Perioperative Malnutrition.

CASE SUMMARY: A 61-year-old man presented with penetrating Crohn's ileocolitis and neoterminal ileal fibrostenotic stricture. He developed an anastomotic leak after a redo ileocolic resection and now has a chronic low-output enterocutaneous fistula. He was transferred from an outside institution for further management and is currently without Crohn's disease (CD)-related medical therapy. The fistula output is 25 to 50 mL/day of GI contents. His weight dropped by 25 pounds in 6 months after surgery with a current BMI of 19.1, albumin of 2.0 g/dL, and hemoglobin of 9.7 g/dL. During a 3-month period, he was optimized for surgery with local wound care, initiation of infliximab, and nutritional support with exclusive enteral nutrition (EEN). He gained 9 pounds (BMI 20.4). Albumin improved to 3.4 g/dL and hemoglobin to 12.1 g/dL. He underwent a successful open takedown of the enterocutaneous fistula with ileocolic anastomosis.

Selective type & screen for elective colectomy based on a transfusion risk score may generate substantial cost savings.

BACKGROUND: Preoperative type and screen are currently recommended for all patients undergoing colectomy. We aimed to identify risk factors for transfusion and define a low-risk cohort of patients undergoing colectomy in whom type and screen may be safely avoided. METHODS: We identified all patients undergoing elective colectomy in the National Surgical Quality Improvement Project-Targeted Colectomy files from 2012 to 2016. Patients transfused preoperatively and those undergoing other concurrent major abdominal procedures were excluded. We compared patients who received blood transfusion on the day of surgery to those who did not. Half of the cohort was randomly selected for development of a points-based model predicting blood transfusion on the day of surgery. This model was then validated using the remaining patients. RESULTS: Of 61,964 patients undergoing colectomy, 3128 (5%) patients were transfused with 1290 (2.1%) occurring on the day of surgery. Preoperative anemia was the strongest predictor of blood transfusion on the day of surgery. Among patients with hematocrit > 35%, day of surgery transfusion risk was 0.8%; 99% of patients with hematocrit > 35% had a score 20 or less. Selective type and screen for patients with score ≤ 20 or hematocrit > 35% would avoid type and screen in 91% and 81% of patients, respectively. CONCLUSION: Transfusion following elective colectomy is rare and can be accurately predicted by preoperative patient characteristics. Selective type and screen based on these parameters have the potential to prevent operative delays and lower cost.

Clinical Characteristics and Longitudinal Outcomes of Primary Mycotic Aortic Aneurysms.

Medical therapy for mycotic aortic aneurysms (MAA) is almost universally fatal, while surgical and endovascular repair carry high morbidity and mortality. The purpose of this study was to compare outcomes between patients receiving treatment for MAA. Records were obtained and patients with MAA were stratified by intervention: endovascular repair, open surgery, and medical therapy. Primary outcomes were aneurysm-related mortality and survival. Risk-adjusted associations with mortality were assessed using time-to-event analysis. Thirty-eight patients were identified (median age, 67). Twenty-one underwent endovascular repair,10 had open surgery and 7 received medical therapy alone. Overall mortality was 47% (n = 18), with 94% aneurysm related. Median survival was significantly longer in the endovascular group (747.0 [161-1249]) vs open surgery and medical therapy (507.5 [34-806] and 66 [13-146] days, respectively; P = .02). The endovascular group had significantly fewer perioperative complications (43% vs 80%, P < .01). However, 4 endovascular patients experienced reinfection versus no open surgery patients. Mortality risk factors included medical therapy (hazard ratio [HR]: 5.3, P < .01) and aneurysm size (HR: 1.4 per 1-cm increase in diameter, P = .03). Endovascular repair of MAA was associated with the best long-term survival and lowest perioperative complication rate, although it is associated with greater reinfection. These tradeoffs should be considered when selecting which procedure is best for a patient.

Methylene Blue for Vasoplegic Syndrome.

Vasoplegic syndrome is a form of vasodilatory shock that occurs frequently in patients who undergo cardiac surgery requiring cardiopulmonary bypass (CBP). Treatment often demands high doses of vasopressors over sustained periods for hypotension that can be refractory to standard vasoactive medications. Furthermore, the development of vasoplegia greatly contributes to morbidity and mortality following cardiac surgery. Methylene blue (MB) has become a popular therapy for cardiac vasoplegia despite a paucity of prospective data to direct its use. Therefore, the aim of this study was to review available data regarding mechanisms, dosing strategies, and side effects of MB, with a focus on its applications for vasoplegia in cardiac surgery.