enough). Choosing the best urinary diversion with respect to morbidity compared to functionality and quality of life remains achallenge in these patients. Physical age alone is not decisive for making a decision. A thorough preoperative assessment of medical features, physical and cognitive impairments is more important. Older patients are generally provided with an ileal conduit as an incontinent urinary diversion, as the intervention involves reduced operating times and complexity compared to continent urinary diversions; however, in the case of good health status with an adequate life expectancy and sufficient compliance, continent diversions may be considered even in aged candidates. In the case of multimorbid patients with a high perioperative risk, ureterostomy with permanent ureteric stents is an important alternative. Most importantly, a thorough preoperative counselling enables patients to reach an informed decision.

A comparative analysis of Charlson's weighted index of comorbidity and perforated peptic ulcer scores in predicting postoperative mortality and high comprehensive complication index.

Limited data exists on Charlson's weighted index of comorbidity (WIC) predictability for postoperative outcomes following perforated peptic ulcer (PPU) surgery. This study assesses the utility of WIC and other predictive scores in forecasting both postoperative mortality and morbidity in PPU. Patients with PPUs operated between 2018 and 2021 in a Malaysian tertiary referral center were included. Clinical data were retrospectively analyzed for association with mortality and morbidity measured with the Comprehensive Complication Index (CCI). Predictability of WIC and other predictors were examined using area under receiver-operator characteristic (ROC) curve (AUC). Among 110 patients included, 18 died (16.4%) and 36 (32.7%) had significant morbidity postoperatively (High CCI, ≥26.2). Both mortality and high CCI were associated with age >65years, female sex, comorbidities (diabetes mellitus, hypertension, and renal disease), and American Society of Anesthesiologist score >2. Most patients who died had renal dysfunction, metabolic acidosis, lactate >2mmol/L upon presentation preoperatively. While surgery >24h after presentation correlated with mortality and high CCI, the benefit of earlier surgery <6h or <12h was not demonstrated. WIC (AUC, 0.89; 95% CI, 0.81-0.99) showed similar predictability to Peptic Ulcer Perforation (PULP) (AUC, 0.97; 95% CI, 0.93-1.00) for mortality. PULP effectively predicted high CCI (AUC, 0.83; 95% CI, 0.73-0.93; p<0.001). WIC is valuable in predicting mortality, highlighting the importance of comorbidity in risk assessment. PULP score was effective in predicting both mortality and high CCI. Early identification of patients with high perioperative risk will facilitate patients' triage for escalated care, leading to a better outcome.

Inhospital outcomes of implantation of a centrifugal left ventricular assist device in patients with endstage heart failure: experience of the Chazov National Medical Research Center of Cardiology

Aim. To study the inhospital outcomes of implantation of a centrifugal left ventricular assist device (LVAD) in patients with end-stage heart failure (HF).Material and methods. There were following inclusion criteria: estimated body surface area &gt;1,2 m2, end-stage HF, LV ejection fraction &lt;30%, cardiac index &lt;2,2 l/min, long-term optimal therapy for HF. Patients were considered for implantation of a centrifugal (LVAD) as part of the final therapy, but subsequent heart transplantation was not ruled out if appropriate.Results. LVAD was implanted in 23 patients. All patients were men (mean age, 59,1±10 years; mean body mass index, 26±4,6 kg/m2). Ten patients had dilated cardiomyopathy, while 13 — ischemic one. Diabetes was revealed on in 3 (13%) patients, while chronic kidney disease and cancer — in 3 (13%) and 4 (17%) patients, respectively. The mean value of the six-minute walk test (6MWT) upon admission to the hospital was 257±71 meters. In one patient with gastric cancer, the device was implanted as a part of bridging therapy strategy. Thirty-day mortality was 9% (n=2). One of the deceased patients had a long history of end-stage heart failure, body weight deficiency, and frailty with severe muscle weakness. The second death was the result of early postoperative right ventricular failure. At discharge, patients had optimal LVAD performance based on anthropometric characteristics and physical activity. According to echocardiography, the criteria for unloading the left heart chambers have been achieved. The distance of 6MWT at discharge was 298±78 meters.Conclusion. Inhospital outcomes of implantation of a centrifugal LVAD in patients with end-stage HF demonstrate high efficiency in supporting systemic hemodynamics with an acceptable safety profile in patients with extremely high perioperative risk.

Morning or Afternoon Scheduling for Elective Coronary Artery Bypass Surgery: Influence of Longer Fasting Periods from Metabolic and Hemodynamic Perspectives.

Prolonged preoperative fasting may worsen postoperative outcomes. Cardiac surgery has higher perioperative risk, and longer fasting periods may be not well-tolerated. We analysed the postoperative metabolic and hemodynamic variables in patients undergoing elective coronary artery bypass grafting (CABG) according to their morning or afternoon schedule. Single-centre retrospective study at University teaching hospital (1-year data collection from electronic medical records). Using a mixed-effects linear regression model adjusted for several covariates, we compared metabolic (lactatemia, pH, and base deficit [BD]) and haemodynamic values (patients on vasoactive support, and vasoactive inotropic score [VIS]) at 7 prespecified time-points (admission to intensive care, and 1st, 3rd, 6th, 12th, 18th, and 24th postoperative hours). 339 patients (n = 176 morning, n = 163 afternoon) were included. Arterial lactatemia and BD were similar (overall P = 0.11 and P = 0.84, respectively), while pH was significantly lower in the morning group (overall P < 0.05; mean difference -0.01). Postoperative urine output, fluid balance, mean arterial pressure, and central venous pressure were similar (P = 0.59, P = 0.96, P = 0.58 and P = 0.53, respectively). A subgroup analysis of patients with diabetes (n = 54 morning, n = 45 afternoon) confirmed the same findings. The VIS values and the proportion of patients on vasoactive support was higher in the morning cases at the 18th (P = 0.002 and p=0.04, respectively) and 24th postoperative hours (P = 0.003 and P = 0.04, respectively). Mean intensive care length of stay was 1.94 ± 1.36 days versus 2.48 ± 2.72 days for the afternoon and morning cases, respectively (P = 0.02). Patients undergoing elective CABG showed similar or better metabolic and hemodynamic profiles when scheduled for afternoon surgery.

Parenchyma-Preserving Hepatectomy in Perihilar Cholangiocarcinoma: A Chance for Critical Patients?

Introduction: Surgery for perihilar cholangiocarcinoma (pCCA) is associated with high rates of postoperative morbidity and mortality. Extended liver resection (EXT) increases R0 resection rate and survival; however, patients with high perioperative risk are not suitable for extended resection. This study aimed to compare overall survival and surgical morbidity in patients with extended liver resection and parenchyma-preserving hepatectomy (PPH). Methods: Between January 2010 and November 2020, 113 consecutive patients with pCCA underwent surgery at our institution. Eighty-two patients were resected in curative intent. Sixty-four patients received extended liver resection, and 18 patients PPH. Outcomes of resections were evaluated. Results: There was no significant difference in overall survival in patients with PPH compared to extended liver resection (log-rank p = 0.286). Patients with PPH experienced lower rates of postoperative morbidity and mortality. There was no case of in-house mortality in PPH-resected patients compared to 10 cases (16%) in patients that received EXT (p = 0.073). Conclusion: PPH shows similar overall survival with lower rates of postoperative morbidity and mortality. Our findings support the role of a PPH, in selected patients with pCCA, that are not suitable for extended resection due to increased perioperative risk.

Myocardial Revascularisation in Calcified Aorta in CKD Patient with Help of ENCLOSEII Device, A Bail Out Situation

In this case, a 56 years dialysis dependent patient presented with complaints of angina at rest for 2 weeks after which she was thoroughly evaluated and was diagnosed with coronary artery disease with calcified aorta along with calcification of other vessels also, following which she was planned for CABG surgery. The unclampable ascending aorta (UAA) is a condition increasingly encountered during CABG procedures[1]. Aging of the population and the increase in patients on dialysis have led to an increasing frequency of “porcelain aorta”[2]. The use of the no-touch technique is associated with a high perioperative risk but a superior possibility of complete revascularisation, whereas the adoption of the no-pump strategy ensures a smoother postoperative course at the expense of a higher incidence of ischemia recurrence[3]. Enclose-II anastomosis assist device was originally developed as an ancillary device for proximal anastomosis in off-pump coronary artery bypass grafting (OPCABG), to assist anastomosis for the vascular grafts without clamping the ascending aorta[3]

Endovascular rotational atherectomy for multivessel coronary calcification involving the main trunk of left coronary artery and the left anterior descending artery

The revascularization strategy for severe calcification is one of the most pressing problems of modern percutaneous coronary interventions, since it is observed more and more often and significantly complicates traditional endovascular treatment. Currently, the method of choice for severe coronary calcification is rotational atherectomy, which allows modification of atheromatous mass with an increase in the vessel lumen to allow satisfactory balloon angioplasty and stenting. This article presents a case of a patient at very high cardiovascular risk with a burdened coronary history and severe clinical symptoms of exertional angina while receiving the optimal multiagent therapy. The examination revealed a multivessel coronary calcification, but the patient was denied coronary artery bypass grafting due to high perioperative risks. SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery score) score I – 25,5 points, SYNTAX score II — 40,4% and 70,1% for percutaneous coronary intervention and coronary bypass surgery, respectively, European System for Cardiac Operative Risk Evaluation (EuroSCORE II) — 4,95%. Attempts at traditional percutaneous intervention were unsuccessful and the patient underwent endovascular rotational atherectomy followed by stenting of affected coronary segments, against the background of which there was an improvement in exercise tolerance with a decrease in angina class.

Animal Models, Pathogenesis, and Potential Treatment of Thoracic Aortic Aneurysm.

Thoracic aortic aneurysm (TAA) has a prevalence of 0.16-0.34% and an incidence of 7.6 per 100,000 person-years, accounting for 1-2% of all deaths in Western countries. Currently, no effective pharmacological therapies have been identified to slow TAA development and prevent TAA rupture. Large TAAs are treated with open surgical repair and less invasive thoracic endovascular aortic repair, both of which have high perioperative mortality risk. Therefore, there is an urgent medical need to identify the cellular and molecular mechanisms underlying TAA development and rupture to develop new therapies. In this review, we summarize animal TAA models including recent developments in porcine and zebrafish models: porcine models can assess new therapeutic devices or intervention strategies in a large mammal and zebrafish models can employ large-scale small-molecule suppressor screening in microwells. The second part of the review covers current views of TAA pathogenesis, derived from recent studies using these animal models, with a focus on the roles of the transforming growth factor-beta (TGFβ) pathway and the vascular smooth muscle cell (VSMC)-elastin-contractile unit. The last part discusses TAA treatment options as they emerge from recent preclinical studies.

A 10-year review on older patients undergoing colorectal cancer surgery: surgeon-led geriatric service and good quality surgery are drivers of good outcomes

BackgroundOlder age and frailty are associated with worse postoperative outcomes and prolonged length of stay (LOS). In this study, we aimed to analyze the long-term outcomes after the implementation of our geriatric surgical service (GSS). MethodsThis was a single-center retrospective study from July 2010 to December 2021 on patients aged ≥75 years or patients aged ≥65 years with frailty. Our GSS includes multidisciplinary assessment and optimization by specialized nurses, physiotherapists, anesthetists, dietitians, and geriatricians. Cumulative sum (CUSUM) analysis was used to assess the performance of our GSS. Our primary outcome was defined as the presence of 30-day mortality, prolonged LOS ≥ 14 days, and/or >10% decrease in the modified Barthel Index at 6 weeks, which depicts the failure of GSS. A downsloping CUSUM curve implies consecutive cases of success. ResultsThere were 233 patients with a mean age of 79.0 ± 4.9 years; of these, 73 patients (31.3%) were frail. The overall 30-day mortality (1.7%), Clavien-Dindo ≥ grade IIIA complications (12.0%), and LOS (median, 7.0 days) were low. The CUSUM analysis showed 3 phases with overall sustained improvement in outcomes. Transient inconsistency in the second phase (during midimplementation of GSS) may be due to the early adoption of laparoscopic surgery (44.6% vs 24.1%; adjusted P =.031) and expansion of service to include patients with higher perioperative risks (weighted Charlson Comorbidity Index score ≥4: 64.9% vs 38.0%; adjusted P =.002) in the second period compared with the first period. The outcomes subsequently improved in the third phase after overcoming the learning curve. ConclusionOur GSS showed sustained performance over the past decade. Good quality surgery and surgeon-led geriatric service are paramount for good postoperative outcomes.

The Impact of Postoperative Pulmonary Complications on Perioperative Outcomes in Patients Undergoing Pneumonectomy: A Multicenter Retrospective Cohort Study of the German Thorax Registry.

Postoperative pulmonary complications have a deleterious impact in regards to thoracic surgery. Pneumonectomy is associated with the highest perioperative risk in elective thoracic surgery. The data from 152 patients undergoing pneumonectomy in this multicenter retrospective study were extracted from the German Thorax Registry database and presented after univariate and multivariate statistical processing. This retrospective study investigated the incidence of postoperative pulmonary complications (PPCs) and their impact on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs and in-hospital mortality were analyzed. A total of 32 (21%) patients exhibited one or more PPCs, and 11 (7%) died during the hospital stay. Multivariate stepwise logistic regression identified a preoperative FEV1 < 50% (OR 9.1, 95% CI 1.9-67), the presence of medical complications (OR 7.4, 95% CI 2.7-16.2), and an ICU stay of more than 2 days (OR 14, 95% CI 3.9-59) as independent factors associated with PPCs. PPCs (OR 13, 95% CI 3.2-52), a preoperative FEV1 < 60% in patients with previous pulmonary infection (OR 21, 95% CI 3.2-52), and continued postoperative mechanical ventilation (OR 8.4, 95% CI 2-34) were independent factors for in-hospital mortality. Our data emphasizes that PPCs are a significant risk factor for morbidity and mortality after pneumonectomy. Intensified perioperative care targeting the underlying risk factors and effects of PPCs, postoperative ventilation, and preoperative respiratory infections, especially in patients with reduced pulmonary reserve, could improve patient outcomes.

Anesthesia and intensive care unit care in pediatric kidney transplantation: An international survey.

Despite the high perioperative risk profile, international guidelines for anesthesia and intensive care unit (ICU) care in pediatric kidney transplantation do not exist. Optimizing hemodynamics can be challenging in these patients, while scientific data to guide decisions in hemodynamic monitoring, hemodynamic targets, and perioperative fluid management are lacking. The limited annual number of pediatric kidney transplantations, even in reference centers, necessitates the urge for international collaboration to share knowledge and develop research and guidelines. The aim of this study was to collect data on current perioperative anesthesia and ICU care practices in pediatric kidney transplantation. An international survey with an anonymized link was sent from a validated electronic data capture system (Castor). Inclusion criteria were: medical doctor in anesthesia, (ICU), or pediatric nephrology working in a pediatric kidney transplantation specialized center; and signed informed consent. Data were analyzed using descriptive statistics. Thirty-three records were analyzed. Responders were anesthesiologists (58%), pediatric nephrologists (30%), and pediatric intensivists (12%), representing 13 countries worldwide. About half of the centers (48%) performed more than 10 pediatric kidney transplantations a year. Perioperative hemodynamic support was guided by intra-arterial blood pressure (88%), central venous pressure (CVP; 88%), and cardiac output (CO; 39%). The most variation was seen in the hemodynamic targets CVP and CO, fluid administration, and inotrope/vasopressor use. The protocolized use of furosemide (46%) and mannitol (61%) also varied between centers. Postoperative care for the youngest recipients occurred in the pediatric intensive care unit at all centers. The results of this survey reveal a large variation in anesthesia and ICU care in pediatric kidney transplantation centers worldwide, particularly in CVP and CO targets, hemodynamic therapy, and the use of furosemide and mannitol. These data identify areas for further research and can be a starting point for international research collaboration and guideline development.