Risk Factors For Major Complications Research Articles

Outcome and survival after open heart surgery for adults with congenital heart disease – a single center experience

Introduction. Congenital heart disease (CHD) is the most common type of birth defect today. The adult congenital heart disease (ACHD) population is constantly growing and becoming older and more patients require cardiac surgery. The objective of this study was to review the surgical outcome of the open heart procedures performed on ACHD patients in the last 10 years at Sahlgrenska University Hospital (SUH) through a retrospective descriptive cohort study. Methods. A retrospective data collection was performed for 421 patients who underwent a total of 439 surgical procedures between 2009 and 2018 at the Cardiothoracic department in SUH. The primary outcomes were early (<30 days) and late survival. Secondary outcomes were postoperative complications and independent risk factors for postoperative complications. Results. 30-day mortality was 1.9%. Long-term survival after 3, 5 and 10 years were 96% ± 1, 94.3% ± 1.3 and 92.4% ± 1.8. 82 major complications occurred after 46 procedures (11.6%). The most common major complication was re-exploration due to hemorrhage. Risk factors for major complications were acute surgery and prolonged extracorporeal circulation time. 173 minor complications occurred after 90 procedures (22.5%). The most common minor complication was prolonged intensive care unit stay (>48 h). Conclusion. This study presents satisfactory early and midterm survival. The survival and frequency of major postoperative complications are well in line with what other studies have presented. Patients undergoing resternotomies had no increased risk for mortality or postoperative complications.

Impact of nutritional status and body composition on postoperative outcomes after pelvic exenteration for locally advanced and locally recurrent rectal cancer.

BackgroundPelvic exenteration for locally advanced rectal cancer (LARC) and locally recurrent (LRRC) rectal cancer provides radical resection and local control, but is associated with considerable morbidity. The aim of this study was to determine risk factors, including nutritional status and body composition, for postoperative morbidity and survival after pelvic exenteration in patients with LARC or LRRC.MethodsPatients with LARC or LRRC who underwent total or posterior pelvic exenteration in a tertiary referral centre from 2003 to 2018 were analysed retrospectively. Nutritional status was assessed using the Malnutrition Universal Screening Tool (MUST). Body composition was estimated using standard-of-care preoperative CT of the abdomen. Logistic regression analyses were performed to identify risk factors for complications with a Clavien–Dindo grade of III or higher. Risk factors for impaired overall survival were calculated using Cox proportional hazards analysis.ResultsIn total, 227 patients who underwent total (111) or posterior (116) pelvic exenteration were analysed. Major complications (Clavien–Dindo grade at least III) occurred in 82 patients (36.1 per cent). High risk of malnutrition (MUST score 2 or higher) was the only risk factor for major complications (odds ratio 3.99, 95 per cent c.i. 1.76 to 9.02) in multivariable analysis. Mean follow-up was 44.6 months. LRRC (hazard ratio (HR) 1.61, 95 per cent c.i. 1.04 to 2.48) and lymphovascular invasion (HR 2.20, 1.38 to 3.51) were independent risk factors for impaired overall survival.ConclusionA high risk of malnutrition according to the MUST is a strong risk factor for major complications in patients with LARC or LRRC undergoing exenteration surgery.

Risk factors for major complications after liver resection: A large liver resection study from Morocco and audit of a non-Eastern/non-Western experience

Background and Study AimsIn developing countries, endemic indications, blood shortages, and the scarcity of liver surgeons and intensive care providers can affect liver resection (LR) outcomes, but these have been rarely addressed in the literature. Therefore, in this study we determined risk factors for major complications after LR in a North African general surgery and teaching department. Patients and MethodsFrom January 2010 to December 2015, 213 consecutive LRs were performed on 203 patients. All patients underwent a postoperative follow-up of >90 days. Postoperative complications were assessed according to the Clavien–Dindo (CD) classification of surgical complications. A score of CD ≥III is considered as major postoperative complications. In this study, we analyzed the variables assumed to affect these complications. ResultsThe overall 90-day complication rate was 35.7% (n = 76), including a CD ≥III of 14% (n = 30) and a mortality rate of 6.1% (n = 14). According to the multivariate analysis, a preoperative performance status (PS) of ≥2 (P = 0.011; odds ratios [OR], 6.8; 95% confidence intervals [CI], 1.55–29.8), an estimated intraoperative blood loss of >500 ml (P = 0.002; OR, 3.71; 95% CI, 1.23–11.20), and bilioenteric anastomosis (P < 0.004; OR, 7.76; 95% CI, 1.5–3.89) were independent risk factors for major complications after LR. ConclusionWe recommend that, in the setting of a non-Eastern/non-Western general surgery and teaching department, patients with a PS of ≥2 should undergo a specific selection and preoperative optimization protocol; intermittent clamping indications should be extended; and special attention should paid to patients undergoing LR associated with biliary reconstruction, such as for perihilar cholangiocarcinoma.

The Effect of Preoperative Nutritional Support on Postoperative Morbidity and Mortality in Patients With Gastric Cancer: A Single Center Retrospective Study

Aim: Weight loss and malnutrition are frequently observed in patients with gastric cancer. Therefore, nutrition is important, especially in patients with gastric cancer. In this study, we aimed to identify the effect of preoperative nutritional support on postoperative morbidity and mortality in patients with gastric cancer. Material and Method: A total of 110 patients underwent gastrectomy due to gastric cancer between December 2015 and December 2019 were retrospectively analyzed. It was determined whether the patients were given preoperative and postoperative nutritional support. Clinicopathological features and short-term results were compared. Results: Overall morbidity was 29.1% (n=32) in patients who underwent gastrectomy. It was observed that the rate of major complications increased statistically with increasing age (p&amp;lt;0.001). Comorbidity was also found to be a risk factor for major complications (OR 3.917, 95% CI 1.423-10.781; p=0.006). The incidence of complications increases especially in patients with a diagnosis of diabetes (OR 3.743, 95% CI 1.201-11.666; p=0.040). While anastomotic leak developed in 6.7% (n=2) of the patients who were taken preoperative nutrition, anastomotic leak developed in 10% (n=8) of the patients who were not taken nutritional support (p=0.588). Likewise, the relationship between the postoperative length of stay, postoperative complications and mortality of patients receiving preoperative nutritional support could not been proven. Conclusion: The present study reveals that preoperative nutrition in patients with gastric cancer was not associated with improved morbidity and mortality rates. Large, multicenter prospective studies focusing on preoperative nutritional support are needed to uncover the exact relation of preoperative nutrition and morbidity-mortality rates in patients with gastric cancer.

Analysis of Risk Factors for Major Complications of 1500 Transvenous Lead Extraction Procedures with Especial Attention to Tricuspid Valve Damage.

Background: Transvenous lead extraction (TLE) is a relatively safe procedure, but it may cause severe complications such as cardiac/vascular wall tear (CVWT) and tricuspid valve damage (TVD). Methods: The risk factors for CVWT and TVD were examined based on an analysis of data of 1500 extraction procedures performed in two high-volume centers. Results: The total number of major complications was 33 (2.2%) and included 22 (1.5%) CVWT and 12 (0.8%) TVD (with one case of combined complication). Patients with hemorrhagic complications were younger, more often women, less often presenting low left ventricular ejection fraction (LVEF) and those who received their first cardiac implantable electronic device (CIED) earlier than the control group. A typical patient with CVWT was a pacemaker carrier, having more leads (including abandoned leads and excessive loops) with long implant duration and a history of multiple CIED-related procedures. The risk factors for TVD were similar to those for CVWT, but the patients were older and received their CIED about nine years earlier. Any form of tissue scar and technical problems were much more common in the two groups of patients with major complications. Conclusions: The risk factors for CVWT and TVD are similar, and the most important ones are related to long lead dwell time and its consequences for the heart (various forms of fibrotic scarring). The occurrence of procedural complications does not affect long-term survival in patients undergoing lead extraction.

Percutaneous transthoracic catheter drainage for lung abscess: a systematic review and meta-analysis.

To evaluate the outcomes of patients receiving image-guided percutaneous catheter drainage (PCD) for lung abscesses in terms of treatment success, major complications, and mortality as well as the predictors of those outcomes. Embase and OVID-MEDLINE databases were searched to identify studies on lung abscesses treated with PCD that had extractable outcomes. The outcomes were pooled using a random-intercept logistic regression model. Multivariate Firth's bias-reduced penalised-likelihood logistic regression analyses were performed to identify predictors of treatment success and complications. Methodological quality was assessed by summing scores of binary responses to items regarding selection, ascertainment of exposure and outcome, causality of follow-up duration, and reporting. From 26 studies with acceptable methodological quality (median score, 4; range, 3-5), 194 patients were included. The pooled rates of treatment success and major complications were 86.5% (95% confidence interval [CI], 78.5-91.8%; I2 = 23%) and 8.1% (95% CI, 4.1-15.3%; I2 = 26%), respectively. Four patients eventually died from uncontrolled lung abscesses (pooled rate, 1.5%; 95% CI, 0.2-11.1%; I2 = 36%). Malignancy-related abscess (odds ratio [OR], 0.129; 95% CI, 0.024-0.724; p = .022) and the occurrence of a major complication (OR, 0.065; 95% CI, 0.02-0.193; p < .001) were significant predictors of treatment failure. Traversing normal lung parenchyma was the only significant risk factor for major complications (OR, 27.69; 95% CI, 7.196-123.603; p < .001). PCD under imaging guidance was effective for lung abscess treatment, with a low complication rate. Traversal of normal lung parenchyma was the sole risk factor for complications, and malignancy-related abscesses and the occurrence of major complications were predictors of treatment failure. • The pooled treatment success rate of PCD for lung abscess was reasonably high (86.5%); malignancy-related abscesses and the occurrence of a major complication were predictors of treatment failure. • The pooled rate of percutaneous transthoracic catheter drainage-related major complications was 8.1% and traversing normal lung parenchyma by the catheter was the only risk factor. • The pooled mortality rate from uncontrolled lung abscesses with percutaneous transthoracic catheter drainage was low.

Racial Disparities in the Surgical Management of Benign Craniomaxillofacial Bone Lesions.

Racial disparities can influence surgical care in the United States. The purpose of this study was to determine if race and ethnicity were independent risk factors for adverse 30-day outcomes after surgical management of benign craniomaxillofacial bone tumors. This was a retrospective cohort study from 2012 to 2018 National Surgical Quality Improvement Program databases. Patients undergoing surgical removal of craniomaxillofacial benign lesions based on Current Procedural Terminology and International Classification of Diseases codes were included. Patients who had unrelated concurrent surgeries, or malignant, skull-based or soft tissue lesions were excluded. Primary outcomes were surgical complications and hospital length of stay (LOS). Univariate analyses were used with race as the independent variable to identify predictors of primary outcomes. Statistically significant factors were added to a multivariable logistic regression model. This study included 372 patients. Postoperative complications were highest among Black patients, who had a 4-fold increase in minor complications (P = 0.023) and over a 6-fold increase in major complications (P = 0.008) compared to White patients. Black patients also had a mean increase of 2.3 days in LOS compared to White patients (P < 0.001). The multivariate regression model showed higher rates of major complications and longer LOS for Black patients (P = 0.003, P = 0.006, respectively). Even when controlling for other variables, Black race was an independent risk factor for major complications and increased LOS. Further research should seek to identify the root cause of these findings in order to ensure safe and equitable surgery for all patients, regardless of race or ethnicity.

Liver resection for octogenarians in a French center: prolonged hepatic pedicle occlusion and male sex increase major complications.

The prolonged life expectancy and increase in aging of the population have led surgeons to propose hepatectomy in the elderly population. In this study, we evaluate the surgical outcome of octogenarians in a single French center. Between 2000 and 2020, 78 patients over 80 years old were retrospectively analyzed. The risk factors of major complications (Clavien-Dindo ≥ grade IIIa) and patient performance after surgery by using textbook outcome (TO) (no surgical complications, no prolonged hospital stay (≤ 15 days), no readmission ≤90 days after discharge, and no mortality ≤90 days after surgery) were studied. The main surgical indication was for malignancy (96%), including mainly colorectal liver metastases (n = 41; 53%) and hepatocellular carcinoma (n = 22; 28%), and major hepatectomy was performed in 28 patients (36%). There were 6 (8%) postoperative mortalities. The most frequent complications were pulmonary (n = 22; 32%), followed by renal insufficiency (n = 22; 28%) and delirium (n = 16; 21%). Major complications occurred in 19 (24%)patients. On multivariate analysis,the main risk factors for major complicationswere the median vascular clamping time (0 vs 35; P = 0.04) and male sex (P = 0.046). TO was ultimately achieved in 30 patients (38%), and there was no prognostic factor for achievement of TO. Hepatectomy in octogenarians is associated with acceptable morbidity and mortality. Meanwhile, prolonged hepatic pedicle clamping should be avoided especially if hepatectomy is planned in a male patient.

Accuracy and complications of percutaneous transthoracic needle lung biopsy for the diagnosis of malignancy in patients with idiopathic pulmonary fibrosis.

To determine the accuracy of CT-guided percutaneous transthoracic needle lung biopsy (PTNB) for the diagnosis of malignancy and the associated complication rates in patients with idiopathic pulmonary fibrosis (IPF). This retrospective study included 91 CT-guided PTNBs performed in 80 patients with IPF from April 2003 through December 2016. Data regarding patients, target lesions, procedures, complications, and pathological reports were collected, and the final diagnosis was made. The diagnostic accuracy, sensitivity, specificity, percentage of nondiagnostic results, and complication rates were determined. Multivariable logistic regression analyses were performed to identify risk factors for nondiagnostic results and major complications. Three biopsies (technical failure [n = 2] and undetermined final diagnosis [n = 1]) were excluded from the diagnostic accuracy calculation. The diagnostic accuracy, sensitivity, and specificity were 89% (78/88), 90% (62/69), and 84% (16/19), respectively. The percentage of nondiagnostic results was 34% (30/88). Lesion size ≤ 3 cm (odds ratio [OR], 8.8; 95% confidence interval [CI], 2.5-31.2; p = 0.001) and needle tip placement outside the target lesion (OR, 13.7; 95% CI, 1.4-132.2; p = 0.02) were risk factors for nondiagnostic results. The overall and major complication rates were 51% (46/91) and 12% (11/91), respectively. The presence of honeycombing along the path of the needle (OR, 11.2; 95% CI, 1.4-89.1; p = 0.02) was an independent risk factor for major complications. CT-guided PTNB shows a relatively reasonable accuracy in diagnosing malignancy in patients with IPF. The complication rate may be high, especially when the needle passes through honeycomb lesions. • In patients with idiopathic pulmonary fibrosis (IPF), CT-guided percutaneous transthoracic needle lung biopsy (PTNB) showed a relativelyreasonable accuracy for the diagnosis of malignancy. • Target lesion size ≤ 3 cm and biopsy needle tip placement outside the target lesion were risk factors for nondiagnostic results of CT-guided PTNB. • The complication rate may be high, especially in cases where the biopsy needle passes through honeycomb lesions.

Intra-operative nociceptive responses and postoperative major complications after gastrointestinal surgery under general anaesthesia: A prospective cohort study.

Surgical procedures stimulate nociception and induce physiological responses according to the balance between nociception and antinociception. The severity of surgical stimuli is associated with major postoperative complications. Although an intra-operative quantitative index representing surgical invasiveness would be useful for anaesthetic management to predict and prevent major complications, no such index is available. To identify associations between major complications after gastrointestinal surgery and intra-operative quantitative values from intra-operative nociception monitoring. A multi-institutional observational study. Two university hospitals. Consecutive adult patients undergoing gastrointestinal surgery under general anaesthesia. Averaged values of nociceptive response index from start to end of surgery (mean NR index) and risk scores of the Surgical Mortality Probability Model (S-MPM) were calculated. Pre and postoperative serum C-reactive protein (CRP) levels were obtained. After receiver-operating characteristic (ROC) curve analysis, all patients were divided into groups with high and low mean nociceptive response index. Associations between mean nociceptive response index and postoperative major complications, defined as Clavien-Dindo grade at least IIIa, were examined using logistic regression analysis. ROC curve analysis showed a nociceptive response index cut-off value for major complications of 0.83, and we divided patients into two groups with mean nociceptive response index less than 0.83 and at least 0.83. The incidence of major complications was significantly higher in patients with mean nociceptive response index at least 0.83 (23.1%; n = 346) than in patients with mean nociceptive response index less than 0.83 (7.7%; n = 443; P < 0.001). Multivariate analysis revealed emergency surgery, S-MPM risk score, mean nociceptive response index and postoperative CRP levels as independent risk factors for major complications. Mean nociceptive response index during surgery likely correlates with major complications after gastrointestinal surgery. The current observational study had no intervention, and was therefore, not registered.

Comparison of short-term outcomes in patients undergoing elective total elbow arthroplasty versus total elbow arthroplasty for fracture

BackgroundTotal Elbow Arthroplasty (TEA) has demonstrated promising functional outcomes for the treatment of complex distal humerus fractures. In many other joints, arthroplasty for trauma is associated with increased risks for acute postoperative complications. The purpose of this investigation is to identify the in-hospital and 30-day postoperative complications for TEA performed because of distal humerus fracture vs. arthritis, and to determine whether acute fracture is associated with differences in complications after TEA. MethodsThe American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent TEA from 2006 to 2018. Patients who were diagnosed with distal humerus fractures were identified and compared with patients without acute fracture. Patients without fracture were further divided into those undergoing TEA for Rheumatoid Arthritis (RA) vs. osteoarthritis (OA). Demographic data, length of hospital stay, readmission rate, reoperation rate, and postoperative complications within 30 days were analyzed by univariate analysis. Multivariable logistic regression was used to isolate the effect of acute fracture on postoperative complications and readmission. ResultsSix hundred fourty-six patients underwent TEA, and 149 (23.1%) had undergone TEA for distal humerus fracture. Patients undergoing TEA for fracture had an overall adverse event rate of 13.42% compared to a complication rate of 12.47% in patients undergoing primary elective TEA (P = .76). On univariate analysis, patients who underwent TEA for fracture were not significantly more likely to require reoperation within 30 days (1.34% vs. 4.63% for RA and 4.11% for OA, P = .24) or require readmission within 30 days (5.37% vs. 4.63% for RA and 4.88% for OA, P = .52). Multivariable logistic analysis found that TEA for fracture was not independently associated with readmission, reoperation, major complications, or minor complications. Increasing age is associated with increased risk of minor complications. Female gender is associated with decreased risk of major complication, and higher ASA classification was associated with increased odds of readmission. ConclusionsAcute fracture is not an independent risk factors for major complications, reoperation, or readmissions in patients undergoing TEA.Level of Evidence Level III; Retrospective Case-Control Study.

Slowly absorbable mesh in contaminated incisional hernia repair: results of a French multicenter study

To analyze the postoperative morbidity and 1-year recurrence rate of incisional hernia repair using a biosynthetic long-term absorbable mesh in patients at higher risk of surgical infection in a contaminated surgical field. All patients undergoing incisional hernia repair in a contaminated surgical field with the use of a biosynthetic long-term absorbable mesh (Phasix®) between May 2016 and September 2018 at six participating university centers were included in this retrospective cohort and were followed-up until September 2019. Regarding the risk of surgical infection, patients were classified according to the modified Ventral Hernia Working Group classification. Preoperative, operative and postoperative data were collected. All patients' surgical site infections (SSIs) and occurrences (SSOs) and recurrence rates were the endpoints of the study. Two hundred and fifteen patients were included: 170 with mVHWG grade 3 (79%) and 45 with mVHWG grade 2 (21%). The SSI and SSO rates at 12months were 22.3% and 39.5%, respectively. According to the Dindo-Clavien classification, 43 patients (20.0%) had at least one minor complication, and 57 patients (26.5%) had at least one major complication. Among the 121 patients (56.3%) having at least 1year of follow-up, the clinical recurrence rate was 12.4%. Multivariate analysis showed that a concomitant gastrointestinal procedure was an independent risk factor for surgical infection (OR = 2.61), and an emergency setting was an independent risk factor for major complications (OR = 11.9). The use of a biosynthetic absorbable mesh (Phasix®) is safe in a contaminated surgical field, with satisfying immediate postoperative and 1-year results. The study is registered on Clinical Trial ID: NCT04132986.

Predictors of major procedure-related complications in transvenous lead extraction

Abstract Background Transvenous lead extraction (TLE) has become the mainstay therapy for device-related infections. Though TLE procedures are associated with low complication and high success rates, risk factors for major procedure-related complications remain not well defined. Purpose To evaluate the safety and efficacy of TLE in a large single centre cohort and to identify risk factors for major complications. Methods All consecutive patients who had undergone TLE in our department between May 2012 and January 2020 were included in a prospective registry. Our protocol for TLE followed a stepwise approach according to lead dwell time and estimated complexity of the procedure: use of simple traction ± locking stylet (LS) ± mechanical and/or powered sheaths ± snare technique. In case of unsuccessful extraction from the venous entry site, femoral or jugular access was approached. Patient characteristics, procedural data and complications were gathered and analysed. Logistic regression analysis was applied to identify risk factors for major procedure-related complications. Results A total of 1717 leads (443 [25.9%] ICD leads) were targeted for TLE in 810 patients (67±15 years; 76% male). The mean lead dwell time was 83±60 months. The leading indication for TLE was cardiac device related infection (CDRI) in 527 patients (65.1%), of whom 273 (51.8%) had systemic and 254 (48.2%) localized infection. Two hundred eighty-three patients (34.9%) underwent TLE for non-CDRI causes. Leads were extracted by simple traction in 28.2%, traction with LS in 4.1%, dilator sheaths with LS in 50.1%, and additional use of powered mechanical sheaths in 13.0%. The snare technique was used in 4.6%. Venous access for TLE was exclusively from the entry site in 94.8%, combined from femoral in 4.0% and jugular in 1.2%. TLE was completely successful in 96.2%, partially successful in 2.1%, and failed in 1.7% of all attempted leads, which translated to a clinical success rate of 96.8%. Eighteen patients (2.2%) experienced minor and 12 patients (1.5%) had major procedure-related complications (cardiac tamponade/perforation) including one intraprocedural death (0.1%) from fulminant pulmonary embolism. Lead-years-per-patient (HR 1.064, 95% CI 1.032–1.096; p&amp;lt;0.001), dwelling time of the oldest lead (HR 1.013, 95% CI 1.007–1.019; p&amp;lt;0.001), and BMI (HR 0.877, 95% CI 0.772–0.997; p=0.020) were significant predictors for major complications in logistic regression analysis. Conclusion TLE is feasible, effective and safe in our large single centre experience. Overall complication and failure rates are low. Following our TLE protocol, dwelling time of the extracted leads and low BMI were associated with major procedure-related complications. Funding Acknowledgement Type of funding source: None

Cardiovascular rehabilitation after valvular heart surgery: predictive factors of major complications

Abstract Background The population of patients affected by valvular heart disease is growing and for many of them valvular surgery is still considered the gold standard treatment. Cardiovascular Rehabilitation (CR) following intervention is fundamental for the post-surgical functional recovery and for the monitoring and management of complications that may occur after surgery. Aim of the study We aimed at identifying predictors of major complications in patients who underwent valvular surgery and subsequently were involved in an in-patient CR program. Major complications were defined as those requiring an in-patient management: severe anemia needing transfusions, infection of the sternal surgical wound requiring an antibiotic treatment, a positive hemoculture in the presence of systemic signs of infection and pericardial effusion requiring surgical drainage. Methods and statistical analysis 1600 patients who have been hospitalized in our CR Unit after valvular surgery were enrolled (median age 64 years; 60% males). We examined the demographic data, the cardiovascular risk factors, the main comorbidities, the type of heart surgery (type of valvular surgery and the presence of concomitant other cardiac intervention), the complications developed in Cardiac Surgery Unit and in the CR Unit, the in-hospital length of stay, the 6 minutes-walking tests and principal blood tests. Results At multivariate analysis we found that chronic renal dysfunction [OR 1,902 (CI 1,103–3,280), p=0,021], complex cardiac intervention [OR 1,554 (CI 1,030–2,344), p=0,036], sternal re-synthesis [OR 4,671 (CI 1,659–13,152), p=0,004], early post-surgical transfusions [OR 1,670 (CI 1,083–2,573), p=0,020] are independent risk factors for major complications, while a higher hemoglobin value at CR admission [OR 0,677 (CI 0,566–0,810), p&amp;lt;0,001] resulted an independent protective factor. Conclusions We identified predictors of major complications during CR after valvular surgery. These factors may help in defining the patients at major risk tailoring the patient management, adopting an individualized clinical and instrumental monitoring. A tailored CR period gives the possibility to optimize the use of hospital economic resources and to achieve a better final outcome. Funding Acknowledgement Type of funding source: None

Gender-specific risk of complications in catheter ablation for atrial fibrillation

Abstract Background Catheter ablation is an established treatment modality for atrial fibrillation (AF). The risk of procedural complications is not negligible. Some studies suggested that female patients have a higher risk of complications. Purpose To identify gender-specific predictors of major complications (MCs) in patients undergoing catheter ablation for AF in a tertiary ablation centre. Methods A total of 4733 catheter ablations for AF (65% paroxysmal, 26% repeated procedures) were performed at our centre between January 2006 and August 2018. Patients (71% males) aged 60±10 years and had body mass index of 29±4 kg/m2 at the time of the procedure. Radiofrequency point-by-point ablation was employed in 96.3% procedures with the use of 3D navigation systems and facilitated by intracardiac echocardiography. Pulmonary vein isolation was mandatory; cavotricuspid isthmus and left atrial substrate ablation were performed in 22% and 38% procedures, respectively. MCs were defined as those that resulted in permanent injury, required intervention or prolonged hospitalization. Variables were assessed by uni- and multivariate analysis, two-sided α&amp;lt;0.05 was considered significant. Results A total of 160 (3.4%) MCs were detected - 60 (4.4%) in females and 100 (2.9%) in males (P=0.012). Both lower body height and the presence of bundle branch block (BBB) were associated with MCs only in females; for left bundle branch block (LBBB), the effect size was higher. On the contrary, higher left ventricular end-diastolic diameter (LVEDd) and persistent AF were associated with MCs in males (Table). Conclusion Females have a higher risk of MCs during catheter ablation for AF. Body height, AF type, BBB, and LVEDd may belong among gender-specific risk factors for MCs in AF ablation procedures. Whether BBB and LVEDd represent true risk factors warrants a validation in further studies. Funding Acknowledgement Type of funding source: None

Frequency and risk factors for major complications after stereotactic radiofrequency ablation of liver tumors in 1235 ablation sessions: a 15-year experience

ObjectivesTo assess the frequency of major complications after multi-probe stereotactic radiofrequency ablation (SRFA) in a large cohort of patients over 15 years and to elucidate risk factors for adverse events.Materials and methodsA retrospective study was carried out between July 2003 and December 2018. Seven hundred ninety-three consecutive patients (median 65.0 years (0.3–88), 241 women and 552 men, were treated in 1235 SRFA sessions for 2475 primary and metastatic liver tumors with a median tumor size of 3.0 cm (0.5–18 cm). The frequency of major complications was evaluated according to SIR guidelines and putative predictors of adverse events analyzed using simple and multivariable logistic regression.ResultsThirty-day mortality after SRFA was 0.5% (6/1235) with an overall major complication rate of 7.4% (91/1235). The major complication rate decreased from 11.5% (36/314) (before January 2011) to 6.0% (55/921) (p = 0.001). 50.5% (46/91) of major complications were successfully treated in the same anesthetic session by angiographic coiling for hemorrhage and chest tube insertion for pneumothorax. History of bile duct surgery/intervention, number of coaxial needles, and location of tumors in segment IVa or VIII were independent prognostic factors for major complications following multivariable logistic regression analysis. Simple logistic regression revealed the number of tumors, tumor size, location close to the diaphragm, tumor conglomerate, and segment VII as other significant predictors.ConclusionSRFA of liver tumors is safe and can extend the treatment spectrum of conventional RFA. Adaptations over time combined with increasing experience resulted in a significant decrease in complications.Key Points• In 1235 ablation sessions in 793 patients over 15 years, we found a mortality rate of 0.5% (6/1235) and an overall major complication rate of 7.4%, which fell from 11.5 (36/314) to 6.0% (55/921, p = 0.001) after January 2011, likely due to procedural adaptations.• History of bile duct surgery/intervention (p = 0.013, OR = 3.290), number of coaxial needles (p = 0.026, OR = 1.052), and location of tumors in segment IVa (p = 0.016, OR = 1.989) or VIII (p = 0.038, OR = 1.635) were found to be independent prognostic factors.• Simple logistic regression revealed that number of tumors, tumor size, location close to the diaphragm, tumor conglomerates, and segment VII were other significant predictors of major complications.

How to ventilate obese patients in the ICU.

Obesity is an important risk factor for major complications, morbidity and mortality related to intubation procedures and ventilation in the intensive care unit (ICU). The fall in functional residual capacity promotes airway closure and atelectasis formation. This narrative review presents the impact of obesity on the respiratory system and the key points to optimize airway management, noninvasive and invasive mechanical ventilation in ICU patients with obesity. Non-invasive strategies should first optimize body position with reverse Trendelenburg position or sitting position. Noninvasive ventilation (NIV) is considered as the first-line therapy in patients with obesity having a postoperative acute respiratory failure. Positive pressure pre-oxygenation before the intubation procedure is the method of reference. The use of videolaryngoscopy has to be considered by adequately trained intensivists, especially in patients with several risk factors. Regarding mechanical ventilation in patients with and without acute respiratory distress syndrome (ARDS), low tidal volume (6 ml/kg of predicted body weight) and moderate to high positive end-expiratory pressure (PEEP), with careful recruitment maneuver in selected patients, are advised. Prone positioning is a therapeutic choice in severe ARDS patients with obesity. Prophylactic NIV should be considered after extubation to prevent re-intubation. If obesity increases mortality and risk of ICU admission in the overall population, the impact of obesity on ICU mortality is less clear and several confounding factors have to be taken into account regarding the “obesity ICU paradox”.Electronic supplementary materialThe online version of this article (10.1007/s00134-020-06286-x) contains supplementary material, which is available to authorized users.

A Nasal High-Flow System Prevents Upper Airway Obstruction and Hypoxia in Pediatric Dental Patients Under Intravenous Sedation

Upper airway obstruction (UAO) and oxygen desaturation are risk factors for major complications of intravenous sedation (IVS) in pediatric dental patients. This study aimed to investigate the use of a nasal high-flow (NHF) system for the prevention of UAO and oxygen desaturation in pediatric dental patients under IVS. The authors implemented a prospective randomized design. Thirty pediatric patients (aged 3 to 12), scheduled for dental treatment under IVS, were enrolled in this study. The subjects were randomly assigned to 1 of 2 groups: patients who received oxygen at 5L/minute through a nasal cannula (NC group) and patients who received oxygen at 2kg/L/minute, up to a maximum of 30L/minute, through the NHF system (NHF group). The predictor variable was flow rate. The primary outcome variable was the need for intervention during treatment, and the secondary outcome variable was the lowest peripheral capillary oxygen saturation values during the procedure. Additional study variables measured included patient age, gender, weight, height, and surgical duration. The Mann-Whitney U test and Fisher exact test were used for statistical analysis, with P<.05 considered as significant. Both the NC (n=15; mean age, 6.2±2.3) and NHF (n=15; mean age, 5.9±2.5) groups had a male:female ratio of 2:1. The use of the NHF system significantly improved the lowest peripheral capillary oxygen saturation values during treatment (P<.05). Jaw lifting, to relieve UAO and facilitate spontaneous breathing, was required in both the NC (n=10) and NHF (n=3) groups (P<.05). The need for interventions during treatment was significantly lower in the NHF group (P<.05). The results of this study suggest that the use of the NHF system can prevent UAO and improve the respiratory condition of pediatric dental patients under IVS.

245. Predicting massive intraoperative blood loss in adult spinal deformity surgery

BACKGROUND CONTEXT Due to inherent patient and surgical factors, some adult spinal deformity patients are at higher risk of larger blood loss. This is associated with increased risk of complications, coagulopathy, and higher requirements for blood component replacement intraoperatively. The medical team should be aware of expected blood loss in order to adequately plan patient monitoring and blood product requirements. PURPOSE This study aims to develop and validate a model based on patient characteristics and surgical strategies to predict which patients undergoing adult spinal deformity surgery are at greater risk of massive intra-operative blood loss. STUDY DESIGN/SETTING Retrospective analysis of a multicenter prospective database. PATIENT SAMPLE Surgical ASD patients undergoing long fusions (>5 levels). OUTCOME MEASURES Massive intraoperative blood loss (>7% of a patient's ideal body weight), ICU stay, complications. METHODS Surgical adult spinal deformity patients undergoing long fusions (> 5 levels) were analyzed. Massive blood loss was defined as an intraoperative blood loss over 7% of a patients’ ideal body weight, in accordance to the anesthesia literature. The impact of mEBL on complications and ICU stay was assessed through multivariate poisson and logistic regression, adjusting for baseline patient demographics and magnitude of surgery. Multivariate logistic regression modeling was used to build a prediction model of mEBL. Potential predictors were identified using univariate analysis. The model was built using a combination of backward elimination and bootstrap selection. Model fit was assessed using the Hosmer-Lemeshow test and the ROC curve. Split sample internal cross-validation was performed. RESULTS A total of 1,205 patients met inclusion criteria, and mEBL occurred in 7.8% (94/1205) of cases. In this cohort, mEBL was an independent risk factor for major complications (IRR 2.89, p=0.0001), and postoperative ICU stay (OR 4.68, p=0.001). Predictors of mEBL included: revision surgery (OR 1.66, p=0.05), performing a three-column osteotomy (OR 2.65, p=0.0001), number of levels fused (OR 1.19, p=0.0001), number of levels decompressed (OR 1.15, p=0.004), and number of LLIF interbodies (OR 0.69, p=0.066). The predictive model had a good discrimination (ROC curve 0.76), and good calibration (Hosmer-Lemeshow p=0.39), which held true when performing split-sample cross-validation. CONCLUSIONS We built and validated a model to predict massive intra operative blood loss in ASD surgery. In this model, baseline patient demographics and elements of the surgical strategy are used to predict which patients are at greater risk for massive blood loss. This tool would be of particular help to the anesthesia team, allowing to identify preoperatively which patients are at greater risk and plan intraoperative care and fluid management accordingly. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Impact of fellowship training on surgical outcomes after appendectomies: a retrospective cohort study

Outcome studies have failed to show significant improvement related to formal fellowship training in different surgical specialties. We aimed to look whether laparoscopic fellowship-trained (FT) surgeons had better outcomes. This is an IRB approved retrospective review from a single institution (inner city hospital) on adults undergoing appendectomy from 2008 to 2017. Demographics and 30-day complications were analyzed with univariate and multivariate logistic regression analyses. Total of 558 appendectomies were reviewed. 151 (27.36%) appendectomies were performed by FT surgeons (MIS/CRS), 401 (72.64%) performed by GS. No difference in age, ASA, BMI, race, gender, insurance status, smoking, diabetes mellitus (DM), or hypertension was found. Also, similar rates of non-iatrogenic perforated appendicitis were seen (16.37% GS vs 20% FT, p = 0.318). For major complications, no difference was found between GS and FT (p = 0.63). However, appendectomies performed by GS showed higher rates of post-op ileus (3.99% vs 0.66%, p = 0.04), higher conversion to open (7.55% vs 2.67%, p = 0.039), higher rates of choosing an open approach (17.46% vs 0.66%, p = < 0.001), and longer length of stay (LOS) (median 1.9 vs 1.8days p = 0.048). Of the 16 patients with ileus from the GS group three were open, two converted to open, and eleven laparoscopic with mean OR time of 70min and LOS of 13.3days. The only laparoscopic case from the FT group with ileus had a mean operative time of 56min and LOS of 15days. On multivariate regression analysis, only DM was found as risk factor for major complications (OR 3.01, 95% CI 1.307-6.92, p = 0.01), while laparoscopic approach was seen as protective factor against major complications (OR 0.53, 95% CI 0.29-0.97, p = 0.04). Laparoscopic fellowship training had a positive outcome on post-op ileus and LOS after appendectomy. This seems to be related to the higher prevalence of choosing laparoscopic technique and lower rate of conversion to open.