Surgical critical care: still at risk?

It has been a great honor and privilege to serve as your president and to give this year's presidential address. Considering that this is the last Western Surgical Association presidential address to be given in the 1900s, it seems necessary to mention the rapidly approaching third millennium. With only a little more than 46 days left, I am not particularly excited about having to write a "00" whenever I date something. It just does not seem like a real date to me. I have, however, resisted the temptation to speculate on the 21st century, let alone the next millennium, largely because my crystal ball is no better than any of yours. When I began as a medical student in the mid 1950s, my wildest dreams could not have predicted what dramatic advances would occur in the last half of this century. At that time, the first cardiopulmonary bypass cases were being performed for valvular and congenital disease. Kidneys had only recently been transplanted in Paris, France, and Boston, Massachusetts. Plastic surgery had yet to do a free flap and video-guided endoscopic surgery was still decades away. Intensive care units (ICUs) were just opening up, but they were little more than places where frequent vital signs and reliable intake and outputs were obtained.     

Who is at increased risk of aspiration?

Editor—We read with interest Asai's editorial about therisks of pulmonary aspiration,¹ which was precipitated by ourreport of three cases of pulmonary aspiration occurring withthe laryngeal mask airway (LMA®).² Asai commented on thesix factors leading to aspiration (predisposing, patient, operation,anaesthesia, device and variability in the material aspirated)and concluded that we lack sufficient data to make evidence-baseddecisions and need to conduct further research to reduce theseuncertainties. While agreeing with Asai's conclusions, we feelthat his comments about device factors,     

Are chronic dialysis patients at increased risk for cancer?

This review summarizes the plausible mechanisms of carcinogenesis, critically analyzes the literature on cancer risk and discusses issues of cancer screening in chronic dialysis patients. Despite conflicting results among various studies, there is sufficient evidence to conclude that there is a heightened incidence of at least some cancers in dialysis patients. The data most convincingly support an increased risk of genitourinary malignancies. Screening for the common solid organ cancers (prostate, colon, breast and cervix) should be individualized, and is appropriate only for the minority of patients with a life expectancy on dialysis of 10 years or longer. Further research is needed before routine screening for bladder or renal cell cancers can be recommended.     

Pressure for beds--does it put our orthopaedic patients at risk?

INTRODUCTION: High occupancy rates of NHS beds has meant that increasing numbers of trauma patients find themselves on non-orthopaedic wards. Nursing staff on these wards may not have the specialist training to nurse such patients and may not recognise complications should they arise. The failure to recognise compartment syndrome was highlighted in a Clinical Governance meeting, leading to an assessment of nursing awareness of this condition. METHODS: Fifty orthopaedic trained nurses and a matched cohort of 50 non-orthopaedic trained nurses were asked a series of questions relating to compartment syndrome. RESULTS: The majority of non-orthopaedic nurses failed to recognise the signs of early compartment syndrome. CONCLUSION: Compartment syndrome is a limb-threatening condition which requires prompt recognition. Patients at risk should be nursed in an appropriate environment.     

Pulmonary embolism: which pediatric trauma patients are at risk?

Background/Purpose

Deep vein thrombosis and pulmonary embolism (DVT/PE) are rare in pediatric trauma patients, and guidelines for prophylaxis are scarce. The authors sought to identify subgroups of patients who may be at higher risk of developing DVT/PE.

Methods

Case-control study of pediatric trauma patients with DVT/PE. Odds ratios (ORs) and confidence intervals (CIs) were calculated for known risk factors of PE using matched trauma controls (χ² analysis).

Results

A total of 3637 pediatric trauma patients was admitted over the last 7 years. Three patients developed DVT/PE (overall incidence, 0.08%). There were 2 girls and 1 boy, aged 15, 15, and 9 years, respectively. All 3 had an Injury Severity Score (ISS) ≥25 and an initial Glasgow Coma Score (GCS) ≤8. None of the known and potential risk factors significantly increased the OR for developing DVT/PE: age 9 years or older (OR, 3.6; CI, 0.4-26), presence of head injury (OR, 2.9; CI, 0.3-22), female sex (OR, 1.2; CI, 0.15-9.1), GCS ≤8 (OR, 9.2; CI, 0.9-230), except ISS ≥25 (OR, 82; CI, 7.6-2058). The OR for a combination of age and GCS was 106, and the OR for the 3 risk factors (age, ISS, GCS) common to all 3 patients was 114 (CI, 10-5000; P < .001).

Conclusions

The overall incidence of DVT/PE in pediatric trauma patients is <0.1% and routine prophylaxis is not recommended. Children aged 9 years or older with an initial GCS ≤8 and patients with an estimated ISS ≥25 may constitute a high-risk group in which prophylaxis could be considered.     

Are older patients with mechanical heart valves at increased risk?

Background. Controversy exists regarding the use of mechanical valves in older patients. Many authorities believe that the use of anticoagulants in the elderly is associated with an increased risk of warfarin-related complications. Therefore, we compared the results with mechanical valves in older patients to a cohort of younger patients.

Methods. Aortic (AVR) or mitral valve replacement (MVR) with a mechanical valve was performed in 1,245 consecutive patients who were followed prospectively. They were grouped by age (group 1, ≤ 65 years; group 2, > 65 years). The study groups consisted of AVR (group 1, 459 patients; group 2, 323 patients) MVR (group 1, 313 patients; group 2, 150 patients).

Results. The average age for the groups was: AVR (group 1, 51 years; group 2, 70 years; p = 0.03) and MVR (group 1, 53 years; group 2, 70 years; p = 0.03). For AVR the incidence of thromboembolism was 0.050 (group 1) and 0.038 (group 2) (p = 0.37) and the actuarial freedom from thromboembolism was 83.0% ± 3.0% and 86.5% ± 1.0%, respectively (p = 0.13). The incidence of bleeding after AVR was 0.021 for group 1 and 0.028 for group 2 (p = 0.49). For MVR the incidence of thromboembolism was 0.059 for group 1 and 0.051 for group 2 (p = 0.75) and the actuarial freedom from thromboembolism was 78.8% ± 3.0% and 75.4% ± 8.7%, respectively (p = 0.71). The incidence of bleeding after MVR was 0.020 for group 1 and 0.027 for group 2 (p = 0.62).

Conclusions. Mechanical valves perform well in selected older patients with no increased risk of bleeding or thromboembolism.     

Which patients are at risk of voiding difficulty immediately after colposuspension?

The objective of the study was to determine preoperative factors (symptoms, history, clinical findings, urodynamic factors or operative findings) associated with voiding difficulties following colposuspension. This retrospective review was undertaken at a urogynaecological clinic in a large district general hospital. Fifty-one patients who had undergone colposuspension for genuine stress incontinence were included. Voiding difficulty was the main outcome measure. This was assessed by time of spontaneous voiding and time of catheter removal. Age was associated with postoperative voiding difficulty when this was assessed by time of catheter removal (P<0.02) and by time of spontaneous voiding (P<0.05). A low preoperative maximum voiding pressure was associated with delayed spontaneous voiding (P<0.05) but not with prolonged catheterization. It was concluded that older patients were at greater risk of voiding difficulty following colposuspension and that HRT did not prevent this complication.EDITORIAL COMMENT: Factors which definitively predict those patients who will be subjected to prolonged catheterization after incontinence surgery are currently unknown. Age is known to be a factor, as is confirmed by this study, and previously low voiding pressure was also determined to be such a factor [11] and also has been confirmed here. A big factor which has not been addressed in the literature is the effect of the degree of elevation of the vesical neck by the surgical procedure, and its effects on voiding difficulty. It would seem reasonable to assume that a patient with a higher vesical neck and a Q-tip test approximating –30° from the horizontal would void less freely and later than one with a Q-tip test of +10° from the horizontal. It has, however, been this editor's clinical experience that there is no relationship of this anatomy factor to ultimate time of catheter removal. Studies would provide a great deal of information if the degree of elevation of the vesical neck was controlled and accounted for in the analysis of data.     

Are elderly haemodialysis patients at risk of falls and postural hypotension?

BACKGROUND: The numbers of older people on haemodialysis is rising. As aging and renal failure are risk factors for autonomic failure and haemodialysis involves significant fluid shifts we hypothesized that older patients would be susceptible to hypotensive events between dialysis sessions. Postural hypotension is a risk factor for falls. Falls are debilitating and a leading cause of morbidity and mortality in the elderly. AIM: To investigate whether postural hypotension and symptoms of hypotension and falls are common in older haemodialysis patients. METHODS: All 47 patients from a single unit aged 70 or over were asked about falls in the previous year and about symptoms that could be due to hypotension (syncope, presyncope, dizziness) between dialysis sessions. Twenty-three patients underwent pre- and post-dialysis orthostatic blood pressure measurement, 18 had 44 hour ambulatory blood pressure recording and 10 subjects had full autonomic function testing. RESULTS: Of 47 patients interviewed, 20 reported syncope/pre-syncope, 34 reported dizziness and 14 recalled at least one fall in the previous year. 8/23 had orthostatic hypotension pre-dialysis and 16/23 post-dialysis. Mean 44-hour blood pressure was 134/68 (+/- 21/9) with no nocturnal dip. Autonomic function was abnormal in all 10 subjects tested. CONCLUSIONS: Elderly haemodialysis patients have a high incidence of hypotensive symptoms between dialysis sessions, recalled falls in the previous year and significant postural hypotension post-dialysis. Physicians supervising elderly haemodialysis patients should ask about symptoms between dialysis sessions and explore the possibility of hypotensive events in symptomatic patients.     

Can screening items identify surgery patients at risk of limited health literacy?

BACKGROUND: Health literacy skills (HLS) have been shown to have a major impact on patient outcomes. To identify patients with limited or marginal HLS, the accuracy of three established screening items were examined. MATERIALS AND METHODS: We studied English-speaking adults (>or=21 years) attending a university-based vascular surgery clinic. Structured interviews were conducted to assess sociodemographic characteristics, screening items, and HLS. Area under the receiver operating characteristic (AUROC) curves were plotted to assess the discriminatory capacity of each screening item in detecting patients with limited/marginal HLS. RESULTS: One hundred patients agreed to enter the study and met inclusion criteria. The mean age was 62.0 +/- 12.9; 65 were female; 96 were Caucasian; and 32 had not completed high school. The three screening items were effective in detecting patients with limited (n=18) or marginal (n=21) HLS. "How often do you have someone (like a family member, friend, or hospital worker) help you read hospital materials?" (AUROC of 0.83; 95% confidence interval [CI]=0.73, 0.92), "How often do you have problems learning about your medical condition because of difficulty understanding written information?" (AUROC of 0.77; 95% CI=0.67, 0.86), and "How confident are you filling out medical forms by yourself?" (AUROC of 0.76; 95% CI=0.66, 0.86) were effective in detecting those with limited/marginal HLS skills. CONCLUSIONS: Our findings provide further evidence of the clinical usefulness of these screening items for detecting inadequate HLS in this patient population. Surgeons should consider administering these easy screening items to identify patients at greatest risk of limited or marginal HLS.     

Blood transfusion after total shoulder arthroplasty: Which patients are at high risk?

Purpose:There are multiple reported risk factors and a wide range of reported blood transfusion rates for total shoulder arthroplasty (TSA). There are no evidence-based guidelines for blood transfusions in TSA patients.Results:The blood transfusion rate in our study was 6.1%. There was no difference in the rate of blood transfusions over the study period (P < 0.001). In our logistic regression model, significant associations were found with increased age (odds ratio [OR] =1.03), white race (OR = 1.05), higher Charlson-Deyo score (OR = 1.12), presence of ischemic heart disease (OR = 1.24), blood loss anemia (OR = 1.65), female gender (OR = 1.94), presence of coagulation disorders (OR = 2.25), and presence of deficiency anemia (OR = 3.5). Patients receiving a blood transfusion had higher total charges, a longer hospital LOS, and were more likely to be Medicare payers (P < 0.001).Conclusions:Our study found five clinically significant risk factors for blood transfusions for TSA: female gender, ischemic heart disease, deficiency anemia, coagulation disorder, and blood loss anemia. Patients with these risk factors should be considered higher risk for requiring a blood transfusion after TSA and counseled appropriately.

Level of Evidence:

Level II, retrospective cohort study, prognostic study.     

Malnutrition after vascular surgery: are patients with chronic renal failure at increased risk?

BACKGROUND: The deleterious effects of perioperative malnutrition on recovery after general surgery are established. Since the effects of perioperative malnutrition on recovery after vascular surgery are not known, we examined the effects of nutritional status, and risk factors predictive of malnutrition, on outcome after vascular surgery. METHODS: The records of all open index vascular cases (abdominal aortic aneurysm [AAA] repair, carotid endarterectomy [CEA], lower extremity bypass) performed at the Veterans Affairs (VA) Connecticut between July 2004 and June 2005 were reviewed. The primary outcome was mortality; secondary outcomes included infection and nutritional risk index (NRI) scores. RESULTS: Sixty-eight open vascular cases were performed during the study period. Nutritional depletion developed in 55% of patients and was more likely in patients undergoing AAA (85%) or bypass (77%) than CEA (30%; P = .0005). Patients who developed malnutrition had similar mortality as patients who did not develop postoperative malnutrition (6.1% vs. 3.7%; P = .68); however, malnourished patients had higher rates of postoperative infection (24.2% vs. 3.7%; P = .03). Chronic renal failure was the only patient-associated risk factor predictive of postoperative nutritional depletion (odds ratio 5.9, confidence interval 1.0 to 33.6; P = .04). CONCLUSIONS: Patients undergoing major open vascular surgery have high rates of postoperative malnutrition, with patients undergoing AAA repair having the highest rates of postoperative malnutrition and infection. Patients with chronic renal failure undergoing vascular surgery are associated with increased risk for postoperative malnutrition and may be a group to target for perioperative risk factor modification and nutritional supplementation.     

Is carotid revascularization worthwhile in patients waiting for kidney transplantation?

Renal failure and haemodialysis are associated with an increased risk of cardiovascular disease. Patients undergoing renal transplantation undergo rigorous pre-operative vascular assessment, including optimisation of risk factors for stroke. The indication for carotid intervention and the threshold for carotid endarterectomy in asymptomatic patients with incidental carotid disease has not been clarified in the context chronic kidney disease (CKD). This review aims to analyse outcomes following carotid endarterectomy in patients with CKD, in order to ascertain whether general guidelines for carotid artery revascularisation apply to this specific cohort. The current literature suggests that outcomes following internal carotid artery (ICA) revascularisation are worse in symptomatic and asymptomatic CKD patients compared to the non-CKD population. Consequently, asymptomatic patients with renal failure should be managed conservatively prior to renal transplantation, whilst those with symptomatic disease should be treated according to general guidelines but be informed of higher associated risk of stroke and death. Multidisciplinary optimisation remains essential in all patients waiting for potential renal transplantation.     

Occult spinal dysraphism and urolithiasis: are patients at higher risk of stone disease?

BACKGROUND AND PURPOSE: Spinal dysraphism is associated with urinary-tract dysfunction in severe cases such as meningomyelocele, in part because of incomplete innervation of the lower urinary tract. Patients with meningomyelocele are at higher risk for stone formation, possibly secondary to stasis of urine from aberrant storage and emptying. However, minimal data exist on the risk of stone formation in patients with milder forms of spinal dysraphism. The purpose of this study was to examine whether an association exists between urolithiasis and occult spinal dysraphism (OSD). PATIENTS AND METHODS: All patients who underwent a non-contrast CT scan of the abdomen and pelvis during a 4-month period were included. The final dataset consisted of 374 consecutive patients (195 men, 179 women) with a mean age of 54.2 years (range 18-95 years). Scans were reviewed for evidence of urolithiasis and, independently, for skeletal abnormalities. Patients with urolithiasis included those with a kidney, ureteral, or bladder stone(s). Patients with OSD included those with bifid lumbosacral bony elements, posterior arch defects, or incomplete fusion or non-fusion of S1, S2, or S3. The association between urolithiasis and OSD was examined by calculating series of crude and adjusted odds ratios (ORs) with corresponding 95% confidence intervals (CIs). RESULTS: Of the 374 patients, 135 (36.1%) had urinary calculi, and 83 (22.2%) had OSD. No relation was found between the prevalence of OSD and stone disease (OR 1.22; 95% CI 0.72, 2.08), even after adjusting for potential confounders. CONCLUSION: Unlike severe spinal dysraphism, OSD does not appear to confer an increased risk of stone disease.