Sequential Surgical Procedures in Vascular Surgery Patients Are Associated With Perioperative Adverse Cardiac Events

Patients at elevated cardiovascular risk are prone to perioperative cardiovascular complications, like myocardial injury after non-cardiac surgery (MINS). We have demonstrated in a mouse model of atherosclerosis that perioperative stress leads to an increase in plaque volume and higher plaque vulnerability. Regulatory T cells (Tregs) play a pivotal role in development and destabilization of atherosclerotic plaques. For this exploratory post-hoc analysis we identified 40 patients recruited into a prospective perioperative biomarker study, who within the inclusion period underwent sequential open vascular surgery. On the basis of protein markers measured in the biomarker study, we evaluated the perioperative inflammatory response in patients' plasma before and after index surgery as well as before and after a second surgical procedure. We also analyzed available immunohistochemistry samples to describe plaque vulnerability in patients who underwent bilateral carotid endarterectomy (CEA) in two subsequent surgical procedures. Finally, we assessed if MINS was associated with sequential surgery. The inflammatory response of both surgeries was characterized by postoperative increases of interleukin-6,−10, Pentraxin 3 and C-reactive protein with no clear-cut difference between the two time points of surgery. Plaques from CEA extracted during the second surgery contained less Tregs, as measured by Foxp3 staining, than plaques from the first intervention. The 2nd surgical procedure was associated with MINS. In conclusion, we provide descriptive evidence that sequential surgical procedures involve repeat inflammation, and we hypothesize that elevated rates of cardiovascular complications after the second procedure could be related to reduced levels of intraplaque Tregs, a finding that deserves confirmatory testing and mechanistic exploration in future populations

A survey of preferences for respiratory support in the intensive care unit for patients with acute hypoxaemic respiratory failure

Publisher Copyright: © 2023 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.Background: When caring for mechanically ventilated adults with acute hypoxaemic respiratory failure (AHRF), clinicians are faced with an uncertain choice between ventilator modes allowing for spontaneous breaths or ventilation fully controlled by the ventilator. The preferences of clinicians managing such patients, and what motivates their choice of ventilator mode, are largely unknown. To better understand how clinicians' preferences may impact the choice of ventilatory support for patients with AHRF, we issued a survey to an international network of intensive care unit (ICU) researchers. Methods: We distributed an online survey with 32 broadly similar and interlinked questions on how clinicians prioritise spontaneous or controlled ventilation in invasively ventilated patients with AHRF of different severity, and which factors determine their choice. Results: The survey was distributed to 1337 recipients in 12 countries. Of these, 415 (31%) completed the survey either fully (52%) or partially (48%). Most respondents were identified as medical specialists (87%) or physicians in training (11%). Modes allowing for spontaneous ventilation were considered preferable in mild AHRF, with controlled ventilation considered as progressively more important in moderate and severe AHRF. Among respondents there was strong support (90%) for a randomised clinical trial comparing spontaneous with controlled ventilation in patients with moderate AHRF. Conclusions: The responses from this international survey suggest that there is clinical equipoise for the preferred ventilator mode in patients with AHRF of moderate severity. We found strong support for a randomised trial comparing modes of ventilation in patients with moderate AHRF.Peer reviewe

Spontaneous massive hemothorax as a complication of necrotizing pneumonia in a patient with severe acute respiratory syndrome coronavirus 2 induced acute respiratory distress syndrome: a case report

Background!#!We present an unusual bleeding complication in a patient with severe acute respiratory distress syndrome in coronavirus disease 2019.!##!Case presentation!#!The patient, a 63-year-old Caucasian man, received venovenous extracorporeal membrane oxygenation support after rapid deterioration of lung function on day 6 after admission to hospital. After initial stabilization on lung protective ventilation and prone positioning, he started to develop mild bleeding complications until he went into occult profound hemorrhagic shock. Causative was a massive hemothorax of the right hemithorax with mediastinal shifting due to spontaneous bleeding from a pulmonal artery in a heavily remodeled right inferior lobe. Histopathological examination of the resected tissue showed signs of an organizing fibrinous pneumonia with focal parenchyma necrosis. After surviving a massive bleeding event caused by necrotizing pneumonia, the patient made a swift recovery and was discharged to rehabilitation 31 days after initial hospital admission.!##!Conclusions!#!The combination of severely elevated inflammatory markers and pulmonary hemorrhage should arouse suspicion of necrotizing pneumonia. In necrotizing pneumonia, the possibility of severe intrathoracic bleeding complications should be kept in mind if it comes to sudden deterioration of the patient

Renal function interferes with copeptin in prediction of major adverse cardiac events in patients undergoing vascular surgery.

OBJECTIVE:Precise perioperative risk stratification is important in vascular surgery patients who are at high risk for major adverse cardiovascular events (MACE) peri- and postoperatively. In clinical practice, the patient's perioperative risk is predicted by various indicators, e.g. revised cardiac index (RCRI) or modifications thereof. Patients suffering from chronic kidney disease (CKD) are stratified into a higher risk category. We hypothesized that Copeptin as a novel biomarker for hemodynamic stress could help to improve the prediction of perioperative cardiovascular events in patients undergoing vascular surgery including patients with chronic kidney disease. METHODS:477 consecutive patients undergoing abdominal aortic, peripheral arterial or carotid surgery from June 2007 to October 2012 were prospectively enrolled. Primary endpoint was 30-day postoperative major adverse cardiovascular events (MACE). RESULTS:41 patients reached the primary endpoint, including 63.4% aortic, 26.8% carotid, and 9.8% peripheral surgeries. Linear regression analysis showed that RCRI (P< .001), pre- (P< .001), postoperative Copeptin (P< .001) and Copeptin level change (P= .001) were associated with perioperative MACE, but CKD remained independently associated with MACE and Copeptin levels. Multivariate regression showed that increased Copeptin levels added risk predictive information to the RCRI (P= .003). Especially in the intermediate RCRI categories was Copeptin significantly associated with the occurrence of MACE. (P< .05 Kruskal Wallis test). Subdivision of the study cohort into CKD stages revealed that preoperative Copeptin was significantly associated with CKD stages (P< .0001) and preoperative Copeptin measurements could not predict MACE in patients with more severe CKD stages. CONCLUSION:Preoperative Copeptin loses its risk predictive potential for perioperative MACE in patients with chronic kidney disease undergoing vascular surgery

ROC analysis comparing the RCRI alone or combined with Copeptin-derived parameters.

<p>Only preoperative Copeptin (blue dotted line) improved risk predictive accuracy of the RCRI (P = .0371, AUC .752). The RCRI-ROC Curve (black line) (AUC .714) indicates prediction of the occurrence of major adverse cardiovascular events (MACE). The combination of RCRI and postoperative Copeptin (red dashed line) (P = .0620, AUC .751) and RCRI and Copeptin changes (P = .1525, AUC .710) during the perioperative course (green dashed and dotted line) do not reach significantly larger AUCs. * marks significant values.</p

Copeptin is elevated in patients sustaining Major Adverse Cardiovascular Events (MACE) throughout the perioperative phase.

<p>Boxplots of pre- (A) and postoperative (B) Copeptin levels as well as perioperative Copeptin change (C) (pmol/L). Groups were analyzed by Mann-Whitney U test (A) P = .0001, (B) P = .0002, (C) P = .014.</p

Copeptin interferes with kidney injury in prediction of MACE.

<p>Preoperative Copeptin levels (pmol/L) are significantly (P<.0001) elevated in patients with chronic kidney disease increasing with severity of kidney injury (A). Preoperative Copeptin is not associated with MACE in patients with CKD 1&2 (B) (P = .3787) or CKD 4&5 (D) (P = .2264) but shows significant association with MACE in CKD 3 (C) (P = .0163). Data were analyzed using Mann Whitney U test for comparing two groups and Kruskal Wallis test followed by Dunns test for multiple comparisons. Blots are depicted as 5–95 percentile.</p

Linear regression analysis of MACE and existing comorbidities.

<p>*marks significant confounders.</p><p>Abbreviations are used as follows: BMI (Body mass index), TIA (transitory ischemic attack) COPD (chronic obstructive pulmonary disease), CAD (coronary artery disease), RCRI (Revised cardiac index), Surgical procedure (type of surgery performed subdivided into aortic, carotid and peripheral arterial procedures). Copeptin preoperative, postoperative and Copeptin change; significant results were additionally used in multivariate regression (significance multivariate) results are shown with p values. Comorbidities and putative risk predictors were analyzed in separate univariate and multivariate analysis.</p><p>Linear regression analysis of MACE and existing comorbidities.</p

Demographical data of study population subdivided into surgical procedures.

<p>P depicts P value of univariate linear regression calculated for each variable and type of surgery. The number of patients (n) for each group as well as percentage (%) is depicted. Other variables are shown as median with 25–75 percentile. Abbreviations are used as follows: coronary artery disease (CAD), revised cardiac risk index (RCRI), glomerular filtration rate (GFR), preoperative values for Copeptin (preop Copeptin), postoperative values for Copeptin (postop Copeptin), change of Copeptin levels between pre- and postoperative sample (Copeptin delta absolute), Major adverse cardiovascular events (MACE).</p><p>Demographical data of study population subdivided into surgical procedures.</p