Effect of chronic beta-blockade on peri-operative outcome in patients undergoing non-cardiac surgery: an analysis of observational and case control studies

Little is known about the effect of chronic beta-adrenoceptor antagonist therapy during the peri-operative period in patients undergoing non-cardiac surgery. We conducted a literature review to identify studies examining the relationship between chronic therapy and adverse peri-operative outcome. Eighteen studies were identified in which it was possible to ascertain the incidence of adverse cardiac outcomes in those patients who were and were not receiving chronic beta-blocker therapy. None of the studies demonstrated a protective effect of chronic beta-blockade. The results of these studies were then combined and a cumulative odds ratio calculated for the likelihood of myocardial infarction, cardiac death and major cardiac complications. Patients receiving chronic beta-blocker therapy were more likely to suffer a myocardial infarction (p < 0.05). These findings differ from the published effects of acute beta-blockade. Reasons for this discrepancy are considered.     

The aetiology and prevention of peri-operative corneal abrasions

Corneal abrasion is the most frequent ocular complication to occur during the peri-operative period. This review describes the aetiology of corneal abrasions and evaluates the current methods of prevention. Most abrasions are caused by lagophthalmos (failure of the eyelids to close fully) during general anaesthesia, resulting in corneal drying. General anaesthesia reduces both the production and the stability of tears and therefore increases the incidence of this painful condition. Taping the eyelids closed, soft contact lenses, the instillation of aqueous gels or paraffin-based ointments are all effective in preventing corneal abrasions, but ointments are associated with significant morbidity.     

脊柱结核术后复发原因分析及再手术疗效观察

目的:回顾性分析脊柱结核术后复发的危险因素,并对再手术治疗效果观察随访。方法:2002年1月至2010年5月收治27例再手术脊柱结核术后复发患者,男15例,女12例,年龄21～65岁,平均36.5岁。应用统计学方法比较分析导致术后复发的危险因素和作用强度,针对主要原因采用个体化手术治疗。再手术方式:单纯病灶清除术5例,病灶清除和窦道切除术7例,Ⅰ期经前路病灶清除植骨融合联合后路内固定术8例,Ⅰ期经后路植骨融合内固定术联合CT引导下经皮穿刺灌注引流和局部化疗2例,单纯CT引导下经皮穿刺灌注引流和局部化疗5例。术后加强抗结核药物治疗,定期检查血沉、X线或CT三维重建评估结核活动及植骨融合情况。结果:脊柱结核术后复发为多种危险因素共同作用的结果,主要原因根据作用强度大小排列为:术前术后未行正规化疗、术后积液未早期发现和处理、自身营养状况差、术中病灶清理不彻底、术后脊柱稳定性差。再次手术术中无大血管、神经或输尿管损伤,术后随访12～36个月,平均24个月。末次随访所有患者结核症状消失,无结核复发、切口感染、窦道形成或内固定失败等并发症,复查血沉正常。术后8～12个月影像学复查提示椎间隙植骨均获骨性愈合,内固定位置正常。结论:脊柱结核再手术原因复杂且为多因素共同作用结果,诊断和治疗难度大。术前应详细分析复发的主要原因,强调正规抗结核药物治疗和个体化手术治疗,同时应加强营养和支持治疗。     

Etiology and outcome of chronic renal failure in hospitalized children in Ho Chi Minh City, Vietnam

The aim of this study was to investigate the etiology and treatment modalities and to determine mortality risks in hospitalized children with chronic renal failure (CRF) in Ho Chi Minh City, Vietnam. We reviewed the records of 310 children with CRF hospitalized in Ho Chi Minh City from January 2001 to December 2005. The average annual number cases was 4.8 per million child population native to Ho Chi Minh City. Median age was 14 years; 85% of patients were in end-stage renal failure. Associated illnesses were anemia (96%), hypertension (74%), and cardiopulmonary diseases (39%). Causes of CRF included glomerulonephritis (30%) and congenital/hereditary anomalies (20%), but in 50% of children, the etiology was unavailable. Seventy-three percent of cases with end-stage renal failure did not benefit from renal replacement therapy. During hospitalization, 47 patients (15%) died. Mortality risks were higher in young children (1–4 years), in boys, and in patients with acquired pathologies. Severe metabolic acidosis was the main predictive factor of mortality by multivariate regression analysis. Our data shows a poor outcome due to late referral and limited facilities for renal replacement therapy in children with CRF hospitalized in Ho Chi Minh City.     

A survey of peri-operative use of magnesium sulphate in adult cardiac surgery in the UK

We conducted a postal survey of cardiac anaesthetists in the UK, to determine the extent of magnesium sulphate (MgSO4) use and the main indications for its administration. Questionnaires were sent to anaesthetists at 35 UK hospitals undertaking adult cardiac surgery. Responses were received from 24 hospitals (69%) totalling 124 individual responses. Twenty-five (20%) of the anaesthetists responding to the questionnaire routinely gave magnesium other than in cardioplegia. The most common indications for administration were arrhythmia prophylaxis and treatment, myocardial protection, and the treatment of hypomagnesaemia.     

Anaesthetic management of Caesarean section in an elderly parturient with pre-eclampsia

The number of women over 40 years of age becoming pregnant has increased over recent years. They suffer a high incidence of hypertensive complications, and require more frequent operative interventions. We present a case report of a 51-year-old woman having a Caesarean section for a twin pregnancy complicated by pre-eclampsia. We discuss the effects of age on pregnancy and the implications for anaesthetic management.     

Retrospective analysis on acute respiratory distress yndrome in ICU

OBJECTIVE: To assess the incidence, etiology, physiological and clinical features, mortality, and predictors of acute respiratory distress syndrome (ARDS) in intensive care unit (ICU). METHODS: A retrospective analysis of 5 314 patients admitted to the ICU of our hospital from April 1994 to December 2003 was performed in this study. The ARDS patients were identified with the criteria of the American-European Consensus Conference (AECC). Acute physiology and chronic health evaluation III (APACHE III), multiple organ dysfunction syndrome score (MODS score), and lung injury score (LIS) were determined on the onset day of ARDS for all the patients. Other recorded variables included age, sex, biochemical indicators, blood gas analysis, length of stay in ICU, length of ventilation, presence or absence of tracheostomy, ventilation variables, elective operation or emergency operation. RESULTS: Totally, 131 patients (2.5%) developed ARDS, among whom, 12 patients were excluded from this study because they died within 24 hours and other 4 patients were also excluded for their incomplete information. Therefore, there were only 115 cases (62 males and 53 females, aged 22-75 years, 58 years on average) left, accounting for 2.2% of the total admitted patients. Their average ICU stay was (11.27+/-7.24) days and APACHE III score was 17.23+/-7.21. Pneumonia and sepsis were the main cause of ARDS. The non-survivors were obviously older and showed significant difference in the ICU length of stay and length of ventilation as compared with the survivors. On admission, the non-survivors had significantly higher MODS and lower BE (base excess). The hospital mortality was 55.7%. The main cause of death was multiple organ failure. Predictors of death at the onset of ARDS were advanced age, MODS > or = to 8, and LIS > or = 2.76. CONCLUSIONS: ARDS is a frequent syndrome in this cohort. Sepsis and pneumonia are the most common risk factors. The main cause of death is multiple organ failure. The mortality is high but similar to most recent series including severe comorbidities. Based on this patient population, advanced age, MODS score, and LIS may be the important prognostic indicators for ARDS.     

Ischemic colitis—analysis of risk factors for postoperative mortality

Background Ischemic colitis is a disease with high postoperative mortality when surgery is necessary. The definition of risk factors for perioperative mortality, which is currently lacking in the literature, could be helpful in clinical decision making and in optimizing perioperative treatment. Materials and methods Based on a prospective database, 85 consecutive patients undergoing surgery for ischemic colitis between November 04, 2001 and October, 26, 2004 at the Department of Surgery, University of Heidelberg, were included in this study. The influence of different known factors on perioperative mortality such as age, type of operation, blood loss, comorbidities, hospital course, and complications was tested by univariate and multivariate analysis. Results Sixty-seven percent of patients were operated as emergency cases (within 24 h after surgical evaluation). About half of the patients underwent subtotal or total colectomy and 80% had stoma creation. Twenty-two percent of patients developed surgical complications and 47% of patients died in the further postoperative course. Univariate analysis showed underlying cardiovascular diseases, American Society of Anesthesiologists (ASA) status, emergency surgery, total colectomy, elevated intraoperative blood loss and intraoperative allogeneic blood transfusion or transfusion of fresh frozen plasma to be associated with an increased postoperative mortality. Multivariate analysis confirmed ASA status > III, emergency surgery, and blood loss to be independently associated with postoperative mortality in ischemic colitis. Conclusions The mortality of patients requiring surgery for ischemic colitis will remain high as the majority of afflicted patients are patients with significant comorbidities in a reduced general condition. But earlier diagnosis and measures to reduce blood loss may contribute to improving the overall outcome. Dalibor Antolovic and Moritz Koch contributed equally to this study.     

Organisational failures in urgent and emergency surgeryA potential peri-operative risk factor

Medical error is an important cause of morbidity and mortality. Organisational failure in the pre-operative period has been associated with catastrophic outcome. Little information is available regarding peri-operative organisational problems. The incidence and nature of organisational failure before urgent and emergency surgery in a district general hospital was studied prospectively in 159 cases over a 30-day period. Organisational failure affected more than half of the cases overall, but varied in both its incidence and its complexity between surgical disciplines. Various causative factors were identified, e.g. 8% of cases were subject to delay due to clinical emergencies. The median [range] time required to rectify the problems was 115 [5-750] min. A consultant anaesthetist and surgeon were present in 30 and 20% of cases, respectively. Difficulty with the preparation of patients for emergency surgery is an important but underevaluated cause of medical error that may put patients at risk.     

7种危险评分系统对CABG术后病死率预测效能的比较

目的 评价7种危险评分系统对于单中心接受冠状动脉旁路移植术(CABG)患者术后病死率的预测效能.方法 收集2010年1月至2011年1月施行CABG患者围手术期资料.应用7种危险评分系统:SinoSCORE、Additive EuroSCORE、Logistic EuroSCORE、OPR、Cleveland model、Parsonnet score、QMMI预测每一位患者术后病死率和全部患者的平均预计病死率.根据预计病死率将全部患者分为6组:Ⅰ组(0～1.99％),Ⅱ组(2.00％ ～ 3.99％),Ⅲ组(4.00％～5.99％),Ⅳ组(6.00％～7.99％),Ⅴ组(8.00％～9.99％),Ⅵ组(＞10％).比较不同危险程度的实际病死率和预计病死率评价评分系统的预测能力.运用Hosmer-Lemeshow拟合优度检验评价评分系统的校准度,运用ROC曲线下面积(AUC)评价评分系统的分辨力.结果 全组共1103例患者,平均年龄(62.8±8.8)岁.患者术后22例死亡,实际病死率1.99％.SinoSCORE、Additive EuroSCORE、Logistic EuroSCORE、OPR、Cleveland model、Parsonnet score、QMMI预测平均全组病死率分别为3.01％、4.38％、3.83％、1.69％、4.42％、6.71％、3.71％,其中最接近实际病死率的是OPR、SinoSCORE、QMMI.分组比较显示:Logistic EuroSCORE在各组中全部高估术后病死率.Additive EuroSCORE在Ⅵ组中预测病死率明显低于实际病死率,其他各组均高估了术后病死率.而SinoSCORE、Cleveland model、Parsonnet score、QMMI除了在Ⅰ组低估了患者术后病死率,其他各组高估了术后病死率.OPR低估了Ⅰ组和Ⅳ组患者的病死率,高估了其他组患者的病死率.利用Hosmer-Lemeshow拟合优度检验评价7种评分系统的校准度,结果显示7种评分系统校准度尚可,P值全部＞0.05.通过ROC检验比较7种评分系统的分辨力,其中只有SinoSCORE的AUC =0.751( ＞0.70),证明SinoSCORE对于本组患者的死亡分辨力良好.结论 通过比较,SinoSCORE对于本中心接受CABG患者术后病死率预测效能好,可以运用于术前危险性评估.     

Postoperative mortality and morbidity in octogenarians and nonagenarians with hip fracture: an analysis of perioperative risk factors

Objective:To evaluate the role of high risk factors in octogenarians and nonagenarians with hip trauma,which may lead to excessive mortality and morbidity postoperatively.Methods:Fifty-four octogenarians and nonagenarians patients were enrolled in the study,receiving surgical repair of hip fracture in our hospital from January 2006 to January 2010.High risk factors were recorded preoperatively in detail.Complications and survival state were followed up by telephone for 2 years postoperatively.All the data were analyzed by Chi-square test with SPSS 13.0.Results:Twenty-six males (48.1％),aged from 80 to 94years with a mean age of 84.2 years,and twenty-eight females (51.9％),aged from 80 to 95 years with a mean age of 83.4 years,were presented in the cohort study.The hip traumas were caused by daily slight injuries (52 cases) and car accidents (2 cases),respectively.Twenty-eight patients (51.9％) with femoral neck fracture while 26 patients (48.1％)with intertrochanteric fracture were diagnosed through an anterior-posterior pelvic radiophotograph.In this series,39patients (72.2％) suffered from one or more comorbidities preoperatively.The morbidity was 48.1％ and the major cause was urinary tract infection,while a significant difference was noted between females and males.The mortality was 20.4％ with a predominant cause of acute renal failure.Conclusions:The gender should be considered as a critical high risk factor in octogenarians and nonagenarians with hip trauma postoperatively.Females are more likely to suffer complications postoperatively,which is especially obvious in senile patients over 80 years (P＜0.05).Urinary tract infection is the most frequent complication after hip surgery,followed by low limb embolism and malnutrition.The mortality is dramatically greater in patients over 80 years old than those below,and major causes are acute renal failure,multiple organ dysfunction syndrome and mental deterioration.Multidisciplinary consultations and mental assessment are encouraged in patients over 80 years old after hip trauma and surgery.Hip fractures in octogenarians and nonagenarians deserve special attention because of their advanced age and comorbidities.     

The risk factors of mortality in peritoneal dialysis patients in different periods

Objective To explore the risk factors and characteristics in patients with peritoneal dialysis who died in different periods. Methods The clinical data of new peritoneal dialysis patients in the Department of Nephrology and Peritoneal Dialysis Center of the First Affiliated Hospital of Nanchang University from November 1, 2005 to February 28, 2017 was retrospectively analyzed. The patients were divided into two groups according to the time of death: those who died within one year and died after one year. The risk factors of mortality between the two groups were analyzed by Cox regression model. Results A total of 997 patients were enrolled and 244 patients died. There were 69 patients (28.3%) died within one year and 175 patients (71.7%) died after one year. Cardiovascular and cerebrovascular disease was the dominating reason of death in both groups, accounting for 59.4% (died within one year group) and 51.4% (died after one year group) respectively. Cox regression analysis showed that for died within one year group, old age (HR=1.035, 95%CI: 1.016-1.055, P＜0.001), low blood total calcium (HR=0.167, 95%CI: 0.053-0.529, P=0.002), low albumin (HR=0.899, 95%CI: 0.856-0.943, P＜0.001) and low apolipoprotein A1 (HR=0.274, 95%CI: 0.095-0.789, P=0.016) were risk factors associated with mortality. However, for died after one year group, old age (HR=1.053, 95%CI: 1.038-1.069, P＜0.001), combined with diabetes (HR=2.181, 95%CI: 1.445-3.291, P＜0.001) and hypertriglyceride (HR=1.204, 95%CI: 1.065-1.362, P=0.003) were risk factors associated with mortality. Conclusions The risk factors of mortality for peritoneal dialysis patients of different periods were not exactly the same. For died within one year patients, old age, low blood total calcium, low albumin and low apolipoprotein A1 were independent risk factors for mortality.However, for died after one year patients, old age, combined with diabetes, and high triglycerides were independent risk factors for mortality.     

Determination of risk factors for burn mortality based on a regional population study in Taiwan

Background

Burns are not only major personal catastrophic events but also constitute a national health problem due to its associated morbidity, rehabilitation, mortality and high cost medical services. Advances in care and treatment have increased survival from major burn injury. However, information on the epidemiology and risk factors of burn mortality in Taiwan is limited. The study aim was to determine the nationwide epidemiological characteristics, trends, and mortality risk factors of burn inpatients in Taiwan.

Long-term mortality outcome of victims of major trauma

Introduction

Although trauma is associated with major acute morbidity and mortality, its long-term outcome is less well defined. We sought to define the rate of readmission to hospital and long-term mortality of victims of major trauma.

Patients and Methods

All Calgary Health Region residents presenting to the regional trauma program with an injury severity score (ISS) ≥12 between April 1, 2002 and March 31, 2006 were included. Readmission to hospital within one-year and deaths occurring on or before September 30, 2008 were identified using regional and provincial databases.

Results

A total of 2652 incident major trauma episodes occurred among 2630 residents; the median age was 41.3 [interquartile range (IQR); 23.1-59.2] years, 1,915 (72%) were male, the median ISS was 19 (IQR; 16-25), and 717 (27%) required intensive care unit admission. Among 2350 survivors to hospital discharge, 537 readmissions occurred (median length of stay 4.0; IQR; 1.6-7.5 days) among 386 patients within one-year of the incident trauma episode, and 323 (60%) required surgery. Re-admitted patients were older, had higher ISS, had longer initial admission length of stay, and were less likely to have sports related injuries. Two hundred and fifteen (8%) of 2350 survivors to hospital discharge died during the median study follow-up duration of 1543 (IQR; 1181-1934) days. Case-fatality rates for 28 days, 90 days, and 365 days were 304 (11%), 327 (12%), and 370 (14%), respectively. Among survivors to 28 days (n = 2348), 66 (3%) suffered delayed one-year mortality (i.e. death occurred between 28 days and 365 days post-trauma). Age ≥65 years of age, initial hospitalisation for ≥28 days, and unintentional falls were independently associated with delayed one-year mortality.

Conclusions

Patients with major trauma are at risk for both acute and delayed adverse outcomes.     

再次肝移植术后早期与死亡率相关的危险因素分析

目的 探讨再次肝移植术后早期与死亡率相关的独立危险因素.方法 回顾性分析2004年1月至2007年12月间的36例再次肝移植的资料.根据再次肝移植术后早期(术后3个月内)的转归,将患者分为死亡组和存活组.收集两组患者术前及术中常用的15项临床或实验室指标作为可能影响死亡率的危险因素进行单因素分析,将有统计学意义的危险因素再进行Logistic回归分析,筛选出与术后早期死亡率相关的独立危险因素.结果 再次肝移植术后早期死亡率为25%(9/36),死亡原因为:严重感染5例(55.6%),急性肾功能衰竭2例(22.2%),心肌梗死和脑出血各1例(各11.1%).经单因素分析显示,死亡组和存活组间术前肌酐水平、终末期肝病模型评分、感染、重症监护室(ICU)监护时间、机械通气时间以及再次肝移植的手术时间和术中出血量的差异有统计学意义(P<0.05),Logistic多元回归分析显示,术前ICU监护时间和术中出血量是术后早期与死亡率相关的独立危险因素.结论 再次肝移植术前ICU监护时间和术中出血量与术后早期死亡率密切相关.     

Mortality during the two years after coronary artery bypass grafting in relation to perioperative factors and urgency of operation

The purpose of this study was to describe mortality during the 2-year-period after coronary artery bypass surgery (CABG) in relation to perioperative risk factors and urgency of operation. All the patients in western Sweden were included in whom CABG was performed between June 1988 and June 1991, without concomitant procedures or re-operations. The study was prospective in design. In all, 2000 patients were operated upon and 186 (9.3%) of the operations were acute. There was a significant relationship between the urgency of the operation and mortality. Early mortality was 2.4% in elective operations and 5.4–62.5% in urgent to emergency operations. The 30-day to 2-year mortality was 4.2%. The perioperative risk indicators independently associated with early mortality were neurologic complications, serum-aspartate aminotransferase (S-ASAT) more than 2.0 μkat/l, urgency of operation, the use of circulatory assist devices, re-operation and ventilator time more than 24 h. The risk indicators for mortality after 30 days were pneumothorax, longer intensive care unit (ICU) time, the use of inotropic drugs and neurologic complications. In conclusion, the multivariate analysis reveals the urgency of the operation as a predictor of early mortality after CABG, but no significant association with mortality was found after 30 days. When excluding death within 30 days, three additional independent predictors of mortality were identified.     

心脏移植近远期疗效危险因素分析——从单中心经验看我国心脏移植特点和现状

目的 探讨我国心脏移植病例的特点和影响受者疗效的危险因素,并与国外数据进行对比分析.方法 单中心完成心脏移植手术200例,所有病例资料和随访信息均进行详细的登记并形成数据库.对其中随访1年以上的160例的术后死亡及危险因素、支持治疗、急性排斥反应和并发症的情况进行分析,并与国外数据进行比较.结果 160例中,术后行体外膜肺氧合(ECMO)者占8.1%,连续肾脏替代治疗(CRRT)者占10%.160例共行550例次心内膜活检(EMB),其中Ⅱ级及Ⅱ级以上排斥反应的发生率为14.9%.患者的院内死亡率为3.8%,吸烟史、术前肺动脉舒张压高、肺毛细血管楔压高、血清总蛋白低和白蛋白水平低与院内死亡相关.术后1年、3年和5年的存活率分别为94.4%,91.9%和88.8%,术前肺动脉舒张压高、血肌酐高和血清NT-proBNP高与总体死亡相关.160例的远期存活率高于国际心肺移植协会(ISHLT)的结果.结论 影响我国心脏移植受者死亡率的危险因素与国外资料不尽相同.采取适当的临床治疗策略心脏移植可以达到很好的治疗效果.