High-risk Postoperative Patients Research Articles

Exploring management reasoning when discharging high-risk postoperative patients from the post-anaesthesia care unit.

Decision-support tools for detecting physiological deterioration are widely used in clinical medicine but have been criticised for fostering a task-oriented culture and reducing the emphasis on clinical reasoning. Little is understood about what influences clinical decisions aided by decision-support tools, including professional standards, policies, and contextual factors. Therefore, we explored management reasoning employed by anaesthesiologists and PACU nurses in the post-anaesthesia care unit during the discharge of high-risk postoperative patients. A qualitative constructivist study, conducting 18 semi-structured with 6 anaesthesiologists and 12 nurses across three Danish teaching hospitals. We analysed data through thematic analysis, utilising Michael Lipsky's theory of "street-level bureaucracy" in combination with David A. Cook's Management Reasoning Framework as a sensitising concept. Standards are frequently ambiguous, requiring interpretation and prioritisation. This allows for professional discretion by circumventing established policies, reducing task-oriented culture and enhancing the clinical reasoning processes. However, discretion in management reasoning depends on whether the clinician is inclined to uphold or adjust policies to maintain professional standards, influencing discharge decisions. While decision-support tools offer cognitive aid and help standardise patient trajectories, they also limit professional discretion in management reasoning and can potentially compromise care and treatment. This highlights the need for a balanced approach that considers both the benefits and limitations of these tools in clinical decision-making.

Establishment and clinical application of a prognostic index for inflammatory status in triple-negative breast cancer patients undergoing neoadjuvant therapy using machine learning

ObjectiveThis study aims to establish a new prognostic index using machine learning models to predict the clinical outcomes of triple-negative breast cancer (TNBC) patients receiving neoadjuvant therapy.MethodsIn this study, we collected data from the electronic medical records system of Harbin Medical University Cancer Hospital to establish a training set of 501 breast cancer patients who received neoadjuvant therapy from January 2017 to December 2021. Additionally, we collected data from Harbin Medical University Affiliated Cancer Hospital, Harbin Medical University Affiliated Second Hospital, and Harbin Medical University Affiliated Sixth Hospital to establish a validation set of 1533 patients during the same period. All patients underwent blood tests, and the following inflammatory and immune indices were calculated for each patient: neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammatory index (SII), systemic inflammatory response index (SIRI), and advanced lung cancer inflammation index (ALI). The observed outcomes included Disease-free survival (DFS) and overall survival (OS). Survival analysis was performed using Kaplan‒Meier survival curves, Cox survival analysis, propensity score matching analysis (PSM), and a nomogram to comprehensively investigate the impact of inflammatory status on patient survival.ResultsThe training set comprised 501 patients with a mean age of 48.63 (9.41) years, while the validation set comprised 1533 patients with a mean age of 49.01 (9.51) years. The formula for ANLR established through Lasso regression analysis on the training set is: ANLR index = NLR − 0.04 × ALB (g/L). In both the training and validation sets, ANLR was significantly associated with patient DFS and OS (all P < 0.05). Additionally, ANLR was found to be an independent prognostic factor in this study. PSM analysis further confirmed its significant correlation with patient DFS and OS (76 cases vs. 76 cases, χ2 = 2.179, P = 0.001 and χ2 = 2.063, P = 0.002). The nomogram containing ANLR also demonstrated high prognostic value. The C-index for the nomogram in the training set was 0.742 (0.619–0.886) for DFS and 0.758 (0.607–0.821) for OS, while in the validation set, the C-index was 0.733 (0.655–0.791) for DFS and 0.714 (0.634-0.800) for OS.ConclusionANLR was associated with the prognosis of TNBC patients receiving neoadjuvant therapy and could identify high-risk postoperative patients.

Postoperative radiotherapy with docetaxel versus cisplatin for high-risk oral squamous cell carcinoma: a randomized phase II trial with exploratory analysis of ITGB1 as a potential predictive biomarker

BackgroundOral squamous cell carcinoma (OSCC) causes significant mortality and morbidity worldwide. Surgical resection with adjuvant radiotherapy remains the standard treatment for locally advanced resectable OSCC. Results from landmark trials have established postoperative concurrent cisplatin-radiotherapy (Cis-RT) as the standard treatment for OSCC patients with high-risk pathologic features. However, cisplatin-related toxicity limits usage in clinical practice. Given the need for effective but less toxic alternatives, we previously conducted a single-arm trial showing favorable safety profiles and promising efficacy of concurrent docetaxel-radiotherapy (Doc-RT).MethodsIn this randomized phase 2 trial, we aimed to compare Doc-RT with the standard Cis-RT in postoperative OSCC patients. Eligible patients had AJCC stage III–IV resectable OSCC with high-risk pathologic features. Two hundred twenty-four patients were enrolled and randomly assigned to receive concurrent Doc-RT or Cis-RT. The primary endpoint was 2-year disease-free survival (DFS). Secondary endpoints included overall survival (OS), locoregional-free survival (LRFS), distant metastasis-free survival (DMFS), and adverse events (AEs). Integrin β1 (ITGB1) expression was analyzed as a biomarker for efficacy.ResultsAfter a median 28.8-month follow-up, 2-year DFS rates were 63.7% for Doc-RT arm and 56.1% for Cis-RT arm (p = 0.55). Meanwhile, Doc-RT demonstrated comparable efficacy to Cis-RT in OS, LRFS, and DMFS. Doc-RT resulted in fewer grade 3 or 4 hematological AEs. Low ITGB1 was associated with improved Doc-RT efficacy versus Cis-RT.ConclusionsThis randomized trial directly compared Doc-RT with Cis-RT for high-risk postoperative OSCC patients, with comparable efficacy and less toxicity. ITGB1 merits further validation as a predictive biomarker to identify OSCC patients most likely to benefit from Doc-RT. Findings indicate docetaxel may be considered as a concurrent chemoradiation option in this setting.Trial registrationwww.ClinicalTrials.gov. NCT02923258 (date of registration: October 4, 2016)

Nursing Care in Prevention of Post-Operative Pulmonary Complications among High-Risk Hospitalized Patients: A Case Study Design

Introduction: Post-operative pulmonary complications (PPCs) such as pneumonia, atelectasis, and respiratory failure significantly impact surgical outcomes, especially among high-risk patients with pre-existing respiratory conditions, advanced age, or those undergoing major surgeries. Effective prevention of PPCs is critical for improving patient outcomes. Nursing care plays a pivotal role in this prevention through early mobilization, respiratory exercises, proper positioning, and vigilant monitoring.Objectives :This study investigates the effectiveness of nursing care in preventing PPCs among high-risk hospitalized patients.Methods: A descriptive case study design was used, involving 15 patients from a multispecialty hospital in Trivandrum who met the inclusion criteria of having more than four risk factors for PPCs and consented to participate. Data collection tools included demographic variables, clinical manifestation checklists, risk factors for PPCs, and an individualized nursing care plan. Over six weeks, patients were selected through convenience sampling and a 24-hour nursing care plan was implemented. Descriptive statistics were used for data analysis. Results: The study sample consisted predominantly of elderly patients (73.3% aged above 60 years), with males constituting 66.7%. Significant risk factors included smoking history (66.7%) and elevated BMI (53.3%). All surgeries were performed under general anesthesia, with 60% lasting over 3-4 hours. Nursing interventions included deep breathing and coughing exercises, frequent position changes, early ambulation, use of an incentive spirometer, prophylactic antibiotics, and strict aseptic techniques. Most severe PPC symptoms were absent; however, mild symptoms like elevated temperature and cough were observed in 20% of patients. Discussion: The results indicate that the comprehensive nursing care strategies effectively prevented most significant PPCs. The absence of severe symptoms suggests the success of interventions such as early mobilization and respiratory exercises. The occurrence of mild symptoms in some patients highlights the need for ongoing refinement of nursing protocols. Conclusion: Effective nursing care significantly reduces PPC incidence in high-risk postoperative patients. This study supports the development of best practice guidelines for nursing care, emphasizing individualized care plans to improve patient outcomes and ensure high-quality healthcare services.

Development of interpretable machine learning models for prediction of acute kidney injury after noncardiac surgery: a retrospective cohort study.

Early identification of patients at high-risk of postoperative acute kidney injury (AKI) can facilitate the development of preventive approaches. This study aimed to develop prediction models for postoperative AKI in noncardiac surgery using machine learning algorithms. The authors also evaluated the predictive performance of models that included only preoperative variables or only important predictors. Adult patients undergoing noncardiac surgery were retrospectively included in the study (76457 patients in the discovery cohort and 11910 patients in the validation cohort). AKI was determined using the KDIGO criteria. The prediction model was developed using 87 variables (56 preoperative variables and 31 intraoperative variables). A variety of machine learning algorithms were employed to develop the model, including logistic regression, random forest, extreme gradient boosting, and gradient boosting decision trees. The performance of different models was compared using the area under the receiver operating characteristic curve (AUROC). Shapley Additive Explanations (SHAP) analysis was employed for model interpretation. The patients in the discovery cohort had a median age of 52 years (IQR: 42-61 years), and 1179 patients (1.5%) developed AKI after surgery. The gradient boosting decision trees algorithm showed the best predictive performance using all available variables, or only preoperative variables. The AUROCs were 0.849 (95% CI: 0.835-0.863) and 0.828 (95% CI: 0.813-0.843), respectively. The SHAP analysis showed that age, surgical duration, preoperative serum creatinine, and gamma-glutamyltransferase, as well as American Society of Anesthesiologists physical status III were the most important five features. When gradually reducing the features, the AUROCs decreased from 0.852 (including the top 40 features) to 0.839 (including the top 10 features). In the validation cohort, the authors observed a similar pattern regarding the models' predictive performance. The machine learning models the authors developed had satisfactory predictive performance for identifying high-risk postoperative AKI patients. Furthermore, the authors found that model performance was only slightly affected when only preoperative variables or only the most important predictive features were included.

Timely Initiation of Radiation Treatment for Primary Head and Neck Squamous Cell Carcinoma in an Urban Safety Net Hospital during the COVID-19 Pandemic

Delayed initiation of radiation treatment for head and neck squamous cell cancer (HNSCC) may lead to worse survival, higher recurrence, and increased financial burden on patients. In times of limited resources, timely treating underserved population of HNSCC patients pose a special challenge to a safety net setting. This single-institutional study aims to characterize and compare treatment delays in HNSCC before and during the COVID-19 pandemic at an urban safety net hospital in Los Angeles to assess the success of efforts made to deliver timely care. Patients who received definitive or post-operative radiotherapy for treatment of primary HNSCC at LAC+USC Medical Center between 2010-2021 were retrospectively reviewed. Time to treatment initiation (TTI) was defined as date of histopathological diagnosis to date of first radiation treatment for definitive and date of surgery to date of first radiation treatment for post-operative patients. Among 70 patients with HNSCC (mean age at diagnosis 55 years, 79% male), 31 patients (18 pre-pandemic, 13 peri-pandemic) were treated definitively with chemoradiation, and 39 patients (24 pre-pandemic, 15 peri-pandemic) were treated post-operatively. Overall, the median TTI was 50 days (interquartile range, IQR 42-74 days); median TTI for pre-pandemic HNSCC patients was 49 days (IQR 43-70 days) and median TTI for peri-pandemic HNSCC patients was 51 days (IQR 43-75 days). The median TTI for definitive radiation was 52 days (IQR 42-93) for pre-pandemic and 52 days (IQR 44-61) for peri-pandemic patients. The median TTI for post-operative radiation was 47 days (IQR 41-75) for pre-pandemic and 50 days (IQR 48-73) for peri-pandemic patients. During the pandemic, there were fewer (38% vs 44%) definitive patients whose TTI exceeded 60 days, whereas more (40% vs 33%) post-operative patients had TTI >60 days. By prioritizing treatment of definitive and high-risk post-operative HNSCC patients according to ASTRO-ESTRO consensus guidelines, expanding the use of telephone follow-up to ensure continuity of care, teleconferencing for multidisciplinary tumor board discussions, and initiating COVID-19 protocols in which mildly symptomatic patients were treated at the end of the day, we were able to maintain timely initiation of radiation treatment not compromised by the pandemic.

Unplanned Return to Cardiac Intensive Care Unit of Children After Congenital Heart Surgery: Incidence, Outcomes, and Risk Factors.

Factors leading to an unplanned return to the cardiac intensive care unit (CICU) in children after congenital heart disease and their impact on mortality have not been well characterized. We sought to determine the incidence and outcomes of unplanned return to the CICU. A secondary objective was to identify risk factors. Retrospective analysis of the registration data collected by our unit. The study subjects included postoperative patients with congenital heart disease who survived to initial transfer out of the CICU. Patients who unexpectedly returned to the CICU due to an acute change in clinical status were defined as unplanned returns. Demographic, preoperative, intraoperative, and postoperative variables were assessed. Univariate comparisons were performed between the return group and non-return group, and multivariate regression analysis was performed to identify potential risk factors for unplanned return to the CICU. Of the 531 children who met the inclusion criteria, 29 were unplanned returns to the CICU. Respiratory symptoms (41.4%) and cardiac symptoms (44.8%) were the most common reasons for returning to the CICU. Patients with unplanned returns had a higher mortality rate (13.8% vs. 0.56%, P < 0.01). In multivariate analysis, unplanned CICU admission was associated with chromosomal abnormalities (P < 0.01), longer ventilator duration (P < 0.01), and more prolonged cardiopulmonary bypass (P < 0.01) was associated with a return to independence. Unplanned return to the CICU during the same hospital stay was uncommon but associated with higher mortality. Chromosomal abnormalities, longer ventilator use duration, and prolonged CPB were significant risk factors for the entire cohort. We hope to minimize the impact of unplanned return after congenital heart disease surgery by changing the process of transferring these high-risk postoperative patients out of the CICU and early postoperative care.

Overtriage, Undertriage, and Value of Care after Major Surgery: An Automated, Explainable Deep Learning-Enabled Classification System.

In single-institution studies, overtriaging low-risk postoperative patients to ICUs has been associated with a low value of care; undertriaging high-risk postoperative patients to general wards has been associated with increased mortality and morbidity. This study tested the reproducibility of an automated postoperative triage classification system to generating an actionable, explainable decision support system. This longitudinal cohort study included adults undergoing inpatient surgery at two university hospitals. Triage classifications were generated by an explainable deep learning model using preoperative and intraoperative electronic health record features. Nearest neighbor algorithms identified risk-matched controls. Primary outcomes were mortality, morbidity, and value of care (inverted risk-adjusted mortality/total direct costs). Among 4,669 ICU admissions, 237 (5.1%) were overtriaged. Compared with 1,021 control ward admissions, overtriaged admissions had similar outcomes but higher costs ($15.9K [interquartile range $9.8K to $22.3K] vs $10.7K [$7.0K to $17.6K], p < 0.001) and lower value of care (0.2 [0.1 to 0.3] vs 1.5 [0.9 to 2.2], p < 0.001). Among 8,594 ward admissions, 1,029 (12.0%) were undertriaged. Compared with 2,498 control ICU admissions, undertriaged admissions had longer hospital length-of-stays (6.4 [3.4 to 12.4] vs 5.4 [2.6 to 10.4] days, p < 0.001); greater incidence of hospital mortality (1.7% vs 0.7%, p = 0.03), cardiac arrest (1.4% vs 0.5%, p = 0.04), and persistent acute kidney injury without renal recovery (5.2% vs 2.8%, p = 0.002); similar costs ($21.8K [$13.3K to $34.9K] vs $21.9K [$13.1K to $36.3K]); and lower value of care (0.8 [0.5 to 1.3] vs 1.2 [0.7 to 2.0], p < 0.001). Overtriage was associated with low value of care; undertriage was associated with both low value of care and increased mortality and morbidity. The proposed framework for generating automated postoperative triage classifications is reproducible.

Neurocritical Care

Neurologic critical care encompasses the management of many nervous system diseases when they present in the extremes of severity. Core conditions managed in the neuroscience intensive care unit (ICU) include stroke, cerebral hemorrhage, status epilepticus (SE), myasthenia gravis (MG), Guillain-Barré syndrome (GBS), traumatic brain and spinal cord injury, and high-risk postoperative neurosurgical patients. The skills and knowledge base required to care for patients with such conditions, and the life-threatening complications associated with them, are drawn from both traditional neurology and from critical care medicine. This chapter covers specialized monitoring in the neurologic intensive care unit and special conditions such as acute intracranial hypertension, acute ischemic stroke, intracerebral hemorrhage, venous sinus thrombosis, myasthenia gravis, GBS, seizure and status epilepticus, spinal cord injury, and traumatic brain injury. The chapter includes 8 tables and 5 figures. Tables provide common etiologies of acute intracranial hypertension; general prophylactic measures, medical interventions, surgical interventions, and stepwise treatment protocol for acute intracranial hypertension; drugs that can exacerbate weakness in myasthenia gravis, cholinergic drug dosage equivalents and duration of action, and antiseizure medications used in status epilepticus. Figures illustrate the Monro-Kellie Doctrine, intracranial pressure waveform and plateau waves, typical herniation patterns, large stroke with malignant edema, and examples of nontraumatic intracerebral hemorrhage. This chapter contains 114 references.

Inciting Events in the High Risk Post-Operative Pediatric Cardiac Patients – A Novel Three Hit Model for Bacteremia Prediction

Background: Blood stream infections (BSI) are well described in pediatric cardiac intensive care units (PCICU). We noted that postoperative high-risk patients may develop BSI after an inciting event. The aim of this study was to investigate whether high risk patients who developed bacteremia experienced more inciting events than a similar group of high-risk patients. Methods: In this retrospective case-control study, we enrolled patients who developed bacteremia from March 2010 to November 2019, after undergoing open-heart surgery at a referral pediatric center. The control group was comprised of case-matched patients with the immediate consecutive same surgery. The following were recorded: operative data, common risk factors, postoperative severity of illness parameters, mortality, and inciting events 72-24 hours before bacteremia emerged. Findings: A total of 200 patients were included (100 with bacteremia, and 100 controls). Main demographic and operative parameters were matched. Bacteremia emerged on average postoperative day (POD) 12·8. Gram-negative bacteria were cultured in 84%, and skin associated gram-positive bacteria in 10% of the patients. Average central-venous lines (CVL) duration was 9·5±8·4 days. Postoperatively (72 hours), severity of illness parameters were significantly worse in patients with bacteremia, with a higher rate of postoperative complications during PCICU length-of-stay (LOS). In the bacteremia group, 72-24 hours prior to development of bacteremia, 92(92%) inciting events were recorded, compared to 21 (21%) in controls during their entire LOS. (OR 43·3,CI 18·2-103·1, p<0·0001). Interpretation: We propose a three hit model demonstrating that high-risk patients undergoing open heart surgery have significant higher risk for bacteremia after an inciting event. Funding Statement: No funding was procured for this work. Declaration of Interests: Mrs· Shochat disclosed work for hire at Rabin Medical Center as a statistical consultant. The remaining authors have disclosed that they do not have any potential conflicts of interest. Ethics Approval Statement: The Institutional Review Board reviewed and approved the study, and waived the need for parental consent.

Oxygen monitoring and management during transfer of high risk postoperative patients: a clinical audit

Oxygen monitoring and management during transfer of high risk postoperative patients: a clinical audit

Clinical study of postoperative adjuvant radiotherapy and postoperative concurrent chemoradiotherapy for locally advanced hypopharyngeal squamous cell carcinoma

Objective: Using propensity score matching method (PSM) to investigate the clinical effect of postoperative adjuvant radiotherapy and postoperative concurrent chemoradiotherapy for locally advanced hypopharyngeal squamous cell carcinoma. Methods: From July 2007 to July 2018,174 postoperative patients with locally advanced hypopharyngeal squamous cell carcinoma were enrolled in pre-PSM cohort, including 168 males and 6 females, the median age was 60 years old (ranged from 37 to 79 years old).Loco-regional control (LRC),progression-free survival (PFS) and overall survival (OS) were compared and analyzed between the patients treated with postoperative adjuvant radiotherapy and postoperative concurrent chemoradiotherapy (cisplatin was given in a dose of 80 mg/m(2) on days 1, 22, and 43). After the propensity score matching (PSM), 61 sub-pairs of 122 patients were generated in post-PSM cohort. Survival rate were assessed with Kaplan-Meier method and Log-rank test. Results: After the propensity score matching(PSM), 61 sub-pairs of 122 patients were generated in post-PSM cohort.The patients were followed up for 3-135 months, the median follow-up was 42 months. No significant differences in 3-year and 5-year LRC, PFS, OS were observed between the two groups (P>0.05) . For postoperative patients who had high-risk factors (extracapsular extension of nodal disease, and/or vascular embolism, and/or lymph node metastasis≥2, and/or positive surgical margin, and/or perineural infiltration),there were significant differences between the two groups in 3-year PFS (60.99% vs 84.49%,P<0.05), 5-year PFS (35.47% vs 56.97%,P<0.05) and 5-year LRC (41.02% vs 68.50%, P<0.05), but no significant difference was found in OS between the two groups (P>0.05). Conclusion: Postoperative concurrent chemoradiotherapy was more efficacious than postoperative radiotherapy alone in terms of loco-regional control and PFS for high-risk postoperative patients with locally advanced hypopharyngeal squamous cell carcinoma.

Chemoradiotherapy for Head and Neck Squamous Cell Carcinoma: A Comparison of Three Platinum-based Regimens

Concurrent chemoradiotherapy (CRT) improves outcomes for patients with locally advanced head and neck squamous cell carcinoma (HNSCC) and high-risk postoperative patients. Current data support cisplatin at a dose of 100 mg/m2 every 3 weeks (Q3WC). Other regimens including weekly cisplatin (QWC) and weekly carboplatin/paclitaxel (CP) have been reported. We aim to compare survival, disease control, and post-treatment nutritional status between these regimens. We identified patients with HNSCC treated with CRT between 2010 and 2017. Patient, tumor, and treatment factors were abstracted from the medical record. Severe comorbidity was defined as Charlson comorbidity index ≥3. Kaplan-Meier estimates of overall survival (OS) and disease-free survival (DFS) and cumulative incidence (CI) of locoregional (LRF) and distant failure (DF) with death as a competing risk were generated from the date of RT completion. Multivariate models adjusting for baseline factors were performed. Gastrostomy tube dependence (GTD) at 6 months was defined as a Functional Oral Intake Scale ≤3. In total, 236 patients were treated with definitive (78%) or postoperative (28%) CRT with Q3WC (n=63), QWC (n=127) and CP (n=46). The Q3WC group had fewer patients >65 years old (10% v. 20% QWC v. 37% CP) or severe comorbidity (32% v. 39% v. 57%) and more frequent use of induction chemotherapy (3% v. 8% v. 20%). Primary sites included oropharynx (56%), larynx (27%), oral cavity (12%), and hypopharynx (5%) and 95% had stage III-IV disease. There were no baseline differences in gender, ECOG performance status, tobacco/alcohol use, clinical or pathologic stage, HPV status, extracapsular extension, or margin status. Cumulative dose ≥200 mg/m2 was achieved in 89% with Q3WC versus 73% with QWC (p=0.02). Twelve Q3WC patients converted to QWC due to one or more toxicity: nausea/vomiting (8), cytopenia (4), acute kidney injury (3), dehydration/weight loss (2), mucositis (1) and dermatitis (1). Median follow-up was 27 months. Three-year OS and DFS were 84%, 62% and 59% (p=0.01) and 74%, 58% and 48%, respectively (p=0.01). Compared to Q3WC, QWC (aHR 2.77) and CP (aHR 3.04) were associated with worse OS on multivariate analysis. Disease-specific survival also favored Q3WC (p=0.05). At 3 years, CI of LRF was 14% for Q3WC, 17% for QWC and 20% for CP (p=0.63); 3-year DF was 10%, 15% and 17%, respectively (p=0.81). No differences in weight change (mean -13% v. -12% v. -10%, p=0.29) or GTD (32% v. 20% v. 31%, p=0.31) were observed. Every-3-week cisplatin was associated with improved survival in patients treated with chemoradiotherapy for HNSCC. No significant differences were detected in locoregional or distant control. This may be related to cumulative dose, competing comorbidity and/or selection biases. There were no significant differences in nutritional outcomes.

Aspiration After Congenital Heart Surgery.

Dysphagia and vocal cord dysfunction are frequent complications after congenital heart surgery. Both are risk factors for aspiration, which can lead to pneumonia, progressive lung disease, and respiratory arrest. A protocol was implemented to promote early detection of aspiration in a high-risk cohort of patients. Retrospective data were collected on all patients under 120 days old who underwent the Norwood procedure, aortic arch repair, Blalock-Taussig shunt placement, or cervical cannulation for extracorporeal membrane oxygenation from 10/2012 to 05/2016 at a single institution. Patients underwent an assessment of symptoms, fiberoptic endoscopic evaluation of swallowing (FEES), and modified barium swallow (MBS) study in the postoperative period prior to initiating oral feeds. Patients with and without aspiration were compared. Of the 96 patients included in the study, one-third (33%) of patients had evidence of vocal cord dysfunction by FEES and just over half (51%) had evidence of aspiration by FEES or MBS. Most (73%) of the patients with aspiration were asymptomatic and a majority (53%) of patients with aspiration had normal vocal cord function. Aspiration is common after congenital heart surgery, and an assessment of vocal cord or swallow function in isolation may lead to underdiagnosis. A comprehensive protocol including MBS and FEES is necessary for the early detection of vocal cord dysfunction and aspiration and may prevent adverse outcomes in high-risk postoperative patients.

Postoperative critical care and high-acuity care provision in the United Kingdom, Australia, and New Zealand

Decisions to admit high-risk postoperative patients to critical care may be affected by resource availability. We aimed to quantify adult ICU/high-dependency unit (ICU/HDU) capacity in hospitals from the UK, Australia, and New Zealand (NZ), and to identify and describe additional 'high-acuity' beds capable of managing high-risk patients outside the ICU/HDU environment. We used a modified Delphi consensus method to design a survey that was disseminated via investigator networks in the UK, Australia, and NZ. Hospital- and ward-level data were collected, including bed numbers, tertiary services offered, presence of an emergency department, ward staffing levels, and the availability of critical care facilities. We received responses from 257 UK (response rate: 97.7%), 35 Australian (response rate: 32.7%), and 17 NZ (response rate: 94.4%) hospitals (total 309). Of these hospitals, 91.6% reported on-site ICU or HDU facilities. UK hospitals reported fewer critical care beds per 100 hospital beds (median=2.7) compared with Australia (median=3.7) and NZ (median=3.5). Additionally, 31.1% of hospitals reported having high-acuity beds to which high-risk patients were admitted for postoperative management, in addition to standard ICU/HDU facilities. The estimated numbers of critical care beds per 100 000 population were 9.3, 14.1, and 9.1 in the UK, Australia, and NZ, respectively. The estimated per capita high-acuity bed capacities per 100 000 population were 1.2, 3.8, and 6.4 in the UK, Australia, and NZ, respectively. Postoperative critical care resources differ in the UK, Australia, and NZ. High-acuity beds may have developed to augment the capacity to deliver postoperative critical care.

2144. Vital Signs Are Vital in Identifying High-Risk Postoperative Patients

BackgroundChanges in vital signs are frequently the first sign to point to pathology in the postoperative setting. There is no prediction model that exists that evaluates risk of postoperative complication in real-time. We are interested in understanding if we are able to risk stratify patients after surgery using novel predictors, trajectories of the various vital signs and evaluating their ability to risk stratify patients.MethodsWe reviewed patients who underwent pancreatectomy at an academic health system from January 2015 to February 2018. Postoperative complications were abstracted using definitions set by the National Surgical Quality Improvement Program (NSQIP) and vital signs, including pain score, were extracted from the Data Warehouse. Group-based trajectory modeling, a technique used to identify distinct clusters of patients with similar trajectories, was used to group patients with similar temperature, heart rate, blood pressure and pain scores. Postoperative complications were tabulated for each risk group and chi-square test was used to compare categorical variables.ResultsA total of 195 patients with pancreatectomy were evaluated and the rate of NSQIP complications was 35.4%. Pancreatectomy patients clustered into two distinct clusters for temperature, heart rate, systolic blood pressure and pain score. All four of these vital signs were able to stratify infectious and inflammatory complications between low- and high-risk groups but only systolic blood pressure was significant in stratifying readmission risk and heart rate and pain score for stratifying sepsis risk (Table 1).ConclusionTrends of vital signs may be important predictors of complications. Some vital signs may be better at predicting distinct complications. More work is required to understand if different covariates within trajectory analysis can be combined to further enhance risk stratification for any and specific postoperative complications.Table 1:Rates of Complications by Trajectory AnalysisSepsis %Any Complication %Readmission %Temperature high6.127.0*14.8Temperature low6.841.9*16.2HR high2.8*25.7*13.8HR low11.3*42.5*17.5SBP high6.923.0*9.2*SBP low5.941.2*20.6*Pain score high3.5*27.0*15.7Pain score low10.8*41.2*14.9* Significant at P < 0.05.Disclosures All authors: No reported disclosures.

Post-operative Catheterization Interventions at the Site of Surgery: An Application of the CRISP Scoring System.

Catheter-based interventions in the early post-operative period are performed with caution due to concerns for increased procedural risk, particularly across fresh suture lines. The recently published CRISP scoring system provides prospective risk stratification based on pre-procedural criterion. In an effort to refine the assessment of risk in patients undergoing post-operative catheter-based interventions, the predicted risk of an adverse event based on CRISP scores was compared to actual adverse event rates. A single-center, retrospective review of patients undergoing catheterization interventions within 6 weeks of cardiac surgery was conducted between Jan 2004 and Dec 2014. Patients who underwent dilation interventions across fresh suture lines (group 1) were compared to patients who underwent interventional procedures at other sites (group 2), and a CRISP score was calculated for all patients. Patients receiving only surveillance biopsies were excluded. Sixty-eight patients underwent 100 interventional procedures. Group 1 was composed of 44 patients receiving 64 interventions, while group 2 had 24 patients who underwent 36 interventions. Group 1 was comprised significantly more single ventricles and patients were smaller/younger. Group 1 had a significantly higher median CRISP score, but both groups were within Category 4. The rates of adverse events were similar between groups and comparable to predicted rates with the CRISP scoring system. Catheter-based interventions in the early post-operative period can be performed with no significant increase in the risk of serious adverse events when intervening across fresh suture lines. The CRISP scoring system can be a valuable tool in pre-procedural counseling of high-risk post-operative patients.

Metabolic Acidosis Assessment in High-Risk Surgeries

(Abstracted from Anesth Analg, 123(5):1163–1171, 2016) High-risk surgical patients frequently exhibit metabolic acidosis during the postoperative period, the clinical significance of which remains unclear. An observational multicenter study was carried out to determine the role of metabolic acidosis in high-risk postoperative patients and to determine the relationship between different types of acidosis and postoperative complications as well as 30-day mortality.

Abstract P4-07-01: Profiling miRNA in high risk post-operative early breast cancer patients to detect possible association to correlation with immune system antitumor response

Abstract Aims: Identifying which patient will be the one who developes metastatis or relapses is still an unsolved problem in breast cancer research. Circulating free nuclei acids such as microRNA (miRNA) are very promising cancer biomarkers to detect those patients. Aim of this study was to unravel an association among whole blood miRNA profiling, circulating tumor cells (CTCs) and clinical outcome in early breast cancer (EBC) patients and to test the utility of miRNAs as prognostic and diagnostic markers in post-operative patients. Methods: 48 high risk EBC patients, a subsample of the German SUCCESS A trial, were included in this retrospective study together with 18 aged-matched healthy donors (HDs) as controls. Peripheral blood was drawn post-operatively before (T0), after (T1) and two years after (T2) chemotherapy directly in Tempus Blood RNA Tubes (ThermoFischer Scientific) to stabilize and isolate total RNA. miRNAs were quantified by qPCR and their relative expression was calculated according to the 2-DCt method. CTCs were detected by immunocytochemistry. Data were analyzed using non-parametric statistical tests and p-values below 0.05 were considered significant. Results: 8 different miRNAs, either with oncogenic (miR-10a, -19a, -21, -22) or tumor suppressive (miR-20a, -127, -155, -200b) properties, in most of the cases linked to immune system regulation (miR-19a, -20a, -21, -127 and -155) were tested. miR-19a, miR-21, miR-22 and miR-127 showed the most promising results as prognostic markers in our tests. They could differentiate patients from HDs (Patients vs. HD: miR-19a at T0, p=0.004), T1 ( p&amp;lt;0.0001), miR-21 at T0 (p=0.001), T1 (p=0.004), miR-22 at T1 (p=0.012), T2 (p=0.034)). Additionally they correlated with the post-operative detection of CTCs (miR-127) and the late development of metastasis (miR-19a). Kaplan-Meier analysis indicated a borderline association between a longer progression free survival and higher miR-19a levels (HR= 2.808, 95% confidence interval [CI] =0.904, p=0.074.) Conclusion: We found a panel of miRNAs that could discriminate post-operative patients from HDs and could predict patients' outcome. We suggest that whole blood miRNA profiling could unravel a correlation with the activation of the immune system, leading to an efficient antitumor response and a better clinical outcome. These findings could open new perspectives in immune oncology and personalized therapy already in the early phase of the disease. Citation Format: Tzschaschel MLJ, Rack B, Majunke L, Trapp EK, Mahner S, Fasching PA, Fehm T, Schneeweiss A, Friedl TWP, Polasik A, Janni W, Alunni-Fabbroni M. Profiling miRNA in high risk post-operative early breast cancer patients to detect possible association to correlation with immune system antitumor response [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-07-01.

Thromboprophylaxis with fondaparinux in high-risk postoperative patients with renal insufficiency

Thromboprophylaxis with fondaparinux in high-risk postoperative patients with renal insufficiency