Biljana Stošić

Addition of biomarker panel improves prediction performance of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator for cardiac risk assessment of elderly patients preparing for major non-cardiac surgery: a pilot study

BackgroundNumber of elderly patients subjected to extensive surgical procedures in the presence of cardiovascular morbidities is increasing every year. Therefore, there is a need to make preoperative diagnostics more accurate.AimsTo evaluate the usefulness of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator as a predictive tool in preoperative assessment of cardiovascular risk in elderly patients.MethodsThis prospective pilot study included 78 patients who were being prepared for extensive non-cardiac surgeries under general anaesthesia. Their data have been processed on the interactive ACS NSQIP calculator. Blood sampling has been performed 7 days prior to surgery, and serum has been separated. Clinical, novel, and experimental biomarkers [hsCRP, H-FABP, and Survivin (BIRC5)] have been measured in specialized laboratories.ResultsMean age of included patients was 71.35 ± 6.89 years. In the case of heart complications and mortality prediction, hsCRP and ACS NSQIP showed the highest specificity and sensitivity with AUC, respectively, 0.869 and 0.813 for heart complications and 0.883 and 0.813 for mortality. When combined with individual biomarkers AUC of ACS NSQIP raised, but if we combined all three biomarkers with ACS NSQIP, AUC reached as much as 0.920 for heart complications and 0.939 for mortality.DiscussionACS NSQIP proved to reduce inaccuracy in preoperative assessment, but it cannot be used independently, which has already been proved by other authors.ConclusionsOur results indicate that ACS NSQIP represents an accurate tool for preoperative assessment of elderly patients, especially if combined with cardiac biomarkers.

Risk factors associated with carotid artery puncture following landmark-guided internal jugular vein cannulation attempts.

Objective: The relationship between certain risk factors and carotid artery puncture (CAP) as an early mechanical complication following internal jugular vein cannulation attempts (IJVCAs) was evaluated. Methods: In a retrospective 1-year observational single-center study, 86 IJVCAs conducted in the operating room by 4 competent anesthesiologists were evaluated. Age, gender, puncture side, number of cannulation attempts, circumstances of the procedure and incidence of CAP were obtained from medical records. Results: Of the 86 IJVCAs performed in patients aged 18–75 years, CAP occurred in 8 (9.3%): 5 (5.8%) in patients >65 years and 3 (3.5%) in patients <65 years of age. CAP was not associated with patient’s age (p = 0.11) and gender (p = 0.76). Multiple cannulation attempts (OR = 26.25; 95% CI = 4.52–152.51; p < 0.001) and placement of CVC under emergency conditions (OR = 14.84; 95% CI = 1.73–127.22; p = 0.014) increased the risk for CAP significantly. Also, the risk for CAP was higher when IJVCAs were performed before induction of general anesthesia (OR = 15.75; 95% CI = 1.83–135.1; p = 0.019). CAP was more likely to happen during left-sided than right-sided IJVCA (OR = 5.98; 95% CI = 1.29–27.59; p = 0.022). In addition, left-sided attempts considerably increased the risk for multiple cannulation attempts (OR = 2.782; 95% CI = 1.342–3.965; p < 0.01). Also, manifold cannulation attempts were more frequent if the IJVCA was performed before induction of anesthesia (OR = 4.219; CI = 1.579–11.271; p = 0.004). Conclusions: Our results strongly suggest that left-sided, multiple IJVCAs, performed under emergency conditions in conscious patients in the operating room, represent considerable risks for possible CAP.

Clinical Utility of Survivin (BIRC5), Novel Cardiac Biomarker, as a Prognostic Tool Compared to High-Sensitivity C-Reactive Protein, Heart-Type Fatty Acid Binding Protein and Revised Lee Score in Elderly Patients Scheduled for Major Non-Cardiac Surgery: A Prospective Pilot Study

Summary Background: Recent studies indicate that survivin (BIRC5) is sensitive to the existence of previous ischemic heart disease, since it is activated in the process of tissue repair and angiogenesis. The aim of this study was to determine the potential of survivin (BIRC5) as a new cardiac biomarker in the preoperative assessment of cardiovascular risk in comparison with clinically accepted cardiac biomarkers and one of the relevant clinical risk scores. Methods: We included 79 patients, female (41) and male (38), with the mean age of 71.35±6.89. Inclusion criteria: extensive non-cardiac surgery, general anesthesia, age >55 and at least one of the selected cardiovascular risk factors (hypertension, diabetes mellitus, hyperlipidemia, smoking and positive family history). Exclusion criteria: emergency surgical procedures and inability to understand and sign an informed consent. Blood sampling was performed 7 days prior surgery and levels of survivin (BIRC5), hsCRP and H-FABP were measured. Results: Revised Lee score was assessed based on data found in patients’ history. Levels of survivin (BIRC5) were higher in deceased patients (P<0.05). It showed AUC=0.807 (95% CI, P<0.0005, 0.698–0.917), greater than both H-FABP and revised Lee index, and it increases the mortality prediction when used together with both biomarkers and revised Lee score. The determined cut-off value was 4 pg/mL and 92.86% of deceased patients had an increased level of survivin (BIRC5), (P=0.005). Conclusions: Survivin (BIRC5) is a potential cardiac biomarker even in elderly patients without tumor, but it cannot be used independently. Further studies with a greater number of patients are needed.

Impact of reconstructive procedures with and without preserving the duodenal passage on body weight in patients after total gastrectomy for gastric cancer

Introduction/Objective The ideal reconstruction procedure after total gastrectomy should replace all lost functions of the stomach. The aim of this study was to evaluate the usefulness of preserving the duodenal passage in subsequent improvement of body weight (BW) and body mass index (BMI) in patients with gastric cancer after total gastrectomy. Methods A total of 30 patients with gastric cancer were prospectively randomly divided into a group of reconstruction with double-tract (n = 15) and a group of reconstruction with simple Roux-en-Y after total gastrectomy. They were stratified by sex, age, their anthropometric measurements (BW, BMI), primary tumor localization, Laurens classification, TNM stage classification, length of hospital stay, operation duration, postoperative complications, and mortality. Postoperatively, BW and BMI were measured at three, six, and 12 months and compared between the two groups. Results The clinical group of double-tract patients had significantly higher the values of BW in the postoperative period after six (66.6 ± 4.9 vs. 61.7 ± 7.6; p < 0.05 paired Students t-test) and after 12 months (67.0 ± 4.9 vs. 62.3 ± 7.2; p < 0.05 paired Students t-test) compared to the group of Roux-en-Y patients. On the other hand, the clinical group of double-tract patients also had significantly higher the values of BMI in postoperative period after 12 months (23.6 ± 1.1 vs. 22.5 ± 1.6; p < 0.05 paired Students t-test) in relation to the Roux-en-Y group of patients. Conclusion Reconstruction procedure carried out after total gastrectomy which implies preserving the duodenal passage has significant increase of BW and BMI, compared to reconstruction procedure without the preservation of the duodenal passage.

Basic Principles of Simulations: In situ and Online Simulation

Summary Medical simulation is an artificial and a faithful representation of real clinical situations with the help of static and interactive doll simulators, standardized patients/actors, models for the exercise, simulation on a computer screen and a “serious” performance of a real clinical situation. That is a modern way of learning that helps students and health workers to achieve a higher level of expertise and provide a safer health care. Medical simulation is one of the greatest and most important innovations in medical education for the past 20 years. The goal of the simulation is to provide an optimal relationship between education and patient’s safety. It is used both in undergraduate and postgraduate studies, as well as in continuing medical education. Simulators used in medical education can be divided into six groups, ranging from the use of paper and pencils to the most modern computerized interactive simulator. Depending on the economic development level and the organization of health care, rigorous high medical simulation can be performed in three ways: in the center for medical simulation, in the form of “in situ” simulation, and as remote simulations.