Effect of perioperative "Internet + rehabilitation guidance" based on IKAP theory on short-term prognosis of patients with esophageal cancer

OBJECTIVE

The aim of the study was to investigate the "Internet + rehabilitation guidance" under the theory of Information-Knowledge-Attitude-Practice (IKAP) in patients with esophageal cancer during the perioperative period and to analyze the influence on the short-term prognosis of patients with esophageal cancer.

PATIENTS AND METHODS

From April 2022 to February 2023, 118 patients who underwent radical esophagectomy in the First Hospital of Huai'an Affiliated Hospital of Nanjing Medical University were enrolled using the convenience sampling method. They were divided into the IKAP group (59 cases) and the Control Group (Group C) (59 cases), according to the random number table method. The conventional intervention was performed during the perioperative period, and the IKAP group was also given "Internet + rehabilitation guidance" based on IKAP theory. The first postoperative defecation time, exhaust time, feeding time, discharge time, and postoperative complication rate of the two groups were compared. Meanwhile, blood samples were collected before surgery and 1, 3, 7, and 30 days after surgery (at outpatient review) for the detection of inflammatory factor indexes and nutritional indexes.

RESULTS

Patients within the IKAP group showed a shorter first postoperative exhaust and defecation time, eating time, and hospital compared to the control group (p<0.05). Before surgery, there was no significant difference in serum inflammatory factors and nutritional indexes between the two groups (p>0.05). Comparing the levels of serum inflammatory factors in the two groups after surgery, the levels of CRP and IL-6 in the IKAP group were lower than those in the control group on days 1, 3, and 7 after surgery. After 30 days, the serum CRP level was found to be lower than the control group, but no statistical difference with the control level of serum IL-6 (p<0.05) was found. Compared with the serum nutritional index levels in the two groups: 1 d after surgery, the serum HGB, PA, and TRF levels were not different (p>0.05). The serum ALB level in the IKAP group was higher than that in the control group (p<0.05). Postoperative 3 d, 7 d, the serum levels of HGB, ALB, PA, and TRF in the IKAP group were higher than those in the control group (p<0.05). After 30 d, there was no statistical difference in serum HGB levels between the two groups (p<0.05); Serum ALB, PA, and TRF levels in the IKAP group were higher than those in the control group (p<0.05). From preoperative to 30 days after surgery, serum CRP and IL-6 levels in 2 groups were first increased and then decreased, while serum HGB, ALB, PA, and TRF levels were first decreased and then increased. After surgery, the IKAP group showed a greater incidence of complications in patients than in controls (p<0.05).

CONCLUSIONS

In patients with esophageal cancer, perioperative "Internet + rehabilitation guidance" based on IKAP theory can effectively shorten the postoperative gastrointestinal function recovery time and rapidly reduce the inflammatory response, improving the nutritional status of the body, thereby reducing the risk of short-term postoperative complications.

Safety of antiplatelet therapy during the perioperative period of revascularization surgery for moyamoya disease patients with ischemic onset

For patients with moyamoya disease, antiplatelet agents are often used during the perioperative periods of revascularization surgeries to prevent ischemic events. However, antiplatelet therapy is associated with the risk of hemorrhagic complications. Further, the influence of antiplatelet therapy on perioperative ischemic or hemorrhagic complications has not been investigated. This study aimed to determine the impact of antiplatelet agents on adult moyamoya disease patients with ischemic onset during the perioperative period. From January 2016 to December 2020, 183 consecutive combined (direct and indirect) revascularization surgeries for moyamoya disease patients were performed. Among these surgeries, 96 consecutive combined revascularization surgeries for adult moyamoya disease patients with ischemic onset were analyzed and perioperative ischemic and hemorrhagic complications were reviewed. Antiplatelet agents were continued during the perioperative period including on the day of surgery and the day after the surgery. Among 96 surgeries, no hemorrhagic complications occurred postoperatively. Infarction occurred in five cases (5.2%). Among the five cases, neurological deficits persisted in two cases and improved in three. The median value of bleeding volume was 112.5 mL (interquartile range, 80.0 - 200.0). Twenty-five cases (26.0%) needed blood transfusion. The modified Rankin Scale score deteriorated in two cases due to cerebral infarction. The incidence of hemorrhagic and ischemic complications after combined revascularization surgery in patients with ischemic moyamoya disease under antiplatelet therapy was low, indicating the safety of continued antiplatelet therapy.

A triple-masked, two-center, randomized parallel clinical trial to assess the superiority of eight weeks of grape seed flour supplementation against placebo for weight loss attenuation during perioperative period in patients with cachexia associated with colorectal cancer: a study protocol

Background

Progressive, involuntary weight and lean mass loss in cancer are linked to cachexia, a prevalent syndrome in gastrointestinal malignancies that impacts quality of life, survival and postoperative complications. Its pathophysiology is complex and believed to involve proinflammatory cytokine-mediated systemic inflammation resulting from tumor-host interaction, oxidative stress, abnormal metabolism and neuroendocrine changes. Therapeutic options for cachexia remain extremely limited, highlighting the need for clinical research targeting new interventions. Thus, this study primarily assesses the effects of grape-seed flour (GSF), rich in polyphenols and fibers, for attenuating perioperative weight loss in colorectal cancer.

Methods

This is a dual-center, triple-masked, placebo-controlled, parallel-group, phase II, randomized clinical trial designed to investigate GSF supplementation in subjects with pre- or cachexia associated with colorectal cancer during the perioperative period. Eighty-two participants will receive 8g of GSF or cornstarch (control) for 8 weeks. Assessments are scheduled around surgery: pre-intervention (4 weeks prior), day before, first week after, and post-intervention (4 weeks later). The primary endpoint is the difference in body weight mean change from baseline to week 8. The secondary endpoints describe the harms from 8-week supplementation and assess its superiority to improve body composition, post-surgical complications, quality of life, anorexia, fatigue, gastrointestinal symptoms, and handgrip strength. The study will also explore its effects on gut bacteria activity and composition, systemic inflammation, and muscle metabolism.

Discussion

The current trial addresses a gap within the field of cancer cachexia, specifically focusing on the potential role of a nutritional intervention during the acute treatment phase. GSF is expected to modulate inflammation and oxidative stress, both involved in muscle and intestinal dysfunction. The research findings hold substantial implications for enhancing the understanding about cachexia pathophysiology and may offer a new clinical approach to managing cachexia at a critical point in treatment, directly impacting clinical outcomes.

Trial registration

The Brazilian Registry of Clinical Trials (ReBEC), RBR-5p6nv8b; UTN: U1111-1285-9594. Prospectively registered on February 07, 2023.

Adult perioperative cardiac arrest: An overview of 684 cases reported to webAIRS

There were 684 perioperative cardiac arrests reported to webAIRS between September 2009 and March 2022. The majority involved patients older than 60 years, classified as American Society of Anesthesiologists Physical Status 3 to 5, undergoing an emergency or major procedure. The most common precipitants included airway events, cardiovascular events, massive blood loss. medication issues, and sepsis. The highest mortality rate was 54% of the 46 cases in the miscellaneous category (this included 34 cases of severe sepsis, which had a mortality of 65%). This was followed by cardiovascular precipitants (n = 424) in which there were 147 deaths (35% mortality): these precipitants included blood loss (53%), embolism (61%) and myocardial infarction (70%). Airway and breathing events accounted for 25% and anaphylaxis 8%. A specialist anaesthetist attended the majority of these cardiac arrests. As webAIRS is a voluntary database, it is not possible to determine the incidence of perioperative cardiac arrest and only descriptive information on factors associated with cardiac arrest can be obtained. Nevertheless, the large number of reports includes a wide range of cases, precipitants, demographics and outcomes, providing ample opportunity to learn from these events. The data also provide rich scope for further research into further initiatives to prevent cardiac arrest in the perioperative period, and to improve outcomes, should a cardiac arrest occur.

[Use of tamsulosin for a prevention of acute urinary retention in the perioperative period in patients undergoing to surgical procedures]

The perioperative management of patients involves multiple aspects. Acute urinary retention (AUR) is one of the possible postoperative complications. Alpha-adrenoblockers are commonly used for treatment and prevention of AUR. Tamsulosin is the most often prescribed drug; there are a lot of studies devoted to its use in different patient subgroups. The aim of our study was to evaluate the efficiency of perioperative use of tamsulosin for the prevention of postoperative AUR. A literature review from January 2013 to June 2023 in Scopus and PubMed databases was carried out. According to the results, tamsulosin results in a significant reduction in the risk of postoperative AUR. A personalized approach allows to overcome difficulties in the perioperative management of patients and significantly improve their quality of life/satisfaction from treatment.

Analysis of risk factors for postoperative delirium in middle-aged and elderly fracture patients in the perioperative period

To investigate the incidence rate and risk factors of postoperative delirium in middle-aged and elderly patients with fracture. A total of 648 middle-aged and elderly fracture patients who underwent surgical treatment in our hospital from January 2018 to December 2020 were included in the study, aged 50-103 years, mean 70.10 ± 11.37 years. The incidence of postoperative delirium was analyzed. Univariate analysis was used to screen the risk factors of gender, age, interval between injury and operation, preoperative complications, fracture site, anesthesia method, operation time, intraoperative blood loss, hidden blood loss and hormone use. For the factors with P < 0.05, multivariate logistic regression analysis was used to determine the main independent risk factors. 115 cases (17.74%) of 648 patients had postoperative delirium. Univariate analysis showed that patients with delirium and patients without delirium had significant correlation in age, medical disease comorbidity, fracture type, anesthesia method, operation time and perioperative blood loss (P < 0.05). Multivariate logistic regression analysis showed that age (OR = 1.061), preoperative complications (OR = 1.667), perioperative blood loss (OR = 1.002) were positively correlated with postoperative delirium. It shows that older age, more preoperative complications, longer operation time and more perioperative bleeding are more likely to lead to postoperative delirium; patients with general anesthesia were more likely to develop postoperative delirium than patients with local anesthesia (OR = 1.628); and patients with hip and pelvic fractures are more likely to develop a postoperative delirious state (OR = 1.316). Advanced age, complex orthopedic surgery, more medical comorbidities, general anesthesia and greater perioperative blood loss may be independent risk factors for the development of delirium after internal fixation of fractures in middle-aged and elderly patients.

Anaesthesia and intensive care management of shoshin beriberi in perioperative period in young adult

Thiamine deficiency presents as dry and wet beriberi. Wet beriberi is a complication of the cardiovascular system. Acute form of wet beriberi known as Shoshin beriberi is an acute presentation of cardiogenic shock which is rapidly reversed with thiamine administration. Here we present successful management of intraoperative acute decompensated heart failure, probably due to thiamine deficiency.

Viscoelastic Management of Coagulopathy during the Perioperative Period of Liver Transplantation

Viscoelastic testing (VET) in liver transplantation (LT) has been used since its origin, in combination with standard laboratory testing (SLT). There are only a few, small, randomized controlled trials that demonstrated a reduction in transfusion rates using VET to guide coagulation management. Retrospective analyses contrasting VET to SLT have demonstrated mixed results, with a recent concern for overtreatment and the increase in postoperative thrombotic events. An oversight of many studies evaluating VET in LT is a single protocol that does not address the different phases of surgery, in addition to pre- and postoperative management. Furthermore, the coagulation spectrum of patients entering and exiting the operating room is diverse, as these patients can have varying anatomic and physiologic risk factors for thrombosis. A single transfusion strategy for all is short sighted. VET in combination with SLT creates the opportunity for personalized resuscitation in surgery which can address the many challenges in LT where patients are at a paradoxical risk for both life-threatening bleeding and clotting. With emerging data on the role of rebalanced coagulation in cirrhosis and hypercoagulability following LT, there are numerous potential roles in VET management of LT that have been unaddressed.

[Risk of postoperative complications in hyperglycemic conditions]

The authors consider the influence of carbohydrate metabolism disorders on postoperative period. Data on the influence of diabetes mellitus on morbidity are summarized. Mechanisms and significance of stress-induced hyperglycemia are described. The authors also discuss modern approaches to the treatment of hyperglycemic conditions in perioperative period.

Perioperative corneal abrasions: A report of 42 cases from the webAIRS database

Corneal abrasions are an uncommon complication of anaesthesia. The aim of this study was to identify potential risk factors, treatment and outcomes associated with corneal abrasions reported to the web-based anaesthesia incident reporting system (webAIRS), a voluntary de-identified anaesthesia incident reporting system in Australia and New Zealand, from 2009 to 2021. There were 43 such cases of corneal abrasions reported to webAIRS over this period. The most common postoperative finding was a painful eye. Common features included older patients, individuals with pre-existing eye conditions, general anaesthesia and procedures longer than 60 minutes. Most cases were treated with a combination of lubricating eye drops or aqueous antibiotic eye drops. The findings indicate that patients who sustain a perioperative corneal abrasion can be reassured that in many cases it will heal within 48 hours, but they should seek earlier review if symptoms persist or deteriorate. None of the cases in this series resulted in permanent harm. Well established eye protective measures are important to utilise throughout the perioperative period, including the time until the patient has recovered in the post-anaesthesia care unit.

Efficacy of active forced air warming during induction of anesthesia to prevent inadvertent perioperative hypothermia in intraoperative warming patients: Comparison with passive warming, a randomized controlled trial

BACKGROUND

This study aimed to evaluate the efficacy of peri-induction forced air warming to prevent inadvertent perioperative hypothermia, defined as a reduction in body temperature to <36.0°C during the perioperative period, in intraoperatively warmed patients receiving major surgery lasting >120 minutes.

METHODS

In total, 130 patients scheduled for elective surgery under general anesthesia lasting >120 minutes were divided into 2 groups: peri-induction warming (n = 65) and control (n = 65). Patients in the peri-induction warming group were warmed during the anesthetic induction period using a forced-air warmer set at 47°C, whereas patients in the control group were covered passively with a cotton blanket. All patients were warmed with a forced-air warmer during surgery. Body temperature was measured using a tympanic membrane thermometer in the pre- and postoperative periods and using a nasopharyngeal temperature probe during surgery. Patients were evaluated for shivering scale score, thermal comfort scale score, and satisfaction score in the post-anesthesia care unit.

RESULTS

The incidence rates of intraoperative and postoperative hypothermia were lower in the peri-induction warming group than in the control group (19.0% vs 57.1%, P < .001; 3.3% vs 16.9%, P = .013, respectively). Body temperature was higher in the peri-induction warming group (P < .001). However, intraoperative blood loss, as well as postoperative thermal comfort scale score, shivering scale score, and patient satisfaction score, were similar between groups. Post-anesthesia care unit duration was also similar between groups.

CONCLUSIONS

Peri-induction active forced air warming is an effective, simple, and convenient method to prevent inadvertent perioperative hypothermia in intraoperatively warmed patients undergoing major surgery lasting >120 minutes.

Approach to Perioperative Anaphylaxis in 2020: Updates in Diagnosis and Management

PURPOSE OF REVIEW

The goal of the paper is to review the epidemiology, pathogenesis, diagnosis, and manifestations of perioperative anaphylaxis (POA). We seek to review the most common culprits of POA and different diagnostic modalities for evaluation.

RECENT FINDINGS

Specific IgE testing has a limited role in POA evaluation due to lack of widespread availability and low sensitivity. Basophil activation testing is complementary to skin tests and can assist NMBA sensitivity diagnosis in complex cases. In the past years, there has been an exponential increase in suspected teicoplanin allergic reactions in the European Union. Chlorhexidine is also being increasingly implicated as a culprit in POA. Multiple classes of perioperative medications cause POA. Diagnostic modalities available include skin testing with nonirritating concentrations, basophil activation tests, specific IgE, and drug provocation testing. An accurate record and critical analysis of perioperative events is more important than isolated test results. Future studies evaluating the pathophysiology of these reactions and other therapeutic strategies, such as targeting the MRGPRX2 receptor, are needed.

Trends, Perioperative Adverse Events, and Survival of Patients With Left Ventricular Assist Devices Undergoing Noncardiac Surgery

IMPORTANCE

Information regarding the performance and outcomes of noncardiac surgery (NCS) in patients with left ventricular assist devices (LVADs) is scarce, with limited longitudinal follow-up data that are mostly limited to single-center reports.

OBJECTIVE

To examine the trends, patient characteristics, and outcomes associated with NCS among patients with LVAD.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined patients enrolled in Medicare undergoing durable LVAD implantation from January 2012 to November 2017 with follow-up through December 2017. The study included all Medicare Provider and Analysis Review Part A files for the years 2012 to 2017. Patients identified by International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision (ICD-10) procedure codes for new LVAD implantation were included. Data analysis was performed from November 2019 to February 2020.

EXPOSURES

NCS procedures were identified using the ICD-9-CM and ICD-10 procedural codes and divided into elective and urgent or emergent.

MAIN OUTCOMES AND MEASURES

The primary outcome was major adverse cardiovascular events (MACEs), defined as in-hospital or 30-day all-cause mortality, ischemic stroke, or intracerebral hemorrhage after NCS. Early (<60 days after NCS) and late (≥60 days after NCS) mortality after NCS were analyzed in both subgroups using time-varying covariate and landmark analysis using patients who did not undergo NCS as reference.

RESULTS

Of the 8118 patients with LVAD (mean [SD] age, 63.4 [10.8] years; 6484 men [79.9%]), 1326 (16.3%, or approximately 1 in 6) underwent NCS, of which 1000 procedures (75.4%) were emergent or urgent and 326 (24.6%) were elective. There was no difference in age between patients who underwent NCS and patients who did not (mean [SD] age, 63.6 [10.6] vs 63.4 [10.9] years). The number of NCS procedures among patients with LVAD increased from 64 in 2012 to 304 in 2017. The median (interquartile range) time from LVAD implantation to NCS was 309 (133-606) days. The most frequent type of NCS was general (613 abdominal, pelvic, and gastrointestinal procedures [46.2%]). Perioperative MACEs occurred in 169 patients (16.9%) undergoing emergent or urgent NCS and 23 patients (7.1%) undergoing elective NCS. Urgent or emergent NCS was associated with higher mortality early (adjusted hazard ratio [aHR], 8.78; 95% CI, 7.20-10.72; P < .001) and late (aHR, 1.71; 95% CI, 1.53-1.90; P < .001) after NCS compared with patients with LVAD who did not undergo NCS. Elective NCS was also associated with higher mortality early (aHR, 2.65; 95% CI, 1.74-4.03; P < .001) and late (aHR, 1.29; 95% CI, 1.07-1.56; P = .008) after NCS.

CONCLUSIONS AND RELEVANCE

One of 6 patients with LVAD underwent NCS. Perioperative MACEs were frequent. Higher mortality risk transcended the early postoperative period in urgent or emergent and elective surgical procedures.

Inadvertent Perioperative Hypothermia Risks and Postoperative Complications: A Retrospective Study

Inadvertent perioperative hypothermia is a widely known patient condition that is associated with postoperative complications. This retrospective comparative study of 298 surgical patients was conducted at a single hospital site in the midwestern United States. Our aims were to describe risk factors and outcomes associated with perioperative hypothermia. We compared the type and frequency of patient factors, clinical factors, and postoperative complications during the inpatient stay of the sample patients to determine whether there were factors or complications associated with perioperative hypothermia. Significant factors associated with the occurrence of perioperative hypothermia included older age and type of surgery. Hypothermia in patients was associated with a higher rate of postoperative complications when compared with normothermic patients. Nurses and perioperative leaders should understand the risk factors and complications associated with perioperative hypothermia to collaboratively develop and test evidence-based initiatives, improve care, and promote optimal patient outcomes.

Risk factors of perioperative blood transfusion in elderly patients with femoral intertrochanteric fracture

This study aimed to discuss the risk factors of perioperative blood transfusion after the application of proximal femoral nail antirotation (PFNA) in the treatment of elderly patients with femoral intertrochanteric fracture (FIF). Moreover, this study also aimed to analyze the causes of perioperative blood transfusion and provide guidance for clinical treatment.Records of elderly patients with FIF who were treated with PFNA in our hospital from September 2014 to May 2017 were reviewed. They were divided into transfused and nontransfused groups. The Student t test, Chi-squared test, and Fisher exact test were used in univariate analysis of 11 variables. Multivariate logistic regression analysis was performed to analyze the possible risk factors associated with postoperative blood transfusion after the application of PFNA in elderly patients with FIF. Correlations were sought using the Spearman rank correlation analysis.The univariate analysis showed that age, sex, type of fracture, admission hemoglobin (Hb), admission albumin, and intraoperative blood loss were significantly associated with perioperative blood transfusion (P = .000, .019, .000, .000, .000, and .007, respectively). The multivariate logistic regression analysis demonstrated that age (P = .019, odds ratio [OR] = 1.062), type of fracture (P = .001, OR = 4.486), and admission Hb (P = .000, OR = 0.883) were independent risk factors of postoperative blood transfusion. We found a significant positive correlation between perioperative blood transfusion and age (r = 0.264, P = .000) and type of fracture (r = 0.409, P = .000), but a negative correlation between perioperative blood transfusion and admission Hb (r = -0.641, P = .000).The main factors affecting perioperative blood transfusion are age, fracture type, and admission Hb. These results indicate that, in high-risk patients who are older in age, more unstable fractures, and lower admission Hb, monitoring Hb concentrations during the perioperative period is important to correct severe anemia in a timely manner and avoid exacerbating existing underlying diseases and inducing severe complications.

Influence of perioperative stress on central and peripheral oxytocin and arginine-vasopressin concentrations

Perioperative stress provides not only physical, but also psychic and emotional aspects, which may influence the hypothalamic neuropeptide system. Studies investigating the perioperative course of central neuropeptide activity are missing. Therefore, the present study aimed to determine perioperative fluctuations in central and concomitant peripheral concentrations of the hypothalamic neuropeptides oxytocin (OXT) and arginine-vasopressin (AVP), as well as their impact on perioperative anxiety and depression. Cerebrospinal fluid (CSF), blood and saliva were collected from 12 patients who underwent elective endovascular aortic repair with a routinely inserted spinal catheter. AVP and OXT concentrations were analysed at four timepoints: (i) the evening before the operation; (ii) the operation day immediately before anaesthesia induction; (iii) intraoperatively after the stent was placed; and (iv) on day 1 after the operation. Patients completed the Hospital Anxiety and Depression Scale (HADS) at timepoints 1 and 4. For CSF OXT, the present study showed a significant intraoperative decline, accompanied by a decrease in saliva. OXT blood concentrations before anaesthesia induction were higher than at the evening before the operation. OXT concentrations in CSF and saliva correlated well at timepoints 2-4. AVP concentrations in CSF, blood and saliva did not show any significant changes perioperatively. However, postoperative AVP blood concentrations showed a significant negative correlation with anxiety and depression scores according to the HADS. This pilot study demonstrates perioperative fluctuations in central OXT concentrations, which are better reflected by saliva than by blood. Further studies are required to determine whether OXT and AVP can predict postoperative post-traumatic stress disorder.

Bariatric surgery in older adults: Should there be an age limit?

Obesity has become one of the most significant health problems worldwide, affecting more than one-third of the global population. The elderly population is not immune to this proportional increase in obesity. To date, there is no cure for obesity, but surgery is the most effective treatment available today.We analyzed the results of bariatric surgery in elderly patients for a period of 3 years. Patients 65 years old and older were included in the study, 451 older adults were included. The mean age of the study group was 67.92 years old (min. 65, max. 84). The mean body mass index (BMI) was 40.32 Kg/m (min. 34 and max. 59). Sleeve gastrectomy (SG) was the most common procedures, and were conducted in 346 (76.72%) patients, gastric bypasses (GBPs) in 53 (11.75%) of which 33 were roux en y GBP (7.32%) and 20 mini GBPs (4.43%), gastric banding in 48 (10.64%), and duodenal switching in 4 (0.89%) cases.There were 40 (8.86%) patients with perioperative complications, 6 (1.33%) required re-operations, 12 (2.66) patients with operative complications were treated conservatively, 8 (1.77%) re-admission 5 of them with intrabdominal abscess, and 14 (3.10%) with co-morbidities complications. More than 76% of the patients had co-morbidities, 1 year after surgery the average remission of diseases was 34.74%, the improvement was49.67% and no changes in the co-morbidities was 15.59%. There were no deaths reported in this cohort.The mean excess body weight (EBW) loss among the patients was 70.76% (from 32% to 92%). No failure of weight loss (less than 25% of EBW loss) was observed after the first postoperative year.Bariatric surgery offers obese elderly patients an acceptable result, and it can be offered to improve the quality of life of these patients. A new consensus conference panel is needed to set appropriate recommendations regarding criteria that limit bariatric surgery in older adults.

Anaphylactic shock perioperative to patent blue dye

Patent blue is one of the most used dyes for the identification of sentinel lymph nodes in breast cancer. This report describes a case of an anaphylactic shock reaction to patent blue dye in a patient with cross-reactivity to methylene blue. Therefore, after allergy confirmation, the operation was repeated avoiding blue dye and an alternative labelling technique with 99mTc albumin nanocolloids was used.

Perioperative onset of acquired von Willebrand syndrome: Comparison between HVAD, HeartMate II and on-pump coronary bypass surgery

OBJECTIVES

Acquired von Willebrand syndrome (AvWS) is associated with postoperative bleeding complications in patients with continuous flow left ventricular assist devices (CF-LVADs). The aim of this study is to analyze the perioperative vWF profile comparing an axial pump (HMII) to a centrifugal pump (HVAD) regarding the correlation between perioperative occurrence of AvWS, early- and late-postoperative bleeding events.

METHODS

From July 2013 until March 2015 blood samples of 33 patients (12 HMII/ 8 HVAD/ 13 controls) were prospectively collected at 12 different time points and analyzed for the vWF antigen (vWF:Ag), its activity (vWF:Ac) and the vWF:Ac/vWF:Ag-ratio (vWF:ratio). The follow up period for postoperative bleeding events was from July 2013 until July 2016.

RESULTS

Postoperatively, there was no difference in the vWF-profile between HVAD and HMII groups. However, a subgroup of patients already had significantly lower vWF:ratios preoperatively. Postoperatively, both CF-LVAD groups presented significantly lower vWF:ratios compared to the control group. Bleeding events per patient-year did not differ between the two groups (HMII vs. HVAD: 0.67 vs. 0.85, p = 0.685). We detected a correlation between vWF:ratio <0.7at LVAD-start (r = -0.583, p = 0.006) or at the end of surgery (r = -0.461, p = 0.035) and the occurrence of pericardial tamponade. In the control group, the drop in both vWF:Ag and vWF:Ac recovered immediately postoperatively above preoperative values.

CONCLUSION

A subgroup of patients with end-stage heart failure already suffers AvWS preoperatively. In both CF-LVAD groups, AvWS begins immediately after surgery. Intraoperative vWF:ratios <0.7 correlate with higher incidences of pericardial tamponade and re-operation. The presumably dilutive effect of the heart lung machine on vWF vanishes immediately at the end of surgery, possibly as part of an acute-phase response.

Medical students' situational motivation to participate in simulation based team training is predicted by attitudes to patient safety

BACKGROUND

Patient safety education, as well as the safety climate at clinical rotations, has an impact on students' attitudes. We explored medical students' self-reported motivation to participate in simulation-based teamwork training (SBTT), with the hypothesis that high scores in patient safety attitudes would promote motivation to SBTT and that intrinsic motivation would increase after training.

METHODS

In a prospective cohort study we explored Swedish medical students' attitudes to patient safety, their motivation to participate in SBTT and how motivation was affected by the training. The setting was an integrated SBTT course during the surgical semester that focused on non-technical skills and safe treatment of surgical emergencies. Data was collected using the Situational Motivation Scale (SIMS) and the Attitudes to Patient Safety Questionnaire (APSQ).

RESULTS

We found a positive correlation between students' individual patient safety attitudes and self-reported motivation (identified regulation) to participate in SBTT. We also found that intrinsic motivation increased after training. Female students in our study scored higher than males regarding some of the APSQ sub-scores and the entire group scored higher or on par with comparable international samples.

CONCLUSION

In order to enable safe practice and professionalism in healthcare, students' engagement in patient safety education is important. Our finding that students' patient safety attitudes show a positive correlation to motivation and that intrinsic motivation increases after training underpins patient safety climate and integrated teaching of patient safety issues at medical schools in order to help students develop the knowledge, skills and attitudes required for safe practice.

Assessing perioperative body weight changes in patients thyroidectomized for a benign nontoxic nodular goitre

BACKGROUND

Following thyroidectomy, patients often complain of weight gain. Our study aimed to evaluate the extent of weight change in patients thyroidectomized for a nontoxic benign goitre after adjusting for patient demographics and pre-operative weight changes.

METHODS

Three different patient groups were studied. The first comprised 898 patients who underwent thyroidectomy for benign nontoxic nodular goitre (group I). The second comprised 179 patients who had benign nontoxic goitre but did not undergo thyroidectomy (group II), and the third comprised 80 patients who underwent a simple excision of a parathyroid adenoma (group III). All patients were weighed 12 months preceding baseline, at baseline and 6 months after baseline.

RESULTS

Baseline characteristics were comparable between groups. Patients in Group I who gained the least weight in the year leading to surgery gained the most weight 12 months after surgery (P = 0·030). After adjusting for demographics and pre-operative weight changes, Group I gained significantly more weight at post 6 and 12 months (0·71 (95% CI=0·46-0·95) kg and 1·21 (95% CI = 0·96-1·46) kg, respectively). Weight gain at post 12 months appeared similar between hemithyroidectomy and total thyroidectomy (1·32 vs 1·16 kg, P = 0·197). Younger age (ß coefficient -0·100, 95% CI = -0·030 to 0·003, P = 0·015) and higher baseline thyroid stimulating hormone (ß coefficient -0·315, 95% CI = -1·468 to 0·134, P = 0·020) were significant factors for weight gain at post 12 months.

CONCLUSIONS

Compared to nonthyroidectomized patients, thyroidectomized patients experienced significant weight increases at post 6 and 12 months. The extent of thyroidectomy did not affect the extent of weight gain. Younger age and higher baseline thyroid stimulating hormone were significant factors of weight gain at post 12 months.

[Myocardial injury and infarction is an overlooked complication after non-cardiac surgery]

Annually, several million patients undergoing non-cardiac surgery develop myocardial injury or a myocardial infarction in the perioperative period. This frequent complication is associated with a high mortality. Despite an increasing focus on the issue the pathophysiology and the treatment of perioperative myocardial injury and infarction still remains partly unclear. Recently a new risk stratification tool was developed, which allows physicians to identify patients at risk. This review offers insight into the prevalence, pathophysiology, diagnostics, risk stratification and treatment of perioperative myocardial injury and infarction.

Comparison of whole blood and peripheral blood mononuclear cell gene expression for evaluation of the perioperative inflammatory response in patients with advanced heart failure

BACKGROUND

Heart failure (HF) prevalence is increasing in the United States. Mechanical Circulatory Support (MCS) therapy is an option for Advanced HF (AdHF) patients. Perioperatively, multiorgan dysfunction (MOD) is linked to the effects of device implantation, augmented by preexisting HF. Early recognition of MOD allows for better diagnosis, treatment, and risk prediction. Gene expression profiling (GEP) was used to evaluate clinical phenotypes of peripheral blood mononuclear cells (PBMC) transcriptomes obtained from patients' blood samples. Whole blood (WB) samples are clinically more feasible, but their performance in comparison to PBMC samples has not been determined.

METHODS

We collected blood samples from 31 HF patients (57±15 years old) undergoing cardiothoracic surgery and 7 healthy age-matched controls, between 2010 and 2011, at a single institution. WB and PBMC samples were collected at a single timepoint postoperatively (median day 8 postoperatively) (25-75% IQR 7-14 days) and subjected to Illumina single color Human BeadChip HT12 v4 whole genome expression array analysis. The Sequential Organ Failure Assessment (SOFA) score was used to characterize the severity of MOD into low (≤ 4 points), intermediate (5-11), and high (≥ 12) risk categories correlating with GEP.

RESULTS

Results indicate that the direction of change in GEP of individuals with MOD as compared to controls is similar when determined from PBMC versus WB. The main enriched terms by Gene Ontology (GO) analysis included those involved in the inflammatory response, apoptosis, and other stress response related pathways. The data revealed 35 significant GO categories and 26 pathways overlapping between PBMC and WB. Additionally, class prediction using machine learning tools demonstrated that the subset of significant genes shared by PBMC and WB are sufficient to train as a predictor separating the SOFA groups.

CONCLUSION

GEP analysis of WB has the potential to become a clinical tool for immune-monitoring in patients with MOD.

Systematic review and meta-analysis of perioperative intravenous tranexamic acid use in spinal surgery

BACKGROUND

Tranexamic acid (TXA) is well-established as a versatile oral, intramuscular, and intravenous (IV) antifibrinolytic agent. However, the efficacy of IV TXA in reducing perioperative blood transfusion in spinal surgery is poorly documented.

METHODOLOGY

We conducted a meta-analysis of randomized controlled trials (RCTs) and quasi-randomized (qi-RCTs) trials that included patients for various spinal surgeries, such as adolescent scoliosis surgery administered with perioperative IV TXA according to Cochrane Collaboration guidelines using electronic PubMed, Cochrane Central Register of Controlled Trials, and Embase databases. Additional journal articles and conference proceedings were manually located by two independent researchers.

RESULTS

Totally, nine studies were included, with a total sample size of 581 patients. Mean blood loss was decreased in patients treated with perioperative IV TXA by 128.28 ml intraoperatively (ranging from 33.84 to 222.73 ml), 98.49 ml postoperatively (ranging from 83.22 to 113.77 ml), and 389.21 ml combined (ranging from 177.83 to 600.60 ml). The mean volume of transfused packed cells were reduced by 134.55 ml (ranging 51.64 to 217.46) (95% CI; P = 0.0001). Overall, the number of patients treated with TXA who required blood transfusions was lower by 35% than that of patients treated with the comparator and who required blood transfusions (RR 0.65; 95% CI; 0.53 to 0.85; P<0.0001, I(2) = 0%). A dose-independent beneficial effect of TXA was observed, and confirmed in subgroup and sensitivity analyses. A total of seven studies reported DVT data. The study containing only a single DVT case was not combined.

CONCLUSIONS

The blood loss was reduced in spinal surgery patients with perioperative IV TXA treatment. Also the percentage of spinal surgery patients who required blood transfusion was significantly decreased. Further evaluation is required to confirm our findings before TXA can be safely used in patients undergoing spine surgery.

[Surgical treatment of duodenal fistulae]

The experience of surgical treatment of 10 patients with external intestinal fistulae was analyzed. The plot of the operation was to exlude the duodenum from the digestion by performing the retrocolic gastroenteroanastomosis after Roux or on the ultrashort loop. Early operation prevent septic complications and electrolyte disbalance. Duodenal fistulae, developed on the background of pancreonecrosis or after endoscopic retrograde cholangiopancreaticography, necessitate the external choledochial drainage.

[Single-step surgical management of lesions of the ascending aorta and aortic arch, coronary and carotid arteries in a male patient with multifocal atherosclerosis]

Described in the article is a clinical case report concerning single-step surgical management of a male patient presenting with multifocal atherosclerosis accompanied by an aneurysm of the ascending aorta and proximal segment of the aortic arch combined with lesions of the coronary and brachiocephalic vessels, thus showing a possibility of surgical treatment in this cohort of patients, if completely and timely diagnosed. Performing a one-stage operation without aggravating the surgical intervention makes it possible to decrease the risk of complications of both the heart and brain in the intra- and postoperative periods.

Periprocedural reversal and bridging of anticoagulant treatment

Anticoagulants are effective agents in reducing the risk of thromboembolism but the most important adverse effect of these agents is the occurrence of bleeding. Bleeding complications may occur spontaneously but the risk of bleeding is particularly increased in case of trauma or around invasive procedures. If patients being treated with anticoagulants need to undergo an invasive intervention, physicians need to consider whether to interrupt the use of this medication or to allow its use to be continued. Suspending the use of anticoagulants increases the risk of thrombosis, whereas continued use may cause bleeding complications. To shorten the period in which anticoagulant treatment is interrupted, bridging strategies have been advocated. No evidence-based scientific research has been carried out regarding best practice for the perioperative use of anticoagulants. The periprocedural anticoagulation policy in patients should be individualised based on the risk of a thromboembolic complication (which can be estimated with available scoring systems) offset against the bleeding risk associated with the intervention.