Postoperative Respiratory Insufficiency Research Articles

Deliberate Oxygen Therapy – How Much Is Too Much of a Good Thing?

Committee News| June 2023 Deliberate Oxygen Therapy – How Much Is Too Much of a Good Thing? Jeffrey M. Carness, MD, FASA; Jeffrey M. Carness, MD, FASA Search for other works by this author on: This Site PubMed Google Scholar Catherine M. Kuza, MD, FASA, FCCM Catherine M. Kuza, MD, FASA, FCCM Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor June 2023, Vol. 87, 33. https://doi.org/10.1097/01.ASM.0000938860.68159.a4 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn Email Cite Icon Cite Get Permissions Search Site Citation Jeffrey M. Carness, Catherine M. Kuza; Deliberate Oxygen Therapy – How Much Is Too Much of a Good Thing?. ASA Monitor 2023; 87:33 doi: https://doi.org/10.1097/01.ASM.0000938860.68159.a4 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: oxygen therapy Oxygen is one of the most common and overused interventions in hospitals. It is a crucial component of atmospheric air, comprising approximately 21%, and is vital to numerous bodily functions and processes. While once reserved to treat and support patients with various life-threatening lung diseases, it has increasingly been routinely employed to prevent hypoxemia, particularly in the perioperative setting. In the OR, much of patient care revolves around oxygen. This includes everything from preoxygenation, to providing adequate oxygenation during the case, to oxygen uptake and delivery to vital organs, to preventing hypoxemia to reduce mortality in scenarios such as traumatic brain injury, and finally to providing sufficient oxygenation to prevent postoperative respiratory insufficiency on emergence. While oxygen is vital to life and an important element of patient care, many providers fail to recognize the harms of over-oxygenation, notwithstanding normal oxygen levels in most patients. Even though oxygen delivery in the... You do not currently have access to this content.

A modified aortic arch "island anastomosis" with stent graft technique for acute type A aortic dissection: a retrospective analysis.

A modified aortic arch "island anastomosis" with a stent graft technique was used in 33 patients with acute type A aortic dissection. We retrospectively reviewed our experience of this procedure and the short-term follow-up results. This retrospective analysis included 33 patients with acute type A aortic dissection undergoing the modified aortic arch island anastomosis with stent graft procedure. Postoperatively, computed tomography angiography images were obtained before discharge and at 12 months. All patients underwent successful surgery without intraoperative death. Three patients received dialysis because of postoperative renal insufficiency, 1 patient received tracheotomy because of postoperative respiratory insufficiency, and 5 patients had postoperative delirium. Surgery caused stroke in 1 patient. No paraplegia was found, and no re-exploration for bleeding was performed. One patient died in the hospital due to multiple organ failure, and the other patients were discharged as expected. Only 1 patient had a proximal endoleak, and the patient was stable under close follow-up. The diameter of the descending thoracic aorta was smaller at 12 months postoperatively than preoperatively (34.5±2.5 mm versus 36.7±2.9 mm, P<0.05). The average diameter of the true lumen of the descending thoracic aorta was larger at 12 months postoperatively than preoperatively (24.1±3.1 mm versus 14.9±2.3 mm, P<0.05). The modified aortic arch island anastomosis with stent graft technique is a feasible and safety surgical strategy for acute type A aortic dissection. Short-term outcomes are satisfactory.

TGA + IVS + LVOTO: patterns of practice and outcomes.

Transposition of great arteries with intact ventricular septum and left ventricular outflow tract obstruction (TGA + IVS + LVOTO) is uncommon. We reviewed operations performed in patients with TGA + IVS + LVOTO in the European Congenital Heart Surgeons Association Congenital Database (ECHSA-CD). All 109 patients with a diagnosis of TGA + IVS + LVOTO in ECHSA-CD who underwent cardiac surgery during a 21-year period (01/2000-02/2021, inclusive) were included. Preoperative variables, operative data, and postoperative outcomes were collected. These 109 patients underwent 176 operations, including 37 (21.0%) arterial switch operations (ASO), 26 (14.2%) modified Blalock-Taussig-Thomas shunts (MBTTS), 11 (6.2%) Rastelli operations, and 13 (7.3%) other palliative operations (8 superior cavopulmonary anastomosis[es], 4 Fontan, and 1 other palliative procedure). Of 37 patients undergoing ASO, 22 had a concomitant procedure.There were 68 (38.6%) reoperations, including 11 pacemaker procedures and 8 conduit operations. After a systemic-to-pulmonary artery shunt, reoperations included shunt reoperation (n = 4), Rastelli (n = 4), and superior cavopulmonary anastomosis (n = 3).Overall Operative Mortality was 8.2% (9 deaths), including three following ASO, two following "Nikaidoh, Kawashima, or LV-PA conduit" procedures, and two following Rastelli. Postoperative complications occurred after 36 operations (20.4%). The most common complications were delayed sternal closure (n = 11), postoperative respiratory insufficiency requiring mechanical ventilation >7 days (n = 9), and renal failure requiring temporary dialysis (n = 8). TGA + IVS + LVOTO is rare (109 patients in ECHSA-CD over 21 years). ASO, MBTTS, and Rastelli are the most common operations performed for TGA + IVS + LVOTO. Larger international studies with long-term follow-up are needed to better define the anatomy of the LVOTO and to determine the optimal surgical strategy.

Optimal timing for inguinal hernia repair in premature infants: surgical issues for inguinal hernia in premature infants.

We analyzed the timing of inguinal hernia repair in premature infants in the neonatal intensive care unit (NICU) considering recurrence, incarceration, and other complications. In this multicenter retrospective review, premature infants (<37 weeks) in the NICU diagnosed with inguinal hernia between 2017 and 2021 were segregated into 2 groups based on the timing of inguinal hernia repair. Of 149 patients, 109 (73.2%) underwent inguinal hernia repair in the NICU and 40 (26.8%) after discharge. Preoperative incarceration did not differ, but complications with recurrence and postoperative respiratory insufficiency were higher in the NICU group (11.0% vs. 0%, P = 0.029; 22.0% vs. 5.0%, P = 0.01). Multivariate analysis showed that the significant factors affecting recurrence were preoperative ventilator dependence and body weight of <3,000 g at the time of surgery (odds ratio [OR], 16.89; 95% confidence interval [CI], 3.45-82.69; P < 0.01 and OR, 9.97; 95% CI, 1.03-95.92; P = 0.04). Our results suggest that when premature infants are diagnosed with inguinal hernia in the NICU, inguinal hernia repair after discharge may decrease the odds of recurrence and postoperative respiratory insufficiency. In patients who have difficulty delaying surgery, it is thought that surgery should be performed carefully in a ventilator preoperatively or weighed <3,000 g at the time of surgery.

Indications for Admission and Its Association with Ocular Surface Disorders among Patients Admitted In Adult Intensive Care Unit of a Tertiary Care Hospital

Background: Present study was done to evaluate the Indications for admission and its association with ocular surface disorders among Patients admitted in Adult Intensive Care Unit of a Tertiary Care Hospital. Material and Methods: It was a prospective observational study carried in AICU over period of one year by Department of Ophthalmology, Dr. RPGMC Kangra at Tanda. All the patients who were admitted in AICU greater than 48 hours between ages of 18-65 years were included and evaluated for socio-demographic information like age, gender, indications for admission etc. Thorough ophthalmic examination was also done for ocular surface disorders and analysed using epi info v7 software. Results: A total of 126 patients were included in the study. Mean age of the study participants was 41.8 years. Maximum patients, 23.8% of the patients were in age group of 51 and 60 years followed by 23% between 21 and 30 years and 41 and 50 years each. 64.3% of the patients were males while 35.7% were females. The most common indication for AICU admission was post-operative monitoring (30.9%) followed by head injury (19.8%) and orthopaedic injury (11.1%). In the present study, 74 (58.7%) of the patients had ocular surface disorders. Ocular surface disorders were observed most commonly among patients who had head injury Followed by Post-operative monitoring and Respiratory Insufficiency as indication for AICU admission. Conclusion: The present study concluded that post-operative monitoring was the most common indication for AICU admission and Ocular surface disorders were observed most commonly among patients who had head injury.

Perioperative Pulmonary Atelectasis: Part II. Clinical Implications.

The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.

Neostigmine versus sugammadex on post-operative recovery following bariatric surgery.

OBJECTIVEThe purpose of our study was to compare the recovery characteristics and side effects of sugammadex (SM) and neostigmine (NT) in morbidly obese patients undergoing bariatric surgery. Residual neuromuscular block is a serious condition that increases pulmonary complications after anesthesia. Although acetylcholinesterase inhibitors help reverse this block, they may be insufficient, especially when administered with inhalational anesthetics. SM, a selective antagonist, may be more effective in reversing the block.METHODSPatients were randomly divided into NT group (Group NT, n=34) and SM group (Group SM, n=34).For the induction, fentanil (1–1.5 µ/kg), propofol (2–3 mg/kg), and rocuronium (0.6 mg/kg) were used.For the maintenance, 50% O2 + air, 1% sevoflurane, and remifentanil (0.5–0.3 µg/kg/min) were used. Additional rocuronium was given to maintain the train of four (TOF) ratio ≤2. On completion of surgery and when the TOF ratio was 2, group NT received 50 µg/kg of NT with 20 µg/kg of atropine, whereas group SM received 2 mg/kg of SM. Hemodynamic parameters and peripheral oxygen saturation (SpO2) were recorded every 10 minfirst, and every 5 min after the reversal agents were given. When the TOF ratio was 0.9 or higher, time to reach a TOF ratio of 0.9, and time to extubation were recorded. Patients were observed in the recovery room for 30 min for adverse effects.RESULTSDemographic characteristics of the patients and total rocuronium use in two groups were similar (p>0.05).Time to extubation, time to TOF ratio of 0.9, time until patients responded to stimuli, time until cooperation, and time until orientation were significantly shorter in the SM group than in the NT group. Time to reach the Aldrete score of 9 was also significantly shorter in the SM group (p<0.05).In the post-operative period, hemodynamic variables and side effects such asrespiratory difficulty, nausea, vomiting, hypo/hypertension, and presence of pain showed no statistically significant differences between the groups (p>0.05).CONCLUSIONConsidering the high risk of post-operative respiratory insufficiency inmorbidly obese patients, SM could be a safer choice in this patient group.

Too big to breathe: predictors of respiratory failure and insufficiency after open ventral hernia repair.

Increased intra-abdominal pressure in open ventral hernia repair (OVHR) is hypothesized to contribute to postoperative respiratory insufficiency (RI) or failure (RF). This study examines the impact of abdominal volumes on postoperative RI in OVHR. OVHR patients with preoperative CT scans were identified. 3D volumetric software measured hernia volume (HV), subcutaneous volume (SQV), and intra-abdominal volume (IAV). The ratio of hernia to intra-abdominal volume (HV:IAV) was calculated. A principal component analysis was performed to create new component variables for collinear volume and hernia variables. There were 1178 OVHR patients with preoperative CT scans. Demographics included a mean BMI of 34.2 ± 7.7kg/m2, age of 58.5 ± 12.4years, and 57.8% were female. RI occurred in 8.3% of patients, including 4.0% requiring > 24h respiratory support with ezPAP, CPAP, or biPAP(RI), and 4.3% requiring intubation (RF). Patients who developed RI had a higher BMI (33.8 ± 7.5 vs. 38.2 ± 9.1kg/m2, p < 0.0001), older age (58.1 ± 12.5 vs. 62.8 ± 10.4years, p = 0.0001), larger defects (140.9 ± 128.4 vs. 254.0 ± 173.9cm2, p < 0.0001), HV (865.8 ± 1200.0 vs. 2005.6 ± 1791.7cm3, p < 0.0001), and HV:IAV (0.26 ± 0.45 vs. 0.53 ± 0.58, p < 0.0001). Three PC variables accounted for 85% of variance: hernia volume PC consists primarily of HV (61.8%), ratio HV:IAV (57.7%), and defect size (50.1%) and accounts for 38.3% variance. Extra-abdominal volume PC consists primarily of SQV (63.7%) and BMI (60.8%) and accounts for 32.5% variance. Intra-abdominal volume PC is primarily IAV (75.8%) and accounts for 14.9% variance. In multivariate analysis, predictors of RI included asthma and COPD (OR 4.04, CI 1.82-8.96), hernia PC (OR 1.47, CI 1.48-1.98), EAV PC (OR 1.24, CI 1.04-1.48), increased age (OR 1.04, CI 1.01-1.06), and diabetes (OR 1.8, CI 1.11-2.91). Component separation, fascial closure, contamination, and panniculectomy were not associated with RI. The impact of defect size, BMI, HV, SQV, IAV, and HV:IAV on respiratory insufficiency after OVHR is collinear. Patients with large defects and a large ratio of HV:IAV (greater than 0.5) are also at significantly increased risk of RI after OVHR. While BMI impacts these parameters, it is not directly predictive of postoperative RI.

Noteworthy Literature published in 2017 for Cardiac Critical Care

In 2017, many high-impact articles appeared in the literature. This is the third edition of an annual review of articles related to postoperative cardiac critical care that may affect the cardiac anesthesiologist. This year explores vasopressor and inotropic support, timing of renal replacement therapy, management of postoperative respiratory insufficiency, and targeted temperature therapy.

Anesthetic considerations for patients with acute cervical spinal cord injury.

Anesthesiologists work to prevent or minimize secondary injury of the nervous system and improve the outcome of medical procedures. To this end, anesthesiologists must have a thorough understanding of pathophysiology and optimize their skills and equipment to make an anesthesia plan. Anesthesiologists should conduct careful physical examinations of patients and consider neuroprotection at preoperative interviews, consider cervical spinal cord movement and compression during airway management, and suggest awake fiberoptic bronchoscope intubation for stable patients and direct laryngoscopy with manual in-line immobilization in emergency situations. During induction, anesthesiologists should avoid hypotension and depolarizing muscle relaxants. Mean artery pressure should be maintained within 85–90 mmHg (1 mmHg = 0.133 kPa; vasoactive drug selection and fluid management). Normal arterial carbon dioxide pressure and normal blood glucose levels should be maintained. Intraoperative neurophysiological monitoring is a useful option. Anesthesiologists should be attentive to postoperative respiratory insufficiency (carefully considering postoperative extubation), thrombus, and infection. In conclusion, anesthesiologists should carefully plan the treatment of patients with acute cervical spinal cord injuries to protect the nervous system and improve patient outcome.

PUB003 Predictors of Mortality, Morbidity and Prolonged Length of Stay after Lobectomy: A Population Based Analysis

There is a wide variation in healthcare delivery in the United States. Some of the variation may be due to disparities in the health and socioeconomic status of patients. To evaluate the impact of health and socioeconomic status on outcomes after lobectomy, we sought to evaluate predictors of mortality, morbidity and prolonged length of stay (LOS) for patients undergoing lobectomy in the contemporary era using the Nationwide Inpatient Sample (NIS) database We examined all patients >18yr who underwent a lobectomy in the NIS database (2007-2011). Multiple regression-analysis was used to evaluate the predictors of mortality, morbidity and prolonged LOS. 165,819 patients underwent lobectomy (2007-2011). Median age 67yr, Females 52%. Leading comorbidities were hypertension (HTN,50.1%), chronic pulmonary disease (CPD,39.4%), coronary artery disease (CAD,19.0%), peripheral vascular disease (PVD,7.2%), and chronic renal disease (CRD,4.3%). 60% of lobectomies were performed in teaching hospital setting, and VATS-lobectomy accounted for 26.1% of resections. Overall mortality was 2.2% with a median hospital LOS of 6 days. Intraoperative bleeding occurred in 1.5% of patients. Leading postoperative morbidities were supraventricular arrhythmia(18.0%), postoperative acute pneumothorax(17.3), pneumonia(8.4%), need for mechanical ventilation(6.6%), postoperative acute respiratory insufficiency(6.4%) and urinary tract infection(3.6%). Multivariate predictors of mortality, morbidity, and prolonged LOS>6 days were performed. Predictors of increased mortality were advancing age, male gender, congestive heart failure(CHF), thoracotomy approach and low socioeconomic status. Predictors of increased morbidity were advancing age, male gender, congestive heart failure, chronic pulmonary disease, chronic renal disease, teaching hospital setting and thoracotomy approach. All of these factors significantly contributed to prolonged LOS as well. For patients undergoing lobectomy in the United States, health and socioeconomic factors of patients together with healthcare delivery methods significantly predict mortality, morbidity and prolonged LOS. Preoperative risk modification, careful patient selection and appropriate use of VATS approach may serve to improve perioperative outcome of patients undergoing lobectomy.

Obstructive Sleep Apnea Increases the Perioperative Risk of Cardiac Valve Replacement Surgery: A Prospective Single-Center Study.

Sleep apnea is common in patients referred for cardiac valve replacement (CVR). We aimed to determine the association of obstructive sleep apnea (OSA) and central sleep apnea (CSA) with perioperative events in CVR surgery in patients with rheumatic valvular heart disease (RVHD). Between April 2010 and April 2014, 290 patients with RVHD undergoing CVR were screened for sleep apnea 1 to 7 days before CVR. Baseline medications, cardiac function, sleep parameters, perioperative events, and related risk factors were evaluated. OSA patients had longer duration of intensive care unit (ICU) stay and mechanical ventilation compared with no sleep-disordered breathing and CSA patients. Patients with CSA had a higher rate of pacemaker use and higher first dose of dobutamine in ICU. NYHA Class and the presence of OSA were independently associated with overall worsening of postoperative recovery (ICU stay ≥ 25 h). Age, NYHA class, and the presence of OSA were independently associated with postoperative respiratory insufficiency (mechanical ventilation ≥ 20 h). Preoperative atrial fibrillation, pulmonary hypertension, and OSA were independently associated with postoperative pacemaker use. RVHD patients with OSA have an increased incidence of perioperative adverse events. OSA was independently associated with overall postoperative recovery, respiratory insufficiency, and higher rate of postoperative pacemaker use, while CSA was not associated with postoperative events.

Postoperative respiratory insufficiency and its treatment

The development of a postoperative respiratory insufficiency is typically caused by several factors and include patient-related risks, the extent of the procedure and postoperative complications. Morbidity and mortality rates in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are high. It is important to have consistent strategies for prevention and preoperative conditioning is essential primarily for high-risk patients. Treatment of established postoperative lung failure requires early tracheotomy, protective ventilation (tidal volume 6ml/kg body weight), elevated positive end expiratory pressure (PEEP, 10-20mmH2O), recurrent bronchoscopy and early patient mobilization. In critical cases an extracorporeal lung assist is considered to be beneficial as a bridge to recovery and for realizing a protective ventilation protocol. Different systems with separate indications are available. The temporary application of a lung assist allows thoracic surgery to be performed safely in patients presenting with insufficient respiratory function.

Preoperative Low-Dose Steroid Can Prevent Respiratory Insufficiency After Thymectomy in Generalized Myasthenia Gravis

Background: Postoperative respiratory insufficiency (PRI) in myasthenia gravis (MG) often occurs within several days after thymectomy and remains problematic. In limited studies reporting that preoperative steroids prevented PRI in patients with MG, high doses of steroids were used and detailed information on the use of steroids is limited. Because high-dose steroids significantly increase the risk of adverse effects, we studied 37 patients with generalized MG to investigate whether low-dose steroids might prevent PRI. Methods: The low-dose steroids were started orally, and the dose was gradually increased to the maximum level (30 mg/day). Immediately before thymectomy, patients received the maximum dose of oral steroids daily. PRI was defined as the development of restrictive dysfunction requiring mechanical ventilation within 3 days after thymectomy and total postoperative mechanical ventilation support time of >24 h. Results: The rate of PRI in the low-dose steroid use group was significantly lower than that in the no-steroid use group. The postoperative stay in the intensive care unit was shorter in the steroid use group. Conclusions: Extended thymectomy is a well-accepted surgical treatment for selected patients with MG. However, PRI remains problematic. Our results suggest that not only preoperative high-dose steroid treatment, but also low-dose steroid treatment can prevent PRI.

Better Short-Term Outcome by Using Sutureless Valves: A Propensity-Matched Score Analysis

Sutureless aortic valve prostheses have the potential of shortening ischemic time. However, whether shorter operative times may also result in improved patient outcomes and have an effect on hospital costs remains to be established. From March 2010 to April 2013, 566 patients underwent aortic valve replacement with bioprostheses; of these, 166 received a sutureless valve, and 400 received a stented valve. Redo and associated procedures were included. A propensity-score analysis was used to create two groups (sutureless and stented) with 82 matched pairs with comparable preoperative characteristics. Hospital outcome, follow-up, and health care resource consumption were compared. There were 3 hospital deaths in the stented group and 2 in the sutureless group (p=0.65). Aortic cross-clamp, cardiopulmonary bypass, and operation times were significantly shorter in the sutureless group (p<0.001). Patients in the sutureless group required blood transfusion less frequently (1.2±1.3 vs 2.5±3.7 units, p=0.005), with a similar need for reexploration for bleeding (2 vs 5, p=0.221). The sutureless group had a shorter intensive care unit stay (2.0±1.2 vs 2.8±1.3 days, p<0.001), hospital stay (10.9±2.7 vs 12.4±4.4 days, p=0.001) and intubation time (9.5±4.6 vs 16.6±6.4 hours, p<0.001), and a lower incidence of postoperative atrial fibrillation (p=0.015), pleura effusions (p=0.024), and respiratory insufficiency (p=0.016). Pacemaker implantation and occurrence of neurologic events were similar between groups (p>0.05). A lower rate of postoperative complications resulted in reduced resource consumption in the sutureless group for diagnostics (€2,153 vs €1,387), operating room (€5,879 vs €5,527), and hospital stay (€9,873 vs €6,584), with a total cost saving of approximately 25% (€17,905 vs €13,498). A shorter procedural time in the sutureless group is associated with better clinical outcomes and reduced hospital costs.

Management of a Patient with Unstable Angina, Left Main Coronary Artery Disease, and Respiratory Insufficiency Due to Eventration of the Diaphragm

The incidence of eventration of diaphragm before cardiac surgery is rare. We describe the management of a patient with eventration of the diaphragm who underwent a coronary artery bypass grafting (CABG) for left main coronary artery disease followed by left diaphragm plication with video-assisted thoracic surgery (VATS) for the postoperative respiratory insufficiency.

In-hospital Management of Diabetes

In-hospital Management of Diabetes

Risk factors and prognosis of critically ill cancer patients with postoperative acute respiratory insufficiency

This study aimed to investigate the risk factors and outcome of critically ill cancer patients with postoperative acute respiratory insufficiency. The data of 190 critically ill cancer patients with postoperative acute respiratory insufficiency were retrospectively reviewed. The data of 321 patients with no acute respiratory insufficiency as controls were also collected. Clinical variables of the first 24 hours after admission to intensive care unit were collected, including age, sex, comorbid disease, type of surgery, admission type, presence of shock, presence of acute kidney injury, presence of acute lung injury/acute respiratory distress syndrome, acute physiologic and chronic health evaluation (APACHE II) score, sepsis-related organ failure assessment (SOFA), and PaO2/FiO2 ratio. Duration of mechanical ventilation, length of intensive care unit stay, intensive care unit death, length of hospitalization, hospital death and one-year survival were calculated. The incidence of acute respiratory insufficiency was 37.2% (190/321). Multivariate logistic analysis showed a history of chronic obstructive pulmonary diseases (P=0.001), surgery-related infection (P=0.004), hypo-volemic shock (P<0.001), and emergency surgery (P=0.018), were independent risk factors of postoperative acute respiratory insufficiency. Compared with the patients without acute respiratory insufficiency, the patients with acute respiratory insufficiency had a prolonged length of intensive care unit stay (P<0.001), a prolonged length of hospitalization (P=0.006), increased intensive care unit mortality (P=0.001), and hospital mortality (P<0.001). Septic shock was shown to be the only independent prognostic factor of intensive care unit death for the patients with acute respiratory insufficiency (P=0.029, RR: 8.522, 95%CI: 1.243-58.437, B=2.143, SE=0.982, Wald=4.758). Compared with the patients without acute respiratory insufficiency, those with acute respiratory insufficiency had a shortened one-year survival rate (78.7% vs. 97.1%, P<0.001). A history of chronic obstructive pulmonary diseases, surgery-related infection, hypovolemic shock and emergency surgery were risk factors of critically ill cancer patients with postoperative acute respiratory insufficiency. Septic shock was the only independent prognostic factor of intensive care unit death in patients with acute respiratory insufficiency. Compared with patients without acute respiratory insufficiency, those with acute respiratory insufficiency had adverse short-term outcome and a decreased one-year survival rate.

An alternative technique for anterior chest wall reconstruction: the sternal allograft transplantation

Sternal resection is indicated for a variety of pathological conditions, mainly neoplastic or related to sternotomy complications. Resection of the sternum generally leaves a large chest-wall defect, and reconstruction is thus the most difficult part of the operation. Correct stabilization of the anterior chest wall is very important to avoid secondary complications and respiratory failure. In the last few years, different technical solutions have been used to reconstruct the sternum. We describe our technique using a sternal allograft to reconstruct the anterior chest wall after partial or complete sternal resection. Between June 2010 and February 2012, four patients underwent sternectomy followed by anterior chest wall reconstruction using sternal allograft. The sternal allograft was harvested from a multitissue donor following Italian legislation for tissue donation. Three patients had neoplastic involvement of the sternum, and one had a complete sternal defect as a complication of a cardiac operation. We had no operative mortality. Three patients underwent partial sternal transplantation, and one underwent total sternal replacement. We had no postoperative respiratory insufficiency, infections or mechanical failure of the reconstructions. The respiratory function was preserved in all patients. The follow-up period was free from complications related to the sternal allograft implantation. The technique of sternal allograft transplantation is simple, reproducible and provides excellent functional and cosmetic results. Further studies including a larger number of patients are needed to understand the biology of the allograft and the long-term results of this technique.

Gender-specific predictors of early mortality after coronary artery bypass graft surgery

Female gender is a risk factor for early mortality after coronary artery bypass graft surgery (CABG). Yet, the causes for this excess mortality in women have not been fully explained. To analyse gender differences in early mortality (30days post surgery) after CABG and to identify variables explaining the association between female gender and excess mortality, taking into account preoperative clinical and psychosocial, surgical and postoperative risk factors. A total of 1,559 consecutive patients admitted to the German Heart Institute Berlin (2005-2008) for CABG were included in this prospective study. A comprehensive set of prespecified preoperative, surgical and postoperative risk factors were examined for their ability to explain the gender difference in early mortality. Early mortality after CABG was higher in women than in men (6.9 vs. 2.4%, HR 2.91, 95% CI 1.70-4.96, P<0.001). Women were older than men (+4.7years, P<0.001), had lower self-assessed preoperative physical functioning (-16 points on a scale from 0 to 100, P<0.001), and had higher rates of postoperative low cardiac output syndromes (6.6 vs. 3.3%, P=0.01), respiratory insufficiency (9.4 vs. 5.3%, P=0.006) and resuscitation (5.2 vs. 1.8%, P=0.001). The combination of these factors explained 71% of the gender difference in early mortality; age and physical functioning alone accounted for 61%. Adjusting for these variables, HR for female gender was 1.36 (95% CI 0.77-2.41, P=0.29). Age, physical function and postoperative complications are key mediators of the overmortality of women after aortocoronary bypass surgery. Self-assessed physical functioning should be more seriously considered in preoperative risk assessment particularly in women.