Malnutrition at the time of surgery affects negatively the clinical outcome of critically ill patients with gastrointestinal cancer.

INTRODUCTION: Malnutrition is a frequent concomitant of surgical illness, especially in gastrointestinal cancer surgery. The aim of the study was to assess the prevalence of malnutrition in the GI cancer patients and its relation with clinical outcome. We also examined associations between the energy balance and clinical outcomes in these patients. METHODS: Prospective study on 694 surgical patients treated in the ICU of the UHC of Tirana. Patients were divided into well-nourished and malnourished groups according to their nutritional status. Multiple regression analysis was used to analyze the effect of malnutrition and cumulated energy balance on clinical outcome. RESULTS: The prevalence of pre-operative malnutrition was 65.3% for all surgical patients and 84.9% for gastrointestinal cancer patients. Malnutrition, as analyzed by a multivariate logistic regression model, is an independent risk factor for higher complications, infections, and mortality, longer stay in the ventilator and ICU. Also this model showed that cumulated energy balance correlated with infections, and mortality and was independently associated with the length ventilator and ICU stay. CONCLUSION: This study shows that malnutrition is a significant problem in surgical patients, especially in patients with gastrointestinal cancer. Malnutrition and cumulated energy deficit in gastro-intestinal surgery patients with malignancy is an independent risk factor on increased post-operative morbidity and mortality.

Metformin-induced lactic acidosis associated with multiorganic failure.

Lactic acidosis is a rare but severe complication in patients with type 2 diabetes treated with metformin. Patients with lactic acidosis show commonly signs of shock, tissue hypoxia, acute hepatic or renal failure and the link between metformin therapy and lactic acidosis may be coincidental, associated or causal. Excessive plasma metformin concentrations show that lactic acidosis is due to a toxicological mechanism. We report a case of severe multiorganic failure in a subject after treatment with high doses of metformin.

Risk Factors for Postoperative Pulmonary Complications after Abdominal Surgery.

BACKGROUND: Incidence of postoperative pulmonary complications (PPC) in patients undergoing non-cardiothoracic surgery remains high and the occurrence of these complications has enormous implications for the patient and the health care system. AIM: The aim of the study was to identify risk factors for PPC in patients undergoing abdominal surgical procedures. MATERIALS AND METHODS: A prospective cohort study in abdominal surgical patients, admitted to the emergency and surgical ward of the UHC of Tirana, Albania, was conducted during the period: March 2014-March 2015. We collected data on the occurrence of a symptomatic and clinically significant PPC using clinical, laboratory, and radiology data. We evaluated the relations between PPCs and various pre-operative or intra-operative factors to identify risk factors. RESULTS: A total of 450 postoperative patients admitted to the surgical emergency and surgical ward were studied. The mean age were 59.85 ±13.64 years with 59.3% being male. Incidence of PPC was 27.3% (123 patients) and hospital length of stay was 4.93 ± 4.65 days. Length of stay was substantially prolonged for those patients who developed PPC (7.48 ± 2.89 days versus 3.97± 4.83 days, p < 0.0001. PPC were identified as risk factors for mortality, OR: 21.84; 95% CI: 11.66-40.89; P < 0.0001. The multivariate regression analysis identified as being independently associated with an increased risk of PPC: age ≥ 65 years (OR 11.41; 95% CI: 4.84-26.91, p < 0.0001), duration of operation ≥ 2.5 hours (OR 8.38; 95% CI: 1.52-46.03, p = 0.01, history of previous pulmonary diseases (OR 11.12; 95% CI: 3.28-37.65, P = 0.0001) and ASA > 2 (OR 6.37; 95% CI: 1.54-26.36, P = 0.01). CONCLUSION: We must do some efforts in reducing postoperative pulmonary complications, firstly to identify which patients are at increased risk, and then following more closely high-risk patients because those patients are most likely to benefit.

The prevalence and consequences of malnutrition risk in elderly Albanian intensive care unit patients.

PURPOSE: Many investigators have reported rising numbers of elderly patients admitted to the intensive care units (ICUs). The aim of the study was to estimate the prevalence of malnutrition risk in the ICU by comparing the prevalence of malnutrition between older adults (aged 65 years and above) and adults (aged 18-64 years), and to examine the negative consequences associated with risk of malnutrition in older adults. MATERIALS AND METHODS: A prospective cohort study in the ICU of the University Hospital Center of Tirana, Albania, was conducted. Logistic regression analysis was used to analyze the effect of malnutrition risk on the length of ICU stay, the duration of being on the ventilator, the total complications, the infectious complications, and the mortality. RESULTS: In this study, 963 patients participated, of whom 459 patients (47.7%) were aged ≥65 years. The prevalence of malnutrition risk at the time of ICU admission of the patients aged ≥65 years old was 71.24%. Logistic regression adjusted for confounders showed that malnutrition risk was an independent risk factor of poor clinical outcome for elderly ICU patients, for 1) infections (odds ratio [OR] =4.37; 95% confidence interval [CI]: 2.61-7.31); 2) complications (OR =6.73; 95% CI: 4.26-10.62); 3) mortality (OR =2.68; 95% CI: 1.72-4.18); and 4) ICU length of stay >14 days (OR =5.18, 95% CI: 2.43-11.06). CONCLUSION: Malnutrition risk is highly prevalent among elderly ICU patients, especially among severely ill patients with malignancy admitted to the emergency ward. ICU elderly patients at malnutrition risk will have higher complication and infection rates, longer duration of ICU stay, and increased mortality. Efforts should be made to implement a variety of nutritional care strategies, to change the nutritional practices not only at ward level, but nationally, according to the best clinical practice and recent guidelines.

Anesthetic challenges of patients with cardiac comorbidities undergoing major urologic surgery.

The cardiac patient undergoing major urologic surgery is a complex case requiring a great attention by the anesthesiologist. Number of this group of patients having to go through this procedure is constantly increasing, due to prolonged life, increased agressiveness of surgery and increased anesthesia's safety. The anesthesiologist usually has to deal with several problems of the patient, such as hypertension, chronic heart failure, coronary artery disease, rhythm disturbances, intraoperative hemodymanic changes, intraoperative bleeding, perioperative fluid imbalance, and metabolic disturbances. A cardiac patient undergoing major urologic surgery is a complex case requiring a great attention by the anesthesiologist. The scope of this review article is to present the most frequent issues encountered with this group of patients, and to synthetically discuss the respective strategies and maneuvers during perioperative period, which is the major challenge for the anesthesiologist.