Does urinalysis predict acute renal failure after heart surgery?

Acute renal failure (ARF) usually develops in 5% to 30% of patients undergoing heart surgery and is associated with a more complicated clinical evolution course and with an excessive mortality of up to 80%. The objective of this study was to verify the frequency of ARF in postoperative coronary artery bypass surgery with and without cardiopulmonary bypass, by the evaluation of renal function markers' performance [plasma creatinine, plasma urea, urinalysis, fractional excretion of sodium, creatinine clearance and Alpha-glutathione S-transferase (alpha-GST)], besides to verify possible relations between clinical variables involved in postoperative heart surgery and the occurrence of renal insufficiency.     

Management of acute appendicitis by an acute care surgery service: is operative intervention timely?

BACKGROUND: Trauma services are increasingly providing emergency surgery care by creating "acute care surgery" teams. We compared two periods at a Level I trauma center to determine if trauma service coverage would negatively impact timely management of acute appendicitis. STUDY DESIGN: All patients admitted through the emergency department of a Level I trauma center who underwent appendectomies between March 2005 and May 2006 (Trauma period) were identified. During this period, the trauma service covered most surgical emergencies. Comparison was made with the earlier 15-month period (Pretrauma). Emergency department to operating room (OR) time, procedure length, and negative appendectomy rates were obtained. RESULTS: In the Pretrauma period, 273 patients underwent appendectomy, compared with 279 in the Trauma period. Two-thirds (66%) of appendectomies in the Trauma period were performed by trauma surgeons. There was no difference in both periods with regard to mean emergency department to OR time (10.5 hours versus 9.9 hours; p = 0.4509), perforation rates (12% Pretrauma versus 7.5% Trauma; p = 0.1134), or negative appendectomy rates (17.9% Pretrauma versus 18.2% Trauma; p = 1.0). In the Trauma period, more appendectomies were completed laparoscopically (84.6% Trauma versus 66.6% Pretrauma; p < 0.0001), and mean OR time was shorter (57.4 minutes versus 67 minutes; p = 0.0006). CONCLUSIONS: In comparing two periods with and without the trauma service coverage of surgical emergencies, no difference was found in emergency department to OR time, perforation rates, or negative appendectomy rates in the management of acute appendicitis. There was a decrease in operative time and an increase in the proportion of laparoscopic appendectomies in the Trauma period. Trauma services can effectively incorporate emergency surgical coverage of procedures, such as appendectomies, without compromising timely intervention.     

How effective is acute normovolaemic haemodilution in femoro-distal bypass surgery?

BACKGROUND: Recent guidelines have emphasised the use of autologous blood in the surgical setting. The aim of this study was to analyse the efficacy and efficiency of acute normovolaemic haemodilution (ANH) as a blood conservation intervention in patients undergoing elective femoro-distal surgery for critical limb ischaemia.METHODS: Forty patients were studied prospectively. The volume of the blood collected was derived as follows: Blood volume removed = patient's blood volume (initial haematocrit - final haematocrit/average haematocrit) where final haematocrit is 30% and patient's blood volume is 70 and 65 ml/kg for a man and a woman, respectively.RESULTS: Twenty-five patients were suitable for ANH and 15 patients were excluded because of poor ventricular function, anaemia or renal disease. Nine of the 25 patients (44%) had <500ml of surgical blood loss and would have avoided homologous blood transfusion (HBT). Four of the patients lost >2000ml of blood and could not avoid HBT through ANH. Twelve patients had moderate blood loss (950-1400 ml), with eight of these patients requiring transfusion. Four patients avoided exposure to homologous blood.CONCLUSION: ANH is in evolution and as a single blood conservation intervention, contributes only modestly to blood conservation.     

Is thrombolysis or surgery the best option for acute prosthetic valve thrombosis?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the optimal treatment strategy for acute prosthetic valve thrombosis (PVT) is surgical management or thrombolytic therapy. Using the reported search 96 papers were identified. Twelve papers represented the best evidence on the subject, and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated for these. Recent AHA/ACC guidelines were also included, as were two large case series of surgical management for comparison. We conclude that the management of obstructive PVT remains widely debated due to a lack of randomised controlled trials. Surgery has been the traditional management of choice, but thrombolysis has recently been proposed as a first-line therapy. Both surgery and thrombolysis can be used with high rates of success and relatively low complication rates, though NYHA class at presentation has a significant bearing on surgical mortality and thrombus size affects complication rates with thrombolysis. Thrombolysis appears particularly favoured when the thrombus area as assessed by transoesophageal echocardiography is small (<0.8 cm(2)), as high success rates and low complication rates have been reported, and thrombolysis does not preclude the patient from proceeding to surgery if it fails. Presentation in a high NYHA class of heart failure or cardiogenic shock is the most difficult patient to decide between surgery and thrombolysis. Surgery for these patients may remain the mainstay of treatment unless the clot burden is particularly small or the patient's co-morbidities make surgery unacceptably high-risk.     

Decompressive surgery in acute head injuries: where should it be performed?

BACKGROUND: In Norway, most patients with severe head injuries are transported to, and operated in, the neurosurgical unit of the regional university hospital. However, some patients are still occasionally operated on in county central hospitals by orthopedic or general surgeons who do not have neurosurgical expertise. The aim was to analyze this surgical activity outside the neurosurgical units. METHODS: Data were collected from two sources: a nation-wide survey and the records of all patients with a severe head injury occurring within Vestfold county (1987-1996). RESULTS: The Norwegian county central hospitals perform each only 2.5 to 3 surgical evacuations of intracranial hematomas per year. In Vestfold county, a total of 161 patients were hospitalized alive with an acute severe head injury. One third of the patients (54 patients) underwent decompressive surgery, mostly evacuations of intracranial hematomas. The patients operated on in the central hospital had a significantly worse outcome than the patients who were transferred to and operated on in the neurosurgical unit of the regional hospital. Only patients with extracerebral hematomas were operated on in the central hospital. Patients with an extradural (epidural) hematoma had a better outcome than patients with an acute subdural hematoma. Based on the surgery records and preoperative and postoperative computed tomographic scans, one third of the operations (10 operations) in the central hospital were classified retrospectively as inadequate, because the hematoma was not evacuated or found or because the surgeons did not achieve control of the perioperative bleeding. The overall mortality rate was 29.8%. CONCLUSION: The present study indicates that, in Norway and countries with a similar hospital system, it must be difficult for general and orthopedic surgeons to achieve and maintain the skills required for emergency operations in patients with acute severe head injuries. Thus, it is probably to the patients' benefit to improve the general hospitals' competency and speed in the detection of candidates for surgical decompression, and stress the importance of these patients being transferred without unnecessary delay to a neurosurgical unit.     

Predictors of early outcome after acute appendicitis: is delaying surgery for acute appendicitis an option? A retrospective study

Purpose

This study analysed the clinical and para-clinical criteria that may allow surgeons and emergency physicians to take a decision regarding the surgery of acute appendicitis.

Methods

A retrospective analysis was conducted on 284 acute appendicitis patients who underwent surgery between January 2007 and December 2009 in our institution. The registered data were extracted from patient files and statistically analysed. These data included past medical history, clinical, laboratory and imaging data, duration of hospital stay and post-operative complications. Patient delay (time between the appearance of symptoms and patient arrival at the emergency department) and hospital delay (time between hospital arrival and operation) were correctly investigated. Statistical analysis was done by using SPSS software.

Results

The patient delay is significantly increased in relation to the severity of appendicitis: 24?h (10.8?C30.8?h) versus 37.4?h (36.8?C38?h) (P?<?0.05), unlike hospital delay, which remains constant (between simple and severe appendicitis): 7.5?h (5?C14.8?h) versus 8?h (5?C13?h). In severe appendicitis, the proportion of guarding, rebound tenderness, tachycardia (P?<?0.05) and fever (P?<?0.005) were significantly high, and leucocytosis (P?<?0.05), C-reactive protein (CRP) (P?<?0.001) and eosinopaenia [37.0 vs. 72.8 (P?<?0.001)] were significantly different. Concerning computed tomography (CT) and echography, perforation, abscess formation (P?<?0.05), phlegmon (P?<?0.005) and peritonitis (P?<?0.05) were significant signs of complicated cases. The length of hospital stay (P?<?0.001) and duration of antibiotic therapy (P?<?0.001) were statistically significant in cases of complicated appendicitis.

Conclusion

Patient delay is a determining factor for the grade of appendicitis. It has an influence on the complications, length of hospital stay and duration of antibiotic treatment, unlike hospital delay.     

Metoprolol and coronary artery bypass grafting surgery: does intraoperative metoprolol attenuate acute beta-adrenergic receptor desensitization during cardiac surgery?

Cardiac surgery results in significant impairment of beta-adrenergic receptor (beta AR) function and is a cause of depressed myocardial function after surgery. We previously demonstrated that acute administration of beta AR blocker during cardiopulmonary bypass (CPB) in an animal model of coronary artery bypass grafting (CABG) surgery attenuates beta AR desensitization, whereas chronic oral beta-blockade therapy in patients undergoing CABG surgery does not prevent it. Therefore we hypothesized that acute administration of metoprolol during CABG surgery would prevent acute myocardial beta AR desensitization. A placebo-controlled initial phase (n = 72) was performed whereby patients were randomized to either metoprolol 10 mg or placebo immediately before CPB. Then a second dose-finding study was performed where patients received 20 mg (n = 20) or 30 mg (n = 20) of metoprolol. Hemodynamic monitoring, atrial membrane adenylyl cyclase activity, atrial beta AR density, and postoperative outcomes were measured. All groups showed similar decreases in isoproterenol-stimulated adenylyl cyclase activity (13%-24%). Cardiac output remained similar in all 4 groups throughout the intraoperative and postoperative period. In addition, patients receiving metoprolol 20 or 30 mg had less supraventricular arrhythmias 24 h postoperatively compared with patients receiving metoprolol 10 mg or placebo. Therefore, unlike our previous animal model of CABG surgery, metoprolol did not attenuate myocardial beta AR desensitization. IMPLICATIONS: We investigated whether IV metoprolol given during cardiac surgery attenuates myocardial beta-adrenergic receptor (beta AR) desensitization. Although metoprolol did not reduce beta AR desensitization, the incidence of supraventricular arrhythmias was reduced by 75% in patients receiving 20 mg or 30 mg metoprolol.     

Increased incidence of acute ascending aortic dissection with off-pump aortocoronary bypass surgery?

BACKGROUND: An apparent increase in the incidence of acute ascending aortic dissection following off-pump coronary artery bypass grafting (OPCAB) led us to assess retrospectively the rate and circumstances of this complication in our institution on a consecutive series of patients undergoing aortocoronary bypass performed with and without extracorporeal circulation (ECC). METHODS: A retrospective analysis of acute ascending aortic dissections complicating coronary artery bypass grafting surgery in 3,031 patients in our institution since April 1, 1995, was performed using the database of the Montreal Heart Institute. RESULTS: There was a greater frequency of hypertension in the OPCAB group. Iatrogenic acute aortic dissection occurred in 3 patients among 308 operated on without ECC (0.97%) and 1 patient among 2,723 operated on under ECC (0.04%). This difference was statistically significant (p < 0.00001). CONCLUSIONS: The risk of aortic dissection may be increased in OPCAB. Careful manipulation of the aorta with a single side-clamping and a control of the arterial pressure should be used to minimize aortic trauma. High-risk patients should undergo CABG without side-clamping of the aorta or CABG with ECC to prevent this redoubtable complication of myocardial revascularization.     

Prompt or delayed appendectomy? Influence of timing of surgery for acute appendicitis

Purpose

The aim of the study was to compare the clinical outcomes and histological findings in prompt and delayed appendectomy for acute appendicitis.

Methods

All patients who underwent appendectomy for histologically confirmed acute appendicitis from 2003 to 2009 were included in this study. Patients were divided into three groups according to the time of surgery after hospital admission: The early appendectomy (EA) group underwent surgery within 12 h, the early-delayed appendectomy (EDA) group between 12 and 24 h and the delayed appendectomy (DA) group more than 24 h. The perioperative data and pathological state of the appendix were evaluated and compared.

Results

A total of 723 patients, with histologically confirmed acute appendicitis, were included in the study: There were 518 patients in the EA group, 140 patients in the EDA group and 65 patients in the DA group. The operative times were similar in each group. Postoperative complications occurred in 49 patients (6.8 %) and were significantly higher in the DA group in comparison to the EA group (p = 0.0012) and EDA group (p = 0.003). Two patients (3 %) in the DA group died. There were no differences in the length of the hospital stay. The gangrenous appendicitis rate was significantly higher in the DA group (p < 0.05) in comparison to the EA and EDA groups.

Conclusions

Performing appendectomy within 24 h from presentation does not increase the length of hospital stay or rate of complications. However, delayed appendectomy after 24 h from onset increases the rate of complications.     

Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis

PurposeThis study carried out a meta-analysis to compare immediate surgery (IS) with conservative treatment (CT) of complicated acute appendicitis (CAA) in children.MethodsSystematic literature research was performed for relevant studies published from 1969 to date. Trials of IS compared with CT were included. Outcomes of interest were postoperative morbidity and length of hospital stay (LOS).ResultsFifteen trials were studied (1.243 patients). CT achieved better rates of any complication type (odds ratio [OR] 0.22, [95% confidence interval (CI): 0.14, 0.38], p = 0.001) and wound infection (OR: 0.40 [95% CI: 0.17, 0.96], p = 0.041). Neither intraabdominal abscess (OR: 1.03 [95% CI: 0.31, 3.37], p = 0.958) nor postoperative ileus (OR: 0.29 [95% CI: 0.06, 1.44], p = 0.130) was affected by the treatment option. The polled difference in LOS showed a trend for shorter LOS in the IS group (standard mean difference [SMD]: 0.25 [95% CI: 0.07, ? 0.43], p = 0.007).ConclusionsIS was associated with shorter LOS, while overall complication rates and wound infection declined significantly with CT. The development of intraabdominal abscess and postoperative ileus was not affected by the treatment of choice. The heterogeneity of most studies depicts the need for randomized controlled trials (RCTs) to discover safe management of CAA in children.Level of evidence: IIIType of study: Meta-analysis.     

Is short-term amiodarone use post cardiac surgery a cause of acute respiratory failure?

AIM: It was believed that amiodarone-related adverse respiratory effects were found only when receiving amiodarone on a long-term basis, but several reports seem to contradict this hypothesis. The aim of this study was to evaluate, in an intensive care unit (ICU), the possibility of acute respiratory toxicity induced by short-term amiodarone administration following cardiac surgery. METHODS: We conducted a prospective clinical trial of 111 consecutive patients admitted to our ICU after cardiac surgery (basically, coronary artery bypass graft and/or valve surgery) and who received short-term prophylactic amiodarone treatment if they were considered at high risk of developing atrial fibrillation. We administered 900 mg/day intravenously for the first 2 days and 600 mg/day on the following days of the ICU stay. The oxygenation index (PaO2/FiO2 ratio) was evaluated at admission, and then 24 and 48 h postsurgery. RESULTS: One-hundred and two patients were included in the study (9 were excluded for bradycardia), and 25 received amiodarone treatment. The Parsonnet and APACHE II scores differed slightly between the treated and nontreated groups. There were no significant differences between the treated and nontreated groups with respect to left atrial pressure, the number of packed red cells transfused or the oxygenation index at admission and 24 and 48 h postsurgery. CONCLUSION: The short-term administration of amiodarone under the conditions of the present study does not seem to affect respiratory function.     

The acute motor-sensory axonal neuropathy variant of Guillain-Barré syndrome after thoracic spine surgery

Guillain-Barré syndrome (GBS) is the eponym used to describe acute inflammatory polyradiculoneuropathies, which manifest with weakness and diminished reflexes. Although the classic form of GBS is considered to be an ascending demyelinating polyneuropathy, several variants have been described in the literature, including the Miller-Fisher syndrome, acute panautonomic neuropathy, acute motor axonal neuropathy, and acute motor-sensory axonal neuropathy (AMSAN). Few cases of postoperative GBS have been documented, particularly for the AMSAN variant. The authors describe the case of a patient who developed AMSAN after thoracic spine surgery and highlight the importance of investigating new-onset weakness in the postoperative period.