Preoperative Intubation Research Articles

Factors Related to Early Postoperative Modified Blalock-Taussig Shunt Thrombosis and In-Hospital Mortality in Infants

Objective: The modified Blalock-Taussig shunt (mBTs) is used palliatively in cyanotic congenital heart diseases when definitive surgery is not possible. However, factors contributing to shunt thrombosis and in-hospital mortality in infancy remain unclear. The present study aimed to identify those risk factors. Materials and Methods: The authors conducted a retrospective review of medical records from the infants diagnosed with cyanotic congenital heart disease who underwent isolated mBTs procedures at Chiang Mai University Hospital between March 1, 2011 and April 30, 2015. Patient characteristics, operative data, and treatment outcomes were extracted. The primary outcome assessed was shunt thrombosis, with in-hospital mortality within 30 days as the secondary outcome. Risk regression analysis was used to identify factors associated with both outcomes. Results: Forty-nine infants were included in the present study, with a mean weight of 3.81 kilograms (range of 2.05 to 7.70 kg) and an average age of 66 days (range of 3 to 349 days). Early shunt thrombosis occurred in eight patients (16.33%), and five patients (10.2%) died. Multivariable analysis revealed only sepsis as a significant predictor (RR 7.93, 95% CI 1.86 to 33.69). Neither weight at surgery nor shunt size showed a significant association with shunt thrombosis. Prognostic factors for in-hospital mortality in the univariable analysis included prematurity (p=0.01), size of pulmonary artery (p=0.033), preoperative intubation (p=0.043) shunt thrombosis (p=0.002), and body weight at surgery of less than 3 kg (p=0.002). However, multivariable analysis could not demonstrate any difference. Conclusion: Postoperative sepsis emerged as the sole statistically significant predictor for early shunt thrombosis following isolated mBTs. However, larger studies are needed to ascertain prognostic factors for in-hospital mortality in infants with cyanotic congenital heart disease.

Investigation of the effectiveness of preoperative intubation simulation using a custom-made simulator for pediatric patients with difficult airway: a pilot study.

The purpose of this study is to investigate whether preoperative intubation simulation using custom-made simulator is useful during anesthesia induction for the children who have difficult airway. We included the children under 15years of age who have difficult airway which had been already known. Prior to the scheduled surgery, CT imaging was performed and a 3D reconstruction of the face from the chest was performed. Then custom-made airway simulator was made. We tried to intubate custom-made simulator of patients preoperatively. We planned how to intubate the patient for anesthesia induction from the result of intubation simulation. The findings of direct laryngoscopy were compared with the findings during intubation. Three patients were included in this study. It took up to 3 weeks to create a simulator, which was difficult due to time constraints to accommodate emergency surgeries. Simulation findings correlated well with findings during anesthesia induction. There were no cases of severe hypotension or hypoxia during induction of anesthesia with the planned intubation method. In conclusion, preoperative intubation simulation using custom-made simulator may be useful for the patients who have difficult airway.

361 The Frailty-Driven Predictive Model for Failure to Rescue After Cervical Decompression and Fusion: An ACS-NSQIP Analysis of 3,632 Cases (2011-2020)

INTRODUCTION: Cervical decompression & fusion (CDF) outcome prognostication relies on preoperative risk factors to predict complications and outcomes in order to help guide pre- and perioperative decision-making. METHODS: CDF cases were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database 2011-2020. Patients who underwent CDF and experienced a major complication were identified. Within this cohort, FTR was calculated as death or hospice within 30 days of a major complication. Frailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Demographics and baseline characteristics of patients were compared by FTR. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic curve analysis. RESULTS: There were 3,632 patients who suffered a major complication from CDF, and 7.6% (277 patients) experienced FTR. Independent predictors of FTR were non-elective surgery, frailty status, preoperative intubation, thrombosis or embolism complication, unplanned intubation, prolonged ventilator use (>48 hours), cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883-0.919). CONCLUSIONS: Preoperative and postoperative risk factors yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication following the development of a major complication. Future studies may determine the predictive ability of this model in other neurosurgical patient populations. Our predictive model may be deployed by-the-beside here: https://nsgyfrailtyoutcomeslab.shinyapps.io/FailureToRescueCervicalFusion/

Should we operate on patients with acute type A aortic dissection who present with cardiopulmonary resuscitation?

Acute aortic dissection type A (AADA) is a life-threatening medical emergency. Emergent surgical repair is the gold standard but mortality remains high. Mortality is even higher in patients who arrive at the hospital in poor condition, especially after cardiopulmonary resuscitation (CPR). This study was designed to analyse the outcome of patients who underwent surgery for AADA and who require preoperative CPR. Between 2000 and 2023, 810 patients underwent emergent surgery for AADA at our centre. Of these, 63 had preoperative CPR. We performed a retrospective analysis with follow-up. Mean age was 64 ± 13 years and 37 (59%) patients were male. Further, 50 (79%) patients had preoperative intubation, and 54 (86%) had pericardial effusion. Twenty-four (38%) patients had out-of-hospital CPR, 19 (30%) required CPR in hospital and 20 (32%) needed CPR in the operating room. Successful CPR with return of spontaneous circulation was achieved in 41 (65%) patients, and 22 (35%) underwent emergent surgery under ongoing CPR. The median time of CPR was 10 (interquartile range 12) min, and the median time from onset of symptoms to start of the operation was 5.5 (interquartile range 4.8) h. The majority of patients underwent ascending aortic replacement with hemiarch repair (n = 37, 59%). Further, 26 (41%) patients underwent full root replacement. Another 15 (24%) patients underwent total arch repair with or without (frozen) elephant trunk repair. Postoperative stroke was present in 8 (13%) patients. The 30-day mortality was 29 (46%). The 30-day mortality of patients with preoperative intubation was not significantly higher (n = 15/28, 54%, P = 0.446). The 1-, 5- and 10-year survival rates of the entire group were 42, 39 and 36%. Early mortality for patients undergoing surgery for AADA with preoperative CPR is extremely high (almost 50%). However, this means that also ∼50% of patients benefit from surgery despite poor preoperative prognosis. Patients with preoperative intubation after CPR and unknown neurological condition should also undergo surgery. Patients who survive the initial operation for AADA have acceptable long-term survival. Emergent surgery should be offered for all patients with AADA regardless of the preoperative condition, even after CPR.

Endotracheal Intubation without Neuromuscular Blocking Agent in Patient with Fracture Cervical Spine C1 and C4 Underwent Fusion C1–2 and C4–6

About 30% of cervical spine fractures involve injuries to the C1 and C2 vertebrae, which are considered unstable. Ensuring the stability of the injured cervical spine throughout perioperative period, including preoperative examinations, anesthesia induction, laryngoscopy, and intubation, is crucial for anesthesiologists. A 40-year-old woman suffered neck pain following a motorcycle accident, suffering a Spinal Cord Injury ASIA Impairment Scale (SCI AIS) E, a fracture of the C5 vertebral body (CV) classified as AO Spine Type A2, a Jefferson Type IV fracture, and mild head trauma. She underwent surgical fusion of the C1–C2 and C4–C6 vertebrae under general anesthesia, which included dexmedetomidine, propofol, sevoflurane, and fentanyl without any neuromuscular blocking agents (NMBA). The primary goal of perioperative airway management in cervical injury is a secured airway, while maintaining cervical stability without inflicting secondary injury. The cervical muscle group is essential for maintaining cervical stability, and the use of NMBA may jeopardize this stability, necessitating external cervical stabilization, especially during laryngoscopy and intubation. Induction agents in combination with opioid, widely used to facilitate laryngoscopy and intubation without using NMBA. Anesthesiologists must precisely arrange the management of cervical spine injuries patient to avoid secondary injury and improve surgical outcomes

The frailty-driven predictive model for failure to rescue among patients who experienced a major complication following cervical decompression and fusion: an ACS-NSQIP analysis of 3,632 cases (2011–2020)

BACKGROUND CONTEXTPreoperative risk stratification for patients considering cervical decompression and fusion (CDF) relies on established independent risk factors to predict the probability of complications and outcomes in order to help guide pre and perioperative decision-making. PURPOSEThis study aims to determine frailty's impact on failure to rescue (FTR), or when a mortality occurs within 30 days following a major complication. STUDY DESIGN/SETTINGCross-sectional retrospective analysis of retrospective and nationally-representative data. PATIENT SAMPLEThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all CDF cases from 2011-2020. OUTCOME MEASURESCDF patients who experienced a major complication were identified and FTR was calculated as death or hospice disposition within 30 days of a major complication. METHODSFrailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Baseline patient demographics and characteristics were compared for all FTR patients. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic (ROC) curve analysis. RESULTSThere were 3632 CDF patients who suffered a major complication and 7.6% (277 patients) subsequently expired or dispositioned to hospice, the definition of FTR. Independent predictors of FTR were nonelective surgery, frailty, preoperative intubation, thrombosis or embolic complication, unplanned intubation, on ventilator for >48 hours, cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR, achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883–0.919). CONCLUSIONPreoperative and postoperative risk factors, combined with frailty, yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication regarding the likelihood of FTR after a major complication postoperatively with CDF patients. Future studies may determine the predictive ability of this model in other neurosurgical patient populations.

The prognosis of preoperative preemptive intubation for acute type A aortic dissection patients: a retrospective propensity score matching study.

Acute type A aortic dissection (AADA) is a life-threatening cardiovascular disease, and improving perioperative mortality remains a significant challenge. The purpose of this study is to investigate the impact of preemptive intubation under adequate sedation and analgesia on the prognosis of AADA patients under the high rupture risk. The medical records of patients diagnosed with AADA and admitted to Changhai Hospital from January 2019 to January 2020 were retrospectively reviewed. Patients were divided into two groups based on whether they received preoperative preemptive intubation in the cardiac intensive care unit (ICU) before surgery. We used propensity score matching (PSM) analysis to conduct statistical analyses on the preoperative, intraoperative, and postoperative clinical data of the two groups. A total of 134 patients were eventually included in the study. One patient (3.8%) in the pre-intubation group and 15 (13.9%) in the control group died of dissection rupture before surgery. After excluding patients with dissection rupture, there were 25 patients in the pre-intubation group and 93 patients in the non-intubation group. After PSM, there were 17 patients in the pre-intubation group and 68 patients in the non-intubation group. Baseline data analysis showed that the pre-intubation group had a higher Sequential Organ Failure Assessment (SOFA) score (10.2±3.9 vs. 8.0±4.7, P=0.036) and a higher proportion of patients with coronary artery disease (16.0% vs. 1.1%, P=0.007). The rate of massive pericardial effusion was also higher in the intubation group (28.0% vs. 10.8%, P=0.049), and preoperative oxygenation index was lower (273.2±97.3 vs. 322.1±100.9, P=0.032) compared to the control group. The results showed no significant differences in intraoperative and postoperative data for the two groups. Kaplan-Meier survival curves indicated a trend towards a more favorable prognosis for patients in the preemptive intubation group, but this difference was not significant either before or after PSM. Preemptive pre-intubation may benefit high-risk patients with factors such as hypoxia, massive pericardial effusion, and agitation, improving the more critically AADA patients' perioperative outcomes.

Study on preoperative treatment of acute Type-A aortic dissection with endotracheal intubation combined with deep analgesia and sedation.

To investigate the efficacy and safety of endotracheal intubation combined with deep analgesia and sedation in the prevention of preoperative dissection rupture in acute Standford type A aortic dissection. This study evaluated the impact of preoperative endotracheal intubation combined with deep analgesia and sedation on acute Stanford Type-A aortic dissection. Conducted at the First Affiliated Hospital of the University of South China's cardiac intensive care unit from June 2018 to December 2021, 134 diagnosed patients participated. They were divided into experimental (n=42) and control (n=92) groups. Data collected included clinical details, biochemical markers, VAS and SAS scores, and preoperative dissection rupture occurrences. Criteria involved acute Stanford Type-A aortic dissection diagnosis and complete data. Exclusions encompassed rupture, vital sign instability after vasoactive drugs, or prolonged coma. Standardized methods were used for sample collection and analysis. The study's design, duration, and location ensured comprehensive evaluation of the intervention's effects on patients. The experimental group showed significantly fewer deaths due to dissection rupture compared to the control group (P < 0.05). Initial VAS and SAS scores (T0) were similar between groups (P > 0.05), indicating good comparability. However, at T1, T2, and T3, analgesia and sedation were significantly better in the experimental group (P < 0.05). By T4, patient numbers were too low in both groups for a significant difference (P > 0.05). Preoperative endotracheal intubation combined with deep analgesia and sedation in patients with acute Stanford Type-A aortic dissection can produce good analgesic and sedative effects, effectively reduce the incidence of preoperative dissection rupture, and create conditions for subsequent surgical treatment of patients.

Bronchoscopic Localization of Tracheoesophageal Fistula in Newborns With Esophageal Atresia: Intubate Above or Below the Fistula?

PurposeIn neonates with suspected type C esophageal atresia and tracheoesophageal fistula (EA/TEF) who require preoperative intubation, some texts advocate for attempted “deep” or distal-to-fistula intubation. However, this can lead to gastric distension and ventilatory compromise if a distal fistula is accidentally intubated. This study examines the distribution of tracheoesophageal fistula locations in neonates with type C EA/TEF as determined by intraoperative bronchoscopy. MethodsThis was a single-center retrospective review of neonates with suspected type C EA/TEF who underwent primary repair with intraoperative bronchoscopy between 2010-2020. Data were collected on demographics and fistula location during bronchoscopic evaluation. Fistula location was categorized as amenable to blind deep intubation (>1.5 cm above carina) or not amenable to blind deep intubation intubation (<1.5 cm above carina or carinal). ResultsSixty-nine neonates underwent primary repair of Type C EA/TEF with intraoperative bronchoscopy during the study period. Three patients did not have documented fistula locations and were excluded (n=66). In total, 49 (74%) of patients were found to have fistulas located <1.5 cm from the carina that were not amenable to blind deep intubation. Only 17 patients (26%) had fistulas >1.5 cm above carina potentially amenable to blind deep intubation. ConclusionsMost neonates with suspected type C esophageal atresia and tracheoesophageal fistula have distal tracheal and carinal fistulas that are not amenable to blind deep intubation. Level of EvidenceLevel III.

Complications of Mandibular Distraction Osteogenesis in Infants with Isolated Robin Sequence.

Mandibular Distraction Osteogenesis (MDO) is now the preferred procedure to alleviate airway obstruction in infants with severe Robin Sequence (RS). However, there have been very few studies investigating complications related to MDO surgery performed on patients affected by isolated RS. In this study, age at distraction, weight at distraction, preoperative intubation, repeat MDO and complications associated with MDO were included as variables. Minor, moderate and major problems were evaluated and recorded as surgical site infections (SSI), injuries to the facial nerve, self-extinction hypertrophic scars, temporomandibular joint ankylosis, device failures, early ossification and fibrous non-union. One hundred and fifty one patients with isolated RS were included. At distraction, the mean age was 72 days (12-540 days) and the mean weight was 4.05 kg (2.4-12.2 kg). Only one patient needed tracheostomy after MDO, and none required further distraction. Ultimately, the complication rate was 15.23%, and there was a total of 7.95% minor, 9.27% moderate and 0% major complications. Minor incidents included surgical site infection (SSI) managed with antibiotics taken orally (n = 8), neuropraxia in the VII cranial nerve (CN) (n = 1), and hypertrophic scarring (n = 3). Incidents reported as moderate were SSIs managed with intravenous antibiotics (n = 9), incision and drainage (n = 3) and self-extubation (n = 2). There was no case of TMJ ankylosis. There were no cases of early or premature ossification, fibrous non-union and device fracture. In conclusion, MDO is an effective and appropriate management technique for infants with isolated RS and severe airway obstruction. Infections at the surgery site accounted for the vast majority of the complications. Further investigations may be needed to determine the long-term consequences of MDO.

Clinical Predictors and Outcomes After Left Ventricular Assist Device Implantation and Tracheostomy.

Postoperative respiratory failure is a major complication that affects up to 10% of patients who undergo cardiac surgery and has a high in-hospital mortality rate. Few studies have investigated whether patients who require tracheostomy for postoperative respiratory failure after continuous-flow left ventricular assist device (CF-LVAD) implantation have worse survival outcomes than patients who do not. To identify risk factors for respiratory failure necessitating tracheostomy in CF-LVAD recipients and to compare survival outcomes between those who did and did not require tracheostomy. Consecutive patients who underwent primary CF-LVAD placement at a single institution between August 1, 2002, and December 31, 2019, were retrospectively reviewed. Propensity score matching accounted for baseline differences between the tracheostomy and nontracheostomy groups. Multivariate logistic regression was used to identify tracheostomy risk factors and 90-day survival; Kaplan-Meier analysis was used to assess midterm survival. During the study period, 664 patients received a CF-LVAD; 106 (16.0%) underwent tracheostomy for respiratory failure. Propensity score matching produced 103 matched tracheostomy-nontracheostomy pairs. Patients who underwent tracheostomy were older (mean [SD] age, 57.9 [12.3] vs 54.6 [13.9] years; P = .02) and more likely to need preoperative mechanical circulatory support (61.3% vs 47.8%; P = .01) and preoperative intubation (27.4% vs 8.8%; P < .001); serum creatinine was higher in the tracheostomy group (mean [SD], 1.7 [1.0] vs 1.4 [0.6] mg/dL; P < .001), correlating with tracheostomy need (odds ratio, 1.76; 95% CI, 1.21-2.56; P = .003). Both before and after propensity matching, 30-day, 60-day, 90-day, and 1-year survival were worse in patients who underwent tracheostomy. Median follow-up was 0.8 years (range, 0.0-11.2 years). Three-year Kaplan-Meier survival was significantly worse for the tracheostomy group before (22.0% vs 61.0%; P < .001) and after (22.4% vs 48.3%; P < .001) matching. Given the substantially increased probability of death in patients who develop respiratory failure and need tracheostomy, those at high risk for respiratory failure should be carefully considered for CF-LVAD implantation. Comprehensive management to decrease respiratory failure before and after surgery is critical.

Systematic Review of the Clinical Efficacy of Various Terms of Non-Surgical Treatment in Patients With Acute Adhesive Intestinal Obstruction

BACKGROUND The question of the duration and volume of conservative measures in patients with acute adhesive intestinal obstruction (AAIO) remains the subject of numerous discussions. Aim of study To evaluate the efficacy and safety of various periods of conservative therapy in patients with AAIO using a systematic review. MATERIAL AND METHODS Criteria for inclusion in the systematic review were cohort studies investigating various regimens and duration of conservative therapy in adult patients with AAIO. The search for primary sources was carried out in the CENTRAL, PubMed and eLibrary databases. The assessment of the safety of various terms of AAIO was carried out by comparing the immediate results of treatment. RESULTS The review included 19 papers with a total of 2,570 observations. At the first stage, the effectiveness of various conservative therapy regimens was evaluated by calculating the risk ratio for the success of non-surgical treatment. Taking into account the significant statistical heterogeneity of the participants, the calculation of the final risk ratio was carried out using a random effects model. The hazard ratio for nonoperative success was 1.91 (95% CI 1.2–3.1) in favor of gastrografin and 3.71 (95% CI 1.3–10.6) in favor of preoperative intestinal intubation. Taking into account the multidirectional pathogenetic action of the studied methods of conservative therapy, the obtained results suggested that the probability of success of non-surgical treatment correlates to a greater extent with the total duration of the AAIO episode than with the duration of conservative therapy, which was indirectly confirmed by constructing scattering graphs with approximation lines and calculating the coefficients determination, which amounted to 0.69 and 0.77 for the subgroups of standard therapy and undiluted gastrografin, respectively. Subsequently, the impact of different duration of an episode of AAIO on the immediate outcomes was assessed: mortality, frequency of resection interventions, complications, and total bed-day. There were no statistically significant differences in favor of early interventions (up to 48 hours) for all compared parameters; an increase in the total duration of AAIO up to 89 hours was not associated with worse results. CONCLUSION The total duration of the episode of acute adhesive intestinal obstruction, including both the pre-hospital duration and the duration of non-surgical treatment is prognostically significant. In other words, when calculating the allowable duration of conservative measures, one should proceed from the total duration of intestinal passage disturbance, which should not exceed 89 hours.

Preoperative pericardial hematoma in patients with acute type A aortic dissection (AAAD): Do we need an adjusted treatment?

ObjectiveAn acute type A aortic dissection (AAAD) is a critical emergency and remains one of the most challenging diseases in cardiothoracic surgery. The existence of a pericardial hematoma caused by an aortic rupture can dramatically reduce the chances of survival (Jerzewski and Kulik in J Card Surg 29(4):529–530, 2014; Mehta et al. in Circulation 105(2):200–206, 2002; Gilon et al. in Am J Cardiol 103(7):1029–1031, 2009; Isselbacher et al. in Circulation 90(5):2375–2378, 1994). We assessed the surgical outcome of a high-risk group of patients with AAAD and a pericardial hematoma.MethodsIn this study we included 430 Patients (67% male; median age: 64 years) who received surgical treatment between January 2000 and January 2018 at our facility for acute aortic dissection DeBakey type I. We divided the cohort in two groups: Group A consisted of high-risk patients with a pericardial hematoma (n = 162) and Group B of patients without pericardial hematoma (n = 268).ResultsPatients with a preoperative pericardial hematoma had a significantly higher requirement for preoperative mechanical resuscitation (A: 21%; B: 1.5%; P: < 0.001) and were relevantly more frequently admitted to the operation theater with an intubated status (A: 19.8%; B: 8.6%; P: < 0.001). The incidence of visceral malperfusion differed significantly between both groups (A. 11.7%, B. 6:0%; P: 0.034). Limited aortic arch repair (proximal aortic arch replacement) was preferred in the high-risk group (A: 51.9%; B: 40.3%; P: 0.020). However, survival time was generally reduced in these patients (A: 7.5 y; B: 9.9 y).ConclusionAAAD patients with preoperative pericardial hematoma present themselves in potentially lethal conditions, with a significantly higher rate of visceral malperfusion. Despite the existence of this risk factor, a limited arch repair was favored. We have proven that cardiac compression is associated with preoperative intubation and mechanical resuscitation. Patients with pericardial hematoma must be further evaluated for preoperative pericardial drainage. In the event of long transfer times to an aortic center a slow drainage should be discussed to prevent early mortality.

Non-invasive positive pressure ventilation can reduce perioperative mortality in acute aortic dissection patients with hypoxemia.

Hypoxemia is a common critical respiratory complication in patients with acute aortic dissection (AAD) before operation and results in adverse outcomes. This study aimed to identify the optimal oxygenation treatment for AAD patients with hypoxemia in the emergency department (ED). This was a retrospective, observational, cohort study. We retrospectively collected data from 187 adult patients with AAD and hypoxemia who had been admitted to our ED. All patients were divided into nasal cannula group (n=91), Venturi mask group (n=60), and non-invasive positive pressure ventilation (NIPPV) group (n=36). The primary outcome was overall mortality in ED; the secondary outcomes were preoperative intubation rate and postoperative mortality, length of intensive care unit (ICU) stay, length of hospital stay, and length of intubation. Among all patients, those who received NIPPV treatment showed the lowest ED intubation rate (2.78%, P=0.004), shortest postoperative length of ICU stay (median 2.31, P<0.001), postoperative length of intubation (median 25.10, P<0.001), and post-operative length of hospital stay (median 21.00, P<0.001). Kaplan-Meier analysis showed the highest 3-day survival (log-rank 7.387, P=0.03) and 5-day survival (log-rank 14.710, P=0.001) in the NIPPV group. After adjustment, NIPPV therapy was independently associated with the reduced 3-day [adjusted hazard ratio (HR) 0.102, 95% confidence interval (CI): 0.013-0.791, P=0.03] and 5-day (adjusted HR 0.057, 95% CI: 0.008-0.427, P=0.005) mortality in ED. Early utilization of NIPPV in AAD patients with hypoxemia in the ED can effectively decrease pre-operative intubation rate and perioperative mortality, and improve postoperative outcomes.

Long-term outcomes of primary aortic valve repair in children with congenital aortic stenosis - 15-year experience at a single center.

BackgroundStudies on the long-term outcomes of children with congenital aortic stenosis who underwent primary aortic repair are limited. We reviewed the long-term outcomes of children who underwent aortic valve (AoV) repair at our center.MethodsAll children (n = 75) who underwent AoV repair between 2006 and 2020 were reviewed. The Kaplan-Meier curve was used to demonstrate the survival estimates. The Cox proportional hazard model and competing risk regression model were used to identify risk factors for death, reintervention, adverse events, and replacement.ResultsThe median age at surgery was 1.8 (IQR, 0.2–7.7) years, and the median weight at surgery was 10.0 (IQR, 5.0–24.0) kg. Early mortality and late mortality were 5.3% (4/75) and 5.6% (4/71), respectively. Risk factors for overall mortality were concomitant mitral stenosis (P = 0.01, HR: 9.8, 95% CI: 1.8–53.9), low AoV annulus Z-score (P = 0.01, HR: 0.6, 95% CI: 0.4–0.9), and prolonged cardiopulmonary bypass time (P < 0.01, HR: 9.5, 95% CI: 1.7–52.1). Freedom from reintervention was 72.9 ± 0.10% (95% CI: 56.3–94.4%) at 10 years. Risk factors for occurrence of adverse event on multivariable analysis included preoperative intubation (P = 0.016, HR: 1.004, 95% CI: 1.001–1.007) and a low AoV annulus Z-score (P = 0.019, HR: 0.714, 95% CI: 0.540–0.945). Tricuspid AoV morphology was associated with a suboptimal postoperative outcome (P = 0.03).ConclusionAortic valve repair remains a safe and durable solution for children with congenital aortic stenosis. Concomitant mitral stenosis and aortic valve anatomy, including tricuspid valve morphology and smaller annulus size, are associated with poor early and long-term outcomes.

Success of Right Thoracotomy versus Exploratory Laparotomy in Right sided Congenital Diaphragmatic Hernia in neonates

Objective: Aim of current study is to determine the success of right thoracotomy versus exploratory laparotomy in right sided congenital diaphragmatic hernia in neonates. Study Design: Retrospective study Place and duration: The Children’s Hospital PIMS Islamabad. Jan 2021 to Dec 2021 Methods: Total 74 neonates had right sided congenital diaphragmatic hernia were included. All the neonates were admitted to hospital for surgery. Neonates were equally divided in two groups. Thirty seven patients in group I received thoracotomy and 37 patients in group II underwent for exploratory laparotomy. Post-surgery success rate among both groups were compared. Results: There were majority 41 (55.4%) males and 33 (44.6%) females. Mean age of the neonates was 13.7±4.19 days. Pre-operative tracheal intubation and cardiac malformation was found in 67 (90.4%) and 14 (18.9%) cases. Compared to thoracotomies, exploratory laparotomies were associated with shorter hospital stays, shorter durations of postoperative mechanical ventilation, and shorter times to optimum feeding. We found that recurrence rate in thoracotomy group was higher as compared to laparotomy group with p value &lt;0.004. There were no any significant differences in postoperative complications between the two groups. In both groups, 3 (8.1%) and 1 (2.7%) patients were died. Conclusion: We concluded in this study that the exploratory laparotomy among patients of right sided congenital diaphragmatic hernia was effective and useful in terms of shorter hospital stay, short mechanical ventilation and less time to optimum feeding as compared to right thoracotomy. No any significant difference was found in terms of post-surgery complication among both groups. Keywords: Congenital Diaphragmatic Hernia (CDH), Exploratory laparotomy, Thoracotomy

Initial Surgical Strategy for the Treatment of Type A Acute Aortic Dissection: Does Proximal or Distal Extension of the Aortic Resection Influence the Outcomes?

(1) Background: We sought to analyze and compare the outcomes in terms of early and late mortality and freedom from a redo operation in patients undergoing surgical treatment for a type A acute aortic dissection in relation to the initial surgical treatment strategy, i.e., proximal or distal extension of the aortic segment resection, compared with isolated resection of the supracoronary ascending aorta. (2) Methods: This is a retrospective study in which we included 269 patients who underwent operations for a type A acute aortic dissection in the Department of Cardiac Surgery of Tor Vergata University from May 2006 to May 2016. The patients were grouped according to the extent of the performed surgical treatment: isolated replacement of the supracoronary ascending aorta (NE, no extension), replacement of the aortic root (PE, proximal extension), replacement of the aortic arch (DE, distal extension), and both (BE, bilateral extension). The analyzed variables were in-hospital mortality, postoperative complications (incidence of neurological damage, renal failure and need for prolonged intubation), late mortality and need for a redo operation. (3) Results: Unilateral cerebral perfusion was performed in 49.3% of the patients, and bilateral perfusion—in 50.6%. The overall in-hospital mortality was 31.97%. In the multivariate analysis, advanced age, cardiopulmonary bypass time and preoperative orotracheal intubation were independent predictors of in-hospital mortality. In the population of patients who survived the surgery, the probability of survival at 92 months was 70 ± 5%, the probability of freedom from a redo operation was 71.5 ± 5%, the probability of freedom from the combined end-point death and a redo operation was 50 ± 5%. The re-intervention rate in the general population was 16.9%. The overall probability of freedom from re-intervention was higher in patients undergoing aortic root replacement, although not reaching a level of statistical significance. Patients who underwent aortic arch treatment showed reduced survival. (4) Conclusions: In the treatment of type A acute aortic dissection, all the surgical strategies adopted were associated with satisfactory long-term survival. In the group of patients in which the aortic root had not been replaced, we observed reduced event-free survival.

Clinical outcomes of limited repair and conservative approaches in older patients with acute type A aortic dissection

BackgroundSurgical indication and the selection of surgical procedures for acute type A aortic dissection in older patients are controversial; therefore, we aimed to examine the surgical outcomes of acute type A aortic dissection in older patients.MethodsFrom January 2012 through December 2019, 174 patients underwent surgical repair for acute type A aortic dissection. We compared the surgical outcomes between the older (≥ 80 years old) and below-80 (≤ 79 years old) age groups. Additionally, we compared the outcomes between the surgical and conservative treatment groups.ResultsThe primary entry was found in the ascending aorta in 51.6% and 32.8% of the older and below-80 groups, respectively (p = 0.049). Ascending or hemiarch replacement was performed in all older group patients and 57.3% of the below-80 group patients (total arch replacement was performed in the remaining 42.7%; p < 0.001). Hospital mortality rates were similar in both groups. The significant risk factors for hospital mortality were age, preoperative intubation, cardiopulmonary bypass time, and postoperative stroke. The 5-year survival rates were 48.4% ± 10.3% (older group) and 86.7% ± 2.9% (below-80 group; p < 0.001). The rates of freedom from aortic events at 5 years were 86.9% ± 8.7% (older group) and 86.5% ± 3.9% (below-80 group; p = 0.771). The 5-year survival rate of the conservative treatment subgroup was 19.2% ± 8.0% in the older group, which was not significantly different from that of the surgical treatment subgroup (p = 0.103).ConclusionThe surgical approach did not achieve a significant survival advantage over conservative treatment and may not always be a reasonable treatment of choice for older patients.

Respiratory problems and associated factors following endoscopic balloon dilatation procedure in children with acquired subglottic stenosıs.

Endoscopic balloon dilatation (EBD) offers a safe and non-invasive surgical option for the treatment of subglottic stenosis. Patient selection is important to achieve good results and to detect which patients are more prone to the development of complications. The aim of this study was to determine predictors of postoperative problems and early complications in primary EBD surgeries. A retrospective analysis was made of patients with acquired subglottic stenosis who were operated on with the EBD technique between January 2010 and December 2019 in the Otolaryngology-Head and Neck Surgery Department of Baskent UniversityHospital. Demographic data including the age and sex of the patients were collected together with etiology, presence of chromosomal or craniofacial anomaly (C/CA), duration of prolonged intubation (DPI), and extubation dilatation timeframe (EDT). Intra and postoperative follow-up data were recorded of the need for intubation or tracheotomy, development of desaturation, and grade and type of stenosis. The male to female ratio was 2:1. The patients comprised 42 males and 22 females with a mean age of 296.52 ± 551.93days. The cause of prolonged intubation was surgery for congenital heart disease in 50 (78.1%) patients and prematurity in 14 (21.9%). The type of lesion was acute granulation in 44 (72.1%) and chronic granulation in 17 (27.9%) patients. C/CA was determined in 13 patients, the mean grade of stenosis was 76.33 ± 15.21%, mean DPI was 25.25 ± 35.49days, and mean EDT was calculated as 78.23 ± 373.82days. Desaturation following endoscopic balloon dilatation developed in 26 (40.6%), orotracheal intubation was required in 10 (15.6%), tracheotomy in 10 (15.6%), and cardiopulmonary arrest occurred in 4 (6.25%). Prematurity, a longer duration of preoperative intubation, longer time from extubation to dilatation, older age, and higher grade of stenosis were determined as factors associated with postoperative early respiratory complications. EBD indication should be carefully considered in children with acquired subglottic stenosis. To achieve better results and minimise complications, EBD should be performed without delay.

Clinical Analysis of Factors Affecting Hospital Mortality After Liver Transplant in Patients With High Model for End-Stage Liver Disease Score

This study was undertaken to identify poor prognostic factors in patients with high Model for End-Stage Liver Disease (MELD) scores. From September 2001 to December 2017, living donor liver transplant and deceased donor liver transplant were performed in 851 (84.4%) and 157 patients (15.6%), respectively, in our center. Eighty-one patients (8.0%) with MELD scores ≥ 35 were classified as patients with high MELD scores. The overall survival rates in patients with high MELD scores were significantly worse than those in patients with low MELD scores (P=.005). However, no significant difference in survival was found between the 2 groups when in-hospital mortality was excluded. In-hospital mortality occurred in 18 patients (22.2%), and the main cause of death was sepsis (n=14, 77.8%). On univariate analysis, the risk factors for in-hospital mortality were mean age (P=.028), mean MELD score (P=.045), intubation status (P < .001), culture positivity (P=.042), and encephalopathy grade 3 or 4 (P=.014). On multivariate analysis, age (P=.006), intubation status (P=.042), and culture positivity (P=.036) were significant. The main cause of in-hospital mortality was sepsis, and the risk factors for in-hospital mortality of patients with high MELD score were older age, preoperative intubation, and culture positivity. Special attention should be paid to the prevention and treatment of infection in the liver transplant of patient with high MELD scores.