Survival after postoperative morbidity: a longitudinal observational cohort study

Prolonged morbidity after surgery is associated with a risk of premature death for a longer duration than perhaps is commonly thought; however, this risk falls with time. We suggest that prolonged postoperative morbidity measured in this way may be a valid indicator of the quality of surgical healthcare. Our findings reinforce the importance of research and quality improvement initiatives aimed at reducing the duration and severity of postoperative complication

The role of gastrointestinal mucosal hypoperfusion in the pathogenesis of post-operative organ failure

SIGLEAvailable from British Library Document Supply Centre- DSC:DXN003370 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Citrated blood does not reliably reflect fresh whole blood coagulability in trials of in vitro hemodilution

Implications: citration and storage of whole blood markedly alter the Thrombelastograph effects of hemodilution on coagulation. The results of hemodilution studies in which citrated blood has been used to study coagulation may not be reliable

Just scratching the surface: varied coagulation effects of polymer containers on TEG variables

Background and objective: Different types of polymer surfaces affect the activation of platelets and coagulation pathway containers depending on their surface qualities. Importantly, this could produce variability of coagulation results obtained with thrombelastographical analysis. We assessed the effects of blood storage on thrombelastograph, TEG, variables using polypropylene and polycarbonate containers.Methods: An in vitro experiment was performed, with eight volunteers in each limb. Fresh whole blood was stored in polypropylene or polycarbonate tubes prior to TEGanalysis, to assess the role of these plastics in the TEG results obtained.Results: The polycarbonate tubes displayed slower onset of coagulation and greater variability of data for all four basic TEG variables (r-time, k-time, alpha-angle and maximum amplitude, P < 0.05). Polycarbonate results fell outside manufacturer reference ranges.Conclusions: It is likely that this is due to the altered surface properties and charge effects of the containers affecting proteins and platelets differently. Caution should be used in choosing which containers are used for storage of fresh blood prior to coagulation assessment, as variable results will follow where different types of plastic containers are employed

Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane systematic review

This systematic review and meta-analysis summarizes the clinical effects of increasing perioperative blood flow using fluids with or without inotropes/vasoactive drugs to explicit defined goals in adults. We included randomized controlled trials of adult patients (aged 16 years or older) undergoing surgery. We included 31 studies of 5292 participants. There was no difference in mortality at the longest follow-up: 282/2615 (10.8%) died in the control group and 238/2677 (8.9%) in the treatment group, RR of 0.89 (95% CI: 0.76-1.05; P=0.18). However, the results were sensitive to analytical methods and withdrawal of studies with methodological limitations. The intervention reduced the rate of three morbidities (renal failure, respiratory failure, and wound infections) but not the rates of arrhythmia, myocardial infarction, congestive cardiac failure, venous thrombosis, and other types of infections. The number of patients with complications was also reduced by the intervention. Hospital length of stay was reduced in the treatment group by 1.16 days. There was no difference in critical care length of stay.The primary analysis of this review showed no difference between groups but this result was sensitive to the method of analysis, withdrawal of studies with methodological limitations, and was dominated by a single large study. Patients receiving this intervention stayed in hospital 1 day less with fewer complications. It is unlikely that the intervention causes harm. The balance of current evidence does not support widespread implementation of this approach to reduce mortality but does suggest that complications and duration of hospital stay are reduced

Systemic oxygen extraction during exercise at high altitude

BackgroundClassic teaching suggests that diminished availability of oxygen leads to increased tissue oxygen extraction yet evidence to support this notion in the context of hypoxaemia, as opposed to anaemia or cardiac failure, is limited.MethodsAt 75 m above sea level, and after 7–8 days of acclimatization to 4559 m, systemic oxygen extraction [C(a?v)O2] was calculated in five participants at rest and at peak exercise. Absolute [C(a?v)O2] was calculated by subtracting central venous oxygen content (CcvO2) from arterial oxygen content (CaO2) in blood sampled from central venous and peripheral arterial catheters, respectively. Oxygen uptake (V.O2) was determined from expired gas analysis during exercise.ResultsAscent to altitude resulted in significant hypoxaemia; median (range) SpO2 87.1 (82.5–90.7)% and PaO2 6.6 (5.7–6.8) kPa. While absolute C(a?v)O2 was reduced at maximum exercise at 4559 m [83.9 (67.5–120.9) ml litre?1 vs 99.6 (88.0–151.3) ml litre?1 at 75 m, P=0.043], there was no change in oxygen extraction ratio (OER) [C(a?v)O2/CaO2] between the two altitudes [0.52 (0.48–0.71) at 4559 m and 0.53 (0.49–0.73) at 75 m, P=0.500]. Comparison of C(a?v)O2 at peak V.O2 at 4559 m and the equivalent V.O2 at sea level for each participant also revealed no significant difference [83.9 (67.5–120.9) ml litre1 vs 81.2 (73.0–120.7) ml litre?1, respectively, P=0.225].Conclusion In acclimatized individuals at 4559 m, there was a decline in maximum absolute C(a?v)O2 during exercise but no alteration in OER calculated using central venous oxygen measurements. This suggests that oxygen extraction may have become limited after exposure to 7–8 days of hypoxaemia

A descriptive study of the variation in baseline levels of antiendotoxin core antibodies between US and UK populations

Low levels of naturally occurring antibodies to the core section of endotoxin (EndoCAb) have been shown to be predictors of poor outcome following major surgery. We performed a retrospective study comparing pre-operative levels in US surgical patients, UK surgical patients and healthy volunteers. Both IgM and IgG EndoCAb levels were higher in the US surgical patients when compared with the other groups (approximately twice as high in the case of IgG EndoCAb). This may reflect genetic or environmental variability between the patient groups, differences in the disease processes, the disparity in the delivery of health care between the two countries or degradation of the samples in transfer

Enhanced recovery from surgery in the UK: an audit of the enhanced recovery partnership programme 2009-2012

This study is the largest assessment of the relationship between Enhanced Recovery protocol compliance and outcome in four surgical specialties. The data suggest that higher compliance with an Enhanced Recovery protocol has a weak association with shorter length of stay. This suggests that changes in process, resulting from highly protocolised pathways, may be as important in reducing perioperative length of stay as any individual element of Enhanced Recovery protocols in isolation