Risk factors and mortality after elective and emergent laparatomies for oncological procedures in 89 patients in the intensive care unit: a retrospective observational cohort study

Background: Abdominal surgeries for cancer are associated with postoperative complications and mortality. A view of the success of anaesthetic, surgical and critical care can be gained by analyzing factors associated with mortality in patients admitted to intensive care units (ICUs). The objective of this study was to identify the postoperative mortality rate and the causes of perioperative death in high-risk patients after abdominal surgery for cancer. A secondary objective was to explore possible risk factors for death in scheduled and emergency surgeries, with a view to finding guidance on preventable risk factors. Methods: An observational study, in a 12-bed surgical ICU of a tertiary hospital. Patients admitted after abdominal surgery for cancer to the ICU for more than 24 hours' care were included from January 1, 2008-December 31, 2009. Data were extracted from the minimum basic dataset. The main outcome considered was 90-day mortalit

Mortalidad en pacientes quirúrgicos: Análisis de los factores de riesgo

OBJETIVO: Determinar los factores de riesgo de mortalidad de los pacientes quirúrgicos. MATERIAL Y MÉTODOS: Se incluyeron todos los pacientes operados que fallecieron en el curso del procedimiento peroperatorio en el periodo 2004-2006. Se realizó un estudio de corte transversal. Se analizaron variables pre, intra y postoperatorias. Se han analizado los factores de riesgo de muerte en los pacientes intervenidos de urgencia y en los intervenidos electivamente. Se ha realizado un análisis multivariado correlacionando las diferentes variables utilizando la Chi cuadrado de Pearson con un intervalo de confianza (IC) del 95%. RESULTADOS: Durante el periodo de tiempo que abarca el estudio fueron intervenidos 38815 pacientes con ingreso hospitalario: 6326 de urgencia y 32489 de forma electiva. Durante el ingreso hospitalario murieron un total de 479 pacientes; 36 intraoperatoriamente y 443 tras la intervención quirúrgica. La presencia de hipertensión arterial, diabetes mellitus y el diagnostico de neoplasia tuvieron significación estadística con la muerte. Las complicaciones quirúrgicas resultaron significativas para los pacientes que fallecieron en el intra-operatorio. La cirugía de urgencia es un factor de riesgo independiente de mortalidad ( 5.5% de mortalidad en relación al 0.4% para la cirugía electiva). Las complicaciones post-operatorias fueron los principales factores de riesgo de mortalidad en especial la sepsis, la muerte por problemas cardiacos, y la muerte por problemas respiratorios. CONCLUSIONES: La prevención y el correcto tratamiento de todos los factores de riesgo pre, intra y postoperatorios se presume disminuirían de forma significativa los índices de mortalidad y morbilidad de los pacientes intervenidos quirúrgicamente, en especial en aquellos pacientes intervenidos urgentemente

Low plasma fibrinogen levels and blood product transfusion in liver transplantation

Aim: Risk of bleeding in liver transplantation is determined by surgical technique, preoperative hemoglobin and antifibrinolitic therapy. We hypothesized that keeping these confounders factors identical, preoperative plasma fibrinogen level of ≤2 g/L influenced on blood product requirements. Methods: Adult patients underwent orthotropic liver transplantation (LT) during the period between January 1998 and December 2009. Cases were selected according to a propensity matching analysis meeting the following criteria: surgical vena cava preservation, tranexamic acid administration and hemoglobin range between 90 to 120 g/L. Intraoperative management was protocolized. The main variable was the percentage of patients that did not require red blood cells (RBC's). Results: Six hundred sixty-four patients with LT, 208 excluded, 266 who cannot be matched, the analysis was performed on 190 patients. Two cohorts: Low fibrinogen (≤2 g/L) (61 cases) and standard fibrinogen (>2 g/L) (129 cases) were analyzed. Preoperative platelet count (73.5±52 vs. 104±65; 103/mm3) was different in contrast to the hemoglobin (104.2±8.6 vs. 105.6±8.3; g/L). Use of RBC's resulted significantly higher in the low fibrinogen group (median, 3 vs. 2). The number of patients with no blood product requirements was fewer in the low fibrinogen group (8 cases, 13% vs. 45 cases, 35%). The critical level of plasma fibrinogen (1 g/L) was reached after graft reperfusion in 7 cases (5.5%) in the standard fibrinogen group vs. 24 cases (39%) in the low fibrinogen group. Conclusion: Our data suggest that preoperative plasma fibrinogen level of ≤2 g/L increases requirements for blood products during the surgical procedure of liver transplantation

Impact of surgical technique and analgesia on clinical outcomes after lung transplantation A STROBE-compliant cohort study

There is paucity of data on the impact of surgical incision and analgesia on relevant outcomes. A retrospective STROBE-compliant cohort study was performed between July 2007 and August 2017 of patients undergoing lung transplantation. Gender, age, indication for lung transplantation, and the 3 types of surgical access (Thoracotomy (T), Sternotomy (S), and Clamshell (C)) were used, as well as 2 analgesic techniques: epidural and intravenous opioids. Outcome variables were: pain scores; postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation, and length of stay at intensive care unit (ICU). Three hundred forty-one patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01; 2.74, P: .045) and no differences were found between Clamshell and Sternotomy incision. The median blood loss was 800 mL [interquartile range (IQR): 500; 1238], thoracotomy patients had 500 mL [325; 818] (P < .001). Median durations of mechanical ventilation in Thoracotomy, Sternotomy, and Clamshell groups were 19 [11; 37] hours, 34 [IQR 16; 57.5] hours, and 27 [IQR 15; 50.5] hours respectively. Thoracotomy group were discharged earlier from ICU (P < .001). Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation, and lower length of stay in ICU, but higher pain scores and need for epidural analgesia

Perfil tromboelastométrico y coagulopatía aguda del paciente politraumatizado: implicaciones clínicas y pronósticas

Introducción: El 25-35% de los pacientes politraumatizados presentan profundas alteraciones de la coagulación a su llegada al hospital (coagulopatía aguda traumática [CAT]). Los test viscoelásticos (ROTEM®) valoran rápidamente la capacidad hemostática y detectan precozmente la CAT. Los objetivos de este estudio son describir el tromboelastograma inicial de estos enfermos y determinar la prevalencia de CAT según unos perfiles tromboelastográficos predefinidos. Métodos: Estudio unicéntrico, observacional y prospectivo en pacientes politraumatizados. Se realizó analítica, prueba tromboelastográfica (ROTEM®) y se registraron datos prehospitalarios y hospitalarios, transfusiones, intervenciones quirúrgicas/arteriografía iniciales, paradas cardiorrespiratorias y fallecimientos. Los pacientes fueron clasificados en grupos según su ROTEM® inicial: «normal», «hipercoagulabilidad», «hipocoagulabilidad», «hipocoagulabilidad + hiperfibrinólisis» e «hiperfibrinólisis aislada». Resultados: Se analizaron 123 pacientes. En 32 casos (26%) se objetivó CAT: 15 pacientes presentaron hipocoagulabilidad, 9 hiperfibrinólisis aislada y 8 hipocoagulabilidad + hiperfibrinólisis. El grupo con CAT, respecto al grupo «normal», presentó mayor ISS (23 vs. 16; p < 0,01), mayor transfusión de hemoderivados (2,5 vs. 0; p = 0,001), más episodios de PCR (19 vs. 1%, p < 0,01) y mayor mortalidad (34 vs. 5%, p < 0,01). El subgrupo con hipocoagulabilidad + hiperfibrinólisis, respecto a los grupos con hipocoagulabilidad o hiperfibrinólisis aislada, presentó mayor ISS (41 vs. 25 vs. 15, p < 0,01), mayor necesidad de arteriografía (62% vs. 13% vs. 0%, p < 0,01) y mortalidad superior (75% vs. 33% vs. 0%, p = 0,05). Conclusiones: El 26% de los enfermos politraumatizados presenta coagulopatía precoz evaluada mediante tromboelastografía, asociada a mayor consumo de hemoderivados y menor supervivencia. El perfil combinado de «hipocoagulabilidad + hiperfibrinólisis» se asocia a mayor gravedad y necesidades superiores de hemoderivados y arteriografía

Beneficial effect of corticosteroids in preventing mortality in patients receiving tocilizumab to treat severe COVID-19 illness

Objectives: To assess the characteristics and risk factors for mortality in patients with severe coronavirus disease-2019 (COVID-19) treated with tocilizumab (TCZ), alone or in combination with corticosteroids (CS). Methods: From March 17 to April 7, 2020, a real-world observational retrospective analysis of consecutive hospitalized adult patients receiving TCZ to treat severe COVID-19 was conducted at our 750-bed university hospital. The main outcome was all-cause in-hospital mortality. Results: A total of 1,092 patients with COVID-19 were admitted during the study period. Of them, 186 (17%) were treated with TCZ, of which 129 (87.8%) in combination with CS. Of the total 186 patients, 155 (83.3 %) patients were receiving noninvasive ventilation when TCZ was initiated. Mean time from symptoms onset and hospital admission to TCZ use was 12 (±4.3) and 4.3 days (±3.4), respectively. Overall, 147 (79%) survived and 39 (21%) died. By multivariate analysis, mortality was associated with older age (HR = 1.09, p < 0.001), chronic heart failure (HR = 4.4, p = 0.003), and chronic liver disease (HR = 4.69, p = 0.004). The use of CS, in combination with TCZ, was identified as a protective factor against mortality (HR = 0.26, p < 0.001) in such severe COVID-19 patients receiving TCZ. No serious superinfections were observed after a 30-day follow-up. Conclusions: In patients with severe COVID-19 receiving TCZ due to systemic host-immune inflammatory response syndrome, the use of CS in addition to TCZ therapy, showed a beneficial effect in preventing in-hospital mortality

Blood component requirements in liver transplantation: effect of 2 thromboelastometry-guided strategies for bolus fibrinogen infusion, the TROMBOFIB randomized trial

Background: A low plasma fibrinogen level influences blood component transfusion. Thromboelastometry provides clinical guidance for fibrinogen replacement in liver transplantation (LT). Objectives: We hypothesized that infusions of fibrinogen concentrate to reach an A10FIBTEM value of 11 mm during LT could reduce red blood cell (RBC) and other component and fluid requirements in comparison to standard care. Methods: This randomized, blinded, multicenter trial in 3 hospitals enrolled 189 LTscheduled patients allocated to an intervention target (A10FIBTEM, 11 mm) or a standard target (A10FIBTEM, 8 mm); 176 patients underwent LT with fibrinogen replacement. Data were analyzed by intention-to-treat (intervention group, 91; control group, 85). Blood was extracted, and fibrinogen kits were prepared to bring each patient's fibrinogen level to the assigned target at the start of LT, after portal vein clamping, and after graft reperfusion. The main outcome was the proportion of patients requiring RBC transfusion during LT or within 24 hours. Results: The proportion of patients requiring RBCs did not differ between the groups: intervention, 74.7% (95% CI, 65.5%-83.3%); control, 72.9% (95% CI, 62.2%-82.0%); absolute difference, 1.8% (95% CI, −11.1% to 14.78%) (P = .922). Thrombotic events occurred in 4% of the patients in both groups; reoperation and retransplantation rates and mortality did not differ. Nearly 70% of the patients in both groups required fibrinogen concentrate to reach the target. Using an 11-mm A10FIBTEM target increased the maximum clot firmness without affecting safety. However, this change provided no clinical benefits. Conclusion: The similar low plasma fibrinogen concentrations could explain the lack of significant between-group outcomes

Risk factors and mortality after elective and emergent laparatomies for oncological procedures in 89 patients in the intensive care unit: a retrospective observational cohort study

Background: Abdominal surgeries for cancer are associated with postoperative complications and mortality. A view of the success of anaesthetic, surgical and critical care can be gained by analyzing factors associated with mortality in patients admitted to intensive care units (ICUs). The objective of this study was to identify the postoperative mortality rate and the causes of perioperative death in high-risk patients after abdominal surgery for cancer. A secondary objective was to explore possible risk factors for death in scheduled and emergency surgeries, with a view to finding guidance on preventable risk factors. Methods: An observational study, in a 12-bed surgical ICU of a tertiary hospital. Patients admitted after abdominal surgery for cancer to the ICU for more than 24 hours' care were included from January 1, 2008-December 31, 2009. Data were extracted from the minimum basic dataset. The main outcome considered was 90-day mortalit

Low plasma fibrinogen levels and blood product transfusion in liver transplantation

Aim: Risk of bleeding in liver transplantation is determined by surgical technique, preoperative hemoglobin and antifibrinolitic therapy. We hypothesized that keeping these confounders factors identical, preoperative plasma fibrinogen level of ≤2 g/L influenced on blood product requirements. Methods: Adult patients underwent orthotropic liver transplantation (LT) during the period between January 1998 and December 2009. Cases were selected according to a propensity matching analysis meeting the following criteria: surgical vena cava preservation, tranexamic acid administration and hemoglobin range between 90 to 120 g/L. Intraoperative management was protocolized. The main variable was the percentage of patients that did not require red blood cells (RBC's). Results: Six hundred sixty-four patients with LT, 208 excluded, 266 who cannot be matched, the analysis was performed on 190 patients. Two cohorts: Low fibrinogen (≤2 g/L) (61 cases) and standard fibrinogen (>2 g/L) (129 cases) were analyzed. Preoperative platelet count (73.5±52 vs. 104±65; 103/mm3) was different in contrast to the hemoglobin (104.2±8.6 vs. 105.6±8.3; g/L). Use of RBC's resulted significantly higher in the low fibrinogen group (median, 3 vs. 2). The number of patients with no blood product requirements was fewer in the low fibrinogen group (8 cases, 13% vs. 45 cases, 35%). The critical level of plasma fibrinogen (1 g/L) was reached after graft reperfusion in 7 cases (5.5%) in the standard fibrinogen group vs. 24 cases (39%) in the low fibrinogen group. Conclusion: Our data suggest that preoperative plasma fibrinogen level of ≤2 g/L increases requirements for blood products during the surgical procedure of liver transplantation

Uso del parche de lidocaína al 5% para el tratamiento del dolor postquirúrgico en cirugía de tórax

Sub-optimal management of acute post-thoracotomy pain is associated to pulmonary complications and has been identified as an independent factor for a post-thoracotomy pain syndrome. Epidural analgesia and paravertebral catheter are the most effective in a multimodal analgesia regime. Lidocaine patch 5% is for a treatment for post-herpetic neuralgia. Some literature suggests its use in other types of pain. We present three patients after different thoracic procedures with uncontrolled pain despite conventional treatment, and their good pain response to lidocaine patch 5%.Una analgesia inadecuada en cirugía torácica facilita las complicaciones respiratorias potencialmente graves y se asocia al síndrome de dolor crónico post-toracotomía. El catéter epidural y el catéter paravertebral son los tratamientos que resultan más efectivos, dentro de una estrategia multimodal. El parche de lidocaína 5% está indicado para el dolor en la neuropatía post-herpética. Existe literatura sobre su utilidad en otros modelos de dolor. Presentamos tres pacientes con dolor postquirúrgico en cirugía de tórax, a pesar del tratamiento convencional, y su buena respuesta analgésica tras la aplicación de parche de lidocaína 5%