Efficacy and safety of postoperative early mobilization for chronic subdural hematoma in elderly patients

BACKGROUND

The incidences of chronic subdural hematoma (CSDH) will probably increase with the aging of the population; thus, postoperative care of elderly CSDH patients may play a more important role in surgical management. The aim of this study was to evaluate the efficacy of and adverse effects after postoperative early mobilization (EM) for elderly CSDH patients.

METHODS

This is a single-institution historical control study. One hundred eighty-two patients with CSDH aged 65 years and older underwent one burr-hole surgery between 2001 and 2008. This institution has prospectively conducted an EM protocol after surgery since 2005. The emphasis of the EM was helping patients not only to an upright position but also to walk beginning the day of operation. The incidences of postoperative complications and recurrence of CSDH were compared between the EM group (n = 91; 76.5 +/- 6.5 years old) and a delayed mobilization (DM) group (n = 91; 77.9 +/- 7.5 years old).

RESULTS

Postoperative complications, such as pneumonia and urinary tract infection, was observed in 24 (26.4%) in the DM group and 11 (12.1%) in the EM group (p < 0.05). The rate of recurrence did not differ between the two groups (6.6% and 8.8%, respectively; p = 0.58).

CONCLUSIONS

The results suggest that EM after one burr-hole surgery prevents postoperative complications without increasing the risk of recurrence in CSDH patients > or =65 years of age.

Peri-operative blood transfusion increases length of hospital stay and number of postoperative complications in non-cardiac surgical patients

OBJECTIVES

To test the hypothesis that blood transfusion alone was a significant risk factor for in-hospital morbidity in non-cardiac patients.

DESIGN

Propensity analysis.

SETTING

University teaching hospital, Hong Kong.

PATIENTS

Consecutive non-cardiac patients seen in our department from 2006 to early 2009 who underwent a major procedure under general or spinal anaesthesia were included. Propensity analysis was performed to neutralise the confounding effects of preoperative variables and identify the true effects of transfusions on surgical outcomes.

MAIN OUTCOME MEASURES

Receipt of intra-operative and postoperative blood transfusion was established and the difference in proportions between patients who did and did not receive donor blood tested for mortality, overall morbidity, individual complications, and number of adverse events.

RESULTS

Transfused patients were significantly older and sicker, more likely to be male, to have lower haemoglobin values and undergo longer and more emergency surgical procedures than those not receiving a transfusion. Blood transfusion was predictive of length of postoperative hospital stay and number of complications before discharge. The amount of transfused blood was predictive of in-hospital mortality, with an odds ratio of 1.4 for each unit of blood received. The risk of a surgical wound infection was almost doubled when the patient had received a blood transfusion.

CONCLUSION

After controlling for the factors associated with an increased likelihood for receiving a blood transfusion, the actual transfusion was predictive of a slower and more eventful postoperative recovery with associated costs to both the patient and health services.

A prospective study of early ambulation 90 minutes post-left heart catheterization using a retrospective comparison group

BACKGROUND

Despite a trend toward a reduction in bedrest time after left heart catheterization (LHC) in many Canadian centres, an evidence-based standard of practice has not been established. Canadian bedrest times range from two to four hours post-LHC. Two recent prospective non-randomized studies (n = 1,000) indicate safety of ambulation at 60 and 90 minutes post-LHC.

PURPOSE

The purpose of this study was to determine safety of ambulating patients at 90 minutes post-LHC sheath removal compared to the current practice of ambulation at three to four hours post-sheath removal.

DESIGN

The study was a prospective non-concurrent design with a retrospective control. METHOD/SAMPLE: Retrospective data from the APPROACH database and chart reviews were analyzed for a period of six months for the control group on the traditional three- to four-hour ambulation protocol (n = 402). Prospective data were gathered for six months for the experimental group (n = 193).

RESULTS

There was no difference in complication rates for the two groups.

CONCLUSIONS

The results suggest that early ambulation for selected patients at 90 minutes is safe and has the potential to increase both patient comfort and quality of care.

Unplanned intubation after surgery: risk factors, prognosis, and medical emergency team effects

Unplanned intubation after surgery is a marker for severe adverse events. We investigated the incidence, risk factors, and prognosis of unplanned intubation after general and vascular surgery and sought to determine whether the deployment of a hospital-wide medical emergency team (MET) had a preventive effect. We included all patients undergoing general and vascular surgical procedures between April 1, 2006, and June 30, 2008, from our American College of Surgeons National Surgical Quality Improvement Program data. Risk factors and incidence rates of unplanned intubation were compared before (preMET) and after (postMET) June 7, 2007. Chart review identified case details and fatality rates. There were 2426 patients included (1815 preMET, 611 postMET). The overall incidence of unplanned intubation was 2.6 per cent; significant risk factors included chronic obstructive pulmonary disease, dependent functional status, and emergent operation. Most (84%) unplanned intubations occurred in a critical care setting and the most common underlying reason was sepsis (40%). The overall case fatality rate was 43 per cent but varied significantly depending on the underlying reason for unplanned intubation. Incidence rates of unplanned intubation did not change significantly after MET deployment, suggesting that other strategies are needed to prevent this rare but highly morbid and mortal event.

An osteoporotic hip fracture in a 14-year-old girl undergoing chemotherapy and operated for knee osteosarcoma

Non-weight-bearing, pre- and postsurgical immobilization, neoadjuvant and adjuvant chemotherapy are known to act on bone turnover, causing osteoporosis over short and long time periods. Treatment of fracture insurgence is very difficult because it really depends on being able to choose the right time (i.e., when immunodeficiency is less important). We report a case of spontaneous neck femur fracture during adjuvant chemotherapy in a young girl treated with resection and prosthesis reconstruction for distal femur osteosarcoma. Possible prevention and the correct approach and surgical timing are emphasized considering immunodeficiency following chemotherapy.

Acute kidney injury in adult postcardiotomy patients with extracorporeal membrane oxygenation: evaluation of the RIFLE classification and the Acute Kidney Injury Network criteria

INTRODUCTION

Acute kidney injury (AKI) is one of the major complications in adult postcardiotomy patients on extracorporeal membrane oxygenation (ECMO) support. The RIFLE (the Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function and End-Stage Kidney Disease) classification and the Acute Kidney Injury Network (AKIN) criteria were proposed to identify and classify AKI recently. This study aims to evaluate the occurrence of AKI during the initial 48 h of ECMO support by using both the RIFLE classification and the AKIN criteria, and to determine which scoring tool has better capability for predicting hospital mortality of adult postcardiotomy patients with ECMO support.

METHODS

From 2004 to 2008, 67 patients (> or = 18 years) who received extracorporeal membrane oxygenation support after undergoing cardiac surgery were enrolled and retrospectively evaluated.

RESULTS

The average age was 50.5+/-13.6 years; 48 patients (72%) were male. According to the RIFLE classification and the AKIN criteria, the incidence of AKI during first 48 h after receiving ECMO support was 81% and 85%, respectively. The overall mortality was 51% and the hospital mortality was much higher among patients who received renal replacement therapy (RRT) than in patients not receiving RRT (73% vs 32%, p=0.001). Either class-Failure for the RIFLE classification (odds ratio (OR)=12.6, 95% confidence interval (CI)=2.2-72.3, p=0.005) or the Stage 3 for the AKIN (OR=30.8, 95% CI=3.3-287.2, p=0.003) was found to be independently associated with the hospital mortality. The area under the receiver operator characteristic (ROC) curve for hospital mortality was 0.738 for the RIFLE classification (p=0.001) and was 0.799 for the AKIN criteria (p<0.001). No significant differences were found in both the incidence of AKI and the hospital mortality of AKI by using the RIFLE/AKIN criteria.

CONCLUSIONS

Acute kidney injury is a major complication and associated with high mortality in adult patients who received ECMO support after undergoing cardiac surgery. Both the RIFLE classification and the AKIN criteria have good short-term prognostic capability in these populations and either class-Failure for the RIFLE classification or the Stage 3 for the AKIN were found to be independently associated with the hospital mortality. However, it does not seem that the AKIN criteria have greater sensitivity and specificity, compared with the RIFLE classification in this study population.

Stomal mucocutaneous dehiscence as a complication of topical negative pressure used to treat an open abdomen: a case series

Although mucocutaneous dehiscence in cases of laparostomies is rare, this complication occurred in three patients in The Netherlands (all men, 53 to 65 years old) who received topical negative pressure (TNP) therapy in the management of open abdomens. Two patients experienced anastomotic failure following colonic resection and one had iatrogenic suturing of the small bowel to the fascia. TNP therapy was initiated and stomal dehiscence occurred after 2 to 3 days, contaminating the area. All patients developed sepsis and one died. Two required numerous additional surgeries and antibiotic treatments for 6 and 8 months, respectively. The complication was believed to have occurred as a result of tension on the proximal bowel of the stoma (the bowel inside the abdomen) not due to tension on the sutures or the small part of the bowel outside the abdomen. A modified TNP procedure, consisting of careful placement of the primary dressing around the stoma using separate primary dressing flaps, has since been used without complications in one patient. With implementation of TNP increasing and because of concerns regarding its use, additional research and innovative, simple solutions to manage complex wounds such as the one presented here are needed.

Degree of risk related to procedures performed in conjunction with surgical myocardial revascularization in octogenarians

INTRODUCTION/OBJECTIVES

We determined the degree of risk produced by the association of other surgical procedures with surgical myocardial revascularization in octogenarian patients and identified the risk factors that best explain hospital mortality.

METHODS

This study was an observational analytical historical cohort study involving octogenarians operated on at our institution between January 1, 2000 and January 1, 2005. We stratified the objective population as follows: Group 1 comprised octogenarians revascularized without associated procedures, and Group 2 comprised octogenarians revascularized with associated procedures. Statistical analyses included the t test for independent samples and multiple logistic regression analysis. Significance was accepted with an alpha error of 5%.

RESULTS

Univariate analyses revealed the following clinical and statistically significant variables: hospital mortality (P=0.002), diabetes mellitus (P=0.017), preoperative endocarditis (P=0.001), cardiogenic shock (P=0.019), use of an intra-aortic balloon pump (P=0.026), preoperative risk score (Parsonnet), P<0.001, procedure associated with revascularization (P<0.001), medium number of affected coronary arteries (P<0.001), use of extracorporeal circulation (P<0.001), time of extracorporeal circulation (P<0.001), number of distal anastomoses (P=0.002), graft type (P<0.001), postoperative breathing support (P<0.001), stroke (P<0.001), infection (P=0.002), creatinine level (P=0.018), and quality of life score (P=0.050).

DISCUSSION/CONCLUSIONS

In octogenarian patients, the need for a procedure associated with surgical myocardial revascularization produces an absolute increase in hospital mortality risk of 45%. The variables that contributed to hospital mortality were preoperative endocarditis, preoperative cardiogenic shock, the use of extracorporeal circulation, the length of time of extracorporeal circulation, postoperative creatinine level, and postoperative need for prolonged respiratory support.

[Complication due to invasive hemodynamic monitoring: formation of vast hematoma of the thigh]

The paper describes a case of the hemorrhagic event--as high as 1500 ml hematoma--resulting from femoral arterial catheterizing puncture for invasive hemodynamic monitoring in a seriously ill neurological care unit patient. The causes of this complication and possible ways of its prevention are discussed.

Ipsilateral re-expansion pulmonary edema in a neurosurgical patient--a case report

We report a case of a 42-year-old female with right parietal glioma, scheduled for elective craniotomy and tumor excision. The patient developed pneumothorax in the postoperative period. An incidence of unilateral pulmonary edema occurring as a result of rapid re-expansion of collapsed lungs is described. This type of pulmonary edema may delay postoperative recovery and have a catastrophic course especially in neurosurgical patients.

Postoperative topical antimicrobial use

Allergic contact dermatitis associated with topical antimicrobial agents is an increasing problem in the postoperative wound care period. We reviewed the topical antimicrobial agents most commonly used postoperatively in North America and Europe, examined the incidence of allergic contact dermatitis from each agent, and provided guidelines for the use of topical antimicrobials on closed and open wounds in the postoperative period. Neomycin was the most common cause of allergic contact dermatitis both in the general patch-tested population (11%) and in the postsurgical population. Bacitracin was also a common culprit, although at a lower rate (8%). There is a risk of co-reactivity between these two agents. Polymyxin B and mupirocin were not significant allergens. The rate of postoperative infectious complications in dermatologic surgery (1-2%) was similar to the rate of allergic contact dermatitis from topical antimicrobials (1.6-2.3%). We concluded that for closed wounds, the use of topical neomycin postoperatively should be avoided. White petrolatum is an efficacious and cost-effective alternative for closed wounds. For open wounds, topical antimicrobials that do not contain neomycin should be recommended.

Cutaneous microangiopathic thrombosis complicated by pyoderma gangrenosum in post-cardiac surgery heparin-induced thrombocytopaenia

Thrombotic cutaneous gangrene is a rare complication of heparin-induced thrombocytopaenia after cardiac surgery. We report a case and discuss management issues with cardiopulmonary bypass for cardiac surgery in this condition.

Inadvertent epidural administration of insulin

A 67-year-old female with insulin-dependent diabetes mellitus underwent an uncomplicated partial liver resection under combined epidural and general anaesthesia. After surgery, 50 U of insulin were accidentally infused into her epidural space over a period of 5 h in addition to her prescribed intravenous insulin infusion. After recognition of the accidental epidural administration, the patient was closely monitored for any neurological signs or symptoms. Blood glucose levels decreased significantly from 17.4 to 6.8 mmol.l(-1) over a period of 7 h. Despite the hazard of potentially neurotoxic preservatives in the insulin preparation, she suffered no neurological sequelae and made an uncomplicated recovery.

Cerebrovascular accidents in patients with a ventricular assist device

OBJECTIVE

A cerebrovascular accident is a devastating adverse event in a patient with a ventricular assist device. The goal was to clarify the risk factors for cerebrovascular accident.

METHODS

Prospectively collected data, including medical history, ventricular assist device type, white blood cell count, thrombelastogram, and infection, were reviewed retrospectively in 124 patients.

RESULTS

Thirty-one patients (25%) had 48 cerebrovascular accidents. The mean ventricular assist device support period was 228 and 89 days in patients with and without cerebrovascular accidents, respectively (P < .0001). Sixty-six percent of cerebrovascular accidents occurred within 4 months after implantation. Actuarial freedom from cerebrovascular accident at 6 months was 75%, 64%, 63%, and 33% with the HeartMate device (Thoratec Corp, Pleasanton, Calif), Thoratec biventricular ventricular assist device (Thoratec Corp), Thoratec left ventricular assist device (Thoratec), and Novacor device (WorldHeart, Oakland, Calif), respectively. Twenty cerebrovascular accidents (42%) occurred in patients with infections. The mean white blood cell count at the cerebrovascular accident was greater than the normal range in patients with infection (12,900/mm3) and without infection (9500/mm3). The mean maximum amplitude of the thrombelastogram in the presence of infection (63.6 mm) was higher than that in the absence of infection (60.7 mm) (P = .0309).

CONCLUSIONS

The risk of cerebrovascular accident increases with a longer ventricular assist device support period. Infection may activate platelet function and predispose the patient to a cerebrovascular accident. An elevation of the white blood cell count may also exacerbate the risk of cerebrovascular accident even in patients without infection. Selection of device type, prevention of infection, and meticulous control of anticoagulation are key to preventing cerebrovascular accident.

Enteral drugs given through a central venous catheter

A 74-year-old lady was given verapamil oral solution and a diclofenac dispersible tablet through her subclavian central venous catheter instead of her nasogastric tube five days after major head and neck surgery. The ensuing respiratory arrest resulting from profound ventilation-perfusion mismatch was made harder to manage by her potentially difficult airway. Information about the management of enteral drugs inadvertently given intravenously is sparse, and this sort of misrouting error is likely to be underreported. This case highlights the ease with which enteral preparations can be given by the wrong route.

Using negative pressure wound therapy following surgery for complex pilonidal disease: a case series

Complex pilonidal disease, an uncommon manifestation of an anorectal condition, is characterized by chronic or recurrent abscesses with extensive, branching sinus tracts. Definitive treatment requires wide excision of all involved tissue followed by secondary intention healing or reconstructive surgery. All treatment options have unique advantages and disadvantages. Following recent reports that negative pressure wound therapy after surgery for complex pilonidal disease may be a useful alternative to moist saline dressing treatments, five patients (three men and two women, median age 21 years [range: 16 to 63 years]) with complex pilonidal disease (symptom duration range 6 months to 30 years) were treated on an outpatient basis. Following wide excision under general anesthesia, a portable negative pressure wound therapy device was applied. Mean wound defect size after excision was 11 cm x 4 cm x 5 cm, or 205 cm(3) (range 90 cm(3) to 410 cm(3)). Negative pressure wound therapy was used for an average of 6 weeks (range 4 to 9 weeks) and mean time to complete epithelialization was 12 weeks (range 9 to 22 weeks), including use of moist saline dressings post negative pressure wound therapy. Treatment was discontinued in one patient due to skin irritation. No other complications were observed. Long-term follow-up is required to assess the risk of recurrent pilonidal disease or wound failure following negative pressure wound therapy. Additional studies of negative pressure wound therapy in the management of pilonidal disease are warranted.

Major complications of epidural analgesia after surgery: results of a six-year survey

We performed a retrospective case note review to identify the major complications of epidural analgesia occurring after surgery at our hospital. By cross-referencing the radiology, microbiology and patient information management system databases, we identified patients who had undergone either spinal magnetic resonance imaging or a lumbar puncture within 60 days of surgery in the period from January 2000 to December 2005. Review of these case notes identified six cases of epidural abscess, three of meningitis and three of epidural haematoma. Symptoms of epidural abscess or meningitis developed a median of 5 days after epidural catheter removal. Methicillin-resistant Staphylococcus aureus was the predominant pathogen. Epidural haematoma symptoms developed while the epidural catheter was in place. These symptoms were initially attributed to the epidural infusion. Diagnostic delays contributed to adverse neurological outcome in three patients. This study suggests that leg weakness is a critical monitor of spinal cord health. A national database is needed to establish a more accurate estimate of the incidence of major complications and to identify relevant risk factors.