Postoperative hemoglobin levels and its association with myocardial ischemia in non-cardiac surgical patients.

BACKGROUND: Low hemoglobin (Hb) levels as well as cardiac complications are common conditions in postoperative surgical patients and both are associated with poor outcome. The aim of this study was to determine the influence of postoperative Hb levels on myocardial ischemia in high-risk patients who underwent non-cardiac surgery. METHODS: In this retrospective observational cohort study, we evaluated 3638 consecutive patients admitted to the 24-hour postoperative anesthesia care unit between 2006 and 2010; 273 (8%) high-risk patients, defined as three or more cardiac risk factors, were selected for analyses. Postoperative Hb levels were divided into tertiles (low, intermediate and high). The endpoint of this study was myocardial ischemia which was defined as new electrocardiographic abnormalities and/or elevated levels of troponin-T. The relationship between postoperative Hb levels and myocardial ischemia was assessed using logistic regression analyses stratified by gender. RESULTS: Postoperative myocardial ischemia was present in 73 (27%) of the 273 patients. After adjustment for significant pre-, intra- and postoperative risk factors, 4 independent risk factors remained for postoperative myocardial ischemia in male patients: age (OR 1.1; 95% CI: 1.0-1.1), a history of ischemic heart diseases (OR 4.2; 95% CI: 1.0-17.8), renal failure (OR 5.4; 95% CI: 2.1-13.9) and postoperative Hb levels: intermediate tertile (10.3-11.6 g/dL) (OR 5.8; 95% CI: 1.6-20.9) and lowest tertile (7.9-10.2 g/dL) (OR 12.9; 95% CI: 3.0-55.5). CONCLUSION: Postoperative Hb levels are independently associated with postoperative myocardial ischemia in high-risk patients undergoing non-cardiac surgery.

Keuskamp and the Amsterdam Infant Ventilator.

At the First International Symposium on the History of Modern Anaesthesia (1982), Professor Keuskamp mentioned that the introduction of breathing machines for lung ventilation during operations had taken over 'the tiresome handwork of ventilation'. This paper traces some aspects of Keuskamp's professional career and his role in the development of the Amsterdam Infant Ventilator. In 1974, Urban and Weitzner from the State University of New York reported that the ventilator was a reliable and effective constant-volume paediatric ventilator. Other clinicians from the United States and Europe echoed this satisfactory clinical evaluation. At present, this paediatric ventilator is still in use for the initial ventilation of small infants and for the mechanical ventilation of different animal species in a variety of experimental settings.

Comparison of one-lung ventilation and high-frequency ventilation in thoracoscopic surgery.

OBJECTIVE: To report our experience of the use of high frequency ventilation (HFV) in thoracoscopic surgery. DESIGN: Retrospective study. SETTING: University Hospital Rotterdam, The Netherlands. SUBJECTS: 31 patients (18 men and 13 women, mean age 42 years, range 26-67 years) who underwent 46 thoracoscopic procedures between January 1992 and December 1997. INTERVENTIONS: Until October 1994 patients had conventional mechanical ventilation with a double-lumen tube. Since then HFV has been used. MAIN OUTCOME MEASURES: Duration of induction, oxygen saturation, and end-tidal carbon dioxide tension. RESULTS: 25 procedures were done with a double-lumen endotracheal tube for one-lung ventilation and in 21 HFV was used. Induction of anaesthesia took significantly less time in the HFV group (median 14 minutes) compared with one-lung ventilation group (median 31 minutes) (p < 0.05). There were no significant differences between the groups in either SaO2 or end-tidal CO2. CONCLUSION: HFV is both safe and simple for use in thoracoscopic surgery.

Evaluation of mortality in surgical neonates over a 10-year period: nonpreventable, permissible, and preventable death.

The mortality pattern and causes of death in surgical neonates were evaluated over the period of 1980 through 1990 in order to assess whether any deaths might have been prevented. In the study period 1,010 neonates were admitted, 104 of whom died (10%). These 104 neonates formed our study population. The Clinical Classification System (CCS) and the Therapeutic Intervention Scoring System (TISS) were used to assess the severity of illness. All 104 nonsurvivors were seriously ill (CCS 3 and 4; TISS greater than 20). The mortality pattern was classified in three groups. Group A (nonpreventable death) included 56 deaths, 48 of which were due to the underlying disease. The other 8 patients died of a nonpreventable complication of treatment. Eleven of the patients in group B (permissible death) had (multiple) congenital anomalies associated with chromosomal anomalies. Three of them were not treated and in the other 8 treatment was initially started but later withdrawn. In most of the other 14 patients further treatment was withdrawn because of serious postoperative complications or inoperable cardiac anomalies. Group C (preventable death) consisted of 23 patients. Six of 10 had irreversible brain damage due to prolonged hypoxemia. In the other 13 patients of group C, death was due to sepsis acquired in the postoperative period and treated inadequately. Staphylococcus epidermidis was the most frequent isolated pathogen (7/13).

Disturbed defecation after colectomy for aganglionosis investigated with monoclonal antineurofilament antibody.

Experience with 108 neonates treated for aganglionosis at the Sophia Children's Hospital, Rotterdam, between 1975 and 1983 has been reviewed. Twenty two of them suffered from disturbed defecation postoperatively, involving 16 cases of classical Hirschsprung's, 4 long-segment aganglionosis, 1 case of aganglionosis up to the cecum, and 1 total aganglionosis. The monoclonal antineurofilament antibody NF2F11 was used to investigate ganglionated as well as aganglionic bowel specimens of these patients as well as 17 patients from the remainder without postoperative constipation serving as controls. The original diagnosis was confirmed in all cases. Proximal ganglionated bowel of all 17 controls appeared normal, while the antibody revealed normal bowel in only 4 out of the 22 patients with postoperative constipation. In 18 cases this new staining technique revealed the picture of pseudo-obstruction. Early recognition of pseudo-obstruction in proximal ganglionated bowel would provide early warning of postoperative complications.

Diagnosis of congenital neurogenic abnormalities of the bowel with monoclonal anti-neurofilament antibodies.

The diagnostic properties of two monoclonal, antineurofilament antibodies were tested in a retrospective investigation of bowel specimens of 24 cases of Hirschsprung's disease, eight cases of long-segment aganglionosis, eight cases of pseudo-obstruction, and six cases of chronic constipation. Immunohistochemical staining with the antibodies in combination with hematoxylin counterstaining revealed six distinctive and divergent pictures, demonstrating innervation disturbances in all cases. Apart from Hirschsprung's disease and long-segment aganglionosis, characteristic pictures also appeared for pseudo-obstruction and, diversely, for chronic constipation. In addition, anomalies were revealed in the ganglionic, proximal bowel of five patients with Hirschsprung's and two with long-segment aganglionosis, who had all suffered from chronic constipation postoperatively.