The effect of tourniquet use on postoperative opioid consumption after ankle fracture surgery - a retrospective cohort study.

OBJECTIVES: A pneumatic tourniquet is often used during ankle fracture surgery to reduce bleeding and enhance the visibility of the surgical field. Tourniquet use causes both mechanical and ischemic pain. The main purpose of this study was to evaluate the effect of tourniquet time on postoperative opioid consumption after ankle fracture surgery. METHODS: We retrospectively reviewed the files of 586 adult patients with surgically treated ankle fractures during the years 2014-2016. We evaluated post hoc the effect of tourniquet time on postoperative opioid consumption during the first 24 h after surgery. The patients were divided into quartiles by the tourniquet time (4-43 min; 44-58 min; 59-82 min; and ≥83 min). Multivariable linear regression analysis was used to evaluate the results. RESULTS: Tourniquets were used in 486 patients. The use of a tourniquet was associated with an increase in the total postoperative opioid consumption by 5.1 mg (95 % CI 1.6-8.5; p=0.004) during the first 24 postoperative hours. The tourniquet time over 83 min was associated with an increase in the mean postoperative oxycodone consumption by 5.4 mg (95 % CI 1.2 to 9.7; p=0.012) compared to patients with tourniquet time of 4-43 min. CONCLUSIONS: The use of a tourniquet and prolonged tourniquet time were associated with higher postoperative opioid consumption during the 24 h postoperative follow-up after surgical ankle fracture fixation. The need for ethical approval and informed consent was waived by the Institutional Review Board of Northern Ostrobothnia Health District because of the retrospective nature of the study.

Unresponsive Low Mixed Venous Oxygen Saturation During Early Intensive Care Unit Stay is Associated With Increased Risk of Organ Dysfunction After Cardiac Surgery: A Single-Center Retrospective Study.

OBJECTIVES: The aim of the study was to determine if unresponsive mixed venous oxygen saturation (SvO2) values during early postoperative hours are associated with postoperative organ dysfunction. DESIGN: A single-center retrospective observational study. SETTING: A university hospital. PARTICIPANTS: A total of 6,282 adult patients requiring cardiac surgery who underwent surgery in a University Hospital from 2007 to 2020. INTERVENTIONS: A pulmonary artery catheter was used to gather SvO2 samples after surgery at admission to the intensive care unit (ICU) and 4 hours later. For the analysis, patients were divided into 4 groups according to their SvO2 values. The rate of organ dysfunctions categorized according to the SOFA score was then studied among these subgroups. MEASUREMENTS AND MAIN RESULTS: The crude mortality rate for the cohort at 1 year was 4.3%. Multiple organ dysfunction syndrome (MODS) was present in 33.0% of patients in the early postoperative phase. During the 4-hour initial treatment period, 43% of the 931 patients with low SvO2 on admission responded to goal-directed therapy to increase SvO2 >60%; whereas, in 57% of the 931 patients, the low SvO2 was sustained. According to the adjusted logistic regression analyses, the odds ratio for MODS (4.23 [95% CI 3.41-5.25]), renal- replacement therapy (4.97 [95% CI 3.28-7.52]), time on a ventilator (2.34 [95% CI 2.17-2.52]), and vasoactive-inotropic score >30 (3.62 [95% CI 2.96-4.43]) were the highest in the group with sustained low SvO2. CONCLUSIONS: Patients with SvO2 <60% at ICU admission and 4 hours later had the greatest risk of postoperative MODS. Responsiveness to a goal-directed therapy protocol targeting maintaining or increasing SvO2 ≥60% at and after ICU admission may be beneficial.

Changes in transcranial near-infrared spectroscopy values reflect changes in cardiac index during cardiac surgery.

To determine whether changes in transcranial near-infrared spectroscopy (NIRS) values reflect changes in cardiac index (CI) in adult cardiac surgical patients. Single-center prospective post hoc analysis. University hospital. One hundred and twenty-four adult patients undergoing cardiac surgery. In each patient, several CI measurements were taken, and NIRS values were collected simultaneously. We used a hierarchical linear regression model to assess the association between NIRS values and CI. We calculated a crude model with NIRS as the only factor included, and an adjusted model, where mean arterial pressure, end-tidal CO2 , and oxygen saturation were used as confounding factors. A total of 1301 pairs of NIRS and CI values were collected. The analysis of separate NIRS and CI pairs revealed a poor association, which was not statistically significant when adjusted with the chosen confounders. However, when the changes in NIRS from baseline or from the previous measurement were compared to those of CI, a clinically and statistically significant association between NIRS and CI was observed also in the adjusted model. Compared to the baseline and to the previous measurement, respectively, the regression coefficients with 95% confidence intervals were 0.048 (0.041-0.056) and 0.064 (0.055-0.073) in off-pump coronary artery bypass patients and 0.022 (0.016-0.029) and 0.026 (0.020-0.033) in patients who underwent cardiopulmonary bypass. In an unselected cardiac surgical population, the changes in NIRS values reflect those in CI, especially in off-pump coronary artery bypass patients. In this single-center post hoc analysis of data from a prospectively collected database of cardiac surgery patients, paired measurements of cardiac output and NIRS revealed that while there was a no correlation between individual paired measurements, a small correlation was found in changes in the two measurements from baseline values. This highlights a potential to utilize changes in NIRS from baseline to suggest changes in cardiac output in cardiac surgical populations.

Association of low mixed venous oxygen saturations during early ICU stay with increased 30-day and 1-year mortality after cardiac surgery: a single-center retrospective study.

BACKGROUND: Low postoperative mixed venous oxygen saturation (SvO2) values have been linked to poor outcomes after cardiac surgery. The present study was designed to assess whether SvO2 values of < 60% at intensive care unit (ICU) admission and 4 h after admission are associated with increased mortality after cardiac surgery. METHODS: During the years 2007-2020, 7046 patients (74.4% male; median age, 68 years [interquartile range, 60-74]) underwent cardiac surgery at an academic medical center in Finland. All patients were monitored with a pulmonary artery catheter. SvO2 values were obtained at ICU admission and 4 h later. Patients were divided into four groups for analyses: SvO2 ≥ 60% at ICU admission and 4 h later; SvO2 ≥ 60% at admission but < 60% at 4 h; SvO2 < 60% at admission but ≥ 60% at 4 h; and SvO2 < 60% at both ICU admission and 4 h later. Kaplan-Meier survival curves, Cox regression models, and receiver operating characteristic curve analysis were used to assess differences among groups in 30-day and 1-year mortality. RESULTS: In the overall cohort, 52.9% underwent coronary artery bypass grafting (CABG), 29.1% valvular surgery, 12.1% combined CABG and valvular procedures, 3.5% surgery of the ascending aorta or aortic dissection, and 2.4% other cardiac surgery. The 1-year crude mortality was 4.3%. The best outcomes were associated with SvO2 ≥ 60% at both ICU admission and 4 h later. Hazard ratios for 1-year mortality were highest among patients with SvO2 < 60% at both ICU admission and 4 h later, regardless of surgical subgroup. CONCLUSION: SvO2 values < 60% at ICU admission and 4 h after admission are associated with increased 30-day and 1-year mortality after cardiac surgery. Goal-directed therapy protocols targeting SvO2 ≥ 60% may be beneficial. Prospective studies are needed to confirm these observational findings.

Factors associated with time delay to angiography in acute ST-elevation myocardial infarction - A retrospective cohort study in Northern Finland.

BACKGROUND: The delay of percutaneous coronary intervention increases the risk of heart failure and mortality in STEMI. The aim of this study was to examine the time intervals of EMS and the factors associated with the time delay to angiography in patients with STEMI. METHODS: The present study was conducted in Northern Ostrobothnia, Finland in 2014-2016. All patients transported to the hospital by EMS who were diagnosed with STEMI and underwent a primary angiography within 24 h of arrival were included. Angiography was defined as delayed if it was performed over 120 min of the first medical contact (FMC). RESULTS: 310 patients met the inclusion criteria during the study period. Time from the FMC to angiography was less than 120 min in 231 patients (74.5%). In multivariate analysis, the factors associated with delayed angiography were the absence of chest pain (OR 2.46 (1.18-5.13),p = 0.016), dyspnea (OR 3.11 (1.54-6.28),p = 0.002), the treatment protocol violations by EMS (OR 2.41 (0.99-5.80),p = 0.050), treatment initiation at a primary health care center (OR 3.64 (1.39-9.48),p = 0.008), and the distance to hospital of over 100 km (OR 11.87 (6.14-22.93),p < 0.001). CONCLUSION: In our study, treatment protocol violations, non-specific symptoms, and the distance to hospital of over 100 km were associated with primary angiography in patients with STEMI transported to the hospital by EMS.

Accuracy, Precision, and Trending Ability of Perioperative Central Venous Oxygen Saturation Compared to Mixed Venous Oxygen Saturation in Unselected Cardiac Surgical Patients.

OBJECTIVE: To determine whether central venous oxygen saturation (ScvO2) measurements could be used interchangeably with mixed venous oxygen saturation (SvO2) measurements in adult cardiac surgery patients. DESIGN: A single-center prospective observational study. SETTING: A university hospital. PARTICIPANTS: Eighty-five adult patients undergoing cardiac surgery. INTERVENTIONS: The study authors compared the oxygen saturations in 590 pairs of venous blood samples drawn from the pulmonary artery catheter (PAC) at three different time points during surgery and four different time points in the intensive care unit. They compared samples obtained from the distal pulmonary artery line (SvO2) to those drawn from the proximal central venous line of the PAC (ScvO2) with the Bland-Altman test and the four-quadrant method. MEASUREMENTS AND MAIN RESULTS: The mean bias between SvO2 and ScvO2 was -1.9 (95% confidence interval [CI], -2.3 to -1.5) and the limits of agreement (LOA) were -11.5 to 7.6 (95% CI, -12.5 to -10.7 and 6.8-8.5, respectively). The percentage error (PE) was 13.2%. Based on the four-quadrant plot, only 50% of the measurement pairs were in agreement, indicating deficient trending ability. CONCLUSION: ScvO2 values showed acceptable accuracy as the mean bias was low. The precision was inadequate; although the PE was acceptable, the LOA were wide. Trending ability was inadequate. The authors cannot recommend the use of ScvO2 values interchangeably with SvO2 measurements in the management of adult cardiac surgery patients.

Difference in postoperative opioid consumption after spinal versus general anaesthesia for ankle fracture surgery-A retrospective cohort study.

BACKGROUND: Surgical treatment of ankle fracture is associated with significant pain and high postoperative opioid consumption. The anaesthesia method may affect early postoperative pain. The main objective of the study was to compare postoperative opioid consumption after ankle-fracture surgery between patients treated with spinal anaesthesia and general anaesthesia. METHODS: We reviewed retrospectively the files of 586 adult patients with surgically treated ankle fracture in the years 2014 through 2016. The primary outcome was opioid consumption during the first 48 postoperative hours. Secondary outcomes were maximal pain scores, postoperative nausea and vomiting, the length of stay in the post-anaesthesia care unit, and opioid use in different time periods up to 48 h postoperatively. Propensity score matching was used to mitigate confounding variables. RESULTS: Total opioid consumption 48 h postoperatively was significantly lower after spinal anaesthesia (propensity score-matched population: effect size -13.7 milligrams; 95% CI -18.8 to -8.5; P < .001). The highest pain score on the numerical rating scale in the post-anaesthesia care unit was significantly higher after general anaesthesia (propensity score-matched population: effect size 3.7 points; 95% CI 3.2-4.2; P < .001). A total of 60 patients had postoperative nausea and vomiting in the post-anaesthesia care unit, 53 (88.3%) of whom had general anaesthesia (P = .001). CONCLUSIONS: Patients with surgically treated ankle fracture whose operation was performed under general anaesthesia used significantly more opioids in the first 48 h postoperatively, predominantly in the post-anaesthesia care unit, compared with patients given spinal anaesthesia.

Nutrition deficit during intensive care stay: incidence, predisposing factors and outcomes.

BACKGROUND: Adequate nutrition support during intensive care has several benefits including lower amount of infectious complications, improved wound healing, shorter length of stay (LOS) and decreased morbidity. The aim of the present study was to survey the adequacy of nutrition throughout Intensive Care Unit (ICU) stay and to examine various factors associated to cumulative nutrition inadequacy during ICU stay. METHODS: The study was a retrospective single center cohort study. The study population consisted of 1771 ICU adult (≥18 years) patients with emergency admission to ICU who had LOS between three and 40 days. Nutrition adequacy and factors associated to inadequate nutrition support during ICU stay were analyzed. RESULTS: Factors related to impaired energy balance were prescribed energy less than 25kcal/kg (OR 11.794 (9.017-15.427), P<0.001) and higher median CRP (OR 1.003 (1.001-1.004), P<0.001). Factors related to improved energy balance were length of stay (OR 0.975 (0.953-0.997), P=0.024), more than 30% Bolus enteral nutrition days (OR 0.314 (0.187-0.526), P<0.001) and Enteral/Parenteral -Ratio (OR 0.970 (0.953-0.987), P=0.001). CONCLUSIONS: The majority of ICU patients did not reach 60% of nutrition adequacy. Nutrition inadequacy was a common finding throughout the study population. Nutrition inadequacy might be partially avoidable since adequacy less than 60% was related to underprescription and failure to administer the prescribed nutrition. Bolus enteral nutrition might be an efficient method to deliver energy in ICU setting.