Search

Background People with kidney failure have a high incidence of major surgery, though the risk of perioperative outcomes at a population-level is unknown. Our objective was to estimate the proportion of people with kidney failure that experience acute myocardial infarction (AMI) or death within 30 days of major non-cardiac surgery, based on surgery type. Methods In this retrospective population-based cohort study, we used administrative health data to identify adults from Alberta, Canada with major surgery between April 1, 2005 and February 28, 2017 that had preoperative estimated glomerular filtration rates (eGFRs) 2 or received chronic dialysis. The index surgical procedure for each participant was categorized within one of fourteen surgical groupings based on Canadian Classification of Health Interventions (CCI) codes applied to hospitalization administrative datasets. We estimated the proportion of people that had AMI or died within 30 days of the index surgical procedure (with 95% confidence intervals [CIs]) following logistic regression, stratified by surgery type. Results Overall, 3398 people had a major surgery (1905 hemodialysis; 590 peritoneal dialysis; 903 non-dialysis). Participants were more likely male (61.0%) with a median age of 61.5 years (IQR 50.0–72.7). Within 30 days of surgery, 272 people (8.0%) had an AMI or died. The probability was lowest following ophthalmologic surgery at 1.9% (95%CI: 0.5, 7.3) and kidney transplantation at 2.1% (95%CI: 1.3, 3.2). Several types of surgery were associated with greater than one in ten risk of AMI or death, including retroperitoneal (10.0% [95%CI: 2.5, 32.4]), intra-abdominal (11.7% [8.7, 15.5]), skin and soft tissue (12.1% [7.4, 19.1]), musculoskeletal (MSK) (12.3% [9.9, 15.5]), vascular (12.6% [10.2, 15.4]), anorectal (14.7% [6.3, 30.8]), and neurosurgical procedures (38.1% [20.3, 59.8]). Urgent or emergent procedures had the highest risk, with 12.1% experiencing AMI or death (95%CI: 10.7, 13.6) compared with 2.6% (1.9, 3.5) following elective surgery. Conclusions After major non-cardiac surgery, the risk of death or AMI for people with kidney failure varies significantly based on surgery type. This study informs our understanding of surgery type and risk for people with kidney failure. Future research should focus on identifying high risk patients and strategies to reduce these risks.

Zuli Fu,1,2 Qian Xu,1 Chiyuan Zhang,1,3 Hui Bai,1 Xuliang Chen,1 Yanfeng Zhang,1 Wanjun Luo,1 Guoqiang Lin1 1Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China; 2Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China; 3Department of Cardiovascular Medicine, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of ChinaCorrespondence: Guoqiang LinDepartment of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, 410008, People’s Republic of ChinaTel/Fax +86-731-84327097Email lgq186snoopy@126.comPurpose: Post-operative delirium (POD) is a common complication after aortic surgery with poor outcomes. Blood pressure may play a role in the occurrence of POD. The study aimed to identify whether admission systolic blood pressure (SBP) level in the intensive care unit (ICU) is correlated with POD in acute Stanford type A aortic dissection (AAAD) patients undergoing aortic surgery.Patients and Methods: We conducted a single-center retrospective cohort study enrolling consecutive 205 patients with acute type A aortic dissection undergoing aortic surgery. Patients were divided into 3 groups: low, normal, and high SBP level group. Outcomes of interest were POD, 30-day mortality and other complications including acute kidney injury, cardiac complications, spinal cord ischemia, stroke, and pneumonia. Confusion Assessment Method for Intensive Care Unit (CAM-ICU) method was used to assess POD. Univariate and multivariate logistic regression, Cox regression, and subgroup analysis were performed to uncover the association between SBP and POD.Results: The mean age of these patients was 51± 16 years old. Thirty-six patients (17.6%) developed POD. Patients with high admission SBP were more likely to develop POD (P < 0.01). Univariate analysis showed that high admission SBP was associated with a higher risk of POD among AAAD patients (OR, 3.514; 95% CI, 1.478– 8.537, P < 0.01). Multivariate logistic regression model confirmed that high SBP was an independent predictor of POD. Subgroup analysis indicated that patients with anemia and high admission SBP were at higher risk of POD.Conclusion: High admission SBP was positively associated with the incidence of POD in AAAD patients who underwent surgical repair in ICU.Keywords: acute Stanford type A aortic dissection, intensive care unit, major surgery, post-operative delirium, systolic blood pressure

RESUMEN Introducción: La técnica OFA (opioid free anaesthesia) se basa en una anestesia multimodal con menor uso de opioides, que consigue un adecuado control del dolor, con menor incidencias de náuseas y vómitos en el postoperatorio y mejora el pronóstico en los pacientes oncológicos. Pacientes y método: Estudio retrospectivo de casos de pacientes sometidos a cirugía mayor en el periodo de noviembre de 2018 a febrero de 2020. Objetivo principal: cuantificar tipo y dosis de opioide administrado en periodo intraoperatorio y en el postoperatorio inmediato. Objetivos secundarios: graduación del dolor en el postoperatorio y al alta a planta de hospitalización y presencia de náuseas/vómitos en el postoperatorio Resultados: 157 pacientes fueron incluidos. El 29,9 % de los pacientes no precisaron ninguna dosis de opioide intraoperatorio. De los que sí la precisaron, un 72,7 % de los mismos solo necesitó morfina y a una dosis media de 3,3 mg (± 0,9); un 8,1 % solo recibieron fentanilo (dosis media de 110,1 mcg, ± 57,1), y un 19,2 % recibieron morfina y fentanilo (3,8 mg ± 1,2 y 90,4 mcg ± 62,4, respectivamente). En cuanto a la necesidad de opioide postoperatorio, solo el 31,7 % de los pacientes precisó su administración; de ellos ⅔ (33 pacientes) solo recibieron morfina (4,8 mg ± 2,6), 1/5 (10 pacientes) solo fentanilo (83,3 mcg ± 28,8) y el resto una combinación de fentanilo y morfina (140,6 mcg ± 119,4 y 8 mg ± 5,9, respectivamente). Respecto a la intensidad de dolor, el valor en la escala EVA a la llegada de los pacientes a la Reanimación tuvo un valor de 1,6 ± 1,9 y al alta de 0,3 ± 0,6. Solo dos pacientes tuvieron náuseas o vómitos. Conclusiones: El uso de una técnica OFA es factible en cirugía mayor y permite un adecuado control del dolor. La necesidad de opioides intravenosos, tanto en el intraoperatorio como en el postoperatorio, es menor cuando se realiza una técnica OFA. ABSTRACT Introduction: Opioid free anaesthesia is a new paradigm that focuses in multimodal analgesia with an opioid sparing approach that provides a good pain management, without nauseas nor vomiting and improves prognosis in oncological patients Patients and method: Cases retrospective study of major surgery patients from november 2018 to february 2020. Main objective: type and dosage of opioid requeriments both in the intraoperatory and postoperative setting. Secondary objectives: pain level score cuantification at the end of the surgery and at leaving the postoperative recovery unit and incidence of nausea/vomiting Results: 157 patients were recruited. 29,9 % need no opioid intraoperatively. Those who requiered it, 72,7 % only needed morphine (3,3 mg ± 0,9), 8,1 % had to recieved fentanyl (110,1 mcg, ± 57,1) and 19,2 % need both morphine and fentanyl (3,8 mg ± 1,2 and 90,4 mcg ± 62,4). At the postoperative recovery unit, only 31,7 % precised opioids: ⅔ (33 patients) recieved morphine (4,8 mg ± 2,6), 1/5 (10 patients) only fentanyl (83,3 mcg ± 28,8) and the rest needed a combination of fentanyl and morphine (140,6 mcg ± 119,4 and 8 mg ± 5,9, respectively). Two of them have nausea or vomyting. Conclusions: An opioid free anaesthesia approach is feasible in major surgery patients and it achieves and adequate pain management. Opioid requeriments in such patients is less than in those who recieved a traditional base opioid analgesia protocol.

Introduction Postoperative anaemia can affect more than 90% of patients undergoing major surgeries. Patients develop an absolute iron deficiency in the face of significant blood loss or preoperative anaemia and major surgery. Studies have shown the negative impact of these factors on transfusion requirements, infections, increased hospitalisation and long-term morbidities. Aim of the study The research was performed to determine the correlation between intravenous iron administration in the postoperative period and improved haemoglobin correction trend. Material and methods A prospective study was conducted to screen and treat iron deficiency in patients undergoing major surgery associated with significant bleeding. For iron deficiency anaemia screening, in the postoperative period, the following bioumoral parameters were assessed: haemoglobin, serum iron, transferrin saturation (TSAT), and ferritin, direct serum total iron-binding capacity (dTIBC), mean corpuscular volume (MCV) and mean corpuscular haemoglobin (MCH). In addition, serum glucose, fibrinogen, urea, creatinine and lactate values were also collected. Results Twenty-one patients undergoing major surgeries (52,38% were emergency and 47,61% elective interventions) were included in the study. Iron deficiency, as defined by ferritin 100-300 μg/L along with transferrin saturation (TSAT) < 20 %, mean corpuscular volume (MVC) < 92 fL, mean corpuscular haemoglobin (MCH) < 33 g/dL, serum iron < 10 μmol/L and direct serum total iron-binding capacity (dTIBC) > 36 μmol/L, was identified in all cases. To correct the deficit and optimise the haematological status, all patients received intravenous ferric carboxymaltose (500-1000 mg, single dose). Using Quadratic statistical analysis, the trend of haemoglobin correction was found to be a favourable one. Conclusion The administration of intravenous ferric carboxymaltose in the postoperative period showed the beneficial effect of this type of intervention on the haemoglobin correction trend in these groups of patients.

Rationale: Poor preoperative physical fitness and respiratory muscle weakness are associated with postoperative pulmonary complications (PPCs) that result in prolonged hospital length of stay and increased mortality.Objectives: To examine the effect of preoperative exercise training on the risk of PPCs across different surgical settings.Methods: We searched MEDLINE, Web of Science, Embase, the Physiotherapy Evidence Database, and the Cochrane Central Register, without language restrictions, for studies from inception to July 2020. We included randomized controlled trials that compared patients receiving exercise training with those receiving usual care or sham training before cardiac, lung, esophageal, or abdominal surgery. PPCs were the main outcome; secondary outcomes were preoperative functional changes and postoperative mortality, cardiovascular complications, and hospital length of stay. The study was registered with PROSPERO (International Prospective Register of Systematic Reviews).Results: From 29 studies, 2,070 patients were pooled for meta-analysis. Compared with the control condition, preoperative exercise training was associated with a lower incidence of PPCs (23 studies, 1,864 patients; relative risk, 0.52; 95% confidence interval [CI], 0.41 to 0.66; grading of evidence, moderate); Trial Sequential Analysis confirmed effectiveness, and there was no evidence of difference of effect across surgeries, type of training (respiratory muscles, endurance or combined), or preoperative duration of training. At the end of the preoperative period, exercise training resulted in increased peak oxygen uptake (weighted mean difference [WMD], +2 ml/kg/min; 99% CI, 0.3 to 3.7) and higher maximal inspiratory pressure (WMD, +12.2 cm H 2 O; 99% CI, 6.3 to 18.2). Hospital length of stay was shortened (WMD, -2.3 d; 99% CI, -3.82 to -0.75) in the intervention group, whereas no difference was found in postoperative mortality.Conclusions: Preoperative exercise training improves physical fitness and reduces the risk of developing PPCs while minimizing hospital resources use, regardless of the type of intervention and surgery performed.Systematic review registered with https://www.crd.york.ac.uk/prospero/ (CRD 42018096956).

Background Preoperative anemia is a common comorbidity that often necessitates allogeneic blood transfusion (ABT). As there is a risk associated with blood transfusions, preoperative intravenous iron (IV) has been proposed to increase the hemoglobin to reduce perioperative transfusion; however, randomized controlled trials (RCT) investigating this efficacy for IV iron are small, limited, and inconclusive. Consequently, a meta-analysis that pools these studies may provide new and clinically useful information. Methods/design Databases of MEDLINE, EMBASE, EBM Reviews; Cochrane-controlled trial registry; Scopus; registries of health technology assessment and clinical trials; Web of Science; ProQuest Dissertations and Theses; Clinicaltrials.gov; and Conference Proceedings Citation Index-Science (CPCI-S) were searched. Also, we screened all the retrieved reference lists. Selection criteria Titles and abstracts were screened for relevance (i.e., relevant, irrelevant, or potentially relevant). Then, we screened full texts of those citations identified as potentially applicable. Results Our search found 3195 citations and ten RCTs (1039 participants) that met our inclusion criteria. Preoperative IV iron supplementation significantly decreases ABT by 16% (risk ratio (RR): 0.84, 95% confidence interval [CI]: 0.71, 0.99, p = 0.04). In addition, preoperatively, hemoglobin levels increased after receiving IV iron (mean difference [MD] between the study groups: 7.15 g/L, 95% CI: 2.26, 12.04 g/L, p = 0.004) and at follow-up > 4 weeks postoperatively (MD: 6.46 g/L, 95% CI: 3.10, 9.81, p = 0.0002). Iron injection was not associated with increased incidence of non-serious or serious adverse effects across groups (RR: 1.13, 95% CI: 0.78, 1.65, p = 0.52) and (RR: 0.96, 95% CI: 0.44, 2.10, p = 0.92) respectively. Conclusions With moderate certainty, due to the high risk of bias in some studies in one or two domains, we found intravenous iron supplementation is associated with a significant decrease in the blood transfusions rate, and modest hemoglobin concentrations rise when injected pre-surgery compared with placebo or oral iron supplementation. However, further full-scale randomized controlled trials with robust methodology are required. In particular, the safety, quality of life, and cost-effectiveness of different intravenous iron preparations require further evaluation.

Hemophilia B is a coagulation disorder characterized by a deficiency of clotting factor IX. Women are often heterozygous carriers of the disease, however if their clotting factor levels are less than 60%, they may have an increased bleeding tendency. This is even higher if levels are under 40%. We present a case of a 14-year-old female, with mild hemophilia B (hemophilia B carrier with factor IX level < 40%) who underwent a major surgery: a posterior spinal instrumentation from D6 to L1. The perioperative management was discussed, including the perioperative administration of blood products and coagulation adjuncts. This was coordinated by a multidisciplinary team (orthopedists, anesthesiologists, hematologists and nurses) to provide the best perioperative care and follow-up. Close collaboration and communication among/with the team members and the patient/family was vital throughout., Hemofilia B é um distúrbio da coagulação caracterizado por uma deficiência do fator IX da coagulação. As mulheres são frequentemente portadoras heterozigóticas da doença, contudo se estas apresentarem níveis de fator inferiores a 60% podem ter uma maior tendência para fenómenos hemorrágicos. Esta tendência é particularmente acentuada se os níveis de fator IX forem inferiores a 40%. Apresentamos o caso de uma rapariga de 14 anos com hemofilia B ligeira (portadora de hemofilia B com nível de fator IX < 40%) que foi submetida a uma cirurgia hemorrágica (instrumentação posterior da coluna de D6 a L1). Discutimos a abordagem perioperatória, incluindo a administração perioperatória de hemoderivados. Para providenciar os melhores cuidados perioperatórios, uma equipa multidisciplinar coordenada (ortopedistas, anestesiologistas, hematologistas, enfermeiros e serviço de Imunohemoterapia) e uma boa comunicação entre os membros da equipa e o doente/família foram fundamentais.

Objective: Precise prediction of postoperative pulmonary function is extremely important for accurately evaluating the risk of perioperative morbidity and mortality after major surgery for lung cancer. This study aimed to compare the accuracy of a single-photon emission computed tomography/computed tomography (SPECT/CT) method that we recently developed for predicting postoperative pulmonary function versus the accuracy of both the conventional simplified calculating (SC) method and the method using planar images of lung perfusion scintigraphy. Methods: The relationship between the postoperative observed % values of the forced expiratory volume in 1 second (FEV1) or diffusing capacity for carbon monoxide (DLCO or DLCO’) and the % predicted postoperative (%ppo) values of FEV1, DLCO, or DLCO’ calculated by the three methods were analyzed in 30 consecutive patients with lung cancer undergoing lobectomy. Results: The relationship between the postoperative observed % values and %ppo values calculated by the three methods exhibited a strong correlation (Pearson r>0.8, two-tailed p

Practical, safe, and effective hemostatic approach to orthopedic surgery using Extended Half‐Life factor IX in hemophilia B. By intraindividual comparison, we found a lower FIX consumption, number of infusions, and cost compared to plasma‐derived FIX.

Background Postoperative pain is a common condition following orthopaedic surgeries and causes prolonged hospitalisation, delayed rehabilitation and hamper the quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs) are effective analgesics and anti-inflammatory mediators in the treatment of postoperative pain. The association of NSAIDs with serious adverse events may however keep some clinicians and clinical decision makers from using NSAIDs perioperatively. The evidence regarding the risks of serious adverse events following perioperative use of NSAIDs in orthopaedic surgery is sparse and needs to be assessed in a systematic review. This is a protocol for a systematic review that aims to identify the risks of serious adverse events from perioperative use of NSAIDs in orthopaedic patients. Methods Our methodology is based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess if NSAIDs versus placebo, usual care or no intervention, will influence the risks of serious adverse events in patients undergoing orthopaedic surgery. We will include all randomised trials assessing the use of NSAIDs perioperatively. To identify trials we will search the Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cochrane Central Register, Science Citation Index Expanded on Web of Science and BIOSIS. Two authors will screen the literature and extract data. We will use the 'Risk of Bias 2 tool' to assess trials. Extracted data will be analysed using RStudio and Trial Sequential Analysis. We will create a 'Summary of Findings' table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Discussion This systematic review can potentially aid clinicians and clinical decision makers in the use of NSAIDs for treatment of postoperative pain following orthopaedic surgeries.

BackgroundThere is scant clinical research on neuraxial analgesia in dogs undergoing major surgery. With this study we compared the perioperative analgesic effects of thoracic epidural anaesthesia (TEA) and intrathecal morphine (ITM) in dogs scheduled for thoracic or cranial abdominal surgery. The dogs received methadone and dexmedetomidine, were anaesthetized with propofol maintained with sevoflurane, and randomly assigned to receive either TEA (ropivacaine 0.5% at 0.2 mg/kg and morphine 0.1 mg/kg administered at T12-T13) or ITM (morphine 30 μg/kg administered at L6-L7). Intraoperative rescue analgesia (iRA) was fentanyl 1 μg/kg administered if heart rate or mean arterial pressure increased by 30% above the pre-stimulation level. Glasgow Pain Composite Scale score (GPCS) dictated the use of postoperative rescue analgesia (pRA) with methadone 0.2 mg/kg.ResultsThere was a statistically significant difference in iRA, median time to first fentanyl bolus, median fentanyl dose after surgical opening, and median GPCS score at 30 minutes (min), 1 ,2, 4, 6, and 8 hours (h) between the two groups (p<0.001;p<0.001;pp<0.01;p<0.01;p<0.001;p<0.01;p=0.01;p=0.01, respectively). Fewer TEA than ITM group dogs required iRA during surgical opening and pRA: 5% (1/18) and 2/18 (11%), respectively, in the TEA and 83% (16/18) and 10/18 (55%), respectively, in the ITM group. Side effects were urinary retention in 3/18 (16%) TEA group dogs and 2/18 (11%) ITM group dogs and prolonged sedation in 2/18 (11%) in ITM group dogs.TEA and ITM were effective in managing perioperative pain in dogs undergoing thoracic or cranial abdominal surgery.

Background Perioperative telemonitoring of patients undergoing major surgery might lead to improved postoperative outcomes. The aim of this systematic review is to evaluate the effectiveness of current perioperative telemonitoring interventions on postoperative clinical, patient-reported, and financial outcome measures in patients undergoing major surgery. Methods For this systematic review, PubMed, CINAHL, and Embase databases were searched for eligible articles published between January 1, 2009 and March 15, 2021. Studies were eligible as they described: (P) patients aged 18 years or older who underwent major abdominal surgery, (I) perioperative telemonitoring as intervention, (C) a control group receiving usual care, (O) any type of postoperative clinical, patient-reported, or financial outcome measures, and (S) an interventional study design. Results The search identified 2958 articles of which 10 were eligible for analysis, describing nine controlled trials of 2438 patients. Perioperative telemonitoring comprised wearable biosensors ( n = 3), websites ( n = 3), e-mail ( n = 1), and mobile applications ( n = 2). Outcome measures were clinical ( n = 8), patient-reported ( n = 5), and financial ( n = 2). Results show significant improvement of recovery time, stoma self-efficacy and pain in the early postoperative phase in patients receiving telemonitoring. Other outcome measures were not significantly different between the groups. Conclusion Evidence for the effectiveness of perioperative telemonitoring in major surgery is scarce. There is a need for good quality studies with sufficient patients while ensuring that the quality and usability of the technology and the adoption in care processes are optimal.

Background: The facilitation of early recovery of acute kidney injury (AKI) is an important step to improve outcome, particularly because of the limited therapeutic interventions currently available for AKI. The combination of an electronic alert and biomarker-guided kidney-protection strategy implemented in the routine care may have an impact on the incidence of early complete reversal of AKI after major non-cardiac surgery. Methods: We studied 294 patients in two cohorts before (n = 151) and after protocol implementation (n = 143). Data collection required 6 months for each cohort. The kidney-protection protocol included an electronic alert to detect patients who were eligible for urinary biomarker [TIMP2 × IGFBP7]-guided kidney-protection intervention. Intervention was stratified according to three levels of immediate AKI risk: low, moderate, and high. After intervention, postoperative changes in the glomerular filtration rate (eGFR) were identified with a tracking software that included an alert for nephrology consultation if the eGFR had declined by &gt, 25% from the preoperative reference value. Primary outcome was early AKI recovery, i.e., the complete reversal of any AKI stage to absence of AKI within the first 7 postoperative days. Results: Protocol implementation significantly increased the recovery of AKI (36/46, 78% compared to control 27/48, 56%, (p = 0.025)) and reduced the length of the ICU stay (p &lt, 0.001). There was no significant difference in the overall incidence of all AKI and moderate and severe AKI in the first 7 postoperative days: 46/143 (32%) and 12/151 (8%) in the protocol implementation group compared to 48/151 (32%) and 18/151 (12%) in the historical control group. Patients with AKI reversal within the first 7 postoperative days had lower in-hospital mortality than patients without AKI reversal. Conclusions: Implementing a combined electronic alert and biomarker-guided kidney-protection strategy in routine care improved early recovery of AKI after major surgery.

Zuli Fu,1,2 Qian Xu,1 Chiyuan Zhang,1,3 Hui Bai,1 Xuliang Chen,1 Yanfeng Zhang,1 Wanjun Luo,1 Guoqiang Lin1 1Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China; 2Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China; 3Department of Cardiovascular Medicine, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of ChinaCorrespondence: Guoqiang LinDepartment of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, 410008, People’s Republic of ChinaTel/Fax +86-731-84327097Email lgq186snoopy@126.comPurpose: Post-operative delirium (POD) is a common complication after aortic surgery with poor outcomes. Blood pressure may play a role in the occurrence of POD. The study aimed to identify whether admission systolic blood pressure (SBP) level in the intensive care unit (ICU) is correlated with POD in acute Stanford type A aortic dissection (AAAD) patients undergoing aortic surgery.Patients and Methods: We conducted a single-center retrospective cohort study enrolling consecutive 205 patients with acute type A aortic dissection undergoing aortic surgery. Patients were divided into 3 groups: low, normal, and high SBP level group. Outcomes of interest were POD, 30-day mortality and other complications including acute kidney injury, cardiac complications, spinal cord ischemia, stroke, and pneumonia. Confusion Assessment Method for Intensive Care Unit (CAM-ICU) method was used to assess POD. Univariate and multivariate logistic regression, Cox regression, and subgroup analysis were performed to uncover the association between SBP and POD.Results: The mean age of these patients was 51± 16 years old. Thirty-six patients (17.6%) developed POD. Patients with high admission SBP were more likely to develop POD (P < 0.01). Univariate analysis showed that high admission SBP was associated with a higher risk of POD among AAAD patients (OR, 3.514; 95% CI, 1.478– 8.537, P < 0.01). Multivariate logistic regression model confirmed that high SBP was an independent predictor of POD. Subgroup analysis indicated that patients with anemia and high admission SBP were at higher risk of POD.Conclusion: High admission SBP was positively associated with the incidence of POD in AAAD patients who underwent surgical repair in ICU.Keywords: acute Stanford type A aortic dissection, intensive care unit, major surgery, post-operative delirium, systolic blood pressure

A man with severe hemophilia A (HA) without factor VIII (FVIII) inhibitors was admitted for total arthroplasty of his elbow. The patient was being treated with emicizumab, with his last administration given 8 days before surgery. Preoperatively, he received a bolus of 4000 international units (IU) of recombinant (r)FVIII. Throughout the operation, a continuous infusion of 4 IU/kg/h was administered and maintained over 24 hours. On the first postoperative day, the FVIII infusion rate was reduced to 225 IU/h for 4 days and stopped on the fifth day. Under this treatment, no bleeding complications occurred. Emicizumab is known to interfere with a wide range of coagulation assays, thereby challenging replacement therapy monitoring before, during, and after surgery. In this case study, we report on the assessment of FVIII levels at different time points using various reagents. We conclude that for both hematologists and non-hematology clinicians, it is crucial to be aware of emicizumab interferences with routine coagulation tests so as to avoid misinterpretation. In addition, laboratory specialists must be familiar with this treatment in order to select appropriate coagulation tests and provide rapid and reliable result interpretations.

We carried out a retrospective exploratory study on 173 patients who underwent major surgery and developed septic shock after surgery. Our findings suggest that CEACAM7 rs1001578, rs10409040, and rs889365 polymorphisms could influence septic shock-related death in individuals who underwent major surgery. This work has been supported by grants given by Instituto de Salud Carlos III (grant number PI15/01451 to ET), “Gerencia de Salud, Consejería de Sanidad, Junta de Castilla y Leon” [grant number GRS 463/A/10 and 773/A/13 to ET], and PFIZER [grant number CT25-ESP01-01 to SR]. MAJS and AFR are supported by “Instituto de Salud Carlos III” [grant numbers CP17CIII/00007 and CP14CIII/00010, respectively] Sí

Summary Background The safety of surgery during and after the coronavirus disease-2019 (COVID-19) pandemic is paramount. Early reports of excessive perioperative mortality in COVID-positive patients promoted the widespread avoidance of operations. However, cancelling or delaying operations for cancer, trauma, or functional restitution has resulted in increased morbidity and mortality. Methods A national multicentre cohort study of all major reconstructive operations carried out over a 12-week period of the ‘COVID-19 surge’ in the United Kingdom and Ireland was performed. Primary outcome was 30-day mortality and secondary outcome measures were major complications (Clavien-Dindo grade ≥3) and COVID-19 status of patients and healthcare professionals before and after surgery. Results A total of 418 patients underwent major reconstructive surgery with a mean operating time of 7.5 hours and 12 days’ inpatient stay. Cancer (59.8%) and trauma (29.4%) were the most common indications. COVID-19 infection was present in 4.5% of patients. The 30-day post-operative mortality was 0.2%, reflecting the death of one patient who was COVID-negative. Overall complication rate was 20.8%. COVID status did not correlate with major or minor complications. Eight healthcare professionals developed post-operative COVID-19 infection, seven of which occurred within the first three weeks. Conclusions Major reconstructive operations performed during the COVID-19 crisis have been mostly urgent cases involving all surgical specialties. This cohort is a surrogate for all major operations across all surgical specialties. Patient safety and surgical outcomes have been the same as in the pre-COVID era. With adequate precautions, major reconstructive surgery is safe for patients and staff. This study helps counsel patients of COVID-19 risks in the perioperative period.

Background: This study aimed to investigate the changes of serum zinc in term neonates who need major operation. Materials and Methods: In this study, 59 neonates who need major operation were studied. All patients underwent major surgical with high stress. The metabolic response to surgery was studied by measuring the serum zinc before and after surgery (24 hours and at discharge time postoperatively). The "repeated measure" analysis was used to test changes of plasma values of zinc over time. Results: The plasma values of zinc was 89.78±14.50 µg/dl after surgery, 74.95±15.86 µg/dl in 24 hours after surgery and 93.78±14.53 µg/dl at discharge. The plasma values of zinc decreased immediately after surgery that this decline continued until the first 24 hours of operation. Serum zinc concentration decreased significantly at 24 hours at discharge. No significant differences were found between the two sex groups. Conclusion: According to the results of this study, zinc levels in term neonates who need major operation were decreased temporary but later returned to normal. It seems that in these patients there is no need for supplementation of zinc during two weeks after operation.

Objective: Venous thromboembolism (VTE) in the form of either pulmonary embolism (PE) or deep vein thrombosis (DVT) complicates major surgery not infrequently. We analyzed in this study superiority of combined approach of thromboprophylaxis compared to conventional nonpharmacological preventive sets. Methods: We prescribed both pharmacological and non-pharmacological thromboprophylactic interventions for patients encountered thoracoabdominal surgery from 2013 to 2018 at clinic named after I.K.Akhunbaev of Bishkek city and Interregional United Clinical Hospital of Osh city. Demographic characteristics and clinical examination data were evaluated. Thrombogenic risk for every patient was assessed. Screening for detection of VTE was conducted in early postoperative period. Results: Two hundred forty-six candidates of abdominal and thyroid surgery were divided into 2 groups according to patient preference for prevention modality: combined and non-pharmacological. In the early postoperative period, venous thrombosis of the lower extremities developed in 17 patients non-pharmacological group and 8 patients of combined interventions (p

Aim: To assess available evidence on the use of rFVIIa in non-orthopaedic surgery including dental surgery in adult patients with congenital haemophilia with inhibitors (PWHI). Methods: A systematic literature search was performed according to a prespecified search string; prespecified criteria were used to select applicable studies including PWHI ≥18 years of age who underwent any non-orthopaedic surgery using rFVIIa. Results: Thirty-three publications met the eligibility criteria, of which 26 publications – including 46 procedures in 44 patients – were selected for the qualitative analysis. Most publications were case reports or case series (21/26). Primary authors assessed rFVIIa as effective in maintaining haemostasis during and after most major surgeries (22/32). rFVIIa dose was mainly on label, with higher doses used in 4 cases, and a lower dose in 1 case. Duration of treatment was mostly 5–10 days (range: 3 days to 1 month post-operatively). Adverse events related to rFVIIa were rare. Conclusions: Assessing non-orthopaedic surgery in this patient population is hampered by a paucity of published data; nevertheless, the current evidence indicates that rFVIIa is effective in achieving haemostasis in haemophilia patients with inhibitors undergoing elective non-orthopaedic or dental surgery. rFVIIa was generally well tolerated in these patients, with thrombotic events occurring rarely. These data, generated to help clinicians manage congenital haemophilia with inhibitors, highlight the need for more systematic reporting of rFVIIa and all other therapeutic agents in non-orthopaedic surgery and dental surgery in patients with congenital haemophilia and inhibitors. (Less)

Intravenous fluid therapy is a key component in the protocols and clinical pathways in enhanced recovery after surgery protocols. This article reviews the new recommendations based on current evidence: from the limitation of preoperative fasting and hemodynamic monitoring of the systolic volume, to a restrictive but permissive balance in the intraoperative and rapid recovery of the oral route in the first hours of surgery. Perioperative patients with hypotension or evidence of inadequate tissue perfusion should first be fluid-optimized before implementation of vasopressor therapy., La fluidoterapia intravenosa constituye uno de los pilares fundamentales en los protocolos y vías clínicas de optimización de recuperación postquirúrgica. En este artículo se revisan las nuevas recomendaciones en base a la evidencia actual: desde la limitación del ayuno preoperatorio y la monitorización hemodinámica del volumen sistólico, pasando por un balance hídrico restrictivo y permisivo en el intraoperatorio y la recuperación rápida de la vía oral en las primeras horas de la intervención. En caso de hipotensión o registro de perfusión tisular deficiente, se debe optimizar la volemia antes de iniciar tratamientos inotrópicos o vasopresores.

BackgroundObservational studies have suggested that a high respiratory exchange ratio (RER) is associated with the occurrence of postoperative complications. The study’s primary objective is to demonstrate that the incidence of postoperative complications is lower in an interventional group (patients monitored using a hemodynamic algorithm that incorporates the RER) than in a control group (treated according to standard practice).MethodsWe shall perform a prospective, multicenter, randomized, open-label, superiority trial of consecutive patients undergoing major noncardiac surgery (i.e., abdominal, vascular, and orthopedic surgery). The control group will be treated according to the current guidelines on standard hemodynamic care. The interventional group will be treated according to an algorithm based on the RER. The primary outcome will be the occurrence of at least one complication in the 7 days following surgery. The secondary outcomes will be the length of hospital stay, the total number of complications per patient, the 30-day mortality, the total intraoperative volume of fluids administered, and the Sequential [sepsis-related] Organ Failure Assessment (SOFA) score and laboratory data measured on postoperative days 1, 2, and 7. A total of 350 patients will be included.DiscussionIn the operating theater, the RER is potentially a continuously available, easy-to-read, indirect marker of tissue hypoperfusion and postoperative complications. If the RER does predict the occurrence of tissue hypoperfusion, it will help the physician to provide personalized hemodynamic management and limit the side effects associated with excessive hemodynamic optimization (volume overload, vasoconstriction, etc.).Trial registrationClinicalTrials.govNCT03852147. Registered on February 25, 2019

ObjectiveTo identify risk factors associated with surgical site infection (SSI) after major oral oncological surgery.MethodsThis retrospective study reviewed data from patients that underwent major surgery for oral cancer at a tertiary referral hospital in China between January 2005 and July 2016. SSI was diagnosed within 30 days. Demographic, cancer-related, preoperative, perioperative and postoperative data were analysed using descriptive statistics and univariate and multivariate analyses of the risk factors for SSI.ResultsA total of 786 patients were enrolled, of whom 125 had SSI (15.9%), which were all incisional. Independent risk factors for SSI, identified by multivariate analysis, were diabetes mellitus (odds ratio [OR] 2.147, 95% confidence interval [CI] 1.240, 3.642), prior radiotherapy (OR 4.595, 95% CI 1.293, 17.317) and oral–neck communication (OR 2.838, 95% CI 1.263, 7.604); and factors reflecting large extent resections were tracheostomy (OR 2.235, 95% CI 1.435, 3.525), anterolateral thigh flap (OR 1.971, 95% CI 1.103, 3.448) and latissimus dorsi flap (OR 4.178, 95% CI 1.325, 13.189).ConclusionsMultiple risk factors were associated with SSI after major oral oncological surgery. To minimize SSI risk, surgeons managing oral cancer patients should have a better understanding of the risk factors, including diabetes mellitus, prior radiotherapy, tracheostomy, oral–neck communication and flap reconstruction.

Background: Major surgery is a term frequently used but poorly defined. The aim of the present study was to reach a consensus in the definition of major surgery within a panel of expert surgeons from the European Surgical Association (ESA). Methods: A 3-round Delphi process was performed. All ESA members were invited to participate in the expert panel. In round 1, experts were inquired by open- and closed-ended questions on potential criteria to define major surgery. Results were analyzed and presented back anonymously to the panel within next rounds. Closed-ended questions in round 2 and 3 were either binary or statements to be rated on a Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement). Participants were sent 3 reminders at 2-week intervals for each round. 70% of agreement was considered to indicate consensus. Results: Out of 305 ESA members, 67 (22%) answered all the 3 rounds. Significant comorbidities were the only preoperative factor retained to define major surgery (78%). Vascular clampage or organ ischemia (92%), high intraoperative blood loss (90%), high noradrenalin requirements (77%), long operative time (73%) and perioperative blood transfusion (70%) were procedure-related factors that reached consensus. Regarding postoperative factors, systemic inflammatory response (76%) and the need for intensive or intermediate care (88%) reached consensus. Consequences of major surgery were high morbidity (>30% overall) and mortality (>2%). Conclusion: ESA experts defined major surgery according to extent and complexity of the procedure, its pathophysiological consequences and consecutive clinical outcomes.

BackgroundThe clinical significance of emergence delirium remains unclear. The purpose of this study was to investigate the association between emergence delirium and postoperative delirium in elderly after general anesthesia and surgery.MethodsThis prospective observational study was done in a tertiary hospital in Beijing, China. Elderly patients (65–90 years) who underwent major noncardiac surgery under general anesthesia and admitted to the postanesthesia care unit (PACU) after surgery were enrolled. Emergence delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit during PACU stay. Postoperative delirium was assessed with the Confusion Assessment Method during the first 5 postoperative days. The association between emergence delirium and postoperative delirium was analyzed with a multivariable logistic regression model.ResultsA total of 942 patients were enrolled and 915 completed the study. Emergence delirium developed in 37.0% (339/915) of patients during PACU stay; and postoperative delirium developed in 11.4% (104/915) of patients within the first 5 postoperative days. After adjusted confounding factors, the occurrence of emergence delirium is independently associated with an increased risk of postoperative delirium (OR 1.717, 95% CI 1.078–2.735,P = 0.023). Patients with emergence delirium stayed longer in PACU and hospital after surgery, and developed more non-delirium complications within 30 days.ConclusionsEmergence delirium in elderly admitted to the PACU after general anesthesia and major surgery is independently associated with an increased risk of postoperative delirium. Patients with emergence delirium had worse perioperative outcomes.Chinese Clinical Trial Registry (chictr.org.cn)ChiCTR-OOC-17012734

International audience; Patients with haemophilia and high-titre inhibitors were often denied surgery due to the high risk of perioperative bleeding. However, data on bypassing agents for the management of major orthopaedic surgery showed efficacy values between 81% and 85% for activated recombinant human factor VII (rFVIIa) (Novoseven®, Novo Nordisk, Bagsværd, Denmark) and between 81% and 91% for plasma-derived activated prothrombin complex concentrates (aPCC) (Giangrande et al., 2018).

Context Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against 'aggressive' measures. Evidence acquisition This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences. Results As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other. Conclusions Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from 'moderate, severe or worst' pain.

Producción Científica, Interferon lambda 3 (IFNL3, previously called IL-28B) is a cytokine with effects against viral and bacterial pathogens. We aimed to analyze the IFNL3 rs12980275 SNP in patients who underwent major surgery, in order to establish its relationship with susceptibility to septic shock and septic shock-related death in these patients. We performed a case-control study on 376 patients to establish the association between IFNL3 rs12980275 SNP and the susceptibility to develop septic shock. Besides, we performed a longitudinal study among 172 septic shock patients using survival analysis with one censoring point of 28-days mortality. The IFNL3 rs12980275 polymorphism was genotyped by Agena Bioscience's MassARRAY platform. IFNL3 rs12980275 polymorphism was not associated with higher susceptibility to infection and septic shock development. Regarding survival analysis, the Kaplan–Meier analysis showed that patients with IFNL3 rs12980275 AA genotype had higher survival than patients with GG genotype (p = 0.003). The Cox regression analysis adjusted by the most relevant clinical and epidemiological characteristics showed that the GG genotype (recessive model) and the presence of the G allele (additive model) were associated with higher risk of death [adjusted hazard ratio (aHR) = 2.15, p = 0.034; aHR = 1.50, p = 0.030, respectively]. In conclusion, IFNL3 rs12980275 polymorphism was associated with septic shock-related death in patients who underwent major surgery. The A allele was linked to protection, and the G allele was associated with an increased risk of death. This is a first preliminary study that suggests for the first time a role of IFNL3 polymorphisms in the prognosis of septic shock., Instituto de Salud Carlos III (grants PI15/01451, CP17CIII/00007 and CP14CIII/00010), Junta de Castilla y León (grants GR463/A/10 and GR773/A/13), PFIZER (grant CT25-ESP01-01)

Yu-Feng Lin,1,2 Tao-Min Huang,2,3 Shuei-Liong Lin,2,4 Vin-Cent Wu,2 Kwan-Dun Wu2 1Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; 2Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; 3Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan; 4Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan Objective: Prompt assessment of perioperative complications is critical for the comprehensive care of surgical patients. Acute kidney injury requiring dialysis (AKI-D) is associated with high mortality, yet little is known about how long-term outcomes of patients have evolved. The association of AKI-D with postsurgical outcomes has not been well studied.Methods: We investigated patients from the National Health Insurance Research Database and validated by the multicenter Clinical Trial Consortium for Renal Diseases cohort. All patients with AKI-D 18 years or older undergoing four major surgeries (cardiothoracic, esophagus, intestine, and liver) were retrospectively investigated (N=106,573). Patient demographics, surgery type, comorbidities before admission, and postsurgical outcomes, including the in-hospital, 30-day, and long-term mortality together with dialysis dependence were collected.Results: AKI-D is the top risk factor for 30-day and long-term mortality after major surgery. Of 1,664 individuals with AKI-D and 6,656 matched controls, AKI-D during the hospital stay was associated with in-hospital (adjusted hazard ratio [aHR]=3.04, 95% CI 2.79–3.31), 30-day (aHR=3.65, 95% CI 3.37–3.94), and long-term (aHR=3.22, 95% CI 3.01–3.44) mortality. Patients undergoing cardiothoracic surgery (CTS) showed less in-hospital (aHR=0.85, 95% CI 0.75–0.97), 30-day (aHR=0.79, 95% CI 0.70–0.89), and long-term (aHR=0.80, 95% CI 0.72–0.90) mortality compared with non-CTS patients with AKI-D. CTS patients had a high risk of 30-day dialysis dependence (subhazard ratio [sHR]=1.67, 95% CI 1.18–2.38), but the risk of long-term dialysis dependence was similar (sHR=1.38, 95% CI 0.96–2.00) after AKI-D by taking mortality as a competing risk. Non-CTS patients had more comorbidities of sepsis, azotemia, hypoalbuminemia, and metabolic acidosis compared with CTS patients.Conclusion: AKI exhibits paramount effects on postsurgical outcomes that extend well beyond discharge from the hospital. The goal of the perioperative assessment should include the reassurance of enhancing renal function recovery among different surgeries, and optimized follow-up is warranted in attenuating the complications after postsurgical AKI has occurred. Keywords: major surgery, acute kidney injury, postsurgical complication, dialysis dependence, mortality

Background Inadvertent intraoperative hypothermia (core temperature

Objective: Blood transfussion is generally performed to improve oxygen delivery (DO2). Transfusion decision is mostly based on hemoglobin levels, regardless of actual DO2 requirement. As central venous oxygen saturation (ScvO2) may reflect the imbalance between DO2 and consumption (VO2), the aim of this study was to investigate the effect of red blood cell transfusion on ScvO2 levels in major surgery patients. Materials and Methods: The cases in which the clinician decided to perform blood transfusion among the major surgical cases between American Society of Anesthesiologists I and IV, which received central venous catheter insertion and admitted to intensive care unit after surgery, were included in the study. Arterial hemoglobin levels, oxygen saturations, lactate and base excess levels were measured before red blood cell transfusion (pre-T) and 1 hour after transfusion (post-T). Analysis of these variables was performed with using the Wilcoxon test or the Mann-Whitney U test, and p

OBJECTIVE: Evaluate the dose-response relationship between intraoperative fluid administration and postoperative outcomes in a large cohort of surgical patients.BACKGROUND: Healthy humans may live in a state of fluid responsiveness without the need for fluid supplementation. Goal-directed protocols driven by such measures are limited in their ability to define the optimal fluid state during surgery.METHODS: This analysis of data on file included 92,094 adult patients undergoing noncardiac surgery with endotracheal intubation between 2007 and 2014 at an academic tertiary care hospital and two affiliated community hospitals. The primary exposure variable was total intraoperative volume of crystalloid and colloid administered. The primary outcome was 30-day survival. Secondary outcomes were respiratory complications within three postoperative days (pulmonary edema, reintubation, pneumonia, or respiratory failure) and acute kidney injury. Exploratory outcomes were postoperative length of stay and total cost of care. Our models were adjusted for patient-, procedure-, and anesthesia-related factors.RESULTS: A U-shaped association was observed between the volume of fluid administered intraoperatively and 30-day mortality, costs, and postoperative length of stay. Liberal fluid volumes (highest quintile of fluid administration practice) were significantly associated with respiratory complications whereas both liberal and restrictive (lowest quintile) volumes were significantly associated with acute kidney injury. Moderately restrictive volumes (second quintile) were consistently associated with optimal postoperative outcomes and were characterized by volumes approximately 40% less than traditional textbook estimates: infusion rates of approximately 6-7 mL/kg/hr or 1 L of fluid for a 3-hour case.CONCLUSIONS: Intraoperative fluid dosing at the liberal and restrictive margins of observed practice is associated with increased morbidity, mortality, cost, and length of stay.

Objective: Arterial pulse pressure variation (PPV) is widely used for predicting fluid responsiveness and supporting fluid management in the operating room and intensive care unit. Available PPV algorithms have been typically validated for fluid responsiveness during episodes of hemodynamic stability. Yet, little is known about the performance of PPV algorithms during surgery, where fast changes of the blood pressure may affect the robustness of the presented PPV value. This work provides a comprehensive understanding of how various existing algorithmic designs affect the robustness of the presented PPV value during surgery, and proposes additional processing for the pulse pressure signal before calculating PPV. Approach: We recorded arterial blood pressure waveforms from 23 patients undergoing major abdominal surgery. To evaluate the performance, we designed three clinically relevant metrics. Main results and Significance: The results show that all algorithms performed well during episodes of hemodynamic stability. Moreover, it is demonstrated that the proposed processing helps improve the robustness of PPV during the entire course of surgery.

Objective: To investigate the relationship between the preoperative HbA1c levels and the complications and mortality rates in the postoperative period in patients with diabetes undergoing a major surgical treatment. Study Design: Descriptive study Place and Duration of Study: Deparment of Internal Medicine, Adana Numune Research and Training Hospital, Turkey, from January 2015 to December 2016. Methodology: Diabetic patients, who underwent major surgery (a large resection) having preoperative HbA1c levels, were considered. A total of 1,013 patients, whose file data were completely accessed, were included in the study. Preoperative HbA1c levels of the patients and complications seen within the first 7 and first 30 days postoperatively were recorded. Results: Fourty-nine (4.8%) of the patients were exitus in the hospital, while 964 (95.2%) of the patients were discharged. Preoperative HbA1c levels of the patients were found to be predictive marker of mortality and complications in the first 7 and 30 days postoperatively (p

Background: In many immune-related diseases, inflammatory responses and several clinical outcomes are related to increased NF-&kappa, B activity. We aimed to evaluate whether SNPs related to the NF-&kappa, B signaling pathway are associated with higher susceptibility to infection, septic shock, and septic-shock-related death in European patients who underwent major surgery. Methods: We performed a case-control study on 184 patients with septic shock and 212 with systemic inflammatory response syndrome, and a longitudinal substudy on septic shock patients. Thirty-three SNPs within genes belonging to or regulating the NF-&kappa, B signaling pathway were genotyped by Agena Bioscience&rsquo, s MassARRAY platform. Results: No significant results were found for susceptibility to infection and septic shock in the multivariate analysis after adjusting for multiple comparisons. Regarding septic-shock-related death, patients with TNFAIP3 rs6920220 AA, TNIP1 rs73272842 AA, TNIP1 rs3792783 GG, and TNIP1 rs7708392 CC genotypes had the highest risk of septic-shock-related death in the first 28 and 90 days. Also, the MyD88 rs7744 GG genotype was associated with a higher risk of death during the first 90 days. Haplotype analysis shows us that patients with the TNIP1 GAG haplotype (composed of rs73272842, rs3792783, and rs7708392) had a lower risk of death in the first 28 days and the TNIP1 AGC haplotype was associated with a higher risk of death in the first 90 days. Conclusions: The SNPs in the genes TNFAIP3, TNIP1, and MyD88 were linked to the risk of septic-shock-related death in patients who underwent major surgery.

To non-invasively predict fluid responsiveness, respiration-induced pulse amplitude variation (PAV) in the photoplethysmographic (PPG) signal has been proposed as an alternative to pulse pressure variation (PPV) in the arterial blood pressure (ABP) signal. However, it is still unclear how the performance of the PPG-derived PAV is site-dependent during surgery. The aim of this study is to compare finger- and forehead-PPG derived PAV in their ability to approach the value and trend of ABP-derived PPV. Furthermore, this study investigates four potential confounding factors, (1) baseline variation, (2) PPV, (3) ratio of respiration and heart rate, and (4) perfusion index, which might affect the agreement between PPV and PAV. In this work, ABP, finger PPG, and forehead PPG were continuously recorded in 29 patients undergoing major surgery in the operating room. A total of 91.2 h data were used for analysis, from which PAV and PPV were calculated and compared. We analyzed the impact of the four factors using a multiple linear regression (MLR) analysis. The results show that compared with the ABP-derived PPV, finger-derived PAV had an agreement of 3.2 ± 5.1%, whereas forehead-PAV had an agreement of 12.0 ± 9.1%. From the MLR analysis, we found that baseline variation was a factor significantly affecting the agreement between PPV and PAV. After correcting for respiration-induced baseline variation, the agreements for finger- and forehead-derived PAV were improved to reach an agreement of − 1.2 ± 3.8% and 3.3 ± 4.8%, respectively. To conclude, finger-derived PAV showed better agreement with ABP-derived PPV compared to forehead-derived PAV. Baseline variation was a factor that significantly affected the agreement between PPV and PAV. By correcting for the baseline variation, improved agreements were obtained for both the finger and forehead, and the difference between these two agreements was diminished. The tracking abilities for both finger- and forehead-derived PAV still warrant improvement for wide use in clinical practice. Overall, our results show that baseline-corrected finger- and forehead-derived PAV may provide a non-invasive alternative for PPV.

Almost half of patients treated on intensive care unit (ICU) experience moderate to severe pain. Managing pain in the critically ill patient is challenging, as their pain is complex with multiple causes. Pharmacological treatment often focuses on opioids, and over a prolonged admission this can represent high cumulative doses which risk opioid dependence at discharge. Despite analgesia the incidence of chronic pain after treatment on ICU is high ranging from 33–73%. Measures need to be taken to prevent the transition from acute to chronic pain, whilst avoiding opioid overuse. This narrative review discusses preventive measures for the development of chronic pain in ICU patients. It considers a number of strategies that can be employed including non-opioid analgesics, regional analgesia, and non-pharmacological methods. We reason that individualized pain management plans should become the cornerstone for critically ill patients to facilitate physical and psychological well being after discharge from critical care and hospital.

Bakgrund: Akut postoperativ smärta är en vanlig men också förväntad konsekvens efter kirurgiska ingrepp som ger negativ påverkan på den efterföljande postoperativa återhämtningen. Syfte: Syftet med studien var att undersöka genomsnittlig självskattad smärtintensitet som gav vuxna patienter problem med att vila, sova och röra sig under det första postoperativa dygnet samt om det hos män/kvinnor, yngre/äldre och kirurgi/ortopedpatienter förekom olika hanterbara smärtnivåer i förhållande till vila och aktivitet under tidig postoperativ återhämtning. Metod: En kvantitativ empirisk deskriptiv studie genomfördes av ett datamaterial från 479 elektiva kirurg- och ortopedpatienter. Resultat: Resultatet visade att ortopedpatienterna i genomsnitt skattade högre värden av smärta jämfört med kirurgpatienterna men att kirurgpatienterna redan vid låga smärtnivåer fick problem med vila, sömn och rörelse. Slutsats: Resultatet understryker att smärta är en subjektiv upplevelse och att smärtbehandlingen i hög grad behöver individualiseras för att därigenom minska smärtans negativa effekter, förbättra den tidiga postoperativa återhämtningen och därmed öka patientsäkerheten. Background: Acute postoperative pain is a common but also expected consequence after surgery that gives negative impact on the following postoperative recovery. Study objectives: The purpose was to investigate the average level of self-assessed intensity of pain that gave adult patients problem to rest, sleep or mobilize during the first postoperative day and if men/women, younger/older and surgical or orthopedic patients had different manageable levels of pain related to rest, sleep and mobilization during the early postoperative recovery. Design: A quantitative empirical descriptive study was performed from datasets from 479 elective surgical and orthopedic patients. Results: The result showed that the orthopedic patients self-assessed higher levels of postoperative pain than the surgical patients, but also that the surgical patients earlier got problems with recovery at low pain levels. Conclusions: The result underlines that pain is a subjective experience and that the pain treatment has to be individualized just to prevent the negative impact of pain but also to enhance the postoperative recovery and improve patient safety.

The article is devoted to the actual problem of ensuring a radical surgical treatment of patients with tumors of oropharyngeal zone. We analyzed initial nutritional status of patients and its dynamics at the stages of preparation and implementation of major surgery. Developed and presented in the form of a flow chart of nutritional support on an outpatient and inpatient. We present the our own results, which show a decrease in the number of postoperative complications, and hospital stay-days due to the use of the developed algorithm.

Despite the increasing number of elderly patients requiring treatment for head and neck cancer, there is insufficient available evidence about the oncological results of treatment and its tolerability in such patients. Owing to comorbidities, elderly patients often need complex evaluation and pretreatment management, which often results in their exclusion from clinical trials. The question of which patients constitute the highest-risk groups regarding treatment-related morbidity and mortality, and who can tolerate and benefit from aggressive treatment, has not been adequately studied. Biologic rather than chronologic age should be a more important factor in treatment protocols. Age-specific prospective clinical studies are needed on the treatment of head and neck cancer in elderly patients.

Yu-Feng Lin,1,2 Tao-Min Huang,2,3 Shuei-Liong Lin,2,4 Vin-Cent Wu,2 Kwan-Dun Wu2 1Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; 2Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; 3Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan; 4Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan Objective: Prompt assessment of perioperative complications is critical for the comprehensive care of surgical patients. Acute kidney injury requiring dialysis (AKI-D) is associated with high mortality, yet little is known about how long-term outcomes of patients have evolved. The association of AKI-D with postsurgical outcomes has not been well studied.Methods: We investigated patients from the National Health Insurance Research Database and validated by the multicenter Clinical Trial Consortium for Renal Diseases cohort. All patients with AKI-D 18 years or older undergoing four major surgeries (cardiothoracic, esophagus, intestine, and liver) were retrospectively investigated (N=106,573). Patient demographics, surgery type, comorbidities before admission, and postsurgical outcomes, including the in-hospital, 30-day, and long-term mortality together with dialysis dependence were collected.Results: AKI-D is the top risk factor for 30-day and long-term mortality after major surgery. Of 1,664 individuals with AKI-D and 6,656 matched controls, AKI-D during the hospital stay was associated with in-hospital (adjusted hazard ratio [aHR]=3.04, 95% CI 2.79–3.31), 30-day (aHR=3.65, 95% CI 3.37–3.94), and long-term (aHR=3.22, 95% CI 3.01–3.44) mortality. Patients undergoing cardiothoracic surgery (CTS) showed less in-hospital (aHR=0.85, 95% CI 0.75–0.97), 30-day (aHR=0.79, 95% CI 0.70–0.89), and long-term (aHR=0.80, 95% CI 0.72–0.90) mortality compared with non-CTS patients with AKI-D. CTS patients had a high risk of 30-day dialysis dependence (subhazard ratio [sHR]=1.67, 95% CI 1.18–2.38), but the risk of long-term dialysis dependence was similar (sHR=1.38, 95% CI 0.96–2.00) after AKI-D by taking mortality as a competing risk. Non-CTS patients had more comorbidities of sepsis, azotemia, hypoalbuminemia, and metabolic acidosis compared with CTS patients.Conclusion: AKI exhibits paramount effects on postsurgical outcomes that extend well beyond discharge from the hospital. The goal of the perioperative assessment should include the reassurance of enhancing renal function recovery among different surgeries, and optimized follow-up is warranted in attenuating the complications after postsurgical AKI has occurred. Keywords: major surgery, acute kidney injury, postsurgical complication, dialysis dependence, mortality

Background Anxiety during the preoperative period is the most common problem with a number of postoperative complications such as an increase in postoperative pain, delay of healing and prolong the hospital stay. Further, patients with a high level of preoperative anxiety require higher doses of anesthetic agents and recover poorly. Despite its serious health complications, its magnitude and associated factors have been poorly explored in Ethiopia particularly in the selected study areas. Objective To assess preoperative anxiety and associated factors among adult surgical patients in Debre Markos and Felege Hiwot Referral Hospitals, Northwest Ethiopia. Method An institution based cross-sectional study was conducted on 353 patients scheduled for surgery using a systematic random sampling technique. The data were collected using the state version of the state-trait anxiety inventory scale. All collected data were entered into Epi-Data version 3.1 and analysis was done by using SPSS version 20 software. Binary logistic regression was performed to assess the effect of independent variables on the dependent variable. A p-value

Jan Máca,1 Matúš Peteja,2 Petr Reimer,1 Ondřej Jor,1 Věra Šeděnková,1 Lucie Panáčková,1 Peter Ihnát,2 Michal Burda,3 Pavel Ševčík1 1Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic; 2The Clinic of Surgery, University Hospital Ostrava, Ostrava, Czech Republic; 3Institute for Research and Applications of Fuzzy Modeling, Centre of Excellence IT4Innovations, University of Ostrava, Ostrava, Czech Republic Background: Major abdominal surgery (MAS) is high-risk intervention usually accompanied by tissue injury leading to a release of signaling danger molecules called alarmins. This study evaluates the surgical injury caused by two fundamental types of gastrointestinal surgical procedures (open surgery and laparoscopy) in relation to the inflammation elicited by alarmins. Patients and methods: Patients undergoing MAS were divided into a mixed laparoscopy group (LPS) and an open surgery group (LPT). Serum levels of alarmins (S100A8, S100A12, HMGB1, and HSP70) and biomarkers (leukocytes, C-reactive protein [CRP], and interleukin-6 [IL-6]) were analyzed between the groups. The secondary objectives were to compare LPT and LPS cancer subgroups and to find the relationship between procedure and outcome (intensive care unit length of stay [ICU-LOS] and hospital length of stay [H-LOS]). Results: A total of 82 patients were analyzed. No significant difference was found in alarmin levels between the mixed LPS and LPT groups. IL-6 was higher in the LPS group on day 2 (p=0.03) and day 3 (p=0.04). Significantly higher S100A8 protein levels on day 1 (p=0.02) and day 2 (p=0.01) and higher S100A12 protein levels on day 2 (p=0.03) were obtained in the LPS cancer subgroup. ICU-LOS and H-LOS were longer in the LPS cancer subgroup. Conclusion: The degree of surgical injury elicited by open MAS as reflected by alarmins is similar to that of laparoscopic procedures. Nevertheless, an early biomarker of inflammation (IL-6) was higher in the laparoscopy group, suggesting a greater inflammatory response. Moreover, the levels of S100A8 and S100A12 were higher with a longer ICU-LOS and H-LOS in the LPS cancer subgroup. Keywords: open surgery, laparoscopy, gastrointestinal surgery, alarmins, surgical injury, major surgery

Intraoperative fluid equilibrium is a decisive matter in perioperative anesthesia management, because most of evaluation studies consider intraoperative fluid administration as a major participating agent in improving or worsening patient outcomes after surgery and it revolves within the responsibility of an anesthesiologist. The understanding of fluid physiology in the human body, clinical features of available intravenous fluid, and nature of surgery indeed will contribute to the success plan of management. Maintaining of patients’ physiological milieu by preserving normal extracellular volume, adequate tissue perfusion, and a balanced acid base condition are the main goals of intraoperative fluid infusion. This review was conducted to overview fundamental basics of fluid therapy during the intraoperative period. Due to the dearth of supporting data for appropriate volume and the available definitions of restrictive and liberal are diffident, the polemic about which particular method of volume expansion still exists. Colloid versus crystalloid controversy in surgical patients is still going on and this would again be encouraged to be a topic for many clinical trials in the future. The current findings’ trend prefers guided and restricted intraoperative fluid therapy with isotonic balanced crystalloids because such fluids are cost effective and have fewer side effects than other fluids.

Background Morphine is worldwide the analgesic of first choice after cardiac surgery in children. Morphine has unwanted hemodynamic and respiratory side effects. Therefore, post–cardiac surgery patients may potentially benefit from a non-opioid drug for pain relief. A previous study has shown that intravenous (IV) paracetamol is effective and opioid-sparing in children after major non-cardiac surgery. The aim of the study is to test the hypothesis that intermittent IV paracetamol administration in children after cardiac surgery will result in a reduction of at least 30% of the cumulative morphine requirement. Methods This is a prospective, multi-center, randomized controlled trial at four level-3 pediatric intensive care units (ICUs) in the Netherlands and Belgium. Children who are 0–36 months old will be randomly assigned to receive either intermittent IV paracetamol or continuous IV morphine up to 48 h post-operatively. Morphine will be available as rescue medication for both groups. Validated pain and sedation assessment tools will be used to monitor patients. The sample size (n = 208, 104 per arm) was calculated in order to detect a 30% reduction in morphine dose; two-sided significance level was 5% and power was 95%. Discussion This study will focus on the reduction, or replacement, of morphine by IV paracetamol in children (0–36 months old) after cardiac surgery. The results of this study will form the basis of a new pain management algorithm and will be implemented at the participating ICUs, resulting in an evidence-based guideline on post-operative pain after cardiac surgery in infants who are 0–36 months old. Trial registration Dutch Trial Registry (www.trialregister.nl): NTR5448 on September 1, 2015. Institutional review board approval (MEC2015–646), current protocol version: July 3, 2017 Electronic supplementary material The online version of this article (10.1186/s13063-018-2705-5) contains supplementary material, which is available to authorized users.

Background Pulmonary embolism (PE) is a life-threatening condition common after major surgery. Although the high incidence (0.3–30%) and mortality rate (16.9–31%) of PE in patients undergoing major surgical procedures is apparent from findings of contemporary observational studies, there is a lack of a summary and meta-analysis data on the epidemiology of postoperative PE in this same regard. Hence, we propose to conduct the first systematic review to summarise existing data on the global incidence, determinants and case fatality rate of PE following major surgery. Methods Electronic databases including MEDLINE, EMBASE, SCOPUS, WHO global health library (including LILACS), Web of Science and Google scholar from inception to April 30, 2017, will be searched for cohort studies reporting on the incidence, determinants and case fatality rate of PE occurring after major surgery. Data from grey literature will also be assessed. Two investigators will independently perform study selection and data extraction. Included studies will be evaluated for risk of bias. Appropriate meta-analytic methods will be used to pool incidence and case fatality rate estimates from studies with identical features, globally and by subgroups of major surgical procedures. Random-effects and risk ratio with 95% confidence interval will be used to summarise determinants and predictors of mortality of PE in patients undergoing major surgery. Discussion This systematic review and meta-analysis will provide the most up-to-date epidemiology of PE in patients undergoing major surgery to inform health authorities and identify further research topics based on the remaining knowledge gaps. Systematic review registration PROSPERO CRD42017065126 Electronic supplementary material The online version of this article (10.1186/s13643-017-0647-8) contains supplementary material, which is available to authorized users.

OBJECTIVE: To test postoperative serum albumin drop (ΔAlb) as a marker of surgical stress response and early predictor of clinical outcomes. DESIGN: Prospective cohort study (NCT02356484). Albumin was prospectively measured in 138 patients undergoing major abdominal surgery. Blood samples were collected before surgery and on postoperative days 0, 1 2 and 3. ΔAlb was compared to the modified estimation of physiologic ability and surgical stress (mE-PASS) score and correlated to the performances of C reactive protein (CRP), procalcitonin (PCT) and lactate (LCT). Postoperative outcomes were postoperative complications according to Clavien classification and Comprehensive Complication Index (CCI), and length of hospital stay (LoS). SETTING: Department of abdominal surgery in a European tertiary centre. PARTICIPANTS: Adult patients undergoing elective major abdominal surgery, with anticipated duration ≥2 hours. Patients on immunosuppressive or antibiotic treatments before surgery were excluded. RESULTS: The level of serum albumin rapidly dropped after surgery. ΔAlb correlated to the mE-PASS score (r=0.275, p=0.01) and to CRP increase (r=0.536, p{\textless}0.001). ΔAlb also correlated to overall complications (r=0.485, p{\textless}0.001), CCI (r=0.383, p{\textless}0.001) and LoS (r=0.468, p{\textless}0.001). A ΔAlb ≥10 g/L yielded a sensitivity of 77.1\% and a specificity of 67.2\% (AUC: 78.3\%) to predict complications. Patients with ΔAlb ≥10 g/L on POD 1 showed a threefold increased risk of overall postoperative complications. CONCLUSIONS: Early postoperative decrease of serum albumin correlated with the extent of surgery, its metabolic response and with adverse outcomes such as complications and length of stay. A decreased concentration of serum albumin ≥10 g/L on POD 1 was associated with a threefold increased risk of overall postoperative complications and may thus be used to identify patients at risk.