Cardiovascular death and progression to end-stage renal disease after major surgery in elderly patients

BACKGROUND

Reliable estimates for risk of cardiovascular-specific mortality and progression to end-stage renal disease (ESRD) among elderly patients undergoing major surgery are not available. This study aimed to develop simple risk scores to predict these events.

METHODS

In a single-centre cohort of elderly patients undergoing major surgery requiring hospital stay longer than 24 h, progression to ESRD and long-term cardiovascular-specific mortality were modelled using multivariable subdistribution hazard models, adjusting for co-morbidity, frailty and type of surgery.

RESULTS

Before surgery, 2·9 and 11·9 per cent of 16 655 patients had ESRD and chronic kidney disease (CKD) respectively. During the hospital stay, 46·9 per cent of patients developed acute kidney injury (AKI). Patients with kidney disease had a significantly higher risk of cardiovascular-specific (CV) mortality compared with patients without kidney disease (adjusted hazard ratio (HR) for CKD without AKI 1·60, 95 per cent c.i. 1·25 to 2·01; AKI without CKD 1·70, 1·52 to 1·87; AKI with CKD 2·80, 2·50 to 3·20; ESRD 5·21, 4·32 to 6·27), as well as increased progression to ESRD (AKI without CKD 5·40, 3·44 to 8·35; CKD without AKI 8·80, 4·60 to 17·00; AKI with CKD 31·60, 19·90 to 49·90). CV Death and ESRD Risk scores were developed to predict CV mortality and progression to ESRD. Calculated CV Death and ESRD Risk scores performed well with c-statistics: 0·77 (95 per cent c.i. 0·76 to 0·78) and 0·82 (0·78 to 0·86) respectively at 1 year.

CONCLUSION

Kidney disease in elderly patients undergoing major surgery is associated with a high risk of CV mortality and progression to ESRD. Risk scores can augment the shared decision-making process of informed consent and identify patients requiring postoperative renal-protective strategies.

A System-Wide Enhanced Recovery Program Focusing on Two Key Process Steps Reduces Complications and Readmissions in Patients Undergoing Bowel Surgery

Enhanced recovery programs (ERPs) can improve outcomes following bowel surgery, but implementing an ERP across a large healthcare system remains challenging. In this study, a simplified ERP that focused on two process steps, early and frequent ambulation and early alimentation, was evaluated to determine its impact on outcomes. Data were collected on 5,000 adult patients undergoing elective small and large bowel operations over a 3-year period. Complication, readmission, and mortality rates were evaluated before and after ERP implementation. A composite score was calculated based on the successful completion of the two process steps. Following implementation, there was a 35.1% increase in the composite score, which was associated with significant (p < .05) reductions in overall complications, gastrointestinal complications, pulmonary complications, and readmissions. A system-wide ERP focusing on early and frequent ambulation and early alimentation is associated with decreased complications and readmissions in adult patients admitted for elective small or large bowel operations.

A Patient Blood Management Program in Prosthetic Joint Arthroplasty Decreases Blood Use and Improves Outcomes

The objective of this study was to determine if a Patient Blood Management (PBM) program implemented for patients undergoing THA or TKA would result in a decrease in the percentage of patients transfused PRBCs and improve outcomes. Decision support, a key driver for this program, was built into the electronic medical record. This retrospective cohort study included 12,590 patients and demonstrated a 44% decrease in the percentage of patients transfused. This was associated with a significant reduction in complications, 30 day readmissions and HLOS. A PBM program for patients undergoing prosthetic joint arthroplasty for primary and revision total hip and knee arthroplasty results in fewer transfusions and is associated with improved outcomes.

A Comparison of the Defect Rate Between Original Equipment Manufacturer and Reprocessed Single-Use Bipolar and Ultrasound Diathermy Devices

Reprocessing has emerged as an attempt to control the cost of single-use bipolar and ultrasound diathermy devices despite limited data on defect rates. This study compares the defect rates, as reported by surgical teams, between original equipment manufacturer (OEM) single-use bipolar and ultrasound diathermy devices and reprocessed (RP) devices. Data were retrospectively collected on 3112 devices over a 7-month period for two types of bipolar and ultrasound diathermy devices. There is a significant difference (p < 0.001) in reported bipolar and ultrasound diathermy device defects between OEM and RP. OEM single-use bipolar and ultrasound diathermy devices were reported to be defective more frequently than RP devices based on reports from the surgical team.

Refractory abdominal-cutaneous fistulas or leaks: percutaneous management with a collagen plug

BACKGROUND

We report the results of abdominal-cutaneous fistula tract occlusion with a collagen plug in a series of patients with fistulas or leaks refractory to conservative therapy.

STUDY DESIGN

Seven patients were found to have persistent fistula or leak after percutaneous drainage of abdominal pelvic fluid collections. All patients but one were refractory to surgical or percutaneous drainage. Under fluoroscopic guidance, modified Vasoseal (Datascope Inc, Montvale, NJ) collagen plugs were deployed into the fistulas using catheter-directed techniques. The plugs were split longitudinally to fit into an 8F or 9F peel-away sheath, placed into the fistula, and deployed. Results were tabulated and patients were followed up.

RESULTS

Six of seven patients undergoing fluoroscopically guided, catheter-directed tract occlusion had resolution of the fistula, with no evidence of fistula or abscess recurrence from 30 to 180 days after closure. There were no procedural complications. The technique was unsuccessful in dosing a gastrocutaneous fistula after removal of a large-bore gastrostomy tube; this failure was believed to be secondary to the short length and large caliber of the tract in a patient with hypercortisolemia.

CONCLUSIONS

Closure of abdominal-cutaneous fistula tracts by occlusion with a modified Vasoseal collagen plug shows promise in the management of fistulas refractory to catheter drainage.

Outcomes evaluation for operative and nonoperative management of the abnormal mammogram

BACKGROUND

This study reviewed the outcome of women with an abnormal mammogram and no mass (n = 194).

METHODS

Patients were immediately biopsied (34%) or followed up mammographically (66%). Information was collected prospectively over a 13-year period.

RESULTS

Eight of those initially biopsied (12%) proved to be cancer. Of the remaining 129 patients, 20 were lost to follow-up, leaving 109 for further review. Thirty of these patients ultimately came to biopsy, with 5 (17%) proving to be cancer. Of those followed up mammographically and not biopsied, the majority (92%) of lesions either remained unchanged or resolved. The average follow-up time is 53 months. Biopsy was avoided in 51%. Of the 179 patients with follow-up information, 40 (23%) developed new lesions. Fourteen of these lesions have been biopsied, and 36% were cancer.

CONCLUSIONS

Most mammographic lesions resolve or remain unchanged. Women who have a lesion on mammography are at increased risk for further mammographic abnormalities.

Modified fluid gelatin. An alternative macromolecular agent for centrifugal leukapheresis

We studied a French modified fluid gelatin (MFG), substituting it for hydroxyethyl starch (HES) in leukapheresis procedures using three currently available blood cell separators, and observing its effects on the function of platelets and granulocytes. As a cell-collecting agent, we found MFG to be as effective as HES with intermittent flow centrifugation (Haemonetics), and slightly less so with one continuous flow device (IBM 2997). MFG was clearly less effective than HES with the Fenwal CS-3000 continuous flow separator, although we have reason to believe it would be possible to improve efficiency with this machine by changing the operating variables. Tests of platelet and granulocyte function showed negligible alteration with either agent and no difference between them. MFG disappears much more rapidly from the circulation than HES (after a single injection, it is undetectable by the third day). Reaction frequency with MFG was about the same as that of HES, with perhaps somewhat more frequent allergic manifestations.

Leukapheresis: increasing the granulocyte yield with the Fenwal CS-3000

By premedicating the donor with 60 mg prednisone in divided doses and processing more donor blood at higher flow rates than those specified by the manufacturer, one can obtain high yields of granulocytes and platelets (mean of 3.3 X 10(10) and 5.9 X 10(11), respectively) with the Fenwal CS-3000 blood cell separator. The steroid effect predominates over that of processing more blood. In the case of donors who are not stimulated by steroid, processing 10 L of donor blood at flow rates of 60 to 70 ml/minute results in a significantly improved yield of granulocytes (mean of 2.2 X 10(10) as opposed to 1.4 in the case of 7 L) and of platelets (6.1 X 10(11) versus 4.7). The concentrates contain about 50 to 60% less lymphocytes when donors are given steroid. With these modifications, the leukapheresis can still be accomplished in less than three hours and with minimal adverse effects on the donors.