Urinary mitochondrial DNA is a biomarker of mitochondrial disruption and renal dysfunction in acute kidney injury

Recent studies show the importance of mitochondrial dysfunction in the initiation and progression of acute kidney injury (AKI). However, no biomarkers exist linking renal injury to mitochondrial function and integrity. To this end, we evaluated urinary mitochondrial DNA (UmtDNA) as a biomarker of renal injury and function in humans with AKI following cardiac surgery. mtDNA was isolated from the urine of patients following cardiac surgery and quantified by quantitative PCR. Patients were stratified into no AKI, stable AKI, and progressive AKI groups based on Acute Kidney Injury Network (AKIN) staging. UmtDNA was elevated in progressive AKI patients and was associated with progression of patients with AKI at collection to higher AKIN stages. To evaluate the relationship of UmtDNA to measures of renal mitochondrial integrity in AKI, mice were subjected to sham surgery or varying degrees of ischemia followed by 24 h of reperfusion. UmtDNA increased in mice after 10-15 min of ischemia and positively correlated with ischemia time. Furthermore, UmtDNA was predictive of AKI in the mouse model. Finally, UmtDNA levels were negatively correlated with renal cortical mtDNA and mitochondrial gene expression. These translational studies demonstrate that UmtDNA is associated with recovery from AKI following cardiac surgery by serving as an indicator of mitochondrial integrity. Thus UmtDNA may serve as valuable biomarker for the development of mitochondrial-targeted therapies in AKI.

Acute metabolic response to fasted and postprandial exercise

The aim of this study was to analyze the acute metabolic response to exercise in fasting and postprandial. For this, ten individuals were submitted to an incremental treadmill test, with an initial speed of 5 and 1 km/h increments every minute, with no inclination, and a body composition assessment. After this 1st day, all volunteers were submitted to two experimental procedures (fasting and postprandial), with an aerobic exercise performed for 36 minutes at 65% of maximal oxygen consumption. At postprandial procedure, all subjects ingested a breakfast containing 59.3 g of carbohydrate (76.73%), 9.97 g of protein (12.90%), 8.01 g of lipids (10.37%), with a total energy intake of 349.17 kcal. An analysis of plasma concentration of triglycerides, lactate, and glucose was performed in two stages: before and after exercise. The Shapiro–Wilk test was used to verify the normality of the data. For analysis of glucose concentration, plasma lactate, and triglycerides, we used a repeated measures analysis of variance factorial 2×2, with Bonferroni multiple comparison test. The significance level of P<0.05 was adopted. The results indicated a maintenance level of glucose at fasting and a decrease in glucose concentration at postprandial exercise. Both conditions increase plasma lactate. Triglycerides also increased in the two experimental conditions; however, after exercise fasting, the increase was significantly higher than in the postprandial exercise. These data suggest that both exercises could increase plasma lactate and triglycerides. However, exercise performed in fasting condition decreases glucose concentration and increases triglycerides, even more than postprandial exercise.

Translation and validation of the Danish version of the postoperative quality of recovery score QoR-15

BACKGROUND

Patient perceived quality of recovery is an important outcome after surgery and should be measured in clinical trials. Quality of recovery after surgery and general anaesthesia can be measured by the QoR-15. A high score indicates a good recovery and the score ranges from 0 to 150. The aim of this study was to translate the QoR-15 questionnaire into Danish and do a full psychometric evaluation of the Danish version.

METHODS

A translation and cultural adaption of the original version of the QoR-15 into a Danish version, the QoR-15D, was performed. After obtaining consent, patients undergoing elective abdominal, orthopaedic or gynaecological surgery under general anaesthesia were included. Patients completed the QoR-15D before surgery and on the first postoperative day. The validity, reliability, responsiveness and clinical feasibility of the QoR-15D were evaluated.

RESULTS

One hundred and forty patients returned their pre- and postoperative questionnaire successfully giving a completion rate of 56%. The postoperative QoR-15 score was negatively correlated with duration of surgery (ρ = -0.21, 95% CI: -0.04 to -0.36, P < 0.02) and postoperative stay (ρ = -0.28, 95% CI: -0.12 to -0.43, P < 0.01). Postoperative QoR-15D scores were inversely related to the extent of surgery: minor, intermediate or major (127 ± 22, 106 ± 29 and 96 ± 24, respectively, P < 0.01). Cronbach's alpha and split-half reliability was 0.90 and 0.88. Test-retest reliability was 0.99 (95% CI: 0.94-1.00). Cohen's effect size was 1.13 and the standardized response mean was 0.82.

CONCLUSION

The QoR-15D has preserved the validity, excellent reliability, high degree of responsiveness and the clinical feasibility of the original English version.

Massive hemorrhage management-a best evidence topic report

Introduction

Massive hemorrhage remains a major cause of potentially preventable deaths. Better control of bleeding could improve survival rates by 10%–20%. Transfusion intervention concepts have been formulated in order to minimize acute traumatic coagulopathy. These interventions still have not been standardized and vary among medical centers.

Materials and Methods

Based on a literature search using free term keywords and Medical Subject Heading (MeSH) index, we analyzed published articles addressing massive hemorrhage, component therapy, fresh whole blood, and fibrinogen from the year 2000 onward, in journals with impact factor >1.000, in Medline, PubMed, and Google Scholar. The evidence was grouped into topics including laboratory testing and transfusion interventions/viscoelastic assays vs standard laboratory tests, the effect of component therapy on patient outcome, the effect of warm fresh whole blood on patient outcome, and the effects of fibrinogen in severe bleeding. The obtained information was compared, evaluated, confronted, and was focused on to present an adequate and individual-based massive hemorrhage management approach.

Results

Viscoelastic whole-blood assays are superior to standard coagulation blood tests for the identification of coagulopathy and for guiding decisions on appropriate therapy in patients with severe bleeding. Replacement of plasma, red blood cells, platelets, and fibrinogen in a ratio of 1:1:1:1 has appeared to be the best substitution for lost whole blood. There is no evidence that cryoprecipitate improves the outcome of patients with severe hemorrhage. Current literature promotes the transfusion of warm fresh whole blood, which seems to be superior to the component therapy in certain clinical situations. Some authors recommend that fibrinogen and other coagulation factors be administered according to the viscoelastic attributes of the blood clot.

Conclusion

This best-evidence topic report brings comprehensive information about massive hemorrhage management.

[Influencing factor of postoperation fast-track recovery and in hospital cost after lobctomy for lung cancer]

BACKGROUND

It is unknown that the postoperation fast-track recovery and in hospital cost of the lobectomy in lung cancer, we explored the influencing factor of postoperative fast-track recovery and in hospital cost after undergoing lobectomy for lung cancer.

METHODS

We retrospectively reviewed the medical records of all patients (n=176) who underwent lobectomy for lung cancer between January 2010 and November 2011 by a thoracic surgeon.

RESULTS

The hospital costs of video-assisted thoracic surgery (VATS) lobectomy (47,308.21 ¥) is significantly higher than open lobectomy (45,664.31 ¥)(P=0.007). The hospital costs of body mass index (BMI) ≥ 24 kg/m2 (51,186.99 ¥) is significantly higher than BMI < 24 kg/m2 (41,701.64 ¥)(P=0.032). The hospital stay of VATS lobectomy (5.70 d) is significantly less than open lobectomy (7.10 d)(P<0.001).

CONCLUSIONS

These findings indicate that preoperative pulmonary rehabilitation and VATS lobectomy is contributed to fast-track recovery for patients who undergo lobectomy, but increase the hospital costs.

Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia

Guidelines are presented for the organisational and clinical peri-operative management of anaesthesia and surgery for patients who are obese, along with a summary of the problems that obesity may cause peri-operatively. The advice presented is based on previously published advice, clinical studies and expert opinion.

Cardiopulmonary exercise testing after laryngectomy: A connection conundrum

A patient presents with a new bronchogenic carcinoma 5 years after laryngectomy for recurrent laryngeal tumor and 13 years after chemoradiation for concurrent lung cancer with synchronous base-of-tongue tumor. Due to his complex history and perceived limited respiratory reserve, he was felt high risk for the completion pneumonectomy needed for resection of this new tumor. The attending surgeon requested a full cardiopulmonary exercise test for risk assessment prior to surgery. We found that there was no commercially available connector that would allow our CPET equipment to reliably collect respiratory gases from a patient with tracheostomy stoma or tube. We report here a simple coupling devised "in house" that allowed for the performance of an interpretable test leading to a significant change in medical care.

Creatinine and myoglobin are poor predictors of anaerobic threshold in colorectal cancer and health

AIMS

Myoglobin is a haem protein produced in skeletal muscles. Serum concentrations of myoglobin have been proposed as a surrogate marker of muscle mass and function in both cachectic cancer patients and healthy non-cancer individuals. Creatinine, a metabolite of creatine phosphate, an energy store found in skeletal muscle, is produced at a constant rate from skeletal muscle. Urinary and plasma creatinine have been used in clinical practice as indicators of skeletal muscle mass in health and disease. Our study aimed to test the hypothesis that plasma myoglobin and creatinine concentration could accurately predict skeletal muscle mass and aerobic capacity in colorectal cancer (CRC) patients and matched healthy controls and thereby an indicative of aerobic performance.

METHODS

We recruited 47 patients with CRC and matching number of healthy volunteers for this study. All participants had their body composition measured by dual-energy X-ray absorptiometry scan, aerobic capacity measured to anaerobic threshold (AT) by cardiopulmonary exercise testing and filled in objective questionnaires to assess the qualitative functions. This study was carried out in accordance with the Declaration of Helsinki, after approval by the local National Health Service (NHS) Research Ethics Committee.

RESULTS

Age-matched groups had similar serum myoglobin and creatinine concentrations in spite of differences in their aerobic capacity. AT was significantly lower in the CRC group compared with matched controls (1.18 ± 0.44 vs. 1.41 ± 0.71 L/min; P < 0.01). AT had significant correlation with lean muscle mass (LMM) among these groups, but myoglobin and creatinine had poor correlation with LMM and AT.

CONCLUSIONS

Serum myoglobin is a poor predictor of muscle mass, and serum myoglobin and creatinine concentrations do not predict aerobic performance in CRC patients or healthy matched controls.

Lithotomy versus jack-knife position on haemodynamic parameters assessed by impedance cardiography during anorectal surgery under low dose spinal anaesthesia: a randomized controlled trial

BACKGROUND

Although the prone position providing better exposure for anorectal surgery is required it can cause a reduction of cardiac output and cardiac index. The goal was to compare haemodynamic changes assessed by impedance cardiography during anorectal surgery under low-dose spinal anaesthesia in lithotomy and jack-knife position.

METHODS

The prospective randomized controlled study included 104, ASA I-II adult patients admitted for elective minor anorectal surgery, assigned to be performed in lithotomy (groupL, n = 52) or jack-knife position (groupJ, n = 52). After arrival to operating room the standard monitoring, impedance cardiography device was connected to the patient, and the following variables were recorded: cardiac output, cardiac index, systemic vascular resistance, stroke index at times of arrival to operating room, placement for, start and end of surgery and placement to bed. Spinal block was made in the sitting position with 4 mg of 0.5% hyperbaric bupivacaine and 10 μg of Fentanyl injected over 2 min. Comparison was based on haemodynamic changes between and inside groups over time. Student's t, chi square tests were used for statistical analysis with p < 0.05 regarded as statistically significant.

RESULTS

The reduction of cardiac output was statistically significant after placement of the patient into the prone position: from baseline 7.4+/-1.6 to 4.9+/-1.2 after placement for and 4.7+/-1.2 at the start and end of surgery (mean +/-SD l/min). The difference of cardiac output between groups was 2.0 l/min after positioning for and the start of surgery and 1.5 l/min at the end of surgery (p < 0.05). Mean cardiac index reduced from baseline 3.9+/-0.8 to 2.6+/-0.7 and 2.4+/-0.6 (mean+/-SD l/min/m(2)) in groupJ and between groups: by 1.0 l/min/m(2) after placement for, 1.1 at the start and 0.8 at the end of surgery (p < 0.05). Systemic vascular resistance increased from baseline 1080+/-338 to 1483+/-479 after placement for, 1523+/-481 at the start and 1525+/-545 at the end of surgery in groupJ (mean+/-SD dynes/sec/cm(-5), p < 0.05).

CONCLUSIONS

According to impedance cardiography, jack-knife position after low-dose spinal anaesthesia produces transitory, but statistically significant reduction of cardiac output and cardiac index with increase of systemic vascular resistance, compared to insignificant changes in lithotomy position.

TRIAL REGISTRATION

Clinical Trials NCT02115178.

Urinary neutrophil gelatinase-associated lipocalin in critically ill surgical cancer patients

BACKGROUND AND AIMS

Neutrophil gelatinase-associated lipocalin (N-GAL) is an early biomarker of acute kidney injury (AKI) due to various etiologies. On the other hand, N-GAL is also elevated in patients with acute inflammatory conditions and in several solid neoplasms. The goal of this study was to assess the efficacy of N-GAL as a predictor of AKI and mortality in oncological surgical patients postoperatively in the intensive care unit (ICU).

METHODS

This was a prospective cohort observation study on adult cancer patients submitted to elective or emergency surgeries and admitted in the ICU. Urinary N-GAL was measured at the first 2 h after admission. AKI incidence and other complications were assessed, including hospital mortality.

RESULTS

A total of 22 patients were assessed (77% male, age 52.8 years, Acute Physiology and Chronic Health Evaluation II [APACHE II] 17.3) in whom the most frequent site of cancer was the gastrointestinal tract. AKI incidence was 13.6%. Urinary N-GAL was a predictor of AKI (22.0 ng/ml in patients without AKI vs. 239.1 ng/ml in patients with AKI, P < 0.001). Multivariate analysis showed that the main predictors of AKI were age, APACHE II, and N-GAL. N-GAL was also higher, although not statistically significant in patients who died in the hospital.

CONCLUSIONS

In oncological postoperative patients admitted to the ICU, urinary N-GAL was an independent predictor of AKI; moreover, its level was higher in the deceased patients.

Traumatic cardiac arrest

Traumatic cardiac arrest is known to have a poor outcome, and some authors have stated that attempted resuscitation from traumatic cardiac arrest is futile. However, advances in damage control resuscitation and understanding of the differences in pathophysiology of traumatic cardiac arrest compared to medical cardiac arrest have led to unexpected survivors. Recently published data have suggested that outcome from traumatic cardiac arrest is no worse than that for medical causes of cardiac arrest, and in some groups may be better. This review highlights key areas of difference between traumatic cardiac arrest and medical cardiac arrest, and outlines a strategy for the management of patients in traumatic cardiac arrest. Standard Advanced Life Support algorithms should not be used for patients in traumatic cardiac arrest.

Proposed research plan for the derivation of a new Cardiac Risk Index

The Revised Cardiac Risk Index (RCRI) was incorporated into the American College of Cardiology/American Heart Association (ACC/AHA) recommendations for the preoperative evaluation of the cardiac patient for noncardiac surgery. The purpose of this review was to analyze studies on cardiovascular clinical risk prediction that had used the previous "standard best" model, the RCRI, as a comparator. This review aims to determine whether modification of the current risk factors or adoption of other risk factors or other risk indices would improve upon the discrimination of cardiac risk prediction when compared with the RCRI. This is necessary because recent risk prediction models have shown better discrimination for major adverse cardiac events, and the pre-eminence of the RCRI is now in question. There is now a need for a new "best standard" cardiovascular risk prediction model to supersede the RCRI. This is desirable because it would: (1) allow for a global standard of cardiovascular risk assessment; (2) provide a standard comparator in all risk prediction research; (3) result in comparable data collection; and (4) allow for individual patient data meta-analyses. This should lead to continued progress in cardiovascular clinical risk prediction. A review of the current evidence suggests that to improve the preoperative clinical risk stratification for adverse cardiac events, a new risk stratification model be built that maintains the clinical risk factors identified in the RCRI, with the following modifications: (1) additional glomerular filtration rate cut points (as opposed to a single creatinine cut point); (2) age; (3) a history of peripheral vascular disease; (4) functional capacity; and (5) a specific surgical procedural category. One would expect a substantial improvement in the discrimination of the RCRI with this approach. Although most noncardiac surgeries will benefit from a standard "generic" cardiovascular risk prediction model, there are data to suggest that patients with human immunodeficiency virus disease who are undergoing vascular surgery may benefit from specific cardiovascular risk prediction models.

The pathophysiological role of interstitial sodium in heart failure

The current understanding of heart failure (HF) does not fully explain the spectrum of HF symptoms. Most HF hospitalizations are related to sodium (Na(+)) and fluid retention resulting from neurohumoral up-regulation. Recent insights suggest that Na(+) is not distributed in the body solely as a free cation, but that it is also bound to large interstitial glycosaminoglycan (GAG) networks in different tissues, which have an important regulatory function. In HF, high Na(+) intake and neurohumoral alterations disrupt GAG structure, leading to loss of the interstitial buffer capacity and disproportionate interstitial fluid accumulation. Moreover, a diminished endothelial GAG network (the endothelial glycocalyx) results in increased vascular resistance and disturbed endothelial nitric oxide production. New imaging modalities can help evaluate interstitial Na(+) and endothelial glycocalyx integrity. Furthermore, several therapies have been proven to stabilize interstitial GAG networks. Hence, a better appreciation of this new Na(+) "compartment" might improve current management of HF.

Perioperative fluid therapy: a statement from the international Fluid Optimization Group

BACKGROUND

Perioperative fluid therapy remains a highly debated topic. Its purpose is to maintain or restore effective circulating blood volume during the immediate perioperative period. Maintaining effective circulating blood volume and pressure are key components of assuring adequate organ perfusion while avoiding the risks associated with either organ hypo- or hyperperfusion. Relative to perioperative fluid therapy, three inescapable conclusions exist: overhydration is bad, underhydration is bad, and what we assume about the fluid status of our patients may be incorrect. There is wide variability of practice, both between individuals and institutions. The aims of this paper are to clearly define the risks and benefits of fluid choices within the perioperative space, to describe current evidence-based methodologies for their administration, and ultimately to reduce the variability with which perioperative fluids are administered.

METHODS

Based on the abovementioned acknowledgements, a group of 72 researchers, well known within the field of fluid resuscitation, were invited, via email, to attend a meeting that was held in Chicago in 2011 to discuss perioperative fluid therapy. From the 72 invitees, 14 researchers representing 7 countries attended, and thus, the international Fluid Optimization Group (FOG) came into existence. These researches, working collaboratively, have reviewed the data from 162 different fluid resuscitation papers including both operative and intensive care unit populations. This manuscript is the result of 3 years of evidence-based, discussions, analysis, and synthesis of the currently known risks and benefits of individual fluids and the best methods for administering them.

RESULTS

The results of this review paper provide an overview of the components of an effective perioperative fluid administration plan and address both the physiologic principles and outcomes of fluid administration.

CONCLUSIONS

We recommend that both perioperative fluid choice and therapy be individualized. Patients should receive fluid therapy guided by predefined physiologic targets. Specifically, fluids should be administered when patients require augmentation of their perfusion and are also volume responsive. This paper provides a general approach to fluid therapy and practical recommendations.

Predictors of rational management of diarrhea in an endemic setting: observation from India

Background

Decades after the establishment of clear guidelines for management, mostly due to irrational approach, diarrhea is still a major concern in the developing world, including India. The scenario is even worse in urban slums owing to poor health-seeking and socio-environmental vulnerability. Determining the distribution of rational diarrhea management by practitioners and identification of its important predictors seemed urgent to minimize the potential for antibiotic resistance, diarrhea-related mortality and morbidity in these areas.

Methods

Between May 2011 and January 2012, 264 consenting, randomly selected qualified and non-qualified practitioners (including pharmacists) were interviewed in the slums of Kolkata, a populous city in eastern India, regarding their characteristics, diarrhea-related knowledge (overall and in six separate domains: signs/symptoms, occurrence/spread, management, prevention/control, cholera and ORS), prescribed antibiotics, intravenous fluid (IVF) and laboratory investigations. Rationality was established based on standard textbooks.

Results

Among participants, 53.03% had no medical qualifications, 6.06% were attached to Governmental hospitals, 19.32% had best knowledge regarding diarrhea. While treating diarrhea, 7.20%, 17.80% and 20.08% respectively advised antibiotics, IVF and laboratory tests rationally. Logistic regression revealed that qualified and Governmental-sector practitioners managed diarrhea more rationally. Having best diarrhea-related knowledge regarding signs/symptoms (OR=5.49, p value=0.020), occurrence/spread (OR=3.26, p value=0.035) and overall (OR=6.82, p value=0.006) were associated with rational antibiotic prescription. Rational IVF administration was associated with best knowledge regarding diarrheal signs/symptoms (OR=3.00, p value=0.017), occurrence/spread (OR=3.57, p value=0.004), prevention/control (OR=4.89, p value=0.037), ORS (OR=2.55, p value=0.029) and overall (OR=4.57, p value<0.001). Best overall (OR=2.68, p value=0.020) and cholera-related knowledge (OR=2.34, p value=0.019) were associated with rational laboratory testing strategy.

Conclusion

Diarrheal management practices were unsatisfactory in urban slums where practitioners’ knowledge was a strong predictor for rational management. Interventions targeting non-qualified, independent practitioners to improve their diarrhea-related knowledge seemed to be required urgently to ensure efficient management of diarrhea in these endemic settings.

Non-invasive hemodynamic monitoring in trauma patients

BACKGROUND

The assessment of hemodynamic status is a crucial task in the initial evaluation of trauma patients. However, blood pressure and heart rate are often misleading, as multiple variables may impact these conventional parameters. More reliable methods such as pulmonary artery thermodilution for cardiac output measuring would be necessary, but its applicability in the Emergency Department is questionable due to their invasive nature. Non-invasive cardiac output monitoring devices may be a feasible alternative.

METHODS

A systematic literature review was conducted. Only studies that explicitly investigated non-invasive hemodynamic monitoring devices in trauma patients were considered.

RESULTS

A total of 7 studies were identified as suitable and were included into this review. These studies evaluated in a total of 1,197 trauma patients the accuracy of non-invasive hemodynamic monitoring devices by comparing measurements to pulmonary artery thermodilution, which is the gold standard for cardiac output measuring. The correlation coefficients r between the two methods ranged from 0.79 to 0.92. Bias and precision analysis ranged from -0.02 +/- 0.78 l/min/m(2) to -0.14 +/- 0.73 l/min/m(2). Additionally, data on practicality, limitations and clinical impact of the devices were collected.

CONCLUSION

The accuracy of non-invasive cardiac output monitoring devices in trauma patients is broadly satisfactory. As the devices can be applied very early in the shock room or even preclinically, hemodynamic shock may be recognized much earlier and therapeutic interventions could be applied more rapidly and more adequately. The devices can be used in the daily routine of a busy ED, as they are non-invasive and easy to master.

Cardiopulmonary exercise testing for risk prediction in major abdominal surgery

Reduced exercise capacity is associated with increased postoperative morbidity. Cardiopulmonary exercise testing variables can be used to risk stratify patients. This information can be used to help guide the choice of surgical procedure and to decide on the most appropriate postoperative care environment. Thus CPET can aid collaborative decision making and improve the process of informed consent. In the future, CPET may be combined with other risk predictors to improve outcome prediction. Furthermore early evidence suggests that CPET can be used to guide prehabilitation training programs, improving fitness and thereby reducing perioperative risk.

The Effect of beta-blockade on objectively measured physical fitness in patients with abdominal aortic aneurysms--A blinded interventional study

BACKGROUND

Perioperative beta-blockade is widely used, especially before vascular surgery; however, its impact on exercise performance assessed using cardiopulmonary exercise testing (CPET) in this group is unknown. We hypothesized that beta-blocker therapy would significantly improve CPET-derived physical fitness in this group.

METHODS

We recruited patients with abdominal aortic aneurysms (AAA) of <5.5 cm under surveillance. All patients underwent CPET on and off beta-blockers. Patients routinely prescribed beta-blockers underwent a first CPET on medication. Beta-blockers were stopped for one week before a second CPET. Patients not routinely taking beta-blockers underwent the first CPET off treatment, then performed a second CPET after commencement of bisoprolol for at least 48 h. Oxygen uptake (.VO2) at estimated lactate threshold and .VO2 at peak were primary outcome variables. A linear mixed-effects model was fitted to investigate any difference in adjusted CPET variables on and off beta-blockers.

RESULTS

Forty-eight patients completed the study. No difference was observed in .VO2 at estimated lactate threshold and .VO2 at peak; however, a significant decrease in .VE/.VCO2 at estimated lactate threshold and peak, an increase in workload at estimated lactate threshold., O2 pulse and heart rate both at estimated lactate threshold and peak was found with beta-blockers. Patients taking beta-blockers routinely (chronic group) had worse exercise performance (lower .VO2 ).

CONCLUSIONS

Beta blockade has a significant impact on CPET-derived exercise performance, albeit without changing .VO2 at estimated lactate threshold and.VO2 at peak. This supports performance of preoperative CPET on or off beta-blockers depending on local perioperative practice.

CLINICAL TRIAL REGISTRATION

NCT 02106286.

Serum bicarbonate may independently predict acute kidney injury in critically ill patients: An observational study

AIM: To explore whether serum bicarbonate at admission to intensive care unit (ICU) predicted development of acute kidney injury (AKI).

METHODS: We studied all patients admitted to our ICU over a 2 year period (February 2010 to 2012). The ICU has a case mix of medical and surgical patients excluding cardiac surgical, trauma and neurosurgical patients. We analysed 2035 consecutive patients admitted to ICU during the study period. Data were collected by two investigators independently and in duplicate using a standardised spread sheet to ensure accuracy. Ambiguous data were checked for accuracy where indicated. AKI was defined using the Kidney Disease Improving Global Outcomes criteria. Patients were divided into two groups; patients who developed AKI or those who did not, in order to compare the baseline characteristics, and laboratory and physiologic data of the two cohorts. Regression analysis was used to identify if serum bicarbonate on admission predicted the development of AKI.

RESULTS: Of 2036 patients 152 (7.5%) were excluded due to missing data. AKI developed in 43.1% of the patients. The AKI group, compared to the non-AKI group, was sicker based on their lower systolic, diastolic and mean arterial pressures and a higher acute physiology and chronic health evaluation (APACHE) III and SAPS II scores. Moreover, patients who developed AKI had more co-morbidities and a higher proportion of patients who developed AKI required mechanical ventilation. The multi-regression analysis of independent variables showed that serum bicarbonate on admission (OR = 0.821; 95%CI: 0.796-0.846; P < 0.0001), APACHE III (OR = 1.011; 95%CI: 1.007-1.015; P < 0.0001), age (OR = 1.016; 95%CI: 1.008-1.024; P < 0.0001) and presence of sepsis at ICU admission (OR = 2.819; 95%CI: 2.122-23.744; P = 0.004) were each significant independent predictors of AKI. The area under the ROC curve was 0.8 (95%CI: 0.78-0.83), thereby demonstrating that the predictive model has relatively good discriminating power for predicting AKI.

CONCLUSION: Serum bicarbonate on admission may independently be used to make a diagnosis of AKI.

The relationship of perioperative fluid administration to outcomes in colorectal and pancreatic surgery: a review of the literature

Optimal perioperative fluid administration in major gastrointestinal surgery remains a challenging clinical problem. Traditional dogma of a liberal approach to fluid administration in order to counteract potential hypovolemia and decreased end-organ perfusion can often result in fluid overload, perhaps negatively impacting perioperative outcomes. This hypothesis has been investigated in several types of gastrointestinal surgery. We discuss the current literature on perioperative fluid administration in colorectal and pancreatic surgery and highlight the controversies that still exist.

Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery (ERAS)

PURPOSE

This review evaluates the current and future role of cardiopulmonary exercise testing (CPET) in the context of Enhanced Recovery After Surgery (ERAS) programs.

PRINCIPAL FINDINGS

There is substantial literature confirming the relationship between physical fitness and perioperative outcome in general. The few small studies in patients undergoing surgery within an ERAS program describe less fit individuals having a greater incidence of morbidity and mortality. There is evidence of increasing adoption of perioperative CPET, particularly in the UK. Although CPET-derived variables have been used to guide clinical decisions about choice of surgical procedure and level of perioperative care as well as to screen for uncommon comorbidities, the ability of CPET-derived variables to guide therapy and thereby improve outcome remains uncertain. Recent studies have reported a reduction in CPET-defined physical fitness following neoadjuvant therapies (chemo- and radio-therapy) prior to surgery. Preliminary data suggest that this effect may be associated with an adverse effect on clinical outcomes in less fit patients. Early reports suggest that CPET-derived variables can be used to guide the prescription of exercise training interventions and thereby improve physical fitness in patients prior to surgery (i.e., prehabilitation). The impact of such interventions on clinical outcomes remains uncertain.

CONCLUSIONS

Perioperative CPET is finding an increasing spectrum of roles, including risk evaluation, collaborative decision-making, personalized care, monitoring interventions, and guiding prescription of prehabilitation. These indications are potentially of importance to patients having surgery within an ERAS program, but there are currently few publications specific to CPET in the context of ERAS programs.

Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery (ERAS)

PURPOSE

This review evaluates the current and future role of cardiopulmonary exercise testing (CPET) in the context of Enhanced Recovery After Surgery (ERAS) programs.

PRINCIPAL FINDINGS

There is substantial literature confirming the relationship between physical fitness and perioperative outcome in general. The few small studies in patients undergoing surgery within an ERAS program describe less fit individuals having a greater incidence of morbidity and mortality. There is evidence of increasing adoption of perioperative CPET, particularly in the UK. Although CPET-derived variables have been used to guide clinical decisions about choice of surgical procedure and level of perioperative care as well as to screen for uncommon comorbidities, the ability of CPET-derived variables to guide therapy and thereby improve outcome remains uncertain. Recent studies have reported a reduction in CPET-defined physical fitness following neoadjuvant therapies (chemo- and radio-therapy) prior to surgery. Preliminary data suggest that this effect may be associated with an adverse effect on clinical outcomes in less fit patients. Early reports suggest that CPET-derived variables can be used to guide the prescription of exercise training interventions and thereby improve physical fitness in patients prior to surgery (i.e., prehabilitation). The impact of such interventions on clinical outcomes remains uncertain.

CONCLUSIONS

Perioperative CPET is finding an increasing spectrum of roles, including risk evaluation, collaborative decision-making, personalized care, monitoring interventions, and guiding prescription of prehabilitation. These indications are potentially of importance to patients having surgery within an ERAS program, but there are currently few publications specific to CPET in the context of ERAS programs.

Validating a scoring tool to predict acute kidney injury (AKI) following cardiac surgery

Background

Acute kidney injury (AKI) after cardiac surgery is associated with an increased risk of mortality. Preoperative risk scores can identify patients at risk for AKI and facilitate preventive strategies. Currently, validated risk scores are used to predict AKI requiring dialysis (AKI-D); less is known about whether these tools predict less severe forms of AKI.

Objective

To evaluate the Cleveland Clinic scoring tool in predicting both AKI-D and less severe stages of AKI in patients after cardiac surgery in a Canadian tertiary care center.

Design

Retrospective case–control study.

Setting

Regina Qu’Appelle Health Region (RQHR) from 2007 to 2011.

Patients

Patients who underwent cardiac surgery and developed postoperative kidney injury (n = 2316).

Measurements

Data on risk factors for AKI and outcomes of cardiac surgery were collected from a retrospective chart review.

Methods

The primary outcome was AKI, defined as Stage 1 (increase in serum creatinine 1.5-1.9 X baseline within 5 days), Stage 2 (increase 2.0-2.9 X baseline), or Stage 3 (increase 3.0 X baseline or more OR initiation of dialysis during hospital stay). We assessed the performance of a modified version of the Cleveland Clinic tool using receiver operating curve analyses.

Results

The incidence of AKI was 6.1% (Stage 1), 2.6% (Stage 2), and 5.8% (Stage 3). The area under the curve (AUC) for the Cleveland score was 0.61 (95% CI: 0.56 to 0.65; p < 0.001) for Stage 1, 0.61 (95% CI: 0.54 to 0.68; p < 0.01) for Stage 2, and 0.78 (95% CI: 0.74 to 0.82; p < 0.001) for Stage 3. Greater level of risk on the Cleveland tool was associated with a higher risk of Stage 3 AKI.

Limitations

Lack of prospective validation.

Conclusions

The modified Cleveland Clinic tool was valid in identifying patients with severe stages of AKI but did not have strong discrimination for early AKI stages.

Electronic supplementary material

The online version of this article (doi:10.1186/s40697-015-0037-x) contains supplementary material, which is available to authorized users.

Comparative evaluation of femoral nerve block and intravenous fentanyl for positioning during spinal anaesthesia in surgery of femur fracture

BACKGROUND

Spinal anaesthesia is the preferred technique to fix fracture of the femur. Extreme pain does not allow ideal positioning for this procedure. Intravenous fentanyl and femoral nerve block are commonly used techniques to reduce the pain during position for spinal anaesthesia however; results are conflicting regarding superiority of femoral nerve block over intravenous fentanyl.

AIMS

We conducted this study to compare the analgesic effect provided by femoral nerve block (FNB) and intra- venous (IV) fentanyl prior to positioning for central neuraxial block in patients undergoing surgery for femur fracture.

PATIENTS AND METHODS

In this randomized prospective study 60 patients scheduled for fracture femur operation under spinal were included. Patients were distributed in two groups through computer generated random numbers table; Femoral nerve block group (FNB) and Intravenous fentanyl group (FENT). In FNB group patients received FNB guided by a peripheral nerve stimulator (Stimuplex; B Braun, Melsungen, AG) 5 minutes prior to positioning. 20mL, 1.5% lidocaine with adrenaline (1:200,000) was injected incrementally after a negative aspiration test. Patients in the fentanyl group received injection fentanyl 1 μg/kg IV 5 mins prior to positioning. Spinal block was performed and pain scores before and during positioning were recorded. Statistical analysis was done with Sigmaplot version-10 computer software. Student t-test was applied to compare the means and P < 0.05 was taken as significant.

RESULTS

VAS during positioning in group FNB: 0.57 ± 0.31 versus FENT 2.53 ± 1.61 (P = 0.0020). Time to perform spinal anesthesia in group FNB: 15.33 ± 1.64 min versus FENT 19.56 ± 3.09 min (P = 0.000049). Quality of patient positioning for spinal anesthesia in group FNB 2.67± 0.606 versus FENT 1.967 ± 0.85 (P = 0.000027). Patient acceptance was less in group FENT (P = 0.000031).

CONCLUSION

Femoral nerve block provides better analgesia, patient satisfaction and satisfactory positioning than IV fentanyl for position during spinal anaesthesia in patients of fracture femur.

Pre-operative anaemia

Pre-operative anaemia is a relatively common finding, affecting a third of patients undergoing elective surgery. Traditionally associated with chronic disease, management has historically focused on the use of blood transfusion as a solution for anaemia in the peri-operative period. Data from large series now suggest that anaemia is an independent risk associated with poor outcome in both cardiac and non-cardiac surgery. Furthermore, blood transfusion does not appear to ameliorate this risk, and in fact may increase the risk of postoperative complications and hospital length of stay. Consequently, there is a need to identify, diagnose and manage pre-operative anaemia to reduce surgical risk. Discoveries in the pathways of iron metabolism have found that chronic disease can cause a state of functional iron deficiency leading to anaemia. The key iron regulatory protein hepcidin, activated in response to inflammation, inhibits absorption of iron from the gastrointestinal tract and further reduces bioavailability of iron stores for red cell production. Consequently, although iron stores (predominantly ferritin) may be normal, the transport of iron either from the gastrointestinal tract or iron stores to the bone marrow is inhibited, leading to a state of 'functional' iron deficiency and subsequent anaemia. Since absorption from the gastrointestinal tract is blocked, increasing oral iron intake is ineffective, and studies are now looking at the role of intravenous iron to treat anaemia in the surgical setting. In this article, we review the incidence and impact of anaemia on the pre-operative patient. We explain how anaemia may be caused by functional iron deficiency, and how iron deficiency anaemia may be diagnosed and treated.

Development and validation of the Surgical Outcome Risk Tool (SORT)

Background

Existing risk stratification tools have limitations and clinical experience suggests they are not used routinely. The aim of this study was to develop and validate a preoperative risk stratification tool to predict 30-day mortality after non-cardiac surgery in adults by analysis of data from the observational National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Knowing the Risk study.

Methods

The data set was split into derivation and validation cohorts. Logistic regression was used to construct a model in the derivation cohort to create the Surgical Outcome Risk Tool (SORT), which was tested in the validation cohort.

Results

Prospective data for 19 097 cases in 326 hospitals were obtained from the NCEPOD study. Following exclusion of 2309, details of 16 788 patients were analysed (derivation cohort 11 219, validation cohort 5569). A model of 45 risk factors was refined on repeated regression analyses to develop a model comprising six variables: American Society of Anesthesiologists Physical Status (ASA-PS) grade, urgency of surgery (expedited, urgent, immediate), high-risk surgical specialty (gastrointestinal, thoracic, vascular), surgical severity (from minor to complex major), cancer and age 65 years or over. In the validation cohort, the SORT was well calibrated and demonstrated better discrimination than the ASA-PS and Surgical Risk Scale; areas under the receiver operating characteristic (ROC) curve were 0·91 (95 per cent c.i. 0·88 to 0·94), 0·87 (0·84 to 0·91) and 0·88 (0·84 to 0·92) respectively (P < 0·001).

Conclusion

The SORT allows rapid and simple data entry of six preoperative variables, and provides a percentage mortality risk for individuals undergoing surgery.

The Use of the Enhanced Recovery After Surgery (ERAS) Protocol in Patients Undergoing Laparoscopic Surgery for Colorectal Cancer – A Comparative Analysis of Patients Aged above 80 and below 55

Age is one of the principal risk factors for colorectal adenocarcinoma. To date, older patients were believed to achieve worse treatment results in comparison with younger patients due to reduced vital capacity. However, papers have emerged in recent years which confirm that the combination of lap-aroscopy and postoperative care based on the ERAS protocol improves treatment results and may be particularly beneficial also for elderly patients.

was to compare the outcomes of laparoscopic surgery for colorectal cancer in combination with the ERAS protocol in patients aged above 80 and below 55.

. The analysis included patients aged above 80 and below 55 undergoing elective laparoscopic colorectal resection for cancer at the 2

Group 1 comprised 34 patients and group 2, 43 patients. No differences were found between both groups in terms of gender, BMI, tumour progression or surgical parameters. Older patients typically had higher ASA scores. No statistically significant differences were found with regard to the length hospital stay following surgery (5.4 vs 7 days, p=0.446481), the occurrence of complications (23.5% vs 37.2%, p=0.14579) or hospital readmissions (2.9% vs 2.4%). The degree of compliance with the ERAS protocol in group 1 and 2 was 85.2% and 83.0%, respectively (p=0.482558). Additionally, recovery parameters such as tolerance of oral nutrition (82.4% vs 72.1%, p=0.28628) and mobilisation (94.1% vs 83.7%, p=0.14510) within 24 hours of surgery did not differ among the groups. However, a smaller proportion of older patients required opioids in comparison with younger patients (26.5% vs 55.8%, p=0.00891).

Similar levels of compliance with the ERAS protocol may be achieved among patients aged ≥80 and younger patients. When laparoscopy is combined with the ERAS protocol, age does not seem to be a significant factor that could account for worse utcomes. Therefore, older patients should not be excluded from perioperative care based on ERAS principles.