Atraumatic splenic rupture in a patient treated with rivaroxaban: A case report and a narrative review.

Atraumatic splenic rupture (ASR) is a rare condition mostly associated with neoplastic, infectious, and inflammatory diseases. ASR associated with drug treatment is even rarer. In this case report, we highlight an unusual complication of the direct oral anticoagulant rivaroxaban. A 64-year-old male patient was admitted to the emergency department with complaints of faintness and diffuse abdominal cramps. The patient had no history of recent trauma. Clinical examination revealed hemodynamic instability with a moderate response to filling and mild abdominal discomfort on palpation. His medical history included chronic hypertension, constipation, and recent atrial flutter ablation. The patient was taking amiodarone, bisoprolol, atorvastatin, and rivaroxaban. Splenic rupture was diagnosed several hours later on contrast-enhanced abdominal computed tomography scan. Massive blood transfusions and emergency laparotomy for splenectomy were performed. Anatomopathological analysis did not reveal any neoplastic, inflammatory, or infectious causes. The patient was successfully discharged from the intensive care unit 3 days later. Clinicians must consider the possibility of ASR as a complication of rivaroxaban in patients with abdominal tenderness and hemodynamic instability. Unfortunately, clinical presentation is not always typical of a ruptured spleen. Delayed diagnosis can be life threatening or fatal. Splenectomy via laparotomy remains the best therapeutic option in cases of splenic rupture in unstable patients on direct oral anticoagulants.

Avoiding, Not Managing, Drug Withdrawal Syndrome in the Setting of COVID-19 Acute Respiratory Distress Syndrome. Comment on Ego et al. How to Manage Withdrawal of Sedation and Analgesia in Mechanically Ventilated COVID-19 Patients? J. Clin. Med. 2021, 10, 4917.

The management of sedation in the setting of COVID-19 ("COVID") by Ego et al. [...].

Procedural Sedation With Dexmedetomidine in Combination With Ketamine in the Emergency Department.

BACKGROUND: Dexmedetomidine is an alternative agent for procedural sedation in the emergency department thanks to its ability to maintain hemodynamic and respiratory stability. Dexmedetomidine must, however, be combined with a powerful analgesic. OBJECTIVE: Our aim was to evaluate the quality and safety of procedural sedation using the combination of dexmedetomidine and ketamine for patients undergoing painful procedures in the emergency department. METHODS: This prospective interventional single-center study was conducted in an academic emergency department of an urban hospital in Brussels, Belgium. Patients received a bolus injection of 1 µg/kg dexmedetomidine over 10 min and then a continuous infusion of 0.6 µg/kg/h followed by a bolus of 1 mg/kg ketamine. The painful procedure was carried out 1 min later. The level of pain was evaluated with a numerical rating scale from 0 (no pain) to 10 (maximal pain). The level of patient comfort for the procedure was measured using a comfort scale. RESULTS: Thirty patients were included. Overall, 90% of patients felt little or no pain (n = 29 of 30) or discomfort (n = 28 of 30) during the procedure. One patient experienced apnea with desaturation, which was resolved by a jaw-thrust maneuver. Although 23% of patients had significant arterial hypertension, none required drug treatment. CONCLUSIONS: The combination of dexmedetomidine and ketamine provides conscious sedation, bringing comfort and pain relief to patients in optimal conditions for respiratory and hemodynamic safety. However, sedation and recovery times are longer than with conventional drug combinations. The dexmedetomidine-ketamine combination should therefore be recommended for nonurgent procedures and fragile patients.

Is Intraoperative Opioids Avoidance A Utopia? A Matched Study in Laparoscopic Hysterectomy.

BACKGROUND: Opioid-sparing strategies are recommended, and Opioid-Free Anaesthesia (OFA) is proposed in the literature. But few data exist about the feasibility of OFA in the routine practice. From a larger series of 21,463 patients receiving OFA, this work investigates the postoperative pain and related outcomes in patients undergoing laparoscopic hysterectomy. MATERIALS AND METHODS: This matched retrospective study concerned 521 patients scheduled for a laparoscopic hysterectomy between 2010 and 2015 (118 receiving OFA and 403 receiving anaesthesia with opioids, AO). Primary outcome was pain in the Post-Anaesthetic Care Unit (PACU). RESULTS: Among the 521 included patients, 403 received sufentanil (mean±SD: 0.1±0.05 mcg/kg), the only synthetic opioid used to balance anaesthesia. Concerning the 118 patients receiving OFA, most of them received an association of clonidine (97%) and ketamine (95%). Most of the patients in both groups received non-steroidal anti-inflammatory drugs. No difference in pain scores was observed between AO and OFA (median [IQR], respectively: 4 [0-5] vs. 4.5 [0-6], P=0.74). A difference in the perioperative morphine equivalent use was observed (mean±SD: 0.18±0.06 mg/kg vs. 0.09±0.06 mg/kg, P<0.001). No difference was observed regarding the nausea/vomiting incidences, use of anti-emetics, sedation scores, or time spent at the PACU. CONCLUSION: Coming from an extensive daily practice, these data show that OFA is feasible and not associated with higher pain scores or longer PACU stay, suggesting the absence of specific immediate complications.

Characterization of Preoperative, Postsurgical, Acute and Chronic Pain in High Risk Breast Cancer Patients.

BACKGROUND: Pain after breast cancer surgery remains largely unexplained and inconsistently quantified. This study aims to describe the perioperative pain patterns in patients with breast cancer, up to two years after surgery. METHODS: This is a pre-planned sub-study of the Ketorolac in Breast Cancer (KBC) trial. The KBC trial was a multicentre, prospective, double-blind, placebo-controlled, randomised trial of a single dose of 30 mg of ketorolac just before breast cancer surgery, aiming to test its effect on recurrences. This sub-study focuses only on pain outcomes. From 2013 to 2015, 203 patients were randomised to ketorolac (n = 96) or placebo (n = 107). Structured questionnaires were delivered by telephone after one and two years, exploring the presence, location, permanence, and frequency of pain. Patients' perceptions of pain were captured by an open-ended question, the responses to which were coded and classified using hierarchical clustering. RESULTS: There was no difference in pain between the ketorolac and the placebo group. The reported incidence of permanent pain was 67% and 45% at one and two years, respectively. The largest category was musculoskeletal pain. Permanent pain was mainly described in patients with musculoskeletal pain. The description of pain changed in most patients during the second postoperative year, i.e., moved from one category to another (no pain, permanent, or non-permanent pain, but also, the localisation). This phenomenon includes patients without pain at one year. CONCLUSIONS: Pain is a complex phenomenon, but also a fragile and unstable endpoint. Pain after breast cancer surgery does not necessarily mean breast pain but also musculoskeletal and other pains. The permanence of pain and the pain phenotype can change over time.

Intraoperative ketorolac in high-risk breast cancer patients. A prospective, randomized, placebo-controlled clinical trial.

BACKGROUND: Ketorolac has been associated with a lower risk of recurrence in retrospective studies, especially in patients with positive inflammatory markers. It is still unknown whether a single dose of pre-incisional ketorolac can prolong recurrence-free survival. METHODS: The KBC trial is a multicenter, placebo-controlled, randomized phase III trial in high-risk breast cancer patients powered for 33% reduction in recurrence rate (from 60 to 40%). Patients received one dose of ketorolac tromethamine or a placebo before surgery. Eligible patients were breast cancer patients, planned for curative surgery, and with a Neutrophil-to-Lymphocyte Ratio≥4, node-positive disease or a triple-negative phenotype. The primary endpoint was Disease-Free Survival (DFS) at two years. Secondary endpoints included safety, pain assessment and overall survival. FINDINGS: Between February 2013 and July 2015, 203 patients were assigned to ketorolac (n = 96) or placebo (n = 107). Baseline characteristics were similar between arms. Patients had a mean age of 55.7 (SD14) years. At two years, 83.1% of the patients were alive and disease free in the ketorolac vs. 89.7% in the placebo arm (HR: 1.23; 95%CI: 0.65-2.31) and, respectively, 96.8% vs. 98.1% were alive (HR: 1.09; 95%CI: 0.34-3.51). CONCLUSIONS: A single administration of 30 mg of ketorolac tromethamine before surgery does not increase disease-free survival in high risk breast cancer patients. Overall survival difference between ketorolac tromethamine group and placebo group was not statistically significant. The study was however underpowered because of lower recurrence rates than initially anticipated. No safety concerns were observed. TRIAL REGISTRATION: ClinicalTrials.gov NCT01806259.

What Can We Learn from Sarcopenia with Curarisation in the Context of Cancer Surgery? A Review of the Literature.

INTRODUCTION: The monitoring of the curarisation is a unique opportunity to investigate the function of the neuromuscular junction (NMJ) during cancer surgery, especially in frailty-induced and age-related sarcopenia. METHOD: We conducted a comprehensive literature review in PubMed, without any limit of time related to frailty, sarcopenia, age and response to neuromuscular blockers in the context of cancer surgery. RESULTS: Several modifications appear with age: changes in cardiac output, a decrease in muscle mass and increase in body fat, the deterioration in renal and hepatic function, the plasma clearance and the volume of distribution in elderly are smaller. These changes can be exacerbated in cancer patients. We also find modifications of the NMJ: dysfunctional mitochondria, modifications in the innervation of muscle fibers and motor units, uncoupling of the excitation-contraction of muscle fibers, inflammation. Neuromuscular blocking agents (NMBAs) compete with acetylcholine and prevent it from fixing itself on its receptor. Many publications reported guidelines for using NMBAs in the elderly, based on studies comparing old people with young people. No one screened frailty before, and thus, no studies compared frail elderly and non-frail elderly undergoing cancer surgery. CONCLUSION: Despite many studies about curarisation in the specific populations, and many arguments for a potential interest for investigation, no studies investigated specifically the response to NMBAs in regard of the frailty-induced and age-related sarcopenia.

Pulmonary lobectomy in two multitrauma patients under extracorporeal circulation placed preoperatively in an intensive care unit: A case report.

The clinical course of our two patients highlights the feasibility of using venovenous extracorporeal membrane oxygenation (ECMO) with heparin for multitraumatic patients needing thoracic surgery. Further research is required to determine if surgery can be performed with totally heparin-free vv-ECMO. All ICU teams should become familiar with this technique.

Pain management in living related adult donor hepatectomy: feasibility of an evidence-based protocol in 100 consecutive donors.

OBJECTIVE: Living donor hepatectomy (LDH) has important consequences in terms of acute and chronic pain. We proposed an anesthetic protocol based on the best currently available evidence. We report the results of this protocol's application. RESULTS: We performed a retrospective descriptive study of 100 consecutive donors undergoing LDH. The protocol included standardized information provided by the anesthetist, pharmacological anxiolysis and preventive analgesia. Specifically, pregabalin premedication (opioid-free) intravenous anesthesia (with clonidine, ketamine, magnesium sulphate and ketorolac) and epidural analgesia were proposed. Postoperative follow-up was conducted by the Postoperative Pain Service. This analysis included 100 patients (53 women, 47 men, median age 32.7 years old [28.4-37.3]), operated by xypho-umbilical laparotomy. All elements of our anesthetic protocol were applied in over 75% of patients, except for the preoperative consultation with a senior anesthesiologist (55%). The median number of applied item was 7 [interquartile range, IQR 5-7]. Median postoperative pain scores were, at rest and at mobilization respectively 3 [IQR 2-4] and 6 [IQR 4.5-7] on day 1; 2 [IQR 1-3] and 5 [IQR 3-6] on day 2; and 2 [IQR 0-3] and 4 [IQR 3-5] on day 3. In conclusion, LDH leads to severe acute pain. Despite the proposal of a multimodal evidence-based protocol, its applicancy was not uniform and the pain scores remained relatively high.

What is the place of clonidine in anesthesia? Systematic review and meta-analyses of randomized controlled trials.

STUDY OBJECTIVE: A place for clonidine has been suggested for many indications in perioperative medicine. The aim of this systematic review and these meta-analyses is to systematically, and quantitatively, evaluate these potential indications of clonidine. DESIGN, SETTING, PATIENTS AND INTERVENTIONS: We selected and analyzed (qualitatively and, when possible, quantitatively) the available literature published on PubMed/Medline and on the Cochrane database. Inclusion criteria included: human randomized controlled trials involving adults who received perioperative systemic (oral, intramuscular, transdermal and intravenous) clonidine for every type of surgery. MEASUREMENTS AND MAIN RESULTS: We identified 775 trials and thereafter excluded 718 and analyzed 57 trials concerning, in total, 14,790 patients of whom 7408 received clonidine and 6836 received placebo. Most important results shows that, in qualitative and quantitative analyses, clonidine vs placebo reduces analgesics consumption in, respectively, (159 vs 154 patients: 24%, 95%CI[16%-32%]; p<0.001), reduces nausea and vomiting (risk ratio, in 180 vs 181 patients: 0.35, 95%CI[0.25-0.51]; p<0.001), improves hemodynamic stability (reduction of HR: 14.9bpm, 95%CI[10.4-19.5]; p<0.001; reduction of the MAP: 12.5mmHg, 95%CI[7.14-17.86]; p<0.001); 1min after tracheal intubation, in 67 vs 68 patients), prevents postoperative shivering (risk ratio, in 140 vs 140 patients: 0.17, 95%CI[0.10-0.29]; p<0.001). On the other hand, clonidine does not have any influence on renal and cardiac outcomes (adverse events rates, in 5873 vs 5533 patients: 0.00, 95%CI[-0.10-0.11]; p=0.96) and does not prolong awakening time. CONCLUSIONS: In conclusion, these systematic review and meta-analyses of 57 trials confirm that clonidine improves pain control, reduces PONV, improves hemodynamic and sympathetic stability, with no adverse consequences on renal function or awakening time, but does not influence cardiac outcome in the general population, after non-cardiac surgery. Nevertheless, given the high heterogeneity between the studies, this does not exclude different results in patient subgroups or specific procedures.

What is the normal value of the neutrophil-to-lymphocyte ratio?

BACKGROUND: Neutrophil-to-lymphocyte ratio (NLR) has proven its prognostic value in cardiovascular diseases, infections, inflammatory diseases and in several types of cancers. However, no cut-off has been proposed on the basis of reference values coming from healthy population. METHODS: Routine blood samples were obtained (n = 413) from workers (age: median 38, range: 21-66 years) involved in a health care prevention program, to determine means, standard deviations (SDs), 95% confidence intervals (95% CI), percentiles P2.5 and P97.5. A second independent sample of healthy volunteers is compared (n = 29). RESULTS: The mean NLR is 1.65 [±1.96 SD: 0.78-3.53] (95% CI [0.75-0.81] and [3.40-3.66]). In the second cohort (healthy control), the NLR values are in the same range, whichever the used analyzer. No NLR assessed in the validation series is out of the proposed limits. CONCLUSIONS: We have identified that the normal NLR values in an adult, non-geriatric, population in good health are between 0.78 and 3.53. These data will help to define the normal values of the NLR.

Does the perioperative analgesic/anesthetic regimen influence the prevalence of long-term chronic pain after mastectomy?

STUDY OBJECTIVE: To investigate if the anesthetic/analgesic regimen is associated with the risk of reporting long-term chronic postmastectomy pain (CPMP). DESIGN: Cross-sectional survey SETTING: Academic hospital PATIENTS: A total of 267 women having undergone mastectomy with axillary lymph node dissection between 2003 and 2008 INTERVENTIONS: All patients were contacted between October and December 2012, with a questionnaire asking for persistent pain after surgery and its characteristics. MEASUREMENTS: Besides demographical data, tumor characteristics, and adjuvant treatment, we recorded type and doses of intraoperative anesthetics/analgesics (sufentanil, ketamine, clonidine, nonsteroidal anti-inflammatory drugs, MgSO4, propofol, or halogenated agents). RESULTS: Of the 128 patients returning analyzable questionnaires, 43.8% reported chronic pain (48.2% with neuropathic characteristics). Multivariate logistic/linear regression model showed 4 factors independently associated with persistent pain: recall of preoperative pain (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.09-1.48), chemotherapy (OR, 1.32; 95% CI, 1.13-1.55), need for strong opioids in postanesthesia care unit (OR, 1.30; 95% CI, 1.11-1.53), and halogenated agent anesthesia (OR, 0.81; 95% CI, 0.70-0.95). CONCLUSION: In conclusion, our study confirms the high prevalence of CPMP, 4 to 9 years after surgery. Recall of preoperative pain, chemotherapy, and need for strong opioids in the postanesthesia care unit were all associated with the presence of chronic pain. Of the intraoperative analgesics/anesthetics studied, only use of halogenated agents was associated with a lower prevalence of CPMP.

Dynamic view of postoperative pain evolution after total knee arthroplasty: a prospective observational study.

BACKGROUND: Having a dynamic view of postoperative pain resolution allows a better understanding of the transition towards chronic pain. Sleep and quality of life are important determinants of satisfaction after total knee arthroplasty (TKA), besides functional recovery and pain. METHODS: For 114 patients undergoing TKA we recorded the presence of pain at rest, pain evoked at movement and pain located at the incision site in the acute (postoperative day 1, 2, 3, 8), subacute (30 days, 3 months) and chronic (6 months and 1 year) period. Analgesics consumption and need of medical assistance for pain were questioned. Quality of life measured by the impact on enjoyment of life, sleep and mood were monitored. RESULTS: Average incidence for subacute pain was 54% at rest, 66% at mobilization. For chronic pain, the incidence was 14% at rest, 22% during mobilization. Pain at rest peaked at day 30 while pain during mobilization displayed a plateau between day 8 and 3 months. Three per cent of the patients complained at 1 year of pain at the incision site. 11% of patients still took analgesics one year after the surgery. More than 40% of patients reported moderate to severe alterations of sleep and quality of life in the acute period, decreasing to less than a half at one year. CONCLUSIONS: The trajectories of the different types of pain after TKA show their non-linear evolution, highlighting the need of a better pain control at precise moments. Sleep disturbances and alterations of quality of life are still present one year after the surgery.

Use of the neutrophil-to-lymphocyte ratio as a component of a score to predict postoperative mortality after surgery for hip fracture in elderly subjects.

BACKGROUND: Hip fracture precedes death in 12-37 % of elderly people. Identification of high risk patients may contribute to target those in whom optimal management, resource allocation and trials efficiency are needed. The aim of this study is to evaluate a predictive score of mortality after hip fracture in older persons on the basis of the objective prognostic factors easily available: age, sex and neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP). PATIENTS AND METHODS: After the ethical committee approval, we analyzed our prospective database including 286 consecutive older patients (>64 years) with hip fracture. A score [range 0-4] was constructed, based on a previous analysis, combining age (1 point per decade above 74 years), sex (1 point for male gender) and NLR at postoperative day +5 (1 point if > 5). A receiver-operating curve (ROC) analysis was performed. Similar analyses were performed with CRP (1 point if > 7.65 mg/dL). RESULTS: In the 286 patients (male 31 %), the median age was 84 (65-102) years, and the mean NLR values were 6.47 ± 6.07. At 1 year, 82/286 patients died (28.7 %). In the 235 patients with complete data, significant differences in term of mortality risk are observed (P < 0.001). Performance analysis shows an AUC of 0.72[95 % CI 0.65-0.79]. CRP performed less than NLR (AUC for CRP alone: 0.53[95 % CI 0.45-0.61], P = 0.42, with a sensitivity of 58.5 % and a specificity of 57.1 % for a cut-off value of 7.65 mg/dL; and for NLR alone: 0.59 [95 % CI 0.51-0.66]; P = 0.02, with a sensitivity of 55 % and a specificity of 65 % for a cut-off value of 4.9). CONCLUSION: A discrete 0-4 scoring systems based on age, sex and the NLR was shown to be predictive of mortality in elderly patients during the first postoperative year following surgery for hip fracture repair.

Unplanned intensive care unit admission after general anaesthesia in children: A single centre retrospective analysis.

OBJECTIVES: To determine the main causes for unplanned admission of children to the paediatric intensive care unit (PICU) following anaesthesia in our centre. To compare the results with previous publications and propose a data sheet for the prospective collection of such information. METHODS: Inclusion criteria were any patient under 16 years who had an unplanned post-anaesthetic admission to the PICU from 1999 to 2010 in our university hospital. Age, ASA score, type of procedure, origin and causes of the incident(s) that prompted admission and time of the admission decision were recorded. RESULTS: Out of a total of 44,559 paediatric interventions performed under anaesthesia during the study period, 85 were followed with an unplanned admission to the PICU: 67% of patients were younger than 5 years old. Their ASA status distribution from I to IV was 13, 47, 39 and 1%, respectively. The cause of admission was anaesthetic, surgical or mixed in 50, 37 and 13% of cases, respectively. The main causes of anaesthesia-related admission were respiratory or airway management problems (44%) and cardiac catheterisation complications (29%). In 62%, the admission decision was taken in the operating room. CONCLUSION: Unplanned admission to the PICU after general anaesthesia is a rare event. In our series, most cases were less than 5 years old and were associated with at least one comorbidity. The main cause of admission was respiratory distress and the main type of procedure associated with admission was cardiac catheterisation.

Biomarkers in immunonutrition programme, is there still a need for new ones? A brief review.

BACKGROUND AND AIMS: Pre-existing malnutrition is one the most important factors affecting postsurgical complications, especially in cancer patients. The consequences of this on the immune function as well as on outcome could be reversed by immunonutrition. To help the clinician as a researcher, a routinely available biomarker (derived from clinical or biological data) would be of great importance. METHODS: We reviewed the potential markers that may routinely be used in perioperative immunonutrition programmes. A comprehensive approach was used to identify and discuss the potential markers, focusing on body mass and serum biomarkers. RESULTS: Body mass (including weight loss and body mass index) are predictive of complications, but not specifically to malnutrition. Serum markers, such as albumin, transthyretin, white blood cells counts, and C-reactive protein are not more specific. Composite scores, including the Nutritional Risk Index (NRI), the Prognostic Inflammatory and Nutritional Index (PINI), the modified Glasgow Prognostic Score (mGPS), the neutrophil-to-lymphocyte ratio (NLR), CD4 and CD8 lymphocytes counts, the platelet-to-lymphocyte ratio (PLR), the Prognostic Index (PI), and the Prognostic Nutritional Index (PNI) are prognostic factors of outcome, but are not always correlated to immunonutrition effect. CONCLUSIONS: In conclusion, there remains a lack of efficient and widely available monitoring of the effects of immunonutrition. To predict and monitor the effect of immunonutrition on immunity, efforts should be directed to the validation of routinely available tools to aid the implementation of advanced immune monitoring (like lymphocytes subpopulations counts) in clinical practices.

Modulation of spinal glial reactivity by intrathecal PPF is not sufficient to inhibit mechanical allodynia induced by nerve crush.

Spinal glial reactivity has been strongly implicated in pain that follows peripheral nerve injury. Among the many therapeutic agents that have been tested for anti-allodynia through immune modulation is the atypical methylxanthine propentofylline. While propentofylline shows a potent anti-allodynia effect after nerve transection injury, we here demonstrate that, when propentofylline is used intrathecally at the effective immune-modulatory dose, allodynia after rat nerve crush injury is completely preserved. Microglial/macrophage Iba-1 and astrocytic GFAP expression, increased in the dorsal horn of nerve crushed animals, was, however, effectively attenuated by propentofylline. Effective modulation of spinal glial reactivity is, thus, no assurance for anti-allodynia.

Is the Neutrophil-to-Lymphocyte Ratio more correlated than C-reactive protein with postoperative complications after major abdominal surgery?

Background. The Neutrophil-to-Lymphocyte Ratio (NLR) is an inflammatory marker that has proven usefulness for predicting late complications. Whether it is associated with immediate postoperative complications after abdominal surgery is not known. In this study, we attempted to correlate the NLR and the C-reactive protein (CRP) with postoperative complications rate. Methods. We performed a post-hoc analysis of previously collected data concerning 82 consecutive patients (median age: 62 years, range: 27-80, female/male 32/50) undergoing major abdominal surgeries. For each patient, we recorded preoperative characteristics, the NLR and CRP values, and postoperative complications (between D + 8 and D + 30) such as infections (N = 29), cardiovascular complications (N = 12) and other complications (N = 28). We performed uni- and multivariate analyses using logistic/linear regression models. Results. Patients with complications did not present a higher preoperative NLR than those without, but a higher ratio at D + 7 (10.73 ± 9.86 vs. 4.73 ± 3.38 without complication) (P < 0.001). In the univariate analysis, the NLR at D + 7 was associated with postoperative complications (P < 0.001). At D + 7, in the multivariate analysis, an increased NLR was associated with more complications (P < 0.001), whereas none of the other factors, including CRP, showed any correlation. Conclusion. Postoperative NLR at day 7 after major abdominal surgery is associated with complications during the first postsurgical month, in contrast with the CRP level. The NLR is a simple and interesting parameter in the perioperative period.

The neutrophil-to-lymphocyte ratio (NLR) after surgery for hip fracture (HF).

BACKGROUND: The NLR is a prognostic factor for outcome and survival in cardiology, oncology and digestive surgery. NLR has not yet been studied in HF. METHODS: Retrospective analysis of a prospective cohort of 247 consecutive patients, older than 65 years, operated for HF. Mortality at 12 months was registered, as the perioperative NLR values. RESULTS: After hip surgery in the 247 patients (women 71%, median age 85 years, range: 66-102), the mortality was 27.2% [95%confidence interval (CI): 21.4-33.0] at 12 months. Univariate analysis detected four risk factors for mortality: age (Hazard Ratio (HR)--by 10 year-increments: 2.08 [95%CI: 1.37-3.17], P<0.001), male gender (HR: 1.92 [95%CI: 1.17-3.14], P=0.009, MCM (≥3) (HR: 1.71 [95%CI: 1.006-2.92], P=0.047 and NLR>5 at day 5 (HR: 1.8 [95%CI: 1.11-2.94], P=0.002). In multivariate analysis, two factors remained significantly associated with mortality: age (HR: 2.28 [95%CI: 1.49-3.47], P<0.001) and male gender (HR: 2.26 [95%CI: 1.38-3.72], P=0.001). Two independent risk factors of postoperative cardiovascular complications were identified: NLR>5 at day 5 (Odds Ratio (OR): 3.34 [95%CI: 2.33-4.80], P=0.001) and MCM (OR: 3.04 [95%CI: 2.16-4.29], P=0.006). A higher risk of infection was independently associated with a NLR>5 at day 5 (OR: 2.12 [95%CI: 1.44-3.11], P=0.02). CONCLUSIONS: The NLR at fifth postoperative day is a risk factor of postoperative mortality and cardiovascular complications.