Preoperative Hyponatremia Research Articles

Clinical Risk Factors and Postoperative Complications Associated with Unplanned Hospital Readmissions After Cranial Neurosurgery

Hospital readmission is a key surgical quality metric associated with financial penalties and greater healthcare costs. We examined the clinical risk factors and postoperative complications associated with 30-day unplanned hospital readmissions after cranial neurosurgery. We queried the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2016 for adult patients who had undergone a cranial neurosurgical procedure. Multivariable logistic regression with backward model selection was used to determine the predictors associated with 30-day unplanned hospital readmission. Of 40,802 cranial neurosurgical cases, 4147 (10.2%) required an unplanned readmission. Postoperative complications were greater in the readmission cohort (18.5% vs. 9.9%; P < 0.001). On adjusted analysis, the clinical factors predictive of unplanned readmission included hypertension, chronic obstructive pulmonary disease, diabetes, coagulopathy, chronic steroid use, and preoperative anemia, hyponatremia, and hypoalbuminemia (P ≤ 0.01 for all). Higher American Society of Anesthesiology class (III to V), operative time >216 minutes, and unplanned reoperation were also associated with an increased likelihood of readmission (P ≤ 0.001 for all). The postoperative complications predictive of unplanned readmissions were wound infection (odds ratio [OR], 4.90; P < 0.001), pulmonary embolus (OR, 3.94; P < 0.001), myocardial infarction or cardiac arrest (OR, 2.37; P < 0.001), sepsis (OR, 1.73; P < 0.001), deep venous thrombosis (OR, 1.50; P= 0.002), and urinary tract infection (OR, 1.45; P= 0.002). Female sex, transfer status, and postoperative pulmonary complications were protective of readmission (P < 0.05 for all). Unplanned hospital readmission after cranial neurosurgery is a common event. The identification of high-risk patients who undergo cranial procedures might allow hospitals to reduce unplanned readmissions and their associated healthcare costs.

Hyponatremia Predicts Poor Outcomes in Patients With Chronic Kidney Disease Undergoing Heart Operation

Preoperative hyponatremia adversely affects outcomes of cardiothoracic operation. However, in patients with chronic kidney disease, the association of sodium levels on postoperative events has never been evaluated. We investigated the impact of preoperative hyponatremia on outcomes after cardiac operation in patients with non-dialysis-dependent chronic kidney disease. Primary end points were operative mortality and acute kidney injury that required dialysis. Secondary end points were major infection and long-term survival. The study is observational and includes all patients with stage III to IV chronic kidney disease (non-dialysis) undergoing cardiac operation between February 2000 and January 2016. Patients were stratified into two groups by preoperative sodium levels: sodium less than 135 mEq/L and sodium of 135 mEq/L or more. There were 1,008 patients (mean estimated glomerular filtration rate [GFR]: 43 ± 14 mL • min-1 • 1.73m-2) with 92 patients (9%) in the low-sodium group. Patients with low sodium had higher operative mortality (p= 0.0004), need for new dialysis (p= 0.0008), and infection (p= 0.002). Predictors of operative mortality were European System for Cardiac Operative Risk Evaluation(EuroSCORE) (hazard ratio [HR] 1.03. 95% confidence interval [CI]: 1.02 to 1.05, p < 0.0001), decreasing values of sodium (HR 1.14. 95% CI: 1.07 to 1.2, p= 0.0002), and decreasing values of GFR (HR 1.01, 95% CI: 1.003 to 1.03, p= 0.007). Sodium less than 135 mEq/L was independently associated with increased need for dialysis (HR 1.3, 95% CI: 1.1 to 1.7, p= 0.0008). By linear regression, decreasing values of preoperative sodium were proportionate to the incidence of operative mortality (p < 0.0001) and need for dialysis (p < 0.0001). Preoperative hyponatremia is a predictor of increased mortality and other adverse events in patients with non-dialysis-dependent chronic kidney disease undergoing cardiac operation. These findings are similar to those in hyponatremic patients without kidney disease.

Preoperative Hyponatremia Is Associated with Reoperation and Prolonged Length of Hospital Stay following Total Knee Arthroplasty.

Hyponatremia is a risk factor for adverse surgical outcomes, but limited information is available on the prognosis of hyponatremic patients who undergo total knee arthroplasty (TKA). The purpose of this investigation was to compare the incidence of major morbidity (MM), 30-day readmission, 30-day reoperation, and length of hospital stay (LOS) between normonatremic and hypontremic TKA patients.The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all primary TKA procedures. Hyponatremia was defined as <135 mEq/L and normonatremia as 135 to 145 mEq/L; hypernatremic patients (>145 mEq/L) were excluded. Multivariable logistic regression was used to determine the association between hyponatremia and outcomes after adjusting for demographics and comorbidities. An α level of 0.002 was used and calculated using the Bonferroni correction. Our final analysis included 88,103 patients of which 3,763 were hyponatremic and 84,340 were normonatremic preoperatively. In our multivariable models, hyponatremic patients did not have significantly higher odds of experiencing an MM (odds ratio [OR]: 1.05; 99% confidence interval [CI] 0.93-1.19) or readmission (OR: 1.12; 99% CI: 1-1.24). However, patients with hyponatremia did experience significantly greater odds for reoperation (OR: 1.24; 99% CI: 1.05-1.46) and longer hospital stay (OR: 1.15; 99% CI: 1.09-1.21). We found that hyponatremic patients undergoing TKA had increased odds of reoperation and prolonged hospital stay. Preoperative hyponatremia may be a modifiable risk factor for adverse outcomes in patients undergoing TKA, and additional prospective studies are warranted to determine whether preoperative correction of hyponatremia can prevent complications.

Seizure outcomes of supratentorial brain tumor resection in pediatric patients.

This study aims to identify the prevalence of and risk factors for seizure development after supratentorial brain tumor resection in pediatric patients. This could be used to guide the postoperative management and usage of anti-epileptic drugs (AEDs). Retrospective study was conducted for patients between 0 and 21 years with supratentorial tumor resection between 2005 and 2015 at a single institution. Two hundred patients (114 males/86 females) were identified. Median age at resection (±SD) was 9.025 ± 5.720 years and mean follow-up was 4 ± 2 years. Resection was gross total in 82 patients (41%) and partial in 118 patients (59%); 66 patients (33%) experienced preoperative seizures, and 67 patients (34%) experienced postoperative seizures; 18 patients (27%) had early seizures, and 49 patients (73%) had late seizures. Univariate analysis identified risk factors for postoperative seizures as: preoperative seizures (P < 0.001), age less than 2 years (P = 0.003), temporal location (P < 0.001), thalamic location (P = 0.017), preoperative hyponatremia (P = 0.017), World Health Organization grade (P = 0.008), and pathology (P = 0.005). Multivariate regression identified 5 robust risk factors: temporal location (odds ratio [OR] 4.7, 95% CI: 1.7-13.3, P = 0.003), age <2 years (OR 3.9, 95% CI: 1.0-15.4; P = 0.049), preoperative hydrocephalus (OR 3.8, 95% CI: 1.5-9.4; P = 0.005), preoperative seizure (OR 2.8, 95% CI: 1.2-6.5; P = 0.016) and parietal location (OR 0.25, 95% CI: 0.06-0.99; P = 0.049). Extent of resection did not correlate with seizure development (P > 0.05). This study reveals 5 risk factors for postoperative seizures after resection of supratentorial tumors. These factors should be considered in postoperative management of these patients.

Prevalence and risk factors for postoperative stress-related cardiomyopathy in adults.

Stress-related cardiomyopathy can develop during the postoperative period due to surgery-related stress factors. However, the prevalence and risk factors for this condition are not yet known. During a retrospective, observational study, patients older than 19 years who underwent procedures from January 2011 to December 2015 at a tertiary hospital were included. The main aim was to identify the prevalence and related risk factors for postoperative stress-related cardiomyopathy. To estimate the incidence per risk factor, univariate and multivariate Poisson regression analyses were performed. During the 5-year period, 95,840 patients older than 19 years underwent 125,314 procedures, and the prevalence of postoperative stress-related cardiomyopathy was 17.74 per 100,000 (95% confidence interval, 9.31–26.17), with an in-hospital mortality of 23.5%. As a result, three risk factors were significantly associated: preoperative American Society of Anesthesiologists classification (incidence rate ratio, 5.901 for American Society of Anesthesiologists class 1–2 [ref] versus 3–6; 95% confidence interval,1.289–27.002; P = 0.022); preoperative body mass index (incidence rate ratio, 1.247 for increases of 18.5 [ref] to 30; 95% confidence interval, 1.067–1.458; P = 0.006); and preoperative serum sodium (incidence rate ratio, 0.830 for each increase of 10 mmol/L from 130; 95% confidence interval, 0.731–0.942; P = 0.004). The incidence rate ratio for age for each increase of 10 years from 50 years was 1.057, but it was not statistically significant (P = 0.064). Our study found that the prevalence of postoperative stress-related cardiomyopathy was 17.74 patients per 100,000 adult patients over the course of 5 years, with four cases of in-hospital mortality. Factors that increased the risk of postoperative stress-related cardiomyopathy included higher American Society of Anesthesiologists class (≥3), preoperative hyponatremia, and higher preoperative body mass index.

Utility of Tolvaptan in the Perioperative Management of Severe Hyponatremia During Liver Transplantation: A Case Report

Severe hyponatremia can complicate the pretransplantation management of patients with decompensated cirrhosis while they await liver transplantation. Before the liver transplant, it is critical to correct severe hyponatremia to an appropriate level to reduce the risks of perioperative complications such as central pontine myelinolysis, cerebral edema, and seizures. Vasopressin receptor antagonists, and in particular tolvaptan, offer a therapeutic modality that can correct severe refractory hyponatremia in a timely and predictable manner before liver transplantation. In this case report, we describe a patient with decompensated cirrhosis and severe hyponatremia in whom administration of tolvaptan led to an optimal correction of preoperative severe hyponatremia and allowed for successful liver transplantation with no associated postoperative complications. In light of the increasing pretransplantation disease severity and higher risk of severe hyponatremia, the use of tolvaptan in the pretransplant period may gain increasing importance as a therapeutic intervention for maintaining peritransplant sodium homeostasis.

P.087 Association of pre-operative hyponatremia with morbidity and mortality in patients undergoing elective degenerative spine surgery

Background: Hyponatremia has been found to be associated with increased complications in a variety of surgical populations. No study looked specifically at patients undergoing spine surgery. We also specifically address whether it has an effect on the typical low-risk patient admitted for degenerative spine disease, a population that forms the major bulk of clinical practice. Methods: Data was obtained from the American college of surgeons National Surgical Quality Improvement Program (ACS-NSQIP). All patients who underwent elective spinal surgery for degenerative disease from 2011 to 2013 were included. The two arms (normonatremic and hyponatremic) were then compared. Results: A total of 58049 patients were included, 3037 were hyponatremic. Hyponatremic patients were older and had more comorbidities. They also developed more minor and major complications. When all comorbidities were controlled for, hyponatremia was only associated with increased minor but not major complications. These patients were more likely to require a blood transfusion (OR=1.23, CI 1.10-1.43) and a prolonged hospital stay (OR=1.52, CI 1.33-1.75). Conclusions: This study finds an association between hyponatremia and postoperative adverse events in a low risk population that forms the major bulk of clinical practice. This addresses a potential target for quality improvement strategies with significant cost saving implications.

Reoperation and readmission after clipping of an unruptured intracranial aneurysm: a National Surgical Quality Improvement Program analysis.

OBJECTIVE Although reoperation and readmission have been used as quality metrics, there are limited data evaluating the rate of, reasons for, and predictors of reoperation and readmission after microsurgical clipping of unruptured aneurysms. METHODS Adult patients who underwent craniotomy for clipping of an unruptured aneurysm electively were extracted from the prospective National Surgical Quality Improvement Program registry (2011-2014). Multivariable logistic regression and recursive partitioning analysis evaluated the independent predictors of nonroutine hospital discharge, unplanned 30-day reoperation, and readmission. Predictors screened included patient age, sex, comorbidities, American Society of Anesthesiologists (ASA) classification, functional status, aneurysm location, preoperative laboratory values, operative time, and postoperative complications. RESULTS Among the 460 patients evaluated, 4.2% underwent any reoperation at a median of 7 days (interquartile range [IQR] 2-17 days) postoperatively, and 1.1% required a cranial reoperation. The most common reoperation was ventricular shunt placement (23.5%); other reoperations were tracheostomy, craniotomy for hematoma evacuation, and decompressive hemicraniectomy. Independent predictors of any unplanned reoperation were age greater than 51 years and longer operative time (p ≤ 0.04). Readmission occurred in 6.3% of patients at a median of 6 days (IQR 5-13 days) after discharge from the surgical hospitalization; 59.1% of patients were readmitted within 1 week and 86.4% within 2 weeks of discharge. The most common reason for readmission was seizure (26.7%); other causes of readmission included hydrocephalus, cerebrovascular accidents, and headache. Unplanned readmission was independently associated with age greater than 65 years, Class II or III obesity (body mass index > 35 kg/m2), preoperative hyponatremia, and preoperative anemia (p ≤ 0.04). Readmission was not associated with operative time, complications during the surgical hospitalization, length of stay, or discharge disposition. Recursive partitioning analysis identified the same 4 variables, as well as ASA classification, as associated with unplanned readmission. The most potent predictors of nonroutine hospital discharge (16.7%) were postoperative neurological and cardiopulmonary complications; other predictors were age greater than 51 years, preoperative hyponatremia, African American and Asian race, and a complex vertebrobasilar circulation aneurysm. CONCLUSIONS In this national analysis, patient age greater than 65 years, Class II or III obesity, preoperative hyponatremia, and anemia were associated with adverse events, highlighting patients who may be at risk for complications after clipping of unruptured cerebral aneurysms. The preponderance of early readmissions highlights the importance of early surveillance and follow-up after discharge; the frequency of readmission for seizure emphasizes the need for additional data evaluating the utility and duration of postcraniotomy seizure prophylaxis. Moreover, readmission was primarily associated with preoperative characteristics rather than metrics of perioperative care, suggesting that readmission may be a suboptimal indicator of the quality of care received during the surgical hospitalization in this patient population.

Influence of preoperative sodium concentration on outcome of patients with hepatitis B virus cirrhosis after liver transplantation.

Whether preoperative serum sodium concentration could influence post-transplant patients' prognosis remains controversial. The aim of this study was to evaluate the influence of patients' pretransplant sodium concentration on the prognosis after liver transplantation in a cohort of patients with hepatitis B virus-related cirrhosis. Data derived from the Chinese Liver Transplantation Registry system from 1 January 2000 to 31 December 2011 were extracted. The serum sodium concentrations and model for end-stage liver disease scores were recorded at listing before liver transplantation, and the relationship between the above parameters and patients' outcome was analyzed. A total of 2733 patients were included in this study. Compared with patients in the normal group (serum sodium between 135 and 150 mmol/l), patients in the severe hyponatremia group (<125 mmol/l) (P=0.022) and hypernatremia group (>150 mmol/l) (P=0.008) had a poorer prognosis. No significant differences were found among the moderate hyponatremia group (125-130 mmol/l) (P=0.113) and the mild hyponatremia group (130-135 mmol/l) (P=0.461). The 5-year cumulative survivals for the hyponatremia (≤135 mmol/l), normal (135-150 mmol/l), and hypernatremia (≥150 mmol/l) pretransplant group are 79.52, 82.23, and 69.30%, respectively. Our analysis showed that for patients with hepatitis B virus-related cirrhosis in mainland China, patients with abnormal serum sodium concentrations have poorer prognosis; both preoperative hyponatremia and hypernatremia were identified as negative risk factors for patients' outcome.

Preoperative hyponatremia in women with ovarian cancer: An additional cause for concern?

ObjectiveTo determine if preoperative hyponatremia in women with ovarian, fallopian tube (FT), and primary peritoneal cancers (PPC) is associated with postoperative complications. MethodsWe performed a retrospective population-based cohort study of women with a postoperative diagnosis of ovarian, FT, or PPC who had a cytoreductive procedure in the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2013. The primary exposure, preoperative sodium, was classified as normal (135mEq/L–142mEq/L) or hyponatremic (≤134mEq/L). Where appropriate, preoperative characteristics were compared with Chi-squared or Fisher's exact tests. Multivariate logistic regression was used to determine adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results4009 subjects met inclusion criteria. Thirty day mortality was higher in the hyponatremic group compared to the normal serum sodium group (3.56% vs 1.18%). When patients of any age were noted to have at least two pertinent preoperative lab abnormalities, including hyponatremia, there was an increased risk of postoperative complications for patients over the age of 65 (Table 3). After adjusting for serum albumin and other confounders, preoperative hyponatremia was associated with an increased risk of hospital stay of >14days (aOR 1.69; 95% CI 1.11–2.57) and 30day postoperative mortality (aOR 2.37; 95% CI 1.13–4.98). ConclusionsHyponatremia is associated with postoperative 30day mortality and morbidity in women with ovarian, FT, and PPC. Serum sodium in conjunction with other markers may have the potential to identify candidates for neoadjuvant chemotherapy. Additional work is needed to determine if correction of hyponatremia in the preoperative period alters outcomes.

Preoperative hyponatremia in women with ovarian cancer: An additional cause for concern?

Preoperative hyponatremia in women with ovarian cancer: An additional cause for concern?

Head and neck microvascular free flap reconstruction: An analysis of unplanned readmissions.

Unplanned readmissions within 30 days of surgery represent a significant marker for healthcare quality. Small institutional studies have described rates of readmission for patients undergoing head and neck free flap reconstruction. However, large, multi-institutional analyses have not previously been described. Retrospective study of cases from the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent free flap reconstruction of the head and neck from 2011 to 2013 were identified. Univariate and multivariate analyses of unplanned readmission based on patient, laboratory, and hospital course characteristics were conducted. In total, 1,238 patients who underwent head and neck microvascular free flap reconstruction were included within the database, of which 1,204 patients had information pertaining to readmission. Overall 30-day readmission rate was 9.6%. A multivariate analysis of preoperative variables demonstrated that leukocytosis, diabetes mellitus, and hyponatremia were all associated with increased rates of readmission (odds ratio 2.224, 1.843, and 1.7423, respectively). A similar analysis of postoperative variables demonstrated that wound-related complications (surgical site infections and wound disruption), perioperative blood transfusion, and sepsis were associated with an increased rate of readmission. In patients with microvascular free flap reconstruction of the head and neck, the 30-day readmission rate was 9.6%. Preoperative diabetes mellitus, hyponatremia, and leukocytosis were associated with an increased rate of 30-day readmissions. Postoperative complications, particularly wound infections, perioperative blood transfusions, and sepsis, were found to be significant contributors to readmission. 4. Laryngoscope, 2016 127:325-330, 2017.

Serum Electrolyte Disturbances in Benign Prostate Hyperplasia after Transurethral Resection of the Prostate

Objectives: The objective of this study was to determine the frequency of serum electrolyte disturbances in patients with benign prostate hyperplasia after transurethral resection of the prostate. Material and Methods: The cross sectional and descriptive study was carried out at the department of urology, Liaquat university hospital Jamshoro/Hyderabad. An informed consent was taken from all patients who were diagnosed as benign prostate hyperplasia in the department of urology by consultant urologist. All such patients were assessed for their serum electrolytes plstoperatively (on the first postoperative day) by taking 3cc venous blood sample in a sterilized disposable syringe and send to laboratory for analysis. The data were collected on pre-designed proforma. Results: The mean age ± SD (range) was 61.25 years ± 8.86 (50 to 90 years). Most of the patients i.e. 44 (29.3%, n=150) were between were seen in the age group 61 to 65 years. 57(38.0%) patients had the frequency of electrolyte disturbance. Mean preoperative and postoperative Hyponatremia was (129.29 ± 1.94) mmol/L and (132.05 ± 2.41) mmol/L (P>0.0001) whereas mean preoperative and postoperative Hypernatremia was (149.8 ± 0.3) mmol/L and (147.2 ± 1.1) mmol/L (P>0.02). Mean preoperative and postoperative Hypochloremia was (2.82 ± 0.5) mmol/L and (3.8± 1.6) mmol/L (P>0.03) whereas mean preoperative and postoperative Hyperkalemia was (110 ± 12.5) mmol/L and (106 ± 9.5) mmol/L (P>0.04). Mean preoperative and postoperative Hypochloremia was (80.0 ± 10.6) mmol/L and (95.0 ± 11.2) mmol/L (P>0.0001) whereas mean preoperative and postoperative Hyperchloremia was (130 ± 7.6) mmol/L and (110 ± 9.6) mmol/L (P>0.05). Mean preoperative and postoperative sodium bicarbonate (HCO3) at lower was (20.0± 1.4) mmol/L and (29.0 ± 2.1) mmol/L (P>0.002) and mean preoperative and postoperative Hyperchloremia was (38.1 ± 2.5) mmol/L and (31.02 ± 3.6) mmol/L (P>0.006). Conclusion: The further research should be required in advance and extended phase at different and wide clinical setting to gives more and better knowledge related to electrolyte disturbances in transurethral resection of prostate.

Prevalence, Timing, Causes, and Outcomes of Hyponatremia in Hospitalized Orthopaedic Surgery Patients.

Hyponatremia is common among orthopaedic patients and is associated with adverse clinical outcomes. We examined the prevalence, timing, causes, and outcomes of hyponatremia in adult hospitalized orthopaedic surgery patients. We evaluated the medical records of 1067 consecutive orthopaedic surgery patients admitted to a tertiary academic institution. The medical records were reviewed to investigate hyponatremia (serum sodium <135 mEq/L) that (1) had been present on hospital admission or (2) had developed postoperatively. The primary outcomes were the prevalence and timing of, and risk factors for, presentation with or development of hyponatremia. Secondary outcomes were hospital length of stay, total hospital cost, and discharge disposition. Multivariable logistic regression models were used to assess the variables associated with hyponatremia and the effects of hyponatremia on clinical outcomes. Of the 1067 patients, seventy-one (7%) had preoperative hyponatremia and 319 (30%) developed hyponatremia postoperatively. Of the latter, 298 (93%) developed hyponatremia within forty-eight hours postoperatively. Compared with patients with normonatremia, those who presented with hyponatremia, on the average, were older (67.2 versus 60.5 years, p < 0.001), had longer hospital stays (4.6 versus 3.3 days, p < 0.001), incurred higher hospital costs ($19,200 versus $17,000, p = 0.006), and were more likely to be discharged to an extended-care facility (odds ratio [OR] = 2.87, p < 0.001). Developing hyponatremia postoperatively resulted, on average, in a longer hospital stay (3.7 versus 3.3 days, p = 0.002) and greater hospital cost ($18,800 versus $17,000, p < 0.001). Age (OR = 1.13 per decade, p = 0.012), spine surgery (OR = 2.76 versus knee, p < 0.001), hip surgery (OR = 1.76 versus knee, p < 0.001), and the amount of lactated Ringer solution used (OR = 1.16, p = 0.002) increased the risk of developing hyponatremia. Hyponatremia in orthopaedic patients is associated with longer, costlier hospitalizations. The factors that significantly increased the risk of developing postoperative hyponatremia were an older age, spine fusion, hip arthroplasty, and the amount of lactated Ringer solution used.

Acute serum sodium concentration changes in pediatric patients undergoing cardiopulmonary bypass and the association with postoperative outcomes.

The objective of this study is to investigate the degree of serum sodium changes and its association with patient outcomes in pediatrics undergoing heart surgery with cardiopulmonary bypass (CPB). We reviewed the medical records of 275 pediatric patients who underwent heart surgery with CPB. Prior to CPB, hyponatremia (≤135 mmol/L) was observed in 21 of 275 patients. After initiation of CPB, serum sodium decreased significantly and severe hyponatermia (≤130 mmol/L) subsequently developed in 32 patients. At the end of CPB, however, hypernatremia (≥145 mmol/L) developed in 86 patients. The degree of acute serum sodium change during CPB was not associated with patient outcomes. However, the patients with preoperative hyponatremia and those with hypernatremia at the conclusion of CPB had longer hospital stays and higher postoperative complication rates. Lower serum sodium prior to CPB and higher serum sodium at the end of CPB, along with age and duration of the operation, were independently associated with worse in-hospital outcomes. Acute and transient hyponatremia occurred frequently after initiation of CPB, and then serum sodium immediately increased above preoperative levels at the end of CPB. Caution is required to avoid serum sodium overcorrection on the conclusion of CPB.

Hyponatremia and perioperative complications in patients with head and neck squamous cell carcinoma.

Recent studies suggest that hyponatremia is associated with perioperative morbidity and mortality after general surgical procedures, as well as mortality among medical inpatients. We investigated the association of hyponatremia with perioperative complications in patients undergoing surgical resection of head and neck squamous cell carcinoma (HNSCC). All patients with pathologically confirmed HNSCC undergoing either primary or salvage surgical resection from March 1, 2013, until May 31, 2014, at a single tertiary care academic center were included in this retrospective review. The primary outcome was 30-day mortality. Secondary outcomes included postoperative complications (respiratory, cardiac, renal, and wound), hospital and intensive care unit (ICU) length of stay, and need for blood transfusion. Two hundred fourteen surgical patients with HNSCC were identified for analysis. Patient ages ranged from 22 to 100 years (mean, 67 years). One hundred thirty-eight men and 76 women were included. Primary tumor sites were oral cavity (47.7%), oropharynx (18.7%), larynx (12.6%), salivary glands (7.9%), cutaneous (7.5%), sinonasal (2.8%), and hypopharynx (2.3%). Surgical resections were balanced between primary (48.1%) and salvage (51.9%). Thirty-five patients (16.4%) carried a presurgical diagnosis of diabetes. Fifteen patients (7.0%) demonstrated preoperative hyponatremia, and 46 (24.9%) had postoperative hyponatremia. Within the primary outcome measure, no difference in mortality was identified. Complications were noted in 58 patients (27.1%), and were more frequent in hyponatremic patients, both preoperatively and postoperatively (60.0% and 41.3%, respectively). Binomial logistic regression demonstrated risk of complications significantly associated with preoperative hyponatremia (odds ratio [OR] = 4.374; 95% confidence interval [CI] = 1.231-15.545; p = .023), increasing age (OR = 1.385; 95% CI = 1.032-1.857; p = .030), and increasing length of surgery (OR = 1.234; 95% CI = 1.046-1.455; p = .013). Postoperative hyponatremia was associated with increased hospital length of stay (p = .034). Hyponatremia is a frequent electrolyte abnormality in patients with HNSCC. Both preoperative and postoperative hyponatremia are associated with perioperative morbidity, thus meriting intensive postoperative medical monitoring and treatment. Additional investigation is warranted to identify the pathophysiologic mechanisms behind this association. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1370-E1374, 2016.

Outcomes in fracture neck of femur patients in an Indian setting

Background: To determine the morbidity and mortality outcomes in patients presenting with a fracture neck of femur in an Indian setting. Unfavourable outcomes were identified in Peri-operative period and planning to improve the peri-operative care was taken. Methods: We performed a retrospective observational study of 230 consecutive adult patients admitted to an Indian metropolitan tertiary care hospital with fracture neck of femur between 2010 and 2012. The main outcome measure were 30 days and one year mortality rates, major complications and factors influencing mortality. Results: The majority of patients were elderly, female and had multiple comorbidities. Multiple peri-operative medical complications were including pre-operative hyponatremia (21%), post-operative hypoxia (14%), anaemia requiring blood transfusion (36%), re-admission with in 30 days of discharge (12%), acute renal complications (8%), and myocardial infraction (4%) Mortality rates were 5% at 30 days and 12.5% at one year. Conclusion: Results from an Indian metropolitan tertiary care hospital confirm the persistently high morbidity and mortality in patients presenting with a fractured neck of femur. Efforts should be aimed at medically optimising patients pre-operatively and early surgery. This study provides planning data for future interventional studies.

Moderate-to-large increases in perioperative serum sodium concentration associated with adverse neurologic events after continuous flow left ventricular assist device implantation.

It was hypothesized that preoperative hyponatremia is associated with increased 30-day mortality after left ventricular assist device placement, and that large increases in sodium concentration are associated with adverse neurologic events and 30-day mortality. Data were collected retrospectively on all patients having continuous flow left ventricular assist device implantation between January 1, 2009 and March 31, 2013. Preoperative variables, operative variables, and perioperative sodium concentrations were recorded. Both 30-day mortality and 72-hour adverse neurologic events (stroke or seizure) were recorded as primary outcome variables. Preoperative sodium and Δ sodium (postoperative sodium-preoperative sodium) were analyzed as tests for 30-day mortality and adverse neurologic events using receiver operating characteristic curves. Both crude and adjusted logistic regression analyses were used to estimate odds ratios for the outcome variables. Tertiary care academic medical center. Patients having durable continuous flow left ventricular assist device placement. None. Among 88 patients, 30-day mortality was 14% (12 of 88) and the rate of perioperative stroke or seizure was 9% (8 of 88). There were 3 strokes and 5 tonic-clonic seizures. Preoperative sodium was a poor discriminative test for 30-day mortality and stroke or seizure (AUC=0.47 and 0.57, respectively). Δ sodium was a poor discriminative test for 30-day mortality, but a fair discriminative test for stroke or seizure (AUC=0.55 and 0.78, respectively). Δ sodium was a good discriminative test for seizure alone (AUC=0.82) and a fair discriminative test for stroke alone (AUC=0.70). It also increased the odds of stroke or seizure significantly, even when adjusting for possible confounders. Moderate-to-large increases in sodium concentration during left ventricular assist device placement appear to be associated with adverse postoperative neurologic events. Preoperative hyponatremia has no relationship with 30-day mortality or adverse perioperative neurologic events.

Sodium Homeostasis During Liver Transplantation and Correlation with Outcomes

Reports of perioperative serum sodium increase in liver transplant (LT) recipients are mostly restricted to unintentional rapid serum sodium overcorrection with subsequent development of central pontine myelinolysis. We examined intraoperative serum sodium changes and their effect on short-term outcomes after LT. We retrospectively analyzed data of all LT recipients over a period of 3.5 years. Collected information included preoperative and postoperative serum sodium (Napre and Napost), delta sodium (ΔNa), intraoperative serum sodium peak and trough with corresponding maximum ΔNa, intraoperative peak blood glucose, history of hepatic encephalopathy, perioperative diuretics, intraoperative administration of vasopressin, dopaminergic agents, alkalizing drugs (sodium bicarbonate [NaHCO3], tromethamine), crystalloids, colloids, fresh frozen plasma (FFP), and packed red blood cells (PRBC). The delta of serum osmolality (ΔOsm) was calculated from Napre and Napost, blood urea nitrogen, and blood glucose values, and the correlation between ΔNa and ΔOsm was examined. Outcomes analyzed included intubation for ≥2 days, postanesthesia care unit/surgical intensive care unit (PACU/SICU) length of stay (LOS) for ≥2 days, need of SICU admission, hospital LOS, postoperative neurological complications, and mortality. Univariate and multivariate analyses were performed to test associations between ΔNa and outcomes. A P value <0.005 was considered significant. Data of 164 patients were analyzed. Their ΔNa was 5.3 ± 4.5 (mean ± SD) mEq/L. A lower Napre was associated with greater ΔNa, a relationship likely due to the regression to the mean. In a subgroup of patients with Napre < 130 mEq/L, ΔNa was 11.0 ± 3.6 mEq/L, significantly higher than in normonatremic patients (P < 0.0001). Mortality and neurologic complications were not affected by changes in ΔNa (all P ≥ 0.41). An increase in ΔNa was associated with higher odds of prolonged intubation and prolonged PACU/SICU LOS in univariate and multivariate regression analyses (P = 0.0003 and P = 0.0049, respectively, for adjusted odds ratios). The odds ratios for associations of ΔNa with those outcomes did not differ between patients treated versus not treated with NaHCO3. The intraoperative ΔNa was significantly higher in patients with intraoperative hyperglycemia (P < 0.0001). Intraoperative administration of NaHCO3 and the number of transfused FFP and PRBC units were also associated with a significantly higher ΔNa (P = 0.0001). The ΔNa correlated significantly with ΔOsm. A larger intraoperative increase in ΔNa is associated with worse recipient short-term outcomes. Patients with preoperative hyponatremia may be at particular risk. ΔNa increases with the intraoperative use of NaHCO3, quantity of FFP, and PRBCs transfused, as well as with intraoperative hyperglycemia. Potential differences on sodium homeostasis between NaHCO3 and tromethamine use for intraoperative pH adjustment should be prospectively investigated.

Serum sodium shift in hyponatremic patients undergoing liver transplantation: a retrospective cohort study

Introduction: We aimed to describe the pre-operative incidence of hyponatremia in patients undergoing liver transplantation (LTx), as well as the rate and consequences of rapid peri-operative sodium rises in these patients. Methods: This was a retrospective before and after observational study performed at a University-affiliated LTx center between January 2007 and June 2013. The primary exposure was pre-operative hyponatremia, defined as a serum sodium (SNa) <133 mmol/L. The primary outcome was occurrence of a rapid SNa shift, defined as ≥10 mmol/L in the first 24 h following LTx. The rates of rapid peri-operative SNa shift were compared before and after a focused quality assurance (QA) initiative performed in July 2009. Results: Of 366 LTx, 69 (18.9%) had pre-operative hyponatremia, 6 (8.7%) of whom had a rapid rise in serum sodium (SNa). Rapid rise was associated with a greater intra-operative positive fluid balance (p < 0.001) and use of intra-operative continuous renal replacement therapy (CRRT) (p = 0.017). A rapid rise in SNa was associated with more neurological investigations in the post-transplant period (brain computed tomography, electroencephalogram, swallow studies), increased neurological deficits (p = 0.006), more abnormal swallowing assessments (p = 0.003), a tendency for more neurology consultations (p = 0.058), increased discharge to a rehabilitation or long-term care facility (p < 0.001), and increased 6-month mortality (p < 0.001). Following a QA initiative, rapid peri-operative rises in SNa among hyponatremic patients was significantly reduced (20% vs. 0%, p < 0.003). Conclusion: Pre-operative hyponatremia and rapid peri-operative SNa shifts are associated with a more complicated post-operative course and worse outcomes following LTx. Increased education and awareness, along with process changes, such as standardizing CRRT prescription, can reduce iatrogenic rapid peri-operative shifts in SNa.