A randomised controlled feasibility trial of a clinical protocol to manage hypotension during major non-cardiac surgery.

Intra-operative hypotension is a risk factor for postoperative morbidity and mortality. Minimally invasive monitors that derive other haemodynamic parameters, such as stroke volume, may better inform the management of hypotension. As a prelude to a multicentre randomised controlled trial, we conducted a single-centre feasibility trial of a protocol to treat hypotension as informed by minimally invasive haemodynamic monitoring during non-cardiac surgery. We recruited adults aged ≥40 years with cardiovascular risk factors who underwent non-cardiac surgery requiring invasive arterial pressure monitoring. Participants were randomly allocated to usual care, or a clinical protocol informed by an arterial waveform contour analysis monitor. Participants, outcome assessors, clinicians outside operating theatres and analysts were blinded to treatment allocation. Feasibility was evaluated based on: consent rate; recruitment rate; structured feedback from anaesthesia providers; and between-group differences in blood pressure, processes-of-care and outcomes. The consent rate among eligible patients was 33%, with 30 participants randomly allocated to the protocol and 30 to usual care. Anaesthesia providers rated the protocol to be feasible and acceptable. The protocol was associated with reduced fluid balance and hypotension exposure in the peri-operative setting. Postoperative complications included: acute myocardial injury in 18 (30%); acute kidney injury in 17 (28%); and surgical site infection in 7 (12%). The severity of complications was rated as moderate or severe in 25 (42%) participants. In summary, this single-centre study confirmed the feasibility of a multicentre trial to assess the efficacy and safety of a physiologically guided treatment protocol for intra-operative hypotension based on minimally invasive haemodynamic monitors.

The association between tranexamic acid and convulsive seizures after cardiac surgery: a multivariate analysis in 11 529 patients.

Because of a lack of contemporary data regarding seizures after cardiac surgery, we undertook a retrospective analysis of prospectively collected data from 11 529 patients in whom cardiopulmonary bypass was used from January 2004 to December 2010. A convulsive seizure was defined as a transient episode of disturbed brain function characterised by abnormal involuntary motor movements. Multivariate regression analysis was performed to identify independent predictors of postoperative seizures. A total of 100 (0.9%) patients developed postoperative convulsive seizures. Generalised and focal seizures were identified in 68 and 32 patients, respectively. The median (IQR [range]) time after surgery when the seizure occurred was 7 (6-12 [1-216]) h and 8 (6-11 [4-18]) h, respectively. Epileptiform findings on electroencephalography were seen in 19 patients. Independent predictors of postoperative seizures included age, female sex, redo cardiac surgery, calcification of ascending aorta, congestive heart failure, deep hypothermic circulatory arrest, duration of aortic cross-clamp and tranexamic acid. When tested in a multivariate regression analysis, tranexamic acid was a strong independent predictor of seizures (OR 14.3, 95% CI 5.5-36.7; p < 0.001). Patients with convulsive seizures had 2.5 times higher in-hospital mortality rates and twice the length of hospital stay compared with patients without convulsive seizures. Mean (IQR [range]) length of stay in the intensive care unit was 115 (49-228 [32-481]) h in patients with convulsive seizures compared with 26 (22-69 [14-1080]) h in patients without seizures (p < 0.001). Convulsive seizures are a serious postoperative complication after cardiac surgery. As tranexamic acid is the only modifiable factor, its administration, particularly in doses exceeding 80 mg.kg(-1), should be weighed against the risk of postoperative seizures.

Pharmacokinetics of tranexamic acid in patients undergoing cardiac surgery with use of cardiopulmonary bypass.

We conducted a study to assess pharmacokinetics of high-dose tranexamic acid for 24 h after administration of the drug in patients undergoing cardiac surgery with cardiopulmonary bypass. High-dose tranexamic acid involved a bolus of 30 mg.kg(-1) infused over 15 min followed by a 16 mg.kg(-1) .h(-1) infusion until chest closure with a 2 mg.kg(-1) load within the pump prime. Tranexamic acid followed first-order kinetics best described using a two-compartment model, with a total body clearance that approximated the glomerular filtration rate. Mean plasma tranexamic acid concentrations during the intra-operative period and in the first 6 postoperative hours were consistently higher than the suggested threshold to achieve 100% inhibition and 80% inhibition of tissue plasminogen activator. With recent studies implicating high-dose tranexamic acid as a possible aetiology of postoperative seizures following cardiac surgery, the minimum effective yet safe dose of tranexamic acid in high-risk cardiac surgery needs to be refined.

Changing characteristics of emergency surgery during COVID-19 pandemic: a retrospective cohort study.

BACKGROUND: In other countries, researchers have noticed diverse variations in the features of patients undergoing emergency surgery during the COVID-19 pandemic. In Mexico, there is not information about this issue. METHODS: Workers of the Mexican Government, who required emergency surgeries were studied by the general surgery service of a General Hospital administered by the Institute of Social Security and Services for State Workers Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), through the periods from March-August 2019 (non-exposed) and March-August 2020 (exposed). The analysis included: demographic data, laboratory information, post-operative diagnoses, symptoms' length, days of emergency stay, and post-operative stay. RESULTS: One hundred and ninety-three emergency surgeries were analyzed; 106 in 2019 and 87 in 2020 (a decrease of 18%). Throughout the pandemic, the number of days between the symptoms' onset and surgery was greater: 2019, 7.6 ± 4.6 days; 2020, 14 ± 6.7 days (p < 0.0001). In addition, cases of acute appendicitis decreased (2019-60.3%; 2020-42.5%), and those of acute calculous cholecystitis increased (2019-12.2%; 2020-24.1%). CONCLUSION: Through the COVID-19 pandemic, there were notable changes in the characteristics of Mexican Government's workers who warranted emergency surgery.

ANTECEDENTES: En otros países, han notado diversos cambios en las características de los pacientes sometidos a cirugía de emergencia durante la pandemia de COVID-19. En México no existe información sobre este tema. MÉTODO: Estudiamos a los trabajadores del gobierno mexicano que requirieron tratamiento quirúrgico de emergencia por el servicio de cirugía general de un Hospital General del Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado (ISSSTE), durante los periodos de marzo-agosto de 2019 (no expuestos) y marzo-agosto de 2020 (expuestos). El análisis incluyó: datos demográficos, datos de laboratorio, diagnósticos postoperatorios, duración de los síntomas, días de estancia en emergencias y estadía postoperatoria. RESULTADOS: Se analizaron 193 cirugías de emergencia; 106 en 2019 y 87 en 2020 (una disminución del 18%). En la pandemia, el número de días entre el inicio de los síntomas y la cirugía fue mayor: 2019, 7.6 ± 4.6 días; 2020, 14 ± 6.7 días (p < 0.0001). Además, disminuyeron los casos de apendicitis aguda (2019-60,3%; 2020-42,5%) y aumentaron los de colecistitis litiásica aguda (2019-12,2%; 2020-24,1%). CONCLUSIÓN: Durante la pandemia de COVID-19, hubo cambios notables en las características de los trabajadores del gobierno mexicano que ameritaron cirugías de emergencia.

Allergic bronchopulmonary mycosis to Fusarium vasinfectum in a child.

BACKGROUND: A 12-year-old boy with asthma and 6 years of recurrent pneumonias who had normal serum immunoglobulin concentrations was suspected of having allergic bronchopulmonary aspergillosis (ABPA). OBJECTIVE: To search for and secure a fungal etiology for a child who did not have ABPA but was suspected of having an allergic bronchopulmonary mycosis. METHODS: Immediate skin testing with fungal extracts, high resolution computerized tomography, and establishment of an ELISA procedure to detect serum IgE and IgG antibodies to Fusarium vasinfectum. RESULTS: Immediate skin reactivity was present for Fusarium, Cladosporium, Helminthosporium, and Aspergillus fumigatus. The ELISA demonstrated serum IgE and IgG antibodies to Fusarium vasinfectum 8.5 and 5.6 times nonatopic control sera. CONCLUSIONS: This 12-year-old with asthma has sufficient criteria for a diagnosis of allergic bronchopulmonary mycosis (ABPM) to Fusarium vasinfectum. Bronchiectasis was not present despite recurrent pneumonias and hemoptysis. This case appears to be the first pediatric example of ABPM to Fusarium species, a fungus more recognized for causing rotting of tomatoes and melons than human disease.