Sex differences in myocardial injury after non-cardiac surgery and postoperative mortality.

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) has recently been accepted as a predictor of mortality. However, sex differences in the incidence of MINS and survival thereafter are not fully understood. This study aimed to compare the incidence of MINS and mortality among male and female patients. METHODS: This single-center study was conducted using the database of a large tertiary referral hospital. Consecutive patients with cardiac troponin (cTn) detected within 30 days after non-cardiac surgery performed between January 2010 and June 2019 were grouped according to sex. The incidence of MINS and mortality of patients with MINS were compared between men and women. RESULTS: Of the 33,311 patients, 18,546 (55.7%) were men and 14,765 (44.3%) were women. In a multivariable analysis, women showed a significantly lower incidence of MINS than did men (17.9% vs. 14.2%; odds ratio, 0.76; 95% confidence interval [CI], 0.71-0.81; P < 0.001). In patients with MINS, the propensity-score-matched analysis showed that 30-day mortality did not differ according to sex, but mortality in females was significantly lower than that in males during the overall follow-up (33.0% vs. 25.7%; hazard ratio, 0.75; 95% CI, 0.66-0.84; P < 0.001). CONCLUSION: The incidence of MINS was lower in women than in men. In patients with MINS, female sex may be associated with a survival benefit. Further studies are needed to confirm these findings.

Risk factors for femoral-to-radial artery pressure gradient after weaning from cardiopulmonary bypass: a historical cohort study.

PURPOSE: After weaning from cardiopulmonary bypass (CPB), the radial artery pressure is frequently lower than the central pressure as reflected by femoral pressure. This discrepancy may cause improper blood pressure management. In this study, we aimed to evaluate the risk factors related to developing a significant postbypass femoral-to-radial pressure gradient, including the incidence of complications related to femoral pressure monitoring. METHODS: From January 2017 to May 2021, we studied consecutive adult cardiovascular surgical patients undergoing CPB in a historical cohort study. Patients were divided into two groups according to developing a significant femoral-to-radial pressure gradient, which was defined as a difference of ≥ 25 mm Hg for systolic pressure or ≥ 10 mm Hg for mean pressure, lasting ≥ 5 minutes for 30 minutes after CPB weaning. Factors associated with a significant pressure gradient and femoral pressure monitoring-related complications were analyzed. RESULTS: Among 2,019 patients, 677 (34%) showed a significant postbypass femoral-to-radial pressure gradient. Multivariable logistic regression analysis revealed the following factors related to the pressure gradient development: age (adjusted odds ratio [aOR] for an increase in 10 years, 1.09; 95% confidence interval [CI], 1.04 to 1.09; P < 0.001), body surface area (BSA) (aOR for an increase in 1 m2, 0.12; 95% CI, 0.07 to 0.21; P < 0.001), aortic cross-clamping time (aOR for an increase in 30 minutes, 1.05; 95% CI, 1.03 to 1.08; P < 0.001), and intraoperative epinephrine use (aOR, 1.55; 95% CI, 1.23 to 1.95; P < 0.001). The femoral pressure monitoring-related complications were observed in 11/2,019 (0.5%) patients. CONCLUSION: Our study showed that old age, smaller BSA, prolonged aortic cross-clamping time, and intraoperative epinephrine use were associated with developing a significant postbypass femoral-to-radial pressure gradient in cardiovascular surgery. Considering monitoring-related complications occurred very infrequently, it might be helpful to monitor both radial and femoral pressure simultaneously in patients with these risk factors for appropriate blood pressure management. Nevertheless, further studies are needed to confirm our findings because our results are limited by a retrospective design and residual confounding factors.

RéSUMé: OBJECTIF: Après le sevrage de la circulation extracorporelle (CEC), la pression dans l'artère radiale est souvent inférieure à la pression centrale, comme en témoigne la pression fémorale. Cette divergence peut provoquer une gestion inadaptée de la tension artérielle. Dans cette étude, nous avons cherché à évaluer les facteurs de risque liés au développement d'un gradient de pression significatif fémoro-radial post CEC, y compris l'incidence des complications liées à la surveillance de la pression fémorale. MéTHODES: Nous avons étudié consécutivement, de janvier 2017 à mai 2021, des patients adultes de chirurgie cardiovasculaire subissant une CEC dans une étude de cohorte historique. Les patients ont été séparés en deux groupes en fonction de la survenue d'un gradient de pression fémoro-radial significatif qui était défini ainsi : différence de ≥ 25 mmHg pour la pression systolique ou ≥ 10 mmHg pour la pression moyenne, durant ≥ 5 minutes pendant les 30 minutes suivant le sevrage de la CEC. Les facteurs associés à un gradient de pression significatif et aux complications liées à la surveillance de la pression fémorale ont été analysés. RéSULTATS: Parmi les 2 019 patients, 677 (34 %) ont présenté un gradient de pression fémoro-radial significatif post CEC. Une analyse par régression logistique multifactorielle a révélé que les facteurs suivants étaient liés à la survenue du gradient de pression : l'âge (rapport de cotes ajusté [aOR] pour une augmentation en dix ans, 1,09; intervalle de confiance [IC] à 95 % : 1,04 à 1,09; P < 0,001), la surface corporelle (SC) (aOR pour une augmentation dans 1 m2, 0,12; IC à 95 %, 0,07 à 0,21; P < 0,001), la durée du clampage aortique (aOR pour une augmentation en 30 minutes, 1,05; IC à 95 %, 1,03 à 1,08; P < 0,001) et l'utilisation peropératoire d'épinéphrine (aOR, 1,55; IC à 95 %, 1,23 à 1,95; P < 0,001). Des complications liées à la surveillance de la pression fémorale ont été observées chez 11 patients sur 2019 (0,5 %). CONCLUSION: Notre étude a montré qu'un âge avancé, une petite SC, une durée prolongée de clampage aortique et l'utilisation peropératoire d'épinéphrine étaient associés à la survenue d'un gradient de pression fémoro-radial significatif en chirurgie cardiovasculaire. Considérant que les complications liées à la surveillance ont été très rares, il pourrait être utile de surveiller simultanément la pression radiale et la pression fémorale chez les patients ayant ces facteurs de risque pour une gestion appropriée de la pression artérielle. Néanmoins, d'autres études sont nécessaires pour confirmer nos constatations, car ces résultats sont limités par le plan rétrospectif de l'étude et des facteurs confondants résiduels.

Comparison of two sizes of GlideScope® blades in tracheal intubation of infants: a randomised clinicaltrial.

BACKGROUND: The appropriate size of GlideScope® blade for tracheal intubation in neonates and premature infants has not been established. We evaluated the impact of the size of the GlideScope® blade on the time taken for intubation in infants weighing 2.5-3.6 kg. METHODS: Sixty infants weighing 2.5-3.6 kg were randomly assigned to use of the size 1 blade (n=30) or the size 2 blade (n=30). The primary outcome was the time taken to intubate. Components related to the laryngoscopic view which could affect the duration of the intubating process were also analysed. RESULTS: The time required for tracheal intubation was shorter with the size 2 blade than with the size 1 blade (16 [14-20] s vs 22 [18-25] s, P=0.002; median difference=-5; 95% confidence interval, -7 to -2). The rate at which the tip of the tracheal tube was located at the centre of the laryngeal inlet was higher with the size 2 blade than with the size 1 blade (83% vs 40%, P<0.001). Correlation analysis indicated that the time required to find the tip of the tube was related to how far the lower border of the arytenoid cartilages was located from the mid-horizontal line of the monitor (r=0.28, P=0.033). CONCLUSION: Use of the size 2 blade significantly reduced the time required to intubate the trachea, compared with the size 1 GlideScope® blade in infants. CLINICAL TRIAL REGISTRATION: KCT 0003867.

Vasoactive inotropic score as a predictor of long-term mortality in patients after off-pump coronary artery bypass grafting.

Increased vasoactive-inotropic score (VIS) is a reliable predictor of mortality and morbidity after cardiac surgery. Here, we retrospectively evaluated the association between VIS and adverse outcomes in adult patients after off-pump coronary artery bypass grafting (OPCAB). We included 2149 patients who underwent OPCAB. The maximal VIS was calculated for the initial 48 postoperative hours using standard formulae. The primary outcome was 1-year death. The composite adverse outcome was death, resuscitation or mechanical support, myocardial infarction, revascularization, new-onset atrial fibrillation, infection requiring antibacterial therapy, acute kidney injury, and stroke. Path-analysis was conducted using lactate and prognostic nutritional index (PNI). VIS was associated with 1-year death (odds ratio [OR] 1.07 [1.04-1.10], p < 0.001) and 1-year composite outcome (OR 1.02 [1.0-1.03], p = 0.008). In path-analysis, high VIS showed a direct effect on the increased risk of 1-year death and composite outcome. In the pathway using lactate as a mediating variable, VIS showed an indirect effect on the composite outcome but no significant effect on death. Low PNI directly affected the increased risk of 1-year death and composite outcome, and had an indirect effect on both outcomes, even when VIS was used as a mediating variable. In patients undergoing OPCAB, high VIS independently predicted morbidity and 1-year death. Patients with increased lactate levels following high VIS had an increased risk of postoperative complications, although not necessarily resulting in death. However, patients with poor preoperative nutritional status had an increased risk of unfavourable outcomes, including death, implying the importance of preoperative nutritional support.

Intravenous iron injection does not impair liver function in a rat model of cirrhosis.

BACKGROUND: There is a lack of convincing data concerning the safety of iron therapy in patients with advanced liver cirrhosis (LC). This study investigated the hepatic effects of ferric carboxymaltose, an intravenous iron supplement, in a rat model of cirrhosis. METHODS: In total, 45 Sprague-Dawley rats were allocated into three groups: normal rats (control group, n=15), cirrhotic rats receiving intravenous normal saline (LC group, n=15), and cirrhotic rats receiving 20 mg/kg intravenous ferric carboxymaltose (LC-iron group, n=15). LC was induced by twice-weekly intraperitoneal injection of carbon tetrachloride. Biochemical parameters were compared at 0, 2, 14, and 28 days. Additionally, liver tissue samples were extracted from five rats in each group at 2, 14, and 28 days for evaluation of the degrees of hepatic fibrosis and iron deposition. Inflammatory and oxidative stress markers were also compared among groups. RESULTS: Serum alanine transferase levels did not significantly differ between the LC and LC-iron groups at 0 (443±110 vs. 444±117 IU/L, P>0.99), 2 (453±117 vs. 479±136 IU/L, P=0.84), 14 (1,535±1,058 vs. 1,578±711 IU/L, P=0.55), or 28 days (2,067±641 vs. 2,533±914 IU/L, P=0.15). The degree of hepatic fibrosis was comparable between the groups, although hepatic iron accumulation was greater in the LC-iron group than in the LC group. The levels of inflammatory and oxidative stress markers were significantly lower in the LC-iron group than in the LC group. CONCLUSIONS: In our rat model of cirrhosis, the administration of intravenous iron appears safe. However, further preclinical and clinical studies are warranted to confirm the safety and efficacy of intravenous iron in patients with LC or end-stage liver disease.