Renal Angina Is a Sensitive, but Nonspecific Identifier of Postcardiac Surgery Acute Kidney Injury.

OBJECTIVES: Acute kidney injury (AKI) is a common complication of cardiac surgery, and early detection is difficult. This study was performed to determine the sensitivity, specificity, positive predictive value, negative predictive value, and statistical performance of renal angina (RA) as an early predictor of AKI in an adult cardiac surgical patient population. DESIGN: Retrospective, nonrandomized, observational study. SETTING: A single, university-affiliated, quaternary medical center. PARTICIPANTS: The study comprised 324 consecutive patients undergoing coronary artery bypass grafting or cardiac valvular surgery from February 1 through July 30, 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred-seven patients at moderate or high risk of developing postoperative renal injury were identified, 82 of whom met criteria for RA. The occurrence of RA was found to have an 80.9% sensitivity and 30.8% specificity for the prediction of AKI using Acute Kidney Injury Network criteria and 89.3% sensitivity and 27.8% specificity when paired with the Risk, Injury, Failure, Loss, End Stage Renal Disease criteria. A receiver operating characteristic area under the curve analysis revealed a nonsignificant predictive ability of 55.8% (95% confidence interval 0.47-0.65) when RA was paired with Acute Kidney Injury Network criteria; however, the receiver operating characteristic area under the curve was significant when paired with Risk, Injury, Failure, Loss, End Stage Renal Disease criteria, with a predictive ability of 0.586 (0.509-0.662). CONCLUSIONS: RA is a sensitive, but nonspecific, predictor of postcardiac surgery AKI, with clinical utility most suited as a screening tool.

Analgesia in the surgical intensive care unit.

Critically ill patients are a heterogeneous group with diverse comorbidities and physiological derangements. The management of pain in the critically ill population is emerging as a standard of care in the intensive care unit (ICU). Pain control of critically ill patients in the ICU presents numerous challenges to intensivists. Inconsistencies in pain assessment, analgesic prescription and variation in monitoring sedation and analgesia result in suboptimal pain management. Inadequate pain control can have deleterious effects on several organ systems in critically ill patients. Therefore, it becomes incumbent on physicians and nurses caring for these patients to carefully evaluate their practice on pain management and adopt an optimal pain management strategy that includes a reduction in noxious stimuli, adequate analgesia and promoting education regarding sedation and analgesia to the ICU staff. Mechanistic approaches and multimodal analgesic techniques have been clearly demonstrated to be the most effective pain management strategy to improve outcomes. For example, recent evidence suggests that the use of short acting analgesics and analgesic adjuncts for sedation is superior to hypnotic based sedation in intubated patients. This review will address analgesia in the ICU, including opioid therapy, adjuncts, regional anaesthesia and non-pharmacological options that can provide a multimodal approach to treating pain.

Effect of positive end-expiratory pressure on blood loss during retropubic and robot-assisted laparoscopic radical prostatectomy.

OBJECTIVES: To study the effect of end-expiratory pressure used during anesthesia on blood loss during radical prostatectomy. METHODS: We evaluated 247 patients who underwent either radical retropubic prostatectomy or robot-assisted laparoscopic prostatectomy at a single institution from 2008 to 2013 by one of four surgeons. Patient characteristics were compared using t-tests, rank sum or χ(2) -tests as appropriate. The association between positive end-expiratory pressure and estimated blood loss was tested using linear regression. RESULTS: Patients were classified into high (≥4 cmH2 O) and low (≤1 cmH2 O) positive-end expiratory pressure groups. Estimated blood loss in radical retropubic prostatectomy was higher in the high positive end-expiratory pressure group (1000 mL vs 800 mL, P = 0.042). Estimated blood loss in robot-assisted laparoscopic prostatectomy was lower in the high positive end-expiratory pressure group (150 mL vs 250 mL, P = 0.015). After adjusting for other factors known to influence blood loss, a 5-cmH2 O increase in positive end-expiratory pressure was associated with a 34.9% increase in estimated blood loss (P = 0.030) for radical retropubic prostatectomy, and a 33.0% decrease for robot-assisted laparoscopic prostatectomy (P = 0.038). CONCLUSIONS: In radical retropubic prostatectomy, high positive end-expiratory pressure was associated with higher estimated blood loss, and the benefits of positive end-expiratory pressure should be weighed against the risk of increased estimated blood loss. In robot-assisted laparoscopic prostatectomy, high positive end-expiratory pressure was associated with lower estimated blood loss, and might have more than just pulmonary benefits.

Regional variation in prosthesis choice for aortic valve replacement in older patients.

BACKGROUND AND AIM OF THE STUDY: The study aim was to investigate regional practice patterns regarding aortic valve replacement (AVR) by comparing bioprosthetic versus mechanical valve usage in patients aged > or = 65 years, and to determine whether the choice of valve type for AVR in these patients varied by geographic region. METHODS: The details were acquired of all mechanical and bioprosthetic AVRs performed in patients aged > or = 65 years between 1999 and 2006, as contained in the Florida State Inpatient Database. By using a small area analysis, the patients' zip codes were aggregated into hospital referral regions based on where they were most likely to receive AVR. The regional rates of both mechanical and bioprosthetic AVR were then determined. RESULTS: Of 23,925 AVRs performed during this period, 15,368 involved a bioprosthetic aortic valve and 8,557 a mechanical aortic valve. Statewide, 64% of AVRs in these patients involved a bioprosthesis. Regional rates of mechanical AVRs varied widely, from 10% to 81%. CONCLUSION: Substantial regional differences were identified in practice patterns for AVR in patients aged > or = 65 years. This suggested that provider preference, in addition to patient pathology, would often determine the type of valve implanted.

Frontal sinus osteoma removal with the ultrasonic bone aspirator.

Osteomas, the most common skull tumors, are typically excised through either an open or endoscopic ostectomy using a high-speed drill, a technically challenging procedure that can result in injury to adjacent soft tissue structures. Osteoma removal through ultrasonic bone emulsification and aspiration (UBA) offers the advantages of decreased blood loss, preservation of adjacent soft tissue structures, and precise bone removal. UBA was used to successfully remove a forehead osteoma without injury to adjacent nerves and with a satisfactory cosmetic outcome. We describe skull osteoma removal with an ultrasonic bone aspirator, which offers potential advantages over conventional bone removal techniques.

Geography or pathology? Regional variation in atrial septal defect closure rates and techniques.

BACKGROUND: Since the introduction of percutaneous closure in the United States, rates of secundum atrial septal defect and patent foramen ovale closures have increased substantially. Whether or not closure rates are uniform or vary due to differences in regional practice patterns is unknown. We sought to investigate this by comparing regional rates of closure across Florida. METHODS: We identified all atrial septal defect closures from 2001 to 2006 in the Florida State Inpatient Database. Using small area analysis, zip codes were assigned to Hospital Referral Regions based on where patients were most likely to go for closure. We obtained population-normalised rates of overall, percutaneous, and surgical closure. RESULTS: Of 1830 atrial septal defect and patent foramen ovale closures from 2001 to 2006, 751 were surgical and 1004 were percutaneous. The statewide closure rate was 1.91 per 100,000 people per year; regional rates varied 3.8-fold from 0.78 to 2.94 per 100,000 people per year. Percutaneous rates varied sevenfold from 0.25 to 1.75 per 100,000 people per year, while surgical rates varied 2.71-fold from 0.53 to 1.44 per 100,000 people per year. CONCLUSIONS: Despite a consistent prevalence of atrial septal defects, and patent foramens ovale, rates of repair vary across regions, suggesting that closure is driven by provider practice patterns rather than patient pathology. Efforts should be directed towards increasing consensus regarding the appropriate, evidence-based indications for closure so as to avoid the costs and potential negative sequelae of over- or undertreatment.

Common ground: measuring intrainstitutional mortality among pediatric surgical procedures.

BACKGROUND: For adult populations, hospitals that have low mortality rates for one surgical discipline tend to have low mortality rates for other surgical disciplines. We sought to determine to what degree mortality rates for high-risk pediatric surgical procedures were correlated within institutions. METHODS: High-risk operations performed on patients ≤ 10 years of age were identified in the 2003/2006 Kids' Inpatient Databases and grouped into cardiac surgical, neurosurgical, and general surgical categories. We calculated the hospital-level risk-adjusted mortality rates of each category ("categorical mortality") and of the other 2 categories combined ("other mortality"); then we calculated the correlation between these groups. Hospitals also were placed into quintiles based on excess other mortality and grouped categorical mortality were estimated. RESULTS: Categorical mortality was correlated with other mortality (R = 0.22-0.26) for all 3 categories. Other mortality was a good predictor of categorical mortality, with categorical mortality rates at hospitals in the bottom quintile of other mortality, on average 1.58 times greater than those in the top quintile (P < .001). Correlations of categorical mortality with other mortality were significantly greater for the subgroup of Children's General Hospitals (R = 0.43-0.57). CONCLUSION: Hospitals with low mortality rates for 1 high-risk pediatric surgical specialty tended to have low rates for other specialties. This observation suggests that diverse surgical fields share institutional resources and processes that affect their mutual performance. Implementation of these common pillars may lead to broader improvements in quality than efforts focused on individual disciplines.