Postoperative negative pressure pulmonary edema

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Liu R, Wang J, Zhao G, Su Z. Negative pressure pulmonary edema after general anesthesia: A case report and literature review. Medicine (Baltimore). 2019 Apr;98(17): e15389. doi: 10.1097/MD.0000000000015389.

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It is widely accepted that the central mechanism of postoperative NPPE is related to rapid negative intrapleural pressure increasing due to forceful inspiration against the obstruction, which can be up to 10 times or more that of normal breathing. [7] A typical event leading to acute airway obstruction associated with postoperative NPPE is laryngospasm. Other procedure that increases the risk of NPPE includes oropharyngeal, head, and neck surgery. Five [8–12] of the reported 29 cases involved upper respiratory tract surgery, and 10 [1,3,6,7,13–18] of the cases involved head and neck surgery, which may be related to tissue swelling and the sensitive dilator muscle of the upper airway in head and neck surgeries.

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Articles of interest: Elimination of the Autopsy Requirement by CMS

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Rueckert J. Elimination of the Autopsy Requirement by CMS. N Engl J Med. 2020 Feb 13;382(7):683-684.

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The autopsy plays a vital role in quality assurance by providing education and feedback to clinicians regarding diagnostic accuracy, therapeutic efficacy, and medical complications. At our institution, we promote a culture of transparency. Discrepant cases are discussed with the treating physicians and families and are also presented at conferences on morbidity and mortality, to educate a broad audience. As is the case at other academic institutions, our autopsy service provides extensive support of cutting-edge research efforts and hence is not “obsolete.”

CMS is making a mistake. A robust autopsy service plays an important role in providing and maintaining high-quality patient care. By eliminating the autopsy requirement, we are burying opportunities for improvement. The autopsy should be supported, not undermined.

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Article of interest: Effect of No Prehydration vs Sodium Bicarbonate Prehydration Prior to Contrast-Enhanced Computed Tomography in the Prevention of Postcontrast Acute Kidney Injury in Adults With Chronic Kidney Disease: The Kompas RCT.

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Timal RJ, et al Effect of No Prehydration vs Sodium Bicarbonate Prehydration Prior to Contrast-Enhanced Computed Tomography in the Prevention of Postcontrast Acute Kidney Injury in Adults With Chronic Kidney Disease: The Kompas Randomized Clinical Trial. JAMA Intern Med. 2020 Feb 17. [Epub ahead of print]

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RESULTS: Of 554 patients randomized, 523 were included in the intention-to-treat analysis. The median (interquartile range) age was 74 (67-79) years; 336 (64.2%) were men and 187 (35.8%) were women. The mean (SD) relative increase in creatinine level 2 to 5 days after contrast administration compared with baseline was 3.0% (10.5) in the no prehydration group vs 3.5% (10.3) in the prehydration group (mean difference, 0.5; 95% CI, -1.3 to 2.3; P < .001 for noninferiority). Postcontrast acute kidney injury occurred in 11 patients (2.1%), including 7 of 262 (2.7%) in the no prehydration group and 4 of 261 (1.5%) in the prehydration group, which resulted in a relative risk of 1.7 (95% CI, 0.5-5.9; P = .36). None of the patients required dialysis or developed acute heart failure. Subgroup analyses showed no evidence of statistical interactions between treatment arms and predefined subgroups. Mean hydration costs were €119 (US $143.94) per patient in the prehydration group compared with €0 (US $0) in the no prehydration group (P < .001). Other health care costs were similar.

Preoperative evaluation & perioperative management of coronary artery disease in patients undergoing vascular surgery

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Bauer SM, Cayne NS, Veith FJ. New developments in the preoperative evaluation and perioperative management of coronary artery disease in patients undergoing vascular surgery. J Vasc Surg. 2010 Jan;51(1):242-51.

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Conclusions: Routine stress testing should not be performed before VS. The Lee index should be used to stratify risk in patients undergoing VS. Patients with >or=3 risk factors or active cardiac conditions should undergo stress testing, if VS can be delayed. All VS patients, except those with 0 risk factors, should be considered for a beta-blocker (bisoprolol, 2.5-5 mg/d started 1 month before VS, titrated to a pulse <70 beats/min and a systolic blood pressure >or=120 mm Hg). Intermediate risk factors may not require aggressive heart rate control but simply maintenance on a low-dose beta-blocker. Statins should be started (ideally 30 days) before all VS using long-acting formulations such as fluvastatin (80 mg/d) for patients unable to take oral medication.

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Immune thrombocytopenia (ITP)

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Cooper N, Ghanima W. Immune Thrombocytopenia. N Engl J Med. 2019 Sep 5;381(10): 945-955. doi: 10.1056/NEJMcp1810479.

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Immune thrombocytopenia (ITP) is an autoimmune disease characterized by isolated thrombocytopenia. Patients may be asymptomatic at presentation or they may present with mild mucocutaneous to life-threatening bleeding. Although only 5% of patients with ITP present with severe bleeding, [1] bleeding leading to hospital admission within 5 years after diagnosis develops in approximately 15%. [2] Irrespective of bleeding problems, patients with ITP often report fatigue and impaired health-related quality of life. [3] The risk of venous thromboembolism is twice as high among patients with ITP as among persons in the general population; the management of venous thromboembolism may be especially problematic given the concomitant risk of bleeding. [4]

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Surgical Grand Rounds: Patient Reported Outcomes in Thoracic Surgery – What are our patients really telling us?

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Presented by: Onkar Khullar MD, Assistant Professor of Surgery
Division of Cardiothoracic Surgery, Emory University School of Medicine

This is a collection of articles, resources, and commentary from Dr. Khullar’s presentation on February 13, 2020. 

Articles:

Jensen RE, Rothrock NE, DeWitt EM, et al. The role of technical advances in the adoption and integration of patient-reported outcomes in clinical care. Med Care. 2015 Feb;53(2): 153-9. doi: 10.1097/MLR.0000000000000289. Free full-text.

Colt HG, Murgu SD, Korst RJ, et al. Follow-up and surveillance of the patient with lung cancer after curative-intent therapy: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e437S-e454S. doi: 10.1378/chest.12-2365. Full-text for Emory users.

Khullar OV, Rajaei MH, Force SD, Binongo JN, Lasanajak Y, Robertson S, Pickens
A, Sancheti MS, Lipscomb J, Gillespie TW, Fernandez FG. Pilot Study to Integrate
Patient Reported Outcomes After Lung Cancer Operations Into The Society of
Thoracic Surgeons Database. Ann Thorac Surg. 2017 Jul;104(1):245-253. doi:
10.1016/j.athoracsur.2017.01.110. Full-text for Emory users.

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