Risk factors affecting adverse outcomes of cardiac surgery in patients aged 70 years and older.

BACKGROUND: The elderly segment of the population in Taiwan is increasing rapidly. According to the latest information from the Directorate-General of Budget, Accounting and Statistics, Executive Yuan, Taiwan, 1,553,367 civilians of the total population of 22,879,510 (6.8%) are seventy years old and older in 2007. The proportion of high-risk patients has increased dramatically owing to a greater number of elderly patients and increased number of average patients with heart diseases presenting for cardiac surgery. We analyzed the preoperative risk factors for in-hospital mortality, morbidity and the likelihood of prolonged intensive care unit (ICU) stay in elderly patients after cardiac surgery. METHODS: We retrospectively studied 952 adult patients who received cardiac surgery during a three-year period (from August 1, 2004 to December 31, 2006) at Taichung Veterans General Hospital. Patients were divided into a control group and a study group. The study group (n=395) exclusively consisted of patients aged seventy or over while the rest of the patients under study served as reference group (n=557). Continuous variables were compared using Student's t test, and categorical variables were compared using Pearson chi-square test. Variables associated with in-hospital mortality, major morbidity and prolonged ICU stay in univariate analysis with P < 0.05 were entered into multivariate analysis using logistic regression with a stepwise forward selection procedure to determine independent variables and identify variables associated with major adverse outcomes. RESULTS: Fifty-six (14.2%) patients died during their hospitalization in the study group and 46 (8.3%) in the reference group. Major mortality in the study group was 58.0% versus 39.7% in the reference group. The patients of the study group spent more days in the ICU than did patients of the reference group (8.7 +/- 12.0 versus 6.1 +/- 10.0 days, P < 0.05). In addition, 114 (28.9%) patients of the study group and 85 (15.3%) of the reference group spent more than 7 days in the ICU. Using multiple logistic regression analysis, risk factors affecting in-hospital mortality in the study group include impairment of renal function, reoperation, congestive heart failure (CHF), catastrophic event. Impaired renal function, complexity of surgical procedure, CHF, chronic obstructive pulmonary disease (COPD) and catastrophic state were significant factors affecting morbidity in the study group. CHF, COPD and catastrophic event contributed to prolonged ICU stay in the study group. CONCLUSIONS: The perioperative risk of cardiac surgery increases in older patient groups, and some risk factors have different influences on mortality, morbidity and ICU stay. Risk assessment in older cardiosurgical patients with convenient risk factors helps the clinicians to apply rational and cost-effective treatment strategies into practice.

Myoclonic seizure in the postanesthesia care unit after thoracic laminectomy.

IMPLICATIONS: We report a patient who developed myoclonic seizure in the postanesthesia care unit after thoracic laminectomy. Expeditious diagnostic evaluation of unrecognized dura tear during surgery must be instituted immediately to avoid untoward sequelae. Specific treatment in addition to supportive care is required if the diagnosis is to be clearly identified.

Myofascial pain syndrome induced by malpositioning during surgery--a case report.

It is a real challenge to the anesthesiologists to differentiate brachial plexus injury (BPI) from myofascial pain syndrome (MPS). The possibility of MPS should be suspected in a patient with complaints of pain and dysfunction of the upper arm immediately after surgery. Here we report a case of gallstone with cervical ankylosing spondylitis who sustained myofascial pain syndrome (MPS) immediately after open cholecystectomy. We utilized dry needle stimulation to deactivate the trigger point of the pectoris minor muscle and stretching the muscle to relieve the muscle pain after the diagnosis was made. The patient completely recovered 2 weeks later.

Oral clonidine reduces myocardial ischemia in patients with coronary artery disease undergoing noncardiac surgery.

BACKGROUND: To access the clinical effect of clonidine on reduction of myocardial ischemia events in patients with history of coronary artery disease undergoing noncardiac surgeries. METHODS: Sixty ASA class III patients with coronary artery disease were allotted at random to two groups in a prospective, double-blind study to receive either clonidine (3 micrograms/kg) or placebo (control group) 90 minutes before arrival at the operating room. Continuous EKG monitoring (Holter monitor) was performed to analyze the ST segment in lead II, V2 and V5 during the preoperative (since late hours the night before operation), intraoperative and early postoperative periods (total monitoring time = 24 hours). The episode of myocardial ischemia defined as the magnitude of ST segment depression of at least 1 mm, occurring 60 ms after the J point and persisting for three minutes or more was recorded. Perioperative hemodynamic data were analyzed with two-way ANOVA with repeated measures. Student's t-test for unpaired data was used for analysis of demographics. Chi-square test was used for ST segment changes. Results are expressed as mean +/- SD and P < 0.05 was considered to be statistically significant. RESULTS: In the control group, 9 patients (30%) were noted to have episodes of ischemia preoperatively, 7 patients (23.3%) intraoperatively, and 12 patients (40%) postoperatively. The occurrence of myocardial ischemia peaked in the early postoperative period (P < 0.05). On the contrary, in the clonidine group, 10 patients (33.3%) saw ischemic episodes preoperatively, 3 patients (10%) intraoperatively and 5 patients (16.7%) postoperatively. The incidence of myocardial ischemia in clonidine group was significantly lower than that in placebo group in intraoperative and postoperative periods. The mean arterial pressure was significantly lower in some clonidine-treated patients during perioperative periods (P < 0.05). A number of patients in clonidine group suffered from drowsiness (66.7%) after operation (P < 0.05), but they could be easily aroused. In regard to dryness of mouth, nausea and vomiting clonidine and control groups did not differ much (P > 0.05). Demerol consumption was significantly lower in clonidine group (43.7 +/- 4.6 mg) than in control group (76.3 +/- 3.7 mg, P < 0.05). CONCLUSIONS: We conclude that premedication with oral clonidine can significantly reduce the incidence of perioperative myocardial ischemia in patients with CAD undergoing noncardiac surgeries. The incidence of myocardial ischemia in these patients is rather high during perioperative period, which deserves our exceptional caution.