Vera Fernandes

Determinants of postoperative acute kidney injury

IntroductionDevelopment of acute kidney injury (AKI) during the perioperative period is associated with increases in morbidity and mortality. Our aim was to evaluate the incidence and determinants of postoperative AKI after major noncardiac surgery in patients with previously normal renal function.MethodsThis retrospective cohort study was carried out in the multidisciplinary Post-Anaesthesia Care Unit (PACU) with five intensive care beds. The study population consisted of 1166 patients with no previous renal insufficiency who were admitted to these intensive care unit (ICU) beds over 2 years. After admission patients were followed for the development of AKI, defined as proposed by The Acute Kidney Injury Network (increment of serum creatinine [greater than or equal to] 0.3 mg/dL or 50% from baseline within 48 hours or urine output < 0.5 mL/kg/hr for > 6 hours despite fluid resuscitation when applicable). Patient preoperative characteristics, intraoperative management and outcome were evaluated for associations with acute kidney injury using an univariate and multiple logistic regression model.ResultsA total of 1597 patients were admitted to the PACU and of these, 1166 met the inclusion criteria. Eighty-seven patients (7.5%) met AKI criteria. Univariate analysis identified age, American Society of Anesthesiologists (ASA) physical status, emergency surgery, high risk surgery, ischemic heart disease, congestive heart disease and Revised Cardiac Risk Index (RCRI) score as independent preoperative determinants for AKI in the postoperative period. Multivariate analysis identified ASA physical status, RCRI score, high risk surgery and congestive heart disease as preoperative determinants for AKI in the postoperative period. Patients that developed AKI had higher Simplified Acute Physiology Score (SAPS) II and Acute Physiology and Chronic Health Evaluation (APACHE) II, higher PACU length of stay (LOS), higher PACU mortality, higher hospital mortality and higher mortality at 6 months follow-up. AKI was an independent risk factor for hospital mortality (OR 3.12, 95% CI 1.41 to 6.93, P = 0.005).ConclusionsThis study shows that age, emergency and high risk surgery, ischemic heart disease, congestive heart disease, ASA physical status and RCRI score were considered risk factors for the development of AKI, in patients needing intensive care after surgery. AKI has serious impact on PACU length of stay and mortality. AKI was an independent risk factor for hospital mortality.

Postoperative Delirium in Intensive Care Patients: Risk Factors and Outcome

BACKGROUND AND OBJECTIVES Postoperative delirium (POD) in Surgical Intensive Care patients is an important independent outcome determinant. The purpose of our study was to evaluate the incidence and determinants of POD. METHODS Prospective cohort study conducted during a period of 10 months in a Post-Anesthesia Care Unit (PACU) with five intensive care beds. All consecutive adult patients submitted to major surgery were enrolled. Demographic data, perioperative variables, length of stay (LOS) and the mortality at PACU, hospital and at 6-months follow-up were recorded. Postoperative delirium was evaluated using the Intensive Care Delirium Screening Checklist (ICDSC). Descriptive analyses were conducted and the Mann-Whitney test, Chi-square test or Fishers exact test were used for comparisons. Logistic regression analysis evaluated the determinants of POD with calculation of odds ratio (OR) and its confidence interval 95% (95% CI). RESULTS There were 775 adult PACU admissions and 95 patients had exclusion criteria. Of the remaining 680 patients, 128 (18.8%) developed POD. Independent determinants of POD identified were age, ASA-PS, emergency surgery and total amount of fresh frozen plasma administered during surgery. Patients with delirium had higher mortality rates, were more severely ill and stayed longer at the PACU and in the hospital. POD was an independent risk factor for hospital mortality DISCUSSION There was a high incidence of delirium had a high incidence in intensive care surgical patients. POD was associated with worse severity of disease scores, longer LOS in hospital, and in PACU and higher mortality rates. The independent risk factors for POD were age, ASAPS, emergency surgery and the amount of plasma administered during surgery.

Quality of life and mortality assessment in patients with major cardiac events in the postoperative period

BACKGROUND AND OBJECTIVES Cardiovascular complications in the postoperative period are associated with high mortality and morbidity. Few studies have assessed the degree of dependence in these patients and their perception of health. The objective of this study was to assess the mortality and the quality of life in patients who developed major cardiac events (MCE) in the postoperative period. METHOD Retrospective study carried out in a Surgical Intensive Care Unit (SICU), between March 2006 and March 2008. The patients were assessed regarding the occurrence of CE. Six months after the hospital discharge, the Short-Form-36 (SF-36) questionnaire was filled out and dependence was assessed in relation to activities of daily living (ADL). The comparisons between independent groups of patients were carried out using Students t test. The comparison between each variable and the occurrence of CE was carried out by logistic regression and included all patients. RESULTS Of the 1,280 patients that met the inclusion criteria, 26 (2%) developed MCE. The univariate analysis identified as independent determinants for the development of major cardiac events: ASA physical status, hypertension, ischemic heart disease, congestive heart disease and score of the Revised Cardiac Risk Index (RCRI). The six-month mortality after the SICU discharge was 35%. Of the 17 surviving patients, 13 completed the questionnaires. Thirty-one percent of them reported that their general health was better on the day they answered the questionnaire, when compared to 12 months before. Sixty-nine percent of the patients were dependent in instrumental ADL e 15% in personal ADL. CONCLUSIONS The development of MCE has a significant impact on the duration of hospital stay and mortality rates. Six months after the discharge from the SICU, more than 50% of the patients were dependent in at least one instrumental ADL.

Outcome and quality of life after aorto-bifemoral bypass surgery.

BackgroundAorto-bifemoral bypass (AFB) is commonly performed to treat aorto-iliac disease and a durable long-term outcome is achieved. Most studies documenting beneficial outcomes after AFB have been limited to mortality and morbidity rates, costs and length of hospital stay (LOS). Few studies have examined the dependency of patients and how their perception of their own health changes after surgery. The aim of the present study was to evaluate outcome after AFB and to study its determinants.MethodsThis retrospective study was carried out in the multidisciplinary Post-Anaesthesia Care Unit (PACU) with five intensive care beds. Out of 1597 intensive care patients admitted to the PACU, 75 were submitted to infrarenal AFB and admitted to these intensive care unit (ICU) beds over 2 years. Preoperative characteristics and outcome were evaluated by comparing occlusive disease with aneurysmatic disease patients. Six months after discharge, the patients were contacted to complete a Short Form-36 questionnaire (SF-36) and to have their dependency in Activities of Daily Living (ADL) evaluated. Patients characteristics and postoperative follow-up data were compared using Mann-Whitney U test, t test for independent groups, chi-square or Fishers exact test. Patient preoperative characteristics were evaluated for associations with mortality using a multiple logistic regression analysis.ResultsThe mortality rate was 12% at six months. Multivariate analysis identified congestive heart disease and APACHE II as independent determinants for mortality. Patients submitted to AFB for occlusive disease had worse SF-36 scores in role physical and general health perception. Patients submitted to AFB had worse SF-36 scores for all domains than a comparable urban population and had similar scores to other PACU patients. Sixty-six percent and 23% of patients were dependent in at least one activity in instrumental and personal ADL, respectively, but 64% reported having better general health.ConclusionThis study shows that congestive heart disease and APACHE II were risk factors for mortality after AFB surgery. Survivors who have undergone AFB perceive an improved quality of life although they are more dependent in ADL tasks and have worse scores in almost all SF-36 than the population to which they belong.

Delirium pós-operatório em pacientes críticos: fatores de risco e resultados

BACKGROUND AND OBJECTIVES: Postoperative delirium (POD) in Surgical Intensive Care patients is an important independent outcome determinant. The purpose of our study was to evaluate the incidence and determinants of POD. METHODS: Prospective cohort study conducted during a period of 10 months in a Post-Anesthesia Care Unit (PACU) with five intensive care beds. All consecutive adult patients submitted to major surgery were enrolled. Demographic data, perioperative variables, length of stay (LOS) and the mortality at PACU, hospital and at 6-months follow-up were recorded. Postoperative delirium was evaluated using the Intensive Care Delirium Screening Checklist (ICDSC). Descriptive analyses were conducted and the Mann-Whitney test, Chi-square test or Fishers exact test were used for comparisons. Logistic regression analysis evaluated the determinants of POD with calculation of odds ratio (OR) and its confidence interval 95% (95% CI). RESULTS: There were 775 adult PACU admissions and 95 patients had exclusion criteria. Of the remaining 680 patients, 128 (18.8%) developed POD. Independent determinants of POD identified were age, ASA-PS, emergency surgery and total amount of fresh frozen plasma administered during surgery. Patients with delirium had higher mortality rates, were more severely ill and stayed longer at the PACU and in the hospital. POD was an independent risk factor for hospital mortality DISCUSSION: There was a high incidence of delirium had a high incidence in intensive care surgical patients. POD was associated with worse severity of disease scores, longer LOS in hospital, and in PACU and higher mortality rates. The independent risk factors for POD were age, ASA-PS, emergency surgery and the amount of plasma administered during surgery.JUSTIFICATIVA Y OBJETIVOS: El delirio postoperatorio (DPO) en pacientes quirurgicos en cuidados intensivos es un resultado independiente y un importante determinante. El objetivo de nuestro estudio fue evaluar la incidencia y los determinantes del DPO. METODOS: Estudio prospectivo de cohorte realizado durante un periodo de 10 meses en una unidad de recuperacion de postanestesia (URPA) con cinco camas especializadas en cuidados intensivos. Todos los pacientes adultos consecutivos que fueron sometidos a cirugia mayor fueron incluidos. Los datos demograficos, las variables perioperatorias, el tiempo de ingreso (TI) y la mortalidad en la URPA en el hospital y en los 6 meses de seguimiento quedaron registrados. El delirio postoperatorio se evaluo utilizando el Checklist para la seleccion de delirio en cuidados intensivos (Intensive Care Delirium Screening Checklist - ICDSC). Los analisis descriptivos fueron realizados y el test de Mann-Whitney, Xi-Cuadrado (Xi2) y el test exacto de Fisher fueron usados para las comparaciones. El analisis de regresion logistica evaluo los factores determinantes del DPO con el calculo de la razon de chances (RC) y su intervalo de confianza de 95% (IC 95%). RESULTADOS: La admision fue de 775 pacientes adultos en la URPA y 95 pacientes no respetaron los criterios de inclusion. De los 680 pacientes restantes, 128 (18,8%) desarrollaron DPO. Los determinantes independientes de DPO identificados fueron la edad, ASA-PS, cirugia de emergencia y la cantidad total de plasma fresco congelado (PFC) administrado durante la cirugia. Los pacientes con delirio tuvieron tasas mas elevadas de mortalidad, estaban mas gravemente enfermos y permanecieron mas tiempo en la URPA y en el hospital. El DPO fue un factor de riesgo independiente para la mortalidad hospitalaria. DISCUSION: La incidencia de delirio fue elevada en los pacientes quirurgicos en cuidados intensivos. El DPO estuvo asociado con una peor puntuacion de gravedad de la enfermedad, tiempo de permanencia mas largo en el hospital y en la URPA y tasas mas elevadas de mortalidad. Los factores de riesgo independientes para DPO fueron la edad, ASA-PS, cirugia de emergencia y cantidad de plasma administrado durante la cirugia.

Postoperative delirium in intensive care patients: factores de riesgo y resultados

BACKGROUND AND OBJECTIVES: Postoperative delirium (POD) in Surgical Intensive Care patients is an important independent outcome determinant. The purpose of our study was to evaluate the incidence and determinants of POD. METHODS: Prospective cohort study conducted during a period of 10 months in a Post-Anesthesia Care Unit (PACU) with five intensive care beds. All consecutive adult patients submitted to major surgery were enrolled. Demographic data, perioperative variables, length of stay (LOS) and the mortality at PACU, hospital and at 6-months follow-up were recorded. Postoperative delirium was evaluated using the Intensive Care Delirium Screening Checklist (ICDSC). Descriptive analyses were conducted and the Mann-Whitney test, Chi-square test or Fishers exact test were used for comparisons. Logistic regression analysis evaluated the determinants of POD with calculation of odds ratio (OR) and its confidence interval 95% (95% CI). RESULTS: There were 775 adult PACU admissions and 95 patients had exclusion criteria. Of the remaining 680 patients, 128 (18.8%) developed POD. Independent determinants of POD identified were age, ASA-PS, emergency surgery and total amount of fresh frozen plasma administered during surgery. Patients with delirium had higher mortality rates, were more severely ill and stayed longer at the PACU and in the hospital. POD was an independent risk factor for hospital mortality DISCUSSION: There was a high incidence of delirium had a high incidence in intensive care surgical patients. POD was associated with worse severity of disease scores, longer LOS in hospital, and in PACU and higher mortality rates. The independent risk factors for POD were age, ASA-PS, emergency surgery and the amount of plasma administered during surgery.JUSTIFICATIVA Y OBJETIVOS: El delirio postoperatorio (DPO) en pacientes quirurgicos en cuidados intensivos es un resultado independiente y un importante determinante. El objetivo de nuestro estudio fue evaluar la incidencia y los determinantes del DPO. METODOS: Estudio prospectivo de cohorte realizado durante un periodo de 10 meses en una unidad de recuperacion de postanestesia (URPA) con cinco camas especializadas en cuidados intensivos. Todos los pacientes adultos consecutivos que fueron sometidos a cirugia mayor fueron incluidos. Los datos demograficos, las variables perioperatorias, el tiempo de ingreso (TI) y la mortalidad en la URPA en el hospital y en los 6 meses de seguimiento quedaron registrados. El delirio postoperatorio se evaluo utilizando el Checklist para la seleccion de delirio en cuidados intensivos (Intensive Care Delirium Screening Checklist - ICDSC). Los analisis descriptivos fueron realizados y el test de Mann-Whitney, Xi-Cuadrado (Xi2) y el test exacto de Fisher fueron usados para las comparaciones. El analisis de regresion logistica evaluo los factores determinantes del DPO con el calculo de la razon de chances (RC) y su intervalo de confianza de 95% (IC 95%). RESULTADOS: La admision fue de 775 pacientes adultos en la URPA y 95 pacientes no respetaron los criterios de inclusion. De los 680 pacientes restantes, 128 (18,8%) desarrollaron DPO. Los determinantes independientes de DPO identificados fueron la edad, ASA-PS, cirugia de emergencia y la cantidad total de plasma fresco congelado (PFC) administrado durante la cirugia. Los pacientes con delirio tuvieron tasas mas elevadas de mortalidad, estaban mas gravemente enfermos y permanecieron mas tiempo en la URPA y en el hospital. El DPO fue un factor de riesgo independiente para la mortalidad hospitalaria. DISCUSION: La incidencia de delirio fue elevada en los pacientes quirurgicos en cuidados intensivos. El DPO estuvo asociado con una peor puntuacion de gravedad de la enfermedad, tiempo de permanencia mas largo en el hospital y en la URPA y tasas mas elevadas de mortalidad. Los factores de riesgo independientes para DPO fueron la edad, ASA-PS, cirugia de emergencia y cantidad de plasma administrado durante la cirugia.

Delirio postoperatorio en pacientes en cuidados intensivos

BACKGROUND AND OBJECTIVES: Postoperative delirium (POD) in Surgical Intensive Care patients is an important independent outcome determinant. The purpose of our study was to evaluate the incidence and determinants of POD. METHODS: Prospective cohort study conducted during a period of 10 months in a Post-Anesthesia Care Unit (PACU) with five intensive care beds. All consecutive adult patients submitted to major surgery were enrolled. Demographic data, perioperative variables, length of stay (LOS) and the mortality at PACU, hospital and at 6-months follow-up were recorded. Postoperative delirium was evaluated using the Intensive Care Delirium Screening Checklist (ICDSC). Descriptive analyses were conducted and the Mann-Whitney test, Chi-square test or Fishers exact test were used for comparisons. Logistic regression analysis evaluated the determinants of POD with calculation of odds ratio (OR) and its confidence interval 95% (95% CI). RESULTS: There were 775 adult PACU admissions and 95 patients had exclusion criteria. Of the remaining 680 patients, 128 (18.8%) developed POD. Independent determinants of POD identified were age, ASA-PS, emergency surgery and total amount of fresh frozen plasma administered during surgery. Patients with delirium had higher mortality rates, were more severely ill and stayed longer at the PACU and in the hospital. POD was an independent risk factor for hospital mortality DISCUSSION: There was a high incidence of delirium had a high incidence in intensive care surgical patients. POD was associated with worse severity of disease scores, longer LOS in hospital, and in PACU and higher mortality rates. The independent risk factors for POD were age, ASA-PS, emergency surgery and the amount of plasma administered during surgery.JUSTIFICATIVA Y OBJETIVOS: El delirio postoperatorio (DPO) en pacientes quirurgicos en cuidados intensivos es un resultado independiente y un importante determinante. El objetivo de nuestro estudio fue evaluar la incidencia y los determinantes del DPO. METODOS: Estudio prospectivo de cohorte realizado durante un periodo de 10 meses en una unidad de recuperacion de postanestesia (URPA) con cinco camas especializadas en cuidados intensivos. Todos los pacientes adultos consecutivos que fueron sometidos a cirugia mayor fueron incluidos. Los datos demograficos, las variables perioperatorias, el tiempo de ingreso (TI) y la mortalidad en la URPA en el hospital y en los 6 meses de seguimiento quedaron registrados. El delirio postoperatorio se evaluo utilizando el Checklist para la seleccion de delirio en cuidados intensivos (Intensive Care Delirium Screening Checklist - ICDSC). Los analisis descriptivos fueron realizados y el test de Mann-Whitney, Xi-Cuadrado (Xi2) y el test exacto de Fisher fueron usados para las comparaciones. El analisis de regresion logistica evaluo los factores determinantes del DPO con el calculo de la razon de chances (RC) y su intervalo de confianza de 95% (IC 95%). RESULTADOS: La admision fue de 775 pacientes adultos en la URPA y 95 pacientes no respetaron los criterios de inclusion. De los 680 pacientes restantes, 128 (18,8%) desarrollaron DPO. Los determinantes independientes de DPO identificados fueron la edad, ASA-PS, cirugia de emergencia y la cantidad total de plasma fresco congelado (PFC) administrado durante la cirugia. Los pacientes con delirio tuvieron tasas mas elevadas de mortalidad, estaban mas gravemente enfermos y permanecieron mas tiempo en la URPA y en el hospital. El DPO fue un factor de riesgo independiente para la mortalidad hospitalaria. DISCUSION: La incidencia de delirio fue elevada en los pacientes quirurgicos en cuidados intensivos. El DPO estuvo asociado con una peor puntuacion de gravedad de la enfermedad, tiempo de permanencia mas largo en el hospital y en la URPA y tasas mas elevadas de mortalidad. Los factores de riesgo independientes para DPO fueron la edad, ASA-PS, cirugia de emergencia y cantidad de plasma administrado durante la cirugia.