Need For Postoperative Mechanical Ventilation Research Articles

Airway management may influence postoperative ventilation need in preterm infantsafter laser eye treatment.

Retinopathy of prematurity is treated with laser photocoagulation under general anaesthesia with intubation using endotracheal tube (ETT), which carries a risk for postoperative mechanical ventilation (MV). Laryngeal mask airway (LMA) may provide a safe alternative. We assessed the need for postoperative MV in preterm infants who received LMA versus ETT. In this single-centre, retrospective cohort study, preterm infants who underwent laser photocoagulation between 2014-2021 were enroled. For airway management, patients received either LMA (n = 224) or ETT (n = 47). The outcome was the rate of postoperative MV. Patients' age were 37 [35;39] weeks of postmenstrual age, median bodyweight of Group LMA was higher than Group ETT's (2110 [1800;2780] g versus 1350 [1230;1610] g, respectively, p < 0.0001). After laser photocoagulation, 8% of Group LMA and 74% of Group ETT left the operating theatre requiring MV. Multiple logistic regression revealed that the use of LMA and every 100 g increase in bodyweight significantly decreased the odds of mechanical ventilation (OR 0.21 [95% CI 0.07-0.60], and 0.73 [95% CI 0.63-0.84], respectively). Propensity score matching confirmed that LMA decreased the odds of postoperative MV (OR 0.30 [95% CI 0.11-0.70]). The use of LMA is associated with a reduced need for postoperative MV. Using laryngeal mask airway instead of endotracheal tube for airway management in preterm infants undergoing general anaesthesia for laser photocoagulation for treating retinopathy of prematurity could significantly decrease the postoperative need for mechanical ventilation. According to our current understanding, this has been the largest study investigating the effect of laryngeal mask airway during general anaesthesia in preterm infants. Our study suggests that the use of laryngeal mask airway is a viable alternative to intubation in the vulnerable population of preterm infants in need of laser treatment.

Deep odontogenic infections – Computed tomography imaging-based spreading routes and risk for airway obstruction

PurposeThis study aimed to evaluate deep odontogenic infection (DOI) spread and features utilizing head and neck computed tomography (CT) imaging. Material and methodsPatients with acute DOI and preoperative contrast-enhanced CT-imaging were included in the study. Infection spaces, radiological features of these infections, CT imaging-based compromised airway and patients’ background factors were evaluated and associations between these and need for postoperative mechanical ventilation (MV) were reported. ResultsAltogether 262 hospitalized patients were included in the final analysis. Typically affected spaces were submandibular (74%), mandibular buccal/vestibular (37%), and sublingual (26%). Retropharyngeal (1%), mediastinal (1%) and danger space (1%) involvements were unusual. The infections were quite evenly distributed between multispace abscesses (53%) and other infections (47%). In multivariate analysis, CT-based compromised airway (OR 5.6, CI 95%, 2.9–10.9, P <0.001), midline crossing (OR 3.3, CI 95%, 1.2–8.8, P = 0.018) and extension at the level or below hyoid body (OR 2.4, CI 95% 1.2–5.1, P = 0.016) predicted the need for MV. Other radiological findings and patients’ background variables remained statistically non-significant for MV. ConclusionAnterolateral and superior spread to the neck is typical in DOIs, whereas caudal progression is rare. Postoperative need for MV can be well recognized from CT.

Ventilation Strategies During General Anesthesia for Noncardiac Surgery: A Systematic Review and Meta-Analysis.

The optimal ventilation strategy during general anesthesia is unclear. This systematic review investigated the relationship between ventilation targets or strategies (eg, positive end-expiratory pressure [PEEP], tidal volume, and recruitment maneuvers) and postoperative outcomes. PubMed and Embase were searched on March 8, 2021, for randomized trials investigating the effect of different respiratory targets or strategies on adults undergoing noncardiac surgery. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed for relevant outcomes, and several subgroup analyses were conducted. The certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE). This review included 63 trials with 65 comparisons. Risk of bias was intermediate for all trials. In the meta-analyses, lung-protective ventilation (ie, low tidal volume with PEEP) reduced the risk of combined pulmonary complications (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.28-0.49; 9 trials; 1106 patients), atelectasis (OR, 0.39; 95% CI, 0.25-0.60; 8 trials; 895 patients), and need for postoperative mechanical ventilation (OR, 0.36; 95% CI, 0.13-1.00; 5 trials; 636 patients). Recruitment maneuvers reduced the risk of atelectasis (OR, 0.44; 95% CI, 0.21-0.92; 5 trials; 328 patients). We found no clear effect of tidal volume, higher versus lower PEEP, or recruitment maneuvers on postoperative pulmonary complications when evaluated individually. For all comparisons across targets, no effect was found on mortality or hospital length of stay. No effect measure modifiers were found in subgroup analyses. The certainty of evidence was rated as very low, low, or moderate depending on the intervention and outcome. Although lung-protective ventilation results in a decrease in pulmonary complications, randomized clinical trials provide only limited evidence to guide specific ventilation strategies during general anesthesia for adults undergoing noncardiac surgery.

Anesthesia and pain management of pediatric cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has shown to improve survival in patients with extensive or refractory abdominal tumors of many different histologies. Postoperative pain control can be challenging as the surgical procedure is performed through a midline laparotomy incision from xiphoid to symphysis pubis, and patients are usually nothing by mouth for the first 8-10 postoperative days. We present the anesthetic management and postoperative pain control strategies for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy using a multimodal, opioid-sparing, and total intravenous anesthetic technique with a tunneled thoracic epidural. A single institution retrospective review of anesthetic management, intraoperative fluid and blood administration, and postoperative pain control for pediatric patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy between July 2018 and December 2020 was conducted. We employed a novel anesthetic and analgesia protocol consisting of premedication with gabapentin followed by intraoperative infusions of propofol, dexmedetomidine, ketamine, and cisatracurium. A tunneled thoracic epidural catheter was placed for management of pain. We reviewed and analyzed the first 25 patient records. The most common diagnosis was desmoplastic small round cell tumor (n=12). Median age of patients was 14 years (range 21 months-22 years). All patients were extubated in the operating room and no patients required reintubation. There were no incidences of acute kidney injury. Epidural infusions were used for a median of 8 days (range 2-14 days). Median postoperative intravenous opioid use (morphine equivalent) through postoperative day 10 was 0.02 mg/kg/day (range 0-0.86 mg/kg/day) administered for a median of 2 days (range 0-17 days). Nine patients (36%) did not require any intravenous opioids in the postoperative period. Utilizing a multimodal, opioid-sparing, total intravenous anesthetic technique in conjunction with a tunneled thoracic epidural catheter, we were able to avoid the need for postoperative mechanical ventilation and minimize both intraoperative and postoperative opioid requirements.

ANALYSIS OF INJURY PATTERNS AND OUTCOMES OF PATIENTS WITH BLUNT ABDOMINAL TRAUMA – A TERTIARY CARE CENTRE EXPERIENCE

OBJECTIVE:Blunt abdominal trauma is one of the leading causes of morbidity and mortality in all age groups. Hemodynamic status of the patients and abdominal imaging play a major role in deciding the mode of management. The aim of this study is to analyse the clinical presentations, management and factors predicting outcome in patients with blunt injury abdomen presenting to a tertiary care centre in South India. METHODS:Combined retrospective and prospective analysis of prospectively maintained institutional database was performed. Data of all patients admitted with blunt abdominal trauma was analysed with regards to baseline characteristics, management and outcomes. RESULTS: One hundred and ten patients were admitted with blunt abdominal trauma in our institution from July 2014 to June 2015. Ninety-eight patients (89.1%) were male. The most common mode of injury was road trafc accidents (75.5%). Most common organs injured were spleen (28.2%), liver (22.7%) and small bowel (18.2%). Majority of the patients (73.6%) underwent operative management. Success rate of non-operative management was 89.7%. Overall mortality rate was 20.9%. CONCLUSION: Blunt abdominal trauma is associated with signicant morbidity and mortality. Computed tomography is the imaging modality of choice in hemodynamically stable patients to decide management. Non-operative management is successful in carefully selected cases. Old age, delayed presentation, presence of peritonitis, hemodynamic instability, and need for postoperative mechanical ventilation are associated with increased mortality.

Preoperative Thoracic CT Findings Associated With Postoperative Mechanical Ventilation in Patients Undergoing Major Abdominal or Pelvic Surgery: A Matched Case-Control Study.

BACKGROUND. Postoperative prolonged mechanical ventilation is associated with increased morbidity and mortality. Reliable predictors of the need for postoperative mechanical ventilation after abdominal or pelvic surgeries are lacking. OBJECTIVE. The purpose of this study was to explore associations between preoperative thoracic CT findings and the need for postoperative mechanical ventilation after major abdominal or pelvic surgeries. METHODS. This retrospective case-control study included patients who underwent abdominal or pelvic surgeries during the period from January 1, 2014, through December 31, 2018, and had undergone preoperative thoracic CT. Case patients were patients who required postoperative mechanical ventilation. Control patients and case patients were matched at a 3:1 ratio on the basis of age, sex, body mass index, chronic obstructive pulmonary disease, smoking status, and surgery type. Two radiologists (readers 1 and 2) reviewed the CT images. Findings were compared between groups. RESULTS. The study included 165 patients (70 women, 95 men; mean age, 67.0 ± 9.7 [SD] years; 42 case patients and 123 matched control patients). Bronchial wall thickening and pericardial effusion were more frequent in case patients than control patients for reader 2 (10% vs 2%, p = .03; 17% vs 5%, p = .01) but not for reader 1. Pulmonary artery diameter (mean ± SD) was greater in case patients than control patients for reader 2 (2.9 ± 0.5 cm vs 2.8 ± 0.5 cm, p = .045) but not reader 1. Right lung height was lower in case patients than control patients for reader 1 (18.4 ± 2.9 cm vs 19.9 ± 2.7 cm, p = .01) and reader 2 (18.3 ± 2.9 cm vs 19.8 ± 2.7 cm, p = .01). Left lung height was lower in case patients than control patients for reader 1 (19.5 ± 3.1 cm vs 21.1 ± 2.6 cm, p = .01) and reader 2 (19.6 ± 2.4 cm vs 20.9 ± 2.6 cm, p = .01). Anteroposterior (AP) chest diameter was greater for case patients than control patients for reader 1 (14.0 ± 2.3 cm vs 12.9 ± 3.7 cm, p = .02) and reader 2 (14.2 ± 2.2 cm vs 13.2 ± 3.6 cm, p = .04). In a multivariable regression model using pooled reader data, bronchial wall thickening exhibited an odds ratio (OR) of 4.6 (95% CI, 1.3-16.5; p = .02); pericardial effusion, an OR of 5.1 (95% CI, 1.7-15.5; p = .004); pulmonary artery diameter, an OR of 1.4 per 1-cm increase (95% CI, 0.7-3.0; p = .32); mean lung height, an OR of 0.8 per 1-cm increase (95% CI, 0.7-1.001; p = .05); and AP chest diameter, an OR of 1.2 per 1-cm increase (95% CI, 1.013-1.4; p = .03). CONCLUSION. CT features are associated with the need for postoperative mechanical ventilation after abdominal or pelvic surgery. CLINICAL IMPACT. Many patients undergo thoracic CT before abdominal or pelvic surgery; the CT findings may complement preoperative clinical risk factors.

Effects of intraoperative adrenergic administration on postoperative hyperlactatemia in open colon surgery: an observational study

BackgroundPostoperative Hyperlactatemia (PO-HL) is a frequent condition associated with poor prognosis. In recent years, there has been growing evidence that adrenergic stimulation may contribute to increased lactate levels. The use of adrenergic agonists for the control of intraoperative hypotension is frequent, and its impact on the development of PO-HL is unknown. ObjectiveTo evaluate whether the use of intraoperative adrenergic agents is associated with the occurrence of PO-HL. MethodsThis was a prospective observational study. The inclusion criteria were undergoing elective open colon surgery, being ≥60 years old and signing informed consent. The exclusion criteria were cognitive impairment, unplanned surgery, and anticipated need for postoperative mechanical ventilation. Baseline and intraoperative variables were collected, and arterial lactate data were collected at baseline and every 6 hours postoperatively for 24 hours. Hyperlactatemia was defined as lactate >2.1 mEq.L-1. ResultsWe studied 28 patients, 61% of whom developed hyperlactatemia. The variables associated with PO-HL in the univariate analysis were anesthetic time, the total dose of intraoperative ephedrine, and lower intraoperative central venous oxygen saturation (ScvO2). Multivariate analysis confirmed the association between the use of ephedrine (p = 0.004), intraoperative hypotension (p = 0.026), and use of phenylephrine (p = 0.001) with PO-HL. ConclusionsThe use of intraoperative ephedrine, phenylephrine and intraoperative hypotension were independently associated with the development of PO-HL. This finding should lead to new studies in this field, as well as a judicious interpretation of the finding of a postoperative increase in lactate levels.

Predictors of Immediate Tracheal Extubation in the Operating Room After Pediatric Liver Transplantation.

Pediatric orthotopic liver transplant recipients frequently need mechanical ventilation during the immediate posttransplant period. However, intensive care unit beds are costly and scarce; therefore, anticipating which patients will require postoperative mechanical ventilation support is important. In addition, immediate postoperative extubation may reduce the incidence of postoperative respiratory complications and improve patient outcomes after orthotopic liver transplant. Here, we aimed to determine the predictors of need for mechanical ventilation after orthotopic liver transplant in pediatric patients. We retrospectively analyzed the records of 57 pediatric patients who underwent orthotopic liver transplant (performed by the same team at Baskent University Hospital from April 1996 to August 2009). Patients were divided into 2 groups according to whether they required postoperative mechanical ventilation or not. Collected data included demographic features; comorbidities; cause of liver failure; perioperative laboratory values; intraoperative hemodynamic parameters; use and volume of crystalloids, colloids, and blood products; albumin levels; portal vein clamping time, requirement of inotropes/vasopressors; and anesthesia duration. Mean age and body weight of patients were 25.0 ± 23.1 months and 10.8 ± 5.3 kg, respectively. Of 57 patients, 26 (46%) needed postoperative mechanical ventilation. Compared with those who did not require postoperative mechanical ventilation, patients who required mechanical ventilation had growth failure (P = .03), higher mean intraoperative lactate level (P = .03), and higher mean intraoperative fresh frozen plasma/erythrocyte suspension (P = .049) and intraoperative vasopressor (P = .022) requirements. Multivariate logistic regression analysis revealed that growth failure (odds ratio = 37; P = .03) and higher intraoperative lactate level (odds ratio = 1.5; P = .03) were predictors of the need for mechanical ventilation. About 46% of our pediatric orthotopic liver transplant recipients required mechanical ventilation postoperatively. Growth failure and higher intraoperative lactate levels were associated with need for postoperative mechanical ventilation.

A comparative study between International normalized Ratio (INR) guided versus clinical discretion guided blood component replacement therapy in patients undergoing major surgery

Bleeding is a frequent complication during surgery. The intraoperative administration of blood products, including packed red blood cells, platelets and fresh frozen plasma (FFP), is often life saving. Complications of blood transfusions contribute considerably to perioperative costs and blood product resources are limited. The aim of the present study was to evaluate and compare the usage of INR guided vs clinician discretion based component replacement therapy which will optimize the use of FFP and may even result in less blood loss during surgery. Materials and Method: This study was conducted in surgical patients in a large tertiary care centre. Ethical clearance was taken from the local ethics committee at the proposal stage itself. Patients consent was taken after providing all necessary information prior to surgery. This study was conducted on 200 patients. The groups were randomised to two groups of Gp 1- study(S) -100 patients (point of care based transfusion management) Gp 2- control (C)- 100 patients (physician discretion based management). After premedication with intravenous morphine (0.05- 0.1 mg/kg body weight), Glycopyrrolate and ondansetron, General anaesthesia was induced with thiopentone sodium. Endotracheal intubation Intubation achieved after vecuronium. Anesthesia was maintained using low flow nitrous oxide: oxygen mixture (fresh gas flow of 1ltr each) and Isoflurane (1 MAC) via a closed circuit cycle absorber system and mechanical ventilation with 5 – 10 ml/kg. Standard monitoring will include HR, ECG (two lead), blood pressure (NIBP/ IABP), SpO2, Naso pharyngeal temperature. Patient warming was done with warm air blower (with a target temp above 360C). In the control group physician discretion was used to guide Blood platelet or FFP transfusion based on the institutional protocol. These are blood if Hb <8 gm %, platelets if <50,000 or between 50,000-80,000 with ongoing blood loss and FFP if bleeding >20% or >2 units blood given and repeated if physician desires. However these are guidelines and physician discretion based on clinical judgment is freely allowed. In the test group if bleeding is estimated to be more than 205 CBC and POC INR is done. If Hb < 8 gm % blood is transfused, if platelets <50,000 then 1 Single Donor Platelets or 6 Random Donor Platelets are transfused. 2 units of FFP are transfused if POC INR >1.8. Test was repeated after 30mins and 2 more units of FFP was given if INR >1.5. Result: there was no difference in age distribution sex weight of pateints between the two group, however the need for blood component therapy was in higher in pateints who were treated based on clinical discretion compared to INR guided treatment. The mean duration of post-operative ventilation required for the patient to be extubated with stable haemodynamic parameters in the test group was 48.55 hrs compared to 78.4 hrs for the control group. The maximum duration of post-operative ventilation in test group was 212 hrs, compared to 281 hrs for the control group. While the minimum duration was comparable being 18 hrs for test group and 19 hrs for control group. One-Sample Kolmogorov-Smirnov Test was done in each group to ensure normal distribution due to wide distribution of data.From our study we concluded that when INR guided blood component therapy was done the need for blood products was much lesser and the need for post-operative mechanical ventilation was much lesser in inr guided group compared to clinical discretion based therapy.

Are Intoxicated Trauma Patients at an Increased Risk for Intraoperative Anesthetic Complications? A Retrospective Study

Background The purpose of this study was to correlate intraoperative anesthetic complications of trauma patients with their respective urine toxicology results. Methods This retrospective, single-center cohort study at a Level 1 trauma center included patients with the following criteria: (1) trauma admission between January 1, 2010, and December 31, 2016, (2) required surgical intervention, (3) are age 18 and older, and (4) urine toxicology screening was completed. Anesthetic records were evaluated for intraoperative complications. Results The final analysis included 847 patients. The mean anesthesia time, American Society of Anesthesiologists physical status classification scores, change in body temperature, anesthetic complication rate, and mortality were not significantly different between urine toxicology positive and negative patients. Of note, a significantly lower proportion of the urine toxicology positive patients were extubated postoperatively in comparison to urine toxicology negative patients (57.32% vs 63.83%). Conclusions Trauma patients who presented with a positive urine toxicology screening are not at an increased risk for intraoperative anesthetic complications compared to those with a negative urine toxicology screening. However, our results indicated that the need for postoperative mechanical ventilation increased in the acutely intoxicated trauma patients when compared to those without preinjury intoxication.

Effects of Sugammadex on the Need for Postoperative Mechanical Ventilation in Patients with Myasthenia Gravis

Effects of Sugammadex on the Need for Postoperative Mechanical Ventilation in Patients with Myasthenia Gravis

Screening and topical decolonization of preoperative nasal Staphylococcus aureus carriers to reduce the incidence of postoperative infections after lung cancer surgery: a propensity matched study.

Health care-associated infections (HAIs) are serious issues following lung cancer surgery, leading to an increased risk of morbidity and hospital cost burden. The aim of this study was to evaluate the impact on postoperative outcomes of a preoperative screening and decolonization strategy of nasal carriers for Staphylococcus aureus prior to lung cancer surgery. We performed a retrospective study comparing 2 cohorts of patients undergoing major lung resection: a control group of patients from the placebo arm of the randomized Clinical Study to Evaluate the Efficacy of Chlorhexidine Mouthwashes operated on between July 2012 and April 2015 without any nasopharyngeal screening (N = 224); an experimental group, with preoperative screening for S. aureus of nasal carriers and selective 5-day decolonization in positive carriers using mupirocin ointment between January 2017 and December 2017 (N = 310). The 2 groups were matched according to a propensity score analysis with 1:1 matching. The primary outcome was the rate of postoperative HAIs, and the secondary outcome was the need for postoperative mechanical ventilation after surgery. After matching, 2 similar groups of 108 patients each were obtained. In the experimental group, 26 patients had positive results for nasal carriage, and a significant decrease was observed in the rate of overall postoperative HAIs [control n = 19, 17.6%; experimental group n = 9, 8.3%; P = 0.043; relative risk 0.47 (0.22-1)] and in the rate of postoperative mechanical ventilation [control n = 12, 11.1%; experimental group n = 4, 3.7%; P = 0.038; relative risk 0.33 (0.11-1)]. After logistic regression and multivariable analysis, screening of S. aureus nasal carriers reduced the rate of HAIs [odds ratio (OR) 0.29, 95% confidence interval (CI) 0.11-0.76; P = 0.01] and reduced the risk of the need for postoperative mechanical ventilation (OR 0.19, 95% CI 0.05-0.74; P = 0.02). There was no significant statistical difference between the 2 groups regarding the rate of postoperative S. aureus-associated infection (control group n = 6, 5.6%; experimental group n = 2, 1.9%; P = 0.28). Identification of nasal carriers of S. aureus and selective decontamination using mupirocin appeared to have a beneficial effect on postoperative infectious events after lung resection surgery.

OPIOID FREE ANESTHESIA IN A PRE-TERM NEONATE: A CASE REPORT

Opioids play a major role in the perioperative management of pain in adults and children. Though there is significant morbidity and mortality associated with overdosage of opioids, they remain the most common means of providing analgesia in the perioperative period. We report the case of a preterm neonate born with low birth weight who underwent high sigmoid loop colostomy for high anorectal malformation using opioid-free general anesthesia with supplementation with caudal block. Successful uncomplicated extubation of preterm baby was achieved with good spontaneous efforts. Opioid free general anesthesia can prevent respiratory depression and the need for postoperative mechanical ventilation even when given to preterm neonates.

Enhancing Recovery After Kasai Portoenterostomy With Epidural Analgesia

BackgroundBiliary atresia (BA) is a rare obstructive cholangiopathy that presents in early infancy. The Kasai portoenterostomy (PE) improves survival with the native liver. Epidural analgesia is an appealing option to control pain in this fragile patient population, yet its safety, efficacy, and potential benefits remain unproven. MethodsPatients undergoing PE for BA between 2001 and 2016 at a single institution were identified by ICD codes. Preoperative laboratories, procedure details, and recovery outcomes were reviewed retrospectively. Outcomes of interest were need for postoperative mechanical ventilation, pain scores, normalized opioid administration, return of bowel function, and length of hospital stay after PE. ResultsOf 47 infants undergoing PE for BA, 25 received epidural analgesia, and 22 did not. Infants with epidurals received less systemic opioids over the first 96 h postoperatively than those without (P < 0.001). Epidurals were associated with lower pain scores between 6 and 30 h postoperatively (P = 0.01 to 0.04), during which the highest median 6-h interval pain score was 0.2 (IQR 0-1.3) for patients with epidurals yet 2.1 (IQR 1.2-3.3) for patients without. Patients with epidurals (88%, n = 22) were more commonly extubated before leaving the operating room than those without (59%, n = 13; P = 0.02). No significant difference was observed in time to first bowel movement (P = 0.48) or first oral feed (P = 0.81). However, infants with epidurals had shorter hospital stays after PE than those without (6 d [IQR 5-7] versus 8 d [IQR 6.3-11], P = 0.01). No major complications were associated with epidural catheters. ConclusionsEpidural analgesia in patients undergoing PE for BA appears safe and effectively controls pain while minimizing the need for systemic opioids. Reduced need for mechanical ventilation postoperatively and shortened hospital stays serve as further evidence for using epidurals to enhance recovery after PE.

Risk Factors and Clinical Outcomes Associated with Perioperative Transfusion-associated Circulatory Overload.

Transfusion-associated circulatory overload remains underappreciated in the perioperative environment. The authors aimed to characterize risk factors for perioperative transfusion-associated circulatory overload and better understand its impact on patient-important outcomes. In this case-control study, 163 adults undergoing noncardiac surgery who developed perioperative transfusion-associated circulatory overload were matched with 726 transfused controls who did not develop respiratory complications. Univariate and multivariable logistic regression analyses were used to evaluate potential risk factors for transfusion-associated circulatory overload. The need for postoperative mechanical ventilation, lengths of intensive care unit and hospital stay, and mortality were compared. For this cohort, the mean age was 71 yr and 56% were men. Multivariable analysis revealed the following independent predictors of transfusion-associated circulatory overload: emergency surgery, chronic kidney disease, left ventricular dysfunction, previous β-adrenergic receptor antagonist use, isolated fresh frozen plasma transfusion (vs. isolated erythrocyte transfusion), mixed product transfusion (vs. isolated erythrocyte transfusion), and increasing intraoperative fluid administration. Patients who developed transfusion-associated circulatory overload were more likely to require postoperative mechanical ventilation (73 vs. 33%; P < 0.001) and experienced prolonged intensive care unit (11.1 vs. 6.5 days; P < 0.001) and hospital lengths of stay (19.9 vs. 9.6 days; P < 0.001). Survival was significantly reduced (P < 0.001) in transfusion recipients who developed transfusion-associated circulatory overload (1-yr survival 72 vs. 84%). Perioperative transfusion-associated circulatory overload was associated with a protracted hospital course and increased mortality. Efforts to minimize the incidence of transfusion-associated circulatory overload should focus on the judicious use of intraoperative blood transfusions and nonsanguineous fluid therapies, particularly in patients with chronic kidney disease, left ventricular dysfunction, chronic β-blocker therapy, and those requiring emergency surgery.

Impact of ejection fraction on infectious, renal, and respiratory morbidity for patients undergoing noncardiac surgery

ObjectiveWe sought to determine if decreased left ventricular systolic function was associated with an increased risk of postoperative infectious, respiratory, or renal complications in patients undergoing noncardiac surgery. DesignRetrospective cohort study. SettingSingle tertiary-care, university-based medical center. PatientsWe studied individuals who participated in the American College of Surgeons National Quality Improvement Program and had a preoperative echocardiogram conducted at our institution. InterventionsNone. MeasurementsThe incidences of postoperative respiratory (need for postoperative mechanical ventilation or unplanned intubation), renal (acute renal failure or renal insufficiency), and infectious (pneumonia, urinary tract infection, sepsis, or wound infection) complications were analyzed. Main resultsPostoperative infections (n=175, 10%) represented the most common postoperative complication seen in the study population of 1692 individuals. Respiratory complications occurred in 77 (5%) and renal complications occurred in 29 (2%) participants. The time between the echocardiogram and surgery ranged from 7 months (interquartile range [IQR] 1.8-15.7) for those with severely reduced left ventricular ejection fraction (LVEF) to 24 months (IQR 2.5-38.6) for those with a normal LVEF (P=.038). Univariate analysis demonstrated a relationship between decreased preoperative LVEF and infectious and renal complications, but not respiratory complications. After adjusting for preoperative characteristics, decreased preoperative LVEF was associated with infectious (odds ratio, 1.33; 95% confidence interval, 1.03-1.68; P=.0265) and renal (odds ratio, 1.69; 95% confidence interval, 1.12-2.48; P=.0142) complications. ConclusionsDecreased preoperative LVEF is associated with postoperative infections and renal complications.

Oblique chondrotomy alone for repair of neglected cleft sternum in adulthood

ObjectivesCleft sternum is an infrequent anomaly which typically drags parents' attention since birth with subsequent surgical repair in early years of life but few cases ask for surgical consultation at adulthood. We report 3 cases during the last 10 years in whom we use only a release oblique osteochondrotomy incision to primary repair the cleft without the need for a prosthetic material or bone graft. MethodsA retrospective descriptive study for three cases of congenital complete cleft sternum surgically repaired between 2004 and 2014 at cardiothoracic surgery department, Assiut University, Egypt. Surgery was done through a vertical midline incision, removal of the redundant skin, and the sternal edges were defined. Pectoralis muscle flap were created on both sides. A sliding cartilage flap was created between the second and fourth costal cartilages, and the sternal bars from both sides were advanced to meet in the midline followed by sternal approximation with stainless steel sutures of appropriate size. ResultsMean ages of cases we have operated were 17.6 years ± SD 1.52. All patients recovered smoothly, extubation was done in the operating room and with no need for postoperative mechanical ventilation. Chest wall movement was stable completely. Patients were discharged between 4th – 6th days postoperatively according to pain tolerance. Cosmetic results were acceptable for all patients. Chronic pain/neuralgia were not reported in 2 years follow up period. ConclusionsWe propose a simple surgical technique for repair of cleft sternum in adulthood without the need for prosthetic material or bone grafts. In comparison with previous techniques, it offers the theoretical advantage of restoring the anatomy without the risk of infection of the prosthesis or hazards of bone graft.

Risk factors for mechanical ventilation and reintubation after pediatric heart surgery

ObjectiveTo determine the prevalence of and risk factors associated with the need for mechanical ventilation in children following cardiac surgery and the need for subsequent reintubation after the initial extubation attempt. MethodsPatients younger than 18 years who underwent cardiac operations for congenital heart disease at one of the participating pediatric intensive care units (ICUs) in the Virtual PICU Systems (VPS), LLC, database were included (2009-2014). Multivariable logistic regression models were fitted to identify factors likely associated with mechanical ventilation and reintubation. ResultsA total of 27,398 patients from 62 centers were included. Of these, 6810 patients (25%) were extubated in the operating room (OR), whereas 20,588 patients (75%) arrived intubated in the ICU. Of the patients who were extubated in the OR, 395 patients (6%) required reintubation. In contrast, 2054 patients (10%) required reintubation among the patients arriving intubated postoperatively in the ICU. In adjusted models, patient characteristics, patients undergoing high-complexity operations, and patients undergoing operations in lower-volume centers were associated with higher likelihood for the need for postoperative mechanical ventilation and need for reintubation. Furthermore, the prevalence of mechanical ventilation and reintubation was lower among the centers with a dedicated cardiac ICU in propensity-matched analysis among centers with and without a dedicated cardiac ICU. ConclusionsThis multicenter study suggests that proportion of patients extubated in the OR after heart operation is low. These data further suggest that extubation in the OR can be done successfully with a low complication rate.

Robotic mitral valve repair.

Mitral valve repair is the standard therapy for patients with severe mitral regurgitation. Currently, robotic mitral valve repair is the least invasive surgical approach and an alternative to the traditional sternotomy. Recent studies and newer guidelines on mitral valve repair advocate for earlier referral to surgery, resulting in better long-term outcomes of valve function and decreased left ventricular remodeling. Robotic mitral valve repair outcomes were compared with nonrobotic mitral repair outcomes through analysis of 4 recent studies, one of which was the Food and Drug Administration trial that granted approval of robotic cardiac surgery. Two studies included their own nonrobotic groups for comparison, with one comparing the robotic approach with complete sternotomy, partial sternotomy, and mini-anterolateral thoracotomy to assess all currently available techniques. All 4 studies showed positive outcomes including decreased need for postoperative mechanical ventilation, intensive care unit length of stay, and hospital length of stay. The studies also showed that postrepair mitral regurgitation was equivalent to that of traditional open repairs at multiple different periods after surgery. Patients should be given the option for minimally invasive robotic mitral valve repair if they have no other risk factors such as peripheral vascular disease that prevent femoral cannulation for cardiopulmonary bypass or the need for concomitant cardiac surgery such as coronary artery bypass. With the equality of robotic outcomes compared with full sternotomy valve surgery comes the need for more research into what kind of complex valve repairs can be done, which methods of repair work best with robotic techniques, whether the learning curve for robotic surgery can be shortened with more widespread use, and what outcomes can be improved upon from this standpoint. Healthcare professionals need to be aware of all choices for patients who need surgical intervention for their mitral regurgitation.

Decreasing the need for mechanical ventilation after surgery for retinopathy of prematurity: sedoanalgesia vs. general anesthesia.

Premature infants experience more respiratory problems after surgical procedures. We aimed to compare general anesthesia with sedation regarding the need for postoperative mechanical ventilation in infants undergoing retinopathy of prematurity (ROP) surgery. Sixty patients who underwent laser surgery for ROP were included in this study. This study was performed between October 2010 and December 2012. The sedation group (Group S, n = 30) received 1 mg/kg ketamine and 1 mg/kg propofol as a bolus for induction. The patients then received an infusion of 100-150 μg kg(-1) min(-1) propofol and 0.25 mg kg(-1) h(-1) ketamine for maintenance. In the general anesthesia group (Group G, n = 30), anesthesia was induced using 8% sevoflurane by inhalation with 50% nitrous oxide in oxygen. Anesthesia was maintained with sevoflurane (2%) and 50% nitrous oxide in oxygen. There was no difference in gestational age, birth weight, current age, or current body weight between the two groups. Preoperative medical histories of the groups were similar. Two patients in Group S and 11 patients in Group G required postoperative mechanical ventilation (P = 0.010). Blood pressures and heart rates were similar. In premature infants, sedoanalgesia administration reduced the need for postoperative mechanical ventilation after surgery for ROP.