Cardiac risk stratification and adverse outcomes in surgically managed patients with isolated traumatic spine injuries

INTRODUCTION

As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries.

METHODS

All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding.

RESULTS

A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score.

CONCLUSION

The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

Predictive Value of Skeletal Muscle Function Test Combined with Climbing Test for Postoperative Cardiopulmonary Complications in Patients with COPD and Concurrent Lung Cancer

Purpose

To explore the predictive value of skeletal muscle function measurement combined with stair climbing test for postoperative cardiopulmonary complications in patients with chronic obstructive pulmonary disease (COPD) and non-small cell lung cancer (NSCLC).

Patients and Methods

A prospective study was conducted from June 2022 to July 2023 at West China Hospital of Sichuan University, including 335 COPD patients with lung cancer who underwent surgery. The patients were divided into two groups based on the occurrence of postoperative cardiopulmonary complications: the complication group and the non-complication group. The demographic data, including gender, age, smoking history, quadriceps strength, body mass index (BMI), respiratory muscle strength, 6-minute walk test (6MWD), stair climbing test, and preoperative pulmonary function tests, were compared between the two groups. Logistic regression analysis was performed to evaluate the predictive power of each parameter for postoperative cardiopulmonary complications.

Results

Among the enrolled patients, 103 (30.7%) developed postoperative cardiopulmonary complications. Significant differences were observed between the two groups in terms of quadriceps strength, respiratory muscle strength, 6MWD, smoking history, stair climbing test, DLCO%, FEV1%, heart rate, oxygen saturation, surgical duration, surgical approach, resection range, and blood loss (P<0.05). Logistic regression analysis revealed that respiratory muscle strength, quadriceps strength, stair climbing test, FEV1%, DLCO%, ΔHR, ΔSPO2, surgical approach were identified as risk factors for postoperative cardiopulmonary complications in patients with COPD and lung cancer.

Conclusion

Skeletal muscle function measurement, stair climbing test, FEV1, surgical approach, and DLCO% can serve as assessment tools for surgical risk in patients with COPD and lung cancer. They can predict the occurrence of postoperative cardiopulmonary complications to a certain extent, providing valuable predictive value for these complications in patients with COPD and NSCLC.

Outcomes of simultaneous versus staged intramedullary nailing fixation of multiple long bone lower extremity fractures

INTRODUCTION

Repair of multiple lower extremity long bone fractures with intramedullary nail (IMN) fixation is associated with significant cardiopulmonary burden and may result in mortality. These patients are at an increased risk for fat embolism syndrome, pulmonary embolism, Acute Respiratory Distress Syndrome (ARDS), and pneumonia. No standardized guidelines exist to guide treatment of these patients. Further, there is a paucity of data regarding the risk of simultaneous versus staged fixation of multiple long bone fractures that includes both tibial and femoral injuries, as patients with multiple concomitant fractures are often excluded from relevant analyses. Our level one trauma center aimed to identify whether simultaneous fixation, defined by definitive fixation of multiple lower extremity long bone fractures during one operative event, led to increased cardiopulmonary complications as compared to a staged approach, defined as multiple operations to reach definitive fixation.

PATIENTS AND METHODS

The Michigan Trauma Quality Improvement Program (MTQIP) database from 35 Level I and II trauma centers was queried to identify patients from January 2016 - December 2019. The primary outcome was incidence of cardiopulmonary complications for staged and simultaneous IMN fixation.

RESULTS

We identified 11,427 patients with tibial and/or femoral fractures during the study period. 146 patients met the inclusion criteria of two or more fractures treated with IMN fixation. 118 patients underwent simultaneous IMN fixation, and 28 patients received staged IMN fixation. There were no significant differences in injury severity score (ISS), demographics, pre-existing conditions, and cardiopulmonary complications between the two groups. There was a statistically significant difference in hospital length of stay (LOS) (p = 0.0012). The median hospital LOS for simultaneous fixation was 8.3 days versus 15.8 days for the staged cohort, a difference of 7.5 days.

CONCLUSION

This is the largest retrospective study to date examining simultaneous versus staged IMN fixation in patients with multiple long bone lower extremity fractures. In contrast to previous studies, we found no difference in cardiopulmonary complications. Given these findings, patients with multiple long bone lower extremity fractures should be considered for simultaneous IMN, an approach which may decrease hospital LOS.

Major Postoperative Complications in Esophageal Cancer After Minimally Invasive Esophagectomy Compared With Open Esophagectomy: An Updated Meta-analysis

BACKGROUND

To evaluate the existing literature comparing cardiopulmonary complications after minimally invasive esophagectomy (MIE) with open esophagectomy (OE) and conduct a meta-analysis based on the relevant studies.

METHODS

A systematic search for articles was performed in Medline, Embase, Wiley Online Library, and the Cochrane Library. The relative risks or odds ratios (ORs) were calculated by using fixed or random-effects models. The I² and X² tests were used to test for statistical heterogeneity. We performed a metaregression for the pulmonary complications with the adenocarcinoma proportion and tumor stage. Publication bias and small-study effects were assessed using Egger's test and Begg's funnel plot.

RESULTS

A total of 30,850 participants were enrolled in the 63 studies evaluated in the meta-analysis. Arrhythmia, pulmonary embolism, pulmonary complications, gastric tip necrosis, anastomotic leakage, and vocal cord palsy were chosen as outcomes. The occurrence rate of arrhythmia was significantly lower in patients receiving MIE than in patients receiving OE (OR = 0.69; 95% CI = 0.53-0.89), with heterogeneity (I² = 30.7%, P = 0.067). The incidence of pulmonary complications was significantly lower in patients receiving MIE (OR = 0.54, 95% CI = 0.45-0.63) but heterogeneity remained (I² = 72.1%, P = 0.000). The risk of gastric tip necrosis (OR = 1.48, 95% CI = 1.07-2.05) after OE was lower than that after MIE. Anastomotic leakage, pulmonary embolism, and vocal cord palsy showed no significant differences between the two groups.

CONCLUSIONS

MIE has advantages over OE, especially in reducing the incidence of arrhythmia and pulmonary complications. Thus, MIE can be recommended as the preferred alternative surgery method for resectable esophageal cancer.

Multimorbidity and Critical Care Neurosurgery: Minimizing Major Perioperative Cardiopulmonary Complications

With increasing prevalence of chronic diseases, multimorbid patients have become commonplace in the neurosurgical intensive care unit (neuro-ICU), offering unique management challenges. By reducing physiological reserve and interacting with one another, chronic comorbidities pose a greatly enhanced risk of major postoperative medical complications, especially cardiopulmonary complications, which ultimately exert a negative impact on neurosurgical outcomes. These premises underscore the importance of perioperative optimization, in turn requiring a thorough preoperative risk stratification, a basic understanding of a multimorbid patient’s deranged physiology and a proper appreciation of the potential of surgery, anesthesia and neurocritical care interventions to exacerbate comorbid pathophysiologies. This knowledge enables neurosurgeons, neuroanesthesiologists and neurointensivists to function with a heightened level of vigilance in the care of these high-risk patients and can inform the perioperative neuro-ICU management with individualized strategies able to minimize the risk of untoward outcomes. This review highlights potential pitfalls in the intra- and postoperative neuro-ICU period, describes common preoperative risk stratification tools and discusses tailored perioperative ICU management strategies in multimorbid neurosurgical patients, with a special focus on approaches geared toward the minimization of postoperative cardiopulmonary complications and unplanned reintubation.

Simultaneous single-stage versus two-staged bilateral total knee arthroplasty: a prospective comparative study

PURPOSE

The study aims to prospectively compare peri-operative morbidity and mortality of simultaneous single-stage bilateral total knee arthroplasty (SS BLTKA) with two-staged bilateral total knee arthroplasty (TS BLTKA) performed within 12 months of the first surgery. We hypothesized that SS BLTKA is as safe as TS BLTKA.

METHODS

Patients with a minimum follow-up of 12 months were included in this study. Oxford knee score and quality of life index SF12 was compared between the 2 groups at six weeks and six month follow-up.

RESULTS

SS BLTKA included 250 patients and TS BLTKA included 210 patients. The minimum time interval between two operations was three weeks (mean 1.6 months, range 3 weeks-12 months). There was no significant difference between the 2 groups in peri-operative mortality, surgical site infection, major peri-operative complications. There was no difference between the 2 groups in the Oxford knee score and quality of life index SF12 at 6-month follow-up. There was no difference in the range of knee flexion between the 2 groups at six months. Post-operative haemoglobin drop was significantly more in SS BLTKA patients and consequently, blood transfusion requirement was significantly higher in SS BLTKA. There was a significantly higher length of hospital stay and duration of surgery in TS BLTKA group.

CONCLUSION

There does not appear to be a difference in complication rates between the 2 groups. SS BLTKA seems to be a logical choice if both knees have severe osteoarthritis. Patients with severe cardiopulmonary compromise were excluded, and a unilateral procedure may be preferred in them.

Effect of postoperative haemoglobin variation on major cardiopulmonary complications in high cardiac risk patients undergoing anatomical lung resections

OBJECTIVES

Recent evidence shows that permissive anaemia strategies are safe in different surgical settings. However, effects of variations in haemoglobin (Hb) levels could have a negative impact in high-risk patients. We investigated the combined effect of postoperative Hb concentration and cardiac risk status on major cardiopulmonary complications after anatomical lung resections.

METHODS

We retrospectively analysed the records, collected in a prospective clinical database, of 154 consecutive patients undergoing anatomical lung resections at our institution (February 2017-February 2019). Hb levels were displayed as preoperative concentration, nadir Hb level before onset of complications and delta Hb (ΔHb). Cardiac risk was stratified according to the Thoracic Revised Cardiac Risk Index (ThRCRI). Univariable and multivariable logistic regression analyses were used to test the associations between patients, surgical variables and cardiopulmonary complications according to the European Society of Thoracic Surgeons definitions.

RESULTS

Cardiopulmonary complications occurred in 63 patients (17%). In the fully adjusted multivariable model, higher values of ΔHb were associated with increased risk of complications [odds ratio (OR) 1.07; P < 0.001], along with higher ThRCRI classes (classes A-B versus C-D: OR 0.09; P < 0.001). Interaction terms with transfusion were not statistically significant, indicating that the harmful effect of ΔHb was independent. According to receiver operating characteristic curve analysis, a ΔHb of 29 g/l was found to be the best cut-off value for predicting complications.

CONCLUSIONS

In our series, ΔHb, rather than nadir Hb, was associated with an increased risk of complications, particularly in patients with higher cardiac risk. Restrictive transfusion strategies should be carefully applied in patients undergoing lung resections and balanced according to individual clinical status.

Pulmonary artery catheter use in adult patients undergoing cardiac surgery: a retrospective, cohort study

Background

The utility of pulmonary artery catheters (PACs) and their measurements depend on a variety of factors including data interpretation and personnel training. This US multi-center, retrospective electronic health record (EHR) database analysis was performed to identify associations between PAC use in adult cardiac surgeries and effects on subsequent clinical outcomes.

Methods

This cohort analysis utilized the Cerner Health Facts database to examine patients undergoing isolated coronary artery bypass graft (CABG), isolated valve surgery, aortic surgery, other complex non-valvular and multi-cardiac procedures, and/or heart transplant from January 1, 2011, to June 30, 2015. A total of 6844 adults in two cohorts, each with 3422 patients who underwent a qualifying cardiac procedure with or without the use of a PAC for monitoring purposes, were included. Patients were matched 1:1 using a propensity score based upon the date and type of surgery, hospital demographics, modified European System for Cardiac Operative Risk Evaluation (EuroSCORE II), and patient characteristics. Primary outcomes of 30-day in-hospital mortality, length of stay, cardiopulmonary morbidity, and infectious morbidity were analyzed after risk adjustment for acute physiology score.

Results

There was no difference in the 30-day in-hospital mortality rate between treatment groups (OR, 1.17; 95% CI, 0.65-2.10; p = 0.516). PAC use was associated with a decreased length of stay (9.39 days without a PAC vs. 8.56 days with PAC; p < 0.001), a decreased cardiopulmonary morbidity (OR, 0.87; 95% CI, 0.79-0.96; p < 0.001), and an increased infectious morbidity (OR, 1.28; 95% CI, 1.10-1.49; p < 0.001).

Conclusions

Use of a PAC during adult cardiac surgery is associated with decreased length of stay, reduced cardiopulmonary morbidity, and increased infectious morbidity but no increase in the 30-day in-hospital mortality. This suggests an overall potential benefit associated with PAC-based monitoring in this population.

Trial registration

The study was registered at clinicaltrials.gov (NCT02964026) on November 15, 2016.

Elevated preoperative heart rate associated with increased risk of cardiopulmonary complications after resection for lung cancer

BACKGROUND

The study aimed to assess whether preoperative resting heart rate could be a risk factor for cardiopulmonary complications (CPCs) after lung cancer resection.

METHODS

Eligible consecutive patients who underwent resection surgery for non-small cell lung cancer (NSCLC) at Ningbo NO.2 Hospital between May, 2010 and July, 2015 were included. The demographic, clinical characteristics and laboratory parameters were compared in patients with or without CPCs within postoperative 30 days. The multivariate logistic regression analysis was used to analyze the association between CPCs and risk factors. Receiver operating characteristic (ROC) curve analysis was utilized for the predictive role of preoperative resting heart rate for CPCs.

RESULTS

One hundred eighty participants were enrolled into the final analysis and 42 of them had an established diagnosis of CPCs within postoperative 30 days. Elevated preoperative resting heart rate was an independent risk factor for postoperative CPCs (OR: 4.48, 95% CI: 1.17-18.42, P = 0.021) by the multivariate logistic regression analysis. ROC curve analysis indicated elevated resting heart rate as a predictor for CPCs with a cut-off value of 86 beats/min (AUC: 0.813, specificity: 80.95%, sensitivity: 72.46%, P < 0.001).

CONCLUSIONS

Elevated preoperative resting heart rate was associated with an increased risk of postoperative CPCs in patients after resection for lung cancer.

Estimated intraoperative blood loss correlates with postoperative cardiopulmonary complications and length of stay in patients undergoing video-assisted thoracoscopic lung cancer lobectomy: a retrospective cohort study

Background

The purpose of our study was to estimate the influence of estimated intraoperative blood loss (EIBL) on postoperative cardiopulmonary complications (PCCs) in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for non-small-cell lung cancer (NSCLC).

Methods

We conducted a single-center retrospective analysis on the clinical data of consecutive patients in our institution between April 2015 and February 2016. Demographic differences between PCC group and non-PCC group were initially assessed. Receiver operating characteristic (ROC) analysis was performed to determine the threshold value of EIBL for the prediction of PCCs. Demographic differences in the PCC rates and length of stay between two groups of patients divided by this cutoff were further evaluated. A multivariable logistic-regression model involving the clinicopathological parameters with P-value< 0.05 was finally established to identify independent risk factors for PCCs.

Results

A total of 429 patients with operable NSCLC were included and 80 of them developed PCCs (rate = 18.6%). The mean EIBL in PCC group was significantly higher than that in non-PCC group (133.3 ± 191.3 vs. 79.1 ± 107.1 mL; P < 0.001). The ROC analysis showed an EIBL of 100 mL as the threshold value at which the joint sensitivity (50.0%) and specificity (73.4%) was maximal. The PCC rate in patients with EIBL≥100 mL was significantly higher than that in patients with EIBL< 100 mL (30.1 vs. 13.5%; P < 0.001). Both the length of stay and chest tube duration were significantly prolonged in the patients with EIBL≥100 mL. Finally, EIBL≥100 mL was identified to be predictive of PCCs by multivariable logistic-regression analysis (odds ratio = 3.01; 95% confidence interval = 1.47–6.16; P = 0.003).

Conclusions

EIBL serves as a significant categorical predictor for cardiopulmonary complications following VATS lobectomy for NSCLC. Thoracic surgeons should minimize the EIBL and strive for the ‘bloodless’ goal to optimize surgical outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0360-0) contains supplementary material, which is available to authorized users.

B-type brain natriuretic peptide as a measure of the severity of hand-foot-mouth disease: a case-control study

Background

Hand-foot-mouth disease (HFMD) is an acute infectious disease caused by enteroviruses, and HFMD complicated by cardiopulmonary failure has a high mortality. B type natriuretic peptide (BNP) is widely applied in monitoring cardiovascular disorders, and thus, we investigated whether this index was associated with the severity of HFMD and the outcome in severe HFMD.

Methods

Serum BNP, lactate, and glucose levels as well as white blood cell (WBC) count, PaO₂/FiO₂, and cardiac output (CO) were analyzed in the 83 enrolled HFMD patients according to different conditions (common, severe, and critical; with and without complication; and survivors and non-survivors). The control group consisted of 29 patients with respiratory tract infections.

Results

No significant differences in CO were observed between the groups. Serum lactate, glucose, BNP, and WBC levels in the critical group were significantly higher than those in the severe, common, and control groups (p < 0.01 or 0.05). The PaO₂/FiO₂ ratio was significantly lower in the critical group (214.286 ± 154.346) than in the other groups. According to logistic regression analysis, the areas under the curve for serum BNP, glucose, and PaO₂/FiO₂ of the patients with complications were 0.774, 0.738, and 0.75, respectively. Moreover, the BNP level was significantly higher in HFMD patients with complications and non-survivors.

Conclusion

Our findings indicate that BNP could be a biochemical indicator for severe (critical) HFMD and used for prognosis in terms of complications and death. Combined with Glu and PaO₂/FiO₂ and clinical symptoms of HFMD, the value of BNP as an indicator became more precise and specific. Our results may provide another valuable, objective biochemical indicator for severe HFMD.

Trial registration number

ChiCTR-DDT-14004576. Name of registry: Chinese Clinical Trial Registry. Date of registration: 2014–09-21.

[Can treatment with anesthetic anticonvulsive drugs worsen outcome in status epilepticus?]

BACKGROUND AND OBJECTIVES

Nowadays, there is an ongoing discussion about the risks and benefits of anesthetic treatment concerning outcome in status epilepticus (SE). Therefore, we performed a retrospective database analysis to examine the influence of treatment with anesthetic drugs and narcosis in SE on mortality and disability.

METHODS

All treatment episodes of SE at the Department of Neurology of the University of Rostock between 01 January 2000 and 31 December 2009 were evaluated. SE severity before treatment, mortality, and disability at discharge were taken into account.

RESULTS

Of 167 treatment episodes of SE, 34 included treatment with anesthetic anticonvulsive drugs and narcosis. In the treatment episodes with use of anesthetic anticonvulsive drugs and narcosis, there was a more than twofold increased risk for death compared to the other treatment episodes. However, due to sample size this difference was not significant (p = 0.09). Cardiopulmonary complications were the cause of death in 4 of 5 patients dying during treatment episodes with anesthetic anticonvulsive drugs and narcosis. At discharge, disability as measured with the Modified Rankin Scale was higher in patients treated with anesthetic anticonvulsive drugs and narcosis than in the others (p = 0.03). A subgroup analysis revealed that especially in patients with nonconvulsive SE with impaired consciousness treatment with narcosis was associated with a higher rate of new deficits or mortality (p = 0.012).

CONCLUSIONS

Especially when considering narcosis for treatment of nonconvulsive SE, risks and benefits should be carefully weighed. When treating SE with anesthetic drugs and narcosis, everything has to be done to avoid cardiopulmonary complications.