Predictors of postoperative complications in HIV-infected children undergoing surgery

Background

An increasing number of HIV-infected children require a surgical procedure. The aim of this study was to investigate factors associated with the development of complications in HIV-infected children undergoing surgery.

Methods

A prospective study of HIV-infected children younger than 60 months undergoing surgery at a tertiary referral pediatric hospital from July 2004 to July 2008 was performed. Children were followed postoperatively for the development of complications, length of stay, and mortality.

Results

Eighty-two HIV-infected children, with a median age of 11.5 months (interquartile range, 6-24 months), were enrolled. Most (68; 82.9%) had World Health Organization stage 3 or 4 HIV disease, 72 (88%) had Centers for Disease Control and Prevention stage 2 or 3 disease, and 60 (73%) were taking highly active antiretroviral therapy. Half (41; 50%) were underweight, 37 (45.1%) underwent emergency surgery, 28 (34.2%) required major surgery, and 40 (48.7%) had surgical site contamination at the time of surgery. The median length of hospital stay was 4 days (interquartile range, 2-14 days), and in-hospital mortality was 6 (7%). Thirty-four (42%) children developed 37 complications. On univariate analysis, malnutrition, HIV stage, or type of surgery was not associated with development of complications. In contrast, young age (6 vs 13.5 months; P = .0004), low hemoglobin (9.6 vs 10.5 g/dL; P = .04), or having a major procedure (14 [42%] vs 9 [18%]; P = .03; relative risk, 2.2 [1.2-4.8]) was associated with complications. On logistic regression, younger age (odds ratio = 4.3; P = .004; 95% confidence interval, 1.6-11.9) and major surgery (odds ratio = 6.8; P = .001; 95% confidence interval, 1.5-31.4) were associated with development of a complication.

Conclusion

Young age and major surgery were the main predicators of complications in HIV-infected children undergoing surgery.     

Predictors of cardiac events in high-risk patients undergoing emergency surgery

Background: The aim of this study was to determine the incidence of myocardial damage and left ventricular myocardial dysfunction and their influence on outcome in high-risk patients undergoing non-elective surgery.
Methods: In this prospective observational study, 211 patients with American Society of Anesthesiologists classification III or IV undergoing emergent or urgent surgery were included.
Troponin I (TnI) was measured pre-operatively, 12 and 48 h post-operatively. Pre-operative N-terminal fragment of B-type natriuretic peptide (NT-proBNP), as a marker for left ventricular systolic dysfunction, was analyzed. The diagnostic thresholds were set to TnI >0.06 μg/l and NT-proBNP >1800 pg/ml, respectively. Post-operative major adverse cardiac events (MACE), 30-day and 3-months mortality were recorded.
Results: Elevated TnI levels were detected in 33% of the patients post-operatively. A TnI elevation increased the risk of MACE (35% vs. 3% in patients with normal TnI levels, P <0.001) and 30-day mortality (23% vs. 7%, P =0.003). Increased concentrations of NT-proBNP were seen in 59% of the patients. Elevated NT-proBNP was an independent predictor of myocardial damage post-operatively, odds ratio, 6.2 [95% confidence interval (CI) 2.1–18.0] and resulted in an increased risk of MACE (21% vs. 2.5% in patients with NT-proBNP ≤1800 pg/ml, P <0.001).
Conclusion: Myocardial damage is common in a high-risk population undergoing unscheduled surgery. These results suggest a close correlation between myocardial damage in the post-operative period and increased concentration of NT-proBNP before surgery. The combinations of TnI and NT-proBNP are reliable markers for monitoring patients at risk in the peri-operative period as well as useful tools in our risk assessment pre-operatively in emergency surgery.     

Postoperative complications among octogenarians after cardiovascular surgery

BACKGROUND: The octogenarian patient is often perceived as too fragile to undergo cardiothoracic surgery. Our study aimed to compare postoperative complications in patients aged less than 80 versus elderly patients (80 years or more) after surgical cardiac intervention (coronary artery bypass or valve replacement). METHODS: Subjects were all patients (n = 8,361) who had an open-heart procedure, either coronary artery bypass or valve implantation or replacement, at two medical centers located in northern Virginia using the same surgical group. A computerized medical record database was reviewed to determine preoperative risk factors and postoperative outcomes. Predictors of complications were identified by univariate and multivariate logistic regression. RESULTS: A total of 3,214 complications were recorded. The most prevalent complications were prolonged ventilation time in the intensive care unit, reoperation for bleeding, and pneumonia. The overall mortality rate was 2.4% (204 of 8,361). Persons aged over 80 years had nearly double the mortality rate compared with younger patients (4.1% [18 of 444] to 2.3% [186 of 7,917]). Age greater than 80 years (odds ratio = 2.65, 95% confidence interval = 2.18 to 3.22) and male gender (odds ratio = 0.62, 95% confidence interval = 0.56 to 0.69) were the best univariate predictors of a single postoperative complication. CONCLUSIONS: Octogenarian patients manifested twice the risk of death from a cardiac intervention with an average 2-day longer hospital stay compared with their younger counterparts. Furthermore, octogenarians were at markedly higher risk of nonfatal postoperative complications.     

Predictors and outcome of gastrointestinal complications in patients undergoing cardiac surgery

OBJECTIVE: To determine the incidence and independent predictors of gastrointestinal complications (GICs) following cardiac surgery. SUMMARY BACKGROUND DATA: Gastrointestinal ischemia and hemorrhage represent a rare but devastating complication following heart surgery. The profile of patients referred for cardiac surgery has changed during the last decade, questioning the validity of previously reported incidence and risk factors. METHODS: We retrospectively analyzed prospectively collected data from 4819 patients undergoing cardiac surgery between 1998 and 2004. Patients with GICs were compared with the entire patient population. Study endpoints were mortality, postoperative morbidities, and long-term survival. RESULTS: GICs occurred in 51 (1.1%) patients. Etiologies were intestinal ischemia (n = 30; 59%) and hemorrhage (n = 21; 41%). The incidence decreased during the study period (1998-2001: 1.3%, 2002-2004: 0.7%; P = 0.04). The incidence per type of procedure was as follows: coronary artery bypass grafting (CABG)/valve (2.4%), aortic surgery (1.7%), valve surgery (1.0%), and CABG (0.5%; P = 0.001). Multivariate analysis revealed age (odds ratio [OR] = 2.1), myocardial infarction (OR = 2.5), CHF (OR = 2.4), hemodynamic instability (OR = 2.8), cardiopulmonary bypass time >120 minutes (OR = 6.2), peripheral vascular disease (OR = 2.2), renal (OR = 3.2), and hepatic failure (OR = 10.8) as independent predictors of GICs. The overall hospital mortality among patients with GICs was 33%. Long-term survival was significantly decreased in patients with GICs compared with the control group. CONCLUSIONS: Gastrointestinal complications following cardiac surgery remain rare with an incidence <1% in a contemporary series. The key to a lower incidence of GICs lies in systematic application of preventive measures and new advances in intraoperative management. Identification of independent risk factors would facilitate the determination of patients who would benefit from additional perioperative monitoring. Future resources should therefore be redirected to mitigate GICs in high-risk patients.     

Psoriasis-induced postoperative cardiac failure

Erythroderma-induced cardiogenic shock is a rare but known manifestation of erythrodermic psoriasis. Erythrodermic psoriasis is an aggressive form of the disease and can be precipitated by numerous factors including stress to the body. In this article we present a case of persistent severe vasodilatation after coronary artery bypass surgery that required prolonged epinephrine administration. This was caused by a flareup of erythrodermic psoriasis that was previously only controlled by methotrexate. This drug was omitted in the perioperative phase. Vasodilatation disappeared after treatment was reinstituted.     

麻醉药物对成人患者心脏术后肺部并发症的影响

目的 评估术中麻醉维持药物(吸入麻醉药或静脉麻醉药)对体外循环下成人心脏手术患者术后肺部并发症(postoperative pulmonary complications,PPCs)的影响.方法 从四川大学华西医院电子病历信息管理系统及麻醉手术临床信息系统中回顾性筛选2018年9月至2019年2月194例行择期体外循环...     

Outcomes in octogenarians undergoing high-risk cancer operation: a national study

BACKGROUND: Current information about outcomes in octogenarians undergoing cancer operations is limited largely to case series from selected centers. Population-based data can provide more realistic estimates of the risks and benefits of operations in this group. STUDY DESIGN: We performed a retrospective cohort study of patients undergoing major resections for lung, esophageal, and pancreas cancer. Using the Nationwide Inpatient Sample (1994 to 2003), we examined operative mortality and discharge disposition in octogenarians (aged 80+ years), relative to younger patients (aged 65 to 69 years) (n = 272,662). We then used the Surveillance and End Results-Medicare-linked database (1992 to 2001) to measure late survival in the elderly (n = 14,088). RESULTS: Operative mortality among octogenarians was substantially higher than that of younger patients (aged 65 to 69 years) for all three cancers (esophagectomy, 19.9% versus 8.8%, p < 0.0001; pancreatectomy, 15.5% versus 6.7%, p < 0.0001; lung resection, 6.9% versus 3.7%, p < 0.0001). A large proportion of octogenarians were transferred to extended care facilities after operation, ranging from 24% after lung resection to 44% after esophagectomy. Five-year survival in octogenarians was low for all three cancers: 11% after pancreatectomy, 18% after esophagectomy and 31% after lung cancer resection. Survival among octogenarians with two or more comorbidities was worse than those with fewer comorbid diagnoses--10% versus 14% for pancreatectomy, 15% versus 23% for esophagectomy, and 27% versus 37% for lung resection. CONCLUSIONS: Population-based outcomes after high-risk cancer operation in octogenarians are considerably worse than typically reported in case series and published survival statistics. Such information might better inform clinical decision making in this high-risk group.     

Life-threatening postoperative pulmonary complications in patients with previous amiodarone pulmonary toxicity undergoing cardiothoracic operations

Amiodarone therapy for cardiac arrhythmias is increasingly being recognized to be associated with pulmonary toxicity. In this report, we describe the case histories of four patients with previously diagnosed amiodarone pulmonary toxicity in whom the adult respiratory distress syndrome developed after cardiothoracic operations for malignant ventricular arrhythmias. Three patients underwent endocardial resection (two died), and a fourth patient had implantation of an automatic defibrillator unit. Radiographic changes and results of pulmonary function testing are evaluated during initial toxicity and preoperatively. These four patients (mean amiodarone dosage of 420 mg/day for 20 months) are compared to 13 other patients undergoing cardiothoracic operations with prior amiodarone treatment (one patient with preoperative pulmonary toxicity) in whom life-threatening postoperative pulmonary complications did not develop (mean dosage of 550 mg/day for 10 months). Mean preoperative serum amiodarone levels for the four patients were 1.5 micrograms/ml. In the two patients who died, desethylamiodarone levels were 510 and 4,400 micrograms/gm in pulmonary tissue. Histologic examination showed "honeycomb" appearance of the lung with prominent septae, alveolar foamy macrophages, and hyperplasia of alveolar lining cells, consistent with amiodarone pulmonary toxicity. Causes including pump-oxygenator time, oxygen toxicity, anesthetic agents, congestive heart failure, and pulmonary infection superimposed on amiodarone pulmonary toxicity are discussed with a review of the literature.     

Cytokine balance in infants undergoing cardiac operation

BACKGROUND: The control of the systemic inflammatory response taking place during cardiac operations depends on adequate antiinflammatory reaction. In this prospective study we tested the hypothesis that cytokine balance during pediatric cardiac surgical procedures would be influenced by the patients' preoperative clinical condition, defined as hypoxemia or heart failure. METHODS: Twenty infants (median age, 8 months) with hypoxemia owing to intracardiac right-to-left shunt (group 1, n = 10) or with heart failure because of intracardiac left-to-right shunt (group 2, n = 10), scheduled for elective primary corrective operation, were enrolled. Plasma levels of the proinflammatory cytokine interleukin (IL) 6, the natural antiinflammatory cytokine IL-10, and the markers of the acute-phase response, C-reactive protein and procalcitonin, were sequentially measured before, during, and after cardiac operation up to the 10th postoperative day. The ratio of IL-10 to IL-6 levels served as a marker for the individual's antiinflammatory cytokine balance. RESULTS: Group 1 showed higher preoperative IL-6 (p < 0.001), lower IL-10 levels (p < 0.02), and lower ratio of IL-10 to IL-6 levels (p < 0.001) than group 2. Preoperative C-reactive protein and procalcitonin were not detectable. In group 1, preoperative IL-6 levels inversely correlated with preoperative oxygen saturation (Spearman correlation coefficient, -0.74, p < 0.02). During cardiopulmonary bypass, IL-6 levels were higher, whereas IL-10 and ratio of IL-10 to IL-6 levels were lower in group 1 than in group 2. In all patients, postoperative IL-6 levels were positively correlated with duration of inotropic support and serum creatinine value and inversely correlated with oxygenation index and diuresis. CONCLUSIONS: Infants with hypoxemia show a preoperative inflammatory state with low antiinflammatory cytokine balance in contrast to those with heart failure. This in turn is associated with lower perioperative antiinflammatory cytokine balance and might contribute to postoperative morbidity.     

Clinical outcome after cardiac operations in patients with cirrhosis

BACKGROUND: To evaluate the clinical outcome after cardiac operations in patients with cirrhosis, a retrospective study was undertaken. METHODS: Between 1989 and 2003, 18 patients with cirrhosis who underwent cardiac operations were identified. Their preoperative status and postoperative clinical results were assessed. RESULTS: Ten patients were classified as having Child-Pugh class A cirrhosis, 7 as having class B cirrhosis, and 1 as having class C cirrhosis. Fifteen of 18 patients underwent cardiac surgery using cardiopulmonary bypass, and the remaining 3 patients with class B cirrhosis received coronary artery bypass grafting without cardiopulmonary bypass. In patients undergoing cardiopulmonary bypass, 60% of those with class A cirrhosis and 100% of those with class B cirrhosis and class C cirrhosis had postoperative major complications, including infection, respiratory failure, renal failure, bleeding, and gastrointestinal disorder. One of 3 patients (33%) with class B cirrhosis undergoing coronary artery bypass grafting without cardiopulmonary bypass had major complications. The overall postoperative mortality rate was 17%. Hospital mortality of patients with class A cirrhosis, class B cirrhosis, and class C cirrhosis undergoing cardiopulmonary bypass was 0%, 50%, and 100%, respectively. None of 3 patients with class B cirrhosis undergoing coronary artery bypass grafting without cardiopulmonary bypass died in this study. CONCLUSIONS: Although the incidence of major complications was high, patients with Child-Pugh class A cirrhosis tolerated cardiac surgery satisfactorily. Patients with more advanced cirrhosis, however, may not be suitable for elective cardiac operations with cardiopulmonary bypass. Although our results are not conclusive, coronary artery bypass grafting without cardiopulmonary bypass can be an alternative therapeutic strategy for patients with advanced cirrhosis requiring surgical revascularization.     

Advance directive use among patients undergoing high-risk operations

BACKGROUND: The Patient Self-Determination Act requires that patients entering hospitals be asked if they have an advance directive. This has led to increased awareness of advance directives, yet surgeons have paid little attention to their use among patients undergoing even major surgery. We sought to evaluate the use of advance directives in patients undergoing pancreaticoduodenectomy and esophagectomy. METHODS: Patients undergoing these operations between 1996 and 2001 at a university teaching hospital were identified and reviewed for statement of advance directive, its presence in the chart, and impact on patient care. RESULTS: A total of 252 patients met inclusion criteria. The number of patients with an advance directive increased, but had little impact on patient care. CONCLUSIONS: More patients having major surgery have advance directives, but the number present in the medical record remains low. Further attention to advance directives would foster increased communication between surgeons and patients and extend patient autonomy.     

Predictors of perioperative and late survival in octogenarians undergoing elective endovascular abdominal aortic repair

ObjectiveThe appropriateness of endovascular aneurysm repair (EVAR) of uncomplicated abdominal aortic aneurysm depends on the risk-benefit ratio, particularly in elderly patients with short life expectancy. The aim of this study was to assess the efficacy of EVAR in >80-year-old patients by evaluating their postoperative survival and analyzing the possible predictors of late mortality.MethodsAll consecutive patients aged >80 years undergoing elective EVAR from 2006 to 2015 were prospectively evaluated. The 30-day mortality and long-term survival were assessed, and independent risk factors for mortality were determined by multivariate logistic and Cox analysis.ResultsOf a total of 1135 EVARs performed in a 10-year period, 201 (18%) occurred in patients older than 80 years. The median age was 84 years (interquartile range, 3 years), and 85% were male. Thirty-four patients (17%) had a score of 4 according to the American Society of Anesthesiologists (ASA) classification. Overall 30-day mortality was 2% (n = 4); it was significantly higher in those with ASA score of 4 compared with ASA score <4 (9.4% vs 0.6%; P = .04) and was also confirmed by multivariate analysis (odds ratio, 12.7; 95% confidence interval [CI], 1.1-141.8; P = .04). The mean follow-up was 36 ± 18 months, and the overall survival at 1 year, 3 years, and 5 years was 85% ± 2%, 77% ± 3%, and 52% ± 4%, respectively. Using multivariate Cox regression, ASA score of 4 and peripheral artery obstructive disease (PAOD) were the only independent predictors for midterm mortality (hazard ratio of 2.0 [95% CI, 1.2-2.9; P = .04] and 3.07 [95% CI, 1.06-5.2; P = .04], respectively). The 2-year survival was significantly influenced by the presence of both (ASA score of 4 and PAOD; survival, 33% ± 2%) or one (ASA score of 4 or PAOD; survival, 67% ± 8%) of the two independent predictors. If neither ASA score of 4 nor PAOD was present, survival was significantly improved (92% ± 3%; P = .02).ConclusionsThe performance of EVAR in >80-year-old patients is associated with an overall early mortality rate as low as 2%. In patients with no or only one risk factor, the survival rate warrants the treatment of abdominal aortic aneurysm; in contrast, patients with ASA score of 4 and PAOD have a significantly higher mortality rate and reduction of life expectancy.     

Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery

BACKGROUND: The development of renal dysfunction in the postoperative course of cardiac surgery is still associated with high mortality in pediatric patients. In particular for small infants peritoneal dialysis offers a secure and useful treatment option. The aim of the present study was to investigate if routinely used laboratory and clinical variables could help predict mortality at initiation of peritoneal dialysis. METHODS: We performed a retrospective chart analysis of pediatric intensive care unit patients with renal dysfunction who were treated with peritoneal dialysis after cardiac surgery between 1993 and 2001 and analyzed variables obtained 3 hours or less before starting peritoneal dialysis. RESULTS: Results are documented as means and standard errors. A total of 1141 children underwent a cardiac operation on cardiopulmonary bypass. Sixty-two children (5.4%) were treated with peritoneal dialysis. Mortality was 40.3% (37 survivors, 25 nonsurvivors). The pH in survivors was 7.35 (0.01); in nonsurvivors it was 7.23 (0.03; p = 0.0037). Base excess in survivors was -1.37 mmol/L (0.61); in nonsurvivors it was -7.17 mmol/L (1.49; p = 0.0026). Lactate in survivors was 4.5 mmol/L (0.60); in nonsurvivors it was 10.5 mmol/L (1.78; p = 0.0089). Positive inspiratory pressure in survivors was 24.6 cm H(2)O (0.78); in nonsurvivors it was 28.9 cm H(2)O (1.08; p = 0.0274). Tidal volume per kilogram bodyweight in survivors was 11.0 mL/kg (0.48); in nonsurvivors it was 8.7 mL/kg (0.50; p = 0.0493). CONCLUSIONS: We conclude from our data that the consideration of pH, base excess, lactate, positive inspiratory pressure, and tidal volume per kilogram bodyweight help predict mortality at initiation of peritoneal dialysis. We were able to observe significant differences between survivors and nonsurvivors using these variables.     

Glove punctures and postoperative skin flora of hands in cardiac surgery

BACKGROUND: Surgical gloves are frequently perforated during operations, including heart operations. This infection risk factor is inadequately studied. METHODS: After preoperative hand disinfection and at the end of 116 heart operations, bacterial samples from hands of surgeons, altogether 800 samples, were taken. Glove punctures were examined with water test. RESULTS: Surgeons changed 70 gloves because of breakage during operations. Additionally, 154 of 400 (39%) gloves had holes in postoperative testing. The breakage rate of gloves increased from 30% in operations shorter than 3 hours to 65% when operations were longer than 5 hours. High bacterial counts of the hands were also more common after prolonged operations. CONCLUSIONS: Glove puncture rates and bacterial counts of hands increase with increasing operation time. We recommend changing of both gloves when a puncture is detected. Before donning new gloves, hands should be disinfected.