1. Aggiornamento del 5 sett

2. Minerva Anestesiol. 1995 May;61(5):173-81. Multivariate prediction of in-hospitalmortality associated with surgical procedures.De Ritis G,Giovannini C, Picardo S, Pietropaoli P.condotto 24,654 pazienti al di sopra di 15 anni di et ,multicentrico gennaio 1989 - dicembre 1990 mortalit nei ricoverati entro 30 gg. Variabili : et Sesso Pressione sistolica Disfunzione renale Disfunzione epatica Malattie concomitanti Severit della chirurgia Priorit della chirurgia Durata dellanestesia. 3. With what certainty can post-anaestheticoutcome be predicted? Short, Timothy G.; Kluger, Michal T. Volume 11(2), April 1998, pp 209-212 4. Arvidsson S, Ouchterlony J, Sjosted L, Svardsudd K. Predictingpostoperative adverse events. Clinical efficiency of four generalclassification systems. Acta Anaesthesiol Scand 1996;40:783-791 prospective perioperative risk assessmentproject 4 simple predictors on 1471 patients ASA physical status, patient age, surgical stress visual analogue scale for intuitively appreciated globalrisk (RISK-VAS). This score was between 0 (almost certain to go through procedure with noadverse outcome) and 10 (patient will almost certainly suffer a seriouscomplication). 5. Arvidsson S, Ouchterlony J, Sjosted L, Svardsudd K. Predictingpostoperative adverse events. Clinical efficiency of four generalclassification systems. Acta Anaesthesiol Scand 1996;40:783-791 All four classification systems correlated to postoperativeadverse events. The best predictor was RISK-VAS. Those with ascore of 4 or more had a 28-fold increased risk of suffering asevere postoperative adverse event compared with patients withscores of less than 4. Positive predictive value was 10% withRISK-VAS score of 7 or more. Low numbers, low mortality andlack of detail on choice of anaesthetic, however, make the resultdifficult to interpret. It is of interest that the overall impressionof the anaesthetist correlated best with outcome, confirming therole of experience and intuition in predicting outcome. 6. Klotz HP, Candinas D, Platz A, Horvath A, Dindo D, Schlumpf R,Largiader F. Preoperative risk assessment in elective generalsurgery. Ann Surg 1996;83:1788-1791. included the impact of surgery itself on risk stratification. In a prospectivereview of 3250 patients using stepwise logistic regression analysis, ASAstatus, severity of operative procedure, symptoms of respiratory diseaseand malignancy were identified as significant risk factors. Patients wereranked according to risk into low (5% complication rate), medium (18%complication rate) and high (33% complication rate) risk categories. Usinga scoring system based on these indices, patients with an adverseoutcome were more likely to be predicted from these indices than fromASA score alone. Both the above studies emphasize the use of somesurgical impact score on outcome. Like the APACHE scoring system inintensive care medicine, however, these scoring systems continue to lacksensitivity, specificity and have positive predictive values of only a few percent. Although useful for population assessment, outcome scores suitablefor application in individuals are still lacking. 7. identified as significant risk factors.Klotz HP, Candinas D, Platz A, Horvath A, Dindo D, Schlumpf R, Largiader F. Preoperative riskassessment in elective general surgery. Ann Surg 1996;83:1788-1791. ASA status, severity of operative procedure symptoms of respiratory disease Malignancy 8. outcomeConseguenza,esito,risultato 9. Surgical Apgar ScoreRegenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++; Greenberg, CapriceC. MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, Atul A. MD, MPH *++ Does the Surgical ApgarScore Measure Intraoperative Performance? Annals of Surgery. 248(2):320-328, August 2008. lowest heart rate lowest mean arterial pressure estimated blood loss A score built from these 3 predictors has provedstrongly predictive of the risk of major postoperativecomplications and death in general and vascular surgery. The score was thus developed using these 3 variables, and their beta coefficientswere used to weight the points allocated to each variable in a 10-point score (Table 1). 10. Regenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++;Greenberg, Caprice C. MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, AtulA. MD, MPH *++ Does the Surgical Apgar Score Measure Intraoperative Performance?Annals of Surgery. 248(2):320-328, August 2008. 11. Regenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++;Greenberg, Caprice C. MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, AtulA. MD, MPH *++ Does the Surgical Apgar Score Measure Intraoperative Performance?Annals of Surgery. 248(2):320-328, August 2008. 12. Regenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++;Greenberg, Caprice C. MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, AtulA. MD, MPH *++ Does the Surgical Apgar Score Measure Intraoperative Performance?Annals of Surgery. 248(2):320-328, August 2008. 13. Regenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++;Greenberg, Caprice C. MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, AtulA. MD, MPH *++ Does the Surgical Apgar Score Measure Intraoperative Performance?Annals of Surgery. 248(2):320-328, August 2008. 14. Frequenza delle complicanze a seconda del Surgical ApgarScoreRegenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++; Greenberg, Caprice C.MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, Atul A. MD, MPH *++ Does the Surgical ApgarScore Measure Intraoperative Performance? Annals of Surgery. 248(2):320-328, August 2008.80706050403020100Ko maggiori0-23-45-67-89-10% 15. Regenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++;Greenberg, Caprice C. MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, AtulA. MD, MPH *++ Does the Surgical Apgar Score Measure Intraoperative Performance?Annals of Surgery. 248(2):320-328, August 2008. We find that even after detailed adjustment for comorbidity and procedure-specific risk factors, the amount of blood loss, lowest heart rate, and lowest blood pressure were still important predictors of the risk of a major complication. The Surgical Apgar Score, therefore, conveyed useful prognostic information, either in isolation or in combination with assessments of the risks that patients brought to the operating room. It also may provide an immediate assessment of how well or poorly the operation has gone for a patient. In this cohort, surgical teams could cut a patients risk-adjusted odds of major complications nearly in half with a score of 9 10, or conversely, nearly triple the risk-adjusted odds with scores 4. This finding, that intraoperative blood loss, heart rate, and blood pressure are critical predictors of postoperative risk, is consistent with a variety of previous observations. 16. Regenbogen, Scott E. MD, MPH *+; Lancaster, R Todd MD *+; Lipsitz, Stuart R. ScD ++;Greenberg, Caprice C. MD, MPH ++; Hutter, Matthew M. MD, MPH +; Gawande, AtulA. MD, MPH *++ Does the Surgical Apgar Score Measure Intraoperative Performance?Annals of Surgery. 248(2):320-328, August 2008. In summary, we have found that a simple clinimetric surgical outcome score can provide both clinical surgeons and surgical safety researchers with useful and important information. The Surgical Apgar Score integrates components of patient susceptibility, procedure complexity, and operative performance, providing a measure of immediate postoperative condition and prognostication beyond standard risk-adjustment. As a decision-support tool, the score can inform postoperative prognostication, communication, and triage, regardless of the sophistication of preoperative risk stratification available. Finally, as a simple intraoperative outcome measure and safety improvement metric, it may prove useful as an indicator of surgical performance 17. Il rischio perioperatorio nei malati mentaliAnn Surg. 2008 Jul;248(1):31-8.Postoperative complications in the seriously mentally ill: a systematic review of the literature.Copeland LA, Zeber JE, Pugh MJ, Mortensen EM, Restrepo MI, Lawrence VA Da quel poco che stato pubblicato la schizofrenia emerge comefattore di rischio per mortalit e morbilit,questultimapeculiare per frequenza di ileo paralitico postop e confusione mentale. questi pazienti sembrerebbero resistenti al dolore . Pazienti affetti da disordini depressivi seri presentano unaelevate incidenza di delirio postop e di confusionementale. Da notare che tali complicanze sono pi frequenti quando sisospendono le terapie abituali nel periodo preop. Ann Surg. 2008 Jul;248(1):31-8.Postoperative complications in the seriously mentally ill: a systematic review of the literature.Copeland LA, Zeber JE, Pugh MJ, Mortensen EM, Restrepo MI, Lawrence VA 18. Table 1: Surgical risk scores classified byoutcome measure and need for intra-operativeinformation Scores predicting mortality Scores predictingmorbidity Scores not requiring operative informationASA1 ASA APACHE-II8 APACHE-II Donati Score16 Goldman Cardiac Risk Index3 Hardman Index38 Veltkamp Score44 19. Cardiac Risk Index in Noncardiac SurgeryCriteria FindingAge (yr) >70 5Cardiac status MI within 6 mo 10Ventricular gallop or jugular venous distention (signs of heartfailure)11Significant aortic stenosis 3Arrhythmia other than sinus or premature atrial contractions 75 premature ventricular contractions/min 7General medical condition Po2 < 60 mm Hg, Pco2 > 50 mm Hg, K < 3 mmol/L, HCO3 50 mg/dL, serum creatinine > 3 mg/dL, elevatedAST, a chronic liver disorder, or bedbound3Type of surgery needed Emergency surgery 4Intraperitoneal, intrathoracic, or aortic surgery 3*Risk is based on the total number of points:Level I: 05Level II: 612Level III: 1325Level IV: >25Adapted from Goldman L et al: Multifactorial index of cardiac risk in noncardiac surgical procedures. NewEngland Journal of Medicine 297:845850, 1977. 20. aoNmnauryaIuaemvosSPar talpnegg Preoperative ityRisk Factors and Surgical Complexity Are MorePredictive of Costs Than Postoperative Complications: A Case StudyUsing the National Surgical Quality Improvement Program (NSQIP)Database [Ann Surg 242(4):463-471, 2005. 2005 LippincottWilliams & Wilkins] 21. aoNmnauryaIuaemvosSPar talpnegg Table Greatest Increase in Mean Variable Direct CostsityThe 25 Preoperative Risk Factors Associated With the3. Comparison of Individual and Sequentially Combined Multiple Linear Regression Models of Preoperative Risk Factors, SurgicalComplexity, and Postoperative Complications Versus Transformed CostsTable 4. The 10 Postoperative Complications Associated With the Greatest Increase in Mean Variable Direct Costs 22. aoNmnauryaIuaemvosSPar talpnegg Table ity3. Comparison of Individual and Sequentially Combined Multiple Linear Regression Models of Preoperative Risk Factors, SurgicalComplexity, and Postoperative Complications Versus Transformed CostsTable 4. The 10 Postoperative Complications Associated With the Greatest Increase in Mean Variable Direct Costs 23. aoNmnauryaIuaemvosSPar talpnegg ity 24. Figure 1. Preoperative risk factor cost predictions versus actual transformedcosts. A multivariate regression of all the preoperative risk factors predicted33% of the variation in costs (P < 0.001). The quartic root transformationyielded the best fit of the data. 25. Clean wounds The wound is considered to be clean when theoperative procedure does not enter into a normallycolonized viscus or lumen of the body. SSI rates in thisclass of procedures are less than 2%, depending uponclinical variables, and often originate from 26. : Arch Otolaryngol Head Neck Surg. 2003Jul;129(7):739-45. Links APACHE II, POSSUM, and ASA scores and therisk of perioperative complications inpatients with oral or oropharyngeal cancer. de Cssia Braga Ribeiro K, Kowalski LP. Hospital Cancer Registry and Department ofHead and Neck Surgery andOtorhinolaryngology, Centro de Tratamento ePesquisa Hospital do Cncer A. C. Camargo, 27. Ann Surg. 2007 Jul;246(1):91-6. The AFC score: validation of a 4-item predictingscore of postoperative mortality after colorectal resection for cancer ordiverticulitis: results of a prospective multicenter study in 1049 patients.Alves A, Panis Y, Mantion G, Slim K, Kwiatkowski F, Vicaut E. age older than 70 years neurologic comorbidity underweight (body weight loss >10% in 18,the O:P ratio was nearer to 1. Physiological score and white cell count were significant in amultivariate model. Conclusion: P-POSSUM underestimated the mortality rate. While P-POSSUM analysis gavea truer prediction of morbidity, underestimation of morbidity and potential for systematicinaccuracy in prediction of complications at lower risk levels is a significant issue forpancreatic surgery. 53. American Journal of Surgery - Volume 194, Issue 2 (August 2007) -Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediateoutcome after elective abdominal aortic aneurysm surgeryTjun Tang,Stewart R. Walsh,Thomas R. Fanshawe, Jonathan H. Gillard,Umar Sadat,Kevin Varty, Michael E. Gaunt, Jonathan R. Boyle. Haga et al [10] derived and validated the Estimation of Physiologic Ability andSurgical Stress (E-PASS) scoring system for risk stratification of patientsundergoing elective general gastrointestinal (GI) surgery. Furthermore, it has beenexternally validated in a different geographical setting from where it wasoriginally developed and has been shown to be reproducible in accuratelypredicting outcome following elective GI surgery [11]. This system comprises apre-operative risk score (PRS), a surgical stress score (SSS), and a comprehensiverisk score (CRS), which is calculated from the PRS and SSS. E-PASS was based onthe premise that morbidity and mortality rates can be correlated with thepatients physiologic risk and the surgical stress applied. Surgical stress can beestimated, in general, because tissue destruction, bleeding and ischemia causedby basic surgical techniques produce inflammatory cytokines, which are thoughtto be an underlying mechanism in the development of organ failure following asurgical insult [12]. 54. [10] Haga Y., Ikei S., Ogawa M.: Estimation of Physiologic Ability andSurgical Stress (E-PASS) as a new prediction scoring system for post-operativemorbidity and mortality following gastrointestinal surgery.Surg Today 29. 219-225.1999;[11] Oka Y., Nishijima J., Oku K., et al: Usefulness of an Estimation ofPhysiologic Ability and Surgical Stress (E-PASS) scoring system to predictthe incidence of postoperative complications in gastrointestinal surgery.World J Surg 29. 1029-1033.2005;[12] Ogawa M.: Mechanisms of the development of organ failurefollowing surgical insult: the second attack theory. Clin IntensCare 7. 34-38.1996;[13] Haga Y., Ikei S., Wada Y., et al: Evaluation of an Estimation ofPhysiologic Ability and Surgical Stress (E-PASS) scoring system to predictpostoperative risk: a multicenter prospective study. Surg Today 31. 569-574.2001; 55. Incidence of mortality and morbidity accordingto CRS. The graph appears todemonstrate that patients in the 1.0 categoryare at particularly high riskof mortality, and in the .5 to 350 m. 89. Dillioglugil, Ozdal; Leibman, Bryan D.;Leibman, Neville S.; Kattan, Michael W.;Rosas, Alejandro L.; Scardino, Peter T. RiskFactors for Complications and Morbidity AfterRadical Retropubic Prostatectomy. Journal ofUrology. 157(5):1760-1767, May 1997.Purpose: With recognition of the efficacy ofsurgical therapy for prostate cancer, there hasbeen a marked increase in the number ofradical prostatectomies performed, andsubstantial changes in surgical technique and 90. Prostatectomia radicale retropubica:Dillioglugil, Ozdal; Leibman, Bryan D.; Leibman, Neville S.; Kattan, Michael W.; Rosas, Alejandro L.;Scardino, Peter T. Risk Factors for Complications and Morbidity After Radical Retropubic Prostatectomy.Journal of Urology. 157(5):1760-1767, May 1997 Complicanze maggiori e mortalitassociate con: ASA Perdite ematiche intraop 91. Bennett-Guerrero, Elliott M.D. *; Panah, Michael H. M.D. +; Robin Barclay, G.Ph.D. ++; Bodian, Carol A. Dr.P.H. [S]; Winfree, Wanda J. B.S.N. [//]; Andres,Lewis A. B.S. #; Reich, David L. M.D. **; Mythen, Michael G. M.D. ++Decreased Endotoxin Immunity Is Associated with Greater Mortality and/orProlonged Hospitalization after Surgery. Anesthesiology. 94(6):992-998, June2001 Background: Patients undergoing noncardiac surgery often develop postoperativemorbidity, potentially attributable to endotoxemia and the systemic inflammatory responsesyndrome. Endogenous antibodies to endotoxin may confer protection from endotoxin-mediatedtoxicity. The authors sought to determine the association of preoperativeantiendotoxin immunity and death or prolonged hospitalization in a broad population ofgeneral surgical patients undergoing major surgery. Methods: To test the hypothesis that low preoperative serum antiendotoxin core antibody(EndoCAb) concentration is an independent predictor of adverse outcome after generalsurgery, 1,056 patients undergoing routine noncardiac surgery were enrolled into aprospective, blinded, cohort study. Immunoglobulin M EndoCAb, immunoglobulin GEndoCAb, total immunoglobulin M, and immunoglobulin G concentrations were measured inserum obtained preoperatively. A physiologic risk score using the established POSSUMcriteria was assigned preoperatively to each patient. The primary predefined composite endpoint (postoperative complication) was either in-hospital death or postoperative length ofstay greater than 10 days. Multivariate logistic regression was used to test the studyhypothesis. 92. Bennett-Guerrero, Elliott M.D. *; Panah, Michael H. M.D. +; Robin Barclay, G. Ph.D. ++;Bodian, Carol A. Dr.P.H. [S]; Winfree, Wanda J. B.S.N. [//]; Andres, Lewis A. B.S. #;Reich, David L. M.D. **; Mythen, Michael G. M.D. ++ Decreased Endotoxin Immunity IsAssociated with Greater Mortality and/or Prolonged Hospitalization after Surgery.Anesthesiology. 94(6):992-998, June 2001 Results: Overall, postoperative complication occurred in 234 of the 1,056patients (22.1%). Lower immunoglobulin M EndoCAb concentration (P =0.006) predicted increased risk of postoperative complicationindependent of POSSUM physiologic risk score (P < 0.001). In contrast,total immunoglobulin M and total immunoglobulin G concentrations didnot predict adverse outcome. Complications involved multiple organsystems and were generally unrelated to the type or site of surgery,consistent with the systemic inflammatory response syndrome. Conclusions: Adverse outcome after routine noncardiac surgery iscommon and is predicted in part by low concentrations of EndoCAb. Theauthors' findings suggest that endotoxemia may be a cause ofpostoperative morbidity after routine noncardiac surgery 93. Bennett-Guerrero, Elliott M.D. *; Panah, Michael H. M.D. +; Robin Barclay, G. Ph.D. ++;Bodian, Carol A. Dr.P.H. [S]; Winfree, Wanda J. B.S.N. [//]; Andres, Lewis A. B.S. #;Reich, David L. M.D. **; Mythen, Michael G. M.D. ++ Decreased Endotoxin Immunity IsAssociated with Greater Mortality and/or Prolonged Hospitalization after Surgery.Anesthesiology. 94(6):992-998, June 2001 low preoperative serum antiendotoxin coreantibody (EndoCAb) concentration is anindependent predictor of adverse outcome 94. Lower immunoglobulin M EndoCAbconcentration (P = 0.006) predicted increasedrisk of postoperative complication independentof POSSUM physiologic risk score (P < 0.001). Incontrast, total immunoglobulin M and totalimmunoglobulin G concentrations did notpredict adverse outcome. Complicationsinvolved multiple organ systems and weregenerally unrelated to the type or site ofsurgery, consistent with the systemicinflammatory response syndrome. 95. BERLAUK, JON F. M.D. *; ABRAMS, JEROME H.M.D. +; GILMOUR, IAN J. M.D. *; O'CONNOR,S. RHIANNON M.D. *; KNIGHTON, DAVID R.M.D. +; CERRA, FRANK B. M.D. + PreoperativeOptimization of CardiovascularHemodynamics Improves Outcome inPeripheral Vascular Surgery. Annals ofSurgery. 214(3):289-299, September 1991.The hypothesis that optimizing hemodynamicsusing pulmonary artery (PA) catheter(preoperative 'tune-up') would improve 96. BERLAUK, JON F. M.D. *; ABRAMS, JEROME H. M.D. +; GILMOUR, IAN J. M.D. *;O'CONNOR, S. RHIANNON M.D. *; KNIGHTON, DAVID R. M.D. +; CERRA, FRANK B.M.D. + Preoperative Optimization of Cardiovascular Hemodynamics ImprovesOutcome in Peripheral Vascular Surgery. Annals of Surgery. 214(3):289-299,September 1991Ottimizzazione dellemodinamica(tune up invasivo con PAcatetere,ottenuto con riduzione del postcarico,miglioramentoinotropico e riempimento volemico , in pazienti candidati achirurgia vascolare degli arti inferiori riduceva : eventi avversi intraop morbidit postop lincidenza di trombosi dei graft.La mortalit generale era del 3.4%, ,ma del 9.5% nel gruppo di controllo edell 1.5% nel gruppo trattato . 97. PA catheter improves outcome. 98. Wiklund, Richard A. MD Preoperative preparation of patientswith advanced liver disease. Critical Care Medicine. CRITICALSURGICAL ILLNESS: PREOPERATIVE ASSESSMENT ANDPLANNING. 32(4) Supplement:S106-S115, April 2004. Objective: To review the characteristic features of patients with advancedliver disease that may lead to increased perioperative morbidity andmortality rates. Design: Literature review. Results: Patients with end-stage liver disease are at high risk of majorcomplications and death following surgery. The most commoncomplications are secondary to acute liver failure and include severecoagulopathy, encephalopathy, adult respiratory distress syndrome, acuterenal failure, and sepsis. The degree of malnutrition, control of ascites,level of encephalopathy, prothrombin time, concentration of serumalbumin, and concentration of serum bilirubin predict the risk ofcomplications and death following surgery. Other determinants ofadverse outcome include emergency surgery, advanced age, andcardiovascular disease. Portal hypertension is a prominent feature ofadvanced liver disease, and it predisposes the patient to varicealhemorrhage, hepatorenal syndrome, hepatopulmonary syndrome, anduncontrolled ascites. Portal hypertension can be ameliorated by 99. Fattori di rischio nei pazienti conmalattia epatica avanzata degree of malnutrition control of ascites level of encephalopathy prothrombin time concentration of serum albumin and concentration of serum bilirubin emergency surgery advanced age cardiovascular disease. 100. Risk Assessment for and Strategies ToReduce Perioperative PulmonaryComplications for Patients UndergoingNoncardiothoracic Surgery: A Guideline fromthe American College of Physicians Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Annals of Internal medicine 18 April 2006 |Volume 144 Issue 8 | Pages 575-580 101. Vedi le considerazioni finali del mioscritto.. 102. Relazione fra ASA PS e complicanzepolmonari 103. Multivariate analysis found that portalclamping (P = 0[middle dot]023) andperioperative blood transfusion (P < 0[middledot]001) were risk factors for morbidity,whereas perioperative blood transfusion (P 0.05). CONCLUSIONS: We thinkPOSSUM can be appropriately used as a tool of surgical audit in lung resectionoperations. 266. Br J Surg. 1998 Jul;85(7):956-61. Ward versus intensive care management of high-risk surgical patients.Curran JE, Grounds RM. Anaesthetic Department, St George's Hospital, London, UK. BACKGROUND: Selection of high-risk surgical patients for preoperative and perioperative admission to anintensive therapy unit (ITU) for enhancement of oxygen delivery may reduce postoperative morbidity andmortality rates. Limited resources may prevent admission of all suitable patients. This audit study examinedwhether it is possible to select patients most at risk and thus reduce surgical morbidity and mortality rateswhen ITU services are limited. METHODS: This was a retrospective audit comparing the actual outcomes ofcomplications and death with predicted outcomes using the POSSUM score (Physiological and OperativeSeverity Score for the enUmeration of Mortality and morbidity) for 101 general surgical and vascular patientswho would have fulfilled previously suggested criteria for preoperative admission to the ITU. Main outcomemeasures were the number of preoperative ITU admission criteria, American Society of Anesthesiologists(ASA) and POSSUM scores, preoperative oxygen delivery values, intravenous fluid therapy, length of ITU stay,length of hospital stay, postoperative complications and 28-day mortality. RESULTS: Medical staff allocatedpatients appropriately. There was a lower mortality rate than predicted from individual POSSUM scores.Patients who were admitted to the ITU before operation had the highest ASA scores, admission criteria andPOSSUM scores; they also had significantly lower mortality and morbidity rates than predicted by thePOSSUM scoring system. CONCLUSION: Patients with the greatest reduction in mortality and morbidity rateswere admitted to the ITU before operation and had cardiovascular physiology 'optimized' before surgery ******* quello che ci chiediamo continuamente,ma lo studio sembramolto flawedperch le outcome measures non sono effettivamentetali 267. Main outcome measures were the number ofpreoperative ITU admission criteria, AmericanSociety of Anesthesiologists (ASA) andPOSSUM scores, preoperative oxygen deliveryvalues, intravenous fluid therapy, length ofITU stay, length of hospital stay, postoperativecomplications and 28-day mortality. 268. Br J Surg. 1996 Jun;83(6):812-5. Links Comment in: Br J Surg. 1996 Oct;83(10):1483-4. An evaluation of the POSSUM surgical scoring system. Whiteley MS, Prytherch DR, Higgins B, Weaver PC, Prout WG. Department of Surgery, Queen Alexandra Hospital, Portsmouth, UK. POSSUM (Physiological and Operative Severity Score for the enUmeration of Morbidity and mortality) hasbeen studied as a possible surgical audit system for a 9-month interval using a sample of 28 per cent ofthe general surgical workload. Mortality or survival was analysed as an endpoint. In this sample thepublished POSSUM predictor equation for mortality overpredicted deaths by afactor of more than two. The bulk of the overprediction occurred in the group atlowest risk (predicted mortality 10 per cent or less), in which death wasoverpredicted by a factor of six. This is the most important group for auditpurposes since it contains the majority of surgical patients and is composed of fitpatients undergoing minor surgery. The published predictor equation formortality returns a minimum predicted mortality of 1.08 per cent, clearly farhigher than that expected for a fit patient having minor surgery. Logisticregression was done on a set of 1485 surgical episodes to generate a localpredictor equation for mortality. This process gave a predictor equation thatfitted well with the observed mortality rate and gave a minimum predicted risk ofmortality of 0.20 per cent. The previously published POSSUM predictor equationfor mortality performed badly when tested using a standard test of goodness offit for logistic regression and must be modified 269. Fin qui 270. It is probable that the Possum scoring systemis well adapted only to major surgery? 271. Dis Colon Rectum. 1996 Jun;39(6):654-8. Links Comparison of individual surgeon's performance. Risk-adjusted analysis with POSSUM scoring system. Sagar PM, Hartley MN, MacFie J, Taylor BA, Copeland GP. Royal Liverpool University Hospital, Liverpool, United Kingdom. Comparison of outcome after colorectal resection among different surgeons is difficult. Crude rates ofmorbidity and mortality can be misleading because such rates make no allowance for differences in casemix and fitness of patients. AIM: The aim of this study was to compare outcome among five surgeons bymeans of the simple, well-validated scoring system POSSUM for risk-adjusted analysis. METHODS: A total of438 patients were studied prospectively. Each patient underwent colorectal resection by one of the fivesurgeons. Demographic details, operative procedure, and postoperative course were recorded, andphysiologic and operative severity scores were determined. Risk of morbidity and mortality was calculatedfor each patient. RESULTS: Incidence of morbidity varied sharply among the fivesurgeons, from 13.6 to 30.6 percent, and the 30-day mortality varied from 4.5to 6.9 percent. However, application of POSSUM to allow risk-adjusted analysisof the data demonstrated that the incidence of morbidity and mortalitypredicted by POSSUM based on patients physiologic and operative risks factors was verysimilar to the observed outcome for each surgeon. CONCLUSION: Direct comparison of individual surgeon'sperformance based on crude rates of morbidity and mortality can be misleading. Risk-adjusted analysisallows more meaningful comparis 272. : Br J Surg. 1994 Oct;81(10):1492-4. Links Comment in: Br J Surg. 1995 Mar;82(3):425-6. Comparative audit of colorectal resection with thePOSSUM scoring system. Sagar PM, Hartley MN, Mancey-Jones B, Sedman PC, May J, Macfie J. University Department of Surgery, Royal Liverpool Hospital, UK. Comparison of outcome after colorectal resection between different surgical units is difficult. Crude ratesof morbidity and mortality may give a distorted picture as such rates fail to account for variations in casemix and physiological status of patients. The simple and validated scoring system POSSUM (Physiologicaland Operative Severity Score for enUmeration of Mortality and morbidity) was used tocompare outcome after colorectal resection in two units. Consecutive series ofpatients who underwent colorectal resection in unit 1 (a university teachinghospital) or unit 2 (a district general hospital) were scored with the POSSUMsystem. Postoperative complications and 30-day mortality were recorded. In unit1, 66 patients underwent colorectal resection with a mortality rate of 6 per centand a morbidity rate of 9 per cent. In unit 2 the rates of mortality and morbiditywere 9 and 26 per cent respectively for 182 patients undergoing colorectalresection. However, application of POSSUM predicted a mortality rate of 5.2 percent for patients in unit 1 and 9.8 per cent for those in unit 2 with predictedmorbidity rates of 11.2 and 23.9 per cent respectively. Direct comparison ofoutcome between these two units would be misleading. Application of POSSUMallows more realistic comparative audit of colorectal resection 273. Ann R Coll Surg Engl. 1993 May;75(3):175-7. Links Comparative vascular audit using the POSSUM scoring system. Copeland GP, Jones D, Wilcox A, Harris PL. Warrington District General Hospital. Comparative audit using overall mortality and morbidity figures can be misleadingas they do not take into account variations in surgical procedure and patientfitness. To examine these effects we have compared vascular surgery in twodiffering hospitals, during a similar 9-month period, using the POSSUM scoringsystem. In one unit, 255 patients underwent vascular surgery with an operativemortality of 9.4%, and morbidity of 37.3%. In the other unit, 89patients underwent vascular procedures with an operative mortalityof 20.2% and morbidity of 47.2%. At first sight there appear to besignificant differences in operative outcome between the two units.However, analysis using the POSSUM system predicts a mortality rateof 10.2% for unit A and 20.2% for unit B (morbidity rates of 38.4% for unit Aand 50.6% for unit B). Receiver operating curve (ROC) analysis demonstrated nosignificant difference between the two units (see Table III). POSSUM analysis maybe of use in comparative audit 274. Br J Surg. 1991 Mar;78(3):355-60. Links POSSUM: a scoring system for surgical audit. Copeland GP, Jones D, Walters M. Department of Surgery, Broadgreen Hospital, Liverpool, UK. POSSUM, a Physiological and Operative Severity Score for theenUmeration of Mortality and morbidity, is described. This systemhas been devised from both a retrospective and prospectiveanalysis and the present paper attempts to validate it prospectively.Logistic regression analysis yielded statistically significant equationsfor both mortality and morbidity (P less than 0.001). Whendisplayed graphically zones of increasing morbidity and mortalityrates could be defined which could be of value in surgical audit. Thescoring system produced assessments for morbidity and mortalityrates which did not significantly differ from observed rates 275. Gastric cancer surgery : Ann R Coll Surg Engl. 2008 Apr;90(3):235-42. Links Gastric cancer surgery--a balance of risk and radicality. Lamb P, Sivashanmugam T, White M, Irving M, Wayman J, Raimes S. Department of Gastrointestinal Surgery, Cumberland Infirmary, Carlisle, UK. INTRODUCTION: The aim of this study was to determine whether tailoring the extent of resectionwould allow radical gastric cancer surgery to be performed safely in a UK population. PATIENTSAND METHODS: A total of 180 consecutive patients (median age 70 years; male:female ratio 2:1)undergoing resection for gastric adenocarcinoma with curative intent were studied. Extent oflymphadenectomy was based upon pre-operative and intra-operative staging, and balancedagainst the patient's age and fitness. RESULTS: In the study group, 83 patients underwent subtotalor distal partial gastrectomy and 97 patients underwent total or proximal partial gastrectomy.Operative procedures were: D1 lymphadenectomy (n = 62); modified (spleen and pancreas pre-serving)D2 lymphadenectomy (n = 73); D2 lymphadenectomy (n = 42); and extended resection (n =3). TNM classification was: stage 1 (n = 45); stage 2 (n = 37); stage 3 (n = 61); and stage 4 (n = 37).Of the patients, 48 developed postoperative complications including 17 patientswith a major surgical complication. The in-hospital mortality was 1.7% (3 of 180).Predicted mortality according to POSSUM and P-POSSUM was 21.4% and 7.8%,respectively. Disease-specific 5-year survival according to stage was 85.4%, 64.2%, 33.3%, and6.9%. CONCLUSIONS: By tailoring the extent of resection and balancing risk and radicality, gastriccancer surgery can be performed with low mortality in Western patients. 276. Zentralbl Chir. 2008 Apr;133(2):156-63. [Influenceable surgical andanesthesiological risk factors for the development of cardiac andpulmonary complications in laparoscopic surgery of the colon]Hermeneit S, Mller M, Terzic A, Rodehorst A, Schamberger M, Bttger T. Klinik fr Viszeral-, Thorax- und Gefsschirurgie, Zentrum fr minimalinvasive Chirurgie. INTRODUCTION: Due to the demographic shift in the age structure of thepopulation, increasingly older, multimorbid patients are operated whohave a substantially higher risk for the occurrence of intra- andpostoperative complications. Apart from the identification of patient-referred,hardly influenceable risk factors, influenceable intraoperativesurgical and anesthesiological risk factors have hardly ever beenexamined. The aim of this investigation was therefore to identifyinfluenceable risk factors for the development of post-operativemorbidity. METHODS: In a period of 44 months, we performed alaparoscopic colon resection in 157 men and 209 women with a mean ageof 63 years. The ASA classification, POSSUM score, status of theanesthesiologist, change of the anesthesiologist, intraoperativemonitoring, kind of anaesthesia, fluctuations of blood pressure and pulseduring the operation, shock-index > 1, substitution of erythrocyteconcentrates and FFPs as well as intraoperative surgical complicationswere documented prospectively. Postoperative general complicationsrequiring therapy, in particular, cardiac and pulmonal problems as well assurgical complications, in particular, infections and hemorrhages, weredocumented. The data analysis was performed using the programpackage SPSS 277. Fin qui 278. Zentralbl Chir. 2008 Apr;133(2):156-63. [Influenceable surgical andanesthesiological risk factors for the development of cardiac andpulmonary complications in laparoscopic surgery of the colon] Hermeneit S,Mller M, Terzic A, Rodehorst A, Schamberger M, Bttger T . RESULTS: Intraoperative monitoring was more frequently used in higher ASA stages,whereas for ASA stage IV no central venous line was used in 17 % and no arterial catheterwas placed in 33 %. a similar tendency concerning the POSSUM score could not bedetermined. Patients cared for by junior surgeons exhibited cardiac complications in 6.7 %and 13.1 % had to be mechanically ventilated postoperatively versus 2 % of cardiaccomplications and 9 % mechanical ventilation among those managed by specialists. Anincrease in postoperative complications could also be found when a change in anesthesiatook place. During treatment by an assistant in case of emergencies, in cases whereintraoperative substitution of erythrocytes or an operation lasting more than two hours,more cardiac complications and a higher rate of mechanical respiration was observed thanduring treatment by a specialist. A mechanical respiration was significantly more necessaryin higher ASA stages (p < 0.01), in an operation lasting more than 2 hours (p < 0.01), in caseswith the occurrence of intraoperative bleeding complications (p < 0.01), procedures with alower status of the anesthesiologist (p < 0.01) and in procedures with a change of theanesthesiologist (p < 0.05). CONCLUSION: Factors such as overweight, ASA classification orurgency cannot be changed. Surgical factors such as a standardisation of the operationtechnique with reduction of the operating time and careful staunching of bleeding can helpto reduce postoperative complications. Anesthesiologists can also help by avoiding a changeof the anesthesiologist as well as by preference of specialists in patients with higher ASAstages and in emergency cases. 279. IIncrease in postop complicationsZentralbl Chir. 2008 Apr;133(2):156-63. [Influenceable surgical and anesthesiological riskfactors for the development of cardiac and pulmonary complications in laparoscopic surgeryof the colon] Hermeneit S, Mller M, Terzic A, Rodehorst A, Schamberger M, Bttger T junior surgeons change in anesthesia treatment by an assistant in case of emergencies intraoperative substitution of erythrocytes operation lasting more than two hours higher ASA stages intraoperative bleeding complications procedures with a lower status of the anesthesiologist 280. P Possum better than Possum incraniotomy Br J Neurosurg. 2008 Apr;22(2):275-8. Links Evaluation of POSSUM and P-POSSUM scoring systems for predicting the mortality in elective neurosurgical patients. Ramesh VJ, Rao GS, Guha A, Thennarasu K. National Institute of Mental Health and Neurosciences, Bangalore, India. A simple way of evaluating surgical outcomes is to compare mortality and morbidity. Such comparisons maybe misleading without a proper case mix. The POSSUM scoring system was developed to overcome thisproblem. The score can be used to derive predictive mortality and morbidity for surgical procedures. POSSUMand a modified version P-POSSUM have been evaluated in various groups of surgical patients for the accuracyof predicting mortality. These scoring systems have not been evaluated in neurosurgical patients. Thus, wetried to evaluate the usefulness of POSSUM and P-POSSUM scoring systems in neurosurgical patients inpredicting in-hospital mortality. POSSUM physiological and operative variables were collected from allneurosurgical patients undergoing elective craniotomy, from April 2005 to Feb 2006. In-hospital mortality wasobtained from the hospital mortality register. The physiological score, operative score, POSSUM predictedmortality rate and P-POSSUM predicted mortality rate were calculated using a calculator. The observednumber of deaths was compared against the predicted deaths. A total of 285 patients with amean age of 38 +/- 15 years were studied. Overall observed mortality was nine patients(3.16%). The mortality predicted by the P-POSSUM model was also nine patients (3.16%).Mortality predicted by POSSUM was poor with predicted deaths in 31 patients (11%). Thedifference between observed and predicted deaths at different risk levels was not significant with P-POSSUM(p = 0.424) and was significantly different with POSSUM score (p < 0.001). P-POSSUM scoring system washighly accurate in predicting the overall mortality in neurosurgical patients. In contrast, POSSUM score was notuseful for prediction of mortality. 281. Colorectal cancer surgery Langenbecks Arch Surg. 2008 Mar 5. [Epub ahead of print] Links Analysis of POSSUM score and postoperative morbidity in patients with rectal cancer undergoing surgery. Valenti V, Hernandez-Lizoain JL, Baixauli J, Pastor C, Martinez-Regueira F, Beunza JJ, Aristu JJ, Alvarez Cienfuegos J. Department of General Surgery, Clinica Universitaria de Navarra, University of Navarra, Avda Pio XII, 36., 31080, Pamplona, Spain, vvalenti@unav.es. BACKGROUND: The Physiological and Operative Severity Score for the enUmeration of Mortalityandmorbidity (POSSUM) and later modifications (P-POSSUM y CR-POSSUM) have been used topredictmorbidity and mortality rates among patients with rectal cancer undergoing surgery. Thesecalculations needsome adjustment, however. The aim of this study was to assess the applicability of POSSUMto a group ofpatients with rectal cancer undergoing surgery, analysing surgical morbidity by means of severalvariables. METHODS: between January 1995 and December 2004, 273 consecutive patientsunderwent surgery forrectal cancer. Information was gathered about the patients,tumour and therapy. To assess the predictioncapacity of POSSUM, subgroups foranalysis were created according to variables related to operativemorbidity andmortality. RESULTS: The global morbidity rate was 23.6% (31.2% predicted byPOSSUM). The mortality rate was 0.7%(6.64, 1.95 and 2.08 predicted by POSSUM,P-POSSUM and CR-POSSUM respectively). POSSUMpredictions may be moreaccurate for patients younger than 51 years, older than 70 years, with lowanaesthetic risk (ASA I/II), DUKES stage C and D, surgery duration of less than 180minutes and for thosereceiving neoadjuvant therapy. CONCLUSION: POSSUM is a goodinstrument to make results between different institutions and publicationcomparable. We found predictionerrors for some variables related to morbidity. Modifications of surgicalvariables and specifications forneoadjuvant therapy as well as physiological variables including life stylemay improve future prediction ofsurgical risk. More research is needed to identify further potential riskfactors for surgical complications. 282. Non Possum Sequi Tibi! Where Am I Going If I Cannot Follow You? DOI: 10.1097/01.prs.0000299652.12576.3a ISSN: 0032-1052 Accession: 00006534-200803000-00071 Full Text (PDF) 1742 K Email Jumpstart Find Citing Articles Table of Contents About this Journal Author(s): Lerman, Oren Z. M.D. Issue: Volume 121(3), March 2008, pp 1072-1073 Publication Type: [LETTERS] Publisher: 2008American Society of Plastic Surgeons Institution(s): Institute of Reconstructive Plastic Surgery, New York University MedicalCenter, TCH-169, New York, N.Y. 10016, oren.lerman@med.nyu.edu Table of Contents: Corrections to the Birth of Plastic Surgery: Reply. Tip Grafts in Closed Rhinoplasty: Insertion and Fixation Made Easy. Links Complete Reference Outline REFERENCE 283. Emergency colorectal surgery Am J Surg. 2008 Apr;195(4):439-41. Links External validation of prognostic models among cancer patients undergoing emergencycolorectal surgery. Ertan T, Yoldas O, Kilic YA, Kilic M, Gcmen E, Koc M, Tez M. Department of Fifth Surgery, Ankara Numune Education and Research Hospital, Ankara, Turkey. BACKGROUND: The aim of this study was to evaluate the predictive accuracy of different scoringsystems on patients undergoing emergency colorectal surgery. METHODS: The Acute Physiologyand Chronic Health Evaluation II or III, the Simplified Acute Physiology Score II, the MortalityProbability Model II, and the Colo-rectal POSSUM scoring systems were applied to 102 patientswho underwent colorectal resection for cancer. Validation of scoring systems was testedby assessing calibration and discrimination. Calibration was assessed using Hosmer-Lemeshowgoodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminativecapability of both models was performed using receiver-operating characteristic curve analysis.RESULTS: Overall, 17 deaths occurred. The Simplified Acute Physiology Score II showed goodcalibration (x(2) = 1.079, P = .982) and discrimination (areas under the receiver-operatingcharacteristic curve .83). CONCLUSIONS: These data suggest that the SAPS II scoring systemwas accurate in predicting outcome for patients undergoing emergencycolorectal surgery 284. renal replacement therapy aftercolorectal surgery. Dis Colon Rectum. 2008 Jun;51(6):961-5. Epub 2008 Feb 21. Links Outcome of patients on renal replacement therapy after colorectal surgery. Krysa J, Patel V, Taylor J, Williams AB, Carapeti E, George ML. Department of Colorectal Surgery, Guys and St. Thomas' Hospital, London, United Kingdom.jokrysa@aol.com PURPOSE: Patients on renal replacement therapy are reported to have a high complication rateafter abdominal surgery, the result of uremia and immunosuppression. A review of this group ofpatients undergoing colorectal surgery was undertaken. METHODS: Seventy-three separatecolorectal operations were performed for 44 patients. Thirty-eight patients were on dialysis and 35had a renal transplant. Data (coexisting disease, preoperative blood results, operative details,complications, and colorectal POSSUM score) were completed for each surgical event. RESULTS:Forty-two elective and 31 emergency procedures were performed. Infective complicationswere common (overall 60 percent). There were two anastomotic leaks in theelective group, but five leaks from seven emergency anastomoses. Stomas werefrequently raised. Ninety percent of patients who survived and had a defunctioning stomaunderwent a successful reversal. The overall major complication rate after elective andemergency surgery was 19 and 81 percent, respectively, and mortality was 5 and26 percent, respectively. CONCLUSIONS: Renal patients have a high rate of complicationsafter colorectal surgery, and emergency surgery has a significant risk of anastomotic leak. Primaryanastomosis should be avoided in all patients undergoing emergency intestinal resections.Subsequent surgery to restore intestinal continuity is possible in 90 percent of patients with farfewer complications 285. Con la chiave POSSUM sono arrivato al 27 diPub med 286. Aggiunte al rischio in anestesia 287. Table 2. Major Cardiac Event Rates by the Revised CardiacRisk Index*Class Events/Patients, n/n Event Rate (95% CI), %I (0 risk factors) 2/488 0.4 (0.051.5)II (1 risk factor) 5/567 0.9 (0.32.1)III (2 risk factors) 17/258 6.6 (3.910.3)IV (3 risk factors) 12/109 11.0 (5.818.4)ROC curve area 0.806* Adapted from Lee et al. (21). ROC receiver-operating cha 288. Cardiac Events in Patients Undergoing Noncardiac Surgery: Shiftingthe Paradigmfrom Noninvasive Risk Stratification to TherapyPaul A. Grayburn, MD, and L. David Hillis, MDAnn Intern Med. 2003;138:506-511. 289. Cardiac Events in Patients Undergoing Noncardiac Surgery:Shiftingthe Paradigm from Noninvasive Risk Stratification toTherapyPaul A. Grayburn, MD, and L. David Hillis, MDAnn Intern Internists and cardiologists are o ftMene adsk.e d2 t0o 0es3ti;m1a3te8 th:5e 0ris6k -fo5r11.perioperative myocardial infarction or cardiac death in patientsbeing considered for noncardiac surgery. Estimating this risk in anindividual patient is difficult and complex. Although noninvasiveimaging tests are often used for this purpose, a review of theliterature reveals that the positive predictive value of noninvasiveimaging tests is uniformly low and that they do not provideinformation beyond that obtained by assessing simple clinical riskvariables. Moreover, no evidence exists that noninvasive imagingtests lead to a therapeutic strategy that reduces the risk for perioperativemyocardial infarction or cardiac death. Since the publicationof guidelines for preoperative risk stratification by theAmerican College of Cardiology/American Heart Association in1996 and the American College of Physicians in 1997, threeclinical trials have shown that -blocker therapy reduces the riskfor perioperative cardiac events. This paper focuses on the relationshipbetween risk stratification and subsequent therapy tominimize or eliminate risk. In short, the paradigm is shifting frompredicting which patient is at high risk for having a perioperativecardiac event to minimizing the likelihood of such an event withspecific perioperative pharmacologic therapy. 290. Apolipoprotein E e4 Allele Increasesthe Risk of EarlyPostoperative Delirium in OlderPatients UndergoingNoncardiac Surgery 291. Apolipoprotein E e4 Allele Increases the Risk of EarlyPostoperative Delirium in Older Patients UndergoingNoncardiac Surgery Leung, JM , Sands LP, Yun Wang , Poon A, Kwok P, Kane JP,Pullinger CR. Anesthesiology 2007; 107:40611 Methods: The authors conducted a nested cohort study to include patients aged > 65 yrwho were scheduled to undergo major noncardiac surgery requiringanesthesia. A structured interview was conducted preoperatively and for the first 2 dayspostoperatively to determine the presence of delirium, defined using the ConfusionAssessment Method. Blood was drawn for measurement of the apolipoprotein genotypes. Bivariate tests ofassociation were conducted between delirium and apolipoprotein genotypes and otherpotentially important risk factors. Variables that had significant bivariate association with postoperative delirium were entered ina forward multivariable logistic regression model. Results: Of the 190 patients studied, 15.3% developed delirium on both days 1 and 2 aftersurgery. Forty-six patients (24.2%) had at least one copy of the apolipoprotein e4 allele. The presence of one copy of the e4 allele was associated with an increased risk of earlypostoperative delirium (28.3% vs. 11.1%; P 0.005). Even after adjusting for covariates, patientswith one copy of the e4 allele were still more likely to have an increased risk of earlypostoperative delirium (odds ratio, 3.64; 95% confidence interval, 1.518.77) compared withthose without the e4 allele. Conclusions: Apolipoprotein e4 carrier status was associated with an increased risk for earlypostoperative delirium after controlling for known demographic and clinical risk factors. These results suggest that genetic predisposition plays a role and may interact withanesthetic/surgical factors contributing to the development of early postoperative delirium. 292. Importance of the E4 allele of theapolipoprotein E(APOE) gene Genetic studies in population-based investigations2,3 have demonstrated arelation between certain genotypes and the risk of dementia and cognitivedecline. Specifically, elevated risk of Alzheimer disease has been demonstratedamong individuals with the E4 allele of the apolipoprotein E(APOE) gene in manypopulations.4,5 The E4 allele of APOE is associated with a shift to an earlier age atonset of Alzheimer disease.6 However, the APOE E4 genotype is neither necessarynor sufficient for the occurrence ofAlzheimer disease.6 The APOE polymorphismalso affects response to trauma, age-related cognitive decline,7 and several otherdisorders.810 APOE is a polymorphic protein associated with plasma lipoproteins.Three major isoforms can be recognized, designated as APOE2, APOE3,and APOE4, according to their relative position after isoelectricfocusing.11 APOE is unique among apolipoproteins in that it has a specialrelevance to nervous tissue.12 APOE is involved in the mobilization and redistribution of cholesterol inrepair,growth, and maintenance of myelin and neuronal membranesduring development or after injury.1315 Whether patients whosubsequently develop postoperative delirium have a genetic predisposition thatrenders them at risk for early postoperative delirium has not been determined. 293. Apolipoprotein E e4 Allele Increases the Risk of EarlyPostoperative Delirium in Older Patients UndergoingNoncardiac Surgery Leung, JM , Sands LP, Yun Wang , Poon A, Kwok P, KaneJP, Pullinger CR. Anesthesiology 2007; 107:40611 The covariates included: age, education, amount of alcohol intake History of central nervous system disorders, preoperative depressive symptoms, preoperative functional status pain levels. amount of alcohol intake (more than 2 drinks vs. 2 drinks or fewer per day) depression, functional status. Depression was measured using the Geriatric Depression Scale and defined as the presence of six or more symptomsof depression.23 Preoperative demographics included age, highest education level achieved, perioperative blood pressure measurements. Other perioperative data : type of surgery; the American Society of Anesthesiologists physical status,26 which incorporates the number and severity of preoperative comorbid conditions; the type of anesthesia (general, regional, or combined). Surgical risk was estimated using the guidelines from the American College of Cardiology and American HeartAssociation update for the perioperative cardiovascular evaluation for noncardiac surgery, which takes intoconsideration the type and duration ofsurgery, and intraoperative blood loss.2 294. patients who developed postoperative delirium thatpersisted for 2 days after surgeryApolipoprotein E e4 Allele Increases the Risk of Early Postoperative Delirium in Older Patients UndergoingNoncardiac Surgery Leung, JM , Sands LP, Yun Wang , Poon A, Kwok P, Kane JP, Pullinger CR.Anesthesiology 2007; 107:40611 were older Dependent in one or more independent activities of daily living Had a history of central nervous system disorder had lower systolic postoperative blood pressures on postoperative day 1 had increased pain levels at rest on postoperative day 1 Patients who had postoperative delirium that persisted for 2 days aftersurgery had significantly longer hospital stay than those without delirium(8.1 6.7 vs. 5.1 3.5 days; P 0.0008). Of the 190 patients studied, 46 (24.2%) had at least one copy of the e4 allele. The presence ofone copy of the e4 allele was associated with an increased risk of postoperative delirium thatpersisted for 2 days after surgery (28.3% vs. 11.1%; P 0.005). Even after adjusting for covariatesassociated with postoperative delirium, which included age, change in postoperative pain levels,history of central nervous disorders, and so on, patients with at least one copy of the e4 allelewere still more likely to have an increased risk of postoperative delirium 295. Factors associated with postop deliriumApolipoprotein E e4 Allele Increases the Risk of Early Postoperative Delirium in Older PatientsUndergoing Noncardiac Surgery Leung, JM , Sands LP, Yun Wang , Poon A, Kwok P, Kane JP, PullingerCR. Anesthesiology 2007; 107:40611 296. Apolipoprotein E e4 Allele Increases the Risk of EarlyPostoperative Delirium in Older Patients UndergoingNoncardiac Surgery Leung, JM , Sands LP, Yun Wang , Poon A, Kwok P, KaneJP, Pullinger CR. Anesthesiology 2007; 107:40611 What is the possible mechanism between apolipoprotein andpostoperative delirium? Previous studies suggest that theeffects of APOE are mediated through alterations in lipidtransport in regenerating neurons,proinflammatory cytokinerelease from activated microglia,amyloid precursor proteinmetabolism, increasedblood brain carrier permeability,alterations in plateletfunction, and systemicinflammation.41,42,43 One hypothesized mechanism isthat APOE e4 allele diminishes the capacity forrepair in cases of cerebral injury or capacity forhomeostasis/maintenance. 297. . Critical Elements for Risk Stratification inPatientsUndergoing Noncardiac Surgery Risk-assessment tool must be accurate Predicts perioperative events (positive likelihood ratio 10) Predicts absence of perioperative events (negative likelihoodratio 0.2) Risk-assessment tool must influence outcome Identifies subgroups in which surgery should be cancelled ortreatmentc changed Identifies subgroups that do or do not benefit from proventherapy to reduce risk Risk-assessment tool must have a favorable harmsbenefittradeoff 298. Pneumonia risk 299. Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major NoncardiacSurgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD;William G. Henderson, PhD; and Jennifer Daley, MDAnn InternMed. 2001;135:847-857 Background: Pneumonia is a common postoperative complication associated with substantial morbidity andmortality. Objective: To develop and validate a preoperative risk index for predicting postoperative pneumonia. Design: Prospective cohort study with outcome assessment based on chart review. Setting: 100 Veterans Affairs Medical Centers performing major surgery. Patients: The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgerybet ween 1 September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoingsurgery between 1 September 1995 and 31 August 1997. Patients with preoperative pneumonia, ventilatordependence, and pneumonia that developed after postoperative respiratory failure were excluded. Measurements: Postoperative pneumonia was defined by using the Centers for Disease Control and Preventiondefinition of nosocomial pneumonia. Results: A total of 2466 patients (1.5%) developed pneumonia, and the 30-day postoperative mortality rate was21%. A postoperative pneumonia risk index was developed that included type of surgery (abdominal aorticaneurysm repair, thoracic, upper abdominal, neck, vascular, and neurosurgery), age, functional status, weightloss, chronic obstructive pulmonary disease, general anesthesia, impaired sensorium, cerebral vascular accident, blood urea nitrogen level, transfusion, emergency surgery, long-termsteroid use, smoking, and alcohol use. Patients were divided into five risk classes by using risk index scores.Pneumonia rates were 0.2% among those with 0 to 15 risk points, 1.2% for those with 16 to 25 risk points, 4.0%for those with 26 to 40 risk points, 9.4% for those with 41 to 55 risk oints, and 15.3% for those with more than 55risk points. The C-statistic was 0.805 for the development cohort and 0.817 for the validation cohort. Conclusions: The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia andmay be useful in guiding perioperative respiratory care. 300. Postoperative pulmonary complications are associated with substantial morbidity and mortality. It has been estimated that nearly one fourth of deaths occurring within 6 days of surgery are related to postoperative pulmonary complications (1). Postoperative infections are also a major source of the morbidity and mortality associated with undergoing surgery. Pneumonia is the most serious postoperative complication that is included in both of these categories. Pneumonia ranks as the third most common postoperative infection, behind urinary tract and wound infection (2). According to the National Nosocomial Infection Surveillance system, pneumonia occurred in 18% of patients after surgery (3). Postoperative pneumonia occurs in 9% to 40% of patients, and the associated mortality rate is 30% to 46%, depending on the type of surgery (1, 4). Previous studies of risk factors used various definitions of postoperative pulmonary complications. Atelectasis 301. Table 1. Definition of PostoperativePneumonia Patient met one of the following two criteria postoperatively: 1. Rales or dullness to percussion on physical examination of chest ANDany of the following: New onset of purulent sputum or change in character of sputum Isolation of organism from blood culture Isolation of pathogen from specimen obtained by transtracheal aspirate,bronchial brushing, or biopsy 2. Chest radiography showing new or progressive infiltrate, consolidation,cavitation, or pleural effusion AND any of the following: New onset of purulent sputum or change in character of sputum. Isolation of organism from blood culture. Isolation of pathogen from specimen obtained by transtracheal aspirate,bronchial brushing, or biopsy Isolation of virus or detection of viral antigen in respiratory secretions Diagnostic single antibody titer (IgM) or fourfold increase in paired serumsamples (IgG) for pathogen Histopathologic evidence of pneumonia 302. Postoperative pneumonia risk index 303. Risk factors for postop pneumonia Long-term steroid use Age older than 60 years dependent functional status, weight loss greater than 10% of body mass in theprevious 6 months recent alcohol use. Recent smoking history of chronic obstructive pulmonary disease history of cerebral vascular accident with a residual deficit impaired sensorium. 304. Fattori di rischio per la polmonite postop:pazienteDevelopment and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH;Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857 Somministrazione di steroidi a lungo termine Et>60 anni Stato funzionale dipendente Perdita di peso > 10% della massa coroorea nei 6 mesiprecedenti Iso recente di alcohol Fumo recente Storia di COPD Storia di accidente cerebrovascolare con deficit residuo. Disturbo di coscienza 305. Fattori di rischio per la polmonitepostop:interventi abdominal aortic aneurysm repair thoracic, neck, upper abdominal peripheral vascular surgery neurosurgery 306. DISCUSSION Our results confirm several previously described risk factors for postoperative pneumonia, including the type of surgery performed. The patient-specific risk factors were related to general health and immune status, respiratory status, neurologic status, and fluid status. These risk factors were used to develop a preoperative risk assessment model for predicting postoperative pneumonia, the postoperative pneumonia risk index. We found that patients undergoing abdominal aortic aneurysm repair; thoracic, neck, upper abdominal, or peripheral vascular surgery; or neurosurgery had an increased likelihood of developing postoperative pneumonia. Previous studies focused on the increased incidence of postoperative pulmonary complications in patients undergoing these types of surgery (2, 4, 5, 8, 9, 11, 12, 14, 29). Impairment of normal swallowing and respiratory clearance mechanisms may be responsible for some of the increased risk in these patients. 307. Patient specific risk factor forpostop pneumonia Long-term steroid use (30) Age older than 60 years (2, 4, 5, 11, 12) dependent functional status, weight loss greater than 10% of body mass in the previous 6 months recent alcohol use. Further studies are needed to assess the effect of interventions, such as preoperativeoptimization of nutritional status and perioperative physical therapy, in reducing theincidence of postoperative pneumonia. Our definition of current smoking included patients who smoked up to 1 year before surgery.Before 1995, the NSQIP definition for current smoking was smoking in the 2 weeks beforesurgery. Using this definitio n,we found that smoking was not significantly associated withpostoperative mortality or overall morbidity (22, 23). On closer examination, it appeared thatsicker patients tended to quit smoking more than 2 weeks before surgery and were thereforebeing classified as nonsmokers. To capture the effect of recent smoking, the NSQIP definitionwas modified in September 1995 to include patients who smoked up to 1 year beforesurgery. 308. Recent smoking and history of chronic obstructive pulmonary disease were previously found to be pulmonary risk factors for postoperative pneumonia (2, 4, 912, 14). Chumillas and colleagues (31) found that preoperative and postoperative respiratory rehabilitation protected against postoperative pulmonary complications in moderate-risk and high-risk patients undergoing upper abdominal surgery. Use of an incentive spirometer or intermittent positive-pressure breathing and control of pain that interferes with coughing and deep breathing have been recommended for preventing postoperative pneumonia in high-risk patients (32). 309. We found two risk factors related to neurologic status: history of cerebral vascular accident with a residual deficit and impaired sensorium. Previously identified neurologic risk factors for postoperative pneumoniaincluded impaired cognitive function (4). These risk factors are often associated with a decreased ability to protect ones airway and may increase the risk for aspiration. Other risk factors related to aspiration inprevious studies included the use of nasogastric tubes and H2 receptor antagonists (6). 310. APPENDIX: DEFINITIONS OF RISK FACTORS IN THE POSTOPERATIVE PNEUMONIA RISK INDEX Type of Surgery Abdominal aortic aneurysm repair: Surgeries to repair ruptured or unruptured aorticaneurysm involving only abdominal incisions. Neck surgery: Surgeries related to the thyroid, parathyroid,and larynx; tracheostomy; cervicaland axillary lymph node excision; and cervical and axillary lymphadenectomy. Neurosurgery: Application of a halo, central nervous system injection, central nervous systemdrainage, creation of a bur hole,craniectomy, craniotomy, arteriovenous malformation oraneurysm repair, stereotaxis, neurostimulator placement, skull repair, and cerebral spinalfluid shunt. Thoracic surgery: Esophageal resection, esophageal repair, mediastinoscopy, pleural biopsy,pneumocentesis, chest wall excision, incision and drainage of neck and thorax, excision ofneck and thorax, repair of fractured ribs, diaphragmatic hernia repair, bronchoscopy,catheterization of trachea, trachea repair, thoracotomy, pericardium, pacemaker placement,heart wound repair, valve repair, thoracic or abdominothoracic aortic aneurysm repair, and pulmonary artery procedures. Upper abdominal surgery: Gastrectomy; vagotomy; intestinal surgery; partial hepatectomy;subfascial abdominal excision; splenectomy; excision of abdominal masses; laparoscopicappendectomy and cholecystectomy; shunt insertion; ventral, umbilical and spigelian herniarepair; and liver, gallbladder, and pancreas surgery. Vascular surgery: Any surgery related to the arteries or veins except central nervoussystem aneurysm or abdominal aortic aneurysm repair 311. Functional Status Functional status: The level of self-care demonstrated by the patient onadmission to the hospital, reflecting his or her prehospitalizationfunctional status. Totally dependent: The patient cannot perform any activities of daily livingfor himself or herself; includes patients who are totally dependent onnursing care, such as a dependent nursing home patient. Partially dependent: The patient requires use of equipment or devices plusassistance from another person for some activities of daily living. Patientsadmitted from a nursing home setting who are not totally dependentwould fall into this category, as would any patient who requires kidneydialysis or home ventilator support yet maintains some independentfunction. Independent: The patient is independent in activities of daily living;ncludes those who are able to function independently with a prosthesis,equipment, or devices. 312. Other History of chronic obstructive pulmonary disease: The patient has chronic obstructivepulmonary disease resulting in functional disability, hospitalization in the past to treatchronic obstructive pulmonary disease, need for bronchodilator therapy with oral orinhaled agents, or FEV1 of less than 75% of predicted value. Patients excluded from this category were those in whom the only pulmonary disease wasacute asthma, an acute and chronic inflammatory disease of the airways resulting inbronchospasm. History of cerebrovascular accident: The patient has a history of cerebrovascular accident(embolic, thrombotic, or hemorrhagic) with persistent motor, sensory, or cognitivedysfunction. Impaired sensorium: The patient is acutely confused or delirious and responds to verbal ormild tactile stimulation; patient with mental status changes or delirium in the context ofthe current illness. Patients with chronic mental status changes secondary to chronicmental illness or chronic dementing llnesses were excluded from this category. Steroid use for chronic condition: The patient has required the regular administration ofparenteral or oral corticosteroid medication in the month before admission. Patients usingonly topical, rectal, or inhalational corticosteroids were excluded from this category. 313. Am J Respir Crit Care Med. 2005 Mar 1;171(5):514-7.Incidence of and risk factors for pulmonary complicationsafter nonthoracic surgery.McAlister FA, Bertsch K, Man J,Bradley J, Jacka M Identifica come fattori di rischio: let>65 anni il fumo(> 40 pacchetti/anno) la diminuzione del FEV1 Diminuzione del FVC e del FEV1/FVC la durata dellanestesia >2.5 hr storia di COPD tosse produttiva giornaliera incisione nelladdome sup presenza di un SNG. Solo 4 sono indipendenti dopo una analisimultivariata: et,test alla tossepositivo,presenza periop del SNG e la duratadellanestesia. 314. Prevedibilit delle complicanzeminoriPONV et al 315. Can PONV be predicted?Servizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk factor analysis 316. Sinclair et al.Can PONV be predicted?Anesthesiology 1999;91:109-18 17,638 consecutive ambulatory surgical patients;>90% ASA I /II 5,812 men and 11,826 women mean ( SD) age of 46.7 21.2 yr. prospectively studied during a 3-yr period ASU of The Toronto Hospital, Western Division telephone interview 24 h after operation was obtained. Preoperative patient characteristics and intraoperative variableswere documented on specifically designed, standardized adverse-outcomecheck-off forms. i.v.24 mg morphine for pain relief and 2550 mg dimenhydrinatefor nausea or vomiting. Overall PONV incidence 4.6%:9.1 % at 24 hrs interview.Servizio di Anestesia eRianimazione Ospedale diFaenza(RA) 317. Independent predictors of PONVSinclair et al.Can PONV be predicted?Anesthesiology 1999;91:109-18 age A 10-yr increase in age was associated with a 13% decrease in the likelihood of PONV. sex Men had one third the risk for PONV compared with women. smoking status Smokers had two thirds the risk for PONV compared with nonsmokers history of previous PONV, had a threefold increase in the likelihood PONV compared with patients with noprevious PONV. type of anesthesia: General anesthesia increased the likelihood of PONV 11 times compared with other types ofanesthesia. duration of anesthesia, direct association between the duration of anesthesia and the risk for PONV. A 30-minincrease in duration predicted a 59% increase in the incidence of PONV type of surgery : plastic surgery had a sevenfold increase in the risk for PONV. orthopedic shoulder surgery, ophthalmologic, or ENT procedures had a four- to sixfold increase. orthopedic (nonshoulder) and gynecologic (non-D&C) procedures had a threefoldincrease in the risk for PONV. Compared with the reference group, which includesgeneral surgery, gynecologic dilation and curettage (D&C), urologic surgery,neurosurgery, and chronic pain blockENT dental surgery 14.3%, orthopedic 7.6%,plastic surgery 7.4%.Urologic, gynecologic,neurologic, or general surgery had an incidence of PONV corresponding to the overallaverage 4%Servizio di Anestesia eRianimazione Ospedale diFaenza(RA) 318. Logistic regression da:Sinclair et al.Can PONV be predicted?Servizio di Anestesia eRianimazione Ospedale diFaenza(RA)Anesthesiology 1999;91:109-18 P=1/1+e esponente con il segno neg. allesponente la probabilit aumenta perch eelevato ad esp negativo diminuisce sempre + con il risultato che1+e tende a 1 e dunque P=1/1,ossia 100% Con il segno positivo allesponente e aumenta sempre + e allora1+e aumenta e dunque il denominatorer dellequazione aumenta edunque 1/un numero in aumento fa scendere la probabilit perchviene 1/5,cio 20%,1/10=10%,ecc.. Esponente=-5,97+(-0,14 *age)+(-1,03*sex)+(-0,42*smoke)+(1,14*PONV history)+(0,46*duration)+(2,36*GA)+(1,48*ENT)+(1,77*ophtalm)+(1,90*plastic)+(1,20 Gynecol non DC)+(1,04 ort knee)+(1,78*ortshoulder)+(0.94 ort other) where Age = age in years/10; Sex = 1 if male and 0 if female; Smoke = 1 if smoker and 0 if nonsmoker;PONV History = 1 if previous PONV and 0 if no previous PONV; Duration = duration of surgery in 30-minincrements; GA = 1 if general anesthesia and 0 if other type of anesthesia; ENT = 1 if ENT and 0 if othertype of surgery; Ophthalm = 1 if ophthalmology and 0 if other type of surgery; Plastic = 1 if plasticsurgery and 0 if other type of surgery; GynNonDC = 1 if gynecologic non D&C procedure and 0 if othertype of surgery; OrtKnee = 1 if orthopedic procedure involving knee and 0 if other type of surgery; 319. Importance of the work by SinclairServizio di Anestesia eRianimazione Ospedale diFaenza(RA)et al Fitting the model to the data, we can obtain themaximum likelihood estimate of the parameters foreach variable. Based on the maximum likelihoodestimates from the final models, it is possible tocalculate an expected risk of occurrence of thespecific adverse event for any patient. 320. Appendix 1 Logistic regression is used to model the relation between explanatory variables and binary outcome variables. The logistic regressionmodeling assumes that the probability of an event (i.e., the occurrence of the outcome) is associated with the values of the explanatoryvariables in the following way: where where p = probability of the occurrence of the outcome, xi = value of the ith independent variable, and bi events for any patient =parameter estimates for the ith variable. Fitting the model to the data, we can obtain the maximum likelihood estimate of the parameters for each variable. Based on themaximum likelihood estimates from the final models, it is possible to calculate an expected risk of occurrence of the specific adverseevent for any patient. Examples The risk for patient 1, a 30-yr-old woman with a history of smoking and previous PONV undergoing a 1-h shoulder (orthopedic)operation with general anesthesia is 35.2%. The risk for patient 2, a 40-yr-old nonsmoking man with no previous PONV undergoing a 1-h knee arthroscopy (orthopedic) withoutgeneral anesthesia is 0.4%. The risk for patient 3, a 70-yr-old smoking man with no previous PONV undergoing a 1-h cataract surgery (ophthalmologic) withoutgeneral anesthesia is 0.3%. The risk for patient 4, a 32-yr-old nonsmoking woman with previous PONV undergoing a 30-min laparoscopy (gynecologic) withgeneral anesthesia is 22.1% The risk for patient 5, a 22-yr-old woman with a history of smoking and previous PONV undergoing a 90-min bilateral breastaugmentation (plastic surgery) with general anesthesia is 52%.Servizio di Anestesia eRianimazione Ospedale diFaenza(RA) 321. Servizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk Factors Non-anesthetic factors Anesthetic relatedfactors Postoperative factors 322. Risk factors da Samba 2007:1 Patient specific Female gender Non smoking status Hx of ponv/motion sicknessServizio di Anestesia eRianimazione Ospedale diFaenza(RA) 323. Risk factors da Samba 2007:2 Anesthetic risk factors Use on intraop volatile anesth Use on intraop and postop opioids Use of intraop N2OServizio di Anestesia eRianimazione Ospedale diFaenza(RA) 324. Risk factors da Samba 2007:3 Surgical risk factors Duration of surgery Each 30 min increase in duration of surgeryoncreases the risk by 60%,so thyat a baseline risk of10% increases to 16% after 30 min Type of surgery laparoscopy;,laparotomy;breast,strabismus,plastic,maxillofacial,gynecological,abdominal,neurologic,opthalmologic,urologicServizio di Anestesia eRianimazione Ospedale diFaenza(RA) 325. Non-anesthetic FactorsServizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk Factors Age Gender Body habitus Hx motion sickness Hx PONV Anxiety Concomitant disease Operative procedure Duration of surgery 326. Anesthetic Related FactorsServizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk Factors Preanesthetic medication Gastric distension Gastric suctioning Anesthetic technique Anesthetic agents 327. Postoperative FactorsServizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk Factors Pain Dizziness Ambulation Oral intake Opioids 328. Postoperative Nausea and Vomiting:Anesthetic Related Factors Nitrous oxide Volatileanesthetics NMB reversal PropofolServizio di Anestesia eRianimazione Ospedale diFaenza(RA) 329. Omitting nitrous oxide from general anesthesia:Servizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk FactorsNitrous Oxide and PONV Decreases POV significantly only if the baselinerisk is high Does not affect nausea or complete control ofemesis Increases the incidence of intraoperativeawarenessTramer et al. BJA 1996;76:186-193 330. IS PONV incidence differentbetween LMA and ETT? Joshi GP, Inagaki Y, White PF, Taylor-KennedyL, Wat LI, Gevirtz C, McCraney JM, McCullochDA: Use of the laryngeal mask airway as analternative to the tracheal tube duringambulatory anesthesia. Anesth Analg 85:5737, 199Servizio di Anestesia eRianimazione Ospedale diFaenza(RA) 331. Risk FactorsVolatile anestheticsRisk Factors OR* CIVolatileanestheticsisoflurane 3.41 2.18; 5.37sevoflurane 2.78 1.79; 4.31enflurane 3.11 1.98; 4.88Apfel et al. BJA 2002;88:659-668* Compared to propofolServizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 332. Servizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk FactorsReversal of Neuromuscular Block Omitting neostigmine may have a clinicallyrelevant antiemetic effect when high dosesare used Omitting NMB antagonism introduces anon-negligent risk of residual paralysiseven when short acting NMB agents areusedTramer MR, Fuchs-Buder T. BJA 1999;82:379-386 333. Servizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk FactorsPropofol and PONVAll Control Event RatesEarly LateNausea Vomiting Any Nausea Vomiting AnyInduction 9.3* 13.7* 20.9 50.1 14.9 NAMaintenance 8* 9.2* 6.2* 5.8* 10.1* 1020% - 60% Control Event RateEarly LateNausea Vomiting Any Nausea Vomiting AnyInduction 5.0* 7.0* 14 28 10 NAMaintenance 4.7* 4.9* 4.9* 6.1* 8.3* 7.1Tramer et al. BJA 1997;78:247-255Analysis by NNT 334. Servizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk FactorsAntiemetic Effects of PropofolInvestigations Randomized Double-Blind Placebo-Controlled EffectiveChemotherapy Induced EmesisScher 1992 no no no yesBorgeat 1993 no no no yesBorgeat 1994 no no no yesPONVCampbell 1991 yes yes yes noBorgeat 1992 yes yes yes yesEwalenko 1996 yes yes yes yesMontgomery 1996 yes yes yes noScuderi 1996 yes yes yes noGan 1997 no no no yesGan 1999 yes yes yes yes 335. Logistic RegressionServizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk FactorsPalazzo M, Evans R. Logistic regression analysis of fixed patientfactors for postoperative sickness: a model for risk assessment. Br JAnaesth 1993;70:135-40.Koivuranta M, Lr E, Snre L, Alahuhta S. A survey of postoperativenausea and vomiting. Anaesthesia 1997;52:443-49.Apfel CC, Greim CA, Haubitz I, et al. A risk score to predict theprobability of postoperative vomiting in adults. Acta Anaesthesiol Scand1998;42:495-501. 336. Logistic RegressionServizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk Factors Younger age Nonsmoking history Female Hx of motion sickness Hx of PONV Increased duration of operation 337. Simplified Scoring SystemServizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk Factors Female Nonsmoking history Hx of motion sickness orPONV Use of postoperative opioidsIncidence of PONVRisk Factors Incidence0 10%1 21%2 39%3 61%4 79% Apfel CC et al. Anesthesiology 1999;91:693-700. 338. Simplified scoring system from ApfelServizio di Anestesia eRianimazione Ospedale diFaenza(RA)for adults For every risk factor the sum is additive: Point 0 risk 10% Point 1 risk 20% Point 2 risk 40% Point 3 risk 60% Point 4 risk 80% 339. Simplified risk score from Apfel et al. to predict thepatients risk for PONVin adults . When 0, 1, 2, 3, or 4 of the depicted independentpredictors are present, the corresponding riskfor PONV is approximately 10%, 20%,Servizio di Anestesia eRianimazione Ospedale diFaenza(RA)40%, 60%, or 80%.Figure 1 340. Simplified scoring system fromEberhardt 39 di Samba for children Surgery> 30 min Age> 3 Strabismus surgery Hx of POV or POnv in relatives Sum 0......4 Risk 10%,10%,30%,55%,70%Servizio di Anestesia eRianimazione Ospedale diFaenza(RA) 341. Simplified risk score from Eberhart et al. (39) to predict therisk for POV in children. When 0, 1, 2, 3, or 4 of the depictedindependent predictors are present, the corresponding riskfor PONV is approximately 10%, 10%, 30%, 55%, or 70%.Servizio di Anestesia eRianimazione Ospedale diFaenza(RA) 342. Servizio di Anestesia eRianimazione Ospedale diFaenza(RA)Problems............ to separate independent factors vs dependentfactors................ No risk model can actually predict thelikelihood of an individual having PONV;riskmodels only allow clinicians to etimate therisk of PONV among patients groups 343. Servizio di Anestesia eRianimazione Ospedale diFaenza(RA)PPOONNVVffaattttoorrii ddii rriisscchhiiooddoonnnneeggiioovvaanniietfertileggrraavviiddeepostpartumiinntteerrvveennttiimuscoliextraoculariorecchiomediopelvifemm.inlaparoscopiadeambulazioneprecocebbaammbbiinniisoggettiacinetosipregressoPONVffaarrmmaacciiooppppiiooiiddiianesteticiinalatoriNeurosurg N2OBreast surgLaparotomyPlastic surg.Nonsmokers 344. Use of prophylactic antiemetics should be based onvalid assessment of the patients risk for POV orPONV. In other words....antiemetic prophylaxis shouild beused only when the patient individual risk issufficiently high. Estimate:baseline risk * baseline risk reductionresulting from prophylaxisUse of prophylacticantiemetics should be based on This approach produces a clinically meaningfuldecrease in the risk of PONVServizio di Anestesia eRianimazione Ospedale diFaenza(RA) 345. Particular medical risk more liberal prophylaxis is appropriate for patients inwhom vomiting poses a particular medical risk: wired jaws increased intracranial pressure gastric or esophageal surgery when the anesthesia care provider determines theneed or the patient has a strong preference to avoid PONVServizio di Anestesia eRianimazione Ospedale diFaenza(RA) 346. Strategies to Reduce BaselineServizio di Anestesia eRianimazione Ospedale diFaenza(RA)Risk Avoidance of general anesthesia by the use of regionalanesthesia (11,16) (randomized, controlled trial, RCT) Use of propofol for induction and maintenance ofAnesthesia(4,14,41,42) (RCT/systematic review, SR) Avoidance of nitrous oxide (3,4,43,44) (RCT/SR) Avoidance of volatile anesthetics (15,28) (RCT) Minimization of intraoperative (SR) and postoperative opioids (3,13,15,17,18,20,28,43) (RCT/SR) Minimization of neostigmine (19,45) (SR) Adequate hydration (46) (RCT) 347. Prevedibilit delle trasfusioni inchirurgia protesica ortopedica Anesth Analg. 2004 Oct;99(4):1239-44,Predicting allogeneic blood transfusion usein total joint arthroplasty.Rashiq S, Shah M,Chow AK, O'Connor PJ, Finegan BA. essa si basa su un semplice punteggio derivatoda et,sesso,peso,Hb,ASA,e se revisione o no: 348. Anesth Analg. 2004 Oct;99(4):1239-44,Predictingallogeneic blood transfusion use in total jointarthroplasty.Rashiq S, Shah M, Chow AK, O'Connor PJ,Finegan BApunteggio Rischio di trasfusione %0-100 10 o meno100-150 10-30150-200 30-50>200 %= 349. Equazione completa ricavata dallatavola 350. Anesth Analg. 2004 Oct;99(4):1239-44,Predicting allogeneicblood transfusion use in total joint arthroplasty.Rashiq S, ShahM, Chow AK, O'Connor PJ, Finegan BApunteggio Rischio di trasfusione %0-100 10 o meno100-150 10-30150-200 30-50>200 %= 351. Predicibilit di anestesia spinale difficileBr J Anaesth. 2004 Mar;92(3):354-60. Epub 2004 Jan22.Development of a difficulty score for spinalanaesthesia.Atallah MM, Demian AD, Shorrab AA. 352. Prevedibilit dellipotermia in anestesia generaleAnesth Analg. 2002 Nov;95(5):1381-3, Preoperative risk factors ofintraoperative hypothermia in major surgery under generalanesthesia.Kasai T, Hirose M, Yaegashi K, Matsukawa T, Takamata A,Tanaka Y modello: Z = -15.014 + 0.097 x (Age) + 0.263 x(Height) - 0.323 x (Weight) - 0.055 x(Preoperative systolic blood pressure) - 0.121x (Preoperative heart rate). La probabilit di andare incontro ad ipotermiapu poi essere stimata secondo: = 1/(1 + e(-)(Z)). La core temp.infatti ha dimostrato un decremento significativo in pazienticon P >0.7.Quindi aumenti di et e altezza e decrementi nella formulapeso * PAS e FC(peso,PAS e FC + bassi) sono in grado di fornire unadiscreta stima della evenienza della ipotermia intraop. durantre chirurgiamaggiore. 353. AFC score