Significant Cardiopulmonary Comorbidities Research Articles

Perioperative morbidity and 3-year survival in non-intubated thoracoscopic surgery: a propensity matched analysis.

Non-intubated thoracoscopic surgery with spontaneous breathing is rarely utilized, but may have several advantages over standard intubation, especially in those with significant cardiopulmonary comorbidities. In this study we evaluate the safety, feasibility, and 3-year survival of thoracoscopic surgery without endotracheal intubation for oncologic and non-oncologic indications. All consecutive patients [2018-2022] selected for lung resection or other pleural space intervention under local anesthesia and sedation were compared to a cohort undergoing elective thoracoscopic procedures with endotracheal intubation. A propensity-score matched cohort was used to compare perioperative outcomes and 3-year overall survival. A total of 72 patients underwent thoracoscopic surgery without intubation compared to 1,741 who were intubated. Non-intubated procedures included 19 lobectomies (26.4%), 9 segmentectomies (12.5%), 25 wedge resections (34.7%), and 19 pleural or mediastinal resections (26.4%). Non-intubated patients had a lower average body mass index (BMI; 24.6 vs. 27.1 kg/m2, P<0.001) and a higher comorbidity burden. Primary lung cancer was the indication in 30 (41.7%) non-intubated patients. The non-intubated cohort had no operative or 30-day mortality. After propensity-score matching, there was no significant difference in pre-operative factors. In propensity-score matched analysis, non-intubated patients had shorter median total operating room time (109 vs. 159 min, P<0.001) and procedure time (69 vs. 119 min, P<0.001). Peri-operative morbidity was rare and did not differ between intubated and non-intubated patients. There was no significant difference in 3-year survival associated with non-intubation in the propensity-score matched cohorts (95% vs. 89%, P=0.10) or in a Cox proportional hazard model [hazard ratio (HR), 1.15; 95% confidence interval (CI): 0.36-3.67; P=0.81]. Non-intubated thoracoscopic surgery is safe and feasible in carefully selected patients for both benign and oncologic indications.

Abstract No. 541 Perirenal nerve plexus block in microwave ablation of stage 1 RCC: a novel application of regional anesthesia

High temperature ablation is widely accepted in treating stage 1 RCC, most commonly with radiofrequency or microwave ablation. Preferred anesthesia is MAC or general anesthesia due to associated procedural pain. Given the need for prone or semi-lateral positioning and the often significant cardiopulmonary comorbidities in the RCC population, an alternative method of achieving safe anesthesia while alleviating procedural discomfort is proposed: perirenal nerve plexus block.

Evaluating consumer and clinical sleep technologies: an American Academy of Sleep Medicine update

Evaluating consumer and clinical sleep technologies: an American Academy of Sleep Medicine update

Is outpatient shoulder arthroplasty safe in patients aged ≥65 years? A comparison of readmissions and complications in inpatient and outpatient settings.

Recent studies indicate that outpatient total shoulder arthroplasty (TSA) is cost-effective and may have a low complication rate similar to inpatient TSA. However, existing studies have included younger patient cohorts who typically possess fewer medical comorbidities. Patients aged ≥65 years are commonly enrolled in Medicare, which has traditionally designated TSA as an inpatient-only procedure. The purpose of this study was to compare surgical complication rates and 90-day readmission rates between inpatient and outpatient TSA performed in adults aged ≥65 years. Medical records for all patients aged ≥65 years who underwent primary anatomic or reverse TSA by a single surgeon from July 2015 to May 2020 were reviewed. Patients were preselected for outpatient or inpatient surgery based on lack of significant cardiopulmonary comorbidities and patient preference. Demographics, body mass index (BMI), and American Society of Anesthesiologists (ASA) scores were collected in addition to emergency department (ED) visits and readmissions within 90 days of the index surgery. Relationships among frequency and types of complications and surgical setting (inpatients vs. outpatient) were assessed. Complication rates and demographic variables between inpatient and outpatient procedures were compared. Logistic regressions were performed to account for interacting predictor variables on the odds of having complications. A total of 145 shoulders (138 patients; 95 male, 43 female) were included in the analysis, of which 98 received inpatient TSA and 47 received outpatient TSA. Average age was 75.5 ± 7.2 for inpatient TSA and 70.5 ± 4.5 for outpatient TSA (P < .001). Patient age (P < .001), ASA score ≥3 (P < .001), and reverse TSA (P = .002) were significantly positively correlated with receiving inpatient surgery. There were 16 complications (16.3%) in the inpatient group and 9 complications (19.1%) in the outpatient group (P = .648). There were no significant differences in the frequency of postoperative complications, return to the ED, or reoperations between inpatient and outpatient procedures (P > .05). Each 1-year increase in age increased the predicted odds of having a surgical complication by 14% (odds ratio = 1.14; P = .021), irrespective of surgical setting. Those who underwent inpatient TSA had a significantly higher frequency of 90-day readmission (inpatient=16, outpatient=1; P = .034). Postoperative complications and ED returns were not significantly different between inpatient and outpatient TSA. Each 1-year increase in age increased the odds of postoperative surgical complications by 14%, regardless of surgical setting. Outpatient TSA was found to be safe for appropriately selected patients aged ≥65 years, and re-evaluation of TSA as an inpatient-only procedure should be considered.

RIB fracture triage pathway decreases ICU utilization, pulmonary complications and hospital length of stay

IntroductionRib fractures are one of the most frequent causes of morbidity following blunt injury to the chest. Many of these patients require ICU care and often develop pulmonary complications. Prior studies have attempted to identify changes in predicted lung volumes or utilized the number of rib fractures to guide clinical decisions. A rib fracture triage pathway was developed to identify which patients will benefit from ICU level of care and shorten hospital length of stay for patients that do not require ICU care. MethodsThe triage pathway utilized patient's age, number of rib fractures, significant cardiopulmonary co-morbidities, and incentive spirometry volumes to determine admission disposition. The triage pathway was implemented on November 2016. All patients with rib fractures from November 2015 to 2017 were identified in the trauma registry. Data was collected on patients age, gender, Glasgow Coma Scale on arrival (GCS), injury severity score (ISS), number of rib fractures, incentive spirometry volumes, days in intensive care (ICU), ventilator days, length of stay (LOS), complications, and mortality. Patients with severe TBI, those arriving intubated, or died within 48 h were excluded. The patients remaining were 278 patients in the pre triage pathway group and 370 in the post triage pathway. ResultsThere was no difference in age, gender, GCS, ISS, predicted incentive spirometry or number of rib fractures. The post treatment patients required significantly lower ICU admissions (64% vs 75%, p = 0.003), significantly lower pulmonary complication (5.1% vs 10.4%, p = 0.01), and significantly shorter hospital length of stay (6.8 d vs 7.5, p = 0.001) with no difference in mortality (1.6% vs 2.5%, p = 0.42) or readmission (0.3% vs. 0.7%, p = 0.4). Patient post triage protocol were also more likely to be discharge home (81% vs 70%, p = 0.0009) with less patients going to a skilled nursing facility (13% vs 21%, p = 0.01). ConclusionsDeveloping a rib fracture treatment and triage pathway can decrease ICU and hospital resource utilization and decrease pulmonary complications without increase in readmissions or mortality. Patients are more likely to be discharge home over a skilled nursing facility further decreasing health care cost. Level of Evidence IV Retrospective Study, Prognostic

Sleep health service in China during the coronavirus disease outbreak.

Citation:Zhang XL, Xiao Y. Sleep health service in China during the COVID-19 outbreak. J Clin Sleep Med. 2020;16(7):1221–1222.

Targeted therapy of pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018

In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines and included new evidence, where available. The treatment algorithm for PAH was modified based on the observation that there are now many patients diagnosed with IPAH who are at an advanced age and have significant cardiopulmonary comorbidities. For patients newly diagnosed with classic forms of PAH, i.e. younger patients without significant cardiopulmonary comorbidities, the consensus-based recommendation was to use initial combination therapy as the standard approach. The use of monotherapies was no longer considered appropriate in such patients. The choice of treatment strategies should be based on the risk assessment as proposed in the European guidelines. In patients presenting with a low or intermediate risk, oral combination therapy with endothelin receptor antagonists and phosphodiesterase-5 inhibitors or soluble guanylate cyclase stimulators, respectively, should be used. In high-risk patients, triple combination therapy including a subcutaneous or intravenous prostacyclin analogue should be considered. For patients who suffer from PAH and significant cardiopulmonary comorbidities, initial monotherapy is recommended and the use of combination therapies should be considered on an individual basis. The latter recommendations are based on the scarcity of evidence supporting the use of combination therapy and the higher risk of drug-related adverse events in such patients.

Tonsillectomies and respiratory complications in children: A look at pre-op polysomnography risk factors and post-op admissions

ObjectiveTo identify predictors of post-operative respiratory complications in children undergoing tonsillectomy. MethodsConsecutive case series with chart review of children who underwent polysomnography (PSG) and subsequent tonsillectomy with or without adenoidectomy for obstructive sleep apnea (OSA). Patients with craniofacial anomalies or significant cardiopulmonary comorbidities were excluded. Rates of post-surgical respiratory complication were reviewed and compared to patient specific factors and PSG findings to identify possible risk factors. ResultsEighty-six patients (mean age 5.3 ± 2.2 years) were included. There was a statistically significant (p = 0.03) relationship between an AHI ≥40 (AHI40) and post-operative respiratory complications. AHI40 also had the greatest magnitude of association with postoperative respiratory complications (OR = 5.313). An AHI ≥25 (AHI25) was marginally significant (p = 0.067). No significant difference in outcome occurrence was found when analyzing rates of complication in patients with BMI above and below 18 (p = 0.20) or oxygen (O2) nadir above and below 80% (p = 0.09). The AHI ranged from 0 to 112.2, and no postoperative respiratory complications were identified in children with an AHI less than 10. ConclusionsOur results indicate an association between an AHI ≥40 and respiratory complications following an adenotonsillectomy, but we were not able to observe any significant difference at a cutoff of 25. An association between BMI or O2 nadir and postoperative respiratory complication was not able to be identified. Our results support the importance of AHI as a predictor of postoperative respiratory complications in children undergoing tonsillectomy for OSA.

Surgeon-Modified Fenestrated Endograft to Treat Ruptured Juxtarenal Aneurysm

No endovascular devices are commercially available in the United States to treat high-surgical risk patients with aneurysms extending to visceral arteries. Treatment options are even further limited for symptomatic patients in need of urgent treatment. To describe a successful urgent endovascular repair of a juxtarenal abdominal aortic aneurysm with contained rupture. A hybrid suite using a surgeon-modified fenestrated endovascular graft and advanced 3-dimensional imaging workstation. The patient was an 82-year-old veteran taking clopidogrel and aspirin for coronary stents with significant cardiopulmonary comorbidities including multiple prior abdominal surgeries and a single functional left kidney. Surgeon-modified fenestrated endovascular aortic aneurysm repair. Clinical, laboratory, and radiographic improvement. The patient was discharged 5 days after an uneventful postoperative course. On short-term follow-up, the patient had an early return to his baseline functional status. The excluded aneurysm sac shrank with patent visceral branches and there was an absence of endoleak on 3-month and 6-month surveillance computed tomography angiography. Surgeon-modified fenestrated stent grafts may be a viable option for selected high-surgical risk patients with symptomatic complex abdominal aortic aneurysms.

Midterm Outcomes After Prearteriotomy Guidewire Access (PAGA) With Antegrade Recanalization in Patients With Extensive Aortoiliofemoral Occlusive Disease Without the Use of a Re-entry Device

A prearteriotomy guidewire access (PAGA) was described to treat bulky iliofemoral occlusive disease. A wire is passed first from the groin into the aorta, before the arteriotomy, to increase technical success. Achieving retrograde intraluminal access in extensive aortoiliofemoral occlusive disease (AIFOD) can be a challenge. We modified the PAGA technique to successfully recanalize extensive aortoiliofemoral occlusion performed with adjunctive femoral artery reconstruction as an alternative to extra-anatomic bypass in high-risk patients for aortobifemoral bypass. We approach these cases via a left brachial approach and groin cutdown. Once brachial access is obtained, the patient is systematically heparinized. Then, a 90-cm destination sheath is placed in the distal aorta. A stiff glidewire and a guide catheter are used to recanalize the chronic AIFOD. The wire is passed in an antegrade fashion across the AIFOD all the way toward the femoral head. A femoral arteriotomy is done to capture the wire, thus establishing access from the groin into the patent aorta. External iliac artery and femoral artery endarterectomy is performed around the wire. The wire is passed through the patch before the patch angioplasty is completed. Once femoral revascularization is done, a sheath is placed over the wire, and retrograde iliac stenting is performed to the level above the patch to avoid crossing the inguinal ligament. This procedure has been performed in 18 patients (13 with critical limb ischemia, 5 with claudication) with 94.4% technical success, without the use of a re-entry device. Four patients required an interposition graft, and 14 (77.8%) required femoral endarterectomy with patch angioplasty. The procedures in 10 patients (55.5%) were done under spinal anesthesia. All patients had significant cardiopulmonary comorbidities, and five had had multiple abdominal surgeries. One patient (5.5%) required oral antibiotics to treat a superficial wound infection. One patient (5.5%) died ≤30 days (massive myocardial infarction), and one patient required an axillobifemoral bypass at 6 months for acute stent occlusion. The remaining 17 patients were symptom free, with patent stents, at a mean of 16.5 months (range, 12-22 months). Modified PAGA can be used to safely revascularize high-risk patients with extensive AIFOD, with acceptable complication rate and patency. This procedure is currently offered to patients with aortoiliofemoral disease, not candidates for aortobifemoral bypass, instead of an extra-anatomic bypass.

Surgery for nonsmall cell lung cancer

Surgery remains the best curative option in patients with early stage lung cancer (stage I and II). Developments in minimally invasive techniques now allow surgeons to perform lung resections on elderly patients, patients with poor pulmonary function or significant cardiopulmonary comorbidities. New techniques, such as stereotactic radiotherapy and ablative procedures, are being evaluated in early-stage lung cancer and may represent an alternative to surgery in patients unfit for lung resection. Perioperative mortality rates have dropped significantly at most institutions in the past two decades and complications are managed more efficiently. Progress in imaging and staging techniques have helped cut futile thoracotomy rates and offer patients the most adequate treatment options. Large randomised trials have helped clarify the role of neoadjuvant, induction and adjuvant chemotherapy, as well as radiotherapy. Surgery remains an essential step in the multimodality therapy of selected patients with advanced-stage lung cancer (stage III and IV). Interventional and endoscopic techniques have reduced the role of surgery in the diagnosis and staging of nonsmall cell lung cancer, but surgery remains an important tool in the palliation of advanced-stage lung cancer. Large national/international surgical databases have been developed and predictive risk-models for surgical mortality/morbidity published by learned surgical societies. Nonetheless, lung cancer overall survival rates remain deceptively low and it is hoped that early detection/screening, better understanding of tumour biology and development of biomarkers, and development of efficient targeted therapies will help improve the prognosis of lung cancer patients in the next decade.

Percutaneous profunda femoris artery revascularization to prevent hip disarticulation: case series and review of the literature

BackgroundLittle is known about the role of percutaneous revascularization of the profunda femoral artery (PFA) in patients with amputation stump ischemia who are at risk of hip disarticulation. MethodsWe identified 4 patients who were treated for persistent amputation stump ischemia by PFA percutaneous revascularization over a 3-year period. All 4 patients had significant cardiopulmonary comorbidities and 2 patients had at least 3 previous groin surgeries. The short- and long-term outcomes of the patients were evaluated with regard to stump salvage, wound healing rate, complications, and mortality rate. ResultsTechnical success was 100% with no procedure-related complications. All 4 patients had multilevel vascular disease involving the iliac, common femoral artery, and the profunda femoral artery. All 4 patients were treated with angioplasty and/or stenting of the PFA. The amputation stump was closed primarily in 3 patients and 1 amputation stump was closed with a skin graft. One patient died during the same hospital stay shortly after declining hemodialysis. Three patients are alive at a mean follow-up period of 9 months (range, 5–14 mo). ConclusionsPercutaneous PFA revascularization should be considered, over open revascularization, in patients with persistent above-knee amputation stump ischemia and multiple previous groin surgeries to avoid hip disarticulation.

Is pancreaticoduodenectomy justified in elderly patients?

BackgroundAlthough mortality & morbidity for pancreaticoduodenectomy (PD) have improved significantly over the last two decades, the concern for elderly undergoing PD remains. This study examines the outcome of the elderly patients who had pancreaticoduodenectomy in our institution. MethodsA prospective database comprising 69 patients who underwent pancreaticoduodenectomy between 2001 and May 2008 was analyzed. Using WHO definition, elderly patient is defined as age 65 and above in this study. Two groups of patients were compared [Group 1: Age ≤65 & Group 2: Age >65]. ResultsThe mean age of our patients was 62 ± 11 years. There were 37 (54%) patients in Group 1 and 32 (46%) patients in Group 2. There was no statistical difference between the two groups in terms of gender and race. However, there were more patients in the Group 2 with >2 comorbidities (p = 0.03).The median duration of operation was significantly longer in Group 2 (550 min vs 471 min, p = 0.04). Morbidity rate in Group 2 was higher (56% vs 44%, p = 0.04). There was higher proportion of post-operative pancreatic fistula (POPF) in the elderly group (37.5% vs 16.7%, p = 0.05). Majority of them are Grade A POPF according to the ISG definition.The median post-operative length-of-stay (LOS) in hospital was 9 days longer in Group 2 (p = 0.01). Mortality rate between the 2 groups of patients was comparable (0% vs 3%, p = 0.28). ConclusionElderly patients are at increased risk of morbidity in pancreatocoduodenectomy, in particular POPF. However, morbidity and mortality rates are acceptable. It is therefore justified to offer PD to elderly patients who do not have significant cardiopulmonary comorbidities.

GI Endoscopy At Ambulatory Surgical Centers Is Safe: Review of 7979 Consecutive Procedures

Background: The number of procedures performed at ambulatory surgical centers (ASCs) has increased markedly over recent years. Limited data are available regarding the safety of endoscopy in this setting, particularly in the elderly and in those with cardiopulmonary comorbidities. Moreover, prior studies have focused on endoscopic complications; sedation related complications have not been studied. Aim: To assess the safety of endoscopy at an ASC. Methods: The study was performed at an ASC with a physician staffed quality assurance committee (QAC) which discusses every endoscopic complication. Endoscopic complication data were extracted from QAC meeting minutes, mandatory monthly physician self-reports of complications, post-procedure follow-up phone calls, mail-in post-procedure patient questionnaires, and hospitalization records. In addition, to overcome inherent limitations of physician/nurse reporting of minor sedation related complications, a sub-set of primary patient charts comprising the most recent 1000 consecutive cases were individually reviewed, and data were extracted from peri-procedural nursing/physician notes and procedure reports. Results: 7979 GI endoscopic procedures (80% colonoscopies and 20% EGDs approx) were performed from 2003-2006 by 8 endoscopists. Major endoscopic complications included 2 colonic perforations (0.03% approx), 1 duodenal perforation (0.06% approx), 2 delayed post-polypectomy bleeds (0.03% approx), 4 serious cardiac arrhythmias (0.05%) with 3 resulting in transfer to a hospital. There were no deaths. Over time, the complication rate decreased, suggesting a positive impact of the QAC. Subanalysis of the most recent 1000 consecutive endoscopic procedures revealed 26% were therapeutic. 44% of procedures were performed in males. Median patient age was 56 years (range 19-88). 19% of procedures were performed in patients aged ≥70 years and 16% in patients with significant cardiopulmonary disease. Minor sedation related complications resulting in reversal agent use were noted in 0.8% of procedures, including 3 cases of sustained desaturation and 5 of significant bradycardia. All these patients were discharged home. Patients aged ≥70 were not more likely to develop sedation related complications than those <70. Cardiopulmonary comorbidities did not influence the complication rate. Conclusions: 1. GI endoscopy can be performed safely at ASCs with low complication rates. 2. Older patients and those with significant cardiopulmonary comorbidities did not have higher complication rates. 3. QACs may have a positive impact on complication rates. None of the authors of this study have any financial interest in the ASC.

Hemodynamic Changes During Laparoscopic Gastric Bypass Procedures

Significant detrimental intra-operative hemodynamic and respiratory changes occur in the morbidly obese during laparoscopic gastric bypass. Case series. Tertiary care university hospital. Thirteen patients, 10 women and 3 men, undergoing uncomplicated laparoscopic gastric bypass for morbid obesity. Using a pulmonary artery catheter and an arterial line, we intraoperatively monitored hemodynamic and respiratory parameters. Parameter values were recorded at set points of the procedure, and the changes were statistically analyzed. Significant hemodynamic and respiratory changes, mostly unfavorable, occur in the morbidly obese when creating the pneumoperitoneum in preparation for laparoscopic gastric bypass. The hemodynamic changes are attenuated when the patient is placed in the reverse Trendelenburg position and almost completely corrected when the abdomen is deflated at the completion of the procedure. The respiratory changes are more persistent. Laparoscopic gastric bypass surgery for morbid obesity leads to a number of predominantly detrimental, if temporary, respiratory and hemodynamic changes, which are most pronounced at the time of creation of the pneumoperitoneum. In the presence of significant cardiopulmonary comorbidities, the use of invasive intra-operative hemodynamic monitoring of the morbidly obese undergoing laparoscopic gastric bypass appears therefore justified.

Ant sting mortality in Australia

We investigated ant sting related fatalities in Australia over the period 1980–1999. Data was obtained from the Australian Bureau of Statistics and state coronial authorities. Six ant sting-related fatalities were identified, five in Tasmania and one in New South Wales. All were males aged between 40 and 80-years-of-age and most (5/6) had prior histories of jumper or bull ant ( Myrmecia spp.) venom allergy. However, none of the deceased carried injectable adrenaline and most died within 20 min of a single sting. Significant cardiopulmonary co-morbidities were identified in all cases and, in addition, moderate–severe laryngeal oedema and coronary atherosclerosis was observed in most (4/6) cases at autopsy. Where ascertained, Myrmecia ant venom specific immunoglobulin E antibodies levels were always elevated and fell into two distinct patterns of immunoreactivity. Adult Tasmanian males with a prior history of ant venom allergy and cardiopulmonary co-morbidities are therefore at highest risk of a fatal outcome from ant stings. Deaths may be avoided by the early recognition of anaphylaxis and self-treatment with adrenaline as well as by the development of purified Myrmecia ant venom immunotherapy.