Electrocardiographic Exercise Stress Testing for Cardiac Risk Assessment in Patients Undergoing Noncardiac Surgery

Background: The value of exercise electrocardiography in the prediction of perioperative cardiac risk has yet to be defined. This study was performed to determine the predictive value of exercise electrocardiography as compared with clinical parameters and resting electrocardiography.

Methods: A total of 204 patients at intermediate risk for cardiac complications prospectively underwent exercise electrocardiography before noncardiac surgery. Of these, 185 were included in the final evaluation. All patients underwent follow-up evaluation postoperatively by Holter monitoring for 2 days, daily 12-lead electrocardiogram, and creatine kinase, creatine kinase MB, and troponin-T measurements for 5 days. Cardiac events were defined as cardiac death, myocardial infarction, minor myocardial cell injury, unstable angina pectoris, congestive heart failure, and ventricular tachyarrhythmia. Potential risk factors for an adverse event were identified by univariate and multivariate logistic regression analysis.

Results: Perioperative cardiac events were observed in 16 patients. There were 6 cases of myocardial infarction and 10 cases of myocardial cell injury. The multivariate correlates of adverse cardiac events were definite coronary artery disease (odds ratio, 8.8; 95% confidence interval [CI], 1.1-73.1;P = 0.04), major surgery (odds ratio, 4.7; 95% CI, 1.3-16.3;P = 0.02), reduced left ventricular performance (odds ratio, 2.0; 95% CI, 1.1-3.8;P = 0.03), and ST-segment depression of 0.1 mV or more in the exercise electrocardiogram (odds ratio, 5.2; 95% CI, 1.5-18.5;P = 0.01). A combination of clinical variables and exercise electrocardiography improved preoperative risk stratification.     

非心脏外科手术患者心脏危险性的评估与预防

随着人口的老龄化 ,越来越多的有症状或无症状的冠心病患者需接受非心脏外科手术。接受非心脏外科手术而死亡的患者大约有 5 0 %是由于心脏并发症所致[1] 。围手术期发生的心脏并发症大约 5 %～ 10 %为心肌梗死 ,主要发生于术后头3天 ,其病死率很高 ,可达 3 2 %～ 69% [2 ,3 ] 。术后发生心肌梗死或不稳定型心绞痛的患者发生心血管问题的几率增加 2 0倍[4] 。因此 ,如何评估非心脏外科手术患者的心脏危险性 ,如何预防围手术期心脏并发症的发生 ,已成为外科医生十分关注的一个问题。1　心脏危险性的评估1.1　评估对象一般来说 ,在任何外科手…     

Impact of Heart Failure on Patients Undergoing Major Noncardiac Surgery

Background: Changes in the demographics and epidemiology of patients with cardiovascular comorbidities who undergo major noncardiac surgery require an updated assessment of which patients are at greater risk of mortality or readmission. The authors evaluated short-term outcomes among patients with heart failure, coronary artery disease (CAD), or neither who underwent major noncardiac surgery.

Methods: Patients were aged 65 and older, had Medicare fee-for-service coverage, and underwent 1 of 13 major noncardiac procedures from 2000 through 2004, excluding patients with end-stage renal disease and patients who did not have at least 1 yr of Medicare fee-for-service eligibility before surgery. Main outcome measures were operative mortality and 30-day all-cause readmission.

Results: Of 159,327 procedures, 18% were performed in patients with heart failure and 34% were performed in patients with CAD. Adjusted hazard ratios of mortality and readmission for patients with heart failure, compared with patients with neither heart failure nor CAD, were 1.63 (95% confidence interval, 1.52-1.74) and 1.51 (95% confidence interval, 1.45-1.58), respectively. Adjusted hazard ratios of mortality and readmission for patients with CAD, compared with patients with neither heart failure nor CAD, were 1.08 (95% confidence interval, 1.01-1.16) and 1.16 (95% confidence interval, 1.12-1.20), respectively. These effects were statistically significant. Patients with heart failure were at significantly higher risk for both outcomes compared with patients with CAD.     

心脏瓣膜手术后呼吸衰竭相关危险因素分析

目的探讨影响心脏瓣膜手术后呼吸衰竭发生的相关危险因素。方法回顾性分析2001年1月至2010年11月兰州军区兰州总医院618例心脏瓣膜疾病患者的临床资料,其中男339例,女279例;年龄10～74(44.01±13.95)岁;风湿性心脏病387例,非风湿性心脏病231例;根据术后是否发生呼吸衰竭分为呼吸衰竭组(74例)和非呼吸衰竭组(544例),采用单因素及多因素logistic回归方法分析术后呼吸衰竭发生的危险因素。结果心脏瓣膜术后早期住院死亡率6.1%(38/618),呼吸衰竭发生率12.0%(74/618)。呼吸衰竭组住院死亡率为17.6%(13/74),非呼吸衰竭组住院死亡率4.6%(25/544),两组差异有统计学意义(χ2=18.994,P=0.000)。单因素分析显示,年龄>65岁(P=0.005)、心功能分级(NYHA)Ⅳ级(P=0.014)、射血分数(EF)<50.0%(P=0.003)、体外循环时间>3 h(P=0.001)、主动脉阻断时间>2 h(P=0.008)、复合手术(同期CABG、主动脉根部置换或射频消融迷宫手术P=0.000)、二次手术(P=0.012)、术后并发症(P=0.000)、输血量>2 000 ml(P=0.000)是心脏瓣膜手术后呼吸衰竭发生的潜在危险因素;多因素logistic回归分析结果显示,复合手术(P=0.003)、二次手术(P=0.010)、术后并发症(P=0.000)、输血量>2 000 ml(P=0.012)是心脏瓣膜手术后呼吸衰竭发生的独立预测因素。结论重视心脏瓣膜术后呼吸衰竭发生的危险因素,加强围手术期处理,缩短体外循环时间,减少并发症,以减少呼吸衰竭的发生,降低病死率。     

Preoperative Nutritional Risk Assessment in Predicting Postoperative Outcome in Patients Undergoing Major Surgery

Introduction Although a variety of nutritional indices have been found to be valuable in predicting patient outcome when used alone, there is no consensus on the best method for assessing the nutritional status of hospitalized patients. Therefore, the aim of this study was to assess the nutritional status of a cohort of patients who underwent major elective surgery using the Nutritional Risk Index (NRI), Maastricht Index (MI), Subjective Global Assessment (SGA), and Mini Nutritional Assessment (MNA) to determine the best possible nutrition screening system in surgical practice. Methods The study population consisted of 460 patients who underwent major elective surgery between December 1999 and March 2002. Each patient had a complete set of the three nutritional assessment techniques (NRI, MI, SGA); in addition, the MNA was performed in patients older than 59 years of age. One of the coauthors who was unaware of the nutritional assessments assessed the patients for postoperative morbidity and mortality. Complications were classified as major or minor and as infectious or noninfectious. To assess the predictive value of the assessment techniques, likelihood ratios were calculated for the various strata of each method. The odds ratio and receiver operating characteristic (ROC) curves were also calculated to describe and compare the diagnostic value of each of the four nutrition indices. Results Twenty patients died during the study period. No complications occurred in 329 of the 460 patients; 42 patients suffered from two or more complications. The frequency of malnutrition was found to be 58.3%, 63.5%, and 67.4% as assessed by the SGA, NRI, and MI, respectively. Morbidity rates, especially severe infectious and noninfectious complications, were significantly higher in malnourished patients in all nutritional indices. The likelihood ratio was well correlated with the risk categories of every nutritional index. The area under the ROC curves revealed that each scoring system proved to be significantly powerful in predicting the morbidity (infectious and noninfectious severe morbidity) and mortality. However, no differences were detected among the nutritional indices in 460 patients. The odds ratio for morbidity between the well nourished and malnourished patients was 3.09 [95% confidence interval (CI), 1.96–4.88], 3.47 (95% CI, 2.12–5.68), 2.30 (95% CI, 1.43–3.71), and 2.81 (95% CI, 0.79–9.95) for the SGA, NRI, MI, and MNA, respectively. All indices except the MNA were significantly predictive for morbidity. The odds ratios were not statistically different among the indices. Conclusions Our findings revealed that all nutritional assessment techniques can be safely applied to the clinical setting with no significant difference in predictive value. We therefore strongly recommend the use of any of these techniques to improve the outcome of surgical care. Meanwhile, further investigations are needed, and much effort must be given to find the best method for assessing nutritional status. This work was presented at a conference of the European Society for Clinical Nutrition and Metabolism (ESPEN), August 31 to September 4, 2002, Glasgow, UK.     

Predicting Postoperative Mortality in Patients Undergoing Colorectal Surgery

Well-known and suitable instruments for surgical audit are the POSSUM and P-POSSUM scoring systems. But these scores have not been well validated across the countries. The objective of the present study was to assess the predictive value of scores for colorectal surgery in France. Patients operated on for colorectal malignant or diverticular diseases, whether electively or on emergency basis, within a 4-month period were included in a prospective multicenter study conducted by the French Association for Surgery (Association Française de Chirurgie, AFC). The main outcome measure was postoperative in-hospital mortality. Independent factors leading to death were assessed by multivariate logistic regression analysis (AFC-index). The ratio of expected versus observed deaths was calculated, and the predictive value of the POSSUM and P-POSSUM scores were analyzed by the receiver operating characteristic (ROC) curve. A total of 1426 patients were included. The in-hospital death rate was 3.4%. Four independent preoperative factors (AFC-index) have been found: emergency surgery, loss of more than 10% of weight, neurological disease history, and age > 70 years. POSSUM had a poor predictive value; it overestimated postoperative death in all cases. P-POSSUM had a good predictive value, except for elective surgery, where it overestimated postoperative death twofold. The predictive value of the AFC-index was also good. It had the same sensitivity and specificity as the P-POSSUM. POSSUM has not been validated in France in the field of colorectal surgery. P-POSSUM was as predictive as the AFC-index which is a simpler instrument based on four clinical parameters (without any mathematical formulas).     

Apolipoprotein E Levels in Pediatric Patients Undergoing Cardiopulmonary Bypass

Apolipoprotein E (apoE) may play a critical role in modulating the response to neurological injury after cardiopulmonary bypass (CPB) in children. Plasma samples were collected from 38 pediatric patients. Half of the patients received nonpulsatile flow and the other half underwent pulsatile flow during CPB. Plasma samples were collected at three time points: at baseline prior to incision (T1), 1 h after CPB (T2), and 24 h after CPB (T3). The study included 38 pediatric patients undergoing heart surgery (mean age 2.5 ± 2.1 years). Baseline apoE levels were low (<30 μg/mL) in 21 patients (55%). ApoE levels were significantly decreased at 1 h after CPB compared with baseline (22 ± 14 vs. 34 ± 18 μg/mL, P = 0.001). At 24 h after CPB, apoE levels were significantly increased compared with baseline (47 ± 25 vs. 34 ± 18 μg/mL, P = 0.002). Pulsatile mode was associated with lower apoE levels at 24 h after CPB compared with nonpulsatile mode (38 ± 14 vs. 57 ± 29 μg/mL, P = 0.018). ApoE levels correlated negatively with pump time (r = ?0.525, P = 0.021) and cross‐clamp time (r = ?0.464, P = 0.045) at 24 h following CPB for the nonpulsatile group but not for the pulsatile group. In this cohort of young children with congenital heart disease, baseline apoE levels were low in the majority of patients prior to surgery. ApoE levels decreased further at 1 h after CPB, and then significantly increased by 24 h. The mode of perfusion and the duration of pump time and clamp time influence the apoE levels after CPB. An improved understanding of these mechanisms may translate into the development of new techniques to improve the clinical outcomes after pediatric CPB.     

Prospective Evaluation of Delirium in Geriatric Patients Undergoing Emergency General Surgery

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A Population-Based Study of Early Postoperative Outcomes in Patients with Heart Failure Undergoing Bariatric Surgery

Background

Weight loss following bariatric surgery can improve cardiac function among patients with heart failure (HF). However, perioperative morbidity of bariatric surgery has not been evaluated in patients with HF.

Study Design

The National Surgical Quality Improvement Project (NSQIP) database for 2006–2014 was queried to identify patients undergoing adjustable gastric band, gastric bypass, sleeve gastrectomy, and biliopancreatic diversion-duodenal switch. Patients with HF were propensity matched to a control group without HF (1:5). Univariate analyses evaluated differences in complications, and multivariate analysis was completed to predict all-cause morbidity.

Results

There were 237 patients identified with HF (mean age 52.8 years, 59.9% female, mean body mass index 50.6 kg/m²) matched to 1185 controls without HF who underwent bariatric surgery. Preoperatively, patients with HF were more likely to be taking antihypertensive medication and have undergone prior percutaneous cardiac intervention and cardiac surgery. There was no difference in operative time, surgical site infections, acute renal failure, re-intubation, or myocardial infarction. HF was associated with increased likelihood of length of stay more than 7 days, likelihood to remain ventilated >?48 h, venous thromboembolism, and reoperation. For patients with HF, the adjusted odds ratio for all-cause morbidity was 2.09 (1.32–3.22).

Conclusion

The NSQIP definition of HF, which includes recent hospitalization for HF exacerbation or new HF diagnosis 30 days prior to surgery, predicts a more than two-fold increase in odds of morbidity following bariatric surgery. This must be balanced with the longer-term potential benefits of weight loss and associated improvement in cardiac function in this population.

     

应用呼吸训练器降低开胸术后肺部并发症探讨

目的 探讨开胸术后应用呼吸训练器行深呼吸训练减少术后肺部并发症的效果.方法 将63例行开胸术患者按住院时间分为两组,对照组(22例)行常规护理,观察组(41例)在常规护理的基础上于术后6 h采用呼吸训练器行深吸气训练,至术后第7天.结果 观察组术后肺部并发症发生率显著低于对照组(P＜0.01).结论 开胸手术患者在常规护理基础上应用呼吸训练器行深呼吸功能锻炼能有效减少术后肺部并发症的发生.     

应用呼吸训练器降低开胸术后肺部并发症探讨

目的探讨开胸术后应用呼吸训练器行深呼吸训练减少术后肺部并发症的效果。方法将63例行开胸术患者按住院时间分为两组，对照组（22例）行常规护理，观察组（41例）在常规护理的基础上于术后6h采用呼吸训练器行深吸气训练，至术后第7天。结果观察组术后肺部并发症发生率显著低于对照组（P〈0．01）。结论开胸手术患者在常规护理基础上应用呼吸训练器行深呼吸功能锻炼能有效减少术后肺部并发症的发生。