Obesity as a risk factor following cadaveric renal transplantation

Obesity has generally been thought to increase the risk of operative mortality and postoperative complications in surgical patients. No data examining obesity as a factor in cadaveric renal transplantation were available. We therefore matched obese patients undergoing cadaveric renal transplantation with nonobese control patients and retrospectively analyzed mortality, morbidity, and graft survival in each group. Patients were matched for age, sex, diabetes mellitus, PRA, graft number, cardiovascular disease, date of transplantation, and posttransplant immunosuppression. There were significant differences found in mortality (11% in obese vs. 2% in nonobese patients, P<0.01), immediate graft function (38% in obese vs. 64% in nonobese patients, P<0.01), 1-year graft survival (66% in obese vs. 84% in nonobese patients, P<0.05), and postoperative complications. Wound complications (20% vs. 2%, P<0.01), intensive-care-unit admissions (10% vs. 2%, P<0.01), reintubations (16% vs. 2%, P<0.03), and new-onset diabetes (12% vs. 0%, P<0.02) were all significantly more common in the obese group. These results suggest that an attempt at significant weight reduction is indicated in obese patients prior to renal transplantation. © 1990 by Williams & Wilkins

Benefits of thoracic epidural analgesia in patients undergoing an open posterior component separation for abdominal herniorrhaphy

INTRODUCTION: The implementation of open posterior component separation (PCS) surgery has led to improved outcomes for complex hernias. While the PCS technique has been shown to decrease recurrence rates, and provide a feasible option to repair hernias in nontraditional locations, there is still significant postoperative pain associated with the laparotomy and extensive abdominal wall manipulation. Systemic opioids and thoracic epidural analgesia (TEA) are both commonly utilized, either together or independently, as postoperative analgesic regimens. The benefits of TEA have been studied following a variety of surgeries, however to date no study has been performed to investigate its efficacy in this particular surgery. The aim of this study is to evaluate the benefits of TEA following open PCS. We hypothesized that the incorporation of TEA in a patients postoperative analgesic regimen would show an advantage in time to bowel recovery. METHODS: An electronic medical record query was done to identify patients who had undergone an open PCS. Once this list was compiled, a retrospective chart review was performed and patients receiving TEA (either alone or combined with systemic opioids) were compared to patients receiving only systemic opioids. The primary endpoint compared time to resumption of a full diet, given by the patients postoperative day (POD). Secondarily, time to resumption of a liquid diet, postoperative length of stay (LOS), intensive care unit (ICU) admission rate, ICU LOS, and rates of several postoperative complications were all recorded and compared. A post-hoc analysis was also performed using the same endpoints. This analysis compared cohorts of patients receiving TEA and avoiding all systemic opioids, to patients who received systemic opioids (whether alone or combined with TEA). RESULTS: Based on inclusion parameters, 101 patients met criteria for analysis. In the initial analysis, 62 patients received TEA with or without systemic opioids, and 39 patients received only systemic opioids. In comparing these groups, there was no statistically significant difference in time to full diet (TEA 2.6 ± 1.7 vs Systemic opioids 3.1 ± 2.1 [mean POD ± SD]; P=0.21). In addition, no differences were found in the secondary outcomes of time to liquid diet, ICU admission, ICU LOS, or postoperative complications. In the post-hoc analysis, the 37 patients that received only TEA, were compared against 64 patients that received systemic opioids (either with or without TEA). In this comparison, the group receiving only TEA was found to have a statically shorter time to bowel recovery compared to patients receiving systemic opioids (TEA alone 2.2 ± 1.0 vs Systemic opioids 3.2 ± 2.2, P=0.0033). This subgroup (TEA only) also showed statically shorter time to liquid diet and a decreased postoperative LOS. CONCLUSION: For patients undergoing an open PCS, the inclusion of TEA in the postoperative analgesic regimen did not shorten return of bowel function. However, when TEA was utilized and systemic opioids were avoided, time to bowel recovery and hospital LOS were both significantly shortened

Preventing Isolated Perioperative Reintubation: Who is at highest risk?

Objectives: 1. We aim to characterize IPR nationally through a retrospective review of the National Surgical Quality Improvement Program participant user file (NSQIP PUF). 2.Identify risk factors for IPR including analysis of procedure type and preoperative characteristics.https://jdc.jefferson.edu/patientsafetyposters/1041/thumbnail.jp

Management of Mechanical Ventilation in Decompensated Heart Failure.

Mechanical ventilation (MV) is a life-saving intervention for respiratory failure, including decompensated congestive heart failure. MV can reduce ventricular preload and afterload, decrease extra-vascular lung water, and decrease the work of breathing in heart failure. The advantages of positive pressure ventilation must be balanced with potential harm from MV: volutrauma, hyperoxia-induced injury, and difficulty assessing readiness for liberation. In this review, we will focus on cardiac, pulmonary, and broader effects of MV on patients with decompensated HF, focusing on practical considerations for management and supporting evidence

A Reinforcement Learning Approach to Weaning of Mechanical Ventilation in Intensive Care Units

The management of invasive mechanical ventilation, and the regulation of sedation and analgesia during ventilation, constitutes a major part of the care of patients admitted to intensive care units. Both prolonged dependence on mechanical ventilation and premature extubation are associated with increased risk of complications and higher hospital costs, but clinical opinion on the best protocol for weaning patients off of a ventilator varies. This work aims to develop a decision support tool that uses available patient information to predict time-to-extubation readiness and to recommend a personalized regime of sedation dosage and ventilator support. To this end, we use off-policy reinforcement learning algorithms to determine the best action at a given patient state from sub-optimal historical ICU data. We compare treatment policies from fitted Q-iteration with extremely randomized trees and with feedforward neural networks, and demonstrate that the policies learnt show promise in recommending weaning protocols with improved outcomes, in terms of minimizing rates of reintubation and regulating physiological stability

Protocolised non-invasive compared with invasive weaning from mechanical ventilation for adults in intensive care : the Breathe RCT

Background: Invasive mechanical ventilation (IMV) is a life-saving intervention. Following resolution of the condition that necessitated IMV, a spontaneous breathing trial (SBT) is used to determine patient readiness for IMV discontinuation. In patients who fail one or more SBTs, there is uncertainty as to the optimum management strategy. Objective: To evaluate the clinical effectiveness and cost-effectiveness of using non-invasive ventilation (NIV) as an intermediate step in the protocolised weaning of patients from IMV. Design: Pragmatic, open-label, parallel-group randomised controlled trial, with cost-effectiveness analysis. Setting: A total of 51 critical care units across the UK. Participants: Adult intensive care patients who had received IMV for at least 48 hours, who were categorised as ready to wean from ventilation, and who failed a SBT. Interventions: Control group (invasive weaning): patients continued to receive IMV with daily SBTs. A weaning protocol was used to wean pressure support based on the patient’s condition. Intervention group (non-invasive weaning): patients were extubated to NIV. A weaning protocol was used to wean inspiratory positive airway pressure, based on the patient’s condition. Main outcome measures: The primary outcome measure was time to liberation from ventilation. Secondary outcome measures included mortality, duration of IMV, proportion of patients receiving antibiotics for a presumed respiratory infection and health-related quality of life. Results: A total of 364 patients (invasive weaning, n = 182; non-invasive weaning, n = 182) were randomised. Groups were well matched at baseline. There was no difference between the invasive weaning and non-invasive weaning groups in median time to liberation from ventilation {invasive weaning 108 hours [interquartile range (IQR) 57–351 hours] vs. non-invasive weaning 104.3 hours [IQR 34.5–297 hours]; hazard ratio 1.1, 95% confidence interval [CI] 0.89 to 1.39; p = 0.352}. There was also no difference in mortality between groups at any time point. Patients in the non-invasive weaning group had fewer IMV days [invasive weaning 4 days (IQR 2–11 days) vs. non-invasive weaning 1 day (IQR 0–7 days); adjusted mean difference –3.1 days, 95% CI –5.75 to –0.51 days]. In addition, fewer non-invasive weaning patients required antibiotics for a respiratory infection [odds ratio (OR) 0.60, 95% CI 0.41 to 1.00; p = 0.048]. A higher proportion of non-invasive weaning patients required reintubation than those in the invasive weaning group (OR 2.00, 95% CI 1.27 to 3.24). The within-trial economic evaluation showed that NIV was associated with a lower net cost and a higher net effect, and was dominant in health economic terms. The probability that NIV was cost-effective was estimated at 0.58 at a cost-effectiveness threshold of £20,000 per quality-adjusted life-year. Conclusions: A protocolised non-invasive weaning strategy did not reduce time to liberation from ventilation. However, patients who underwent non-invasive weaning had fewer days requiring IMV and required fewer antibiotics for respiratory infections. Future work: In patients who fail a SBT, which factors predict an adverse outcome (reintubation, tracheostomy, death) if extubated and weaned using NIV? Trial registration: Current Controlled Trials ISRCTN15635197. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 48. See the NIHR Journals Library website for further project information

New anthropometric classification scheme of preoperative nutritional status in children: A retrospective observational cohort study

Objective: WHO uses anthropometric classification scheme of childhood acute and chronic malnutrition based on low body mass index (BMI) (\u27wasting\u27) and height for age (\u27stunting\u27), respectively. The goal of this study was to describe a novel two-axis nutritional classification scheme to (1) characterise nutritional profiles in children undergoing abdominal surgery and (2) characterise relationships between preoperative nutritional status and postoperative morbidity. Design: This was a retrospective observational cohort study. Setting: The setting was 50 hospitals caring for children in North America that participated in the American College of Surgeons National Surgical Quality Improvement Program Paediatric from 2011 to 2013. Participants: Children \u3e28 days who underwent major abdominal operations were identified. Interventions/main predictor: The cohort of children was divided into five nutritional profile groups based on both BMI and height for age Z-scores: (1) underweight/short, (2) underweight/tall, (3) overweight/short, (4) overweight/tall and (5) non-outliers (controls). Main outcome measures: Multiple variable logistic regressions were used to quantify the association between 30-day morbidity and nutritional profile groups while adjusting for procedure case mix, age and American Society of Anaesthesiologists class. Results: A total of 39 520 cases distributed as follows: underweight/short (656, 2.2%); underweight/tall (252, 0.8%); overweight/short (733, 2.4%) and overweight/tall (1534, 5.1%). Regression analyses revealed increased adjusted odds of composite morbidity (35%) and reintervention events (75%) in the underweight/short group, while overweight/short patients had increased adjusted odds of composite morbidity and healthcare-associated infections (43%), and reintervention events (79%) compared with controls. Conclusion: Stratification of preoperative nutritional status using a scheme incorporating both BMI and height for age is feasible. Further research is needed to validate this nutritional risk classification scheme for other surgical procedures in children

Incidence of Pulmonary Complications with the Prophylactic Use of High-flow Nasal Cannula after Pediatric Cardiac Surgery: Prophylactic HFNC Study Protocol

We will investigate the incidence of postoperative pulmonary complications (PPCs) with the prophylactic use of a high-flow nasal cannula (HFNC) after pediatric cardiac surgery. Children < 48 months old with congenital heart disease for whom cardiac surgery is planned will be included. The HFNC procedure will be commenced just after extubation, at a flow rate of 2 L/kg/min with adequate oxygen concentration to achieve target oxygen saturation ≥ 94%. This study will reveal the prevalence of PPCs after pediatric cardiac surgery with the prophylactic use of HFNC

Intraperitoneal photodynamic therapy causes a capillary-leak syndrome.

BackgroundIn patients undergoing intraperitoneal (IP) photodynamic therapy (PDT), the combination of aggressive surgical debulking and light therapy causes an apparent systemic capillary-leak syndrome that necessitates significant intensive care unit (ICU) management after surgery.MethodsFrom May 1997 to May 2001, 65 patients underwent surgical debulking and PDT as part of an ongoing phase II trial for disseminated IP cancer. Perioperative data were reviewed retrospectively, and statistical analyses were performed to determine whether any identifiable factors were associated with the need for mechanical ventilation for longer than 1 day and with the occurrence of postoperative complications.ResultsForty-three women and 22 men (mean age, 49 years) were treated. Operative time averaged 9.8 hours, and mean estimated blood loss was 1450 mL. The mean crystalloid requirement for the first 48 hours after surgery was 29.3 L, and 49 patients required blood products. Twenty-four patients were intubated for longer than 24 hours, with a mean of 8.3 days for those intubated longer than 1 day. The median ICU stay was 4 days. Overall, 110 complications developed in 45 (69%) of the 65 patients. Significant complications included 6 patients with acute respiratory distress syndrome, 28 patients with infectious complications, and 4 patients with anastomotic complications. Statistical analyses revealed that surgery-related factors were significantly associated with these complication outcomes.ConclusionsPatients who undergo surgical debulking and IP PDT develop a significant capillary-leak syndrome after surgery that necessitates massive volume resuscitation, careful ICU monitoring, and, frequently, prolonged ventilatory support