Novel predictors of mortality in emergency bowel surgery: a single-centre cohort study

Pre-operative risk stratification is a key part of the care pathway for emergency bowel surgery, as it facilitates the identification of high-risk patients. Several novel risk scores have recently been published that are designed to identify patients who are frail or significantly unwell. They can also be calculated pre-operatively from routinely collected clinical data. This study aimed to investigate the ability of these scores to predict 30-day mortality after emergency bowel surgery. A single centre cohort study was performed using our local data from the National Emergency Laparotomy Audit database. Further data were extracted from electronic hospital records (n = 1508). The National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score were then calculated. The most abnormal National or Laboratory Decision Tree Early Warning Score in the 24 or 72 h before surgery was used in analysis. Individual scores were reasonable predictors of mortality (c-statistic 0.699–0.740) but all were poorly calibrated. A National Early Warning Score ≥ 4 was associated with a high overall mortality rate (> 10%). A logistic regression model was developed using age, National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score as predictor variables, and its performance compared with other established risk models. The model demonstrated good discrimination and calibration (c-statistic 0.827) but was marginally outperformed by the National Emergency Laparotomy Audit score (c-statistic 0.861). All other models compared performed less well (c-statistics 0.734–0.808). Pre-operative patient vital signs, blood tests and markers of frailty can be used to accurately predict the risk of 30-day mortality after emergency bowel surgery.     

Design and internal validation of an obstetric early warning score: secondary analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database

We designed and internally validated an aggregate weighted early warning scoring system specific to the obstetric population that has the potential for use in the ward environment. Direct obstetric admissions from the Intensive Care National Audit and Research Centre's Case Mix Programme Database were randomly allocated to model development (n = 2240) or validation (n = 2200) sets. Physiological variables collected during the first 24 h of critical care admission were analysed. Logistic regression analysis for mortality in the model development set was initially used to create a statistically based early warning score. The statistical score was then modified to create a clinically acceptable early warning score. Important features of this clinical obstetric early warning score are that the variables are weighted according to their statistical importance, a surrogate for the F_IO₂/P_aO₂ relationship is included, conscious level is assessed using a simplified alert/not alert variable, and the score, trigger thresholds and response are consistent with the new non‐obstetric National Early Warning Score system. The statistical and clinical early warning scores were internally validated using the validation set. The area under the receiver operating characteristic curve was 0.995 (95% CI 0.992–0.998) for the statistical score and 0.957 (95% CI 0.923–0.991) for the clinical score. Pre‐existing empirically designed early warning scores were also validated in the same way for comparison. The area under the receiver operating characteristic curve was 0.955 (95% CI 0.922–0.988) for Swanton et al.'s Modified Early Obstetric Warning System, 0.937 (95% CI 0.884–0.991) for the obstetric early warning score suggested in the 2003–2005 Report on Confidential Enquiries into Maternal Deaths in the UK, and 0.973 (95% CI 0.957–0.989) for the non‐obstetric National Early Warning Score. This highlights that the new clinical obstetric early warning score has an excellent ability to discriminate survivors from non‐survivors in this critical care data set. Further work is needed to validate our new clinical early warning score externally in the obstetric ward environment.     

Dexmedetomidine for adult cardiac surgery: a systematic review,meta-analysis and trial sequential analysis

The effects of dexmedetomidine in adults undergoing cardiac surgery are inconsistent. We conducted a systematic review and meta-analysis to analyse the effects of peri-operative dexmedetomidine in adults undergoing cardiac surgery. We searched MEDLINE via Pubmed, EMBASE, Scopus and Cochrane for relevant randomised controlled trials between 1 January 1990 and 1 March 2022. We used the Joanna Briggs Institute methodology checklist to assess study quality and the GRADE approach to certainty of evidence. We assessed the sensitivity of results to false data. We used random-effects meta-analyses to analyse the primary outcomes: durations of intensive care and tracheal intubation. We included 48 trials of 6273 participants. Dexmedetomidine reduced the mean (95%CI) duration of intensive care by 5.0 (2.2–7.7) h, p = 0.001, and tracheal intubation by 1.6 (0.6–2.7) h, p = 0.003. The relative risk (95%CI) for postoperative delirium was 0.58 (0.43–0.78), p = 0.001; 0.76 (0.61–0.95) for atrial fibrillation, p = 0.015; and 0.49 (0.25–0.97) for short-term mortality, p = 0.041. Bradycardia and hypotension were not significantly affected. Trial sequential analysis was consistent with the primary meta-analysis. Adjustments for possible false data reduced the mean (95%CI) reduction in duration of intensive care and tracheal intubation by dexmedetomidine to 3.6 (1.8–5.4) h and 0.8 (0.2–1.4) h, respectively. Binary adjustment for methodological quality at a Joanna Briggs Institute score threshold of 10 did not alter the results significantly. In summary, peri-operative dexmedetomidine reduced the durations of intensive care and tracheal intubation and the incidence of short-term mortality after adult cardiac surgery. The reductions in intensive care stay and tracheal intubation may or may not be considered clinically useful, particularly after adjustment for possible false data.     

Association between anaesthetic technique and unplanned admission to intensive care after thoracic lung resection surgery: the second Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) National Audit

Unplanned intensive care admission is a devastating complication of lung resection and is associated with significantly increased mortality. We carried out a two-year retrospective national multicentre cohort study to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission. All patients undergoing lung resection surgery in 16 thoracic surgical centres in the UK in the calendar years 2013 and 2014 were included. We defined critical care admission as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy, and sought an association between mode of anaesthesia (total intravenous anaesthesia vs. volatile) and analgesic technique (epidural vs. paravertebral) and need for intensive care admission. A total of 253 out of 11,208 patients undergoing lung resection in the study period had an unplanned admission to intensive care in the postoperative period, giving an incidence of intensive care unit admission of 2.3% (95%CI 2.0–2.6%). Patients who had an unplanned admission to intensive care unit had a higher mortality (29.00% vs. 0.03%, p < 0.001), and hospital length of stay was increased (26 vs. 6 days, p < 0.001). Across univariate, complete case and multiple imputation (multivariate) models, there was a strong and significant effect of both anaesthetic and analgesic technique on the need for intensive care admission. Patients receiving total intravenous anaesthesia (OR 0.50 (95%CI 0.34–0.70)), and patients receiving epidural analgesia (OR 0.56 (95%CI 0.41–0.78)) were less likely to have an unplanned admission to intensive care after thoracic surgery. This large retrospective study suggests a significant effect of both anaesthetic and analgesic technique on outcome in patients undergoing lung resection. We must emphasise that the observed association does not directly imply causation, and suggest that well-conducted, large-scale randomised controlled trials are required to address these fundamental questions.     

Comparison of the Aotearoa New Zealand Early Warning Score and National Early Warning Score to predict adverse inpatient events in a vital sign dataset

Aotearoa New Zealand uses a single early warning score (EWS) across all public and private hospitals to detect adult inpatient physiological deterioration. This combines the aggregate weighted scoring of the UK National Early Warning Score with single parameter activation from Australian medical emergency team systems. We conducted a retrospective analysis of a large vital sign dataset to validate the predictive performance of the New Zealand EWS in discriminating between patients at risk of serious adverse events and compared this with the UK EWS. We also compared predictive performance for patients admitted under medical vs. surgical specialties. A total of 1,738,787 aggregate scores (13,910,296 individual vital signs) were obtained from 102,394 hospital admissions to six hospitals within the Canterbury District Health Board of New Zealand's South Island. Predictive performance of each scoring system was determined using area under the receiver operating characteristic curve. Analysis showed that the New Zealand EWS is equivalent to the UK EWS in predicting patients at risk of serious adverse events (cardiac arrest, death and/or unanticipated ICU admission). Area under the receiver operating characteristic curve for both EWSs for any adverse outcome was 0.874 (95%CI 0.871–0.878) and 0.874 (95%CI 0.870–0.877), respectively. Both EWSs showed superior predictive value for cardiac arrest and/or death in patients admitted under surgical rather than medical specialties. Our study is the first validation of the New Zealand EWS in predicting serious adverse events in a broad dataset and supports previous work showing the UK EWS has superior predictive performance in surgical rather than medical patients.     

A prospective multicentre observational study of adverse iatrogenic events and substandard care preceding intensive care unit admission (PREVENT)

We examined the current incidence, type, severity and preventability of iatrogenic events associated with intensive care unit admission in five hospitals in England. All unplanned adult admissions to intensive care units were prospectively reviewed over a continuous six‐week period. In the week before admission, 76/280 patients (27%) experienced 104 iatrogenic events. The majority of iatrogenic events were categorised as medical (37%), drug (17%) or nursing events (17%). Seventy‐seven per cent of the events were considered preventable and 80% caused or contributed to admission. Eleven events were thought to have contributed to a patient's death. The mean (SD) age of patients who had an event was greater (63 (21) years) than those who had not (57 (19) years, p = 0.023), and they had a longer median (IQR [range]) intensive care stay, 4 (1–8 [0–29]) days vs 3 (1–5 [0–20]) days, respectively, p = 0.043.     

Anaemia among intensive care unit survivors and association with days alive and at home: an observational study

Anaemia is highly prevalent at the time of intensive care unit discharge and is persistent for a high proportion of intensive care unit survivors. Whether anaemia is a driver of impaired recovery after critical illness is uncertain. The aim of this study was to test the hypothesis that, in adult intensive care survivors, anaemia at the time of intensive care unit discharge independently predicts decreased days at home-90. This retrospective cohort study was conducted in a tertiary intensive care unit in Perth, Western Australia. All patients aged ≥ 16 years, discharged alive from their index intensive care unit admission and without documented treatment limitations were included. Median (IQR [range]) age of the 6358 participants was 61 (46–72 [16–95]) years and included 3385 (53.2%) unplanned admissions. Intensive care unit discharge with a haemoglobin concentration < 100 g.l^-1 occurred in 2886 (45.4%) patients, a threshold that identified a cohort with significantly lower days at home-90 (median (IQR [range]) 80 (64–85 [0–90]) days vs. 85 (77–88 [0–90]) days (median difference 5 days, 95%CI 4.4–5.5, p < 0.0001). The association followed a severity-response relationship with more severe anaemia predicting lower days at home-90. When accounting for prespecified covariates including admission haemoglobin concentration and red blood cell transfusion, anaemia at intensive care unit discharge remained a significant predictor of decreased days at home-90, relative risk 0.96 (0.93–0.98), p < 0.002. These findings support the need for interventional trials investigating whether this risk is modifiable.     

Cerebral oximetry and postoperative delirium after cardiac surgery: a randomised,controlled trial

Postoperative delirium is associated with increased morbidity and mortality. We hypothesised that restoration of regional cerebral oxygen desaturation would reduce the incidence of postoperative delirium in elderly patients after cardiac surgery. After institutional ethics review board approval and informed consent, a double‐blinded, prospective, randomised, controlled trial was conducted in patients ≥ 60 years of age undergoing cardiac surgery with cardiopulmonary bypass. In the intervention group, an algorithm was commenced if regional cerebral oxygen saturation decreased below 75% of baseline value for 1 min or longer. In the control group, the cerebral oximetry monitor screen was electronically blinded. Assessment of delirium was performed with confusion assessment method for intensive care unit or confusion assessment method after discharge from intensive care unit at 12‐h intervals for seven postoperative days. Postoperative delirium was present in 30 out of 123 (24.4%) and 31 out of 126 (24.6%) patients in the intervention and control groups, respectively, odds ratio 0.98 (95%CI 0.55–1.76), p = 0.97. Postoperative delirium was present in 20 (71%) out of 28 and in 41 (18%) out of 221 patients with baseline regional cerebral oxygen saturation ≤ 50, or > 50%, respectively, p = 0.0001. Higher baseline regional cerebral oxygen saturation and body mass index were protective against postoperative delirium. Restoration of regional cerebral oxygen desaturation did not result in lower postoperative delirium after cardiac surgery. Pre‐operative regional cerebral oxygen saturation ≤ 50% was associated with increased postoperative delirium rates in elderly patients following cardiac surgery.     

A prospective,observational study of cerebrovascular autoregulation and its association with delirium following cardiac surgery

This aim of this prospective observational cohort study was to evaluate any association between postoperatively impaired cerebrovascular autoregulation and the onset of delirium following cardiac surgery. Previous studies have shown that impaired intra-operative cerebrovascular autoregulation during cardiopulmonary bypass is associated with delirium. However, postoperative changes in cerebrovascular autoregulation and its association with delirium have not been investigated. One-hundred and eight consecutive adult cardiac surgical patients without baseline cognitive dysfunction or aphasia were included in the study. Cerebrovascular autoregulation was assessed by the Pearson correlation between near-infrared spectroscopy-derived cerebral tissue oxygen saturation and mean arterial pressure to derive the tissue oximetry index. Cerebrovascular autoregulation was monitored for a minimum of 90 min on postoperative day 0 and postoperative day 1. Delirium was assessed throughout intensive care unit admission using the confusion assessment method for the intensive care unit. We observed delirium in 24 of the 108 patients studied. The mean (SD) tissue oximetry index was higher in delirious patients on postoperative day 0 compared with non-delirious patients; 0.270 (0.199) vs. 0.180 (0.142), p = 0.044, but not on postoperative day 1; 0.130 (0.160) vs. 0.150 (0.130), p = 0.543. All patients showed improvement in tissue oximetry index on postoperative day 1 compared with postoperative day 0. Logistic regression analysis demonstrated tissue oximetry index on postoperative day 0 to be independently associated with delirium; odds ratio 1.05 (95%CI 1.01–1.10), p = 0.043. In conclusion, we found an association between impaired cerebrovascular autoregulation, measured by near-infrared spectroscopy, and delirium in the early postoperative period.     

A comparative study of four intensive care outcome prediction models in cardiac surgery patients

Background  

Outcome prediction scoring systems are increasingly used in intensive care medicine, but most were not developed for use in cardiac surgery patients. We compared the performance of four intensive care outcome prediction scoring systems (Acute Physiology and Chronic Health Evaluation II [APACHE II], Simplified Acute Physiology Score II [SAPS II], Sequential Organ Failure Assessment [SOFA], and Cardiac Surgery Score [CASUS]) in patients after open heart surgery.     

Recognition of the critically ill patient and escalation of therapy

Critical illness often involves multiple organ failures and is associated with significant morbidity and mortality. In the vast majority of patients, there is a recognizable period of physiological deterioration which heralds the development of organ failure and critical illness. Despite efforts to improve the detection and management of critical illness, signs of deterioration are often missed and decisions to move patients to critical care units are delayed. Standardized approaches which implement an effective ‘chain of response’ are now utilized worldwide. They focus on attempting to reduce the incidence of serious adverse events (SAEs) such as in-hospital cardiac arrest and unplanned intensive care unit (ICU) admission using preventative measures. These systems should include: accurate recording and documentation of vital signs, recognition and interpretation of abnormal values, rapid bedside patient assessment by trained teams and appropriate interventions. Early warning systems (EWS) are an important part of this and can help identify patients at risk of deterioration and SAEs. Assessment of the critically ill patient should be undertaken by an appropriately trained clinician and follow a structured ABCDE (airway, breathing, circulation, disability and exposure) format. This facilitates correction of life-threatening problems by priority and provides a standardized communication framework between professionals. Lastly, timely support and input from members of the critical care team are vital to ensure optimal outcomes for critically ill patients.     

Hydroxyethyl starch and acute kidney injury in high-risk patients undergoing cardiac surgery: A prospective multicenter study

BackgroundHydroxyethyl starch (HES) solutions increase the risk of acute kidney injury (AKI) in critically ill patients admitted to intensive care unit (ICU) for medical indications. We conducted a cohort study to evaluate the renal safety of modern 6% HES solutions in high-risk patients having cardiac surgery.MethodIn this multicentre prospective cohort study, we recruited 261 consecutive patients at high-risk for developing cardiac surgery-associated AKI, based on a Cleveland score ≥ 4 points, from July to December 2017th in 14 hospitals in Spain and the United Kingdom. Multivariable logistic regression modeling and propensity-score matched-pairs analysis were used to determine the adjusted association between administration of HES and AKI.ResultsOf the cohort, 95 patients (36.4%) received 6% HES 130/0.4 either intraoperatively or postoperatively. Postoperative AKI occurred in 145 patients (55.5%). The unadjusted odds of AKI was significantly higher in the HES group, when compared to those not receiving HES (OR 2.22, 95% CI 1.30–3.80, p = 0.003). In multivariable logistic regression models, modern HES was not associated with significantly increased risk of AKI (adjusted OR 0.84, 95% CI 0.41–1.71, p = 0.63). In propensity score match-pairs analysis of 188 patients, the HES group experienced similar adjusted odds of AKI (OR 1.05, CI 95% 0.87–1.27, p = 0.57) and RRT (OR 1.06, CI 95% 0.92–1.22, p = 0.36).ConclusionsThe use of modern hydroxyethyl starch 6% HES 130/0.4 was not associated with an increased risk of AKI nor dialysis in this cohort of patients at elevated risk for developing AKI after cardiac surgery.     

Factors associated with time to defecate and outcomes in critically ill patients: a prospective,multicentre, observational study

Delayed defecation is common in patients on intensive care. We aimed to determine factors associated with time to defecation after admission to intensive care and in turn its association with length of stay and mortality. We studied 396 adults admitted to one of five intensive care units in whom at least 2 days’ invasive ventilation was anticipated during an expected stay of at least 3 days. The median (IQR [range]) time to defecate by the 336 out of 396 (84%) patients who did so before intensive care discharge was 6 (4-8 [1–18]) days. Defecation was independently associated with five factors, hazard ratio (95%CI), higher values indicating more rapid defecation: alcoholism, 1.32 (1.05–1.66), p = 0.02; laxatives before admission, 2.35 (1.79–3.07), p < 0.001; non-invasive ventilation, 0.54 (0.36–0.82), p = 0.004; duration of ventilation, 0.78 (0.74–0.82), p < 0.001; laxatives after admission, 1.67 (1.23–2.26), p < 0.001; and enteral nutrition within 48 h of admission, 1.43 (1.07–1.90), p = 0.01. Delayed defecation was associated with prolonged intensive care stay but not mortality.     

Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward

Admissions to the intensive care unit (ICU) from the wards havea higher mortality when compared to patients admitted from theoperating theatres/recovery and accident and emergency department.¹Suboptimal care may contribute to morbidity and mortality ofpatients admitted from the ward.² Failure to appreciate physiologicalderangements of breathing and mental status has been demonstratedin patients who subsequently suffered cardiac arrest, and theseevents may have been apparent up to 8 h prior to the event.³⁴ The Early Warning Score (EWS) was developed as a simple scoringsystem to be used at ward level utilising routine observationstaken by nursing staff.⁵ Deviations from the normal score pointsand a total is calculated. The EWS was evaluated prospectively for 1 month. The score wasthen modified to include urine output, to make temperature deviationsless sensitive and to include normalised blood pressure (Table8). We then evaluated this prospectively for 9 months. A total score of 4 or more resulted in the patient being reviewedby ward medical staff and help sought from the intensive careteam if appropriate. Over a 9-month period 206 patients on twogeneral surgical wards were put on the scoring system, of these26 were admitted to the ICU. The APACHE II scores of these patientswas 16.6 (± 7.3). Eleven patients were admitted to theICU from the surgical ward who had not been monitored on themodified EWS and their admission APACHE II scores were 23.5(± 4.1). This compares with admission APACHE II scoresof 22.3 (± 5.5) in 43 patients admitted from surgicalwards in the 9-month period prior to introduction of the system.The introduction of the system has appeared to lead to earlierreferral to the intensive care unit.     

Clinical results of arthroscopic rotator cuff repair in diabetic and non-diabetic patients

BackgroundAlthough the clinical outcomes of arthroscopic rotator cuff repair (ARCR) have been reported, few studies have focused on diabetic patients. We investigated and compared the clinical results of ARCR in patients with and without diabetes.MethodsThis retrospective study involved 195 consecutive patients who underwent ARCR from 2015 to 2018 in our hospital. Twenty-seven and 168 shoulders were assigned to diabetes and non-diabetes groups, respectively. Diabetic patients with poor control were preoperatively hospitalized for perioperative diabetic control. We evaluated range of motion (ROM), Japanese Orthopaedic Association shoulder (JOA) score, Constant Shoulder Score, and University of California, Los Angeles (UCLA) score preoperatively and at 6 months and 1 year post-ARCR. Rates of rotator cuff retear 1 year post-ARCR and preoperative and postoperative stiff shoulder were also evaluated. We compared the results between groups and analyzed them statistically. A p-value of <0.05 was considered statistically significant.ResultsPreoperative ROM, JOA score, Constant Shoulder Score and UCLA scores showed significant improvement at post-ARCR in both groups (p < 0.05). On comparing the groups, although preoperative JOA score and Constant Shoulder Score were significantly lower in diabetes group than in non-diabetes group (diabetic/non-diabetic group; 60.0/65.3 for JOA score; p = 0.003, 59.7/64.2 for Constant Shoulder Score; p = 0.003), there was no significant difference postoperatively (6 months post-ARCR; 88.0/89.7 for JOA score; p = 0.783, 88.1/88.6 for Constant Shoulder Score; p = 0.597, 1 year post-ARCR; 96.7/95.4 for JOA score; p = 0.238, 96.6/95.4 for Constant Shoulder Score; p = 0.248). Furthermore, preoperative and postoperative stiff shoulder and retear rates were not significantly different between groups (p = 0.152, p = 0.344, p = 0.347, and p = 0.563, respectively).ConclusionDiabetic patients showed comparable clinical results with non-diabetic patients post-ARCR. Perioperative diabetic control may be recommended for preoperatively uncontrolled diabetic patients.     

Critical care after lung resection: CALoR 1, a single‐centre pilot study

Lung resection is associated with significant perioperative morbidity, and a proportion of patients will require intensive care following surgery. We set out to characterise this population, assess their burden of disease and investigate the influence of anaesthetic and surgical techniques on their admission rate. Over a two‐year period, 1169 patients underwent surgery, with 30 patients (2.6%) requiring unplanned intensive care. Patients requiring support had a higher mortality (0.2% vs 26.7%, p < 0.001). Logistic regression (following adjustment for Thoracoscore) revealed that an open surgical approach was associated with higher likelihood of admission (p = 0.025, odds ratio = 5.25). There was also a trend towards increased likelihood of admission in patients who received volatile anaesthesia (p = 0.061, odds ratio = 2.08). This topic has been selected for further investigation as part of the 2015 Association of Cardiothoracic Anaesthetists (ACTA) second national collaborative audit, with this study providing pilot data before a multi‐centre study.     

Continuous monitoring is superior to manual measurements in detecting vital sign deviations in patients with COVID-19

Background

Patients admitted to the emergency care setting with COVID-19-infection can suffer from sudden clinical deterioration, but the extent of deviating vital signs in this group is still unclear. Wireless technology monitors patient vital signs continuously and might detect deviations earlier than intermittent measurements. The aim of this study was to determine frequency and duration of vital sign deviations using continuous monitoring compared to manual measurements. A secondary analysis was to compare deviations in patients admitted to ICU or having fatal outcome vs. those that were not.

Methods

Two wireless sensors continuously monitored (CM) respiratory rate (RR), heart rate (HR), and peripheral arterial oxygen saturation (SpO₂). Frequency and duration of vital sign deviations were compared with point measurements performed by clinical staff according to regional guidelines, the National Early Warning Score (NEWS).

Results

SpO₂ < 92% for more than 60 min was detected in 92% of the patients with CM vs. 40% with NEWS (p < .00001). RR > 24 breaths per minute for more than 5 min were detected in 70% with CM vs. 33% using NEWS (p = .0001). HR ≥ 111 for more than 60 min was seen in 51% with CM and 22% with NEWS (p = .0002). Patients admitted to ICU or having fatal outcome had longer durations of RR > 24 brpm (p = .01), RR > 21 brpm (p = .01), SpO₂ < 80% (p = .01), and SpO₂ < 85% (p = .02) compared to patients that were not.

Conclusion

Episodes of desaturation and tachypnea in hospitalized patients with COVID-19 infection are common and often not detected by routine measurements.     

Association between intra-operative cardiac arrest and country Human Development Index status: a systematic review with meta-regression analysis and meta-analysis of observational studies*

Intra-operative cardiac arrests differ from most in-hospital cardiac arrests because they reflect not only the patient's condition but also the quality of surgery and anaesthesia care provided. We assessed the relationship between intra-operative cardiac arrest rates and country Human Development Index (HDI), and the changes occurring in these rates over time. We searched PubMed, EMBASE, Scopus, LILACS, Web of Science, CINAHL and SciELO from inception to 29 January 2020. For the global population, rates of intra-operative cardiac arrest and baseline ASA physical status were extracted. Intra-operative cardiac arrest rates were analysed by time, country HDI status and ASA physical status using meta-regression analysis. Proportional meta-analysis was performed to compare intra-operative cardiac arrest rates and ASA physical status in low- vs. high-HDI countries and in two time periods. Eighty-two studies from 25 countries with more than 29 million anaesthetic procedures were included. Intra-operative cardiac arrest rates were inversely correlated with country HDI (p = 0.0001); they decreased over time only in high-HDI countries (p = 0.040) and increased with increasing ASA physical status (p < 0.0001). Baseline ASA physical status did not change in high-HDI countries (p = 0.106), while it decreased over time in low-HDI countries (p = 0.040). In high-HDI countries, intra-operative cardiac arrest rates (per 10,000 anaesthetic procedures) decreased from 9.59 (95%CI 6.59–13.16) pre-1990 to 5.17 (95%CI 4.42–5.97) in 1990–2020 (p = 0.013). During the same time periods, no improvement was observed in the intra-operative cardiac arrest rates in low-HDI countries (p = 0.498). Odds ratios of intra-operative cardiac arrest rates in ASA 3–5 patients were 8.48 (95%CI 1.67–42.99) times higher in low-HDI countries than in high-HDI countries (p = 0.0098). Intra-operative cardiac arrest rates are related to country-HDI and decreased over time only in high-HDI countries. The widening gap in these rates between low- and high-HDI countries needs to be addressed globally.     

Influence of sesamoid position after scarf osteotomy for hallux valgus on patient-reported outcome. A prospective cohor study

BackgroundThe objective was to evaluate the influence of the postoperative sesamoid position as measured with conventional radiographs on the patient-reported outcome after scarf osteotomy. The hypothesis was that incomplete reduction of the sesamoid would result in a decreased functional outcome.MethodsEighty-two patients who underwent scarf osteotomy for hallux valgus were prospectively assessed for up to two postoperative years. The Self-Reported Foot and Ankle Score (SEFAS) was used to assess the quality of life, and the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale (AOFAS) for the functional outcome. A visual analogue scale (VAS) assessed pain, and Likert scale for patient satisfaction. Radiologically, hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), and sesamoid position were analyzed. According to the final sesamoid position, patients were classified as normal position (48 patients) and outlier position (34 patients). A power analysis, conventional and logistic regression statistical analysis were performed.ResultsAt the final follow-up, significant improvements in all clinical scores were observed for both groups (p = 0.001) with no significant difference in AOFAS score (p = 0.413), but SEFAS score (p = 0.023), VAS-pain (p = 0.006), and satisfaction (p = 0.014) were significantly better in the normal group than in the outlier group. There were significant differences between groups in final HVA (p = 0.042) and IMA (p = 0.040). In multivariate analysis, only lower VAS-pain score (OR 0.4, 95% CI 0.2–0.6; p = 0.039) and normal sesamoid position (OR 2.4, 95% CI 1.6–3.2; p = 0.012) were significant predictor of patient satisfaction.ConclusionAt two postoperative years, normal sesamoid position as measured on weight-bearing radiographs was associated with lower pain and better patient satisfaction in patients underwent scarf osteotomy for moderate to severe hallux valgus.     

Postoperative intensive care in infants and children after cardiac surgery

Background The postoperative course of infants and children after open heart surgery is often complicated by cardiopulmonary insufficiency or low cardiac output. Methods From January 1989 to April 1992 441 infants and children with congenital heart disease underwent cardiac surgery. 128 of these patients (29%) required prolonged or extensive intensive care because of cardiopulmonary insufficiency or low cardiac output. Aortic cross clamp and cardiopulmonary bypass times were measured in all patients. In the postoperative period duration of mechanical ventilation, duration of intensive care, special monitoring and therapeutic strategies and clinical scores were documented. Results The overall mortality rate was 9.9%, the mortality rate in patients with postoperative cardiopulmonary insufficiency or low cardiac output was 34%. The mortality rate increased significantly up to 73% when the cardiopulmonary bypass time exceeded 200 min. Mean duration of intensive care of survivors (S) and nonsurvivors (NS) was 10.3±0.8 and 4.1±1.2 days, respectively (p<0.01), mean duration of mechanical ventilation was 7.1±0.5 (S) and 4.1±1.2 (NS) days, respectively (p<0.01). NS had a significantly higher degree of physiologic derangement assessed by the Acute Physiologic Score for Children and needed more monitoring and therapeutic interventions assessed by the Therapeutic Intervention Scoring System than S. Conclusion Complex cardiac surgery, a cardiopulmonary bypass time over 200 min, high catecholamine infusion rates combined with a persisting low mean arterial pressure are associated with a high postoperative mortality rate in infants and children with congenital heart defects.