Prevention of Early Postoperative Deep Vein Thrombosis by Passive Exercise of Leg during Surgery

A clinical trial assessed the effect of passive exercise of the lower limb during surgery on the incidence of early postoperative deep vein thrombosis. Thrombosis was diagnosed by means of the ¹²⁵I-fibrinogen uptake test. Passive exercise of the lower limb during the operation was achieved by using a motorized foot mover designed for use on supine subjects, and by pedalling only one leg each patient acted as his own control.In a sequential statistical analysis, 47 patients were required to reach the 5% level of significance. Thrombosis was detected in 11 control (unpedalled) legs alone, and in only one pedalled leg alone. Two patients developed thrombosis bilaterally. The investigation shows that the incidence of early thrombosis in legs which were exercised during surgery was reduced by 77%.     

Prevention of Early Postoperative Deep Vein Thrombosis by Intermittent Compression of the Leg during Surgery

A clinical trial is described in which the effect of intermittent compression of the lower limb during surgery on the incidence of early postoperative deep vein thrombosis was assessed. Deep vein thromboses were diagnosed by the ¹²⁵I-fibrinogen uptake test. Peroperative intermittent compression was achieved by means of an inflatable plastic splint coupled to a pneumatic controller. By compressing only one leg of each patient, each patient acted as his own control.With a sequential statistical analysis, 39 patients were required to pass the 5% level of significance. Eleven thrombi were detected in the control (uncompressed) legs and two occurred in the compressed legs; one of the latter was bilateral. The investigation shows that increasing the pulsatility of the venous flow in the leg is a potent prophylactic against postoperative deep vein thrombosis.     

Myocardial Infarction and Deep-vein Thrombosis

In a study of 52 patients admitted into the coronary intensive care unit the incidence of deep-vein thrombosis was measured with the ¹²⁵I-fibrinogen test. Of these patients 31 were eventually confirmed to be suffering from acute myocardial infarction. This preliminary study showed that in patients with a confirmed infarct who were not treated with anticoagulants the incidence of deep-vein thrombosis was 38% and in those treated it was 5·5%. In patients who were “severely ill” from whatever the cause there was a high incidence of deep-vein thrombosis (68%).     

Diagnostic Accuracy in Venous Thrombosis

A group of 111 surgical patients at high risk of venous thrombosis were studied after operation by independent clinical assessment and with ¹²⁵I-fibrinogen to detect venous thrombosis. Almost half of the patients developed venous thrombosis. Of these, two-thirds were not suspected clinically despite careful scrutiny. In the patients in whom a clinical diagnosis of venous thrombosis was made this diagnosis was falsely positive in a quarter. More than half of all thrombotic episodes were detectable on the day after operation.The prevalence of venous thrombosis, together with the difficulty in diagnosing it, strongly supports the argument that a reduction in the incidence of pulmonary embolism must depend on widespread adoption of effective prophylaxis, especially in the large number of patients at high risk of venous thrombosis. Prophylactic trials must be objectively assessed, and it is in this field that the ¹²⁵I-fibrinogen technique probably has the most to offer.     

Safety of withholding anticoagulation in pregnant women with suspected deep vein thrombosis following negative serial compression ultrasound and iliac vein imaging

Background:

Compression ultrasonography performed serially over a 7-day period is recommended for the diagnosis of deep vein thrombosis in symptomatic pregnant women, but whether this approach is safe is unknown. We evaluated the safety of withholding anticoagulation from pregnant women with suspected deep vein thrombosis following negative serial compression ultrasonography and iliac vein imaging.

Methods:

Consecutive pregnant women who presented with suspected deep vein thrombosis underwent compression ultrasonography and Doppler imaging of the iliac vein of the symptomatic leg(s). Women whose initial test results were negative underwent serial testing on 2 occasions over the next 7 days. Women not diagnosed with deep vein thrombosis were followed for a minimum of 3 months for the development of symptomatic deep vein thrombosis or pulmonary embolism.

Results:

In total, 221 pregnant women presented with suspected deep vein thrombosis. Deep vein thrombosis was diagnosed in 16 (7.2%) women by initial compression ultrasonography and Doppler studies; none were identified as having deep vein thrombosis on serial testing. One patient with normal serial testing had a pulmonary embolism diagnosed 7 weeks later. The overall prevalence of deep vein thrombosis was 7.7% (17/221); of these, 65% (11/17) of cases were isolated to the iliofemoral veins and 12% (2/17) were isolated iliac deep vein thromboses. The incidence of venous thromboembolism during follow-up was 0.49% (95% confidence interval [CI] 0.09%–2.71%). The sensitivity of serial compression ultrasonography with Doppler imaging was 94.1% (95% CI 69.2%–99.7%), the negative predictive value was 99.5% (95% CI 96.9%–100%), and the negative likelihood ratio was 0.068 (95% CI 0.01–0.39).

Interpretation:

Serial compression ultrasonography with Doppler imaging of the iliac vein performed over a 7-day period excludes deep-vein thrombosis in symptomatic pregnant women.Over the last 2 decades, venous compression ultrasonography has become the imaging test of choice for diagnosing deep vein thrombosis in the lower extremities of men and nonpregnant women.^1–4 Although this test is highly sensitive (about 97%) for deep vein thrombosis involving the femoral and popliteal veins, compression ultrasonography is less sensitive for the detection of isolated deep vein thrombosis in the calf.⁵ Because proximal propagation of isolated calf deep vein thrombosis occurs in about 20% of cases, serial compression ultrasonography performed over a 7-day period is recommended to definitely exclude such thromboses if the results of the initial compression ultrasound are negative.⁶The use of serial compression ultrasonography in symptomatic men and nonpregnant women has been validated in prospective studies,^1,7 suggesting that withholding anticoagulation from symptomatic patients whose serial compression ultrasound results are negative is safe, with less than 2% of patients subsequently being diagnosed with deep vein thrombosis.^1,7,8 Although the use of serial compression ultrasonography has not been validated in pregnant women, this strategy is also advocated for symptomatic pregnant women.⁹The appeal of using compression ultrasonography for diagnosing deep vein thrombosis in pregnant women is obvious: it is noninvasive, widely available and does not expose the fetus to ionizing radiation. However, generalizing results from studies involving men and nonpregnant women to pregnant women is problematic because of differences in clinical presentation and anatomic distribution of deep vein thromboses.¹⁰ Compared with men and nonpregnant women, pregnant women more often present with very proximal deep vein thrombosis (including isolated iliac vein deep vein thrombosis); isolated distal calf deep vein thromboses are infrequent.¹⁰ In a recent review of the literature, we found that 62% of all deep vein thromboses in symptomatic pregnant women were in the iliofemoral veins, 17% were in the iliac vein alone, and 6% were in the calf veins.¹⁰ In contrast, in the general population, more than 80% of deep vein thromboses involved calf veins, and iliofemoral deep vein thromboses or isolated iliac veins are uncommon (< 5%).^1–4Physiologic changes associated with pregnancy might affect blood flow patterns and normal compressibility of the proximal veins, thereby affecting the diagnostic accuracy of compression ultrasonograpy. This technique cannot be used to detect isolated deep vein thromboses in the iliac vein; these veins are not compressible because of their intrapelvic location. Whether Doppler studies are sensitive for detecting deep vein thromboses in these high proximal veins (i.e., iliac veins) has not been well studied, but data suggest that this method of detection compares favourably to compression ultrasonography in men and nonpregnant women for proximal deep vein thromboses.¹¹ The use of Doppler imaging in pregnant women for the purpose of detecting iliac vein deep vein thromboses has been reported in the literature,^12,13 but it has not been adequately evaluated.Currently, the standard practice of diagnosing deep vein thrombosis in symptomatic pregnant women is by compression ultrasonography. If the results of the compression ultrasound are negative, Doppler imaging of the iliac vein (with or without vagal manoeuvres) is recommended, particularly for women with a high clinical probability of deep vein thrombosis in the iliac vein.^9,12,13 This diagnostic approach is advocated despite the absence of any prospective studies validating its use. In this study, we evaluated the diagnostic accuracy of serial compression ultrasonography and Doppler imaging of the iliac veins over a 7-day period among symptomatic pregnant women.     

Incidence of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents

Background

Peripherally inserted central catheters (PICC) in children and adolescents are being used with increasing frequency. We sought to determine the incidence and characterize risk factors of deep vein thrombosis associated with peripherally inserted central catheters in a pediatric population.

Methods

We conducted a prospective study involving consecutive patients referred to the radiology department of a tertiary care university-affiliated hospital for insertion of a peripherally inserted central catheter. We included patients aged 18 years or less who weighed more than 2.5 kg and had a peripherally inserted central catheter successfully inserted in his or her arm between June 2004 and November 2005. The primary outcome was the occurrence of partial or complete deep vein thrombosis evaluated by clinical examination, ultrasonography and venous angiography.

Results

A total of 214 patients (101 girls, 113 boys) were included in the study. Partial or complete deep vein thrombosis occurred in 20 patients, for an incidence of 93.5 per 1000 patients and 3.85 per 1000 catheter-days. Only 1 of the cases was symptomatic. In the univariable analyses, the only variable significantly associated with deep vein thrombosis was the presence of factor II mutation G20210A (odds ratio 7.08, 95% confidence interval 1.11–45.15, p = 0.04), a genetic mutation that increases the risk of a blood clot and that was present in 5 (2.3%) of the 214 patients.

Interpretation

The incidence of deep vein thrombosis related to peripherally inserted central catheters in our study was lower than the incidence related to centrally inserted venous catheters described in the pediatric literature (11%–50%).Most data available in the adult and pediatric literature on the incidence of deep vein thrombosis concern centrally inserted venous catheters, which are inserted directly in a central vein (jugular, subclavian or femoral). Typical symptoms of deep vein thrombosis are frequently absent in children and adolescents. Although the diagnosis of deep vein thrombosis is more reliable when based on Doppler ultrasonography or venous angiography,^1–10 in most studies these diagnostic tests were performed only when patients presented clinical symptoms of deep vein thrombosis or catheter dysfunction. In studies focused on the pediatric population, the frequency of deep vein thrombosis related to centrally inserted venous catheters has varied from 11% to 50%.^1,5,6,8,11In the past 10 years, peripherally inserted central catheters (PICC) have been used with increasing frequency in children and adolescents. The catheter is inserted percutaneously via a peripheral vein, with its tip residing in the superior vena cava. The main indications for this type of catheter insertion are difficult venous access, home intravenous antibiotic therapy, administration of chemotherapy or other hyperosmolar solution and long-term parenteral nutrition. The risk of deep vein thrombosis related to peripherally inserted central catheters could be greater among children and adolescents than among adults, given the size of the veins. Several studies have published complications related to peripherally inserted central catheters,^12–20 but few focused on the pediatric population.^13–21 Furthermore, in all of these studies, screening for deep vein thrombosis was not systematic. The real incidence of deep vein thrombosis related to peripherally inserted central catheters and their complications in the pediatric population are therefore unknown. We conducted this study to determine the incidence and characterize the risk factors of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents in our institution.     

Patient-specific computational modeling of upper extremity arteriovenous fistula creation: its feasibility to support clinical decision-making

Introduction

Inadequate flow enhancement on the one hand, and excessive flow enhancement on the other hand, remain frequent complications of arteriovenous fistula (AVF) creation, and hamper hemodialysis therapy in patients with end-stage renal disease. In an effort to reduce these, a patient-specific computational model, capable of predicting postoperative flow, has been developed. The purpose of this study was to determine the accuracy of the patient-specific model and to investigate its feasibility to support decision-making in AVF surgery.

Methods

Patient-specific pulse wave propagation models were created for 25 patients awaiting AVF creation. Model input parameters were obtained from clinical measurements and literature. For every patient, a radiocephalic AVF, a brachiocephalic AVF, and a brachiobasilic AVF configuration were simulated and analyzed for their postoperative flow. The most distal configuration with a predicted flow between 400 and 1500 ml/min was considered the preferred location for AVF surgery. The suggestion of the model was compared to the choice of an experienced vascular surgeon. Furthermore, predicted flows were compared to measured postoperative flows.

Results

Taken into account the confidence interval (25^th and 75^th percentile interval), overlap between predicted and measured postoperative flows was observed in 70% of the patients. Differentiation between upper and lower arm configuration was similar in 76% of the patients, whereas discrimination between two upper arm AVF configurations was more difficult. In 3 patients the surgeon created an upper arm AVF, while model based predictions allowed for lower arm AVF creation, thereby preserving proximal vessels. In one patient early thrombosis in a radiocephalic AVF was observed which might have been indicated by the low predicted postoperative flow.

Conclusions

Postoperative flow can be predicted relatively accurately for multiple AVF configurations by using computational modeling. This model may therefore be considered a valuable additional tool in the preoperative work-up of patients awaiting AVF creation.     

Prophylaxis of postoperative deep vein thrombosis: selective use of low-dose heparin in high-risk patients.

Administration of prophylactic low-dose subcutaneous heparin to prevent postoperative deep vein thrombosis is expensive, entails treating many patients unnecessarily, and causes some side effects. By using a predictive index a population of patients who are at particularly high risk of developing postoperative deep vein thrombosis may be identified preoperatively. Prophylaxis was given only to these patients, resulting in an incidence of deep vein thrombosis of 3.8% compared with 16.1% in previous studies in which no specific prophylaxis was given. By limiting prophylaxis to the group of patients identified by the predictive index as being at high risk of developing postoperative deep vein thrombosis results may be obtained that are as good as those expected from treating the whole population. Thus many patients are saved from exposure to low-dose subcutaneous heparin.     

Criteria in Radioisotope Detection of Venous Thrombosis

Forty-one patients out of a larger series undergoing elective surgery were examined for the presence of venous thrombosis in the legs by means of the ¹²⁵I-fibrinogen technique. The radioisotope data were analysed by three different methods. The percentage uptake was calculated and, by the generally accepted difference of 15%, 22 patients had evidence of thrombosis. The statistical index, which takes account of the errors due to radioactivity counting inherent in the percentage uptake calculation, indicated thrombosis in 36 patients. The relative uptake index, which allows for the errors due to unequal distribution of radioactivity throughout the normal limb as well as the errors due to radioactivity counting, provided evidence of thrombosis in a total of 34 patients, compared with only 22 patients when assessed by the “15%” criterion.     

脾切除及贲门周围血管离断术对肝硬化门静脉高压患者肝脏血流动力学的影响及其术后门静脉血栓形成的因素分析

目的:探讨脾切除及贲门周围血管离断术对肝硬化门静脉高压患者肝脏血流动力学的影响,并分析患者术后门静脉血栓形成的危险因素。方法:选择2016年1月-2017年12月在我院进行脾切除及贲门周围血管离断术的96例肝硬化门静脉高压患者,于术前、术后1d、3d、7d采用彩色多普勒超声对患者的肝脏血流动力学指标进行动态监测。统计术后7d内患者门静脉血栓的发生率,并将患者分为血栓组(n=28)和无血栓组(n=68),对两组患者的一般资料、手术指标、彩色多普勒超声监测指标等进行单因素分析,并采用Logistic多因素回归分析门静脉血栓形成的危险因素。结果:患者在术前、术后1d、3d、7d时的门静脉内径、最大流速、血流量呈逐渐降低的趋势,肝动脉内径、最大流速、血流量呈逐渐升高的趋势,且各时间点间两两比较差异有统计学意义(P0.05)。术后7d内有28例患者出现门静脉血栓,发生率为29.17%。血栓组和无血栓组患者在性别、年龄、体质量指数、手术时间、术前门静脉流速比较差异无统计学意义(P0.05);血栓组患者Child-Pugh分级为B级比例、术中出血量、脾质量、腹水量、术前门静脉内径均高于无血栓组,术后门静脉内径、术后门静脉流速均低于无血栓组(P0.05)。经Logistic多因素回归分析显示,患者术后门静脉内径、术后门静脉流速是门静脉血栓形成的危险因素(P0.05)。结论:行脾切除及贲门周围血管离断术的肝硬化门静脉高压患者术后进行肝脏血流动力学监测,有助于患者术后的疗效判断,且术后门静脉内径、术后门静脉流速是门静脉血栓形成的危险因素。     

Caprini血栓风险评分及血清D-D、VEGF、PDGF-B对创伤性骨折患者术后深静脉血栓形成的预测价值及模型构建

摘要 目的：探讨Caprini血栓风险评分及血清D-二聚体（D-D）、血管内皮生长因子（VEGF）、血小板衍生生长因子B（PDGF-B）对创伤性骨折患者术后深静脉血栓形成（DVT）的预测价值,并构建风险预测模型。方法：选取2019年6月至2022年5月徐州医科大学附属医院收治的216例创伤性骨折住院患者为研究对象,依据术后DVT发生情况分为DVT组（62例）和非DVT组（154例）,对比两组Caprini血栓风险评分、血清D-D、VEGF、PDGF-B及临床资料的差异,多因素Logistic回归分析明确DVT的危险因素,建立预测模型,并进行模型的验证,绘制受试者工作特征曲线（ROC）进行效能评估。结果：创伤性骨折患者术后DVT发生率为28.70%。DVT组骨折至入院时间＞24 h患者占比多于非DVT组,凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、D-D、VEGF、PDGF-B、Caprini血栓风险评分均高于非DVT组（P＜0.05）。多因素Logistic回归分析显示,骨折至入院时间>24 h、血清D-D、VEGF、PDGF-B高水平及Caprini血栓风险评分升高是创伤性骨折患者术后发生DVT的独立危险因素（P＜0.05）。以Logistic回归分析筛选的创伤性骨折患者术后发生DVT的5个独立危险因素,建立预测模型方程：Logit（P）=-0.171 +1.170×骨折至入院时间 +1.041×血清D-D +0.046×血清VEGF +0.100×血清PDGF-B +0.080×Caprini血栓风险评分,内部验证结果显示C-index指数为0.825（95%CI：0.740~0.892）,Calibration曲线显示校正曲线与理想曲线趋近重合（P＞0.05）。使用本研究样本进行外部验证：曲线下面积AUC为0.901、灵敏度为0.887、特异度为0.870,显示该模型具有很高的预测效能,明显高于D-D、VEGF、PDGF-B、Caprini血栓风险评分单独应用的预测效能。结论：骨折至入院时间、血清D-D、VEGF、PDG及Caprini血栓风险评分均是创伤性骨折患者术后发生DVT的影响因素,构建的预测模型对DVT的发生具有较好的预测效能。     

Postoperative Deep Vein Thrombosis in Sudanese Patients

The incidence of postoperative deep vein thrombosis diagnosed by radioisotope scanning in 100 Sudanese patients aged 40 or over was 12%. This compares with an incidence of nearly 30% in 542 patients reported from British hospitals using the same diagnostic technique. The reason for the difference is obscure and needs further investigation.     

Results of ultra-high streptokinase (Awelysin) doses in patients with thrombophlebitis

The results of 6-hour fibrinolysis with ultra-high streptokinase doses in 30 patients with peripheral venous thrombosis were presented. In 33.3% of the patients complete, and in 40% partial repatency was attained, while no repatency occurred in 20%. Deterioration was observed in two patients. The most beneficial effects were seen in postoperative and posttraumatic thrombosis. Bleeding complications did not occur. In one female patient treatment was discontinued due to bronchospasm.     

Prevention of Postoperative Leg Vein Thrombosis by Electrical Muscle Stimulation. An Evaluation with 125I-Labelled Fibrinogen

In a prospective trial of preventing deep vein thrombosis electrical stimulation of the calf muscles of one leg was used in 110 patients undergoing major surgery. Deep vein thrombosis was detected by means of the ¹²⁵I-fibrinogen uptake test in nine of the stimulated legs and in 23 of the unstimulated legs. It is suggested that this technique, which is both simple and effective, should be used on all patients undergoing major surgery.     

Predictors of early and late stroke following cardiac surgery

Background:

Much is known about the short-term risks of stroke following cardiac surgery. We examined the rate and predictors of long-term stroke in a cohort of patients who underwent cardiac surgery.

Methods:

We obtained linked data for patients who underwent cardiac surgery in the province of Ontario between 1996 and 2006. We analyzed the incidence of stroke and death up to 2 years postoperatively.

Results:

Of 108 711 patients, 1.8% (95% confidence interval [CI] 1.7%–1.9%) had a stroke perioperatively, and 3.6% (95% CI 3.5%–3.7%) had a stroke within the ensuing 2 years. The strongest predictors of both early and late stroke were advanced age (≥ 65 year; adjusted hazard ratio [HR] for all stroke 1.9, 95% CI 1.8–2.0), a history of stroke or transient ischemic attack (adjusted HR 2.1, 95% CI 1.9–2.3), peripheral vascular disease (adjusted HR 1.6, 95% CI 1.5–1.7), combined coronary bypass grafting and valve surgery (adjusted HR 1.7, 95% CI 1.5–1.8) and valve surgery alone (adjusted HR 1.4, 95% CI 1.2–1.5). Preoperative need for dialysis (adjusted odds ratio [OR] 2.1, 95% CI 1.6–2.8) and new-onset postoperative atrial fibrillation (adjusted OR 1.5, 95% CI 1.3–1.6) were predictors of only early stroke. A CHADS₂ score of 2 or higher was associated with an increased risk of stroke or death compared with a score of 0 or 1 (19.9% v. 9.3% among patients with a history of atrial fibrillation, 16.8% v. 7.8% among those with new-onset postoperative atrial fibrillation and 14.8% v. 5.8% among those without this condition).

Interpretation:

Patients who had cardiac surgery were at highest risk of stroke in the early postoperative period and had continued risk over the ensuing 2 years, with similar risk factors over these periods. New-onset postoperative atrial fibrillation was a predictor of only early stroke. The CHADS₂ score predicted stroke risk among patients with and without atrial fibrillation.Stroke remains a devastating complication following cardiac surgery, with substantial functional and economic impact.^1–3 Stroke research in cardiac surgery has focused on the immediate postoperative period;^4–9 however, most patients undergoing cardiac surgery have conditions such as hypertension, diabetes and atrial fibrillation, which place them at long-term risk of stroke.Early and late outcomes among patients undergoing cardiac surgery could be improved if the risk of postoperative stroke was defined and predictors of stroke identified. With this information, clinicians could optimize medical therapy for stroke risk factors such as hypertension,^10,11 improve the evidence-based use of oral anticoagulation in patients with atrial fibrillation and evaluate intraoperative surgical strategies (e.g., removal of the left atrial appendage¹²) in patients whose clinical characteristics predict an increased risk of stroke. We examined the rate and predictors of long-term stroke within 2 years after cardiac surgery.     

Prevalence and Geographical Variation of Prothrombin G20210A Mutation in Patients with Cerebral Vein Thrombosis: A Systematic Review and Meta-Analysis

Objectives

To compare the prevalence of prothrombin G20210A in patients with objectively confirmed cerebral vein or cortical vein thrombosis against healthy controls, and evaluate geographical variations.

Design

Systematic review and meta-analysis of case control studies.

Methods

We conducted a systematic review of electronic databases including MEDLINE and EMBASE. The main outcome was the prevalence of prothrombin G20210A in patients with objectively confirmed cerebral vein or cortical vein thrombosis; we also analyzed individual country variations in the prevalence. The random-effects model OR was used as the primary outcome measure.

Results

In total 19 studies evaluated 868 cases of cerebral venous thrombosis and 3981 controls. Prothrombin G20210A was found in 103/868 of the patients with cerebral venous thrombosis and 105/3999 of the healthy controls [random effects pooled OR 5.838, 95% CI 3.96 to 8.58; I²17.9%]. The prevalence of prothrombin G20210A was significantly elevated in Italian studies (OR 9.69), in Brazilian studies (OR 7.02), and in German studies (OR 3.77), but not in Iranian studies (OR 0.98).

Conclusion

Prothrombin G20210A is significantly associated with cerebral venous thrombosis when compared to healthy controls, although this association is highly dependent on the country of origin.     

Clinical significance, angiographic characteristics, and short-term outcomes in 30 patients with early coronary artery graft failure

BackgroundDespite technical advances in coronary artery bypass grafting (CABG), early postoperative myocardial ischaemia still remains a challenging problem. The aim of this study was to determine the incidence, clinical features, angiographic characteristics, and management of early graft failure in the present CABG era. MethodsBetween January 1997 and December 2002, 1731 patients underwent CABG at our institution. Coronary angiography was performed in patients with clinical evidence of early postoperative ischaemia (≤3 months). Thirty of these patients with graft failure constituted the population of this study. ResultsOff-pump and on-pump CABG were almost evenly performed in these patients [n=16 (53%) and n=14 (47%) respectively]. Acute myocardial infarction and unstable angina were the leading indications for coronary angiography in the majority of patients [n=28 (93%)]. The most common cause of graft failure was occlusion / thrombosis [n=20 (67%)]. Percutaneous coronary intervention (PCI) was offered to the majority of patients [n=22 (73%)]. Of these patients, 14 underwent PCI to native coronary arteries, whereas eight underwent PCI to the culprit vessel. Three patients underwent reoperation, and five received medical management. Four patients (13%) died in hospital (two after redo CABG, one after unsuccessful PCI, and one patient managed medically). Two patients (7%) had nonfatal major complications (one non-ST-elevation myocardial infarction and one stroke). ConclusionEarly graft failure generally presents as acute coronary syndrome. Graft occlusion/ thrombosis is the leading cause of ischaemia. Patients with graft failure can undergo PCI with a relatively low risk, but the need for redo CABG in associated with a high mortality. (Neth Heart J 2009;17:13-7.)     

Interrelationship of Postoperative Delirium and Cognitive Impairment and Their Impact on the Functional Status in Older Patients Undergoing Orthopaedic Surgery: A Prospective Cohort Study

Background

The impact of postoperative delirium on post-discharge functional status of older patients remains unclear, and little is known regarding the interrelationship between cognitive impairment and post-operative delirium. Therefore, the main purpose was to evaluate the post-discharge functional status of patients who experience delirium after undergoing orthopaedic surgery and the interrelationship of postoperative delirium with underlying cognitive impairment.

Method

This prospective cohort study, conducted at a tertiary care medical center from April 2011 to March 2012, enrolled all subjects aged over 60 years who were admitted for orthopaedic surgery. The baseline characteristics (age, gender, BMI, and living arrangement), surgery-related factors (ASA class, admission type, type of surgery, and length of hospital stay), results of geriatric assessment (postoperative delirium, cognition, depressive mood, comorbidity, pain, malnutrition, polypharmacy, ADL, and instrumental [I]ADL) and 1–12-month postoperative ADL and IADL functional status were collected for analysis.

Results

Overall, 9.1% of 232 patients (mean age: 74.7±7.8 years) experienced postoperative delirium, which was significantly associated with IADL decline at only 6 and 12 months postoperatively (RR: 6.22, 95% CI: 1.08–35.70 and RR: 12.54, 95% CI: 1.88–83.71, respectively). Delirium superimposed on cognitive impairment was a significant predictor for poor functional status at 6 and 12 months postoperatively (RR: 12.80, 95% CI: 1.65–99.40 for ADL at the 6^th month, and RR: 7.96, 95% CI: 1.35–46.99 at the 12^th month; RR: 13.68, 95% CI: 1.94–96.55 for IADL at the 6^th month, and RR: 30.61, 95% CI: 2.94–318.54 at the 12^th month, respectively).

Conclusion

Postoperative delirium is predictive of IADL decline in older patients undergoing orthopaedic surgery, and delirium superimposed on cognitive impairment is an independent risk factor for deterioration of ADL and IADL functional status. Early identification of cognitive function and to prevent delirium are needed to improve functional status following orthopaedic surgery.     

门静脉高压症脾切断流术后血栓形成的临床研究

目的:探讨门静脉高压症脾切断流术后门静脉系统血栓形成的相关原因。方法:回顾性分析2010年4月-2011年12月我科450例因肝硬化门静脉高压症行脾切断流术患者的临床资料,应用超声多普勒检测手术前后门静脉血流速度、门静脉直径及脾静脉、肠系膜上静脉、门静脉血栓情况,用Logistic回归分析术前肝功能Child-Pugh分级、门静脉直径、门静脉血流速度、脾脏的质量及术后血小板数量与门静脉系统血栓形成的关系。结果:术前门静脉系统有血栓患者75例,占16.7%。术后门静脉血栓再形成率52.9%。Logistic单因素分析提示门静脉系统血栓形成与门静脉内径、门静脉血流速度、脾脏质量、血清总胆红素、术后血小板数量有关。多因素分析发现门静脉系统血栓形成与门静脉内径、门静脉血流速度、脾脏质量有关,而与血清总胆红素、术后血小板数量无关。结论:肝硬化门静脉高压症脾切除术后门静脉系统血栓形成与门静脉内径、门静脉血流速度、脾脏质量有关。     

股神经阻滞和收肌管阻滞对全膝关节置换术后下肢静脉血栓形成的影响

目的:探究股神经阻滞(femoral nerve block,FNB)和收肌管阻滞(adductor canal block,ACB)对全膝关节置换术(total knee arthroplasty,TKA)后下肢静脉血栓形成的影响。方法:将2019年3月-2019年4月拟在全身麻醉下行全膝关节置换术的40例患者随机分为FNB组和ACB组,所有患者均给予超声引导下单次注射,术后均给予标准化抗凝治疗。术后评估两组患者不同时间节点的疼痛评分、股四头肌肌力及术后下肢静脉血栓形成情况。结果:两组患者术后2、6、12、24、48、72 h患肢术区局部疼痛的VAS评分差异无统计学意义(P0.05)。ACB组患者术后2、6、12、24、48 h股四头肌肌力均明显高于FNB组(P0.05),术后72 h两组患者股四头肌肌力无明显差异(P0.05)。ACB组在术后患者首次直腿抬高时间(4.5±4.6)h,显著低于FNB组在术后患者首次直腿抬高时间(25.6±12.6)h,两组对比差异有统计学意义(P0.05)。术后72 h给予两组患者复查双下肢血管超声,复查结果显示,FNB组19例患者中共有2例出现下肢静脉血栓,均为肌间隙静脉血栓形成;ACB组20例患者中无患者出现下肢静脉血栓形成,差异无有统计学意义(P0.05)。结论:FNB与ACB在全膝关节置换术后镇痛方面无明显差异,但ACB组较好的保留患者术后早期股四头肌肌力,对于术后功能锻炼和快速康复有较积极的作用,两种神经阻滞方式对患者VTE风险的影响相同。