Preoperative Systolic Blood Pressure Research Articles

Changes in Cortical Thickness Are Associated With Cognitive Ability in Postoperative School-Aged Children With Tetralogy of Fallot.

In children with tetralogy of Fallot (TOF), there is a risk of brain injury even if intracardiac deformities are corrected. This population follow-up study aimed to identify the correlation between cerebral morphology changes and cognition in postoperative school-aged children with TOF. Resting-state functional magnetic resonance imaging (rs-fMRI) and the Wechsler Intelligence Scale for Children–Chinese revised edition (WISC-CR) were used to assess the difference between children with TOF and healthy children (HCs). Multiple linear regression showed that the TOF group had a lower verbal intelligence quotient (VIQ, 95.000 ± 13.433, p = 0.001) than the HC group and that VIQ had significant positive correlations with the cortical thickness of both the left precuneus (p < 0.05) and the right caudal middle frontal gyrus (p < 0.05) after adjustment for preoperative SpO2, preoperative systolic blood pressure (SBP), preoperative diastolic blood pressure (DBP) and time of aortic override (AO). Our results suggested that brain injury induced by TOF would exert lasting effects on cortical and cognitive development at least to school age. This study provides direct evidence of the relationship between cortical thickness and VIQ and of the need for strengthened verbal training in school-aged TOF patients after corrective surgery.

Comparison of a new sublingual sedation troche with midazolam, ketamine, and ondansetron with intravenous sedation and the effects on vital signs.

To compare effects of the MKO Melt (midazolam 3 mg, ketamine 25 mg, and ondansetron 2 mg) with intravenous (IV) sedation on vital signs of patients who underwent cataract surgery. Two private ophthalmology practices in Sioux Falls, South Dakota, USA. Retrospective analysis. Preoperative, intraoperative, and postoperative vital signs were compared between individuals who underwent cataract surgery and received exclusively either MKO (n = 991) or traditional IV methods (n = 120) for sedation. Clinical significance was defined as a 5 mm Hg change in blood pressure, 3 beats per minute (bpm) change in heart rate, a change of 2 respirations per minute, or a change of 3% in O2 saturation. MKO Melt but not IV sedation was given before the reported preoperative vital signs. There were 1111 patients included in this study. Preoperative systolic blood pressure (SBP) was 133.7 ± 15.6 mm Hg in the MKO group and 139.6 ± 17.3 mm Hg in the IV group (P = .0001). Postoperative SBP was 130.8 ± 12.9 mm Hg in the MKO group and 135.8 ± 19.3 mm Hg in the IV group (P < .01). Postoperative heart rate was 66.3 ± 10.4 bpm in the MKO group compared with 69.8 ± 10.5 bpm in the IV group (P < .001). No other clinically and statistically significant differences were found. The mean number of melts used was 1.5. Clinically and statistically significant improvements in preoperative and postoperative SBP and postoperative heart rate were observed in patients who received MKO Melt. The MKO Melt was safe, effective, and well tolerated and a viable alternative to IV sedation.

592 - Postoperative renal impairment and longitudinal change in renal function after adrenalectomy in patients with Cushing’s syndrome

Objectives To evaluate the renal function after adrenalectomy in patients with Cushing's syndrome in comparison with that in patients with primary aldosteronism. Methods This retrospective study included 35 patients with Cushing's syndrome and 51 patients with primary aldosteronism who underwent unilateral adrenalectomy and were followed up for >6 months. The renal function was analyzed before and after adrenalectomy using the estimated glomerular filtration rate. Postoperative renal impairment was defined as a >25% reduction in the estimated glomerular filtration rate from baseline at 1 month after adrenalectomy. Multivariate logistic regression analyses were carried out to examine whether the differences between Cushing's syndrome and primary aldosteronism increased the risk of postoperative renal impairment. Longitudinal changes were calculated starting 1 month after adrenalectomy using the linear mixed model. Results The mean estimated glomerular filtration rate in both groups significantly decreased at 1 month after adrenalectomy from baseline. Postoperative renal impairment was observed in four (11%) and 12 (24%) patients in the Cushing's syndrome and primary aldosteronism groups, respectively. Multivariate analysis showed that preoperative systolic blood pressure was independently associated with postoperative renal impairment, but not with the type of the disease. There was no significant increase or decrease in postoperative estimated glomerular filtration rate observed after the initial decrease after adrenalectomy in either group. Conclusions Patients with Cushing's syndrome show the same persistent renal impairment after adrenalectomy as that reported in patients with primary aldosteronism. Attention should be given to possible masked renal damage in clinical practice for the management of Cushing's syndrome.

Outcomes of Chimney or Snorkel Endovascular Repair for Symptomatic and Ruptured Abdominal Aortic Aneurysms

Symptomatic and ruptured abdominal aortic aneurysms (AAAs) are increasingly managed with endovascular aneurysm repair (EVAR). We aimed to identify the 30-day outcomes of symptomatic and ruptured AAAs that underwent EVAR with chimney or snorkel techniques (Ch-EVAR). A retrospective cohort study was performed using the Vascular Quality Initiative registry from March 2013 to July 2019. All patients with symptomatic and ruptured AAAs with proximal aortic zone of disease from 6 through 9 who underwent Ch-EVAR were included. Outcomes were analyzed per the Society for Vascular Surgery reporting standards for EVAR. Ch-EVAR was performed in 77 patients (35 [45.5%] ruptures, 42 [54.5%] symptomatic). Median age was 73 (interquartile range [IQR], 67-81) years, and 54 (70.1%) patients were male. Maximum aneurysm diameter was 67.5 (IQR, 54.5-83.3) mm. All patients were assigned to American Society of Anesthesiologists class 3 or above, with 56 (72.7%) class 4. Among ruptured AAAs, the mean lowest preoperative systolic blood pressure was 95.3 (±29.3) mm Hg. Fluoroscopy time was 57.4 (IQR, 41.2-79.0) minutes. The proximal aortic zone of disease was zone 6 in 9 (11.7%), zone 7 in 21 (27.3%), zone 8 in 36 (46.8%), and zone 9 in 11 (14.3%) patients. Ch-EVAR involved one vessel in 28 (36.4%) patients, two vessels in 22 (9.1%) patients, three vessels in 19 (24.7%) patients, and four vessels in 8 (10.4%) patients. Configurations of the Ch-EVAR are shown in Table I. Technical success was achieved in 67 (87.0%) patients. Outcomes of symptomatic and ruptured Ch-EVAR are summarized in Table II. Reintervention was required in 10 (13.0%) patients at a median time of 9 postoperative days. This involved the aorta/chimneys in five (6.5%) patients, access ischemia in one (1.3%), complete device removal in one (1.3%), new stent placement in two (2.6%), and glue repair of endoleak in one (1.3%). Postoperatively, 31 (40.3%) patients had a major complication, including 4 (5.2%) access site hematomas, 1 (1.3%) access site occlusion, 2 (2.6%) strokes, 2 (2.6%) pneumonias, 5 (6.5%) reintubations, 8 (10.4%) renal ischemia, 11 (14.3%) postoperative dialysis, 4 (5.2%) intestinal ischemia, 3 (3.9%) leg ischemia, and 1 (1.3%) leg compartment syndrome. Ch-EVAR for symptomatic and ruptured AAAs may be performed with acceptable rates of morbidity and mortality. Long-term data are needed to determine durability.Table IConfigurations of Ch-EVARConfigurationNumber of patients (n = 77) (%)Bilateral Renal10 (13.0)Left Renal11 (14.3)Right Renal10 (13.0)SMA, Bilateral Renal16 (20.8)SMA, Left Renal4 (5.2)SMA, Right Renal5 (6.5)SMA7 (9.1)Celiac, SMA3 (3.9)Celiac, SMA, Left Renal3 (3.9)Celiac, SMA, Bilateral Renal8 (10.4) Open table in a new tab Table IIComparison between ruptured and symptomatic Ch-EVAROutcomeRuptured (n = 35)Symptomatic (n = 42)Overall (n = 77)P-valueMortality4 (11.4%)3 (7.1%)7 (9.1%).695Converted to Open Procedure1 (2.9%)1 (2.4%)2 (2.6%)1.000Type 1 Endoleak7 (20.0%)2 (4.8%)9 (11.7%).071Type 2 Endoleak0 (0.0%)4 (9.52%)4 (5.2%).121Type 3 Endoleak0 (0.0%)1 (2.4%)1 (1.3%)1.000Postoperative length of stay (days)13.67.610.3.110Number of vessels stented1.82.32.1.038 Open table in a new tab

Direct Distal Renal Artery Aneurysm Repair

Treatment of renal artery aneurysms (RAA) remains controversial. Endovascular treatment has increased for main trunk and for very distal aneurysms, whereas for lesions located at the bifurcation surgical treatment seems to be a valid option. The goal of this study was to describe the technique of direct reconstruction of RAA and to report on outcomes. This study comprised single centre prospective collection of data with retrospective analysis (January 2015 to August 2018) of patients operated on for distal RAA using direct reconstruction. A total of 24 RAA in 21 patients (seven men and 14 women, mean age 59±13 years) was included. History of hypertension was found in 15 patients and renal insufficiency was present in one. Mean pre-operative systolic and diastolic blood pressures were 134±21mmHg and 74±10mmHg, and mean pre-operative rates of creatinine and glomerular filtration rate were 67±13μmol/L and 93±49mL/min/1.73m2, respectively. Indications for repair were a diameter >20mm in seven cases (mean diameter=25±2mm) or rapid growth in one case, symptomatic aneurysm in 12 cases (hypertension, haematuria, pain), and a concomitant lesion in four cases (splenic aneurysm, abdominal aortic aneurysm, occlusive visceral artery lesions). All lesions were distal, main artery bifurcation in 22 cases and hilar in two cases. The main aetiology was fibromuscular dysplasia (16 cases) followed by atherosclerosis (seven cases) and one case of Ehlers Danlos Syndrome. In situ reconstruction was possible for 22 RAA, while two cases required kidney autotransplantation. The mean renal ischaemia time was 18±5min. At two years, the patency rate was 100%, and mean systolic blood pressure decreased (134mmHg-122mmHg, p=.047). Renal function was stable from 93±49 pre-operatively to 95±35mL/min/1.73m2 in the post-operative course (p=.56). Direct reconstruction appears to be efficient for most RAA. This technique is complementary to exvivo autotransplantation and endovascular treatment.

Postoperative renal impairment and longitudinal change in renal function after adrenalectomy in patients with Cushing's syndrome.

To evaluate the renal function after adrenalectomy in patients with Cushing's syndrome in comparison with that in patients with primary aldosteronism. This retrospective study included 35 patients with Cushing's syndrome and 51 patients with primary aldosteronism who underwent unilateral adrenalectomy and were followed up for >6months. The renal function was analyzed before and after adrenalectomy using the estimated glomerular filtration rate. Postoperative renal impairment was defined as a >25% reduction in the estimated glomerular filtration rate from baseline at 1month after adrenalectomy. Multivariate logistic regression analyses were carried out to examine whether the differences between Cushing's syndrome and primary aldosteronism increased the risk of postoperative renal impairment. Longitudinal changes were calculated starting 1month after adrenalectomy using the linear mixed model. The mean estimated glomerular filtration rate in both groups significantly decreased at 1month after adrenalectomy from baseline. Postoperative renal impairment was observed in four (11%) and 12 (24%) patients in the Cushing's syndrome and primary aldosteronism groups, respectively. Multivariate analysis showed that preoperative systolic blood pressure was independently associated with postoperative renal impairment, but not with the type of the disease. There was no significant increase or decrease in postoperative estimated glomerular filtration rate observed after the initial decrease after adrenalectomy in either group. Patients with Cushing's syndrome show the same persistent renal impairment after adrenalectomy as that reported in patients with primary aldosteronism. Attention should be given to possible masked renal damage in clinical practice for the management of Cushing's syndrome.

Factors associated with mortality in patients with peritonitis presenting for anesthesia and surgery in a tertiary center in Nigeria - A cross-sectional study

Background: Peritonitis is one of the surgical emergencies commonly encountered by the general surgeons. Sepsis, dehydration, hypovolemia, and multiple organ dysfunctions have been associated with high mortality rate. The study aimed to assess risk factors associated with mortality in patients with peritonitis presenting for anesthesia and surgery in a tertiary institution. Methods: We conducted a prospective cross-sectional study involving consenting patients managed for peritonitis under general anesthesia over a year period. A study proforma was used to collect the data on demographic characteristics and clinical and biochemical parameters. The association between postoperative mortality and demographic characteristics and clinical and biochemical parameters was determined with Chi-square test, and the level of significance was set at P < 0.05. Results: A total of 52 adult patients were studied with 38 (73.1%) males and 14 (26.9%) females. The mean age was 39.7 ± 15.3 years. Nineteen patients died, and the mortality rate was 36.5%. Mortality was more in females and in patients more than 50 years (P = 0.917 and P = 0.34), respectively. Preoperative high American Society of Anesthesiologists (ASAs) physical status (P = 0.002), higher Mannheim Peritonitis Index (MPI) scores (P = 0.005), preoperative systolic blood pressure <100 mmHg (P = 0.006) and preoperative respiratory rate more than 30 breaths/min (P = 0.002), serum creatinine level more than 1.5 (P = 0.04), and acidosis (P = 0.02) were statistically significant risk factors for mortality in this study. Conclusion: The mortality following perforation peritonitis is high in our center. Poor outcome is seen in patients with high ASA status, high MPI scores, preoperative shock, acidosis, renal failure, and tachypnea. Proper resuscitation from shock, correction of acidosis, and improving the ASA status will improve survival in patients with perforated peritonitis.

Effect of Phenylephrine and Ephedrine on Cerebral (Tissue) Oxygen Saturation During Carotid Endarterectomy (PEPPER): A Randomized Controlled Trail

Introduction - Adequate blood pressure during carotid endarterectomy (CEA) is essential to preserve cerebral perfusion. To achieve and maintain adequate blood pressure intraoperative, short-acting vasopressor agents like phenylephrine or ephedrine can be used. Previous studies in healthy subjects revealed that besides a systemic hemodynamic effect, these vasopressors also affected frontal lobe cerebral tissue oxygenation (ScO2) showing a decrease after administration of phenylephrine.1,2 This decrease in ScO2 after phenylephrine administration is unwarranted in patients with jeopardized cerebral perfusion, like CEA patients. The aim of this study was to evaluate the impact of both phenylephrine and ephedrine on ScO2 during CEA. Methods - In this double blinded randomized controlled trial 29 patients underwent CEA under general anesthesia for > 70% symptomatic or asymptomatic stenosis. This number of patients matches the number of subjects required according to the power calculation, which suggested 14 patients for each vasopressor study arm.3 Patients were preoperative allocated randomly (1:1) by computer-generated randomization for receiving either phenylephrine or ephedrine in case intraoperative hypotension occurs. During CEA mean arterial pressure (MAP) was measured by radial artery line, placed on the arm with the highest preoperative systolic blood pressure. In case of a decreased MAP ³20% compared to (awake) baseline, patients received a bolus of either phenylephrine (50μg; N=14) or ephedrine (5mg; N=15). After administration the MAP, cardiac output, heart rate, stroke volume and ScO2 were measured. The chosen timeframe for data analysis was 120 seconds before, until 300 seconds after administration. Results - Both phenylephrine (70±9 to 99±22 mmHg; P<0.001; mean±SD) and ephedrine (75±11 mmHg to 109±19 mmHg; P<0.01) adequately restored the MAP. Heart rate did not change significantly after infusion of both vasopressors. However cardiac output was raised after administration of both, 15% and 14% for phenylephrine and ephedrine respectively. ScO2 did not change significantly after administration of either phenylephrine or ephedrine (from 73% to 71% and 72% to 71% respectively). Conclusion - Within this randomized prospective study, we did not observe a different response in ScO2 when MAP was corrected by either phenylephrine or ephedrine in patients who underwent CEA.

Operative Mortality and Morbidity in Ruptured Abdominal Aortic Aneurysms in the Endovascular Age

Controversy exists about technique of repair for ruptured abdominal aortic aneurysms (rAAA). We studied rAAA treated at a single tertiary center from 2005 to 2015 to determine operative morbidity and mortality in open and endovascular aortic aneurysm repair (EVAR) of rAAA. All rAAA (n=144) treated from 2005 to 2015 were reviewed using an IRB-approved database. "EVAR first" strategy was used after 2010. rAAA treatment was open (rAAA began with open surgery); EVAR (rAAA began with EVAR and included EVARs converted to open); and EVAR only (successful EVAR). Preoperative, intraoperative and outcome variables were analyzed with t-test, chi-square and logistic and multivariate regression using SAS. One hundred forty-four rAAAs were treated from 2005 to 2015. Seventy-five percent (108/144) began with open surgery. Twenty-five percent (36/144) began with EVAR. After 2010, 54.5% began with EVAR. Eleven percent of EVARs (4/36) converted to open and 89% (32/36) had EVAR only. Fifty-nine percent (83/144) had preoperative systolic blood pressure (SBP)<90mm Hg. Eighty-four percent of these (70/83) had open surgery and 16% (13/83) had EVAR. Hospital mortality for all rAAAs was 23.6% (34/144). Operative mortality was 25% (27/108) in open and 19.4% (7/36) in EVAR (P=0.486). Mortality was 75% (3/4) in EVARs that converted to open and 12.5% (4/32) in EVAR only patients. In univariate analysis age, ASA 5, preoperative SBP <90mm Hg, intraoperative complications, dialysis, MI/CHF, respiratory failure, stroke and reintervention were significant for mortality. In multivariate modeling preoperative SBP <90mm Hg (P=0.0018), ASA 5 (P=0.0175), intraoperative complications (P=0.0017), MI/CHF (P=0.0045), respiratory failure (P=0.0159) and new renal failure (P=0.0073) were significant for mortality. There was no difference in mortality between open and EVAR (P=0.9554) and no difference in cardiac or respiratory failure. Open had more renal failure and EVAR more endoleaks. Fifty-eight percent (21/36) of EVARs started with local anesthesia (LA) and 52.8% (19/36) finished with LA. Nineteen percent (4/21) of EVARs with LA versus 60% (9/15) with general anesthesia (GA) had preoperative SBP<90mm Hg. In EVAR only there was no difference in mortality between LA (4/18, 22.2%) and GA (3/14, 21.4%) (P=0.94). Operative mortality in ruptured AAA was associated with hypotension, ASA status 5, uncontrolled hemorrhage, cardiac events, and respiratory failure but not with type of repair. EVAR and open surgery also had comparable cardiac and respiratory morbidity. Selection was critical in EVAR for rAAA because mortality of unsuccessful EVAR was very high. There was no difference in mortality between LA and GA for EVAR.

Results of a Preventive Rebleeding Protocol in Patients with Ruptured Cerebral Aneurysm: A Retrospective Cohort Study.

Objective:In 2015, a protocol to prevent rebleeding was implemented to improve the outcome of patients with ruptured intracranial aneurysm. We performed a single-center retrospective analysis to compare the outcomes of pre/post using protocol.Methodology:Over a 3-year period, 208 patients with ruptured cerebral aneurysm were treated at our institution. The protocol for preventing rebleeding was initiated in 2015. We compared the two cohorts between the group of patients before initiating the protocol (n = 104) and after initiating the protocol (n = 104). We analyzed the protocol for preventing rebleeding which consisted of absolute bed rest, adequate pain control, avoiding stimuli (R), keeping euvolemia (E), preoperative systolic blood pressure <160 mmHg and within 140–180 mmHg after definite treatment (S), a short course (<72 h) of intravenous transaminic acid, and aneurysm treatment as early as possible (T). Outcomes are presented as in-hospital rebleeding, delayed cerebral ischemia (DCI), and proportion of unfavorable outcomes (score of 4–6 on a modified Rankin scale at 6 and 12 months).Results:Postprotocol, there was a reduction in the incidence of in-hospital rebleeding from 6.7% to 2.8% (P = 0.20, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.10–1.63) and in the proportion of patients who presented with good WFNS grades (1–3) with unfavorable clinical outcomes at 12 months from 27.0% to 12.8% (P = 0.03, OR = 0.40, 95% CI = 0.17–0.95). The DCI experienced a significant reduction from 44.2% to 7.7% (P < 0.001, OR = 0.10, 95% CI = 0.04–0.23), and their 180-day mortality rate in good WFNS grades patients decreased from 16.3% to 8.8% (hazard ratio 0.80, 95% CI = 0.28–2.28).Conclusion:Ruptured cerebral aneurysm patients benefit from this protocol due to its ability to reduce the incidence of DCI and reduce unfavorable outcome on good WFNS grade patients.

The Results of Surgical Treatment of Hypertension in Mild and Moderate Obstructive Sleep Apnea Syndrome

Background: Obstructive sleep apnea syndrome (OSAS) is the most common respiratory disorder related to sleep. It is characterized by recurrent upper airway obstruction episodes and a decrease in arterial oxygen saturation during sleep. The most important complications of OSAS are related to the cardiovascular system. Hypertension (30% - 60%) is the leading cause of these complications. Objectives: This study aimed to investigate the removal of upper airway obstruction through surgical operations in the tension treatment of OSAS patients with hypertension. Methods: This retrospective study included 42 patients with hypertension from 2008 to 2017 who were diagnosed with OSAS based on the result of polysomnogram (PSG) test. All the patients were examined in detail in otorhinolaryngology and cardiology clinics, their endoscopic and imaging evaluations were carried out and their blood pressure was followed-up. Preoperative and postoperative arterial blood pressure values for upper airway obstruction were statistically analyzed. Results: The mean preoperative systolic and diastolic arterial blood pressure values of the patients with hypertension were 152.3 ± 21.2 and 97.2 ± 12.3 mmHg, respectively. Their postoperative systolic and diastolic arterial blood pressure levels were found to be 124.5 ± 19.3 and 86.4 ± 12.1 mmHg, respectively (P < 0.05). This decrease in the arterial blood pressure was significant. Conclusions: Removal of upper airway obstruction through a surgical operation was found to play an important role in the blood pressure treatment of OSAS patients with hypertension.

Clinical outcomes of postcarotid endarterectomy hypertension

ObjectiveThe objective of this study was to determine the clinical relevance of postcarotid endarterectomy hypertension (PEH) by investigating the effect of PEH on hospital length of stay (LOS) and by investigating short-term and long-term complications of PEH. In addition, risk factors for PEH were determined. MethodsA single-center retrospective cohort study was performed. Demographic, preoperative, intraoperative, and postoperative outcomes of 192 patients undergoing carotid endarterectomy were evaluated. Outcomes were compared between patients with PEH and patients without PEH. PEH was defined as an acute systolic blood pressure (SBP) rise >170 mm Hg or persistent SBP >150 mm Hg on the ward and leading to the consultation of an internist. The overall survival and event-free survival were compared using a Kaplan-Meier analysis and a Cox regression analysis. A multivariate logistic regression analysis was performed to determine risk factors for PEH. ResultsPEH developed in 44 of 192 patients (25%). Preoperative hypertension (SBP >150 mm Hg) was determined to be a risk factor for PEH (odds ratio, 3.3; 95% confidence interval [CI], 1.6-6.9). Hospital LOS was prolonged in patients with PEH compared with patients without PEH (median LOS of 5 days vs 3 days, respectively; P < .001). No difference in the occurrence of ischemic neurologic events or rebleeding during hospitalization was observed (P = .58 and P = .72, respectively). Cardiovascular and ischemic neurologic events during follow-up did not occur more often in patients with PEH than in patients without PEH (P = .46). There was no difference in mortality between the PEH and non-PEH groups (hazard ratio, 1.6; 95% CI, 0.6-4.3). The same applies to the event-free survival (hazard ratio, 0.77; 95% CI, 0.4-1.7). Combined event-free survival for stroke and myocardial infarction was 92% (95% CI, 87%-97%) at 2 years for patients without PEH and 86% (95% CI, 74%-98%) at 2 years for patients with PEH (P = .25). Event-free survival for mortality was 90% (95% CI, 85%-96%) at 2 years for patients without PEH and 94% (95% CI, 86%-100%) at 2 years for patients with PEH (P = .36). ConclusionsPatients with PEH had a significant increase in hospital LOS. However, adverse short-term and long-term events did not occur more often in patients with PEH. High preoperative SBP was identified as a risk factor for PEH; no other demographic and clinical variables were associated with PEH.

Analysis of clinical characteristics for hypertensive attack during pheochromocytoma and paraganglioma operation: a single center case report of 219 cases

Objective To analyze the clinical characteristics for hypertensive attack during operation and clinical experience of preoperative evaluation and preparation in patients with pheochromocytoma and paraganglioma(PHEO/PGL). Methods A total 219 PHEO/PGL cases from September 2016 to September 2018 were retrospectively reviewed. It included 99 males and 120 females, aged 13 to 76(average 47)years old.The mean diameter of tumor was 5.3 cm(1.5-18.0 cm).140 cases were unilateral PHEO, 6 cases were bilateral PHEO, 68 cases were PGL(jugular, mediaphragm, heart, retroperitoneum, pelvic and bladder) and 5 cases were PHEO combined with PGL. Preoperative highest systolic blood pressure (SBP)was 240 mmHg(1 mmHg=0.133 kPa) and highest diastolic blood pressure(DBP) was 160 mmHg. 20 cases were occult PHEO without hypertension. 217 cases accepted preoperative preparation of alpha-blocker [phenoxy-benzamine, dosage ranging from 5 mg Q12h to 40 mg Q8h, maximum dosage not exceeding 1 mg/(kg·24 h)]. 2 cases did not accept preoperative preparation. All cases accepted open or endoscope surgery. The patients were divided into 2 groups depending on the presence or absence of hypertensive attack at the time of surgery. Patient demographic characteristics and preoperative evaluations were assessed for their prognostic relevance with respect to hypertensive attack. Results Histopathological results showed that all cases were PHEO or PGL, while 205 cases were benign, 14 cases were malignant. Hypertensive attack were recorded in 112 cases(51%). The diameter of tumors in the hypertensive attack group were larger than that in the non-hypertensive attack group[(6.70±2.95)cm vs.(3.95±1.70)cm, P=0.005]. There was no significant difference between the two groups among age[(51.0±10.8)years vs.(38.5±17.6)years, P=0.105], preoperative catecholamine level [norepinephrine (111.20±41.49)μg/24 h vs.(419.15±154.81)μg/24 h, P=0.075], time of use of alpha blockers[(53.0±7.5)d vs.(38.0±6.4)d, P=0.139], daily dosage of alpha blocker[(40.0±7.2)mg vs.(27.1±1.8)mg, P=0.111] and blood pressure at diagnosis[(173.75±26.69)mmHg vs.(155.0±20.75)mmHg, P=0.139]. Among 219 cases, 2 case had emergency hemostasis after operation, 1 case had catecholamine cardiomyopathy after operation for occult pheochromocytoma, and no perioperative death occurred. Conclusions Patients with large tumor tend to have hypertensive attack during operation so that should be better prepared. Key words: Pheochromocytoma; Paraganglioma; Alpha-blockade; Hypertension

Effect of preoperative education on anxiety in children undergoing day-care surgery.

Background and Aims:There have been various methods tested for reducing preoperative anxiety in children, but very limited literature is available in the Indian scenario. Our aim was to analyse the effect of an informative video about the anaesthetic technique on preoperative anxiety in children.Methods:In all, 94 children were randomly allotted into two groups. Children in the study group were shown a peer modelling video depicting induction of general anaesthesia and recovery during the preanaesthetic check (PAC). Patients in the control group were given only verbal information during PAC. Anxiety was assessed on visual analog scale (VAS) for anxiety at two times. Baseline VAS score was recorded during PAC and preoperative VAS score was assessed prior to induction of anaesthesia. The VAS score was represented as median value. Data were analysed using the Mann–Whitney U-test for ordinal data and skewed quantitative data. Categorical data was analysed by using Chi-square test and t-test was applied for quantitative data. The significance threshold of P value was set at <0.05.Results:The median (interquartile range) preoperative VAS score was significantly lower in the study group [1 (0–1.3)] when compared with the control group [5 (3–5)] (P < 0.001). The mean preoperative pulse rate, mean preoperative systolic blood pressure and mean preoperative diastolic blood pressure were significantly lower in the study group when compared with the control group (P < 0.001).Conclusion:Multimedia information in the form of a peer modelling video helped reduce preoperative anxiety in children between 7 and 12 years of age.

Impact of lumbar hypolordosis on the incidence of symptomatic postoperative spinal epidural hematoma after decompression surgery for lumbar spinal canal stenosis.

Potential associations between radiographic parameters and the incidence of symptomatic postoperative spinal epidural hematoma (PSEH) have not been identified. This study aimed to identify risk factors including radiographic parameters for symptomatic PSEH after posterior decompression surgery for lumbar spinal canal stenosis (LSS). We retrospectively reviewed 1007 consecutive patients who underwent lumbar decompression surgery for lumbar spinal canal stenosis (LSS) at our institution. We identified 35 cases of symptomatic PSEH, defined by clinical symptoms and MRI findings, and selected 3 or 4 age- and sex-matched control subjects for each PSEH subject (124 controls). We compared radiographic parameters and previously reported risk factors between PSEH and control subjects. Compared to the control group, PSEH patients had significantly higher preoperative systolic (p = .020) and diastolic (p = .048) blood pressure, and more levels of decompression (p = .001). PSEH and control subjects had significant differences in lumbar lordosis (PSEH 24.8° ± 14.6°, control 34.8° ± 14.5°), pelvic tilt (25.1° ± 11.7° vs. 20.8° ± 8.4°), sacral slope (23.4° ± 9.4° vs. 27.6° ± 8.3°), and pelvic incidence minus lumbar lordosis (23.7° ± 15.0° vs. 13.7° ± 14.6°). Multivariate analysis revealed two significant risk factors for PSEH: decompression of two or more levels and lumbar lordosis < 25°. Multilevel decompression and hypolordosis are significant risk factors for symptomatic PSEH after decompression surgery for LSS. LSS patients with lumbar hypolordosis or multilevel stenosis should be carefully observed for PSEH after decompression surgery. These slides can be retrieved under Electronic Supplementary Material.

Short-term outcomes after emergency surgery for complicated peptic ulcer disease from the UK National Emergency Laparotomy Audit: a cohort study

ObjectivesThis study used national audit data to describe current management and outcomes of patients undergoing surgery for complications of peptic ulcer disease (PUD), including perforation and bleeding. It was also...

The Association Between Common Clinical Characteristics and Postoperative Morbidity and Overall Survival in Patients with Glioblastoma.

The impact of noncancerous factors on the morbidity and mortality of glioblastoma multiforme (GBM) has not been well studied. Using a large surgical cohort, we examined the association between multiple clinical characteristics and postoperative morbidities and survival in patients with GBM. The study included 404 consecutive GBM patients who underwent initial tumor resection at MD Anderson Cancer Center between January 1, 2010, and December 31, 2014. Data about clinical characteristics, treatments, and postoperative complications were collected. The associations between clinical parameters and postoperative complications and survival were analyzed. Charlson Comorbidity Index was positively related to a higher incidence of postoperative total (odds ratio [OR] = 1.20; p = .002) and neurological (OR = 1.18; p = .011) complications. Preoperative systolic blood pressure (SBp) over 140 mmHg was associated with a higher incidence of postoperative intracranial hemorrhage (OR = 4.42; p = .039) and longer hospital stay (OR = 2.48; p = .015). Greater postoperative fluctuation of SBp (OR = 1.14; p = .025) and blood glucose (mmol/L; OR = 1.48; p = .023) were related to a higher incidence of neurological complications, whereas higher postoperative blood glucose (OR = 0.64; p < .001) was related to a lower incidence. Long-term lower SBp (<124 mmHg; hazard ratio [HR] = 1.47; p = .010) and higher blood glucose (HR = 1.12; p < .001) were associated with shorter survival. Long-term serum albumin level (g/dL; HR = 0.32; p < .001) was positively associated with survival. Short-term SBp and blood glucose levels and fluctuations are associated with postoperative complications in GBM patients. Their long-term optimization may impact survival of these patients. Future clinical trials are needed to confirm the benefit of optimizing medical comorbidities on GBM patients' outcomes. Glioblastoma multiforme (GBM) is one of the most feared cancer diagnoses because of its limited survival and treatment. This study revealed significant associations of noncancerous factors on the morbidity and mortality of GBM. The complexity of medical comorbidities, as well as short-term postoperative levels and fluctuations of blood pressure and blood glucose, was associated with postoperative complications, but not overall survival. However, long-term levels of these common clinical parameters were significantly associated with survival. Optimization of medical conditions may be critical for reducing the morbidity and mortality of GBM patients. Future clinical trials are needed to validate the observed associations in an independent cohort.

Close-loop Administration System Based on Bispectral Index for Anesthesia of ERCP

Objectives: To analyse the safety and efficacy of venous propofol sedation with closeloop administration system based on bispectral index (BIS) in elderly patients during endoscopic retrograde electroencephalography (ERCP). Methods: Selected 150 consecutive elderly patients undergoing EPCP procedures, anesthesia by propofol sedation of close-loop administration system with BIS target at 60. Patients were divided into 3 groups according to their age: group A, 50-70 years old (n=50); group B, aged 71-80 (n=50); group C, older than 80 years (n=50). Propofol dosage and adverse events (hypotension and hypoxaemia) during ERCP were the prime data to be recorded. Results: Lower target concentration of propofol might be more suitable for older patients. Median target concentration are respectively 2.6μg/mL,2.1μg/mL and 1.6μg/mL for the three groups. Hypo-tension is more commonly happened in the younger group, and the incidence of hypoxaemia is significantly higher in the older groups, although the amount of adverse events was small. Low preoperative systolic blood pressure (<80 mm Hg) was more possible turned into perioperative hypo-tension, patients with abnormal pulmonary function was associated with hypoxaemia in groups B and C. Conclusions: Close-loop administration system is stable and dependable for intravenous anesthesia for ERCP. Lower dosage of propofol is suitable for elderly patients with the same target BIS of 60 More attention of hypoxaemia should be paid to the elderly patients, particularly with abnormal pulmonary function.

Efficacy of coarctation resection and aortoplasty with autologous pulmonary artery patch strategy for treating coarctation of the aorta combined with hypoplastic aortic arch in infants

Objective: To investigate the outcomes of coarctation resection and aortoplasty with autologous pulmonary artery patch for treating coarctation of the aorta combined with hypoplastic aortic arch in infants. Methods: Clinical data of 21 infants with coarctation of the aorta and hypoplastic aortic arch, who underwent coarctation resection and aortoplasty with autologous pulmonary artery patch in Fuwai hospital from January 2009 to June 2016 were retrospectively analyzed. The age of the patients was 4 (2, 5) months,and the body weight of the patients was (5.3±1.6) kg. The patients were followed up to observe the surgery effect. Results: No perioperative death and serious complications occurred. When the patients were discharged,the systolic blood pressure of the right upper limb was lower than the preoperative systolic blood pressure ((85.7±5.9) mmHg(1 mmHg=0.133 kPa) vs. (100.7±16.6) mmHg, P<0.001),and the systolic blood pressure of the right lower limb was higher than the preoperative systolic blood pressure ((98.7±13.3) mmHg vs. (85.6±20.8) mmHg, P<0.001). The pressure gradient of aortic coarctation detected by echocardiography was lower than the preoperative pressure gradient ((13.1±3.8) mmHg vs. (46.2±17.1) mmHg, P<0.001). No restenosis was detected by echocardiography at discharge. Follow-up data were obtained in 19 patients, and the follow-up time was 18 (8, 45) months.The patients grew well, and no death occurred. Restenosis occurred in 3 cases, 1 patient underwent aortic balloon dilatation and the remaining 2 patients were under follow up observation. Computed tomography angiography showed that the morphology of aortic arch was normal without signs of aortic aneurysm. Conclusion: Coarctation resection with autologous pulmonary artery patch aortoplastystrategy is considered as a safe and effective surgical method for management of infant coarctation with hypoplastic aortic arch, and this surgery method is related with satisfactory early and mid-term outcomes in this patient cohort.

Preoperative risk factors for haemodynamic instability during pheochromocytoma surgery in Chinese patients.

Pheochromocytoma surgery carries a high risk of haemodynamic instability (HI). However, there are few studies investigating the risk factors for HI for pheochromocytoma surgery in a Chinese population. Therefore, our objective was to identify preoperative risk factors for HI during surgery in a Chinese population with pheochromocytoma. In this retrospective study, 134 patients undergoing surgery for pheochromocytoma at a single university-affiliated hospital between November 2002 and July 2017 were enrolled. Demographics, comorbidities, preoperative medical preparation, operation details and perioperative haemodynamics of these patients were retrospectively collected and analysed. Multivariable logistic regression analysis was performed to identify the preoperative risk factors for intraoperative HI. 32.8% (44/134) patients suffered from intraoperative HI. According to the result of multivariate analysis, tumour diameter >50mm (odds ratio [OR] 2.526; 95% confidence interval [CI] 1.163-5.485; P=.019), diabetes/prediabetes (OR 2.251; 95% CI 1.039-4.876; P=.040) and preoperative systolic blood pressure fluctuation >50mm Hg (OR 3.163; 95% CI 1.051-9.522, P=.041) were independent predictors for intraoperative HI. The observed incidence of HI was 8.9%, 42.6%, 47.8% and 60% when zero, one, two or three risk factors were present, respectively. HI is common among Chinese patients undergoing surgery for pheochromocytoma. Our study identified three predictive factors for intraoperative HI: a large tumour diameter, diabetes/prediabetes and a great preoperative systolic blood pressure fluctuation. Furthermore, patients are more likely to suffer from HI when they have more predictive risk factors. Identification of these risk factors can help to improve perioperative management.