Morning Report is a time-honored tradition where physicians-in-training present cases to their colleagues and clinical experts to collaboratively examine an interesting patient presentation. The Morning Report section seeks to carry on this tradition by presenting a patient's chief concern and story, inviting the reader to develop a differential diagnosis and discover the diagnosis alongside the authors of the case.This report examines the story of a 52-year-old woman with abdominal pain, weakness, and confusion. Using questions, physical examination, and testing, an illness script for the presentation emerges. As the clinical course progresses, the differential is refined until a diagnosis is made.
Cold renal perfusion (CRP) with 4°C crystalloid fluids has been described as a method to reduce renal injury during open surgical repair of complex aortic aneurysms (cAAs) (those requiring at least a suprarenal clamp site). We performed a meta-analysis to ascertain whether CRP improves kidney-related outcomes after open surgical cAA repair.
Methods:
Patients of any age or gender who had undergone open surgical repair of cAAs were included. Primary outcomes were the presence of postoperative kidney injury, the need for dialysis and mortality related to kidney injury. We compared patients who were treated with any intraoperative CRP strategy to a control population without CRP. We used a fixed-effects model to analyze derived odds ratios (ORs) and assess heterogeneity. We performed risk of bias analysis to identify potential confounding elements.
Results:
Among the 935 studies screened, 5 primary articles met the inclusion criteria. Cold renal perfusion significantly reduced postoperative acute kidney injury (OR 0.46 [95% confidence interval 0.32–0.68], Z = 3.98, p = 0.001). Only 1 study included data for the other primary outcomes. The data were considered homogeneous, with Cochrane Q = 0.23 and I2 of 0%.
Conclusion:
This meta-analysis showed reduced postoperative acute kidney injury with the use of CRP during open cAA repair. A prospective randomized controlled trial to perform further subgroup analysis and research the various types of CRP solutions may be warranted to identify further possible benefits.
CEREBROVASCULAR DISEASE101205 Rescue of immediate post-transcarotid artery revascularization carotid stent thrombosis due to clopidogrel resistance using flow-reversal and aspiration thrombectomy
Hip fracture patients on oral anticoagulants (OACs) experience increased time-to-surgery and higher mortality compared to non-anticoagulated patients. However, it is unclear whether pre-injury OAC status and its associated operative delay are associated with worsening of peri-operative hemostasis or an increased risk of postoperative thromboembolism.We performed a systematic review to identify studies that directly compared hemostatic and thromboembolic outcomes among hip fracture patients on an OAC prior to admission with those not on anticoagulants. Random effects meta-analyses were used to pool all outcomes of interest (estimated blood loss, transfusion requirements, and postoperative thromboembolism).Twenty-one studies involving 21 417 patients were included. Estimated blood loss was higher among patients presenting with OACs compared to those not anticoagulated (mean difference 31.0 mL, 95% confidence interval [CI] 6.2-55.7). Anticoagulated patients also had a 1.3-fold higher risk of receiving red blood cell transfusions (odds ratio [OR] 1.34, 95% CI 1.20-1.51); however, rates of postoperative thromboembolism were similar regardless of anticoagulation status (OR 0.96, 95% CI 0.40-2.79 for venous thromboembolism; OR 0.58, 95% CI 0.25-1.36 for arterial thromboembolism). No subgroup effect was found based on anticoagulant type or degree of surgical delay.Hip fracture patients on OACs experience increased surgical blood loss and higher risk of red blood cell transfusions. However, the degree of surgical delay did not mitigate this risk, and there was no difference in postoperative thromboembolism. The impact of appropriate, timely OAC reversal on blood conservation and expedited surgery in anticoagulated hip fracture patients warrants urgent evaluation.
Cerebrospinal fluid (CSF) drainage is used to reduce spinal cord ischemia (SCI) in patients undergoing thoracoabdominal aortic procedures. Recent literature has found high rates of complication associated with CSF drainage, which has led to changes in practice. The aim of this study was to investigate rates of CSF drain–related complications in patients undergoing a thoracoabdominal aortic procedure with perioperative placement of a CSF drain.
Methods
We conducted a single-centre retrospective cohort study. We defined major complications as intracranial hemorrhage, epidural hematoma or abscess, meningitis, and catheter retention requiring a reoperation. Minor complications assessed included drain-induced neurologic deficits, CSF leak, postdural puncture headache, asymptomatic blood in the CSF, drain failure, and catheter retention not requiring a reoperation. We recorded postoperative neurologic deficits as secondary outcomes.
Results
There were 129 patients who met the inclusion criteria. We found 5 cases of permanent paraplegia in the overall cohort (3.9%), with only 2 occurring in the patients with prophylactic CSF drains (1.6%). There were no major CSF drain–related complications. The rate of minor complications was 17.8%. We found no association between complication rates and indication for procedure or type of operation.
Conclusion
The lack of major complications in this series adds to existing variability in recent literature and provides support for continued use of this adjunct for SCI prevention. Further research is required to identify the etiology of significant differences in CSF drain complication rates seen at other centres.
