Preoperative Creatinine Level Research Articles

Vancomycin Dosing and Its Association With Acute Kidney Injury in Pediatric Cardiac Intensive Care Patients Under 3 Months of Age.

The standard vancomycin regimen for term neonates is 45 mg/kg/day. However, the optimal starting vancomycin dosing for achieving therapeutic levels in young infants in cardiac intensive care units remains unknown. Moreover, data on the association of supratherapeutic vancomycin levels with acute kidney injury (AKI) are limited. Retrospective study of infants ≤3 months old, receiving vancomycin following congenital heart surgery at postoperative intensive care unit admission. Assessed were vancomycin dosing, achievement of therapeutic trough concentration of 10-20 mg/L and development of AKI, based on the modified Kidney Disease Improving Global Outcomes criteria. Inclusion criteria were met by 109 patients with a median age of 8 days (IQR: 6-16). The mean (SD) vancomycin dose required for achieving therapeutic concentration was 28.9 (9.1) mg/kg at the first postoperative day. Multivariate logistic regression identified higher preoperative creatinine levels and shorter cardiopulmonary bypass time as predictors of supratherapeutic vancomycin concentrations (c-index 0.788). During the treatment course, 62 (56.9%) developed AKI. Length of stay and mortality were higher in those who developed AKI as compared with those who did not. Multivariate logistic regression identified higher vancomycin concentration as a predictor for postoperative AKI, OR, 3.391 (95% CI: 1.257-9.151), P = 0.016 (c-index 0.896). Our results support a lower starting vancomycin dose of ~30 mg/kg/day followed by an early personalized therapeutic approach, to achieve therapeutic trough concentrations of 10-20 mg/L in cardiac postoperative term infants. Supratherapeutic concentrations are associated with an increased risk for AKI, which is prevalent in this population and associated with adverse outcomes.

Value of nutritional indices in predicting survival free from pump replacement and driveline infections in centrifugal left ventricular assist devices

ObjectiveThere is a paucity of data assessing the impact of nutritional status on outcomes in patients supported with the HeartMate 3 (HM3) left ventricular assist device (LVAD). MethodsPatients ≥18 years of age who underwent HM3 LVAD implantation between 2015 and 2020 were identified from a single tertiary care center. The primary outcome assessed was death or device replacement. A secondary outcome of driveline infection was also evaluated. Kaplan-Meier survival analysis and a multivariate Cox-proportional hazards model were used to identify predictors of outcome. ResultsOf the 289 patients identified, 94 (33%) experienced a primary outcome and 96 (33%) a secondary outcome during a median follow-up time of 2.3 years. Independent predictors of the primary outcome included peripheral vascular disease (hazard ratio [HR], 3.40; 95% confidence interval [CI], 1.66-6.97, P < .01), diabetes mellitus (HR, 0.46; 95% CI, 0.27-0.80, P < .01), body mass index ≥40 kg/m2 (HR, 2.63 per 1 kg/m2 increase; 95% CI, 1.22-5.70, P < .05), preoperative creatinine level (HR, 1.86 per 1 mg/dL increase; 95% CI, 1.31-2.65, P < .01), and preoperative prognostic nutritional index (PNI) score (HR, 0.88 per 1-point increase; 95% CI, 0.81-0.96, P < .01). Independent predictors of driveline infection included age at the time of implantation (HR, 0.97; 95% CI, 0.96-0.99, P < .01) and diabetes mellitus (HR, 1.79; 95% CI, 1.17-2.73, P < .01). ConclusionsPreoperative PNI scores may independently predict mortality and the need for device replacement in patients with HM3 LVAD. Routine use of the PNI score during preoperative evaluation and, when possible, supplementation to PNI >33, may be of value in this population.

Nephrectomy with Autotransplantation-A Key Treasure.

Background: Nephrectomy with autotransplantation (NAT) has been performed as an alternative treatment for complex renovascular lesions, intricate ureteral strictures and nephron-sparing surgery in complex renal tumors. Methods: A retrospective observational study was conducted including patients who underwent a NAT from January 2010 to September 2023. Data collected included surgery indications, surgical technique, complications according to Clavien-Dindo classification and mean hospital stay. Descriptive and inferential statistical analysis was performed using IBM® SPSS® Statistics version 28.0.1.0. Results: A total of 34 consecutive patients underwent 38 NATs at our institution. Surgery indications were complex renovascular conditions in 35 cases (92.1%), of which 24 had renal artery aneurysms, and ureteral injuries in 3 cases (7.9%). Thirty-four kidneys (89.5%) were retrieved through a laparoscopic approach. No significant difference was observed between post- and pre-operative creatinine levels (0.81 vs. 0.72, p = 0.303). Early high-grade complications developed in 12 procedures (31.6%). Median cold ischemia time was significantly longer in patients who developed complications (163.0 vs. 115.0, p = 0.010). The median hospital stay was 10 days (8-13). The median follow-up was 51.5 months. Conclusions: NAT emerges as a successful therapeutic strategy for a highly select group of patients dealing with intricate ureteral lesions and kidney vascular abnormalities, demonstrating positive outcomes that endure in the long term.

(239) Postoperative Outcomes and Risk Factors in Patients Receiving Partial vs Total Penectomy for Penile Malignancy

Abstract Introduction Partial penectomies (PP) and total penectomies (TP) are both performed for penile cancer in the United States. Compared to TP, PP is performed more frequently to preserve functional urinary outcomes. To date TP and PP outcomes have not been compared, in this study we compared clinical characteristics and post-operative outcomes between TP and PP conducted between 2006–2016. Objective We conducted a retrospective review of penile cancer patients from National Surgical Quality Improvement Program (NSQIP) database for the years 2010–2016 using international classification of diseases clinical modification (ICD-CM) ninth revision codes. A total of 260 patients, 67 TP and 193 PP patients, were included. Methods We conducted a retrospective review of penile cancer patients from National Surgical Quality Improvement Program (NSQIP) database for the years 2010–2016 using international classification of diseases clinical modification (ICD-CM) ninth revision codes. A total of 260 patients, 67 TP and 193 PP patients, were included. Results Partial penectomy patients were less likely to be transferred patients (7.3% vs 20.9%, p=0.002), less likely to be suffering from diabetes (25.9% vs 40.3%, p=0.026), and were more likely to have preoperative laboratory values within normal limits. TP was associated with increased preoperative white blood cell count x109, preoperative white blood cell count &amp;gt; 7.5x109 (p&amp;lt;0.001), preoperative hematocrit (p&amp;lt;0.001). PP patients were, in contrast, shown to have higher pre-operative creatinine levels (p=.037) and lower platelet levels than TP patients (p=.045). PP patients had shorter operation times (78.8 vs 145.5 min, p&amp;lt;0.001). PP patients also had decreased levels of inpatient stay length (1.67 vs 4.31, p&amp;lt;0.001), any 30-day post-surgery complication (7% vs 31%, p&amp;lt;0.001), deep incisional surgical site infection (0.5% vs 6% p=0.017), wound disruption (0.5% vs 6.0%p=0.017), intraoperative or postoperative transfusion (1.6% vs 7.5%, p=0.029), and sepsis (0.5% vs 7.5%, p=0.005), when compared to patients who underwent TP. TP patients displayed a significantly greater number of concurrent surgical procedures (p&amp;lt;0.001), when compared to PP patients. There was no information on urinary, sexual, and erectile outcomes in the database. Conclusions PP is associated with fewer post-operative complications, shorter surgeries, shorter hospital stays, and fewer concurrent surgical procedures. Total penectomy is associated with a greater proportion of patients suffering from comorbid conditions, suggesting that TP patients are at higher risk for post-surgical complications and longer hospital stays. There is a gap in reported data pertaining to post-operative sexual function and erectile outcomes for PP at a national level. Disclosure No.

(020) Comparing Postoperative Outcomes and Risk Factors for Patients Undergoing Partial vs Total Penectomy for Penile Carcinoma

Abstract Introduction The American Cancer Society estimates that 2,200 men develop penile cancer annually and 440 men will die from the disease. Partial penectomies (PP) and total penectomies (TP) are both performed for penile cancer in the United States. Compared to TP, PP is performed more frequently to preserve functional urinary outcomes. Objective To date TP and PP outcomes have not been compared, in this study we compared clinical characteristics and post-operative outcomes between TP and PP conducted between 2006-2016. Methods We conducted a retrospective review of penile cancer patients from National Surgical Quality Improvement Program (NSQIP) database for the years 2010-2016 using international classification of diseases clinical modification (ICD-CM) ninth revision codes. A total of 260 patients, 67 TP and 193 PP patients, were included. Results Partial penectomy patients were less likely to be transferred patients (7.3% vs 20.9%, p=0.002), less likely to be suffering from diabetes (25.9% vs 40.3%, p=0.026), and were more likely to have preoperative laboratory values within normal limits. TP was associated with increased preoperative white blood cell count x109, preoperative white blood cell count &amp;gt; 7.5x109 (p&amp;lt;0.001), preoperative hematocrit (p&amp;lt;0.001). PP patients were, in contrast, shown to have higher pre-operative creatinine levels (p=.037) and lower platelet levels than TP patients (p=.045). PP patients had shorter operation times (78.8 vs 145.5 min, p&amp;lt;0.001). PP patients also had decreased levels of inpatient stay length (1.67 vs 4.31, p&amp;lt;0.001), any 30-day post-surgery complication (7% vs 31%, p&amp;lt;0.001), deep incisional surgical site infection (0.5% vs 6% p=0.017), wound disruption (0.5% vs 6.0%p=0.017), intraoperative or postoperative transfusion (1.6% vs 7.5%, p=0.029), and sepsis (0.5% vs 7.5%, p=0.005), when compared to patients who underwent TP. TP patients displayed a significantly greater number of concurrent surgical procedures (p&amp;lt;0.001), when compared to PP patients. There was no information on urinary, sexual, and erectile outcomes in the database. Conclusions PP is associated with fewer post-operative complications, shorter surgeries, shorter hospital stays, and fewer concurrent surgical procedures. Total penectomy is associated with a greater proportion of patients suffering from comorbid conditions, suggesting that TP patients are at higher risk for post-surgical complications and longer hospital stays. There is a gap in reported data pertaining to post-operative sexual function and erectile outcomes for PP at a national level. Disclosure No.

Risk factors for postoperative adverse airway events in patients with primary oral cancer undergoing reconstruction without prophylactic tracheostomy

ObjectiveTo identify risk factors associated with adverse airway events (AAEs) in primary oral cancer patients undergoing tumor ablation followed by free tissue transfer without prophylactic tracheostomy. MethodsWe retrospectively collected primary oral cancer patients who underwent tumor ablation surgery following free-tissue transfer without prophylactic tracheostomy during February 2017 to June 2019 in Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan. 379 patients were included. Data were analysed from 2020 to 2021. Demographics, comorbidities, intraoperative variables and postoperative respiration profile were obtained from the medical record. Main outcome was postoperative AAEs, including requirement of endotracheal intubation after extubation and tracheostomy after prolonged intubation. ResultsOf the 379 patients, postoperative AAEs happened in 29 patients (7.6 %). In reintubation group, patients were older with more diabetes mellitus, hypertension and cerebrovascular disease. These patients had lower preoperative hemoglobin, creatinine, and albumin level with more intraoperative blood transfusion. In postoperative respiration profile, rapid shallow breathing index (RSBI) and PaO2/FiO2 (PF) ratio were poorer. On multivariate analysis, patient's age, tumor location, and cross-midline segmental mandibulectomy and a lower PF ratio were independent risk factors for postoperative AAEs. ConclusionsIn head and neck cancer patients that underwent tumor ablation followed by free tissue transfer without prophylactic tracheostomy, patient's age, tumor location, cross-midline segmental mandibulectomy and P/F ratio are associated with postoperative AAEs.

Abstract 18595: Predictors of Prolonged Post-Operative Stay in Patients Undergoing Coronary Artery Bypass Grafting: The Impact of Multi-Disciplinary Quality of Care Protocols, a Single Center Experience From the Middle East

Background: Prolonged postoperative stay (POS) in patients undergoing CABG is associated with increased cost, inefficient utilization of resources, and poor quality of care (QOC). We aim to identify predictors of prolonged POS and evaluate the overtime impact of multidisciplinary team (MDT) QOC protocols on POS at a newly established tertiary care center. Methods: A total of 1168 consecutive patients undergoing isolated CABG between 2015-2022 were evaluated. POS was identified as prolonged (&gt;6 days) and short (≤ 6 days). Short vs. prolonged stay groups were compared by appropriate testing methods. Predictors of prolonged POS were determined by multivariable logistic regression. Trends in prolonged POS were determined using Joinpoint Software to calculate the average annual percentage change (AAPC). Results: Overall, 44.3% (517/1168) of patients had prolonged POS. Patients in the prolonged POS group were older (59.1±10.5 vs. 56.3± 9.5, P&lt;0.001), more likely females (16.6% vs. 9.7%, P&lt;0.001), and had a higher burden of hypertension (88.1% vs. 81.9%, P=0.004), and diabetes (74.8% vs. 62.7%, P&lt;0.001). The prolonged POS group featured worse ejection fraction, higher serum creatinine, and more frequently required preoperative intra-aortic balloon pump insertion (Table) . On multivariable logistic regression, age, female gender, NYHA class ≥II, history of diabetes, preoperative creatinine level, preoperative EF, and preoperative IABP placement were independent predictors of prolonged POS (Figure A) . Between 2015-2022, more QOC protocols were initiated, with a 67% relative reduction in the proportion of patients with prolonged POS (85.7% to 28.3%), with an AAPC of -12.8, 95% CI [-16.3, -9.2], P&lt;0.001 (Figure B). Conclusion: Initiating MDT QOC protocols was associated with a reduction in POS among patients undergoing CABG. Identifying predictors of prolonged POS can help in timely planning of milestones aimed at eliminating unnecessary POS.

Comparison of early postoperative results in patients with and without diabetes with low ejection fraction and normal serum creatinine values who underwent coronary artery bypass operation.

Low left ventricular ejection fraction and renal insufficiency are factors that increase the risk of coronary artery bypass graft surgery in patients with diabetes mellitus. The aim of this study was to group patients with low left ventricular ejection fraction undergoing coronary artery bypass graft surgery according to the presence or absence of diabetes mellitus and to evaluate postoperative changes in serum creatinine levels and postoperative outcomes. A total of 93 patients undergoing isolated coronary artery bypass grafting were included in this single-centre, retrospective, cohort study. Patients with a pre-operative low left ventricular ejection fraction of less than 35% were included in the study. Patients were divided into diabetic and non-diabetic groups and intra- and intergroup values were compared. Pre-operative, and postoperative days 2 and 5 serum creatinine levels of the patients were measured and compared. Of the 93 patients included in the study, 60 were in the diabetic group (group 1) and 33 were in the non-diabetic group (group 2). Postoperative 2- and 5-day creatinine levels were significantly higher in group 1 than in group 2 (p = 0.033 and p = 0.005, respectively). Postoperative 2- and 5-day creatinine levels were significantly higher than pre-operative creatinine levels in group 1 (p = 0.008 and p = 0.001, respectively). The intensive care unit stay was significantly longer in the diabetes mellitus group than in the group without diabetes mellitus (p = 0.031). Following coronary artery bypass graft surgery in patients with low left ventricular ejection fraction, which is already a risk factor, creatinine levels were found to have increased in the diabetes mellitus group.

Current Transthoracic Supra-Aortic Trunk Surgical Reconstruction Has Similar 30-Day Cardiovascular Outcomes Compared to Extra-Anatomic Revascularization but With Higher Morbidity Burden

Operative risk for supra-aortic trunk (SAT) surgical revascularization for occlusive disease, particularly transthoracic reconstruction (TR), remains ill-defined. This study sought to describe and compare 30-day outcomes of TR and extra-anatomic (ER) SAT surgical reconstruction for an occlusive indication across the United States over a contemporary 15-year period. Using the National Surgical Quality Improvement Program, TR and ER performed during 2005-2019 were identified. Procedures performed for nonocclusive indications and those concomitant with coronary or valve operations were excluded. Rates of stroke, death, myocardial infarction (MI) and these as composite outcome (S/D/M) were compared. Logistic regression with stabilized inverse probability weighting (IPW) was used to compare groups via average treatment effect (ATE) while adjusting for covariate imbalances. Over the 15-year period, 166TR and 1,900 ER patients were identified. The majority of ERs were carotid-subclavian bypass (n=1,344; 70.7%) followed by carotid-carotid bypass (n=261; 13.7%) and subclavian/carotid transpositions (n=123; 6.5%). TR consisted of aorto-SAT bypass (n=120; 72.3%) and endarterectomy (n=46; 27.7%). The median age was 64years for TR and 65years in ER (P=0.039). Those undergoing TR were more often women (69.0% vs. 56.9%; P=0.001) and less likely to have undergone previous cardiac surgery (9.2% vs. 20.8%; P=0.006). TR were also less frequently hypertensive (68.1% vs. 75.4%; P=0.038) and had statistically lower preoperative creatinine levels (0.86 vs 0.91; P=0.002). Unadjusted rates of MI (0.6% vs. 1.3%; P=0.72) and stroke (3.6% vs. 1.9%; P=0.15) were similar between groups with mortality (3.6% vs. 1.5%; P=0.05) and S/D/M (6.6% vs. 3.9%; P=0.10) trending higher with TR. IPWs could be calculated for 1,754 patients (148TR; 1,606 ER). The estimated probability of S/D/M was 3.8% in the ER group and 6.2% in TR; no difference was seen in ATE (2.4%; 95% confidence interval [CI]: -1.5 to 6.2; P=0.23). No differences were seen in individual component ATEs (stroke: 3.0% vs. 1.7%; ATE=1.3%; 95% CI: -3.9 to 1.3; P=0.32; mortality: 3.8% vs. 1.4%; ATE=2.4%; 95% CI: -5.6 to 0.7; P=0.13). Secondary outcomes showed TR patients were more likely to have non-home discharge (18.7% vs. 6.6%; ATE=12.1%; 95% CI: 5.0-19.2; P<0.001) and longer lengths of stay (6.1 vs. 4.0; ATE=2.2days; 95% CI: 0.9-3.4; P<0.001). Moreover, TR patients were more likely to require transfusion (22.7% vs. 5.0%; ATE=17.7%; 95% CI: 10.2-25.2; P<0.001) and develop sepsis (2.7% vs. 0.2%; ATE=2.5%; 95% CI: 0.1-5.0; P=0.04). Transthoracic and extra-anatomic surgical reconstruction of the SATs for occlusive disease have similar operative cardiovascular risk. However, morbidity tends to be higher with TR due to higher transfusion requirements, sepsis risk, and need for facility stay. These results suggest ER as a first-line approach in those with proper disease anatomy is reasonable with lower morbidity, while TR remains justified in appropriate patients.

Renal implications of off-pump coronary artery bypass grafting: A retrospective cohort study analyzing postoperative creatinine levels

Background/Aim: Coronary artery disease is a significant health concern worldwide. While coronary artery bypass grafting is a gold standard of treatment, acute kidney injury (AKI) is a possible postoperative complication of concern. Off-pump coronary artery bypass grafting (OPCABG) aims to curtail perioperative complications; however, its impact on postoperative AKI is debated. This retrospective study aims to inform patient care by identifying potential effects of OPCABG on AKI utilizing postoperative creatinine alterations. Methods: This retrospective study was conducted at Koç University Hospital in Istanbul, Turkey. We reviewed the records of patients who underwent OPCABG between June 2018 and June 2019. Patients with incomplete records or individuals who had undergone renal replacement therapy prior to surgery were excluded. The primary metric was serum creatinine levels, which were assessed preoperatively and up to 7 days postoperatively. Preoperative creatinine levels were compared with postoperative levels using the Wilcoxon signed-rank test. Acute kidney injury was defined using Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Results: Seventy-two patients satisfied the inclusionary criteria. A significant increase in creatinine was observed on postoperative Day 1 (P&lt;0.001); creatinine levels fell below baseline by postoperative Day 4 and 5. We note that the incidence of AKI was low; there were no instances of Stage 2 or higher AKI during the observation period. Conclusion: Our data suggest that OPCABG may result in a transient increase in creatinine post-surgery. Creatinine levels normalize over time, implicating the renal safety of OPCABG. Despite these promising findings, additional comprehensive studies are essential to validate these observations and assess long-term renal outcomes after OPCABG.

Risk Factors for Postoperative Morbidity, Suture Insufficiency, Re-Surgery and Mortality in Patients with Gastroduodenal Perforation.

(1) Background: The aim of the present study was to identify risk factors associated with postoperative morbidity, suture/anastomotic insufficiency, re-surgery, and mortality in patients undergoing surgery for gastroduodenal perforation. (2) Methods: A retrospective analysis of 273 adult patients who received surgical treatment for gastroduodenal perforation from January 2006 to June 2021 at the University Hospital Erlangen was performed. The patient demographics and preoperative, intraoperative, and postoperative parameters were collected and compared among the different outcome groups (in-hospital morbidity, suture/anastomotic insufficiency, re-surgery, and 90-day mortality). (3) Results: In-hospital morbidity, suture/anastomotic insufficiency, need for re-surgery, and 90-day mortality occurred in 71%, 10%, 26%, and 25% of patients, respectively. The independent risk factors for morbidity were a significantly reduced general condition, a lower preoperative hemoglobin level, and a higher preoperative creatinine level. The independent risk factors for suture/anastomotic insufficiency could be identified as an intake of preoperative steroids and a perforation localization in the proximal stomach or duodenum. The four parameters were independent risk factors for the need for re-surgery: a significantly reduced general condition, a perforation localization in the proximal stomach, a higher preoperative creatinine level, and a higher preoperative CRP level. An age over 66 years and a higher preoperative CRP level were independent risk factors for 90-day mortality. (4) Conclusions: Our study could identify relevant risk factors for the postoperative outcome of patients undergoing surgical treatment for gastroduodenal perforation. Patients exhibiting the identified risk factors should receive heightened attention in the postoperative period and may potentially benefit from personalized and tailored therapy.

Predicting Factors for Blood Transfusion in Primary Total Knee Arthroplasty Using a Machine Learning Method.

Acute blood loss anemia requiring allogeneic blood transfusion is still a postoperative complication of total knee arthroplasty (TKA). This study aimed to use machine learning models for the prediction of blood transfusion after primary TKA and to identify contributing factors. A total of 2,093 patients who underwent primary TKA at our institution were evaluated using data extracted from the hospital quality improvement database to identify patient demographics and surgical variables that may be associated with blood transfusion. A multilayer perceptron neural network (MPNN) machine learning algorithm was used to predict risk factors for blood transfusion and factors associated with increased length of stay. Statistical analyses including bivariate correlate analysis, Chi-Square test, and Student t-test were performed for demographic analysis and to determine the correlation between blood transfusion and other variables. The results demonstrated important factors associated with transfusion rates, including preoperative hemoglobin level, preoperative creatinine level, length of surgery, simultaneous bilateral surgeries, tranexamic acid usage, American Society of Anesthesiologists Physical Status score, preoperative albumin level, ethanol usage, preoperative anticoagulation medications, age, and TKA type (conventional versus robotic-assisted). Patients who underwent a blood transfusion had a markedly greater length of stay than those who did not. The MPNN machine learning model achieved excellent performance across discrimination (AUC = 0.894). The MPNN machine learning model showed its power as a statistical analysis tool to predict the ranking of factors for blood transfusion. Traditional statistics are unable to differentiate importance or predict in the same manner as a machine learning model. This study demonstrated that MPNN for the prediction of patient-specific blood transfusion rates after TKA represented a novel application of machine learning with the potential to improve preoperative planning for treatment outcomes.

Individual Assessment of Perioperative Brain Growth Trajectories in Infants With Congenital Heart Disease: Correlation With Clinical and Surgical Risk Factors.

Background Infants with congenital heart disease (CHD) are at risk of neurodevelopmental impairments, which may be associated with impaired brain growth. We characterized how perioperative brain growth in infants with CHD deviates from typical trajectories and assessed the relationship between individualized perioperative brain growth and clinical risk factors. Methods and Results A total of 36 infants with CHD underwent preoperative and postoperative brain magnetic resonance imaging. Regional brain volumes were extracted. Normative volumetric development curves were generated using data from 219 healthy infants. Z-scores, representing the degree of positive or negative deviation from the normative mean for age and sex, were calculated for regional brain volumes from each infant with CHD before and after surgery. The degree of Z-score change was correlated with clinical risk factors. Perioperative growth was impaired across the brain, and it was associated with longer postoperative intensive care stay (false discovery rate P<0.05). Higher preoperative creatinine levels were associated with impaired brainstem, caudate nuclei, and right thalamus growth (all false discovery rate P=0.033). Older postnatal age at surgery was associated with impaired brainstem and right lentiform growth (both false discovery rate P=0.042). Longer cardiopulmonary bypass duration was associated with impaired brainstem and right caudate growth (false discovery rate P<0.027). Conclusions Infants with CHD can have impaired brain growth in the immediate postoperative period, the degree of which associates with postoperative intensive care duration. Brainstem growth appears particularly vulnerable to perioperative clinical course, whereas impaired deep gray matter growth was associated with multiple clinical risk factors, possibly reflecting vulnerability of these regions to short- and long-term hypoxic injury.

Renal perfusion improvement in the perioperative period after unilateral endovascular revascularization in patients with atherosclerotic renal artery stenosis.

The clinical benefits of endovascular treatment in renal artery stenosis (RAS) remain controversial. This study used an intraoperative renal perfusion imaging technique, called flat-panel detector parenchymal blood volume imaging (FD-PBV), to observe the change in renal perfusion after endovascular treatment in RAS. In a prospective, single-center study, we assigned 30 patients with atherosclerotic RAS who underwent endovascular treatment between March 2016 and March 2021. The preoperative and postoperative results of renal perfusion, blood pressure, and renal function, were compared. Both median kidney volume (p < 0.001) and median preoperative mean density of contrast medium (MDCM) (p = 0.028) increased significantly after endovascular treatment. The ratio of postoperative and preoperative MDCM differed greatly among the patients. For patients with preoperative MDCM <304.0 HU (Subgroup A, 15 cases), MDCM significantly increased after treatment (p = 0.001) and 12 (80.0%) patients had more than 10% increase in renal perfusion. For patients who had relatively high preoperative renal perfusion (MDCM ≥304.0 HU, Subgroup B, 15 cases), preoperative and postoperative MDCM were similar (p = 0.776). On the other hand, the serum creatinine levels significantly decreased in Subgroup A (p = 0.033) and fewer antihypertensive drugs were used after endovascular revascularization (p = 0.041). The preoperative and postoperative creatinine levels and number of antihypertensive drugs were similar in Subgroup B. During the perioperative period, RAS patients with relatively low preoperative renal perfusion levels had greater improvement in renal perfusion, renal function, and blood pressure control after endovascular treatment. The improvement of renal function needs to be confirmed by long-term follow-up.

Postoperative Acute Kidney Injury and Long-Term Outcomes After Lung Transplantation

BackgroundThis study sought to characterize perioperative risk factors of acute kidney injury (AKI) and report outcomes associated with its development in the immediate postoperative setting after lung transplantation. MethodsStudy investigator performed a retrospective analysis of all adult patients undergoing primary lung transplantation at a single institution from January 1, 2011 to December 31, 2021 AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) criteria after lung transplantation and was stratified on the basis of whether patients required renal replacement therapy (RRT; AKI–no RRT vs AKI-RRT). ResultsOf the 754 patients included, 369 (48.9%) any AKI developed in the postoperative period (252 AKI–no RRT vs 117 AKI-RRT). Risk factors for postoperative AKI included higher preoperative creatinine levels (odds ratio [OR], 5.15; P < .001), lower preoperative estimated glomerular filtration rate (OR, 0.99; P < 0.018), delayed chest closure (OR, 2.72; P < .001), and higher volumes of postoperative blood products (OR, 1.09; P < .001) in the multivariable analysis. On univariate analysis, both AKI groups were also associated with higher rates of pneumonia (P < .001), reintubation (P < .001), mortality on index admission (P < 0.001), longer ventilator duration (P < .001), longer intensive care unit length of stay (P < .001), and longer hospital length of stay (P < .001), with the highest rates in the AKI-RRT group. In a multivariable survival analysis, postoperative AKI–no RRT (hazard ratio [HR], 1.50; P = .006) and AKI-RRT (HR, 2.70; P < .001) were associated with significantly worse survival independent of severe grade 3 primary graft dysfunction at 72 hours (HR, 1.45; P = .038). ConclusionsThe development of postoperative AKI was associated with numerous preoperative and intraoperative factors. Postoperative AKI remained significantly associated with poorer posttransplantation survival. Severe cases of AKI necessitating RRT portended the worst survival after lung transplantation.

Single-Center Retrospective Subgroup Analysis of "Primary Aortic" (Aneurysm, Aortic Dissection, PAU) and "Secondary Aortic" (Iatrogenic, Trauma, Aortoesophageal Fistula) Indications for Emergency TEVAR.

The aim of this study was to analyze the outcome of emergency thoracic endovascular aortic repair (TEVAR) in the treatment of "primary aortic" (aneurysm, aortic dissection, penetrating aortic ulcer (PAU)) and "secondary aortic" (iatrogenic, trauma, and aortoesophageal fistula) pathologies. Retrospective review of a cohort of patients treated at a single tertiary referral center from 2015 to 2021. The primary end point was postoperative in-hospital mortality. Secondary end points were the duration of the procedure, duration of postoperative intensive care treatment, length of hospital stay, and the nature and severity of postoperative complications according to the Dindo-Clavien classification. A total of 34 patients underwent TEVAR for emergency indications. Twenty-two patients were treated for primary and twelve patients for secondary aortic pathologies. Concerning in-hospital mortality, no statistically significant difference could be observed between the primary and secondary aortic groups (27.3% vs. 33.3%, p = 0.711). Patients with an aortoesophageal fistula had a mortality rate of 66.7%. Postoperative morbidity (Dindo-Clavien > 3) was also not statistically significantly different between the primary and secondary aortic groups (36.4% vs. 33.3%, p = 0.86). Preoperative hemoglobin level (p < 0.001 for mortality, p = 0.002 for morbidity), hemoglobin level difference (p = 0.022, p = 0.032), postoperative creatinine level (p = 0.009, p = 0.035), and pre- and postoperative lactate levels (p < 0.001 for both mortality and morbidity) were found to be independent factors associated with postoperative mortality and morbidity (Dindo-Clavien > 3), respectively. The preoperative creatinine level was found to be associated with mortality (p = 0.024) but not morbidity. Morbidity and in-hospital mortality are still considerable after emergency TEVAR for both primary and secondary aortic indications. Pre- and postoperative levels of hemoglobin, creatinine, and lactate may be valuable to predict patient outcomes.

Expression and Significance of KIM-1, NGAL, and HO-1 in Patients with Acute Kidney Injury After Cardiac Valve Replacement.

To investigate the changes and significance of perioperative expression levels of kidney injury molecule-1 (KIM-1), neutrophil gelatinase-related lipocalin (NGAL), and heme oxygenase-1 (HO-1) in patients with acute kidney injury (AKI) after cardiac valve replacement under cardiopulmonary bypass. A total of 80 patients were divided into the AKI group and non-AKI group based on the postoperative occurrence of AKI. The expression levels of urinary KIM-1, NGAL, serum creatinine, urea nitrogen, and HO-1 were compared between the two groups before surgery and at 12 h, 24 h, and 48h after surgery. There were 22 patients with postoperative AKI (AKI group), the incidence of postoperative AKI were 27.5%, and there were 58 patients without AKI (non-AKI group). There was no significant difference in general clinical data between the two groups (P > 0.05). Compared between AKI group and preoperative group, KIM-1, NGAL, HO-1, blood creatinine, and BUN levels were significantly increased, with significant differences (P < 0.05). Compared with non-AKI groups, KIM-1, NGAL, HO-1, blood creatinine, and blood urea nitrogen levels increased at all time points, but the difference was not significant (P > 0.05). Compared with AKI group and non-AKI group, KIM-1, NGAL, HO-1, blood creatinine, and BUN levels increased significantly, the differences were statistically significant (P < 0.05). AKI can easily occur after cardiac valve replacement and postoperative expression levels of KIM-1, NGAL, and HO-1 can be early warning indicators of postoperative AKI.

Medicare Patients with Symptomatic Carotid Disease Requiring Carotid Revascularization Are Likely to Have Delayed Access: An Analysis of a Multicenter Surgical Data

The Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease recommends carotid revascularization as soon as the patient is neurologically stable after 48 hours and before 14 days of symptom onset in patients with recent stroke. In the United States, insurance status has been demonstrated to play a role in wait times for surgical care. There are no large-scale studies that assess the effect of patient primary insurance status on time to surgery in patients with symptomatic carotid disease. We utilized the Vascular Quality Initiative (VQI) database to evaluate our hypothesis that insurance status is associated with waiting times before surgery in patients with symptomatic carotid disease. All patients who underwent carotid revascularization in the VQI dataset from 2010 to 2022 were included. Patients with incomplete or missing outcomes data, Modified Rankin score of >2 and asymptomatic were excluded. Primary outcome was time between onset of symptomatic carotid disease and intervention. Categorical variables were compared using χ2 test and one-way analysis of variance for continuous variables. Multivariable logistic regression was used to assess the association between insurance status and waiting time to surgery while adjusting for potential confounders. The study consisted of 11,973 patients who had carotid revascularization within 14 days of symptoms (early cohort) and 21,253 patients in the late cohort (after 14 days). Patients in the late cohort were older (70.1 ± 9.8 vs 69.8 ± 10.5; P = .02), less likely to undergo carotid endarterectomy (85.9% vs 88.4%; P < .01), and more likely to have an elective procedure (90.3% vs 44.3%; P < .01). Fig 1 shows the distribution of insurance coverage among the study cohort. After adjusting for potential confounders, compared to Medicare, recipients of other insurer types had lower odds of experiencing delayed surgery: Medicare Advantage (adjusted odds ratio [aOR], 0.89; 95% confidence interval [CI], 0.80-0.99; P = .03), commercial (aOR, 0.84; 95% CI, 0.78-0.90; P < .001), military/Department of Veterans Affairs (aOR, 0.67; 95% CI, 0.54-0.84; P < .001), and self-pay (aOR, 0.54; 95% CI, 0.45-0.65; P < .001). Medicaid patients had similar delay (aOR, 0.90; 95% CI, 0.78-1.03; P = .14) and non-US insurance had longer delay to surgery (aOR, 1.48; 95% CI, 1.13-1.95; P = .005), in comparison to Medicare patients (Fig 2). Symptomatic carotid patients on Medicare and Medicaid are more likely to receive delayed revascularization procedures compared to patient with commercial insurance. Future studies are needed to investigate and potentially mitigate the underlying causes for the delay and the overall health implications of such a delay on the long-term outcomes of these patients.Fig 2Adjusted odds of receiving late carotid revascularization in symptomatic patients requiring surgery: comparing other major insurance providers with Medicare. *Model adjusted for urgency of procedure, prior coronary artery disease, prior carotid endarterectomy/coronary artery stenting, preoperative beta-blocker use, prior congestive heart failure, type of procedure (carotid endarterectomy, transcarotid artery revascularization, transfemoral carotid artery stenting), age, race, body mass index, preoperative creatinine levels, preoperative hemoglobin concentration, preoperative dysrhythmia, previous major amputation, preoperative functional status, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, and degree of stenosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Impact of Abdominal Aortic Calcification on Chronic Kidney Disease After Liver Transplantation: A Retrospective Study

With improved graft and patient survival after liver transplantation (LT), the onset of late complications, such as renal dysfunction, has become a problem. In this study, we aimed to investigate abdominal aortic calcification (AAC), a potential indicator of systemic atherosclerosis, and evaluate the relationship between preoperative AAC and postoperative chronic kidney disease (CKD), as the latter might be a long-term complication after LT. Among the 184 LTs performed at our center between 2008 and 2021, 110 LTs with normal renal function (estimated glomerular filtration rate [eGFR] 60 mL/min per 1.73 m2) before surgery were included. These were divided into high- (≥100 mm3) and low-AAC groups (<100 mm3) consisting of 51 and 59 patients, respectively. The AAC volume was automatically calculated for calcifications located in the abdominal aorta using the Agatston method. The high-AAC group was older, consisted of more men, and had lower preoperative creatinine and eGFR levels. No significant difference in the onset of postoperative CKD was found between the 2 groups. However, the cumulative incidence of postoperative CKD was significantly higher in the high-AAC group compared with the low-AAC group. Multivariate analysis of postoperative CKD using the Cox proportional hazards model showed significant differences in preoperative AAC ≥100 mm3, recipient age ≥50 years, and preoperative eGFR <75 mL/min per 1.73 m2. The development of postoperative CKD should be monitored in liver transplant recipients despite normal preoperative renal function. Our study suggests that preoperative AAC may influence postoperative renal dysfunction.

Frequency of Postoperative Acute Kidney Injury and its Related Risk Factors in Patients Undergoing Major Orthopedic Surgery in Rasht, Iran

Background: Patients who undergo major orthopedic surgery are at risk of acute kidney injury (AKI) due to blood loss, electrolyte disorders, infection, and other co-morbidities. In this study, we aim to investigate the frequency of AKI and its risk factors in patients undergoing major orthopedic surgery in Rasht, Iran. Objective: This is an analytical cross-sectional study on 180 patients undergoing major orthopedic surgery. Those with a history of chronic kidney disease and dialysis were excluded. Methods: The data including patients’ age, gender, drug history, history of underlying diseases, duration of surgery, mean arterial pressure during and after surgery, and use of inotrope during and after surgery, and creatinine level before and after the surgery. Results: The mean age of patients was 47.3±22.8 years. The incidence of AKI was 11.11%. The use of some drugs, duration of surgery, MAP, and inotrope use had no significant relationship. The occurrence of AKI had a significant relationship with the history of heart disease, diabetes, and kidney disease. Multiple linear regression analysis results showed that with the increase of one unit in preoperative creatinine level, the postoperative creatinine level increased by 0.3. Conclusion: The incidence of AKI after major orthopedic surgery in Rasht city is relatively high. Careful monitoring of kidney function before, during, and after major orthopedic surgery is important; it can prevent the occurrence of postoperative AKI.