Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery?

BACKGROUND: International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes. METHODS: This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records. MAIN RESULTS: A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year. CONCLUSIONS: This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.

Progressive disseminated histoplasmosis mimicking a flare of systemic lupus erythematosus: a European case report.

INTRODUCTION: Diagnosing progressive disseminated histoplasmosis (PDH) in patients with systemic lupus erythematosus (SLE) is diagnostically challenging. Since PDH is lethal when untreated, awareness of this infection in patients with SLE is of utmost importance. To the best of our knowledge, this is the first description of a case of PDH in a patient with SLE in Europe. CASE PRESENTATION: A 56-year-old woman of Surinamese descent with a history of SLE, presented with fever and polyarthritis. Although a flare of SLE was suspected initially, cultures of bone marrow and broncho-alveolar lavage fluid grew Histoplasma capsulatum. CONCLUSION: This case report highlights that physicians should be aware of progressive disseminated histoplasmosis in patients with SLE treated with immunosuppressive agents. The signs and symptoms can easily mimic a SLE flare, which would then be treated with more aggressive immunosuppression. Failure to recognize the infection will therefore invariably lead to death of the patient. Progressive disseminated histoplasmosis is usually not recognized by doctors in non-endemic areas such as Europe. However, globalisation and more frequent intercontinental traffic of immunocompromised patients currently increases the incidence of histoplasmosis in these areas. It is therefore of life-saving importance that doctors are aware of the features of the infection in areas where H. capsulatum is not endemic.

Low-dose fondaparinux in suspected heparin-induced thrombocytopenia in the critically ill.

BACKGROUND: In critically ill patients, heparin-induced thrombocytopenia (HIT) is estimated to account for approximately 1 to 10% of all causes of thrombocytopenia. HIT exerts a strong procoagulant state. In case of suspected HIT, it is an important clinical decision to stop heparin and start treatment with alternative nonheparin anticoagulation, awaiting the results of laboratory testing for the final diagnosis of HIT (bridging therapy). Fondaparinux acts by factor Xa inhibition and expresses no cross-reactivity with HIT antibodies. Excretion of fondaparinux is mainly renal. We describe our early experience with fixed low-dose fondaparinux bridging therapy and monitoring of anticoagulant activity for safety reasons. METHODS: This retrospective cohort study was conducted in a closed format general intensive care unit in a teaching hospital. Consecutive critically ill patients suspected of HIT were treated with fondaparinux after discontinuation of unfractionated heparin or nadroparin. Anti-Xa levels were determined afterwards. RESULTS: Seven patients were treated with fondaparinux 2.5 mg/day for 1.8 to 6.5 days. Anti-Xa levels varied from 0.1 to 0.6 U/ml. A negative correlation was found between creatinine clearance and mean and maximum anti-Xa levels. No thromboembolic complications occurred. Bleeding complications were only minor during fondaparinux treatment. Transfusion requirements did not differ significantly between treatment episodes with fondaparinux or with heparin anticoagulants. CONCLUSION: In this small sample of critically ill patients suspected of HIT, bridging therapy with fixed low-dose fondaparinux resulted in prophylactic and therapeutic anti-Xa levels. Monitoring of anticoagulant activity is advised in patients with renal insufficiency.

Disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection in a patient with infliximab and methotrexate.

CASE PRESENTATION: Despite chemoprophylaxis with isoniazid a 58-year-old Creole patient with mild rheumatoid arthritis developed disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection during treatment with infliximab and methotrexate. TREATMENT: The patient received antituberculous drugs (ethambutol, isoniazid, pyrazinamide, rifampicin), amphotericin B, flucytosine, and valaciclovir, along with prolonged intensive care treatment and mechanical ventilation. CONCLUSIONS: The present case confirms that isoniazid prophylaxis (300 mg once daily, during 6 months) does not protect against the reactivation and dissemination of latent tuberculosis. It also shows that combined treatment with infliximab and methotrexate may induce severe immunosuppression with prolonged leukocytopenia and depressed cellular immunity, leading to multiple opportunistic infections. Extensive diagnostic testing, early start of antimicrobial therapy and enteral immunonutrition, and further infection prevention with selective decontamination of the digestive tract may have been the key to a good clinical outcome.

[Diagnostic image (76). A woman with acute pancreatitis]. / Diagnose in beeld (76). Een vrouw met acute pancreatitis. Hemorragische pancreatitis met bloedingen in de flanken (teken van Gray Turner).

A 59-year-old woman had severe acute pancreatitis and Grey Turner's sign of bluish discoloration of the flanks with local infiltration at CT.

Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ failure--a prospective, double-blind, placebo-controlled trial.

OBJECTIVE: Critical illness-related colonic ileus (CIRCI) is characterized by the non-passage of stools in critically ill patients as a result of the absence of prokinetic movements of the colon, while the upper gastrointestinal tract functions properly and mechanical ileus is absent: We investigated whether neostigmine resulted in defecation in patients with CIRCI. DESIGN: Double-blinded, placebo-controlled prospective study. SETTING: Eighteen-bed intensive care unit. PATIENTS: Thirty ventilated patients with multiple organ failure with CIRCI for > 3 days. INTERVENTION: Continuous intravenous administration of neostigmine 0.4-0.8 mg/h over 24 h, or placebo. MEASUREMENTS AND RESULTS: Time to first defecation and adverse reactions were recorded. Thirty patients were randomized, 24 could be evaluated. The mean prestudy time was 5 days, mean APACHE II score on admission was 23.2, and mean MOF score on the day of the study was 6.4. Of the 13 patients receiving neostigmine, 11 passed stools, whereas none of the placebo-treated patients passed stools (P < 0.001). After 24 h, the non-responders received in a cross-over fashion neostigmine or placebo respectively. Eight out of the 11 neostigmine patients now passed stools (mean 11.4 h), and none of the placebo patients. Overall, in none of the patients did passage of stools occur during placebo infusion, whereas 19 of the 24 neostigmine-treated patients had defecation (79%). No acute serious adverse effects occurred, but three patients had ischemic colonic complications 7-10 days after treatment. CONCLUSION: Continuous infusion of 0.4-0.8 mg/h of neostigmine promotes defecation in ICU patients with a colonic ileus without important adverse reactions.

Outcome of critically ill patients treated with intermittent high-volume haemofiltration: a prospective cohort analysis.

OBJECTIVE: To evaluate intervention and outcome in critically ill patients treated with high-volume haemofiltration (HV-HF). DESIGN: Prospective cohort analysis. SETTING: 18-bed closed format general intensive care unit (ICU) of a teaching hospital. PATIENTS: 30-month cohort of ICU patients treated with HV-HF. INTERVENTIONS: Intermittent high-volume venovenous haemofiltration. ENDPOINTS: Observed and predicted mortality in prospectively stratified prognostic groups. MEASUREMENTS AND RESULTS: Clinical and filtration data, Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II and the Madrid Acute Renal Failure (ARF) score and predicted mortality. A total of 306 patients were haemofiltrated (140 medical, 166 surgical), 52 % were oliguric. Mean APACHE II score was 31 (SD 8) and mean SAPS II score 60 (SD 16). Mean ultrafiltrate rate was 63 ml/min (SD 20). A median total of 160 litres (90 % range 49 to 453) were filtrated per patient, material costs were 565 ECU (90 % range 199 to 1514). ICU mortality was 33 %, hospital mortality 40 % [95 % confidence interval (CI) 34 to 45], predicted mortality by the ARF score 67 % (CI 66 to 69). Non-cardiac surgery mortality was 47 % (CI 39 to 54), 73 % (CI 70 to 76) predicted by APACHE II and 67 % (CI 64 to 70) by SAPS II. Observed mortality was significantly lower than predicted in all prognostic groups. The standardised mortality ratio (SMR) was no higher than the SMR in the overall ICU population. CONCLUSIONS: Mortality in HV-HF patients was lower than that predicted by illness severity scores, as was the case in all patients in our ICU. Treatment with HV-HF appears to be safe and feasible. The efficacy of HV-HF should be tested in randomised, controlled trials of suitable power.

Myocardial contusion as a result of isolated sternal fractures: a fact or a myth?

Isolated sternal fractures are seen with an increasing frequency in traffic road accidents especially after the introduction of the seatbelt legislation. In most cases, the victims are young, otherwise healthy individuals. The medical records of all patients who were treated with a diagnosis of sternal fracture over the past 10 years were retrospectively reviewed. All patients with a radiologic diagnosis of sternal fracture were admitted for cardiac monitoring for at least 24 hours. ECG, determinations of cardiac enzyme levels CK (creatinephosphokinase) and CK-MB and evaluation by a cardiologist were routinely performed. An echocardiography was performed when indicated by the cardiologist. A total of 86 patients had sustained a sternal fracture during the 10-year study period. There were 39 males and 47 females with a mean age of 50 years (range 15-97 years). Serial 12-lead electrocardiograms, which were performed in 83 (97%) patients, revealed no information about myocardial contusion or cardiac arrhythmias with consequent therapy. In eight patients, a significant elevation in cardiac enzyme levels (elevation of CK-MB fraction above 10% of CK) was observed. All were normalized within 24 hours without development of any arrhythmias. Echocardiography was performed in 31 patients. In two patients, dyskinesia of the right ventricle (without enzyme elevations or arrhythmias) was observed. Within 24 hours these abnormalities resolved. The cardiac rhythm was monitored in 61 (71%) patients for a total of 1550 hours. No arrhythmias were observed. The cardiac enzyme studies, ECG and echocardiography revealed no consequent information about arrhythmias. In case of a sternal fracture, we recommend a chest X-ray to exclude other associated intrathoracic injuries. If no abnormalities are identified, admission to hospital is not necessary.

Intraoperative continuous hemofiltration for metabolic management in acute aortoiliac occlusion.

Acute aortoiliac occlusion, or Leriche's syndrome, carries a risk of the development of severe ischemia-reperfusion injury, characterized by electrolyte and acid-base balance disturbances. These injuries are often fatal, because of the rapid deterioration of multiple organ systems. We present a case in which we intraoperatively and postoperatively treated hyperkalemia and metabolic acidosis by high-volume, continuous, veno-venous hemofiltration, which is a recently developed form of continuous renal replacement therapy.

[Heart tamponade: a life-threatening complication of a central venous catheter]. / Harttamponade: een levensbedreigende complicatie van een centraal-veneuze katheter.

A 57-year-old female patient initially admitted with acute pancreatitis became extremely hypotensive, with increased central venous pressure, a few hours after insertion of a central venous catheter into the right subclavian vein. Echocardiography revealed a large amount of pericardial fluid, which was removed by pericardiocentesis. A cardiac tamponade as a result of central venous cannulation is a rare but serious complication with a high mortality rate. The tamponade may be the result of perforation of the V. cava superior, the right atrium or the right ventricle (as in the patient described). Cardiac tamponade should be suspected in any patient with severe hemodynamic problems after insertion of a central venous line.

[Toxic damage of kidney, liver and muscle attributed to the administration of germanium-lactate-citrate]. / Toxische beschadiging van nier, lever en spier toegeschreven aan het gebruik van germanium-lactaat-citraat.

The case history is described of a woman aged 57 years with renal, hepatic and muscular damage attributed to intake of germanium lactate-citrate (a cumulative dose of 32.1 g germanium) over at least one year, as alternative treatment of metastatic breast cancer. Histological examination of biopsies showed highly vacuolated cytoplasm of the epithelial cells of the distal renal tubules and micro- and macrovesicular steatosis of centrilobular hepatocytes. After discontinuation of the germanium, serum aminotransferases and creatine kinase values returned to normal, but moderately severe renal impairment persisted.