Radiation Dose and Fluoroscopy Time of Extracranial Carotid Artery Stenting : Elective vs. Emergency Treatment Including Combined Mechanical Thrombectomy in Tandem Occlusion

PURPOSE

Fluoroscopically guided endovascular carotid artery stenting (CAS) of extracranial carotid stenosis (ECS) is a reasonable alternative to carotid endarterectomy in selected patients. Diagnostic reference levels (DRL) for this common neurointervention have not yet been defined and respective literature data are sparse. We provide detailed dosimetrics for useful expansion of the DRL catalogue.

METHODS

A retrospective single-center study of patients undergoing CAS between 2013 and 2021. We analyzed dose area product (DAP) and fluoroscopy time considering the following parameters: indications for CAS, semielective/elective versus emergency including additional mechanical thrombectomy (MT) in extracranial/intracranial tandem occlusion, etiology of ECS (atherosclerotic vs. radiation-induced), periprocedural features, e.g., number of applied stents, percutaneous transluminal angioplasty (PTA) and MT maneuvers, and dose protocol. Local DRL was defined as 75% percentile of the DAP distribution.

RESULTS

A total of 102 patients were included (semielective/elective CAS n = 75, emergency CAS n = 8, CAS + MT n = 19). Total median DAP was 78.2 Gy cm2 (DRL 117 Gy cm2). Lowest and highest median dosimetry values were documented for semielective/elective CAS and CAS + MT (DAP 49.1 vs. 146.8 Gy cm2, fluoroscopy time 27.1 vs. 43.8 min; p < 0.005), respectively. Dosimetrics were significantly lower in patients undergoing 0-1 PTA maneuvers compared to ≥ 2 maneuvers (p < 0.05). Etiology of ECS, number of stents and MT maneuvers had no significant impact on dosimetry values (p > 0.05). A low-dose protocol yielded a 33% reduction of DAP.

CONCLUSION

This CAS study suggests novel local DRLs for both elective and emergency cases with or without intracranial MT. A dedicated low-dose protocol was suitable for substantial reduction of radiation dose.

Emergency treatment with intravenous infusion of methylene blue followed by oral administration in a cat presented with severe recurrent methemoglobinemia

OBJECTIVE

To describe the use of IV infusion followed by oral administration of methylene blue (MB) to successfully treat recurrent methemoglobinemia (MetHb) in a young cat.

CASE SUMMARY

A 6-month-old male Ragdoll cat presented with recurrent episodes of severe MetHb and was successfully managed with IV infusion of MB followed by a course of oral MB. Although the definitive cause of the patient's MetHb remains unknown, the cat made a full recovery following treatment without developing any significant side effects secondary to therapy and at the time of writing not had any further recurrences. Follow-up at 6 months found the patient in good health and without any long-term consequences.

NEW INFORMATION PROVIDED

To the authors' knowledge, this is the first report of a cat presented with severe MetHb quantitatively assessed via co-oximetry and successfully treated with both IV and oral administration of MB.

Emergency treatment of airway obstruction caused by a laryngeal neuroendocrine tumor: A case report

RATIONALE

Laryngeal obstruction is a life-threatening adverse event that requires urgent and appropriate management, particularly in patients with coexisting cardiopulmonary and brain comorbidities. However, laryngeal obstruction caused by laryngeal neuroendocrine tumors has rarely been reported.

PATIENT CONCERNS

Neuroendocrine tumors can cause pathological changes in the neuro-humoral system, and asphyxia caused by airway obstruction has a more adverse effect on patients with neuroendocrine tumors.

DIAGNOSES

We report the case of a 64-year-old man with clinical manifestations of dyspnea. Preoperative and intraoperative pathological examination indicated that the patient was diagnosed with life-threatening airway obstruction caused by a laryngeal neuroendocrine tumor, pneumonia, and scoliosis.

INTERVENTIONS

The patient underwent laryngeal tumor resection under general anesthesia. He was recovered well and was generally good without the necessity of undergoing radiotherapy and chemotherapy at the 6-months follow-up.

OUTCOMES

This case report has provided an emergency treatment strategy associated with awake intubation. We concluded that flexible establishment of an artificial airway, skilled anesthesia and surgical manipulation, and necessary postoperative intensive care are extremely important for improving the prognosis of patients with severely difficult airway. It is noteworthy that the timely adjust for endotracheal intubation strategy according to the patient's response is needed. It is important for the long-term prognosis of patients to avoid the establishment of a traumatic artificial airway and the occurrence of adverse complications.

LESSONS

1. Introduction; 2. Case presentation; 3. Discussion; 4. Conclusion.

The new SUMPOT to predict postoperative complications using an Artificial Neural Network

An accurate assessment of preoperative risk may improve use of hospital resources and reduce morbidity and mortality in high-risk surgical patients. This study aims at implementing an automated surgical risk calculator based on Artificial Neural Network technology to identify patients at risk for postoperative complications. We developed the new SUMPOT based on risk factors previously used in other scoring systems and tested it in a cohort of 560 surgical patients undergoing elective or emergency procedures and subsequently admitted to intensive care units, high-dependency units or standard wards. The whole dataset was divided into a training set, to train the predictive model, and a testing set, to assess generalization performance. The effectiveness of the Artificial Neural Network is a measure of the accuracy in detecting those patients who will develop postoperative complications. A total of 560 surgical patients entered the analysis. Among them, 77 patients (13.7%) suffered from one or more postoperative complications (PoCs), while 483 patients (86.3%) did not. The trained Artificial Neural Network returned an average classification accuracy of 90% in the testing set. Specifically, classification accuracy was 90.2% in the control group (46 patients out of 51 were correctly classified) and 88.9% in the PoC group (8 patients out of 9 were correctly classified). The Artificial Neural Network showed good performance in predicting presence/absence of postoperative complications, suggesting its potential value for perioperative management of surgical patients. Further clinical studies are required to confirm its applicability in routine clinical practice.

The hidden burden of unplanned readmission after emergency general surgery

BACKGROUND

There are no national studies of nonelective readmissions after emergency general surgery (EGS) diagnoses that track nonindex hospital readmission. We sought to determine the rate of overall and nonindex hospital readmissions at 30 and 90 days after discharge for EGS diagnoses, hypothesizing a significant portion would be to nonindex hospitals.

METHODS

The 2013 to 2014 Nationwide Readmissions Database was queried for all patients 16 years or older admitted with an EGS primary diagnosis and survived index hospitalization. Multivariable logistic regression identified risk factors for nonelective 30- and 90-day readmission to index and nonindex hospitals.

RESULTS

Of 4,171,983 patients, 13% experienced unplanned readmission at 30 days. Of these, 21% were admitted to a nonindex hospital. By 90 days, 22% experienced an unplanned readmission, of which 23% were to a nonindex hospital. The most common reason for readmission was infection. Publicly insured or uninsured patients accounted for 67% of admissions and 77% of readmissions. Readmission predictors at 30 days included leaving against medical advice (odds ratio [OR], 2.51 [2.47-2.56]), increased length of stay (4-7 days: OR, 1.42 [1.41-1.43]; >7 days: OR, 2.04 [2.02-2.06]), Charlson Comorbidity Index ≥2 (OR, 1.72 [1.71-1.73]), public insurance (Medicare: OR, 1.45 [1.44-1.46]; Medicaid: OR, 1.38 [1.37-1.40]), EGS patients who fell into the "Other" surgical category (OR, 1.42 [1.38-1.48]), and nonroutine discharge. Risk factors for readmission remained consistent at 90 days.

CONCLUSION

Given that nonindex hospital EGS readmission accounts for nearly a quarter of readmissions and often related to important benchmarks such as infection, current EGS quality metrics are inaccurate. This has implications for policy, benchmarking, and readmission reduction programs.

LEVEL OF EVIDENCE

Epidemiological study, level III.

Emergency general surgery: Impact of hospital and surgeon admission case volume on mortality

BACKGROUND

Emergency general surgery (EGS) is a high-volume and high-risk surgical service. Interhospital variation in EGS outcomes exists, but there is disagreement in the literature as to whether hospital admission volume affects in-hospital mortality. Scotland collects high-quality data on all admitted patients, whether managed operatively or nonoperatively. Our aim was to determine the relationship between hospital admission volume and in-hospital mortality of EGS patients in Scotland. Second, to investigate whether surgeon admission volume affects mortality.

METHODS

This national population-level cohort study included EGS patients aged 16 years and older, who were admitted to a Scottish hospital between 2014 and 2018 (inclusive). A logistic regression model was created, with in-hospital mortality as the dependent variable, and admission volume of hospital per year as a continuous covariate of interest, adjusted for age, sex, comorbidity, deprivation, surgeon admission volume, surgeon operative rate, transfer status, diagnosis, and operation category.

RESULTS

There were 376,076 admissions to 25 hospitals, which met our inclusion criteria. The EGS hospital admission rate per year had no effect on in-hospital mortality (odds ratio [OR], 1.000; 95% confidence interval [CI], 1.000-1.000). Higher average surgeon monthly admission volume increased the odds of in-hospital mortality (>35 admissions: OR, 1.139; 95% CI, 1.038-1.250; 25-35 admissions: OR, 1.091; 95% CI, 1.004-1.185; <25 admissions was the referent).

CONCLUSION

In Scotland, in contrast to other settings, EGS hospital admission volume did not influence in-hospital mortality. The finding of an association between individual surgeons' case volume and in-hospital mortality warrants further investigation.

LEVEL OF EVIDENCE

Care management, Level IV.

Postoperative complications and mortality following emergency digestive surgery during the COVID-19 pandemic: A multicenter collaborative retrospective cohort study protocol (COVID-CIR)

ABSTRACT

Infection with the SARS-CoV-2 virus seems to contribute significantly to increased postoperative complications and mortality after emergency surgical procedures. Additionally, the fear of COVID-19 contagion delays the consultation of patients, resulting in the deterioration of their acute diseases by the time of consultation. In the specific case of urgent digestive surgery patients, both factors significantly worsen the postoperative course and prognosis. Main working hypothesis: infection by COVID-19 increases postoperative 30-day-mortality for any cause in patients submitted to emergency/urgent general or gastrointestinal surgery. Likewise, hospital collapse during the first wave of the COVID-19 pandemic increased 30-day-mortality for any cause. Hence, the main objective of this study is to estimate the cumulative incidence of mortality at 30-days-after-surgery. Secondary objectives are: to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for COVID-19-infected patients.A multicenter, observational retrospective cohort study (COVID-CIR-study) will be carried out in consecutive patients operated on for urgent digestive pathology. Two cohorts will be defined: the "pandemic" cohort, which will include all patients (classified as COVID-19-positive or -negative) operated on for emergency digestive pathology during the months of March to June 2020; and the "control" cohort, which will include all patients operated on for emergency digestive pathology during the months of March to June 2019. Information will be gathered on demographic characteristics, clinical and analytical parameters, scores on the usual prognostic scales for quality management in a General Surgery service (POSSUM, P-POSSUM and LUCENTUM scores), prognostic factors applicable to all patients, specific prognostic factors for patients infected with SARS-CoV-2, postoperative morbidity and mortality (at 30 and 90 postoperative days). The main objective is to estimate the cumulative incidence of mortality at 30 days after surgery. As secondary objectives, to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for SARS-CoV-2 infected patients.The protocol (version1.0, April 20th 2020) was approved by the local Institutional Review Board (Ethic-and-Clinical-Investigation-Committee, code PR169/20, date 05/05/20). The study findings will be submitted to peer-reviewed journals and presented at relevant national and international scientific meetings.ClinicalTrials.gov Identifier: NCT04479150 (July 21, 2020).

Urgent-start peritoneal dialysis versus haemodialysis for people with chronic kidney disease

BACKGROUND

Patients with chronic kidney disease (CKD) who require urgent initiation of dialysis but without having a permanent dialysis access have traditionally commenced haemodialysis (HD) using a central venous catheter (CVC). However, several studies have reported that urgent initiation of peritoneal dialysis (PD) is a viable alternative option for such patients.

OBJECTIVES

This review aimed to examine the benefits and harms of urgent-start PD compared to HD initiated using a CVC in adults and children with CKD requiring long-term kidney replacement therapy.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 for randomised controlled trials through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. For non-randomised controlled trials, MEDLINE (OVID) (1946 to 11 February 2020) and EMBASE (OVID) (1980 to 11 February 2020) were searched.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-RCTs and non-RCTs comparing urgent-start PD to HD initiated using a CVC.

DATA COLLECTION AND ANALYSIS

Two authors extracted data and assessed the quality of studies independently. Additional information was obtained from the primary investigators. The estimates of effect were analysed using random-effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI). The GRADE framework was used to make judgments regarding certainty of the evidence for each outcome.

MAIN RESULTS

Overall, seven observational studies (991 participants) were included: three prospective cohort studies and four retrospective cohort studies. All the outcomes except one (bacteraemia) were graded as very low certainty of evidence given that all included studies were observational studies and few events resulting in imprecision, and inconsistent findings. Urgent-start PD may reduce the incidence of catheter-related bacteraemia compared with HD initiated with a CVC (2 studies, 301 participants: RR 0.13, 95% CI 0.04 to 0.41; I² = 0%; low certainty evidence), which translated into 131 fewer bacteraemia episodes per 1000 (95% CI 89 to 145 fewer). Urgent-start PD has uncertain effects on peritonitis risk (2 studies, 301 participants: RR 1.78, 95% CI 0.23 to 13.62; I² = 0%; very low certainty evidence), exit-site/tunnel infection (1 study, 419 participants: RR 3.99, 95% CI 1.2 to 12.05; very low certainty evidence), exit-site bleeding (1 study, 178 participants: RR 0.12, 95% CI 0.01 to 2.33; very low certainty evidence), catheter malfunction (2 studies; 597 participants: RR 0.26, 95% CI: 0.07 to 0.91; I² = 66%; very low certainty evidence), catheter re-adjustment (2 studies, 225 participants: RR: 0.13; 95% CI 0.00 to 18.61; I² = 92%; very low certainty evidence), technique survival (1 study, 123 participants: RR: 1.18, 95% CI 0.87 to 1.61; very low certainty evidence), or patient survival (5 studies, 820 participants; RR 0.68, 95% CI 0.44 to 1.07; I² = 0%; very low certainty evidence) compared with HD initiated using a CVC. Two studies using different methods of measurements for hospitalisation reported that hospitalisation was similar although one study reported higher hospitalisation rates in HD initiated using a catheter compared with urgent-start PD.

AUTHORS' CONCLUSIONS

Compared with HD initiated using a CVC, urgent-start PD may reduce the risk of bacteraemia and had uncertain effects on other complications of dialysis and technique and patient survival. In summary, there are very few studies directly comparing the outcomes of urgent-start PD and HD initiated using a CVC for patients with CKD who need to commence dialysis urgently. This evidence gap needs to be addressed in future studies.

Urgent-start peritoneal dialysis versus conventional-start peritoneal dialysis for people with chronic kidney disease

BACKGROUND

Urgent-start peritoneal dialysis (PD), defined as initiation of PD within two weeks of catheter insertion, has been emerging as an alternative mode of dialysis initiation for patients with chronic kidney disease (CKD) requiring urgent dialysis without established permanent dialysis access. Recently, several small studies have reported comparable patient outcomes between urgent-start and conventional-start PD.

OBJECTIVES

To examine the benefits and harms of urgent-start PD compared with conventional-start PD in adults and children with CKD requiring long-term kidney replacement therapy.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. For non-randomised controlled trials, MEDLINE (OVID) (1946 to 27 June 2019), EMBASE (OVID) (1980 to 27 June 2019), Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov (up to 27 June 2019) were searched.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and non-RCTs comparing the outcomes of urgent-start PD (within 2 weeks of catheter insertion) and conventional-start PD ( ≥ 2 weeks of catheter insertion) treatment in children and adults CKD patients requiring long-term dialysis were included. Studies without a control group were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted and quality of studies were examined by two independent authors. The authors contacted investigators for additional information. Summary estimates of effect were examined using random-effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI) as appropriate for the data. The certainty of evidence for individual outcome was assessed using the GRADE approach.

MAIN RESULTS

A total of 16 studies (2953 participants) were included in this review, which included one multicentre RCT (122 participants) and 15 non-RCTs (2831 participants): 13 cohort studies (2671 participants) and 2 case-control studies (160 participants). The review included unadjusted data for analyses due to paucity of studies reporting adjusted data. In low certainty evidence, urgent-start PD may increase dialysate leak (1 RCT, 122 participants: RR 3.90, 95% CI 1.56 to 9.78) compared with conventional-start PD which translated into an absolute number of 210 more leaks per 1000 (95% CI 40 to 635). In very low certainty evidence, it is uncertain whether urgent-start PD increases catheter blockage (4 cohort studies, 1214 participants: RR 1.33, 95% CI 0.40 to 4.43; 2 case-control studies, 160 participants: RR 1.89, 95% CI 0.58 to 6.13), catheter malposition (6 cohort studies, 1353 participants: RR 1.63, 95% CI 0.80 to 3.32; 1 case-control study, 104 participants: RR 3.00, 95% CI 0.64 to 13.96), and PD dialysate flow problems (3 cohort studies, 937 participants: RR 1.44, 95% CI 0.34 to 6.14) compared to conventional-start PD. In very low certainty evidence, it is uncertain whether urgent-start PD increases exit-site infection (2 cohort studies, 337 participants: RR 1.43, 95% CI 0.24 to 8.61; 1 case-control study, 104 participants RR 1.20, 95% CI 0.41 to 3.50), exit-site bleeding (1 RCT, 122 participants: RR 0.70, 95% CI 0.03 to 16.81; 1 cohort study, 27 participants: RR 1.58, 95% CI 0.07 to 35.32), peritonitis (7 cohort studies, 1497 participants: RR 1.00, 95% CI 0.68 to 1.46; 2 case-control studies, participants: RR 1.09, 95% CI 0.12 to 9.51), catheter readjustment (2 cohort studies, 739 participants: RR 1.27, 95% CI 0.40 to 4.02), or reduces technique survival (1 RCT, 122 participants: RR 1.09, 95% CI 1.00 to 1.20; 8 cohort studies, 1668 participants: RR 0.90, 95% CI 0.76 to 1.07; 2 case-control studies, 160 participants: RR 0.92, 95% CI 0.79 to 1.06). In very low certainty evidence, it is uncertain whether urgent-start PD compared with conventional-start PD increased death (any cause) (1 RCT, 122 participants: RR 1.49, 95% CI 0.87 to 2.53; 7 cohort studies, 1509 participants: RR 1.89, 95% CI 1.07 to 3.3; 1 case-control study, 104 participants: RR 0.90, 95% CI 0.27 to 3.02; very low certainty evidence). None of the included studies reported on tunnel tract infection.

AUTHORS' CONCLUSIONS

In patients with CKD who require dialysis urgently without ready-to-use dialysis access in place, urgent-start PD may increase the risk of dialysate leak and has uncertain effects on catheter blockage, malposition or readjustment, PD dialysate flow problems, infectious complications, exit-site bleeding, technique survival, and patient survival compared with conventional-start PD.

Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility

BACKGROUND

Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database.

METHODS

Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses.

RESULTS

Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived.

CONCLUSIONS

The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.

Impact of interhospital transfer on patient outcomes in emergency general surgery

BACKGROUND

Emergency general surgery patients are at an increased risk for morbidity and mortality compared to their elective surgery counterparts. The complex nature of emergency general surgery conditions can challenge community hospitals, which may lack appropriate systems and personnel. Outcomes related to transfer have not been well-established. We aimed to compare postoperative outcomes of patients who were transferred from another hospital to a center with dedicated acute care surgery services with patients admitted directly to the acute care surgery centers.

METHODS

We performed a secondary analysis of a national, multicenter review of emergency general surgery patients undergoing complex emergency general surgery at 5 centers across Canada. The primary outcome was the development of any complication. The adjusted odds of postoperative complication was assessed using logistic regression, controlling for age, comorbidities, duration of stay before transfer, American Society of Anesthesiologists classification, and booking priority.

RESULTS

A total of 1,846 patients were included in the study, and 176 (9.5%) were transferred. Of these 21% (n = 37) underwent an operative procedure, and 15% (n = 27) underwent an operation at the transferring center. Transferred patients were more likely to have at least 1 comorbidity (68% vs 57%; P = .004), were classified as greater urgency on arrival (<2 hours booking priority, 43% vs 17%; P < .001), had a greater American Society of Anesthesiologists classification (American Society of Anesthesiologists ≥3 = 81% vs 65%; P < .001), a greater duration of operation (119 vs 110 minutes; P = .004), and were more likely to undergo a second operation (28% vs 14%; P < .001) compared to patients directly admitted to an acute care surgery center. On univariate analysis, transferred patients had greater rates of complications (48% vs 31%; P < .001), mortality (14% vs 7%; P = .005), and admission to the intensive care unit (22% vs 12%; P < .001). Transfer status remained an independent predictor of complication (odds ratio 1.9 [95% confidence interval 1.3-2.7]; P < .001) and intensive care unit admission (odds ratio 1.9 [95% confidence interval 1.2-3.0]; P = .007), but not mortality (odds ratio 1.1 [95% confidence interval 0.6-1.9]; P = .79) on regression analysis.

CONCLUSION

Complex emergency general surgery patients transferred to acute care surgery centers may have worse outcomes and greater use of resources compared to those admitted directly. This finding has clinically and financially important implications for the design and regionalization of acute care surgery services as well as resource allocation at acute care surgery centers.

Indocyanine green does not decrease the need for bail-out operation in an acute care surgery population

BACKGROUND

The use of indocyanine green during laparoscopic cholecystectomy has been postulated to help to define anatomy. Studies have not specifically evaluated patients with acute cholecystitis. We sought to assess whether use of indocyanine green can decrease the rate of bail-out operation (subtotal cholecystectomy or conversion to an open operation) in an acute care surgery population where acute cholecystitis is more frequent.

METHODS

Using a retrospective cohort design, we examined all inpatient cholecystectomies performed by the acute care surgery service under urgent or semiurgent (biliary colic as the presentation in the emergency room) conditions at a single institution from 7/1/18 to 6/30/19 during which indocyanine green was available for use at the surgeon's discretion.

RESULTS

A total of 198 patients were included in the analysis. Demographic variables were similar in groups receiving indocyanine green versus not. Pathology confirmed acute cholecystitis was present in 96 of 198 (48.5%) patients; of those, 55 (57.2%) received indocyanine green. Indocyanine green did not change the rate of bail-out operation between patients who received indocyanine green and those who did not (6.7% vs 4.3%, P = .468). No significant differences in complications were observed. Bail-out operation was more likely in cases of acute cholecystitis (9.4%) versus nonacute cholecystitis (2.0%) (odds ratio = 5.172, P = .039). In patients with acute cholecystitis, indocyanine green did not change the rate of bail-out operation (indocyanine green: 12.7% vs no indocyanine green: 4.9%, P = .293).

CONCLUSION

This is the first series looking at the use of indocyanine green specifically in an acute care surgery population. Indocyanine green did not decrease operative time or need for a bail-out operation in acute cholecystitis. Further study is needed to determine whether indocyanine green use is justified in this population.

Incidence and Cost of Deep Vein Thrombosis in Emergency General Surgery Over 15 Years

BACKGROUND

Deep vein thromboses (DVTs) are a significant sequela of surgery and are associated with significant of morbidity and mortality in the United States. Operative emergency general surgery (EGS) cases have been demonstrated to have a greater burden of DVT than other types of surgery.

MATERIALS AND METHODS

DVT in EGS cases were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2015 Q3 based on ICD-9 code specification. National incidence of DVT in EGS was calculated using the National Inpatient Sample-Healthcare Cost and Utilization Project sampling methodology, and propensity score matching was used to assess costs associated with DVT.

RESULTS

Among 15,148,352 sample-weighted hospitalizations, 0.623% (94,392) experienced DVT. Incidence of DVT was greatest in GI ulcer surgery (1.705%) and lowest in appendectomy (0.095%). Patients with a perioperative DVT incurred $22,301 more in hospital-related costs than their counterparts who did not have a DVT. Although rates of DVT remained stable over the period analyzed, DVT-associated costs increased at a 2.09% annual rate in excess of inflation during the period analyzed. This increase in costs was most significant for laparotomy, which increased at a rate of 8.09% annually.

CONCLUSIONS

DVT continues to be a significant burden on resources in EGS in spite of efforts with DVT prophylaxis. Considering the increase in costs and little change in incidence, further research on cost-effective management of DVT in EGS is warranted.

Prospective Study of Factors Associated With Postoperative Delirium After Urgent Abdominal Surgery

INTRODUCTION

Delirium is a frequent complication in elderly patients after urgent abdominal surgery.

METHODS

Prospective study of consecutive patients aged ≥65years who had undergone urgent abdominal surgery from 2017-2019. The following variables were recorded: age, sex, ASA, physiological state, cognitive impairment, frailty (FRAIL Scale), functional dependence (Barthel Scale), quality of life (Euroqol-5D-VAS), nutritional status (MNA-SF), preoperative diagnosis, type of surgery (BUPA Classification), approach and diagnosis of postoperative delirium (Confusion Assessment Method). Univariate and multivariate analyses were performed to analyze the correlation of these variables with delirium.

RESULTS

The study includes 446 patients with a median age of 78years, 63.6% were ASA ≥III and 8% had prior cognitive impairment. 13.2% were frail and 5.4% of the patients had a severe or total degree of dependence. 13.6% developed delirium in the postoperative period. In the univariate analysis, all the variables were statistically significant except for sex, type of surgery (BUPA) and duration. In the multivariate analysis the associated factors were: age (P<.001; OR: 1,08; 95%CI: 1,038-1,139), ASA (P=.026; OR: 3.15; 95%CI: 1.149-8.668), physiological state (P<.001; OR: 5.8; 95%CI: 2.176-15.457), diagnosis (P=.006) and cognitive impairment (P<.001; OR: 5.8; 95%CI: 2.391-14.069).

CONCLUSION

The factors associated with delirium are age, ASA, physiological state in the emergency room, preoperative diagnosis and prior cognitive impairment.

Longer small bowel segments are resected in emergency surgery for ileocaecal Crohn's disease with a higher ileostomy and complication rate

BACKGROUND

Repeated intestinal resections may have disabling consequences in patients with Crohn's disease even in the absence of short bowel syndrome. Our aim was to evaluate the length of resected small bowel in patients undergoing elective and emergency surgery for ileocolic Crohn's disease.

METHODS

A prospective observational study was conducted on patients undergoing surgery for ileocolonic Crohn's disease in a single colorectal centre from May 2010 to April 2018. The following patients were included: (1) patients with first presentation of ileocaecal Crohn's disease undergoing elective surgery; (2) patients with ileocaecal Crohn's disease undergoing emergency surgery; (3) patients with recurrent Crohn's disease of the distal ileum undergoing elective surgery. The primary outcomes were length of resected small bowel and the ileostomy rate. Operating time, complications and readmissions within 30 days were the secondary outcomes.

RESULTS

One hundred and sixty-eight patients were included: 87 patients in the elective primary surgery group, 50 patients in the emergency surgery group and 31 in the elective redo surgery group. Eleven patients (22%) in the emergency surgery group had an ileostomy compared to 10 (11.5%) in the elective surgery group (p < 0.0001). In the emergency surgery group the median length of the resected small bowel was 10 cm longer than into the group having elective surgery for primary Crohn's disease.

CONCLUSIONS

Patients undergoing emergency surgery for Crohn's disease have a higher rate of stoma formation and 30-day complications. Laparoscopic surgery in the emergency setting has a higher conversion rate and involves resection of longer segments of small bowel.

Laparoscopic Cholecystectomy Is Safe in Emergency General Surgery Patients with Cirrhosis

Cirrhosis is associated with adverse outcomes after emergency general surgery (EGS). The objective of this study was to determine the safety of laparoscopic cholecystectomy (LC) in EGS patients with cirrhosis. We performed a two-year retrospective cohort analysis of adult patients who underwent LC for symptomatic gallstones. The primary outcome was the incidence of intraoperative complications. Of 796 patients, 59 (7.4%) were cirrhotic, with a median model for end-stage liver disease (MELD) score of 15 (IQR, 7). On unadjusted analysis, patients with cirrhosis were older, more likely to be male (both P < 0.01), diabetic (P < 0.001), had a higher incidence of preadmission antithrombotic therapy use (P < 0.02), and experienced a longer time to surgery (3.2 vs 1.8 days, P < 0.001). Coarsened exact matching revealed no difference in intra- or postoperative complications between groups (P = 0.67). Operative duration was longer in patients with cirrhosis (162 vs 114 minutes, P = 0.001), who also had a nonsignificant increase in the rate of conversion to an open cholecystectomy (14% vs 4%, P = 0.07). The results of this study indicate that LC may be safely performed in EGS patients with cirrhosis.

Living Donor Liver Transplantation for Acute Liver Failure: Donor Safety and Recipient Outcome

In countries where deceased organ donation is sparse, emergency living donor liver transplantation (LDLT) is the only lifesaving option in select patients with acute liver failure (ALF). The aim of the current study is living liver donor safety and recipient outcomes following LDLT for ALF. A total of 410 patients underwent LDLT between March 2011 and February 2018, out of which 61 (14.9%) were for ALF. All satisfied the King's College criteria (KCC). Median admission to transplant time was 48 hours (range, 24-80.5 hours), and median living donor evaluation time was 18 hours (14-20 hours). Median Model for End-Stage Liver Disease score was 37 (32-40) with more than two-thirds having grade 3 or 4 encephalopathy and 70% being on mechanical ventilation. The most common etiology was viral (37%). Median jaundice-to-encephalopathy time was 15 (9-29) days. Preoperative culture was positive in 47.5%. There was no difference in the complication rate among emergency and elective living liver donors (13.1% versus 21.2%; P = 0.19). There was no donor mortality. For patients who met the KCC but did not undergo LT, survival was 22.8% (29/127). The 5-year post-LT actuarial survival was 65.57% with a median follow-up of 35 months. On multivariate analysis, postoperative worsening of cerebral edema (CE; hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.01-6.31), systemic inflammatory response syndrome (SIRS; HR, 16.7; 95% CI, 2.05-136.7), preoperative culture positivity (HR, 6.54; 95% CI, 2.24-19.07), and a longer anhepatic phase duration (HR, 1.01; 95% CI, 1.00-1.02) predicted poor outcomes. In conclusion, emergency LDLT is lifesaving in selected patients with ALF. Outcomes of emergency living liver donation were comparable to that of elective donors. Postoperative worsening of CE, preoperative SIRS, and sepsis predicted outcome after LDLT for ALF.

Room for Improvement: A Systematic Review and Meta-analysis on the Informed Consent Process for Emergency Surgery

OBJECTIVE

To compare recall of complications and surgical details discussed during informed consent and perception of the consent process in patients undergoing emergent vs elective surgery.

METHODS

Studies were identified from PubMed, Cochrane, Web of Science, and Scopus from January 1, 1966, through April 18, 2018. Included studies compared patient recall and perception regarding informed consent in those undergoing emergent vs elective surgery. Pooled odds ratios (ORs) were calculated for recall of complications and surgical details, patient satisfaction, perception of sufficient information being delivered on surgical risks, report of having read written consent, and factors that interfered with consent.

RESULTS

Eleven observational studies (3178 patients) were included. The rate of recall of surgical complications (255 of 504 [50.6%] vs 321 of 446 [72.0%]; OR, 0.29; 95% CI, 0.11-0.80) was lower in patients undergoing emergent vs elective surgery. Meta-analysis revealed a decreased rate of patient satisfaction with the consent process (319 of 459 [69.5%] vs 882 of 1064 [82.9%]; OR. 0.53; 95% CI, 0.34-0.83) and fewer patients having read the consent form (130 of 395 [32.9%] vs 424 of 714 [59.4%]; OR, 0.35; 95% CI, 0.27-0.46) when undergoing emergent compared with elective surgery. Patients undergoing emergent surgery listed pain, analgesic medications, and fatigue as factors likely to interfere with consent.

CONCLUSION

Patients undergoing emergent surgery have poor recall of the informed consent process and surgical complications. Furthermore, patients report lower rates of satisfaction, and with fewer patients reading written consent documentation, our findings illuminate problems with the current communication process. There is a need to develop effective tools to improve informed consent in emergency surgery.

Intraoperative Mortality in Malawi

BACKGROUND

Surgical care is essential to improving population health, but metrics to monitor and evaluate the continuum of surgical care delivery have rarely been applied in low-resource settings, and improved efforts at benchmarking progress are needed. The objective of this study was to measure the intraoperative mortality at a Central Referral Hospital in Malawi, evaluate whether there have been changes in intraoperative mortality between 2 time periods, and assess factors associated with intraoperative mortality.

METHODS

This was a retrospective cohort study of patients undergoing surgery at Kamuzu Central Hospital in Lilongwe, Malawi. Data describing daily consecutive operative cases were collected prospectively during 2 time periods: 2004-2006 (early cohort) and 2015-2016 (late cohort). The primary outcome was intraoperative mortality. Inverse probability of treatment weighting was used to analyze the association of intraoperative mortality with time using logistic regression models. Multivariable logistic models were performed to evaluate factors associated with intraoperative mortality.

RESULTS

There were 21,090 surgeries performed during the 2 time periods, with 15,846 (75%) and 5244 (25%) completed from 2004 to 2006 and 2015 to 2016, respectively. Intraoperative mortality in the early cohort was 57 deaths per 100,000 surgeries (95% confidence interval [CI], 26-108) and in the late cohort was 133 per 100,000 surgeries (95% CI, 56-286), with 76 per 100,000 surgeries (95% CI, 44-124) overall. After applying inverse probability of treatment weighting, there was no evidence of an association between time periods and intraoperative mortality (odds ratio [OR], 1.6; 95% CI, 0.9-2.8; P = .08). Factors associated with intraoperative mortality, adjusting for demographics, included American Society of Anesthesiology physical status III or IV versus I or II (OR, 4.4; 95% CI, 1.5-12.5; P = .006) and emergency versus elective surgery (OR, 7.7; 95% CI, 2.5-23.6; P < .001).

CONCLUSIONS

Intraoperative mortality in the study hospital in Malawi is high and has not improved over time. These data demonstrate an urgent need to improve the safety and quality of perioperative care in developing countries and integrate perioperative care into global health efforts.

Modified enhanced recovery after surgery protocols are beneficial for postoperative recovery for patients undergoing emergency surgery for obstructive colorectal cancer: A propensity score matching analysis

Enhanced recovery after surgery (ERAS) is acknowledged to reduce perioperative stress in several surgical diseases. Here, we investigated whether modified ERAS is associated with beneficial effects in the setting of emergency colorectal surgery.We retrospectively evaluated the medical records of 839 consecutive patients with obstructive colorectal cancer undergoing surgical intervention at 4 institutes. Among them, 356 cases were managed with a multidisciplinary team approach to care (modified ERAS protocols), and the remaining 483 cases were treated based on traditional protocols. According to modified ERAS or traditional care, propensity score (PS) matching was performed to adjust biases in patient selection. The primary outcome was gastrointestinal function recovery. Secondary outcomes included postoperative complications and length of hospital stay.Modified ERAS was associated with postoperative gastrointestinal function recovery, including time to first flatus (P = .002), first defecation (P = .008), and prolonged ileus (P = .016). According to the Clavien-Dindo classification, fewer total episodes of grade II or higher postoperative complications were observed in patients cared for with modified ERAS than in patients with traditional care (P = .002). Median (interquartile range) postoperative hospital stay in the modified ERAS group was 6 (3-22) days versus 9 (7-27) days in the traditional care group (P < .001). Furthermore, the interval from operation to postoperative chemotherapy (d) was significantly shorter in the modified ERAS group (35.6 ± 11.5 vs 47.6 ± 23.8, P < .001).The modified ERAS was safe and associated with clinical benefits, including fast recovery of bowel function, reduced postoperative complications, and shorter hospital stay for patients with obstructive colorectal cancer.

Laparoscopic Cholecystectomy is Safe Both Day and Night

BACKGROUND

It is reported that performing laparoscopic cholecystectomy (LC) at night leads to increased rates of complications and conversion to open. We hypothesize that it is safe to perform LC at night in appropriately selected patients.

MATERIALS AND METHODS

We performed a retrospective review of nonelective LC in adults at our institution performed between April 2007 and February 2015. We dichotomized the cases to either day or night.

RESULTS

Five thousand two hundred four patients underwent LC, with 4628 during the day and 576 at night. There were no differences in age, body mass index, American Society of Anesthesiologists class, race, insurance type, pregnancy rate, or white blood cell count. There were also no differences in the prevalence of hypertension, diabetes, or renal failure. However, daytime patients had higher median initial total bilirubin (0.6 [0.4, 1.3] versus 0.5 [0.3, 1.0] mg/dL, P = 0.002) and lipase (33 [24, 56] versus 30 [22, 42] U/L, P < 0.001) values. There was no difference in case length, estimated blood loss, rate of conversion to open, biliary complications, length of stay (LOS) after operation, unanticipated return to the hospital in 60 d, or 60-d mortality. Daytime patients spent more time in the hospital with longer median LOS before surgery (1 [1, 2] versus 1 [0, 2] d, P < 0.001) and median total LOS (3 [2, 4] versus 2 [1, 3] d, P < 0.001) compared with night patients.

CONCLUSIONS

At our institution, we perform LC safely during day or night. The lack of complications and shorter LOS justify performing LC at any hour.

Intranasal glucagon for hypoglycaemia in diabetic patients. An old dream is becoming reality?

In 1983 it was shown that glucagon administered intranasally (IN) was absorbed through the nasal mucosa and increased blood glucose in healthy subjects. Shortly thereafter, it was shown that IN glucagon counteracts with hypoglycaemia in insulin-treated diabetic patients. In spite of this evidence, IN glucagon was not developed by any pharmaceutical company before 2010, when renewed interest led to intensive evaluation of a possible remedy for hypoglycaemia in insulin-treated diabetic adults and children. IN glucagon is now being developed as a needle-free device that delivers glucagon powder for treatment of severe hypoglycaemia; the ease of using this device stands in stark contrast to the difficulties encountered in use of the current intramuscular glucagon emergency kits. Studies have demonstrated the efficacy, safety and ease-of-use of this IN glucagon preparation, and suggest IN glucagon as a promising alternative to injectable glucagon for treating severe hypoglycaemia in children and adults who use insulin. This would meet the unmet medical need for an easily administered glucagon preparation.

Early and Late Outcome after Surgery for Colorectal Cancer Elective versus Emergency Surgery

Aims and Background

Emergency surgery for colorectal cancer is associated with a higher postoperative morbidity and mortality rate and a poor long-term outcome compared with elective surgery. The aim of the present study was to compare early and late outcome after elective and emergency surgery for malignant colorectal cancer, looking for the principal determinants of a worse outcome after emergency colorectal surgery.

Methods

A retrospective study of 236 patients presenting with colorectal cancer over an 8-year period was undertaken. Of these, 118 presented as emergencies, whereas 118 patients, well matched for age, sex, site of tumor and TNM admitted as elective, were included in the study. Data reviewed included postoperative mortality and morbidity and long-term outcome.

Results

The 30-day operative mortality rate was significantly higher in the emergency group than in the electively treated group (11.9% versus 3.4%, P<0.01). The higher mortality rate was observed in the perforation group. The 30-day operative morbidity was higher in the emergency group (27.1% versus 12.7%, P <0.05). Anastomotic failure was a serious complication: following primary resection, we observed 4 non-fatal (5.4%) and two fatal (2.7%) anastomotic leaks after 74 primary anastomoses. Among emergency-treated patients, the procedures characterized by the highest percentage of postoperative complications were three-stage resections (63.6%). The 5-year survival rate was greater after elective surgery (59% versos 39%).

Conclusions

The early and long-term outcome following emergency colorectal surgery was significantly lower than that after elective surgery. Although medical complications in patients with end-stage cancer played an important role, surgical failures still had an important impact on outcome.

Systemic Inflammatory Response Syndrome in Surgical Patients

OBJECTIVE

To determine the incidence of systemic inflammatory response of the organism in surgical patients and its impact on the outcome of treatment.

METHODS

A prospective study was conducted on 60 patients undergoing abdominal surgical procedures, between January 2014 and December 2015 in the Surgery Clinic at the University Clinical Center Tuzla. Two groups of thirty were formed by the method of consecutive sampling. The first group consisted of subjects who were prepared for elective abdominal surgery (laparoscopic cholecystectomy), and the second group subjects underwent an emergency surgery due to acute abdomen (laparoscopic cholecystectomy).

RESULTS

The body temperature difference was statistically significant between the two investigated groups in all stages (c2: t0=3,486; t1=3,098; t2=2,453, t: t0=-11,210; t1=-7,360; t2=-4,927, p < 0,05). Non-elective surgery group had a statistical significant difference of the heart rate at all stages (c2: t0=3,873; t1=3,357; t2=3,227, t: t0=-16,524; t1=-10,407; t2=-9,842, p < 0,05). There is a statistically significant difference in the pCO2 values in all stages between groups (c2: t0=2,582; t1=1,678; t2=1,162, t: t0=4,323; t1=2,653; t2=2,229, p < 0,05). The SIRS score has a good positive correlation with the length of treatment, while the correlation with the outcome of treatment has no statistical significance.

CONCLUSION

Inflammation scores monitoring in surgical patients is important for the surgical treatment success analysis. By modifying the therapy and influencing the inflammatory response, the results of treatment are improved.

Clinical emergency treatment of 68 critical patients with severe organophosphorus poisoning and prognosis analysis after rescue

This study reports the clinical emergency treatment of 68 critical patients with severe organophosphorus poisoning, and analyzes the prognosis after rescue.The general data of 68 patients with severe organophosphorus poisoning treated in our hospital were retrospectively analyzed. These patients were divided into 2 groups: treatment group, and control group. Patients in the control group received routine emergency treatment, while patients in the treatment group additionally received hemoperfusion plus hemodialysis on the basis of routine emergency treatment. The curative effects in these 2 groups and the prognosis after rescue were compared.Compared with the control group, atropinization time, recovery time of cholinesterase activity, recovery time of consciousness, extubation time, and length of hospital stay were shorter (P < .05); the total usage of atropine was significantly lower (P < .05); Glasgow Coma Score was significantly higher (P < .05); acute physiology and chronic health score (APACHE II) was significantly lower (P < .05); and mortality and poisoning rebound rate was significantly lower (P < .05) in the treatment group.Hemoperfusion and hemodialysis on the basis of routine emergency treatment for critical patients with organophosphorus poisoning can improve rescue outcomes and improve the prognosis of patients, which should be popularized.

A Randomized Controlled Trial of a Citywide Emergency Department Care-Coordination Program to Reduce Prescription Opioid-Related Visits: An Economic Evaluation

BACKGROUND

Care provided in the emergency department (ED) can cost up to five times as much as care received for comparable diagnoses in alternative settings. Small groups of patients, many of whom suffer from an opioid use disorder, often account for a large proportion of total ED visits. We recently conducted, and demonstrated the effectiveness of, the first randomized controlled trial of a citywide ED care-coordination program intending to reduce prescription-opioid-related ED visits. All EDs in the metropolitan study area were connected to a Web-based information exchange system.

OBJECTIVE

The objective of this article was to perform an economic evaluation of the 12-month trial from a third-party-payer perspective.

METHODS

We modeled the person-period monthly for the 12-month observation period, and estimated total treatment costs and return on investment (ROI) with regard to cost offsets, over time, for all visits where the patient was admitted to and discharged from the ED.

RESULTS

By the end of month 4, the mean cumulative cost differential was significantly lower for intervention relative to treatment-as-usual participants (-$1370; p = 0.03); this figure climbed to -$3200 (p = 0.02) by the end of month 12. The ROI trended upward throughout the observation period, but failed to reach statistical significance by the end of month 12 (ROI = 3.39, p = 0.07).

CONCLUSION

The intervention produced significant cost offsets by the end of month 4, which continued to accumulate throughout the trial; however, ROI was not significant. Because the per-patient administrative costs of the program are incurred at the time of enrollment, our results highlight the importance of future studies that are able to follow participants for a period beyond 12 months to more accurately estimate the program's ROI.

Feasibility and safety of emergency laparoscopic partial splenectomy: A retrospective analysis

The increased awareness of asplenia-related life-threatening complications has led to the development of parenchyma sparing splenic resections in past few years. The aim of this study is to retrospectively analyze the feasibility and safety of laparoscopic partial splenectomy (LPS) in selected emergency patients.From January 2013 to December 2015, there were 46 emergency patients, diagnosed with splenic rupture, admitted in our department. Selection criteria for LPS: (1) Preoperative CT scan revealed single pole rupture without spleen pedicle injury; (2) BP>90/60 mm Hg and heart rates <120 bpm; (3) No sigh of multiple organ injury. Eventually, LPS was performed in 21 patients (Group LPS), while laparoscopic splenectomy (LS) was performed in 20 patients (Group LS).The main cause of splenic rupture was traffic accident, followed by blunt injury and high falling injury. Abdominal CT scan showed the mean longitudinal diameter of spleen of group LPS was 14.2 ± 1.8 cm (range 12-17 cm), while the size of remnant spleen was 5.5 ± 1.2 cm. Between 2 groups, operation time (LPS: 122.6 ± 17.2 min vs LS: 110.5 ± 18.7 minutes, P = .117), and intraoperative blood loss (LPS: 174 ± 22 mL vs LS: 169 ± 29 mL, P = .331) were similar. There were 2 patients suffered subsequent unstable vital sign altering during mobilization when performing LPS. Conversion to LS (2/21, 9.52%) was decided and successfully completed. Although there was no patient suffered postoperative OPSI or thrombocytosis events in both groups after 6-month follow-up, the mean platelets and leukocyte count were significantly lower in group LPS. Splenic regrowth was evaluated in 20 patients of group LPS. And the mean regrowth of splenic volume reached 19% (10%-26%).Due to its minimal invasive effect and functional splenic tissue preservation, LPS may be a safe and feasible approach for emergency patients. And prospective trials with clear inclusion criteria are needed to proof the benefit of LPS.

Capnography versus standard monitoring for emergency department procedural sedation and analgesia

BACKGROUND

Procedural sedation and analgesia (PSA) is used frequently in the emergency department (ED) to facilitate painful procedures and interventions. Capnography, a monitoring modality widely used in operating room and endoscopy suite settings, is being used more frequently in the ED setting with the goal of reducing cardiopulmonary adverse events. As opposed to settings outside the ED, there is currently no consensus on whether the addition of capnography to standard monitoring modalities reduces adverse events in the ED setting.

OBJECTIVES

To assess whether capnography in addition to standard monitoring (pulse oximetry, blood pressure and cardiac monitoring) is more effective than standard monitoring alone to prevent cardiorespiratory adverse events (e.g. oxygen desaturation, hypotension, emesis, and pulmonary aspiration) in ED patients undergoing PSA.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (2016, Issue 8), and MEDLINE, Embase, and CINAHL to 9 August 2016 for randomized controlled trials (RCTs) and quasi-randomized trials of ED patients requiring PSA with no language restrictions. We searched meta-registries (www.controlled-trials.com, www.clinicalstudyresults.org, and clinicaltrials.gov) for ongoing trials (February 2016). We contacted the primary authors of included studies as well as scientific advisors of capnography device manufacturers to identify unpublished studies (February 2016). We handsearched conference abstracts of four organizations from 2010 to 2015.

SELECTION CRITERIA

We included any RCT or quasi-randomized trial comparing capnography and standard monitoring to standard monitoring alone for ED patients requiring PSA.

DATA COLLECTION AND ANALYSIS

Two authors independently performed study selection, data extraction, and assessment of methodological quality for the 'Risk of bias' tables. An independent researcher extracted data for any included studies that our authors were involved in. We contacted authors of included studies for incomplete data when applicable. We used Review Manager 5 to combine data and calculate risk ratios (RR) and 95% confidence intervals (CI) using both random-effects and fixed-effect models.

MAIN RESULTS

We identified three trials (κ = 1.00) involving 1272 participants. Comparing the capnography group to the standard monitoring group, there were no differences in the rates of oxygen desaturation (RR 0.89, 95% CI 0.48 to 1.63; n = 1272, 3 trials; moderate quality evidence) and hypotension (RR 2.36, 95% CI 0.98 to 5.69; n = 986, 1 trial; moderate quality evidence). There was only one episode of emesis recorded without significant difference between the groups (RR 3.10, 95% CI 0.13 to 75.88, n = 986, 1 trial; moderate quality evidence). The quality of evidence for the primary outcomes was moderate with downgrades primarily due to heterogeneity and reporting bias.There were no differences in the rate of airway interventions performed (RR 1.26, 95% CI 0.94 to 1.69; n = 1272, 3 trials; moderate quality evidence). In the subgroup analysis, we found a higher rate of airway interventions for adults in the capnography group (RR 1.44, 95% CI 1.16 to 1.79; n = 1118, 2 trials; moderate quality evidence) with a number needed to treat for an additional harmful outcome of 12. Although statistical heterogeneity was reduced, there was moderate quality of evidence due to outcome definition heterogeneity and limited reporting bias. None of the studies reported recovery time.

AUTHORS' CONCLUSIONS

There is a lack of convincing evidence that the addition of capnography to standard monitoring in ED PSA reduces the rate of clinically significant adverse events. Evidence was deemed to be of moderate quality due to population and outcome definition heterogeneity and limited reporting bias. Our review was limited by the small number of clinical trials in this setting.

[Comparison of execution time and tissue damage by using four ready-to-use percutaneous emergency airway access devices available in Poland]

OBJECTIVE

Objective: Assessment of execution time and tissue damage during providing percutaneous airway access using four ready-to-use sets: Quicktrach I (Q1) and II (Q2), Portex Cricothyroidothomy Kit (PCK) and Surgicric I (SC).

PATIENTS AND METHODS

Material and methods:Prospective laboratory test. Each of 54 participants carried out 1 puncture on porcine larynx preparation for each of 4 sets, which resulted in a total of 216 trials. Efficacy was defined as placing a cannula in the tracheal lumen ensuring adequate ventilation. Safety was assessed based on the size and type of laryngeal damage, improper placement of the cannula, perforation of the esophagus and extensive destruction of surrounding tissues.

RESULTS

Results: The percentage of effective procedures for respective sets was: PCK - 94.4%; Q1 - 100.0%; Q2 - 96.3%; SC - 96.3%. Differences were not statistically significant. There were significant differences in duration of the procedure: PCK - 59.20 s (20.0-188.0 s, SD ± 35.25), Q1 - 21.76 s (6.0-61.0 s; SD ± 10.62), Q2 - 28.36 s (5.0-71.0 s, SD ± 14.86), SC - 48.71 s (29.0-9.0 s, SD ± 15.07). The size of the lesions of anterior and posterior walls of the larynx and trachea were significantly different. The mean (SD) lesions of the anterior laryngeal wall for respective sets were: PCK - 11.18 mm ± 5.11; Q1 - 6.59 mm ± 2.22; Q2 - 7.71 mm ± 1.87; SC - 19.85 mm ± 5.72, and for the posterior wall of the trachea: PCK - 8.29 ± ± 8.43; Q1 - 0.44 mm ± 1.22; Q2 - 0.92 mm ± 3.79; SC - 0.08 mm ± 0.27. Percentage of additional damages for respective sets: PCK - 18.5%, Q1 - no damages; Q2 - 5.6% and SC - 3.7%.

CONCLUSION

Conclusions: There were no differences in the efficacy of particular sets. Significant differences were demonstrated for the duration and safety of the procedure. The average time as well as the size of posterior wall damage and the amount of additional damage was the highest for PCK and the lowest in case of Q1.

Tracheal laceration as a complication of out-of-hospital emergency tracheal intubation in a patient with COPD

Tracheobronchial injuries related to emergency endotracheal intubations are reported to be associated with an increased risk of mortality. Many mechanical risk factors may become more frequent in an emergency setting leading to such injuries. Aside from these factors that may complicate endotracheal intubation, this procedure is not recommended a priori for ventilation due to the resulting interruptions in external chest compressions, by 2010 cardiopulmonary resuscitation (CPR) and external chest compression guidelines. We present a 78-year-old woman with known chronic obstructive pulmonary disease who had a tracheal laceration after emergency endotracheal intubation during CPR. Thorax computed tomography revealed an overinflated tube cuff. The trachea was repaired surgically; however, our patient died on the fourth postoperative day due to multiple-organ failure. Prehospital providers must remain especially vigilant to priorities in airway management during CPR and aware of the dangers associated with field tracheal intubation under less than ideal conditions.

Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study

BACKGROUND

To assist physicians with difficult decisions about hospital admission for patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) presenting in the emergency department, we sought to identify clinical characteristics associated with serious adverse events.

METHODS

We conducted this prospective cohort study in 6 large Canadian academic emergency departments. Patients were assessed for standardized clinical variables and then followed for serious adverse events, defined as death, intubation, admission to a monitored unit or new visit to the emergency department requiring admission.

RESULTS

We enrolled 945 patients, of whom 354 (37.5%) were admitted to hospital. Of 74 (7.8%) patients with a subsequent serious adverse event, 36 (49%) had not been admitted after the initial emergency visit. Multivariable modelling identified 5 variables that were independently associated with adverse events: prior intubation, initial heart rate ≥ 110/minute, being too ill to do a walk test, hemoglobin < 100 g/L and urea ≥ 12 mmol/L. A preliminary risk scale incorporating these and 5 other clinical variables produced risk categories ranging from 2.2% for a score of 0 to 91.4% for a score of 10. Using a risk score of 2 or higher as a threshold for admission would capture all patients with a predicted risk of adverse events of 7.2% or higher, while only slightly increasing admission rates, from 37.5% to 43.2%.

INTERPRETATION

In Canada, many patients with COPD suffer a serious adverse event or death after being discharged home from the emergency department. We identified high-risk characteristics and developed a preliminary risk scale that, once validated, could be used to stratify the likelihood of poor outcomes and to enable rational and safe admission decisions.

Skin preparation before hip replacement in emergency setting versus elective scheduled arthroplasty: bacteriological comparative analysis

INTRODUCTION

Hip arthroplasty needs to be performed in an emergency setting after intracapsular femur neck fracture, whereas pain makes preoperative skin preparation of the limb difficult and it may therefore be incomplete. To date no study has analyzed the patient's skin bacteriological status in these surgical conditions.

HYPOTHESIS

The skin's bacterial flora is quantitatively and qualitatively different in the trauma context compared to an elective scheduled arthroplasty for chronic hip disease.

MATERIALS AND METHODS

Two groups of patients, undergoing hip arthroplasty and having the same preparation at the time of surgery but different skin preparation procedures the day before and the day of surgery, were prospectively compared: 30 patients operated on in an emergency setting for fracture (group A) had no skin preparation and 32 patients operated on in scheduled surgery (group B). Group A had no skin disinfection before going into surgery, whereas group B followed a predefined protocol the day before surgery. Skin samples were taken on gelose at three different stages of skin preparation at the time of surgery (before and after detersive cleaning, and at the end of the surgery) and on two sites (inguinal and greater trochanter). The bacteriological analysis took place after 48 hours of incubation.

RESULTS

Before detersive cleaning, group A had 3.6 times more bacteria than group B in the trochanter region and 2.7 times more in the inguinal area. After detersive cleaning, the contamination rate in the trochanter area was similar in both groups (group A: 10%; group B: 12.5%), but different in the inguinal region (group A: 33%; group B: 3%; P=0.002). At the end of the surgery, no difference was identified. Coagulase-negative Staphylococcus and Bacillus cereus accounted for 44% and 37%, respectively, of the bacteria isolated. In addition, the frequency of pathogenic non-saprotrophic bacteria was higher in group A (38%) compared to group B (6%). At a mean follow-up of 9.7 months (range: 8-11 months), no infection of the surgical site was identified.

CONCLUSION

The dermal flora is more abundant and different when the patient is managed in an emergency context. Although effective in the trochanter area, cutaneous detersive cleaning in the operating room is insufficient in the inguinal area and the frequency of pathogenic bacteria warrants identical rigor in preoperative preparation in all situations.

LEVEL OF EVIDENCE

III. Prospective case - control study.

Unplanned reoperations: is emergency surgery a risk factor? A cohort study

BACKGROUND

Unplanned reoperations have been proposed as a quality indicator in surgery but have not been studied extensively, especially concerning risk factors.

METHODS

This was a prospective cohort study in a third-level general surgery service. Data regarding patients operated on between July 2007 and February 2008 and followed up for 30 postoperative days were collected. Unplanned reoperations were the primary end point. The secondary end points were 30-d mortality and length of stay. A multivariate logistic regression analysis evaluated the hypothesis that patients operated on in emergency conditions had a greater chance of being reoperated on, after adjusting for relevant covariates.

RESULTS

There was a 5.9% cumulative incidence of unplanned reoperations. Patients operated on in emergency conditions had a 1.79 crude relative risk (RR) (95% confidence interval [CI], 1.15-2.78) of reoperation. Reoperated patients' RR of mortality was 8.94 (95% CI, 6.11-13.07). The mean postoperative hospital stay was 3d for patients who were not reoperated on and 19d for those who were reoperated on (P=0.00001). The logistic regression model gave a 2.83 odds ratio (95% CI, 1.65-4.87) for reoperation on emergency patients when adjusted for age, gender, body mass index, American Society of Anesthesiology classification, intraoperative inotropic use, and operation complexity.

CONCLUSIONS

Tertiary general surgery service patients had a significantly increased risk of being reoperated on if the initial surgery was an emergency surgery compared with elective surgery. Unplanned reoperations led to a significantly increased mortality risk and a longer postoperative hospital stay, which could be regarded as warning signs in the care of surgical patients.

High morbidity after laparoscopic emergency colectomy for inflammatory bowel disease

INTRODUCTION

Only limited data are available on subtotal laparoscopic colectomy (STC) in patients with in inflammatory bowel disease. We present the first Danish experiences with intended laparoscopic STC for inflammatory bowel disease (IBD). The primary outcome was 30-day morbidity.

MATERIAL AND METHODS

The present study is a retrospective single-centre study with consecutive enrolment of patients undergoing intended STC for IBD from 1 January 2005 to 31 July 2009. The results were analysed as either emergency or elective operations. Only the most severe complication was noted for each patient. Data on medical treatment, blood tests and complications and death within 30 days were registered.

RESULTS

A total of 32 patients underwent surgery (15 elective and 17 emergency procedures). Patients in the emergency group had significantly more severe disease activity than elective patients. Severe complications were recorded in 47% and 20% of the patients undergoing emergency and elective STC, respectively (p = 0.15). The overall morbidity was 72%. One emergency patient died. Five of eight emergency patients and one of three elective patients underwent conversion and experienced a major complication (p = 0.55). The overall conversion rate was 32% (p = 0.15).

CONCLUSION

We found high morbidity and conversion rates in patients undergoing SLC for IBD. A prospective national Danish survey on early postoperative outcome is suggested.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Outcomes of emergent incisional hernia repair

This study examines the effect of emergent repair on incisional hernia repair outcomes at 16 Veteran's Affairs Medical Centers between 1998 and 2002. Of the 1452 cases reviewed, 63 (4.3%) were repaired emergently. Patients undergoing emergent repair were older (P = 0.02), more likely to be black (P = 0.02), and have congestive heart failure (P = 0.001) or chronic obstructive pulmonary disease (P = 0.001). Of emergent repairs, 76.2 per cent involved intestinal incarceration versus 7.2 per cent of elective repairs (P < 0.0001), and 17.5 per cent had concomitant bowel resection compared with 3.9 per cent of elective cases (P < 0.0001). Patients undergoing emergent repair were also more likely to receive primary suture repair (49.2 vs 31.1%, P = 0.003), develop a postoperative complication (26.0 vs 11.3%, P = 0.002), and have increased postoperative length of stay (7 vs 4 days, P < 0.0001). There were nine (14.3%) deaths at 30 days for the emergent group compared with 10 (0.7%) in the elective group (P < 0.001). However, there was no significant difference between emergent and elective repairs in long-term complications. Emergent hernia repair is associated with increased mortality rates, early complications, and longer length of stay; however, long-term outcomes are equivalent to elective cases. These data suggest that technical outcomes for emergent repairs approach those of elective operations.

The effect of music on parental participation during pediatric laceration repair

The purpose of this quasi-experimental study was to test an intervention on the use of music during simple laceration repair to promote parent-led distraction in children aged 1 to 5. Children's songs were broadcast via speakers during laceration repair and parents were encouraged to participate in distracting their child. The proportion of parental participation was determined. Laceration procedures were videotaped and objectively scored using the Procedure Behavior Check List. A total of 57 children participated in the study. There was no difference in parental involvement between the control and intervention groups. When age, sex, and condition were controlled for, distress scores were significantly higher if the father was present in the procedure room than if only the mother was present (43.68 vs. 23.39, t(54) 4.296, p = < 0.001). It was concluded that distress varies with the age of the child and the parent who is present during the procedure. Providing music during simple laceration repair did not increase the proportion of parents who were involved in distraction.

[Emergency colonic surgery: analysis of risk factors predicting morbidity and mortality]

The aim of the present study was to identify risk factors for morbidity and mortality in patients submitted to emergency colonic surgery. Between 1997 and 2008 157 patients, 106 of whom affected by colon cancer (67.5%) and 51 by benign disease (32.5%), were treated. The risk factors for morbidity and mortality were evaluated by univariate and multivariate analysis considering clinical and demographic data. The overall 30-day morbidity and mortality rates were 19.1% (30 patients) and 12.7% (20 patients), respectively. Among patients affected by cancer the mortality rate was 15% (16 patients) and the morbidity rate 23.6% (25 patients), while among the patients with benign disease the mortality rate was 7.8% (4 patients) and the morbidity rate 9.8% (5 patients). No postoperative surgical complications were noted. The strongest risk factors for early death were postoperative medical complications such as cardiopulmonary, renal, thrombo-embolic and infectious complications. The results of the univariate analysis showed that advanced age, neoplastic disease, advanced stage of cancer and associated medical disease prior to surgery play a role as risk factors for morbidity and mortality. In the multivariate analysis only the presence of associated medical disease proved to be a significant independent predictor of outcome. Emergency surgery for both neoplastic and benign colonic disease is still associated with an increased risk of death. Although restorative colectomy should be regarded as the first choice procedure in the emergency setting, Hartmann's procedure is still widely used in high-risk patients.

Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study

BACKGROUND

Surgical care is delivered around the clock. Elective cases within the Veterans Affairs health system starting after 4 pm appear to have an elevated risk of morbidity, but not mortality, compared with earlier cases. The relationship between operation start time and patient outcomes is not described in private-sector patients or for emergency cases.

STUDY DESIGN

We performed a retrospective cohort study of 56,920 general and vascular surgical procedures performed from October 2001 through September 2004, and entered into the National Surgical Quality Improvement Program database. Operation start time was the independent variable of interest. Random effects, hierarchical logistic regression models adjusted for patient, operative, and facility characteristics. Two independent models determined associations between start time and morbidity or mortality. Subset analysis was performed for emergency and nonemergency cases.

RESULTS

After adjustment for patient and procedure characteristics, mortality had a moderately strong association with start time, but only for nonemergency cases starting 9:30 pm to 7:30 am (odds ratio = 1.752; p = 0.028; reference 7:30 am to 9:30 am). As for morbidity, after adjustment, operations starting 9:30 am to 1:30 pm and 5:30 pm to 9:30 pm were associated with a weakly elevated risk of morbidity, but those starting 9:30 pm to 7:30 am demonstrated a strong effect on morbidity (odds ratio = 1.32; p < 0.0001). Subgroup analysis showed this effect was largely a result of elevated risk of morbidity in emergency cases from this overnight time period (odds ratio = 1.48; p = 0.001).

CONCLUSIONS

Surgical start times are associated with risk-adjusted patient outcomes. In terms of facility operations management and resource allocation, consideration should be given to the capacity to accommodate cases with differences in risk during different time periods.

The impact of time of admission on major complications and mortality in patients undergoing emergency trauma surgery

BACKGROUND

Previous studies have shown a relationship between time of admission to hospital and mortality rates; however, it is uncertain whether such a relationship exists for patients requiring emergency trauma surgery.

METHODS

We included all trauma patients, except those with moderate to severe burns, who presented to a university-affiliated level 1 trauma center and underwent surgery, from 1995 until 2001 (n = 1044). We conducted univariate and multivariate analyses in which the dependent variables were in-hospital mortality and major complications, and the independent variables were the time of presentation to the trauma centre (nighttime vs. daytime, weekend vs. weekday, month of year, and year), age, sex, injury severity score, type of operative procedure, and total number of operative procedures.

RESULTS

None of the factors related to time of presentation were associated with major complications or mortality. Factors predictive of increased mortality were higher ISS (odds ratio 1.07; 95% confidence interval 1.03-1.08), older age (1.04; 1.03-1.07), operations involving the cardiovascular system (1.7; 1-2.6), "miscellaneous" operative procedures (1.8; 1.1-2.9), and major complications (2.4; 1.4-4.2).

INTERPRETATION

Time of presentation for emergency trauma surgery was not associated with differences in major complications or in mortality.

[Increased postprocedural neutrophil count is an independent predictive factor of poor prognosis in acute ST elevation myocardial infarction patients treated with percutaneous coronary intervention]

OBJECTIVE

The aim of the study was to evaluate the prognostic value of the postprocedural neutrophil count in patients with first acute ST elevation myocardial infarction (STEMI) treated with successful primary percutaneous coronary intervention (PCI).

METHODS

A total of 226 consecutive STEMI patients underwent successful primary PCI were enrolled. Electrocardiograms were recorded before PCI and 2 hours after PCI. Neutrophil counts were measured within 12 hours after PCI. All patients were followed up for 2 years. Logistic regression analysis was used to evaluate predictive values of postprocedural neutrophil for ST-segment resolution (STR) after PCI and for death, non-fatal myocardial infarction and heart failure at 30 days and 2 years post PCI. Time-to-event analyses were performed using the Kaplan-Meier survival curves in patients with various ranges of postprocedural neutrophil counts.

RESULTS

Postprocedural neutrophil count ranged from 2.83x10(9)/L to 18.74x10(9)/L, first quartile, median and fourth quartile were 5.66x10(9)/L, 7.38x10(9)/L and 9.34x10(9)/L respectively. Multivariable logistic analysis showed that when postprocedural neutrophil count increased 1x10(9)/L, the risk of non-STR increased 2.28 fold (OR: 2.28, P=0.009), the risk of death (OR: 1.63, P=0.010) and heart failure (OR: 1.16, P=0.035) at 30 days increased 1.63 and 1.16 folds respectively, and the risk of death (OR: 1.29, P=0.003) and heart failure (OR: 1.20, P=0.007) at 2 years increased 1.29 and 1.20 folds respectively, but the risk of non-fatal myocardial infarction was not affected by postprocedural neutrophil count. Furthermore, the patients with postprocedural neutrophil count>or=9.34x10(9)/L had significant lower 30-day (89.1% vs. 99.1% vs. 98.2%, P=0.010) and 2-year (82.4% vs. 96.1% vs. 96.3%, P=0.003) survival rates compared with the patients with postprocedural neutrophil count from 5.66x10(9)/L to 9.33x10(9)/L and the patients with postprocedural neutrophil count<5.66x10(9)/L (all P<0.05).

CONCLUSION

Postprocedural neutrophil count is an independent predictor of short- and long-term death and heart failure in first acute STEMI patients treated with successful primary PCI.

The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of three surfaces

BACKGROUND

The development of a pressure ulcer is of great significance to the life-long rehabilitative management of the person with a spinal cord injury, and may indeed delay and repeatedly interfere with that process. That the period preceding admission to the specialized spinal injury unit is crucial with regard to pressure ulcer development is evident in the professional literature. Both anecdotal and empirical evidence indicates that a significant number of pressure ulcers occur as a result of management provided prior to admission, and that such ulcers are more likely to occur in those patients who have undergone a transfer process from a hospital distal to the specialist unit on a hard spinal board.

AIM

In consideration of this and of the fact that, in Ireland, the interhospital transfer of spinal injured patients has usually involved the employment of such spinal boards to achieve immobilization, this study sought to identify whether or not the pressure experienced by individuals at two anatomical locations was dependent on the support surface employed.

METHODOLOGY

Pressure under the occiput and sacrum of three healthy volunteers immobilized on three support surfaces was measured using air-filled pressure-measuring sacks. The surfaces employed were an uncovered spinal board; a spinal board with inflatable raft devise; and a full-body vacuum splint.

DISCUSSION

Marked reductions in pressure were measured when using the inflatable raft and the vacuum mattress. The results of this study will provide a basis for a larger study and, through that, the formulation of recommendations for standardized practice along a national care pathway.

Results of coronary bypass and valve operations for mitral valve regurgitation

Combined coronary bypass grafting and valve procedures for mitral valve regurgitation result in poor outcomes, but the impact of the etiology of valve regurgitation on operative and long-term outcomes is not well defined. A retrospective analysis of 468 patients who had combined coronary bypass grafting and valve operations for mitral regurgitation showed that 78% had valve repairs and 22% had replacements for ischemic (45%) or degenerative (55%) disease. Predictors of operative mortality were ischemic mitral regurgitation, failure to use the internal mammary artery for grafting, severe coronary disease, acute myocardial infarction, low ejection fraction, advanced heart failure, emergency operation, and mitral valve replacement. The 5-year survival rates for propensity-matched patients with ischemic or degenerative disease were similar (66%). Low ejection fraction (< 35%), advanced age (> 67 years), valve replacement surgery, residual mitral regurgitation, and severe coronary artery disease were predictors of poor long-term outcome. Although the operative outcomes of ischemic mitral regurgitation were poor compared to those of degenerative disease, the long-term survival was similar in both groups of propensity-matched patients. Left ventricular remodeling, an optimal valve procedure without residual mitral regurgitation, and left ventricular function are more important determinants of long-term outcome than the etiology of valve regurgitation.

Hospital risk factors for bovine pericardial bioprosthesis valve implantation

BACKGROUND

Identification of preoperative heart valve surgery risk factors aim to improve surgical outcomes with the possibility to offset conditions related to increased morbidity and mortality.

OBJECTIVE

Intent of this study is to identify hospital risk factors in patients undergoing bovine pericardial bioprosthesis implantation.

METHODS

Retrospective study including 703 consecutive patients who underwent implantation of at least one St. Jude Medical-Biocor bovine pericardial bioprosthesis between September 1991 and December 2005 at the Rio Grande do Sul Cardiology Institute; 392 were aortic, 250 were mitral and 61 were mitroaortic. Characteristics analyzed were gender, age, body mass index, NYHA (New York Heart Association) functional class, ejection fraction, valve lesions, systemic hypertension, diabetes mellitus, kidney function, arrhythmias, prior heart surgery, coronary artery bypass graft, tricuspid valve surgery and elective, urgent or emergency surgery. Main outcome was in-hospital mortality. Relationship between risk factors and in-hospital mortality was analyzed using logistic regression.

RESULTS

Were 101 (14.3%) in-hospital deaths. Characteristics with significant relationship to increased mortality were female gender (p<0.001), age over 70 years (p=0.004), atrial fibrillation (p=0.006), diabetes mellitus (p=0.043), creatinine > 2.4 mg/dl (p=0.004), functional class IV (p<0.001), mitral valve lesion (p<0.001), previous heart surgery (p=0.005), tricuspid valve surgery (p<0.001) and emergency surgery (p<0.001).

CONCLUSION

Mortality rate observed is accepted by literature and is justifiable due to the high prevalence of risk factors, showing an increased significance level for female gender, age above 70, functional class IV, tricuspid valve repairs and emergency surgery. Offsetting these factors could contribute to reduced in-hospital mortality for valve surgery.