The anaesthetic assessment, management and risk factors of bariatric surgical patients requiring postoperative intensive care support: a state-wide, five-year cohort study.

Bariatric surgery is a rapidly growing and dynamic discipline necessitating a specialised anaesthetic approach coordinating high-risk patients with appropriate post-operative intensive care (ICU) support. The relationship between the anaesthetic and ICU utilisation after bariatric surgery is poorly understood. All adult bariatric surgery patients admitted to any ICU over a five-year period between 2007 and 2011 in Western Australia were identified from hospital admission records and cross-referenced against the Western Australian Department of Health Data Linkage Unit database. During the study period 12,062 patients under went bariatric surgery with 581 (4.8%) patients admitted to ICU immediately following surgery. The mean pre-operative ASA score was 3.3 [standard deviation 1.1] with 76.9% of patients were assessed by their anaesthetist for the first time on the day-of-surgery. Blood pathology (75%) and ECG (46.3%) were the most common preoperative investigations. Intra-operatively, 2.1% of patients had a grade 4 intubation with only 3.4% of patients requiring a videoscopic assisted intubation. Despite being deemed at high risk, 23.6% of patients were managed with 20 gauge or smaller intravenous access. Anaesthetic complications were extremely uncommon (0.5% of all bariatric cases) but accounted for 9.7% of all postoperative ICU admissions. Smoking history, but not body-mass-index (P=0.46), was the only significant prognostic factor for respiratory or airway related anaesthetic complications (P=0.012). In summary, the anaesthesia management of bariatric surgery varied widely in Western Australia, with smoking as the only significant preoperative risk factor for respiratory or airway related anaesthesia complications.

Incidence and risk factors for intensive care unit admission after bariatric surgery: a multicentre population-based cohort study.

BACKGROUND: With increasing rates of bariatric surgery and the consequential involvement of increasingly complex patients, uncertainty remains regarding the use of intensive care unit (ICU) services after bariatric surgery. Our objective was to define the incidence, indications, and outcomes of patients requiring ICU admission after bariatric surgery and assess whether unplanned ICU admission could be predicted using preoperative factors. METHODS: All adult bariatric surgery patients between 2007 and 2011 in Western Australia were identified from the Department of Health Data Linkage Unit database and merged with a separate database encompassing all subsequent ICU admissions pertaining to bariatric surgery. The minimal and mean follow-up periods were 12 months and 3.4 yr, respectively. RESULTS: Of the 12 062 patients who underwent bariatric surgery during the study period, 590 patients (4.9%; 650 ICU admissions) were admitted to an ICU after their bariatric surgery. Patients admitted to the ICU were older (48 vs 43 yr, P<0.001), more likely to be male (49.7 vs 20.2%, P<0.001), and more likely to require revisional bariatric surgery (14.4 vs 7.1%, P<0.001). One hundred and seventy-six patients required an emergent unplanned ICU admission, with 51 requiring multiple ICU admissions. Revisional or open surgery, diabetes mellitus, chronic respiratory disease, and obstructive apnoea were the strongest preoperative factors associated with unplanned ICU admission. CONCLUSIONS: Intensive care unit admission after bariatric surgery was uncommon (4.9% of all patients), with 30.9% of all referrals being unplanned. A nomogram and smartphone application based on five important preoperative factors may assist anaesthetists to conduct preoperative planning for high-risk bariatric surgical patients.

Profound hypocalcaemia in a patient being anticoagulated with citrate for continuous renal replacement therapy.

Citrate, as an anticoagulant for continuous renal replacement therapy in critically ill patients, has some potential advantages over heparin, including a prolonged dialysis filter life and reduced risk of bleeding. The key parameter involved in monitoring the adequacy and safety of citrate anticoagulation during continuous renal replacement therapy pertains to the ionised and total plasma calcium levels. We report a case of severe systemic hypocalcaemia during continuous renal replacement therapy with citrate anticoagulation resulting from relentless sequestration of calcium due to undiagnosed evolving rhabdomyolysis. Although excessive systemic citrate accumulation can also cause hypocalcaemia, this complication was not observed in our patient. While an acceptable lower limit of ionised calcium remains unknown, severe rhabdomyolysis needs to be considered when a patient's ionised calcium levels are not responsive to standard calcium replacement therapy during continuous renal replacement therapy using citrate anticoagulation in critically ill patients.

When ascites is not ascites.

The case is reported of a patient presenting with ascites and acute renal failure resulting from spontaneous rupture of the urinary bladder, 30 years after the successful initial treatment of childhood rhabdomyosarcoma. The delay in the presentation until the patient began to experience the symptoms due to urinary ascites, the diagnostic dilemma because of the rarity of the condition, and the possible aetiologies are discussed.

Neuropsychological profile of young adults with spina bifida with or without hydrocephalus.

OBJECTIVES: To determine the relative impact of hydrocephalus and spinal dysraphism in young adults on intellectual and cognitive functioning. Sub-groups of patients with congenital hydrocephalus and/or spina bifida were assessed between 1995 and 2003. The entry criteria were that individuals should have (i) intact global function, (ii) average verbal intelligence (or above), and (iii) should not have clinical depression. There were three sub-groups: patients with hydrocephalus and spina bifida, patients with hydrocephalus without spina bifida, and patients with spina bifida without hydrocephalus. METHODS: Patients were neuropsychologically assessed as part of their normal clinical assessment during their annual medical review. Each individual completed a screening battery assessing global functioning, verbal intelligence, and mood. In addition they completed additional tests including measures of emotional intelligence, memory, attention, and executive function. Results were analysed to compare the performance of the patient sub-groups and to compare them to a healthy control group. RESULTS: Patients with hydrocephalus (with or without spina bifida) were significantly impaired on the vast majority of all test scores as compared to patients with spina bifida and healthy controls. They were particularly poor on measures assessing executive function. By contrast for patients with spina bifida with no associated hydrocephalus, the significant majority of all test scores fell within the average range or above. CONCLUSIONS: The neuropsychological profile of patients with hydrocephalus is one of relative impairment and this is so whether or not spina bifida is present. In spina bifida alone, in the absence of hydrocephalus, cognitive function is relatively spared.