Glycemic Stress Index: Does It Correlate with the Intensive Care Length of Stay?

Postoperative hyperglycemia is an independent risk factor for postoperative complications. In adults, perioperative hyperglycemia is influenced by prolonged fasting, but data in children are lacking. The Glycemic Stress Index (GSI) has been shown to predict prolonged Pediatric Intensive Care Unit (PICU) stays in neurosurgical patients. This study aimed to confirm the correlation between GSI and duration of intubation, PICU stay, and postoperative complications in infants undergoing elective open heart surgery. The correlation between preoperative fasting and GSI was also investigated.

METHODS

A retrospective chart review of 85 infants ≤ 6 months undergoing elective open heart surgery was performed. GSI values ≥ 3.9 and 4.5 were tested to determine whether they carried a higher incidence of postoperative complications (metabolic uncoupling, kidney injury, ECMO, and death). The correlation between GSI and the length of intubation, PICU stay, and duration of fasting were also investigated. Perioperative factors such as age, weight, blood gas analysis, use of inotropes, and risk adjustment for congenital heart surgery were also analyzed as possible predictors.

RESULTS

GSI correlated with the duration of intubation and PICU stay. A GSI ≥ 4.5, but not 3.9, was associated with a higher incidence of metabolic uncoupling. GSI was not influenced by preoperative fasting. None of the preoperative patient factors analyzed was associated with prolonged intubation, PICU stay, or PICU complications. An abnormal creatinine before surgery increased the risk of developing acute kidney injury postoperatively.

CONCLUSIONS

GSI may be valuable to predict prolonged intubation, PICU stay, and metabolic derangement in infants undergoing cardiac surgery. Fasting does not appear to affect GSI.

Monitoring cerebral oxygen saturation in elderly patients undergoing general abdominal surgery: a prospective cohort study

BACKGROUND AND OBJECTIVES

The aim of this prospective, observational study was to evaluate changes in regional cerebral oxygen saturation (rSO2) and incidence of intraoperative cerebral desaturation in a cohort of elderly patients undergoing major abdominal surgery.

METHODS

rSO2 was continuously monitored on the left and right sides of the forehead in 60 patients older than 65 yr (35 males and 25 females; ASA II-III; age: 72 +/- 5 yr; without pre-existing cerebral pathology, and baseline Mini Mental State Examination (MMSE) score >23) undergoing sevoflurane anaesthesia for major abdominal, non-vascular surgery >2 h.

RESULTS

Baseline rSO2 was 63 +/- 8%; cerebral desaturation (rSO2 decrease <75% of baseline or <80% in case of baseline rSO2 <50%) occurred in 16 patients (26%). The MMSE decreased from 28 +/- 1 before surgery to 27 +/- 2 on 7th postoperative day (P = 0.05). A decline in cognitive function (decrease in MMSE score > or = 2 points one week after surgery as compared to baseline value) was observed in six patients without intraoperative cerebral desaturation (13.6%) and six patients who had intraoperative cerebral desaturation (40%) (P = 0.057) (odds ratio: 4.22; CI95%: 1.1-16). Median (range) hospital stay was 14 (5-41) days in patients with an area under the curve of rSO2 <50% (AUCrSO2<50%) >10 min%, and 10 (4-30) days in those with an AUCrSO2<50% <10 min% (P = 0.0005).

CONCLUSIONS

In a population of healthy elderly patients, undergoing non-vascular abdominal surgery cerebral desaturation can occur in up to one in every four patients, and the occurrence of cerebral desaturation is associated with a higher incidence of early postoperative cognitive decline and longer hospital stay.

Locoregional anesthesia and coagulation

The introduction of low molecolar weith heparin (LMWE) and the strong antithromboembolic prophylaxis protocols used in the USA, underlined the risk of spinal hemorrhage in patients receveing a neuraxial blockade. On the other side, the efficacy of these techniques over general anesthesia doesn't allow the anesthesist to miss this pratice, where possible. So it's necessary to quantify the spinal hematoma risk in patients assuming these drugs. Unfortunately, routine investigations on coagulation factors and platelets count are not reliable if patients are receiving LMWE. Waiting for dynamic tests concerning the coagulative status such as thromboelastography (TEG), many hospitals follow many different guidelines. For these reasons peripherical nerve block techniques are a good alternative, since they are not influenced by the efficacy of the coagulation system.