Preoperative asymptomatic leukocytosis and postoperative outcome in cardiac surgery patients

<div><p>Background</p><p>Despite showing a prognostic value in general surgical patients, preoperative asymptomatic elevated white blood cell (WBC) count is not considered a risk factor for cardiac surgery. Whereas there is sporadic evidence of its value as a preoperative risk marker, it has not been looked at methodically as a specific index of outcome during cardiac surgery. Using a national database we sought to determine the relationship between preoperative WBC count and postoperative outcome in cardiac surgical patients.</p><p>Methods</p><p>Cardiac surgeries were extracted from the 2007–2013 American College of Surgeons National Surgical Quality Improvement Program database. Leukocytosis was defined by a preoperative WBC count greater than 11,000 cells/μL. A univariate analysis compared the incidence of adverse outcomes for patients with and without leukocytosis. A multivariate logistic regression model was constructed in order to test whether leukocytosis was an independent predictor of morbidity and mortality.</p><p>Results</p><p>Out of a total of 10,979 cardiac surgery patients 863 (7.8%) had preoperative leukocytosis. On univariate analysis, patients with leukocytosis experienced greater incidences of 30-day mortality, wound complications, and medical complications. Wound complications included surgical site infection as well as wound dehiscence. The medical complications included all other non-surgical causes of increased morbidity and infection leading to urinary tract infection, pneumonia, ventilator dependence, sepsis and septic shock. After stepwise model adjustment, leukocytosis was a strong predictor of medical complications (OR 1.22, 95% CI: 1.09–1.36, p = 0.002) with c-statistic of 0.667. However, after stepwise model adjustment leukocytosis was not a significant predictor of 30-day mortality and wound complications.</p><p>Conclusion</p><p>Preoperative leukocytosis is associated with adverse postoperative outcome after cardiac surgery and is an independent predictor of infection-related postoperative complications.</p></div

Wound complications vs. white blood cell count.

<p>Stepwise plot of wound complications rate against white blood cell count for the sample of 10,979 cardiac surgery patients, illustrating a positive relationship between the two variables.</p

30-day mortality vs. white blood cell count.

<p>Stepwise plot of 30-day mortality rate against white blood cell count for the sample of 10,979 cardiac surgery patients, illustrating a positive relationship between the two variables.</p

Medical complications vs. white blood cell count.

<p>Stepwise plot of medical complications rate against white blood cell count for the sample of 10,979 cardiac surgery patients, illustrating a positive relationship between the two variables.</p

Univariate associations between leukocytosis and baseline characteristics.

<p>Univariate associations between leukocytosis and baseline characteristics.</p

Final multiple logistic regression model summaries.

<p>Final multiple logistic regression model summaries.</p

Ultrasound images of the Simulab and 3D printed phantoms.

<p>Ultrasound views were taken with a linear ultrasound probe. Images from the Simulab phantom are shown in the left column, those from the 3D printed phantom in the right. Images collected were: (A1, A2) Paramedian sagittal view, (B1, B2) Transverse view at inter-space and (D1, D2) Transverse view at spinous process.</p

Slicing settings.

<p>Slicing settings.</p

Comparison of tactile fidelity for surface palpation, soft tissue resistance and ligamentum flavum resistance between Simulab and the 3DP Phantom.

<p>Rating for the 3D Phantom from each expert is plotted against the expert’s rating of the Simulab Phantom. Size of bubble and number indicate the number of experts. Bubbles above the diagonal line represent experts rating the 3D Phantom higher than the Simulab Phantom.</p

Comparison of tactile fidelity for loss of resistance (epidural) and dural puncture (spinal) between Simulab and the 3DP Phantom.

<p>Rating for the 3D Phantom from each expert is plotted against the expert’s rating of the Simulab Phantom. Size of bubble and number indicate the number of experts. Bubbles above the diagonal line represent experts rating the 3D Phantom higher than the Simulab Phantom.</p