Articles: postoperative-complications.
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Multicenter Study
Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study.
The importance...
The growth in procedural medicine has seen increasing numbers of older patients undergoing surgery, with significant concern for the unproven potential of surgery and anaesthesia to hasten cognitive decline. Perioperative stroke is a major adverse event with high mortality (32%) and morbidity (59%) with cognitive consequences.
The NeuroVISION investigators sought to quantify the burden of covert stroke, that is stroke without overt symptoms.
What did they do?
The researchers conducted a multi-center prospective cohort study of 1,114 patients ≥65 years having elective non-cardiac, non-intracranial, non-carotid surgery. All patients underwent post-operative MRI to identify cerebral infarction, and 1 year follow-up to quantify cognitive decline.
And they found?
7% of patients showed MRI features of covert stroke. Of these 42% demonstrated cognitive decline at 1 year, compared to 29% of those without covert stroke (OR CI 1.22-3.20). There were associations with delirium (HR CI 1.06-4.73) and symptomatic stroke or TIA (HR CI 1.14-14.99).
Thus covert stroke is relatively common in this cohort of patients, and is associated with cognitive decline. Notably there was no associated increase in non-neurological outcomes or death, nor association with anaesthetic technique.
Hang on...
Although covert stroke was associated with greater incidence of cognitive decline, the later was still common among non-stroke patients (almost 30%), and around 25% of all patients showed MRI evidence of old chronic infarcts. Additionally because there was no non-surgical control, it is difficult to implicate surgery and anaesthesia itself as a precipitant of the covert strokes (compared with the disease process requiring surgery, or comorbidity).
Perhaps the greater take-home is that in an elderly population with significant morbidity (64% HT, 44% smokers, 27% DM) both stroke (chronic, covert and overt) and cognitive decline are not uncommon.
And the big question
Are any of these stroke related outcomes actually modifiable perioperatively? To meaningfully improve perioperative outcomes, there must be an available improvement in anaesthetic technique, surgical technique or triaging, or postoperative care.
It is likely that the greatest impact is still to be made through primary health care and not perioperative interventions.
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J Cardiothorac Surg · Sep 2019
Multicenter Study Observational StudyZero balance ultrafiltration using dialysate during nationwide bicarbonate shortage: a retrospective analysis.
Zero balance ultrafiltration (Z-BUF) utilizing injectable 8.4% sodium bicarbonate is utilized to treat hyperkalemia and metabolic acidosis associated with cardiopulmonary bypass (CPB). The nationwide shortage of injectable 8.4% sodium bicarbonate in 2017 created a predicament for the care of cardiac surgery patients. Given the uncertainty of availability of sodium bicarbonate solutions, our center pro-actively sought a solution to the sodium bicarbonate shortage by performing Z-BUF with dialysate (Z-BUF-D) replacement fluid for patients undergoing cardiopulmonary bypass. ⋯ Z-BUF with dialysate appears to be analternative to Z-BUF with sodium chloride with marked lower utilization of intravenous sodium bicarbonate.
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Multicenter Study Comparative Study
What are the important morbidities associated with paediatric cardiac surgery? A mixed methods study.
Given the current excellent early mortality rates for paediatric cardiac surgery, stakeholders believe that this important safety outcome should be supplemented by a wider range of measures. Our objectives were to prospectively measure the incidence of morbidities following paediatric cardiac surgery and to evaluate their clinical and health-economic impact over 6 months. ⋯ Evaluation of postoperative morbidity is more complicated than measuring early mortality. However, tracking morbidity after paediatric cardiac surgery over 6 months offers stakeholders important data that are of value to parents and will be useful in driving future quality improvement.
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Orthop Traumatol Sur · Sep 2019
Multicenter StudyThree-dimensional analyses to predict surgical outcomes in non-displaced or valgus impaction fractures of the femoral neck: A multicenter retrospective study.
The aim of our study was to (1) report our surgical outcomes of internal fixation in patients with non-displaced or valgus impaction fractures of the femoral neck, (2) introduce our new three-dimensional assessment method using a combination of X-ray and CT imaging, and (3) determine which radiologic measurements significantly predicted fixation failure. ⋯ III, Retrospective comparative study.
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The new Score for Prediction Of Postoperative Respiratory Complications (SPORC-2) more reliably predicts the need for early post-operative re-intubation.
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