Perioperative Risk Stratification: A Need for an Improved Assessment in Surgery and Anesthesia-A Pilot Study

Background and Objectives: Numerous scoring systems have been introduced into modern medicine. None of the scoring systems assessed both anesthetic and surgical risk of the patient, predict the morbidity, mortality, or the need for postoperative intensive care unit admission. The aim of this study was to compare the anesthetic and surgical scores currently used, for a better evaluation of perioperative risks, morbidity, and mortality. Material and Methods: This is a pilot, prospective, observational study. We enrolled 50 patients scheduled for elective surgery. Anesthetic and surgery risk was assessed using American Society of Anesthesiologists (ASA) scale, Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM), Acute Physiology and Chronic Health Evaluation (APACHE II), and Surgical APGAR Score (SAS) scores. The real and the estimated length of stay (LOS) were registered. Results: We obtained several statistically significant positive correlations: ASA score–P-POSSUM (p < 0.01, r = 0.465); ASA score–SAS, (p < 0.01, r = −0.446); ASA score–APACHE II, (p < 0.01 r = 0.519); predicted LOS and ASA score (p < 0.01, r = 0.676); predicted LOS and p-POSSUM (p < 0.01, r = 0.433); and predicted LOS and APACHE II (p < 0.01, r = 0.454). A significant negative correlation between predicted LOS, real LOS, ASA class, and SAS (p < 0.05) was observed. We found a statistically significant difference between the predicted and actual LOS (p < 001). Conclusions: Anesthetic, surgical, and severity scores, used together, provide clearer information about mortality, morbidity, and LOS. ASA scale, associated with surgical scores and severity scores, presents a better image of the patient’s progress in the perioperative period. In our study, APACHE II is the best predictor of mortality, followed by P-POSSUM and SAS. P-POSSUM score and ASA scale may be complementary in terms of preoperative physiological factors, providing valuable information for postoperative outcomes.

Results after Using Bioactive Glass S53P4 in Reconstructive Orthopaedic Surgery - A 36 - Month Follow-up Clinical Study

Osteocartilaginous tissue normally has the capability of regeneration, which means that many osteoarticular problems or bony defects will heal spontaneously, not needing important interventions. Although the high regenerative capacity of this tissue, large osseous defects encountered difficulties in optimal healing process and remain a clinical challenge, demanding surgical procedures. This aim of this study was to evaluate clinical and radiological outcomes using bioactive glass S53P4 (BonAlive�) as a synthetic bone substitute material in some specific orthopedic pathologies like prosthesis revision surgery, and pseudarthrosis.

Autologous Matrix-Induced Chondrogenesis vs Microfracture with PRP for Chondral Lesions of the Knee in a Rabbit Model

Currently, microfracturing is the most commonly used cartilage repair procedure in cartilage defects. Our aim was to study the mechanism of in vivo cartilage repair in case of full-thickness articular cartilage damage of the knee using a three-dimensional matrix implanted without any preseeded cells in the defect. We also investigated whether platelet-rich plasma application after microfracture procedure of the knee is associated with improved outcome compared with traditional microfracture treatment alone in a rabbit model. Histological examination of the chondral defects, revealed the largest amount of new tissue with hyaline-like cartilage features in Hyalofast group. At 12 weeks from implantation of the Hyalofast scaffold demonstrated complete filling of the defect with hyaline cartilage in admixture with the scaffold and bone metaplasia in the deepest areas. In the PRP group, complete filling of the defect with an admixture of fibrous and hyaline-like cartilage tissue appeared with a discreet tendency of endochondral ossification. We confirmed the superiority of the autologous matrix-induced chondrogenesis compared to microfracture and PRP or microfracture alone in case of full-thickness articular cartilage damage of the knee.

Effect of Osteoplasty with Bioactive Glass (S53P4) in Bone Healing - In vivo Experiment on Common European Rabbits (Oryctolagus cuniculus)

Osteoplasty, is a procedure mostly applied in complicated bone fractures. Nowadays this method is widely used in primary fracture treatment while the native bone graft is progressively replaced with various synthetic bone substitutes. From the numerous bone grafts we�d like to mention a representative of ceramics, the S53P4 bioactive glass. (BonAlive�). The aim of this study was to investigate the healing process of different fracture types generated on rabbit femurs. During this experiment we used seven common European rabbits. We separated these animals into two groups; in the first group we surgically generated a total fracture in the middle 1/3 of the femur, while in the second group, we produced only a bone defect on the femur. The osteoplasty was carried out with bioactive glass and autologous bone grafts. The radiographic follow-up was immediate after the operation and after 3, 6 and 7 weeks. The animals were euthanized after 19, 20 and 21 weeks, for histomorphometric examination of the femur. It was also studied the ionic release from the used bioactive glass at physiological pH and the etching of the glass was studied by Scanning Electron Microscopy.

Role of the Biomimetic Scaffolds in the Regeneration of Articular Tissue in Deep Osteochondral Defects in a Rabbit Model

The ability of damaged articular cartilage to recover with normal hyaline cartilage is limited. Our aim was to study the mechanism of in vivo cartilage repair in case of severe osteochondral lesions using a three-dimensional matrix implanted without any preseeded cells in the osteochondral defect in a rabbit model. According to the ICRS scores from macroscopic observations of the femoral condyles, the average scores in the scaffold groups were higher than those in the control groups at every time (P[0.001). Histological examination of the ostheochondral defects, revealed regeneration of new tissue with hyaline-like cartilage features only in matrix groups. At twelve weeks from implantation, complete filling of the defect with hyaline cartilage with a tendency of mineralization and the absence of implant material is observed. The superficial area of the defect is completely covered with hyaline-like cartilage. The scaffold used leaded to the regeneration of articular tissue with an ordered histoarchitecture.

Plasma Neutrophil Gelatinase Associated Lipocalin (NGAL) - Early Biomarker for Acute Kidney Injury in Critically Ill Patients

Introduction

NGAL (Neutrophil Gelatinase Associated Lipocalin) is a biomarker recently introduced into clinical practice for the early diagnosis of acute kidney injury (AKI). The aim of this study was to correlate the plasmatic NGAL value determined at admission with clinical progression and severity of AKI in critically ill patients.

Material and method

Thirty two consecutive critically ill adult patients at risk of developing AKI (trauma, sepsis), admitted in Intensive Care Unit of the Clinical County Emergency Hospital Mures, between January to March 2015 were enrolled in the study. For each patient included in the study plasma NGAL levels were determined on admission, and these were correlated with the degree of AKI development (according to AKIN criteria) at 48 hours and 5 days post admission. The discriminatory power of NGAL, creatinine, creatinine clearance and corrected creatinine (depending on water balance) were determined using the ROC (receiver-operating characteristic) and likelihood ratios.

Results

ROC curve analysis showed a better discriminatory capacity in terms of early diagnosis of AKI for NGAL (AUC=0.81 for NGAL, AUC=0.59 for creatinine, AUC=0.62 for corrected creatinine, AUC=0.29 for creatinine clearance). The value of likelihood ratio was also significantly higher for NGAL (3.01±2.73 for NGAL, 1.27±1.14 for creatinine, 1.78±1.81 for corrected creatinine, and 0.48±0.33 for creatinine clearance).

Conclusions

NGAL biomarker has a better discrimination capacity for early prediction of acute kidney injury compared to previously used markers.

Blood sampling as a cause of anemia in a general ICU - a pilot study

OBJECTIVE

The objective of our pilot study was to evaluate the influence of daily phlebotomy on patients' haemoglobin levels from our general intensive care unit.

METHODS

We prospectively enrolled 35 patients who did not present with acute haemorrhage or developed it during the study period. For each patient we recorded: the diagnosis, age, sex, haemoglobin, hematocrit, SOFA and APACHE II score, blood volume drawn in standardized vials, number of blood tests ordered per day, fluid balance per day, number of ICU days. The collected data were analyzed using the linear regression model, paired t-test, receiver operating characteristic curves, and descriptive analysis. Statistical analysis was performed with SPSS v.17 trial version (IBM, NY, USA).

RESULTS

The mean volume of blood drawn per day was 18.1 (SD ± 14.4) ml and the number of blood tests was 3.8 (SD ± 1.75) per day. On univariate linear regression analysis both the blood volume drawn daily (p = 0.04) and the number of blood tests per day (p = 0.009) correlated with a drop in mean haemoglobin concentration. The difference in the mean value of haemoglobin at admission and discharge correlated with overall mortality (p = 0.03). The sensitivity of admission haemoglobin equal to 10.6 g/dL in predicting mortality was 82.4% with a specificity of 50%, (p = 0.019, AUC = 0.732).

CONCLUSIONS

We evidenced the predictive power of blood sampling and number of blood tests done on haemoglobin concentration. Besides the main objective of the study we noticed that the difference in the mean value of haemoglobin at admission and discharge correlated with overall mortality. Considering that blood sampling contributes to anemia among ICU patients, we should limit the daily tests undertaken, to the tests absolutely necessary for guiding our therapy.

Evaluation of O-POSSUM vs ASA and APACHE II scores in patients undergoing oesophageal surgery

BACKGROUND AND AIMS

Risk and prognostic scores quantify the patient's risk of death or complication according to the severity of his illness. The aim of this study was to evaluate the predictive accuracy of O-POSSUM vs ASA and APACHE II models on patients undergoing oesophageal surgery.

MATERIAL AND METHOD

In this observational retrospective study 55 patients were enrolled who had undergone surgical interventions of excision and reconstruction of the oesophagus for neoplastic oesophageal stenosis, in the Surgical Clinics (I and II) of the Clinical County Emergency Hospital Mures, between January 2011 and January 2014. By using patients file records after extracting the data we calculated the predictive mortality, according to the prognostic scores O-POSSUM, ASA and APACHE II and we analyzed its correlations with the postoperative evolution. We evaluated the discriminatory power of the three scores using the ROC (receiver-operating characteristic) curves. According to the cut-off value corresponding to each score, we compared the Kaplan Meier survival curves during the hospitalization period.

RESULTS

ROC curves analysis revealed that O-POSSUM had a better discriminatory power for mortality compared to the other two scores: AUC = 0.73 for O-POSSUM, AUC = 0.57 for APACHE II and AUC = 0.64 for ASA (p < 0.001). The cut-off value was statistically significant only in case of O-POSSUM, as it derives from the statistical analysis of the survival curves (p = 0.035).

CONCLUSION

O-POSSUM predicts mortality more accurately compared to ASA or APACHE II in patients undergoing oesophageal surgery.