Relationship between volume and in-hospital mortality in digestive oncological surgery.

INTRODUCTION: The results previously obtained in Spain in the study of the relationship between surgical caseload and in-hospital mortality are inconclusive. The aim of this study is to evaluate the volume-outcome association in Spain in the setting of digestive oncological surgery. METHODS: An analytical, cross-sectional study was conducted with data from patients who underwent surgical procedures with curative intent of esophageal, gastric, colorectal and pancreatic neoplasms between 2006-2009 with data from the Spanish MBDS. In-hospital mortality was used as outcome variable. Control variables were patient, health care and hospital characteristics. Exposure variable was the number of interventions for each disease, dividing the hospitals in 3 categories: high volume (HV), mid volume (MV) and low volume (LV) according to the number of procedures. RESULTS: An inverse, statistically significant relationship between procedure volume and in-hospital mortality was observed for both volume categories in both gastric (LV: OR=1,50 [IC 95%: 1,28-1,76]; MV: OR=1,49 (IC 95%: 1,28-1,74)) and colorectal (LV: OR=1,44 [IC 95%: 1,33-1,55]; MV: OR=1,24 [IC 95%: 1,15-1,33]) cancer surgery. In pancreatic procedures, this difference was only statistically significant between LV and HV categories (LV: OR=1,89 [IC 95%: 1,29-2,75]; MV: OR=1,21 [IC 95%: 0,82-1,79]). Esophageal surgery also showed an inverse relationship, which was not statistically significant (LV: OR=1,89 [IC 95%: 0,98-3,64]; MV: OR=1,05 [IC 95%: 0,50-2,21]). CONCLUSIONS: The results of this study suggest the existence in Spain of an inverse relationship between caseload and in-hospital mortality in digestive oncological surgery for the procedures analyzed.

[Hospital care of patients with A/H1N1 influenza: evaluation of the first 1000 reported cases in Spain]. / Demanda de atención hospitalaria por gripe A/H1N1: evaluación de los primeros 1.000 casos atendidos.

INTRODUCTION AND OBJECTIVES: Influenza A is expected to have a great impact in countries in the northern hemisphere yet little has been reported about how this outbreak can affect hospital care. The aim of this study is to assess patients who demand care for flu symptoms and their outcome. MATERIAL AND METHODS: From the beginning of the outbreak a specific protocol was established for the care of patients with potential influenza A in admission, emergency and hospitalization ward. A nominal registry was designed with clinical and epidemiological data. RESULTS: 1018 patients were evaluated for potential influenza A from the beginning of the outbreak until the 31(st) August, 2009. 77% of them fulfilled clinical criteria and were classified as suspected cases. Mean age was 31,7 years (SD17,2), 52% were women, 3,3% pregnant or puerperal. The admission rate was 23,4% with a global mean stay of 3,5 days, and 2,5 for the adults who were admitted to the short stay hospital unit. 2,8 % had pneumonia, two patients required admission to the intensive care unit and one of them died. CONCLUSIONS: Our data show an outbreak with mild illness, with a remarkable percentage of pneumonia but with good outcome. Despite of the high percentage of admissions, and in order to avoid the misleading attention to other patients, we believe that an assistance model based in specific units, short stay and post-discharge follow up could be suitable.

Alveolar fluid clearance in healthy pigs and influence of positive end-expiratory pressure.

INTRODUCTION: The objectives were to characterize alveolar fluid clearance (AFC) in pigs with normal lungs and to analyze the effect of immediate application of positive end-expiratory pressure (PEEP). METHODS: Animals (n = 25) were mechanically ventilated and divided into four groups: small edema (SE) group, producing pulmonary edema (PE) by intratracheal instillation of 4 ml/kg of saline solution; small edema with PEEP (SE + PEEP) group, same as previous but applying PEEP of 10 cmH2O; large edema (LE) group, producing PE by instillation of 10 ml/kg of saline solution; and large edema with PEEP (LE + PEEP) group, same as LE group but applying PEEP of 10 cmH2O. AFC was estimated from differences in extravascular lung water values obtained by transpulmonary thermodilution method. RESULTS: At one hour, AFC was 19.4% in SE group and 18.0% in LE group. In the SE + PEEP group, the AFC rate was higher at one hour than at subsequent time points and higher than in the SE group (45.4% vs. 19.4% at one hour, P < 0.05). The AFC rate was also significantly higher in the LE + PEEP than in the LE group at three hours and four hours. CONCLUSIONS: In this pig model, the AFC rate is around 20% at one hour and around 50% at four hours, regardless of the amount of edema, and is increased by the application of PEEP.

Intratracheal dopamine attenuates pulmonary edema and improves survival after ventilator-induced lung injury in rats.

INTRODUCTION: Clearance of alveolar oedema depends on active transport of sodium across the alveolar-epithelial barrier. beta-Adrenergic agonists increase clearance of pulmonary oedema, but it has not been established whether beta-agonist stimulation achieves sufficient oedema clearance to improve survival in animals. The objective of this study was to determine whether the increased pulmonary oedema clearance produced by intratracheal dopamine improves the survival of rats after mechanical ventilation with high tidal volume (HVT). METHODS: This was a randomized, controlled, experimental study. One hundred and thirty-two Wistar-Kyoto rats, weighing 250 to 300 g, were anaesthetized and cannulated via endotracheal tube. Pulmonary oedema was induced by endotracheal instillation of saline solution and mechanical ventilation with HVT. Two types of experiment were carried out. The first was an analysis of pulmonary oedema conducted in six groups of 10 rats ventilated with low (8 ml/kg) or high (25 ml/kg) tidal volume for 30 or 60 minutes with or without intratracheally instilled dopamine. At the end of the experiment the animals were exsanguinated and pulmonary oedema analysis performed. The second experiment was a survival analysis, which was conducted in two groups of 36 animals ventilated with HVT for 60 minutes with or without intratracheal dopamine; survival of the animals was monitored for up to 7 days after extubation. RESULTS: In animals ventilated at HVT with or without intratracheal dopamine, oxygen saturation deteriorated over time and was significantly higher at 30 minutes than at 60 minutes. After 60 minutes, a lower wet weight/dry weight ratio was observed in rats ventilated with HVT and instilled with dopamine than in rats ventilated with HVT without dopamine (3.9 +/- 0.27 versus 4.9 +/- 0.29; P = 0.014). Survival was significantly (P = 0.013) higher in animals receiving intratracheal dopamine and ventilated with HVT, especially at 15 minutes after extubation, when 11 of the 36 animals in the HVT group had died as compared with only one out of the 36 animals in the HVT plus dopamine group. CONCLUSION: Intratracheal dopamine instillation increased pulmonary oedema clearance in rats ventilated with HVT, and this greater clearance was associated with improved survival.

Intermittent alveolar overdistension for 30 or 240 minutes does not produce acute lung injury in normal pig lung.

BACKGROUND: The objective is to study whether alveolar overdistension can induce acute lung injury in pigs as assessed by analysis of respiratory and histological parameters and inflammatory markers. MATERIALS AND METHODS: Experimental study, using mixed-breed pigs. Animals were assigned to one of the following groups: Control Group (CG) (n = 5), applying mechanical ventilation with tidal volume (Vt) of 10 ml/kg, respiratory rate (RR) of 18 bpm, and FiO2 of 1 for 240 min; High Vt for 30 min (HVt-30) Group (n = 5), applying ventilation with Vt of 50 ml/kg and RR of 8 bpm and FiO2 of 1 for 30 min, followed by ventilation as in the CG for a further 210 min; and HVt-240 Group (n = 5), applying ventilation with Vt of 50 ml/kg, RR of 8 bpm, and FiO2 of 1 for 240 min. Hemodynamic parameters, airway pressures, arterial blood gases, extravascular lung water (EVLW), and cytokines (IL-2, IL-4, IL-6, IL-10, TNF-alpha, and ITF-gamma) in plasma and bronchoalveolar lavage (BAL) were determined. Lungs were fixed with 10% formalin for histological analysis. Results are expressed as mean +/- standard deviation. The ANOVA test was used to compare measurements among the three groups. RESULTS: At 30 min, airway pressures and oxygenation of HVt-30 and HVt-240 groups were higher than those of controls [Pplateau: 39.2 +/- 5.6 and 33.0+/- 5.1 versus 12.2 +/- 1.3 (P < 0.01); PaO2/FiO2: 443.8 +/- 55 and 430.6 +/- 34 versus 194.4 +/- 77 (P < 0.01)]. In HVt-240 group, these parameters were also higher than in the other two groups at the subsequent measurement times. There were no differences among the groups in EVLW values. Cytokines were undetected or negligible in plasma and BAL in all of the groups. The histological analysis showed no changes suggestive of acute lung injury. CONCLUSIONS: In this animal model, ventilation for 4 h with large tidal volume did not cause ventilator-induced lung injury.