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Background Postextubation dysphagia (PED) is a serious postoperative complication following cardiovascular surgery that can lead to a worse prognosis. On the other hand, frailty is a prognostic factor in patients who undergo cardiac surgery. Objectives This study investigated the effect of frailty status on PED and impact of PED on postoperative complications. Methods This single-center retrospective cohort study included 644 consecutive patients who underwent elective cardiovascular surgery between May 1, 2014, and December 31, 2020; they were assigned to the PED or non-PED group based on postoperative swallowing status, and postoperative complications were investigated. Frailty status and physical functions, including walking speed, grip strength, Short Physical Performance Battery, and 6-minute walking distance, were preoperatively assessed; the frailty-status cutoff for predicting PED was determined from the receiver-operating characteristic curve. Results In this study cohort (mean age 67.7 years), the overall PED prevalence was 14.8%; preoperative frailty had a significantly higher prevalence in the PED group (50.0%) than in the non-PED group (20.3%; P < 0.001). PED correlated with a higher incidence of postoperative pneumonia and prolonged intensive care unit or hospital stay (P < 0.05 for all). After adjustment for confounders, multiple regression analysis revealed that preoperative frailty was independently associated with PED (P < 0.001). Conclusions PED occurred commonly after cardiovascular surgery and increased the risk of postoperative complications. Preoperative frailty was independently associated with PED. The 6-minute walking distance was the most powerful predictor of PED. Evaluation of preoperative frailty status is important for risk stratification and prevention of postoperative morbidity in patients undergoing surgery.

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Background: Postoperative pneumonia (POP) is a frequent complication following cardiac surgery, related to increased morbidity, mortality and healthcare costs. The objectives of this study were to investigate the predictors associated with POP in adults undergoing elective cardiac surgery and to develop and validate nomogram models. Methods: We conducted a multicenter retrospective study in four cardiac centers in China. Adults operated with elective open-heart surgery from 2016-2020 were included. Patients were randomly allocated to training and validation sets by 7:3 ratio. Risk factors for POP were identified by univariate and multivariate analysis. Nomograms were constructed based on the multivariate logistic regression models and were evaluated with calibration, discrimination and decision curve analysis. Findings: A total of 13,380 patients meeting the criteria were included and POP developed in 882 patients (6.6%). The mortality was 2.0%, but it increased significantly in patients with POP (25.1% versus 0.4%, P

Background/Aims: Postoperative pneumonia commonly occurs in patients after orthotopic liver transplantation ( OLT ), contributing to both morbidity and mortality. Until now, it remains a change in predicting postoperative pneumonia among patients following OLT. In this study, we aimed to develop machine learning (ML) models and to assess their performance for predicting postoperative pneumonia in OLT patients. Methods: Preoperative, intraoperative, and postoperative data of 591 adult patients who underwent OLT from January 2015 to September 2019 were retrospectively analyzed in this study. Six ML models, including logistic regression (LR), support vector machine ( SVM ), random forest ( RF ), multilayer perceptron ( MLP ), extreme gradient boosting ( XGBoost ), and gradient boosting machine ( GBM ) were developed using the training set and assessed using the testing set for their performance in predicting operative pneumonia. Findings: Postoperative pneumonia occurred in 42.81% of OLT patients, which contributed significantly to increased postoperative hospital stay and mortality. 14 features, including INR, HCT, PLT, ALB, ALT, FIB, WBC, PT, serum Na+, TBIL, anesthesia time, preoperative length of hospital stay, total fluid transfusion, and operation time, were significantly associated with postoperative pneumonia. Performance comparison of the six ML models revealed that the XGBoost model exhibited the best overall performance in predicting postoperative pneumonia, with the area under the receiver operating characteristics (ROC) curve (AUC) of 0.734, sensitivity of 52.6%, and specificity of 77.5%. Conclusions: This study has successfully established six novel ML models, of which the XGBoost model has demonstrated best over performance for predicting postoperative pneumonia in OLT patients, and thus it holds promise for clinical application in the future. Trial Registration : No.[2019]02-609-01 Funding Statement: This study was supported by the National Natural Science Foundation of China (Grant No. 81772127; 81974296), Postdoctoral Science Foundation of China (Grant No. 2019M663260) and the Fundamental Research Funds for the Central Universities, China (Grant No. 20ykpy20). Declaration of Interests: The authors declare no conflicts of interest. Ethics Approval Statement: This study was approved by the Ethnic Committee of in the Third Affiliated Hospital of Sun Yat-sen University-Lingnan Hospital (No. [2019]02-609-01). The requirement for informed consent was waived by the committee, mainly due to the retrospective nature of this study

To describe and compare incidence, characteristics and outcomes of postoperative pneumonia among patients with or without COPD.We included hospitalized patients aged ≥40 years whose medical diagnosis included pneumonia and ventilator-associated pneumonia in the secondary's diagnosis field and who were discharged from Spanish hospitals from 2001 to 2015. Irrespectively of the position at the procedures coding list, we retrieved data about the type of surgical procedures using the enhanced ICD-9-CM codes. We grouped admissions by COPD status. The data were collected from the National Hospital Discharge Database.We included 117,665 hospitalizations of patients that developed postoperative pneumonia (18.06% of them had COPD). The incidence of postoperative pneumonia was significantly higher in COPD patients than in those without COPD (IRR 1.93, 95%CI 1.68-2.24). In hospital-mortality (IHM) was significantly lower in the first group of patients (29.79% vs 31.43%, p 0.05). Factors independently associated with IHM, among COPD and non-COPD patients, were older age, more comorbidities, mechanical ventilation, pleural drainage tube, red blood cell transfusion, dialysis and emergency room admission. Time trend analysis showed a significant decrease in IHM from 2001 to 2015. COPD was associated with lower IHM (OR 0.91, 95%CI 0.88-0.95).The incidence of postoperative pneumonia was higher in COPD patients than in those without this disease. However, IHM was lower among COPD patients. IHM decreased over time, regardless of the existence or not of COPD.

Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement.

Despite best efforts, postoperative complications such as postoperative respiratory failure may occur and prompt recognition of the process and management is required. Postoperative respiratory failure, such as postoperative pneumonia, postpneumonectomy pulmonary edema, acute respiratory distress-like syndromes, and pulmonary embolism, are associated with high morbidity and mortality. The causes of these complications are multifactorial and depend on preoperative, intraoperative, and postoperative factors, some of which are modifiable. The article identifies some of the risk factors, causes, and treatment strategies for successful management of the patient with postoperative respiratory failure.

To evaluate the teaching dictum "wind, water, wound, walk" in the modern surgical environment.A retrospective cohort study.Hospitals enrolled in the American College of Surgeons National Surgical Quality Improvement Program.We identified 11,137 patients enrolled in American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2011) who were older than 18 years; underwent a general surgical procedure; and developed a postoperative pneumonia (PNA, "wind"), urinary tract infection (UTI, "water"), surgical site infection (SSI, "wound"), or venous thromboembolic event (VTE, "walk") for inclusion in the study. Patients were excluded if they had an infection present at the time of surgery or were missing information on the time of diagnosis.The median day of diagnosis differed significantly according to occurrence type (median day of PNA = 5, UTI = 8, SSI = 11, and VTE = 9, p0.001). The sequence of occurrences diagnosed before discharge (median day of PNA = 4, UTI = 5, SSI = 7, and VTE = 5) differed from that of occurrences diagnosed following discharge (median day of PNA = 10, UTI = 14, SSI = 14, and VTE = 14). Within the predischarge and postdischarge subsets, the median day of diagnosis remained significantly different according to occurrence type (all p's0.001).The dictum should be taught as, "wind, water, walk, wound" to reflect the timing and progression of the diagnosis of PNA, UTI, VTE, and SSI. The dictum did not reflect the timing or sequence of the occurrences in the cohort diagnosed after discharge. Educators must teach trainees to apply the dictum in the appropriate patient setting. As surgical care changes, we must continue to reassess our educational pearls to ensure that they reflect the modern reality.

To identify preoperative factors associated with an increased risk of postoperative pneumonia and subsequently develop and validate a risk calculator.The American College of Surgeons' National Surgical Quality Improvement Program, a multicenter, prospective data set (2007-2008) was used. Univariate and multivariate logistic regression analyses were performed. The 2007 data set (N=211,410) served as the training set, and the 2008 data set (N=257,385) served as the validation set.In the training set, 3825 patients (1.8%) experienced postoperative pneumonia. Patients who experienced postoperative pneumonia had a significantly higher 30-day mortality (17.0% vs 1.5%; P.001). On multivariate logistic regression analysis, 7 preoperative predictors of postoperative pneumonia were identified: age, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, dependent functional status, preoperative sepsis, smoking before operation, and type of operation. The risk model based on the training data set was subsequently validated on the validation data set, with model performance being very similar (C statistic: 0.860 and 0.855, respectively). The high C statistic indicates excellent predictive performance. The risk model was used to develop an interactive risk calculator.Preoperative variables associated with an increased risk of postoperative pneumonia include age, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, dependent functional status, preoperative sepsis, smoking before operation, and type of operation. The validated risk calculator provides a risk estimate for postoperative pneumonia and is anticipated to aid in surgical decision making and informed patient consent.

BACKGROUND: Allogeneic blood transfusion is associated with an increased frequency of postoperative infection. We studied whether such events can be avoided by the intraoperative and postoperative use of leucocyte-depleted blood. METHODS: 589 consecutive patients scheduled for elective colorectal surgery were randomised to receive buffy-coat poor (n = 299) or filtered leucocyte-depleted red-cells (n = 290) when transfusion was indicated. 260 patients actually received blood transfusion. Three patients were excluded from analysis. FINDINGS: The 142 patients randomised to and transfused with buffy-coat-poor blood had a significantly higher frequency of wound infections and intra-abdominal abscesses than the 155 patients who were allocated to this group but who were not transfused. (12 vs 1%, p < 0.0001) and (5 vs 0%, p = 0.005), respectively. Those receiving buffy-coat-poor blood also had a significantly higher frequency of wound infections and intra-abdominal abscesses than the 118 randomised to and receiving leucocyte-depleted blood (12 vs 0%, p < 0.0001) and (5 vs 0%, p = 0.017), respectively. Postoperative pneumonia occurred at a significantly higher rate in patients receiving buffy-coat-poor blood: 23 versus 3% in non-transfused patients (p < 0.0001), and 23 versus 3% in patients transfused with leucocyte-depleted blood (p < 0.001). The mortality rate between the groups was not statistically different. INTERPRETATION: Our data suggests that the association between allogeneic blood transfusion and postoperative infection is limited to allogeneic blood products that are not adequately depleted of immunosuppressive leucocytes. This undesirable effect can be reduced by leucocyte depletion with high-efficiency filters BACKGROUND: Allogeneic blood transfusion is associated with an increased frequency of postoperative infection. We studied whether such events can be avoided by the intraoperative and postoperative use of leucocyte-depleted blood.METHODS: 589 consecutive patients scheduled for elective colorectal surgery were randomised to receive buffy-coat poor (n = 299) or filtered leucocyte-depleted red-cells (n = 290) when transfusion was indicated. 260 patients actually received blood transfusion. Three patients were excluded from analysis.FINDINGS: The 142 patients randomised to and transfused with buffy-coat-poor blood had a significantly higher frequency of wound infections and intra-abdominal abscesses than the 155 patients who were allocated to this group but who were not transfused. (12 vs 1%, p < 0.0001) and (5 vs 0%, p = 0.005), respectively. Those receiving buffy-coat-poor blood also had a significantly higher frequency of wound infections and intra-abdominal abscesses than the 118 randomised to and receiving leucocyte-depleted blood (12 vs 0%, p < 0.0001) and (5 vs 0%, p = 0.017), respectively. Postoperative pneumonia occurred at a significantly higher rate in patients receiving buffy-coat-poor blood: 23 versus 3% in non-transfused patients (p < 0.0001), and 23 versus 3% in patients transfused with leucocyte-depleted blood (p < 0.001). The mortality rate between the groups was not statistically different.INTERPRETATION: Our data suggests that the association between allogeneic blood transfusion and postoperative infection is limited to allogeneic blood products that are not adequately depleted of immunosuppressive leucocytes. This undesirable effect can be reduced by leucocyte depletion with high-efficiency filters.

Thirty-three patients who developed nosocomial pneumonia postoperatively were treated with ceftazidime, 4-6 g daily, over an average period of 7 days. Twenty-nine patients were evaluated; 13 (45%) patients were cured, five showed improvement, two relapsed, and one could not be assessed. X-rays of the chest showed no infiltrates in 17 out of the 29 cases (59%) after treatment. On the first day of treatment, ceftazidime concentrations in bronchial secretions of nine patients were estimated. The mean values of serum concentrations were: 15 min after infusion, 98 micrograms ml-1; 60 min, 63; 120 min, 44; 360 min, 20; 480 min, 13 micrograms ml-1. The mean values of the corresponding bronchial secretions were 2.9, 5.8, 10.2, 7.11 and 5.2 micrograms ml-1.

Most research on postoperative medical complications has focused on cardiac complications, whereas less attention has gone to pulmonary complications and the least attention to combined cardiac-noncardiac complications. Recent research has shown that postoperative pulmonary and cardiac complications after elective abdominal surgery and hip fracture repair are equally important clinically in terms of mortality and length of stay, and that patients with multiple complications are an important minority with the poorest outcomes (1,2). In a recent study of a predictive index for postoperative pneumonia in a large cohort of veterans undergoing various operations, the incidence of postoperative myocardial infarction was 7.5-fold greater in patients with postoperative pneumonia compared with those without pneumonia, but no information was given as to which occurred first

A review of the literature of bleeding duodenal diverticula is presented. Two adequately documented cases of bleeding from duodenal diverticula have been found. A third case is described of massive gastrointestinal hemorrhage from such a lesion, which was adequately controlled by surgery, although death followed, caused by overwhelming postoperative pneumonia. The uncontrollable or recurrent gastrointestinal bleeding in a patient with a radiographically demonstrable duodenal diverticulum and no other significant lesion should be considered an indication for exploration.

T HE administration of bIood as a therapeutic agent is a very oId procedure, and in primary anemic cases where the repIacement of substance pIays the main roIe, is, of course, we11 known. The appIication we have in mind is the withdrawa of a smaI1 amount of bIood from the patient’s vein and reinjection directIy into the body. In 1898, Grafstrom and EIfstroml appIied autotransfusion in a case of pneumonia. Ten years Iater BaIfour2 used this method as a specific therapy. AI1 authors empIoyed it pureIy empiricaIIy without expIanation of its action. In 1913 autohemotherapy was advocated by Spiethoff3 in dermatoIogy and considered an unspecific protein therapy. Autohemotherapy has since been used extensiveIy in a variety of diseases and conditions. The resuIts were encouraging in postoperative pneumonia, furuncuIosis, bronchitis, eczemas and urticaria. A good resuIt in postoperative Iung compIications is manifested by the dechne of temperature within twenty-four to forty-eight hours after administration and disappearance of symptoms. There are five different methods of appIication : I. Intramuscular injection of defibrinated bIood; 20 C.C. of bIood is dehbrinated by shaking in a flask with gIassbeads and injected immediately. 2. IntramuscuIar injection of 16 C.C. of fresh bIood mixed with 4 C.C. of distiIIed water. 3. IntramuscuIar injection of unaItered fresh bIood. YORK