The role of elective perioperative dialysis in nondialysis renal failure patients.

BACKGROUND: Patients with renal insufficiency represent a difficult group. They show an increased morbidity and mortality after heart surgery. Nondialysis chronic kidney disease patients show higher mortality than patients receiving chronic dialysis. Their management is not standardized. This study was undertaken to determine whether elective perioperative dialysis in these patients improved outcomes. METHOD: A retrospective review of records of nondialysis chronic kidney disease patients was carried out. Patients who were not dialyzed before surgery (group A, n = 28) were compared with a propensity-matched group of patients (group B, n = 28) who received elective dialysis preoperatively for their baseline characteristics and outcomes of their heart surgery. RESULTS: Patients who received elective dialysis in the perioperative period (group B) showed fewer neurologic complications (p = 0.004), shorter postoperative length of stay (p = 0.053), fewer gastrointestinal complications (p = 0.051), and fewer major adverse events (p = 0.013). Multiorgan failure and discharge to an extended care facility were also less frequent in group B, although this did not reach statistical significance. CONCLUSIONS: Nondialysis renal failure patients, particularly those with higher creatinine concentrations, may benefit from elective perioperative dialysis in terms of decreased rates of complications and shorter postoperative length of stay.

Abdominal complications after heart surgery.

BACKGROUND: Up to 3% of patients undergoing heart surgery suffer from an intraabdominal complication (IAC). These complications carry a high mortality besides adding to the morbidity and cost. This review was undertaken to see if a subset of patients with increased risk of IAC could be identified. METHODS: Medical records of 7,731 consecutive patients undergoing heart surgery in a single center were screened for identification of postoperative IAC. One hundred and twenty (120) cases were found. One hundred and six (106) cases were compared with the same number of matched controls. RESULTS: Significant predictors of the development of IAC were increased cardiopulmonary bypass times (> 99 minutes), peripheral vascular disease, chronic steroid use, and low left ventricular ejection fraction. Patients on postoperative antiplatelet therapy or warfarin had a lower risk of IAC. Significant predictors of mortality in IAC were increased cardiopulmonary bypass times (> or = 120 minutes.), use of inotropes, cerebral vascular disease, and incremental age. CONCLUSIONS: A subset of patients can be identified who are at higher risk for IAC and an associated adverse outcome. Patients who have prolonged cardiopulmonary bypass, have a low left ventricular ejection fraction, are on steroids, and suffer from other vascular disease should be observed carefully for development of IAC. Postoperative anticlotting strategies may be helpful. Early diagnosis and intervention are essential for improving outcomes in cases of IAC.

Prospective randomized study of carotid endarterectomy with polytetrafluoroethylene versus collagen-impregnated Dacron (Hemashield) patching: perioperative (30-day) results.

PURPOSE: Several studies have reported that carotid endarterectomy (CEA) with patch angioplasty has results that are superior to primary closure. Polytetrafluoroethylene (PTFE) patching has been shown to have results comparable with autogenous vein patching; however, it requires a prolonged hemostasis time. Therefore, many surgeons are using collagen-impregnated Dacron patching (Hemashield [HP]). This study is the first prospective randomized trial comparing CEA with PTFE patching versus HP patching. METHODS: Two hundred CEAs were randomized into two groups, 100 PTFE and 100 HP patching. All patients underwent immediate postoperative and 1-month postoperative color duplex ultrasound scanning studies. Demographic and clinical characteristics were similar in both groups, including the mean operative diameter of the internal carotid artery. RESULTS: The perioperative stroke rates were 0% for PTFE, versus 7% for HP (4 major and 3 minor strokes, P =.02). The combined perioperative stroke and transient ischemic attack rates were 3% for PTFE, versus 12% for HP (P =.047). The operative mortality rate for PTFE was 0%, versus 2% for HP (P =.477). Five perioperative carotid thromboses were noted in patients undergoing HP patching, versus none in patients undergoing PTFE patching (P =.07). After 1 month of follow-up, 2% of patients in the PTFE group had a 50% or more restenosis, versus 12% of patients in the HP group (P =.013). The mean operative time for PTFE patching was 119 minutes, versus 113 minutes for HP patching (P =.081). The mean hemostasis time was significantly higher for PTFE patching than for HP patching, 14.4 versus 3.4 minutes (P <.001). CONCLUSION: CEA with HP patching had a higher incidence of perioperative strokes, carotid thrombosis, and 50% or more early restenosis than CEA with PTFE patching. However, the mean hemostasis time was higher for PTFE patching than for HP patching.