Intensive Care Unit Admission Parameters Improve the Accuracy of Operative Mortality Predictive Models in Cardiac Surgery

BACKGROUND: Operative mortality risk in cardiac surgery is usually assessed using preoperative risk models. However, intraoperative factors may change the risk profile of the patients, and parameters at the admission in the intensive care unit may be relevant in determining the operative mortality. This study investigates the association between a number of parameters at the admission in the intensive care unit and the operative mortality, and verifies the hypothesis that including these parameters into the preoperative risk models may increase the accuracy of prediction of the operative mortality. METHODOLOGY: 929 adult patients who underwent cardiac surgery were admitted to the study. The preoperative risk profile was assessed using the logistic EuroSCORE and the ACEF score. A number of parameters recorded at the admission in the intensive care unit were explored for univariate and multivariable association with the operative mortality. PRINCIPAL FINDINGS: A heart rate higher than 120 beats per minute and a blood lactate value higher than 4 mmol/L at the admission in the intensive care unit were independent predictors of operative mortality, with odds ratio of 6.7 and 13.4 respectively. Including these parameters into the logistic EuroSCORE and the ACEF score increased their accuracy (area under the curve 0.85 to 0.88 for the logistic EuroSCORE and 0.81 to 0.86 for the ACEF score). CONCLUSIONS: A double-stage assessment of operative mortality risk provides a higher accuracy of the prediction. Elevated blood lactates and tachycardia reflect a condition of inadequate cardiac output. Their inclusion in the assessment of the severity of the clinical conditions after cardiac surgery may offer a useful tool to introduce more sophisticated hemodynamic monitoring techniques. Comparison between the predicted operative mortality risk before and after the operation may offer an assessment of the operative performance

Relationship of nuclear DNA content to clinicopathologic features in colorectal cancer.

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Factors influencing the rising rates of adrenal surgery: analysis of 25 years experience.

BACKGROUND: Adrenal surgery has been radically changed by laparoscopy and it is reasonable to wonder whether the increase in the number of adrenalectomies is entirely justified. There is still debate on the transperitoneal versus the retroperitoneal approach, the advantages and drawbacks of which are discussed here. METHODS: Between 1983 and 2007, we performed 279 adrenalectomies in 264 consecutive patients, divided into two groups: before and after the advent of laparoscopic adrenalectomy (LA). We analyzed the factors that increased the number of adrenalectomies in recent years. The LAs were further divided into three consecutive periods and the morbidity and conversion rates, and mean operating times were compared. RESULTS: More procedures were performed after the advent of LA, i.e., 55 (19.7%) beforehand versus 224 (80.3%) afterwards, irrespective of the type of disease, for instance: incidentaloma, 17.6% versus 82.4% (p \ 0.0001); pheochromocytoma, 20.7% versus 79.3% (p\0.0001); Conn's disease, 19.8% versus 80.2% (p \ 0.0001); Cushing's disease, 17.2% versus 82.8% (p\0.0001); cortical carcinoma, 30% versus 70% (p\0.001). Analyzing the three LA periods, operating times were the only statistically significant variable (p\0.0001). CONCLUSIONS: The progressive increase in the number of adrenalectomies performed is due more to a better understanding of adrenal disease than to the availability of minimally invasive techniques. The choice of a laparoscopic approach (trans- or retroperitoneal) should depend on the surgeon's experience

Neuromonitoring and Emergency EEG

Intraoperative and Intensive Care Unit (ICU) EEG monitoring is very useful in cases of possible brain damage, for example, during carotid endarterectomy, cardiac surgery and neurosurgery, or when subclinical seizures are suspected. Continuous EEG (cEEG) monitoring during surgery is a valid and sensitive instrument for recognizing and/or preventing perioperative ischemic insults or any epileptiform activity responsible for convulsive or nonconvulsive symptoms. Furthermore, it allows brain functions monitoring for anesthetic drug administration, to determine the depth of anesthesia and for adjusting drug levels to achieve a predefined neural effect, such as burst suppression. In ICU, cEEG monitoring is essential to identify electrical discharges that occur frequently in critically ill patients and that are often clinically undetected, but potentially harmful if the diagnosis and the treatment are delayed. In the last years, cEEG monitoring has become a widespread practice, especially because of the use of new digital equipments, which are extremely compact and easy to use, not requiring a constant connection to the power grid and thus avoiding artifacts. EEG tracings can be visualized in real-time or analyzed after acquisition, either online or offline, with qualitative and/or quantitative methods. Finally, it is worth remembering that EEGs can be recorded bedside from a peripheral recording unit and then sent to the central unit, so that neurophysiologists can examine the recordings from distance and process them without interfering with the patients’ management