Exercise-induced myocardial dysfunction detected by cardiopulmonary exercise testing is associated with increased risk of mortality in major oncological colorectal surgery.

BACKGROUND: Cardiopulmonary exercise testing (CPET) identifies high-risk patients before major surgery. In addition to using oxygen uptake and ventilatory efficiency to assess functional capacity, CPET can be used to identify underlying myocardial dysfunction through the assessment of the oxygen uptake to heart rate response (oxygen pulse response). We examined the relationship of oxygen pulse response, in combination with other CPET variables and known cardiac risk factors, with mortality after colorectal cancer surgery. METHODS: This work focused on a retrospective cohort study of patients who had CPET and underwent colorectal cancer surgery. The primary outcome was a composite of in-hospital and 30-day mortality. Ventilatory inefficiency (Ve/Vco2>34) and exercise-induced myocardial dysfunction (abnormal oxygen pulse response) were investigated for an association with mortality using bivariable analysis and multivariable Cox regression. RESULTS: A total of 1214 patients who underwent colorectal cancer surgery were included, and the primary outcome occurred in 26 patients (2.1%). Multivariable Cox regression showed abnormal oxygen pulse response was independently associated with the primary outcome (odds ratio [OR]=2.75; 95% confidence interval [CI], 1.17-6.47). Bivariable analysis showed that Ve/Vco2 >34 was associated with the primary outcome (OR=3.43; 95% CI, 1.47-8.01). Combining Ve/Vco2 >34 and abnormal oxygen pulse response conferred an increased risk for the primary outcome (OR=4.47; 95% CI, 1.62-12.34), compared with Ve/Vco2 >34 and normal oxygen pulse response. CONCLUSION: Ventilatory inefficiency and an abnormal oxygen pulse response were independently associated with short- (30-day) and long-term (2-yr) mortality. Oxygen pulse response may provide additional information when considering perioperative risk stratification.

Correction to: Does C-reactive protein day 1 post-surgery have a predictive role for post-operative complications: a single-centre perspective following published meta-analysis.

The first sentence of the article should read as follows.

Predictive Value of C-Reactive Protein for Complications Post-Laparoscopic Roux-En-Y Gastric Bypass.

BACKGROUND: Laparoscopic roux-en-Y gastric bypass (LRYGB) has gained increasing popularity as the primary procedure of choice for the management of patients with morbid obesity. Despite the advances, a few patients will still develop complications and predicting these early complications in morbidly obese patients can prove to be difficult. Radiological investigations have limited diagnostic value and have associated side effects and cost. We propose that C-reactive protein (CRP) is a useful predictor for early postoperative complications. This study aims to determine the ability of CRP taken on postoperative day 1 (POD 1) and 2 to predict occurrence of complications within 30 days of surgery. METHODS: This retrospective observational study selected 183 consecutive patients from the York bariatric database between 01 December 2010 and 23 March 2015. EXCLUSIONS: Patients undergoing dual procedures, conversion to open, and if no postoperative CRP measurement was performed. RESULTS: In total, 138 patients satisfied the inclusion criteria during the study period (median age 44 years [20-68], BMI 50.6 kg/m2 [38.3-62.5]). Fifteen (10.8 %) patients had minor complications (CD of 2) and 8 (5.6 %) had major complications (CD 3 or above). A CRP of greater than 127 mg/L on POD 2 was found to predict complications with 93 % sensitivity and 64 % specificity with diagnostic accuracy 0.82 (95 % confidence interval 0.731-0.908). CONCLUSIONS: In our patients, CRP on POD 2 has been shown to be a good predictor of both minor and major complications and can therefore be used to guide clinicians in making decision as to which patients may need further investigation or who can be safely discharged.

Changes in consciousness, conceptual memory, and quantitative electroencephalographical measures during recovery from sevoflurane- and remifentanil-based anesthesia.

UNLABELLED: It is unclear whether opioid-induced changes in electroencephalogram (EEG) or auditory evoked potentials (AEPs) reliably correspond with consciousness. We examined the correlation between 1) the clinically assessed state of consciousness, 2) implicit and explicit memory (by use of word pairs), and 3) various measures of EEG and AEP-bispectral index (BIS), A-Line ARX AEP index, spectral entropy, and entropy of the singular value decomposition (SVDEN; a measure of the complexity of the EEG). We studied 21 women during a two-stage awakening (sevoflurane washout followed by remifentanil washout) after anesthesia for gynecological surgery. All were amnesic, and 19 were unresponsive to verbal command with remifentanil alone. In six patients, BIS decreased paradoxically as the remifentanil concentration decreased; this was caused by a low-amplitude EEG, which was misinterpreted by the Aspect algorithm as burst suppression. Most of the EEG/AEP variables were sensitive to the decrease in sevoflurane and the recovery of consciousness, but not to the effects of decreasing remifentanil concentrations. SVDEN was the only variable that demonstrated significant increases for both the sevoflurane and remifentanil washout phases. With the prediction probability statistic during remifentanil washout, SVDEN = 0.79, spectral entropy = 0.81, A-Line ARX AEP index = 0.63, and BIS = 0.58. Entropy measures appear to be worthy of further clinical evaluation in a larger series of patients. SVDEN may be a useful variable for assessing anesthetic and analgesic effects on the central nervous system. IMPLICATIONS: During the recovery phase from a remifentanil-based anesthetic, the bispectral index is not reliably predictive of the depth of consciousness, because of suppression ratio artifacts. Entropy measures of the electroencephalogram show promise, but there is still no gold standard to estimate anesthetic depth.