Toward a standard approach to measurement and reporting of perioperative mortality rate as a global indicator for surgery

INTRODUCTION: The proportion of patients who die during or after surgery, otherwise known as the perioperative mortality rate (POMR), is a credible indicator of the safety and quality of operative care. Its accuracy and usefulness as a metric, however, particularly one that enables valid comparisons over time or between jurisdictions, has been limited by lack of a standardized approach to measurement and calculation, poor understanding of when in relation to surgery it is best measured, and whether risk-adjustment is needed. Our aim was to evaluate the value of POMR as a global surgery metric by addressing these issues using 4, large, mixed, surgical datasets that represent high-, middle-, and low-income countries. METHODS: We obtained data from the New Zealand National Minimum Dataset, the Geelong Hospital patient management system in Australia, and purpose-built surgical databases in Pietermaritzburg, South Africa, and Port Moresby, Papua New Guinea. For each site, we calculated the POMR overall as well as for nonemergency and emergency admissions. We assessed the effect of admission episodes and procedures as the denominator and the difference between in-hospital POMR and POMR, including postdischarge deaths up to 30 days. To determine the need for risk-adjustment for age and admission urgency, we used univariate and multivariate logistic regression to assess the effect on relative POMR for each site. RESULTS: A total of 1,362,635 patient admissions involving 1,514,242 procedures were included. More than 60% of admissions in Pietermaritzburg and Port Moresby were emergencies, compared with less than 30% in New Zealand and Geelong. Also, Pietermaritzburg and Port Moresby had much younger patient populations (P < .001). A total of 8,655 deaths were recorded within 30 days, and 8-20% of in-hospital deaths occurred on the same day as the first operation. In-hospital POMR ranged approximately 9-fold, from 0.38 per 100 admissions in New Zealand to 3.44 per 100 admissions in Pietermaritzburg. In New Zealand, in-hospital 30-day POMR underestimated total 30-day POMR by approximately one third. The difference in POMR if procedures were used instead of admission episodes ranged from 7 to 70%, although this difference was less when central line and pacemaker insertions were excluded. Age older than 65 years and emergency admission had large, independent effects on POMR but relatively little effect in multivariate analysis on the relative odds of in-hospital death at each site. CONCLUSION: It is possible to collect POMR in countries at all level of development. Although age and admission urgency are strong, independent associations with POMR, a substantial amount of its variance is site-specific and may reflect the safety of operative and anesthetic facilities and processes. Risk-adjustment is desirable but not essential for monitoring system performance. POMR varies depending on the choice of denominator, and in-hospital deaths appear to underestimate 30-day mortality by up to one third. Standardized approaches to reporting and analysis will strengthen the validity of POMR as the principal indicator of the safety of surgery and anesthesia care.

Comparison of peri-operative core temperature in obese and non-obese patients*

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Genotoxicity, cytotoxicity and gene expression in patients undergoing elective surgery under isoflurane anaesthesia

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Post-operative analgesic effects of butorphanol or firocoxib administered to dogs undergoing elective ovariohysterectomy

ObjectiveTo compare the post-operative analgesic effects of butorphanol or firocoxib in dogs undergoing ovariohysterectomy.Study designProspective, randomized, blinded, clinical trial.AnimalsTwenty-five dogs > 1 year of age.MethodsDogs received acepromazine intramuscularly (IM), 0.05 mg kg-1 and either butorphanol IM, 0.2 mg kg-1 (BG, n = 12) or firocoxib orally (PO), 5 mg kg-1 (FG, n = 13), approximately 30 minutes before induction of anesthesia with propofol. Anesthesia was maintained with isoflurane. Ovariohysterectomy was performed by the same surgeon. Pain scores using the dynamic and interactive visual analog scale (DIVAS) were performed before and at 1, 2, 3, 4, 6, 8 and 20 hours after the end of surgery by one observer, blinded to the treatment. Rescue analgesia was provided with morphine (0.5 mg kg-1) IM and firocoxib, 5 mg kg-1 (BG only) PO if DIVAS > 50. Groups were compared using paired t-tests and Fisher's exact test (p < 0.05). Data are presented as mean +/- SD.ResultsThe BG required significantly less propofol (BG: 2.6 +/- 0.59 mg kg-1; FG: 5.39 +/- 0.7 mg kg-1) (p < 0.05) but the anesthesia time was longer (BG: 14 +/- 6, FG: 10 +/- 4 minutes). There were no differences for body weight (BG: 7.9 +/- 5.0, FG: 11.5 +/- 4.6 kg), sedation scores, and surgery and extubation times (BG: 10 +/- 2, 8 +/- 5 minutes; FG: 9 +/- 3, 8 +/- 4 minutes, respectively) (p > 0.05). The FG had significantly lower pain scores than the BG at 1, 2 and 3 hours following surgery (p < 0.05). Rescue analgesia was administered to 11/12 (92%) and 2/13 (15%) dogs in the BG and FG, respectively (p < 0.05).Conclusion and clinical relevanceFirocoxib produced better post-operative analgesia than butorphanol. Firocoxib may be used as part of a multimodal analgesia protocol but may not be effective as a sole analgesic.

Respiratory pressures and expiratory peak flow rate of patients undergoing coronary artery bypass graft surgery

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Influence of fresh frozen plasma as a trigger factor for kidney dysfunction in cardiovascular surgery

OBJETIVO: A disfunção renal é uma complicação importante no cenário de pós-operatório de cirurgia cardiovascular. Como fatores de risco conhecidos no intraoperatório para o seu desenvolvimento destacam-se a circulação extracorpórea, a hemodiluição, drogas antifibrinolíticos e a transfusão sanguínea. O objetivo deste estudo é identificar os fatores de risco na transfusão de sangue e derivados para o desenvolvimento de disfunção renal em pacientes submetidos à cirurgia cardiovascular. MÉTODOS: Noventa e sete pacientes foram estudados e 84 foram analisados. A amostra foi estratificada em dois grupos, sendo que o incremento de 30% na creatinina sérica no pós-operatório foi considerado para o grupo com disfunção renal (n = 9; 10,71%). O grupo não disfunção renal foi caracterizado pela creatinina sérica, que permaneceu inferior a aumento de 30% no pós-operatório (n = 75; 89,28%). RESULTADOS: Foi observado que a transfusão de plasma fresco congelado no grupo não disfunção renal foi de 2,05 ± 0,78 unidades e 3,80 ± 2,16 unidades no grupo disfunção renal com P= 0,032. CONCLUSÃO: Foi possível associar, nesta série de pacientes, que a transfusão de plasma fresco congelado foi um fator de risco para disfunção renal pós-operatório de cirurgia cardiovascular.

Comparison of inflammatory cytokine profiles in plasma of patients undergoing otorhinological surgery with propofol or isoflurane anesthesia

Objective and design: The effects of anesthetics on cytokine release in patients without comorbidities who undergo minor surgery are not well defined. We compared inflammatory cytokine profiles in adult patients undergoing minimally invasive surgery who received isoflurane or propofol anesthesia. Methods: Thirty-four patients without comorbidities undergoing minor surgery were randomly assigned to receive an inhaled anesthetic (isoflurane; n = 16) or an intravenous anesthetic (propofol; n = 18). Blood samples were drawn before premedication and anesthesia (T1), 120 min after anesthesia induction (T2), and on the first post-operative day (T3). Plasma concentrations of interleukins (IL-) 1β, 6, 8, 10 and 12 and tumor necrosis factor (TNF)-α were measured using flow cytometry. Results: The pro-inflammatory cytokine IL-6 was increased in the isoflurane group at T2 and T3 compared to T1 (P < 0.01). In the propofol group, IL-6 and IL-8 were significantly increased at T3 compared to T1. However, there were no significant differences in cytokine concentrations between the isoflurane and propofol groups. Conclusion: An inflammatory response occurred earlier in patients who received an inhaled agent compared with an intravenous anesthetic, but no differences in plasma cytokine profiles were evident between isoflurane and propofol anesthesia in patients without comorbidities undergoing minimally invasive surgeries. © 2013 Springer Basel.

Ultrasonographic, computed tomographic, and operative findings in dogs infested with giant kidney worms (Dioctophyme renale)

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Pre- and post-operative evaluations of eight dogs following right nephrectomy due to Dioctophyma renale

Background: Dioctophyma renale is a large nematode distributed worldwide that may cause progressive and severe destruction of renal parenchyma.Objectives: The present study aimed to evaluate pre- and post-operatively dogs submitted to right nephrectomy due to D. renale and to assess the histopathological damage of the removed kidney.Animals and methods: Eight crossbred dogs, aged from 12 to 48 months that were unilaterally nephrectomized due to the presence of D. renale were evaluated. Physical examination, urinalysis, complete blood count, serum biochemistry, and abdominal ultrasound were performed immediately before and one month after nephrectomy. The nephrectomized right kidneys were submitted to macroscopic and microscopic evaluations.Results: Urinalysis preoperatively detected occult blood in all dogs and D. renale eggs in five cases. Complete blood count showed all parameters within the reference range, except one dog post-operatively. Serum biochemistry performed before and after surgery verified that urea, creatinine and sodium were within the reference range values in all dogs. Other findings varied among the dogs. The length and arterial resistive index mean values of the left kidney were similar pre- and post-operatively.Conclusions: Thus, the inconsiderable change in laboratory findings pre- and post-operatively was attributable to compensation by left kidney function for the removed abnormal right kidney. Right kidney histology revealed chronic nephropathy due to D. renale.Clinical importance: Imaging diagnosis should be performed on dogs suspected as carrying the disease or on those from an enzootic area since the laboratory findings are not specific except eggs in the urine.

Innovation in pediatric surgery: the use of ultrasonic CVD tips: case report

The non-eruption of teeth due to highly keratinized gingival mucosa is a frequent event in the pediatric dentistry, which harms the oral aesthetics and function. A surgical excision of the involved area is indicated, exposing the non-erupted tooth. This procedure involves anesthesia and cutting instruments that may increase the fear and anxiety in young patients. The use of new technologies has avoided these instruments and has promoted more comfort to the patients. This study presents clinical cases in which gingivectomy was performed using the innovative method with an ultrasound-activated CVD tip. It was concluded that this method presented effectiveness, promoted more comfort, and less fear to the patients, making its use a viable alternative to pediatric surgery.

Late evaluation of the relationship between morphological and functional renal changes and hypertension after non-operative treatment of high-grade renal injuries

Objective: To evaluate the anatomical and functional renal alterations and the association with post-traumatic arterial hypertension. Methods: The studied population included patients who sustained high grades renal injury (grades III to V) successfully non-operative management after staging by computed tomography over a 16-year period. Beyond the review of medical records, these patients were invited to the following protocol: clinical and laboratory evaluation, abdominal computed tomography, magnetic resonance angiography, DMSA renal scintigraphy, and ambulatory blood pressure monitoring. The hypertensive patients also were submitted to dynamic renal scintigraphy (Tc-99m EC), using captopril stimulation to verify renal vascular etiology. Results: Of the 31 patients, there were thirteen grade III, sixteen grade IV (nine lacerations, and seven vascular lesions), and two grade V injuries. All the patients were asymptomatic and an average follow up post-injury of 6.4 years. None had abnormal BUN or seric creatinine. The percentage of renal volume reduction correlates with the severity as defined by OIS. There was no evidence of renal artery stenosis in Magnetic Resonance angiography (MRA). DMSA scanning demonstrated a decline in percentage of total renal function corresponding to injury severity (42.2 +/- 5.5% for grade III, 35.3 +/- 12.8% for grade IV, 13.5 +/- 19.1 for grade V). Six patients (19.4%) had severe compromised function (< 30%). There was statistically significant difference in the decrease in renal function between parenchymal and vascular causes for grade IV injuries (p < 0.001). The 24-hour ambulatory blood pressure monitoring detected nine patients (29%) with post-traumatic hypertension. All the patients were male, mean 35.6 years, 77.8 % had a familial history of arterial hypertension, 66.7% had grade III renal injury, and average post-injury time was 7.8 years. Seven patients had negative captopril renography. Conclusions: Late results of renal function after conservative treatment of high grades renal injuries are favorable, except for patients with grades IV with vascular injuries and grade V renal injuries. Moreover, arterial hypertension does not correlate with the grade of renal injury or reduction of renal function.

Post-operative mediastinitis in a Heart Hospital of Recife: contributions for nursing care

The objective of this study was to determine the prevalence of post-operative mediastinitis with the purpose to contribute to nursing care knowledge. To do this, an analysis was performed on 896 medical records of patients who underwent heart surgery involving sternotomy at the Cardiology Emergency Room of Recife-PE, in the period between June 2007 and June 2009. The following variables were considered: gender, age, type of surgery, personal history, length of stay, use of antibiotics, and culture of the surgical wound. A high death rate from mediastinitis was observed (33.3%). Several risk factors were identified, including: systemic arterial hypertension (80.9%); smoking (61.9%); diabetes mellitus (42.8%); and obesity (33.3%), most of which (76.2%) were identified in patients who underwent surgery for myocardial revascularization. It is concluded that mediastinitis is a serious infection that needs continuous nursing supervision and preventive measures to assure an early diagnosis and, thus, reduce mortality.

Comparison between endoscopic and open surgery in 37 patients with nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma is a rare benign vascular tumor of the nasopharynx. Although the treatment of choice is surgery, there is no consensus on what is the best approach. Aim: To compare surgical time and intraoperative transfusion requirements in patients undergoing endoscopic surgery versus open / combined and relate the need for transfusion during surgery with the time between embolization and surgery. Material and Methods: Study descriptive, analytical, retrospective study with a quantitative approach developed in the Otorhinolaryngology department of a teaching hospital. Analyzed 37 patients with angiofibroma undergoing surgical treatment. Data obtained from medical records. Analyzed with tests of the Fisher-Freeman-Halton and Games-Howell. Was considered significant if p <0.05. Study design: Historical cohort study with cross-sectional. Results: The endoscopic approach had a shorter operative time (p <0.0001). There is less need for transfusion during surgery when the embolization was performed on the fourth day. Conclusion: This suggests that the period ahead would be ideal to perform the process of embolization and endoscopic surgery by demanding less time would be associated with a lower morbidity. This study, however, failed to show which group of patients according to tumor stage would benefit from specific technical.

Impact of pediatric epilepsy surgery on intellectual efficiency

Introduction. Epilepsy surgery may be a promising alternative therapy for seizure control in patients with refractory seizures, resistant to medication. Cognitive outcome is another important factor in favor of the surgical decision. Aim. To investigate the correlation between seizure outcome and cognitive outcome after epilepsy surgery in a pediatric population. Patients and methods. A total of 59 pediatric patients were retrospectively assessed with the WISC-III (Full Scale, Verbal Scale and Performance Scale) before and, at least, 6 months after surgery. Patients were divided into two groups according whether or not improvement of seizure control after surgery. Data collected for each child included: epileptic syndrome, etiology, age at epilepsy onset, duration of epilepsy and seizure frequency. Results. Comparison using a MANOVA test revealed significant differences across pre-operative Full Scale, Verbal Scale and Performance Scale (p = 0.01) with seizure reduction group performing better than no seizure reduction group. Seizure improvement group achieved significant Performance Scale improvement (p = 0.01) and no seizure improvement group showed significant Verbal Scale worsened after surgery (p = 0.01). Conclusions. Our results suggest that the success of the epilepsy surgery in childhood when the seizure control is achieved may also provide an improvement in the Performance Scale whereas the seizure maintenance may worsen the Verbal Scale.

Preoperative 6-min walking distance does not predict pulmonary complications in upper abdominal surgery

Background and objective: Field exercise tests have been increasingly used for pulmonary risk assessment. The 6-min walking distance (6MWD) is a field test commonly employed in clinical practice; however, there is limited evidence supporting its use as a risk assessment method in abdominal surgery. The aim was to assess if the 6MWD can predict the development of post-operative pulmonary complications (PPCs) in patients having upper abdominal surgery (UAS). Methods: This prospective cohort study included 137 consecutive subjects undergoing elective UAS. Subjects performed the 6MWD on the day prior to surgery, and their performance were compared with predicted values of 6MWD (p6MWD) using a previously validated formula. PPCs (including pneumonia, tracheobronchitis, atelectasis with clinical repercussions, bronchospasm and acute respiratory failure) were assessed daily by a pulmonologist blinded to the 6MWD results. 6MWD and p6MWD were compared between subjects who developed PPC (PPC group) and those who did not (no PPC group) using Student's t-test. Results: Ten subjects experienced PPC (7.2%) and no significant difference was observed between the 6MWD obtained in the PPC group and no PPC group (466.0 +/- 97.0 m vs 485.3 +/- 107.1 m; P = 0.57, respectively). There was also no significant difference observed between groups for the p6MWD (100.7 +/- 29.1% vs 90.6 -/+ 20.9%; P > 0.05). Conclusions: The results of the present study suggest that the 6-min walking test is not a useful tool to identify subjects with increased risk of developing PPC following UAS.