Postoperative Atrial Fibrillation Prophylaxis and Lung Resection ­ Our Experience with 608 Consecutive Patients

Postoperative atrial fibrillation is a common complication after lung resection. It is burdened by increased mortality and morbidity, prolonged hospitalization, and higher resource utilization in thoracic surgery patients. Therefore, some kind of pharmacological prophylaxis is recommended. In our patients, diltiazem, a calcium antagonist, is administered. We collected data on all 608 patients having undergone lung resection (no less than lobectomy) between November 2012 and May 2015. This period included patients having received diltiazem during their postoperative stay in our Intensive Care Unit and surgical ward, and those that did not receive it. Patients having had atrial fibrillation before the surgery and patients with cardiac pacemaker were excluded from the trial. Other patients were divided into three groups: patients with some kind of antiarrhythmic therapy before and continued after the surgery; patients with diltiazem prophylaxis; and patients without any antiarrhythmic prophylaxis. The data collected were statistically analyzed. We found no statistically significant difference in the incidence of postoperative atrial fibrillation among the groups (p<0.05).

Prognostic performance of the Simplified Acute Physiology Score II in major Croatian hospitals: a prospective multicenter study.

AIM: To perform an external validation of the original Simplified Acute Physiology Score II (SAPS II) system and to assess its performance in a selected group of patients in major Croatian hospitals. METHODS: A prospective, multicenter study was conducted in five university hospitals and one general hospital during a six-month period between November 1, 2007 and May 1, 2008. Standardized hospital mortality ratio (SMR) was calculated from the mean predicted mortality of all the 2756 patients and the actual mortality for the same group of patients. The validation of SAPS II was made using the area under receiver operating characteristic curve (AUC), 2×2 classification tables, and Hosmer-Lemeshow tests. RESULTS: The predicted mortality was as low as 14.6% due to a small proportion of medical patients and the SMR being 0.89 (95% confidence interval [CI], 0.78-0.98). The SAPS II system demonstrated a good discriminatory power as measured by the AUC (0.85; standard error [SE]=0.012; 95% CI=0.840-0.866; P<0.001). This system significantly overestimated the actual mortality (Hosmer-Lemeshow goodness-of-fit H statistic: χ(2) =584.4; P<0.001 and C statistics: χ(2)(8) =313.0; P<0.001) in the group of patients included in the study. CONCLUSION: The SAPS II had a good discrimination, but it significantly overestimated the observed mortality in comparison with the predicted mortality in this group of patients in Croatia. Therefore, caution is required when an evaluation is performed at the individual level.

Successful use of activated recombinant factor VII in life threatening bleeding after thoracic surgery.

We present three patients in whom life-threatening haemorrhage following lung resection was successfully managed using activated recombinant factor VII (NovoSeven). In one case, activated recombinant factor VII was the only therapy administered to manage bleeding, and in the two remaining cases, activated recombinant factor VII was administered after patients failed to respond to conventional therapy. All patients demonstrated effective haemostasis and improved coagulation parameters as a result of treatment with activated recombinant factor VII. Our experience with the clinical use of rFVIIa suggests that this agent may provide effective hemostasis following lifethreatening postoperative bleeding after major thoracic surgery. Despite these favorable results, randomized, placebo - controlled trials are needed to identify optimal treatment strategy, patient selection, and safety of treatment in patients with massive bleeding following major thoracic surgery.

[Unsuspected posterior mediastinal paraganglioma--anesthetic risk]. / Neprepoznati paragangliom straznjeg medijastinuma--anestezioloski rizik.

A 70-year old female patient was admitted to the hospital because of scheduled thoracotomy and biopsy of posterior mediastinal retrocardiac tumor of unrecognized etiology. The patient had no complaints regarding the tumor. Routine anesthesiological preoperative examination revealed status ASA III. Induction in anesthesia was usually stable. At the moment when the surgeon intraoperatively touched the tumor, hemodinamic instability started and arterial blood pressure and heart rate dramatically increased. Our first reaction was to deepen the anesthesia. Very soon it was obvious that blood pressure increased by the surgeon's manipulation of the tumor and we started to doubt on catecholamine-secreting tumor. During the course of the operation there were several hypertensive episodes and we managed them by alternately using atenolol, glyceroltrinitrate and anesthetic drug. The patient was extubated 5 hours after transfer to the intensive care unit. Postoperative period was hemodynamically stable. The level of catecholamines in 24-hour urine collection was significantly increased. Pathohistologic diagnosis was mediastinal paraganglioma.

[Role of transthoracic echocardiography in evaluation of cardiac risk in thoracic surgery]. / Uloga transtorakalne ehokardiografije u procjeni kardijalnog rizika u torakokirurskog bolesnika.

BACKGROUND AND OBJECTIVE: It is not precisely defined which group of non-cardiac surgery patients should undergo transthoracic echocardiography in preoperative preparation. This study was prospectively performed to find out whether the routine use of echocardiography is justified in patients scheduled for lung resection, and to assess its role in cardiac risk evaluation. METHODS: Patients classified as ASA III who were identified as having minor or intermediate predictors of cardiac risk were included in the study. Based on this triage, 130 patients underwent transthoracic echocardiography. RESULTS: Intermediate index of increased perioperative cardiovascular risk was recorded in 36.2% and low index in 63.8% of patients. Preoperative anesthesiologic examination revealed some form of cardiac arrhythmia in 28.5%, symptoms of coronary disease in 25.4%; hypertension in 52.3%, and chronic obstructive pulmonary disease in 16.9% of patients. Transthoracic echocardiography showed the ejection fraction of 60% in 86.9% and of 40%-49% in only one patient. Left ventricular contractility was preserved in 96.2% of patients. Diastolic relaxation was weakened in 42.3% of patients. Mild mitral insufficiency was found in 29.2%; aortic stenosis in 1.5%, mild aortic insufficiency in 2.3%, mild pulmonary hypertension in 70.8%, and severe pulmonary hypertension in only 1.5% of patients. Pulmonectomy was performed in 26.9%, lobectomy in 62.3% and segmental tumor resection in 10.8% of patients. Only 26.2% of patients had peri- and postoperative complications: tachyarrhythmia and atrial fibrillation with rapid ventricular answer in 16.2%, hypotension 1.5%; hypertension in 2.3% and hypertension and arrhythmia in 1.5% of patients. Three (2.3%) patients died. None of our patients had Goldman's score higher than 25; according to Detsky index our patients belonged to 0-15 point group, class I, with the foreseen risk %. CONCLUSIONS: Transthoracic echocardiography is not justified in the routine preoperative preparation of thoracosurgical patients classified as ASA III with clinically minor and intermediate indexes of increased cardiovascular risk. It should be done in selected patients, primarily those that have history data and clinical picture consistent with major indices of an increased cardiovascular risk.