Maged Argalious

The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium.

BACKGROUND:In this study, we sought to determine the frequency and outcomes of epidural hematomas after epidural catheterization. METHODS:Eleven centers participating in the Multicenter Perioperative Outcomes Group used electronic anesthesia information systems and quality assurance databases to identify patients who had epidural catheters inserted for either obstetrical or surgical indications. From this cohort, patients undergoing laminectomy for the evacuation of hematoma within 6 weeks of epidural placement were identified. RESULTS:Seven of 62,450 patients undergoing perioperative epidural catheterizations developed hematoma requiring surgical evacuation. The event rate was 11.2 × 10−5 (95% confidence interval [CI], 4.5 × 10−5 to 23.1 × 10−5). Four of the 7 had anticoagulation/antiplatelet therapy that deviated from American Society of Regional Anesthesia guidelines. None of 79,837 obstetric patients with epidural catheterizations developed hematoma (upper limit of the 95% CI, 4.6 × 10−5). The hematoma rate in obstetric epidural catheterizations was significantly lower than in perioperative epidural catheterizations (P = 0.003). CONCLUSIONS:In this series, the 95% CI for the frequency of epidural hematoma requiring laminectomy after epidural catheter placement for perioperative anesthesia/analgesia was 1 event per 22,189 placements to 1 event per 4330 placements. Risk was significantly lower in obstetric epidurals.

Preoperative Statin Therapy Is Not Associated with a Reduced Incidence of Postoperative Acute Kidney Injury After Cardiac Surgery

BACKGROUND: Our objective was to examine the association between preoperative statin therapy and the prevalence of postoperative acute kidney injury (AKI) in patients undergoing cardiac surgery with the use of cardiopulmonary bypass. METHODS: We performed a retrospective investigation of 10,648 consecutive patients undergoing coronary artery bypass grafting using cardiopulmonary bypass and/or valve surgery between January 2002 and December 2006. Patients were divided into 2 groups depending on preoperative therapy with statin drugs. The primary outcome was postoperative AKI based on the RIFLE (Risk, Injury, Failure, Loss, End-stage) criteria. Secondary outcomes included requirement for postoperative dialysis and hospital mortality. Multivariable logistic regression models were developed for the primary and secondary outcomes. To control for selection bias related to statin therapy, a propensity score was developed using a greedy matching technique. RESULTS: The incidence of AKI was 12.1% (n = 1286). AKI occurred in 13.31% of patients receiving preoperative statins (819 of 6152 patients) versus 10.41% in the no statin group (467 of 4487 patients) (P < 0.001). The incidence of postoperative dialysis was 1.71% (n = 182). Postoperative dialysis was needed in 1.75% of patients in the statin group (108 of 6157 patients) compared with 1.65% of patients (74 of 4491 patients) in the no statin group (P = 0.68). Hospital mortality after surgery occurred in 1.71% (n = 182) of patients. The incidence of mortality for patients in the statin group was 1.71% (105 of 6157 patients) and this was not different from mortality in the no statin group of 1.71% (77 of 4491 patients) (P = 0.97). In multivariate logistic regression analysis, statin therapy was not associated with AKI (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.84–1.12; P = 0.68), postoperative dialysis (OR 0.80, 95% CI 0.55–118; P = 0.23), or hospital mortality (OR 0.803, 95% CI 0.56–1.16; P = 0.24). In 2646 propensity-matched pairs, the incidence of AKI was 12.0% in the statin group versus 12.8% in the no statin group (P = 0.38). The statin group had a 1.63% incidence of postoperative dialysis versus 2.08% in the no statin group (P = 0.22). In the same propensity-matched population, hospital mortality occurred in 1.63% of patients in the statin group compared with 2.1% in the no statin group (P = 0.19). CONCLUSION: These results suggest that previously reported reductions in perioperative mortality for patients taking preoperative statins and undergoing cardiac surgery is likely not mediated through a reduction in postoperative AKI.

Renal dose dopamine is associated with the risk of new-onset atrial fibrillation after cardiac surgery

Objective:“Renal dose” dopamine (rDA; 1–3 &mgr;g/kg per min) is administered to patients after cardiac surgery to preserve or improve renal function. Many of these patients develop new-onset postoperative atrial fibrillation or atrial flutter (pAF) that could be related to rDA administration. The objective of this investigation was to determine whether there was an association between rDA and new-onset pAF in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass (CABG). Setting:Research hospital. Subjects:The study population consisted of 1,731 patients undergoing CABG. Interventions:CABG with and without rDA. Design:After approval by the institutional review board, a retrospective study using the Cardiothoracic Anesthesia Patient Registry was undertaken to determine the association between rDA and pAF in patients undergoing CABG. Patients with a documented history of atrial fibrillation, those who required inotrope use during or after surgery, and those having valve surgery were excluded. Measurements and Main Results:One-thousand seven-hundred thirty-one patients undergoing CABG during the period of January 1, 2000, through June 30, 2002, were the study population; of these, 15.0% (260/1,731) developed pAF. The incidence of pAF was 23.3 % (41/176) among patients who received rDA and 14.1% (219/1,555) among those who did not receive rDA. In the multivariable logistic regression model, patient age, gender, chronic obstructive pulmonary disease or asthma, and rDA were associated with pAF (p < .01). Receipt of rDA increased the odds of developing pAF by 74%, independent of the effect of other variables. Conclusions:Renal-dose dopamine is associated with a 1.74 odds ratio of pAF developing after CABG.

The association between perioperative hemoglobin and acute kidney injury in patients having noncardiac surgery

BACKGROUND:Acute kidney injury (AKI) is a common complication of noncardiac surgery and is associated with excess morbidity and mortality. Perioperative hemoglobin concentrations are strongly associated with surgical mortality, but little is known about their relationship with AKI. We studied hemoglobin concentration before and 24 hours after surgery and its association with AKI. METHODS:We performed a single-center observational cohort study using clinical and administrative data from the Cleveland Clinic, Cleveland, OH. In patients with normal preoperative renal function, we examined the association between the outcome of AKI and the exposures of preoperative hemoglobin concentration and decrements in hemoglobin concentration in the first 24 hours after surgery using logistic regression and controlling for important confounding variables. RESULTS:We included 27,381 patients who had 33,330 noncardiac surgeries. AKI developed in 2478 (7.4%) surgeries. Preoperative hemoglobin concentrations were <12.0 g/dL in 9566 (29%) patients. Hemoglobin concentrations decreased by >4.0 g/dL in 10,808 (32%) patients. Compared with patients with a preoperative hemoglobin >12.0 g/dL, the adjusted odds ratio (OR) for AKI was 2.01 (95% confidence interval [CI], 1.8–2.3) for those with a preoperative hemoglobin between 10.1 and 12.0 g/dL and was 3.7 (95% CI, 2.6–5.4) for those with a preoperative hemoglobin <8.0 g/dL. Compared with patients who did not have a decrease in postoperative hemoglobin, a decrement of 1.1 to 2.0 g/dL was associated with an adjusted OR of 1.51 (95% CI, 1.15–1.98), and a decrement of >4.0 g/dL with an OR of 4.7 (95% CI, 3.6–6.2) for AKI. CONCLUSIONS:Low preoperative and early postoperative decrements in hemoglobin concentrations are strongly associated with postoperative AKI in a graded manner. Given the frequency of low perioperative hemoglobin and decreases in hemoglobin concentration, research is needed to determine whether there are safe treatment strategies to mitigate the risk of AKI.

The use of dexmedetomidine in anesthesia and intensive care: a review.

The alpha-2 agonist dexmedetomidine is being increasingly used for sedation and as an adjunctive agent during general and regional anesthesia. It is used in a number of procedures and clinical settings including neuroanesthesia, vascular surgery, gastrointestinal endoscopy, fiberoptic intubation, and pediatric anesthesia. The drug is also considered a nearly ideal sedative agent in the intensive care setting. However, the drug frequently produces hypotension and bradycardia, and also decreases cerebral blood flow without concomitantly decreasing the cerebral metabolic rate for oxygen. This review discusses recent advances in the use of dexmedetomidine in anesthesia and intensive care settings, as well as discuss potential problems with its use.

Dynamic left ventricular outflow tract obstruction in an orthotopic liver transplant recipient

A 53 year‐old man with Laennecs and hepatitis C–related cirrhosis was found to have dynamic left ventricular outflow tract obstruction during routine evaluation for orthotopic liver transplantation. The outflow tract obstruction gradient was quantified as being 155 to 189 mmHg maximally during dobutamine stress echocardiography. The patient subsequently underwent successful orthotopic liver transplantation at our institution. We discuss here the use of intraoperative transesophageal echocardiography to detect early signs of dynamic outflow tract obstruction and provide a rational guide for fluid and hemodynamic management. We conclude that the measured pressure across the left ventricular outflow tract during dobutamine stress testing does not necessarily predict either intraoperative hemodynamic perturbations such as obstruction or outcome in these patients. (Liver Transpl 2005;11:692–695.)

Circulating-water garment or the combination of a circulating-water mattress and forced-air cover to maintain core temperature during major upper-abdominal surgery

BACKGROUND A recent heat-balance study in volunteers suggested that greater efficacy of circulating-water garments (CWGs) results largely from increased heat transfer across the posterior skin surface since heat transfer across the anterior skin surface was similar with circulating-water and forced-air. We thus tested the hypothesis that the combination of a circulating-water mattress (CWM) and forced-air warming prevents core temperature reduction during major abdominal surgery no worse than a CWG does. METHODS Fifty adult patients aged between 18 and 85 yr old, undergoing major abdominal surgery, were randomly assigned to intraoperative warming with a combination of forced-air and a CWM or with a CWG (Allon ThermoWrap). Core temperature was measured in the distal oesophagus. Non-inferiority of the CWM to the CWG on change from baseline to median intraoperative temperature was assessed using a one-tailed Students t-test with an equivalency buffer of -0.5°C. RESULTS Data analysis was restricted to 16 CWG and 20 CWM patients who completed the protocol. Core temperature increased in both groups during the initial hours of surgery. We had sufficient evidence (P=0.001), to conclude that the combination of a CWM and forced-air warming was non-inferior to a CWG in preventing temperature reduction, with mean (95% CI) difference in the temperature change between the CWM and the CWG groups (CWM-CWG) of 0.46°C (-0.09°C, 1.00°C). CONCLUSIONS The combination of a CWM and forced-air warming is significantly non-inferior in maintaining intraoperative core temperature than a CWG. TRIAL REGISTRY This trial has been registered at clinical trials.gov, identifier: NCT 00651898.

The anesthetic management of ventricular septal defect (VSD) repair in a child with mitochondrial cytopathy

PurposeTo present the anesthetic management for the correction of a ventricular septal defect (VSD) in a patient with multiple acyl CoA dehydrogenase deficiency (glutaric aciduria type II; GAII). A review of the literature about anesthetic management of patients with mitochondrial diseases undergoing cardiopulmonary bypass (CPB) is also included.Clinical featuresAn 11-yr-old girl with GAII manifested as severe hypoglycemia since she was a newborn and generalized muscle weakness. She underwent open-heart surgery for VSD correction with CPB. The anesthetic management avoided inhalational anesthetics, maintained the blood sugar within normal limits and continued normothermia during CPB in order to avoid the stress of hypothermia for her abnormal mitochondria. The patient tolerated the procedure well and experienced a good recovery.ConclusionThe anesthetic management of patients with any mitochondrial disease requires normoglycemia, normothermia and the avoidance of metabolic stress in order to preserve energy production by the diseased mitochondria.RésuméObjectifPrésenter la démarche anesthésique adoptée pour la correction d’une communication interventriculaire (CIV) chez une enfant souffrant de déficience multiple d’acyl-CoA déshydrogénase (acidurie glutarique de type II; AGII). Nous incluons également une revue de la prise en charge anesthésique de patients atteints de maladies mitochondriales qui subissent une circulation extracorporelle (CEC).Éléments cliniquesUne enfant de 11 ans, atteinte d’AGII, présentait une hypoglycémie sévère depuis sa naissance et une faiblesse musculaire généralisée. Elle a subi une opération à cœur ouvert pour la correction d’une CIV sous CEC. Nous avons évité les anesthésiques d’inhalation, maintenu la glycémie dans les limites de la normale et poursuivi la normothermie pendant la CEC afin d’éviter le stress de l’hypothermie sur les anomalies mitochondriales. La patiente a bien toléré l’intervention et connu une bonne récupération.ConclusionL’anesthésie de patients atteints de maladie mitochondriale exige une normoglycémie, une normothermie et l’absence de stress dans le but de préserver la production d’énergie par les mitochondries lésées.

Transfusion of older red blood cells is associated with decreased graft survival after orthotopic liver transplantation.

Investigations have demonstrated conflicting results regarding the influence of the red blood cell (RBC) storage duration on outcomes. We evaluated whether graft failure or mortality after orthotopic liver transplantation (OLT) increased when recipients were transfused with older RBCs. This study included 637 patients who underwent OLT between January 2001 and June 2011. Baseline and perioperative data were obtained from our blood bank, the Unified Transplant Center database, and the United Network for Organ Sharing database. Recipients whose transfused RBCs were all stored for ≤15 days were grouped in a younger group, and recipients who were transfused with RBCs stored for >15 days were placed in an older group. The relationship between graft survival/mortality and the age of intraoperatively transfused RBCs was studied by Kaplan‐Meier estimation with a log‐rank test and multivariate Cox proportional hazards regression. Three hundred thirty‐four patients and 303 patients were grouped in the younger and the older RBC groups, respectively, on the basis of the ages of intraoperatively transfused RBCs. Kaplan‐Meier estimates of graft survival/mortality as a function of the posttransplant time were significantly different: the older group experienced the outcome sooner than the younger group [P = 0.02 (log‐rank test)]. After covariate adjustments, the risk of graft failure/mortality was significantly different at any given time after transplantation between patients receiving intraoperative transfusions of older RBC units and patients receiving intraoperative transfusions of younger RBC units (hazard ratio = 1.65, 95% confidence interval = 1.18‐2.31). In conclusion, patients who received intraoperative transfusions of RBCs with longer storage times had an increased risk of adverse outcomes. Liver Transpl 19:1181–1188, 2013.

The association of preoperative statin use and acute kidney injury after noncardiac surgery.

BACKGROUND:Our objective was to examine the association between preoperative statin therapy and the incidence of postoperative acute kidney injury (AKI) in patients undergoing elective noncardiac surgery. METHODS:We analyzed the electronic records of 57,246 patients who had elective noncardiac surgery at the Cleveland Clinic Main Campus between December 2004 and March 2010. Patients were divided into 2 groups depending on preoperative therapy with statin drugs. Our primary outcome was AKI, defined as “risk,” “injury,” or “failure” using the RIFLE (Risk, Injury, Failure, Loss, and End-stage Kidney) criteria. Secondary outcomes included postoperative dialysis and all-cause hospital mortality. Each statin user was matched to a nonuser based on propensity scores. The propensity scores were estimated using a multivariable logistic regression model, incorporating all available baseline potential confounders. After the propensity-matching procedure, we performed final analyses for the primary and secondary outcomes. For the primary analysis, we used a univariable logistic regression model to estimate the odds ratio (OR) (and 95% confidence intervals) for AKI, postoperative dialysis, and hospital mortality between matched statin users and nonusers. RESULTS:Of the total group, 23,745 records were unusable because of missing data. Among the remaining 28,508 patients analyzed, the overall incidence of AKI was 6.1%. Three hundred sixty-one of 4805 statin users (7.5%) and 1377 of 23,703 nonusers (5.8%) experienced AKI. The incidence of postoperative dialysis was 0.05%. Six statin users (0.12%) and 8 nonusers (0.03%) required dialysis postoperatively. The incidence of hospital mortality was 0.62%. Mortality was observed for 47 patients (1.0%) and 130 patients (0.5%), respectively. Among 4172 matched pairs, the incidence (95% confidence interval) of AKI was 7.1% (6.2%, 8.1%) in the matched statin users and 8.0% (7.1%, 9.0%) in the nonusers, corresponding to an OR of 0.88 (0.75, 1.03), which was not statistically significant (P = 0.12, &khgr;2 test). The secondary outcomes were also not significantly different in matched statin users and nonusers. Postoperative dialysis was required for 0.10% (0.02%, 0.33%) and 0.12% (0.04%, 0.37%) of patients in the respective groups (OR = 0.80 [0.16, 3.70]; P = 0.74). Hospital mortality occurred in 1.0% (0.7%, 1.5%) and 1.3% (0.9%, 1.8%) of patients, respectively (OR = 0.76 [0.47, 1.20]; P = 0.18). CONCLUSIONS:Our data did not support the hypothesis that preoperative statin therapy in doses routinely used to treat hypercholesterolemia is associated with a change in the incidence of AKI, postoperative dialysis, or hospital mortality in patients undergoing noncardiac surgery.