[Impact of intraoperative hypotension and blood loss on acute kidney injury after pancreas surgery]. / Impacto da hipotensão e perda sanguínea intraoperatórias na lesão renal aguda após cirurgia de pâncreas.

PURPOSE: This study aimed to investigate factors associated with postoperative Acute Kidney Injury (AKI) focusing on intraoperative hypotension and blood loss volume. METHODS: This was a retrospective cohort study of patients undergoing pancreas surgery between January 2013 and December 2018. The primary outcome was AKI within 7 days after surgery and the secondary outcome was the length of hospital stay. Multivariate analysis was used to determine explanatory factors associated with AKI; the interaction between the integrated value of hypotension and blood loss volume was evaluated. The differences in length of hospital stay were compared using the Mann-Whitney U-test. RESULTS: Of 274 patients, 22 patients had experienced AKI. The cube root of the area under intraoperative mean arterial pressure of < 65 mmHg (Odds Ratio = 1.21; 95% Confidence Interval 1.01-1.45; p = 0.038) and blood loss volume of > 500 mL (Odds Ratio = 3.81; 95% Confidence Interval 1.51-9.58; p = 0.005) were independently associated with acute kidney injury. The interaction between mean arterial hypotension and the blood loss volume in relation to acute kidney injury indicated that the model was significant (p < 0.0001) with an interaction effect (p = 0.0003). AKI was not significantly related with the length of hospital stay (19 vs. 28 days, p = 0.09). CONCLUSION: The area under intraoperative hypotension and blood loss volume of > 500 mL was associated with postoperative AKI. However, if the mean arterial pressure is maintained even in patients with large blood loss volume, the risk of developing postoperative AKI is comparable with that in patients with small blood loss volume.

Impact of intraoperative hypotension and blood loss on acute kidney injury after pancreas surgery / Impacto da hipotensão e perda sanguínea intraoperatórias na lesão renal aguda após cirurgia de pâncreas

Abstract Purpose: This study aimed to investigate factors associated with postoperative Acute Kidney Injury (AKI) focusing on intraoperative hypotension and blood loss volume. Methods: This was a retrospective cohort study of patients undergoing pancreas surgery between January 2013 and December 2018. The primary outcome was AKI within 7 days after surgery and the secondary outcome was the length of hospital stay. Multivariate analysis was used to determine explanatory factors associated with AKI; the interaction between the integrated value of hypotension and blood loss volume was evaluated. The differences in length of hospital stay were compared using the Mann-WhitneyU-test. Results: Of 274 patients, 22 patients had experienced AKI. The cube root of the area under intraoperative mean arterial pressure of < 65 mmHg (Odds Ratio = 1.21; 95% Confidence Interval 1.01-1.45; p = 0.038) and blood loss volume of > 500 mL (Odds Ratio = 3.81; 95% Confidence Interval 1.51-9.58; p = 0.005) were independently associated with acute kidney injury. The interaction between mean arterial hypotension and the blood loss volume in relation to acute kidney injury indicated that the model was significant (p < 0.0001) with an interaction effect (p = 0.0003). AKI was not significantly related with the length of hospital stay (19 vs. 28 days, p = 0.09). Conclusion: The area under intraoperative hypotension and blood loss volume of > 500 mL was associated with postoperative AKI. However, if the mean arterial pressure is maintained even in patients with large blood loss volume, the risk of developing postoperative AKI is comparable with that in patients with small blood loss volume.

Resumo Justificativa: O presente estudo teve como objetivo examinar os fatores associados à Lesão Renal Aguda (LRA) no pós-operatório, centrando-se na hipotensão e perda de sangue intraoperatórias. Método: Estudo de coorte retrospectivo de pacientes submetidos a cirurgia de pâncreas entre Janeiro de 2013 e Dezembro de 2018. O desfecho primário foi ocorrência de LRA em até 7 dias após a cirurgia e o secundário, o tempo de hospitalização. A análise multivariada foi usada para determinar os fatores explicativos associados à LRA; a interação entre o valor integrado da hipotensão e volume de perda de sangue foi avaliada. As diferenças no tempo de hospitalização foram comparadas pelo teste U de Mann-Whitney. Resultados: Dos 274 pacientes, 22 pacientes apresentaram LRA. A raiz cúbica da área sob a pressão arterial média intraoperatória < 65 mmHg (Odds Ratio = 1,21; Intervalo de Confiança de 95% 1,01-1,45; p = 0,038) e volume de perda sanguínea > 500 mL (Odds Ratio = 3,81; Intervalo de Confiança de 95% 1,51-9,58; p = 0,005) estavam independentemente associados à lesão renal aguda. A interação entre hipotensão arterial média e volume de perda sanguínea em relação à lesão renal aguda apontou o modelo como significante (p < 0,0001) com efeito de interação (p = 0,0003). A LRA não apresentou relação significante com o tempo de hospitalização (19 vs. 28 dias, p = 0,09). Conclusões: A área sob hipotensão arterial e o volume de perda sanguínea > 500 mL no intraoperatório apresentaram associação com LRA no pós-operatório. Entretanto, se a pressão arterial média se mantém, mesmo em pacientes com grande volume de perda sanguínea, o risco de desenvolver LRA no pós-operatório é comparável ao risco dos pacientes com pequeno volume de perda sanguínea.

Neutrophil-to-lymphocyte ratio as indicator to severe complication after pancreaticoduodenectomy or distal pancreatectomy.

BACKGROUND: Pancreaticoduodenectomy and distal pancreatectomy are complex procedures with high rates of post-operative complications. We evaluated the factors associated with post-operative complications, focusing on pre-operative hematologic markers such as the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and prognostic nutritional index. METHODS: Data from patients (≥age 20) who underwent pancreaticoduodenectomy or distal pancreatectomy between January 2013 and December 2017 at a Japanese tertiary hospital were retrospectively reviewed. Patients who failed to complete the operation and those who underwent additional procedure were excluded. The primary outcome was reoperation and unplanned intensive care unit admission before first discharge, and secondary outcome was the length of hospital stay. Multivariate analysis was used to identify explanatory factors associated with post-operative complications. The differences in length of hospital stay were compared with the Mann-Whitney U test. RESULTS: Of 238 eligible patients, 208 with a median age of 71 years were included in the analysis. The median values [1st interquartile range, 3rd interquartile range] of the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and prognostic nutritional index were 2.65 [1.69, 4.04], 247 [146, 407], and 46.0 [42.0, 49.7], respectively. Eleven patients (5.3%) experienced post-operative complications. The neutrophil-to-lymphocyte ratio (odds ratio, 1.13; 95% confidence interval, 1.02-1.26; P = 0.03) and blood loss volume (odds ratio per 100 mL, 1.11; 95% confidence interval, 1.00-1.22; P = 0.039) were independently associated with post-operative complications. Post-operative complications contributed to longer hospital stays (19 [15, 28] vs 33 [22, 65] days, P = 0.005). CONCLUSION: The neutrophil-to-lymphocyte ratio and blood loss volume were significantly associated with post-operative complications, leading to prolonged hospitalization.

A case of thoracic pneumatosis due to severe coughs and tracheal tube displacement induced by tracheal tube size mismatch.

BACKGROUND: Thoracic pneumatosis during mechanical ventilation may be life-threatening. We encountered a patient with thoracic pneumatosis after frequent displacement of the tracheal tube with an overinflated cuff. CASE PRESENTATION: We admitted a 62-year-old man to the intensive care unit (ICU) due to respiratory failure. We secured his airway using a cuffed 8.5-mm tracheal tube. However, air leakage did not stop with the regular intracuff pressure (25 cm H2O) because the diameter of his trachea was too large for the tracheal tube inserted. In addition, a chest X-ray examination revealed rostral tube displacement. Therefore, we applied a higher intracuff pressure (35 cm H2O) to prevent air leakage and tracheal tube movement. However, severe coughing episodes developed, and 3 days after ICU admission, a chest X-ray and CT scan revealed pneumomediastinum and pneumothorax. We did not have larger tracheal tubes in stock. We decided to use a tracheostomy tube instead, which we expected to be placed securely and to prevent tube displacement. After tracheostomy, the severe coughing episodes became infrequent. Finally, we weaned the patient from mechanical ventilation 12 days after ICU admission. CONCLUSIONS: The clinical signs and symptoms in our patient point to tracheal tube size mismatch as the cause of pneumothorax.