Postoperative Hypotension Research Articles

Untreated distal intimal tears may be associated with paraplegia after total arch replacement and frozen elephant trunk treatment of acute Stanford type A aortic dissection

ObjectiveTo investigate the possible overlooked causes of early postoperative paraplegia, a severe complication of acute Stanford type A aortic dissection (ATAAD) after total arch replacement and frozen elephant trunk (FET). MethodsWe reviewed the clinical data and perioperative aortic computed tomography angiography records of 110 consecutive patients with ATAAD who underwent total arch replacement and FET (12 cm) between December 2014 and September 2017 and investigated the possible risk factors related to early postoperative paraplegia. ResultsParaplegia occurred in 5 (4.5%) patients. No significant differences were found between patients with and without paraplegia in terms of sex, age, medical history, cardiopulmonary bypass time, antegrade cerebral perfusion time, rectal temperature during antegrade cerebral perfusion, postoperative hypotension, maximum first 24-hour vasoactive-inotropic score, upper-lower pressure gradient, or false lumen thrombosis. Postoperative aortic computed tomography angiography showed a “cutoff” phenomenon in the lower descending aorta in 4 of the 5 patients. Univariate logistical analysis showed that paraplegia was associated with the “cutoff” phenomenon (P < .05). The patients with a distance ≥30 mm from the distal end of the stent to the first untreated intimal tear had significantly greater rates of the “cutoff” phenomenon and paraplegia than those with the distance <30 mm (P < .05). ConclusionsTotal arch replacement and FET is safe and feasible for ATAAD involving the descending aorta. Early postoperative paraplegia is associated with the “cutoff” phenomenon in the lower descending aorta. The position of the first untreated intimal tear may be related with the occurrence of the “cutoff” phenomenon and paraplegia.

PS01.180: IMPACT OF INTRAOPERATIVE FLUID MANAGEMENT ON POSTOPERATIVE CARDIOPULMONARY FUNCTION AFTER THORACIC ESOPHAGECTOMY: A RETROSPECTIVE COHORT STUDY

Abstract Background This study aims to investigate the impact of intraoperative infusion balance on postoperative hemodynamics and oxygenation in patients undergoing elective transthoracic esophagectomy. Although adequate volume control is often deemed imperative to reduce complications, definitions of practical infusion dosages for the fluid management during surgery are absent. Methods In this retrospective cohort study, we examined 200 patients who underwent transthoracic esophagectomy from 2008 to 2017. During anesthesia, we followed our protocol that recommends the infusion volume of 10 mL/kg/h. Postoperatively, we followed the postoperative fluid protocol (Kobayashi M. Dis Esophagus 2010 23:565–71). Then, we collected data on actual volume of water infused both intraoperatively and postoperatively, and also evaluated ratios of intrapulmonary shunting (Qs/Qt), the occurrence of hypotension, the necessity of fluid resuscitation, and postoperative complications. Results In this study, postoperative hypotension was more frequent in patients who required more amount of fluid during surgery than the amount anticipated per the protocol. In addition, we determined a correlation of the amount of fluid volume between during surgery and postoperative day 0 (P = 0.001)(Fig.1a). Notably, an increased amount of intraoperative fluid did not deteriorate Qs/Qt (Fig.1b) or elevate the risk of postoperative complications. Conclusion This study deduces that higher increase in the intraoperative infusion volume could predict postoperative variation in the circulation after esophagectomy. In addition, although postoperative hypotension readily caused more infused volume than the expected balance, overdosed infusion in POD 0 demonstrated no apparent correlation with the impairment of pulmonary function. Disclosure All authors have declared no conflicts of interest.

Predicting Factors Associated with Postoperative Hypotension following Carotid Artery Stenting

Prolonged hemodynamic instability after carotid artery stenting (CAS) has been associated with increased incidence of stroke and other major adverse events. The objective of this study is to determine the factors associated with hypotension following CAS. In particular, this study evaluates whether involvement of the carotid bifurcation/bulb and degree of calcification can predict postoperative hypotension. A retrospective review of 90 CASs performed in 88 patients at a single tertiary center was completed. In patients with proximal internal carotid stenosis involving the carotid bifurcation, the extent of bifurcation/bulb calcification on preoperative computed tomography angiography was assessed using a scoring system. Calcium scores were assigned based on the percent of circumferential calcification of carotid bifurcation as follows: grade 1, <10%; grade 2, 10-50%; grade 3, 50-90%; and grade 4, >90%. Perioperative factors associated with prolonged postoperative hypotension requiring vasopressor infusion were analyzed. Overall, postoperative hypotension requiring vasopressors occurred in 26 (28.9%) of CAS. There were no differences in baseline demographics, comorbidities, or CAS indication between patients who required postoperative vasopressors for hypotension and those who did not. The majority of patients (64.4%) were on 2 or more antihypertensive medications preoperatively. Stenosis involved carotid bifurcation in 64 (71.1%) cases. Of these, 27 (42.2%) were grade 1, 19 (29.7%) were grade 2, 10 (15.6%) were grade 3, and 8 (12.5%) were grade 4 based on our calcium scoring system. On risk-adjusted analysis, carotid bifurcation/bulb involvement (adjusted odds ratio [aOR] 4.5, 95% confidence interval [CI] 1.1-18.5) and preoperative regimen of 2 or more antihypertensives (aOR 4.2, 95% CI 1.1-16.0) were independent predictors of hypotension requiring vasopressors following CAS. Among patients with carotid bifurcation involvement, severity of calcium score was not a significant predictor of postoperative hypotension. CAS for carotid stenosis involving the carotid bifurcation/bulb is associated with a higher risk for postoperative hypotension requiring vasopressors. Patients with preoperative hypertension requiring 2 or more antihypertensive medications are also at increased risk. However, severity of carotid bifurcation calcification is not a significant predictor of need for postoperative vasopressors.

Left ventricular strain is associated with acute postoperative refractory hypotension in patients with constrictive pericarditis and preserved ejection fraction.

Pericardiectomy is an effective treatment for constrictive pericarditis (CP). Early postoperative complications such as refractory hypotension and congestive heart failure occur in these patients and are associated with increased morbidity and mortality. We hypothesized that left ventricular (LV) myocardial strain measured by two-dimensional speckle tracking echocardiography (2DSTE) could identify early cardiac dysfunction and relate to acute postoperative adverse events in CP patients. Forty-four CP patients with preserved left ventricular ejection fraction (LVpEF, 64%±8%) and 44 age- and sex-matched controls were enrolled. Conventional 2DSTE was performed before pericardiectomy. Global and segmental peak systolic strain values were measured. The primary endpoint was a composite of postoperative refractory hypotension, congestive heart failure and cardiogenic death. Refractory hypotension was defined as hypotension requiring prolonged usage of intravenous inotropic medication (IVIM) (≥2 days). Postoperative refractory hypotension occurred in 26 cases, and no patients experienced congestive heart failure or cardiogenic death. Compared to controls, CP patients had decreased absolute global and segmental circumferential strain (CS), radial strain (RS), and longitudinal strain (LS) except septal LS. Patients with refractory hypotension exhibited lower epicardial CS (P=0.04). Epicardial CS was an independent risk factor correlated with postoperative adverse outcome [P=0.014, OR =1.236 (1.044-1.464)] while LVEF was not. Lower absolute value of epicardial CS was related to higher (P=0.02) and longer usage of intravenous furosemide (P=0.04) to keep negative fluid balance perioperatively. LV strain value is markedly reduced in patients with CP and LVpEF. Lower preoperative epicardial CS value is associated with greater risk of early refractory hypotension and more aggressive fluid management.

The characteristics of peroperative blood pressure and heart rate in patients with normotensive incidental pheochromocytomas

Objective To investigate the characteristics of peroperative blood pressure and heart rate in patients with normotensive incidental pheochromocytomas in order to provide the basis for peroperative treatment. Methods This retrospective study collected the data of 104 patients with a pathological diagnosis of unilateral pheochromocytoma at PLA General Hospital during January 2011 to December 2016. They were divided into normotensive incidental pheochromocytomas(NIP)group(n=50)if the patients were normotensive and HIP group(n=54)if the patients were with hypertension. The clinical features, imaging features and peroperative hemodynamics were analyzed. Results (1)The age, urinary norepinephrine, daily dosage and duration of phenoxybenzamine in NIP group were less than those of HIP group(all P<0.05). (2)Preinduction blood pressure, maximum blood pressure, and total fluid intake in NIP group were lower than those in HIP group(all P<0.05). The blood pressure range, heart rate range, increased blood pressure, minimum mean arterial pressure, vasoactive medication were without statistical significance between these two groups.(3)The times and rate of intraoperative systolic blood pressure more than 30% baseline, 200 mmHg(1 mmHg=0.133 kPa), 180 mmHg, 160 mmHg, intraoperative tachycardia, bradycardia, intraoperative hypotension and postoperative hypotension were without statistical significance between these two groups.(4)Stratified analysis of age(50 years), phenoxybenzamine(40 mg/d), tumor diameter(50 mm)and preinduction blood pressure(130/80 mmHg)showed that intraoperative blood pressure and heart rate were without statistical significance between these two groups.(5)There was no correlation between phenoxybenzamine(daily dosage or duration)and peroperative hypotension. Applying phenoxybenzamine or vasoactive medication was not correlated with peroperative hypotension in NIP group. Conclusion The peroperative blood pressure and heart rate of patients with NIP are similar to those of patients with HIP. Adequate peroperative treatment should be applied to NIP to avoid hemodynamic instability. (Chin J Endocrinol Metab, 2018, 34: 466-471) Key words: Pheochromocytoma; Hypertension; Peroperation; Blood pressure; Heart rate

Association Between Early Postoperative Acetaminophen Exposure and Acute Kidney Injury in Pediatric Patients Undergoing Cardiac Surgery

Acute kidney injury (AKI) is a common and serious complication for pediatric cardiac surgery patients associated with increased morbidity, mortality, and length of stay. Current strategies focus on risk reduction and early identification because there are no known preventive or therapeutic agents. Cardiac surgery and cardiopulmonary bypass lyse erythrocytes, releasing free hemoglobin and contributing to oxidative injury. Acetaminophen may prevent AKI by reducing the oxidation state of free hemoglobin. To test the hypothesis that early postoperative acetaminophen exposure is associated with reduced risk of AKI in pediatric patients undergoing cardiac surgery. In this retrospective cohort study, the setting was 2 tertiary referral children's hospitals. The primary and validation cohorts included children older than 28 days admitted for cardiac surgery between July 1, 2008, and June 1, 2016. Exclusion criteria were postoperative extracorporeal membrane oxygenation and inadequate serum creatinine measurements to determine AKI status. Acetaminophen exposure in the first 48 postoperative hours. Acute kidney injury based on Kidney Disease: Improving Global Outcomes serum creatinine criteria (increase by ≥0.3 mg/dL from baseline or at least 1.5-fold more than the baseline [to convert to micromoles per liter, multiply by 88.4]) in the first postoperative week. The primary cohort (n = 666) had a median age of 6.5 (interquartile range [IQR], 3.9-44.7) months, and 341 (51.2%) had AKI. In unadjusted analyses, those with AKI had lower median acetaminophen doses than those without AKI (47 [IQR, 16-88] vs 78 [IQR, 43-104] mg/kg, P < .001). In logistic regression analysis adjusting for age, cardiopulmonary bypass time, red blood cell distribution width, postoperative hypotension, nephrotoxin exposure, and Risk Adjustment for Congenital Heart Surgery score, acetaminophen exposure was protective against postoperative AKI (odds ratio, 0.86 [95% CI, 0.82-0.90] per each additional 10 mg/kg). Findings were replicated in the validation cohort (n = 333), who had a median age of 14.1 (IQR, 3.9-158.2) months, and 162 (48.6%) had AKI. Acetaminophen doses were 60 (95% CI, 40-87) mg/kg in those with AKI vs 70 (95% CI, 45-94) mg/kg in those without AKI (P = .03), with an adjusted odds ratio of 0.91 (95% CI, 0.84-0.99) for each additional 10 mg/kg. These results indicate that early postoperative acetaminophen exposure may be associated with a lower rate of AKI in pediatric patients who undergo cardiac surgery. Further analysis to validate these findings, potentially through a prospective, randomized trial, may establish acetaminophen as a preventive agent for AKI.

Clonidine versus other adjuncts added to local anesthetics for pediatric neuraxial blocks: a systematic review and meta-analysis.

BackgroundClonidine is a common adjunct to local anesthetics for pediatric neuraxial block; however, the pros and cons between clonidine and other adjuncts remain unclear. Thus, we performed this meta-analysis of randomized controlled trials to assess the efficacy and adverse effects between clonidine and other adjuncts added to local anesthetics.Materials and methodsThe systematic search, data extraction, critical appraisal, and pooled analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Randomized controlled studies were searched in Cochrane (to present), Medline (1946 to present), Embase (1974 to present), and Biosis (1995 to present). Relative risks (RRs), standard mean difference (SMD), and associated CIs were calculated using RevMan statistical software to assess continuous and dichotomous data. Heterogeneity in studies was measured by forest plots and I2 values. Subgroup analysis was performed for continuous and dichotomous variables, while meta-regression was applied for continuous data with high I2 values.ResultsA total of 15 randomized controlled studies met the inclusion criteria. There was a longer duration of postoperative analgesia in the clonidine group than for other adjuncts (SMD=1.54, p=0.005, I2=96%). The number of patients requiring rescue analgesia was lower in the clonidine group without the addition of epinephrine (RR=0.55, p=0.0002, I2=0), while the RR for the comparison with epinephrine was significant (p=0.62, I2=95%). The duration of motor block was longer in the clonidine group (mean difference [MD]=1.06, p<0.00001, I2=0). The clonidine group also had a lower incidence of postoperative nausea and vomiting (PONV; RR=0.49, p<0.00001, I2=0). Postoperative bradycardia, hypotension, and urinary retention were not significantly different between clonidine and other adjuncts (p>0.05).ConclusionClonidine, compared with other adjuncts, added to local anesthetics for neuraxial block, provides a longer duration of postoperative analgesia with lower incidence of PONV. However, the duration of motor block may also be prolonged by clonidine.

OP-379 - May High Level of Renalase be the Primary İndicator of Postoperative Term Hypotension after Coronary Artery Bypass Graft Surgery?

Background: The most common problem that we faced after coronary artery bypass graft surgery is the development of hypotension in the postoperative term. There is a direct relationship between catecholamines (dopamine, epinephrine, and norepinephrine) and blood pressure. In recent years, the presence of renalase enzyme which is synthesized primarily by kidneys is detected. In that case, there might be an association between renalase amounts and hypotension observed in the postoperative term. For that matter, we aimed to reveal whether there was a relationship between renalase amount and hypotension developed in the postoperative term by measuring renalase amounts and catecholamine levels of healthy and volunteered patients with normal tension and with patients who underwent coronary artery bypass graft surgery.

The short-term intraocular pressure after 25G+ pars plana vitrectomy and analysis of possible influence factors in rhegmatogenous retinal detachment and proliferative diabetic retinopathy

Objective To observe the short-term intraocular pressure after 25G+ pars plana vitrectomy(PPV) and analyze the possible influencing factors in rhegmatogenous retinal detachment (RRD) and proliferative diabetic retinopathy (PDR) eyes. Methods This is a retrospective case-control study. A total of 160 patients (163 eyes) of RRD and PDR who underwent 25G+ PPV were enrolled in this study. There were 88 males (89 eyes) and 72 females (74 eyes), with the mean age of (50.37±13.24) years. There were 90 patients (92 eyes) with RRD (the RRD group) and 70 patients (74 eyes) with PDR (the PDR group). Best corrected visual acuity (BCVA) and intraocular pressure (IOP) were performed on all the patients. The BCVA was ranged from hand motion to 0.6. The average IOP was (12.61±4.91) mmHg (1 mmHg=0.133 kPa). There were significant differences in crystalline state (χ2=9.285, P=0.009), IOP (χ2=58.45, P=0.000), history of PPV (χ2=4.915, P=0.027) and hypertension (χ2=24.018, P=0.000), but no significant difference in sex (χ2=0.314, P=0.635) and age (χ2=5.682, P=0.056) between the two groups. A non-contact tonometer has been used to measure IOP on postoperative day 1 and 3. The postoperative IOP distribution has been divided into five groups: severe ocular hypotension (≤5 mmHg), mild ocular hypotension (6 - 9 mmHg), normal (10 - 21 mmHg), mild ocular hypertension (22 - 29 mmHg), severe ocular hypertension (≥30 mmHg). Logistic regression analysis has been used to analyze the risk and protective factors. Results On the first day after surgery, there were 21 eyes(12.9%) in mild ocular hypotension, 96 eyes (58.9%) in normal, 22 eyes (13.4%) in mild ocular hypertension and 24 eyes (14.7%) in severe ocular hypertension. On the first day after surgery, there were 18 eyes (11.0%) in mild ocular hypotension, 117 eyes (71.7%) in normal, 23 eyes (14.1%) in mild ocular hypertension and 5 eyes (3.1%) in severe ocular hypertension. There was no significant difference of IOP distribution between the two groups(Z=−1.235, −1.642; P=0.217, 0.101). The results of logistic regression analysis showed that silicone tamponade was a risk factor for ocular hypertension in PDR eyes on the first day after surgery [odds ratio (OR)=15.400, 95% confidence interval (CI) 3.670 - 64.590; P<0.001], while intraocular lens was the risk factor for ocular hypotension in PDR eyes on third day after surgery (OR=19.000, 95%CI 1.450 - 248.2; P=0.025). As for RRD eyes, the ocular hypotension before surgery was a risk factor for ocular hypertension on the third day after surgery (OR=3.755, 95%CI 1.088 - 12.955; P=0.036). For all eyes, silicone tamponade (OR=0.236, 95%CI 0.070 - 0.797), air tamponade (OR=0.214, 95%CI 0.050 - 0.911) and inert gas tamponade (OR=0.092, 95%CI 0.010 - 0.877) were protective factors for ocular hypotension on the first day after surgery (P=0.020, 0.037, 0.038); silicone tamponade was protective factor for ocular hypotension on the third day after surgery (OR=0.249, 95% CI 0.066 - 0.94, P=0.040); while aphakic eyes was the risk factor for ocular hypotension on third day after surgery (OR=7.765, 95% CI 1.377 - 43.794, P=0.020). The ocular hypotension before surgery was a risk factor for ocular hypertension on the third day after surgery (OR=4.034, 95% CI 1.475 - 11.033, P=0.007). Conclusions The abnormal IOP is common after 25G+ PPV with a rate from 28.3% to 31.1%. Silicone tamponade, air tamponade and inert gases tamponade are protective factors for postoperative ocular hypotension, aphakic eye is risk factor for postoperative ocular hypotension. Ocular hypotension before surgery and silicone oil tamponade are risk factors for postoperative ocular hypertension. Key words: Vitreoretinal surgery/adverse effects; Intraocular pressure; Diabetic retinopathy/ surgery; Retinal detachment/surgery; Root cause analysis

Manual compression and reflex syncope in native renal biopsy

BackgroundComplications associated with diagnostic native percutaneous renal biopsy (PRB) must be minimized. While life threatening major complications has been extensively investigated, there is little discussion regarding minor bleeding complications, such as a transient hypotension, which directly affect patients’ quality of life. There is also little evidence supporting the need for conventional manual compression following PRB. Therefore, this study evaluated the relationship between minor and major complications incidence in patients following PRB with or without compression.MethodsThis single-center, retrospective study included 456 patients (compression group: n = 71; observation group: n = 385). The compression group completed 15 min of manual compression and 4 h of subsequent strict bed rest with abdominal bandage. The observation group completed 2 h of strict bed rest only. The primary outcome of interest was transient symptomatic hypotension (minor event).ResultsOf the 456 patients, 26 patients encountered intraoperative and postoperative transient hypotension, which were considered reflex syncope without tachycardia. Univariate analysis showed that symptomatic transient hypotension was significantly associated with compression. This association remained significant, even after adjustment of covariates using multivariate logistic regression analysis (adjusted odds ratio 3.27; 95% confidential interval 1.36–7.82; P = 0.0078).ConclusionManual compression and abdominal bandage significantly increased the frequency of reflex syncope during native PRB. It is necessary to consider the potential benefit and risk of compression maneuvers for each patient undergoing this procedure.

Safety of Injectable HPβCD-Diclofenac in Older Patients with Acute Moderate-to-Severe Postoperative Pain: A Pooled Analysis of Three Phase III Trials

BackgroundHydroxypropyl-β-cyclodextrin-diclofenac (HPβCD-diclofenac) is an NSAID used to treat acute moderate-to-severe postoperative pain. This post hoc analysis investigated the safety of HPβCD-diclofenac in patients aged ≥ 65 years.MethodsData from three phase III trials of HPβCD-diclofenac in adult patients with acute moderate-to-severe postoperative pain were pooled (NCT00448110, NCT00507026, and NCT00726388). Patients who received one or more dose of HPβCD-diclofenac or placebo were included and stratified according to age: < 65, 65–74, or ≥ 75 years. Numerical and categorical variables were compared across the groups using ANOVA and Cochran–Mantel–Haenszel tests, respectively. Cochran–Mantel–Haenszel relative risks compared with placebo were calculated, adjusted by study.ResultsOverall, 1289 patients were included: 878, 282, and 129 in the < 65, 65–74, and ≥ 75-years groups, respectively. Overall incidence of treatment-emergent adverse events (TEAEs) was similar in the three groups (p = 0.4360). Incidences of postoperative anemia (p < 0.0001), constipation (p = 0.0017), and hypotension (p = 0.0003) increased significantly across the age groups, whereas headache (p = 0.0008) and flatulence (p = 0.0118) decreased significantly. Relative risks for all System Organ Class categories and preferred terms investigated were similar among the groups and similar to placebo.ConclusionsOverall incidence of TEAEs in patients aged 65–74 or ≥ 75 years was similar to patients aged < 65 years. The groups displayed similar relative risks for the most frequent TEAEs, which were all similar to placebo. The TEAE profiles of the groups showed differences, all of which may be anticipated due to age-related differences in susceptibility and the types of surgery most commonly performed in each group.Clinicaltrials.gov identifiersNCT00448110, NCT00507026, and NCT00726388.

Period-dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death: A Substudy of the POISE-2 Trial.

The relative contributions of intraoperative and postoperative hypotension to perioperative morbidity remain unclear. We determined the association between hypotension and a composite of 30-day myocardial infarction and death over three periods: (1) intraoperative, (2) remaining day of surgery, and (3) during the initial four postoperative days. This was a substudy of POISE-2, a 10,010-patient factorial-randomized trial of aspirin and clonidine for prevention of myocardial infarction. Clinically important hypotension was defined as systolic blood pressure less than 90 mmHg requiring treatment. Minutes of hypotension was the exposure variable intraoperatively and for the remaining day of surgery, whereas hypotension status was treated as binary variable for postoperative days 1 to 4. We estimated the average relative effect of hypotension across components of the composite using a distinct effect generalized estimating model, adjusting for hypotension during earlier periods. Among 9,765 patients, 42% experienced hypotension, 590 (6.0%) had an infarction, and 116 (1.2%) died within 30 days of surgery. Intraoperatively, the estimated average relative effect across myocardial infarction and mortality was 1.08 (98.3% CI, 1.03, 1.12; P < 0.001) per 10-min increase in hypotension duration. For the remaining day of surgery, the odds ratio was 1.03 (98.3% CI, 1.01, 1.05; P < 0.001) per 10-min increase in hypotension duration. The average relative effect odds ratio was 2.83 (98.3% CI, 1.26, 6.35; P = 0.002) in patients with hypotension during the subsequent four days of hospitalization. Clinically important hypotension-a potentially modifiable exposure-was significantly associated with a composite of myocardial infarction and death during each of three perioperative periods, even after adjustment for previous hypotension.

Complications following radical surgery for malignant pleural mesothelioma—prevention and management

Radical surgery for malignant pleural mesothelioma (MPM) is a major undertaking for any patient and whilst it cannot be assumed to lead to a cure from the disease it is performed with the intent of prolonging survival. The surgical techniques used are either extra-pleural pneumonectomy (EPP) or extended pleurectomy/decortication (EPD). Patients undergoing EPD surgery have a lower short-term mortality compared to those undergoing EPP surgery. The better perioperative mortality has led to a recent trend towards preference to EPD, whenever possible. The prompt treatment of post-operative complications, may improve the patients survival, therefore, heightened awareness of their possibility and where possible preventive measures should be employed. Complications following surgery for MPM can be considered in three categories—pleuropulmonary: parenchymal atelectasis, pneumonia, pulmonary oedema, acute respiratory distress syndrome (ARDS), bronchopleural fistula (BPF), persistent air leak and pleural empyema—cardiovascular: post-operative hypotension, arrhythmias, cardiac herniation and pulmonary embolism (PE)—technical: haemothorax, chylothorax, prosthetic patch dehiscence and oesophagopleural fistula. We discuss the early warning signs, preventative actions and management strategies.

Pulmonary hypertension and post-operative outcome in renal transplant: A retrospective analysis of 170 patients

Background and Aims:Renal transplant is the best possible treatment for patients suffering with end-stage renal disease (ESRD). Cardiovascular events are the commonest factors contributing to perioperative morbidity and mortality in this population. These patients have a high incidence (up to 60%) of pulmonary hypertension (PH) and that may affect the perioperative outcome.Methods:In this study, we aimed to study the impact of PH on perioperative outcome after renal transplant. PH was defined as patients with pulmonary artery systolic pressure ≥35 mmHg on pre-operative echocardiography. Medical records of 170 patients who had undergone renal transplantation in the past 3 years were reviewed. Primary outcome was delayed graft functioning and secondary outcomes were perioperative complications such as hypotension, arrhythmias, need of post-operative mechanical ventilation, atelectasis and pulmonary oedema.Results:We observed 46.5% incidence of PH in ESRD patients. Compared to patients without PH, more patients with PH had postoperative hypotension (26.58% vs. 9.89%, P = 0.004) and delayed graft functioning (8.8% vs. 1.1%, P = 0.026). On multivariate analysis, however, PH was not an independent predictor of delayed graft functioning.Conclusion:In ESRD patients, although PH is not an independent predictor of delayed graft functioning, patients having PH are more prone for perioperative hypotension and delayed graft functioning after renal transplant.

Renalase decisive enzyme about the postoperative term hypotension after coronary artery bypass graft surgery

Renalase decisive enzyme about the postoperative term hypotension after coronary artery bypass graft surgery

Optimization of Postoperative Intravenous Patient-Controlled Analgesia with OpioidDexmedetomidine Combinations: An Updated Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials

Background: It is still a challenge to optimize postoperative pain management. The effects of adding dexmedetomidine (DEX) to opioid-based postoperative intravenous patient-controlled analgesia (PCA) are not fully understood. Objectives: The aim of this study is to assess the efficacy and safety of opioid-DEX combinations for postoperative PCA, and a trial sequential analysis (TSA) is utilized to evaluate the robustness of the current evidence. Study Design: A systematic review and meta-analysis. Setting: Randomized controlled trials that compared opioid-DEX combinations with opioid-only for PCA in adult surgical patients. Methods: MEDLINE, EMBASE, and CENTRAL databases were searched for relevant articles. The main outcomes analyzed were postoperative pain intensity, opioid requirement, and opioid-related adverse events. The random-effects model was used to estimate mean differences (MDs) or relative risks (RRs) with 95% confidence intervals (CIs). A TSA was performed to test whether the evidence was reliable and significant. The quality of evidence for the main outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results: Eighteen studies involving 1,284 patients were included. The meta-analysis indicated that opioid-DEX combinations were associated with lower postoperative pain intensity (at rest: MD [24 hours] = -0.48, 95% CI [-0.75, -0.21], P = 0.0005), lower morphine-equivalent requirement (MD [0 – 24 hours] = -12.16 mg [-16.12, -8.21], P &lt; 0.00001), and lower adverse events (nausea: RR = 0.66 [0.52, 0.83]; vomiting: RR = 0.65 [0.49, 0.87]; and pruritus: RR = 0.57 [0.40, 0.81]). For the above results, the TSA revealed that the cumulative Z-curve exceeded both the traditional boundary and the trial sequential monitoring boundary for benefit. DEX had no effect on the incidence of hypotension or bradycardia, which was also confirmed by the TSA. The GRADE level of evidence was high for postoperative nausea, moderate for pain intensity at rest at 24 hours postoperatively, morphine-equivalent requirement during 0 – 24 hours postoperatively, and postoperative vomiting, pruritus, and bradycardia, and low for postoperative hypotension. Limitations: The risk of introducing potentially significant heterogeneity exists, and this study did not evaluate the effects of DEX combined with opioids on long-term outcomes including chronic pain and patients’ satisfaction after hospital discharge. Conclusions: Postoperative PCA strategies with opioid-DEX combinations decreased postoperative pain, opioid requirement, and opioid-related adverse events. DEX is a useful adjuvant to opioid-based PCA. Key words: Dexmedetomidine, pain, postoperative analgesia, opioid, patient-controlled

Curriculum Using the In-Situ Operating Room Setting

The American College of Surgeons/Association of Program Directors in Surgery is a comprehensive, simulation-based curriculum for General Surgery residents which exists in 3 phases. While phases 1 and 2 deal with core skills and advanced procedures respectively, phase 3 targets team-based skills. To date, the 3rd phase of this curriculum has not seen wide scale implementation. This is a pilot study to verify the feasibility of implementing the phase 3 curriculum in the in-situ setting. In our initial attempt to implement Phase 3 at our institution, we chose to perform the training in an in-situ setting within an operating room (OR) at our main hospital, despite our having a separate simulation center. By choosing the in-situ OR environment for this training we were able to minimize concerns regarding resident and faculty availability and able to successfully complete 8 separate sessions during the academic year. During 7 sessions, 2 separate scenarios were performed while a single scenario was performed in 1 session. This single session was excluded from analysis, leaving a total of 14 scenarios to evaluate. The unique scenarios included laparoscopic crisis, postoperative myocardial infarction, anaphylaxis, and postoperative hypotension. All sessions were audiovisually recorded. In order to evaluate the effect of the training, the videos were viewed by 3 independent reviewers and all surgery, anesthesia and nursing participants were rated using the NOTECHs II scale. Degree of inter-rater agreement was established. The difference between the first and second simulations on the same day was then assessed. In addition, participant opinions of the simulations were assessed through electronic surveys following the training. Tertiary Care University Hospital. We performed a total of 8 sessions, for a total of 15 scenarios. Eight surgery residents at the postgraduate year 1 (PGY1)-PGY3 level, 16 anesthesia residents at the PGY3-PGY4 level, 16 nurses and 13 ancillary staff participated. From the first to the second scenario, the total team NOTECHs II score increased from 69.4 ± 1.4 to 77.3 ± 0.5 (p = 0.007). The NOTECHs II scores for each subteam also improved, from 24.2 ± 0.6 to 26.4 ± 0.5 (p = 0.007) for surgery residents, 23.7 ± 0.9 to 26.7 ± 0.4 (p = 0.03) for anesthesia, and 21.6 ± 0.3 to 24.3 ± 0.5 (p = 0.01) for nursing. The inter-rater reliability as measured by Kendall's coefficient of concordance was modest for the whole team score. Most of the participant responses were either favorable or strongly favorable. The in-situ OR environment is both a unique and effective setting to perform team-based training. Furthermore, training in the in-situ setting minimizes or removes many of the logistic issues involved in designing and implementing team-based training curricula for general surgery residency programs. However, we found that administrative and departmental (surgery, anesthesia, and nursing) "buy in" as well as protected faculty time for education were all necessary for in-situ training to be successful. NOTECHs II is an established scale for the evaluation of teams in this simulation setting and appears to be a valid tool based on the results of this study. However, further assessment of inter-rater reliability as well as improved training of evaluators are necessary to determine if inter-rater reliability can improve.

Overlapped Stenting Is Associated with Postoperative Hypotension after Carotid Artery Stenting

Hypotension (HT) is well recognized to frequently occur during and after carotid artery stenting (CAS), which sometimes causes postoperative complications such as stroke or myocardial infarction. This study aimed to examine the risk factors associated with HT after CAS based on the hypothesis that overlapped stenting may affect postoperative HT. A total of 106 lesions in 95 patients with carotid artery stenosis who underwent CAS were reviewed. Bradycardia and HT were defined as a heart rate and a systolic blood pressure less than 60 beats/min and 100 mm Hg, respectively. The patients were categorized by the presence (group H) or the absence (group N) of postoperative HT, respectively, and demographic data, risk factors, conditions of carotid artery stenosis, procedures, and pre- and intraoperative hemodynamics were compared between these 2 groups. Multivariate analysis was performed to evaluate independent factors associated with postoperative HT. In total, postoperative HT was observed in 30 (28.3%) cases. The incidence of overlapped stenting, the use of an open-cell stent, and intraoperative HT were significantly higher in group H (P = .03, .01 and < .01, respectively). The distance from carotid bifurcation and the maximum stenotic lesion tended to be shorter in group H (P = .09). In the multivariate logistic regression analysis, using all these variables, the overlapped stenting and intraoperative HT were found to be independent predictors for postoperative HT. The overlapped stenting affected postoperative HT after CAS. Blood pressure should be strictly controlled in cases with overlapped stenting or intraoperative HT after CAS.

Efficacy of foldable intraocular lens implantation with suture fixation in the ciliary groove after lensovitrectomy

Objective To evaluate the efficacy of foldable intraocular lens implantation with suture fixation in the ciliary sulcus in aphakic eyes after lensovitrectomy. Methods The clinical data of 22 eyes of 22 aphakic patients after lensovitrectomy were retrospectively analyzed. All patients were treated with implantation of a foldable posterior chamber intraocular lens with suture fixation through corneal micro incision. Patients were followed up from 6 to 30 months. Results During operation intraocular pressure was stability. No eyeball collapsing, choroid detachment, retinal detachment or expulsion of choroid cavity bleeding occurred. In 22 eyes, early postoperative ocular hypotension happened in 5 eyes and intraocular hypertension in 4 eyes, the IOP recovered to normal after drag treatment for 5-7 days. Three eyes with small amount of vitreous hemorrhage were absorbed 7 days after surgery . At the last follow-up time, best corrected visual acuity achieved or exceed preoperative one. The intraocular lens were all in the correct situation. There was no severe complication occurred such as corneal endothelial decompensation, subchoroidal expulsive hemorrhage, suture exposure, endophthalmitis, secondary glaucoma, retinal detachment or eyeball atrophy. Conclusion Foldable intraocular lens implantation with suture fixation in the ciliary sulcus through corneal micro incision for aphakic eyes in patients after lensovitrectomy is a safe and effictive therapy, with small injured and less complications. But the further observation is needed for long-term observation. Key words: Aphakic eye, after lensovitrectomy; Lens, intraocular, posterior chamber; Suture fixation, ciliary suleus

Predictors and incidence of orthostatic headache associated with lumbar drain placement following endoscopic endonasal skull base surgery.

Orthostatic headache (OH) is a potential complication of lumbar drainage (LD) usage. The incidence and risk factors for OH with the use of lumbar drainage during endoscopic endonasal procedures have not been documented. To investigate the incidence of post-procedure OHs associated with placement of LD in patients undergoing endoscopic endonasal procedures. We prospectively noted the placement of LDs in a consecutive series of endoscopic endonasal skull base surgeries. Charts were retrospectively reviewed, and patients were divided into two groups: those with OH and those without. The patient demographics, drain durations, imaging findings of intracranial hypotension, pathologies and need for a blood patch were compared between the two groups. Two hundred forty-nine patients were included in the study. Seven patients (2.8%) suffered post-dural puncture OH, which was mild to moderate and disappeared 2-8 days (median 3 days) after treatment. Blood patches were used in four patients. Significant predisposing factors were age (33.0 vs. 53.5, P = 0.014) and a strong trend for female gender (85.7% vs. 47.9%, P = 0.062). BMI and drain duration were not significant. Postoperative intracranial hypotension was diagnosed radiographically in 43% of OH patients and in 5.4% of those without OH (P = 0.003). Four (1.6%) patients required treatment with an epidural blood patch. OH associated with intracranial hypotension in patients undergoing endoscopic endonasal procedures with LDs is an infrequent complication seen more commonly in young female patients. Radiographic signs of intracranial hypotension are a specific but not sensitive test for OH.