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Implication: Although propofol is deemed expensive, its use may bejustified in cardiac surgery. Trends and practices in the current era havelowered the cost of caring for cardiac surgical patients despite the use ofmore expensive drugs such as propofol. Patients in a fast-track protocolwho receive propofol have a shorter duration of mechanical ventilation,shorter stay in the ICU, and a shorter duration of hospitalization.

RENAL FUNCTION AND CARDIAC SURGERY

Abrahamov D, Tamariz M, Fremes S, et al: Renaldysfunction after cardiac surgery. Can J Cardiol 17:565-570, 2001

In a large retrospective analysis of.2,000 cardiac surgical patients, riskfactors for the development of mild and severe renal dysfunction wereanalyzed. The incidence of renal dysfunction, defined as a creatinineclearance,40 mL/min, was 3%. Risk factors identified by stepwiselogistic regression included reoperation, age.65 years, valvular surgery,poor left ventricular function, and low cardiac output postoperatively.Preoperative renal dysfunction was not a risk factor. Patients with milddysfunction (,2 mg/dL creatinine) were likely to have normalization ofrenal function, whereas patients with severe dysfunction (.3 mg/dL cre-atinine) had a 30% chance of requiring dialysis. Mortality rates did notdiffer in mild versus severe renal dysfunction.

Implication: Low cardiac output should be identified and aggres-sively treated to prevent the occurrence of renal dysfunction.

CARDIAC SURGERY IN THE ELDERLY

Deiwick M, Roschner C, Rothenburger M, et al:Feasibility and risks of heart surgery in very elderly:Analysis of 200 consecutive patients of 80 years andabove. Arch Gerontol Geriatr 32:295-304, 2001

Octogenarians with a mean age of 82.26 2.1 years underwent avariety of surgical procedures. This prospective analysis of 200 patientsincluded patients presenting for emergency operations. Overall mortal-ity was 9.5%.

Implication: Elderly patients can undergo cardiac surgery, even onan emergency basis, with acceptable survival statistics.

Deviri E, Merin G, Medalion B, Borman JB: Openheart surgery in octogenarians: A review. Am J Geri-atr Cardiol 4:8-16, 1995

Cardiac surgery in the elderly can be safely performed with awell-tolerated profile of adverse events. Mortality, morbidity, andlengths of stay are highly variable and depend on preoperative riskfactors. Complex or combined surgical procedures carry a higher riskand should be considered carefully in this population.

Implication: Return to a functional quality of life is the reasonthat many octogenarians are being offered the benefits of cardiacsurgery.

OUTCOME AND PULMONARY DISEASE

Ian Conacher, MDGuest Reviewer

Eyraud D, Bertrand M, Fleron MH, et al: Periop-erative mortality in abdominal aortic surgery. Ann FrAnesth Reanim 19:452-458, 2000

Identification and management of patients with high periopera-tive risk is an important component of the perioperative patientevaluation in major noncardiac surgery. In this prospective study,658 consecutive patients undergoing elective abdominal aortic sur-gery were included. Fourteen preoperative and 6 intraoperativevariables were recorded. Age (696 10 yearsv 65 6 10 years;p ,0.01), history of myocardial infarction (p, 0.001), preoperativemyocardial revascularization (p, 0.01), and excessive bloodloss (2,997 6 3,698 mL v 1,424 6 1,208 mL; p , 0.02)were predictive factors of mortality by univariate analysis only. Inunivariate and multivariate analysis, angina pectoris (odds ratio[OR] 5 5.47; p , 0.001), chronic obstructive pulmonary disease(OR 5 2.27; p , 0.05), and duration of surgery (4.76 2 hoursv3.6 6 1.5 hours; OR5 1.60; p , 0.001) were independent predic-tive factors of mortality. Cardiac death was responsible for 30% ofmortality.

Implication: Patients with preoperative angina or chronic obstruc-tive pulmonary disease or both and patients with long duration ofabdominal aortic surgery have poor perioperative outcome. Thesepatients may benefit from aggressive perioperative monitoring andprophylactic treatment for reducing the risk of death.

Jordan S, Mitchell JA, Quinlan GJ, et al: Thepathogenesis of lung injury following pulmonary re-section. Eur Respir J 15:790-799, 2000

This is a comprehensive review of postpneumonectomy pulmo-nary edema and the host of conditions related to the use of one-lungventilation and pulmonary resection. Starting with a history of thecondition, definitions, and incidence, this review logically anddeftly discusses the suggested macroscopic causes, the microscopicfactors, and the pathophysiologic biochemistry. One-lung ventila-tion and its effects on the inflammatory, antioxidant and ischemia-reperfusion cascades are discussed with the endothelium as a majororgan.

Implication: With a 5% incidence after pulmonary resection, a 50%mortality, and several anesthesiologic causative triggers, the postpneu-monectomy pulmonary edema syndrome continues to be a medicalconundrum in thoracic anesthesiology.

Tandon S, Batchelor A, Bullock R, et al: Perioper-ative risk factors for acute lung injury after electiveoesophagectomy. Br J Anaesth 86:633-638, 2001 (seealso accompanying editorial, Br J Anaesth 86:611-617, 2001)

This is a retrospective analysis of a single-center series of 168cases. Acute respiratory distress syndrome developed in 14.5% ofpatients, and what is defined as acute lung injury occurred in 23.8%:The former had a 50% mortality. A low body mass index and historyof cigarette smoking were associated with the syndrome. Prolongedoperative time, prolonged periods of one-lung ventilation, cardio-pulmonary instability, and the development of anastomotic leakswere also predictive. The authors suggested that there is an associ-ation between the development of lung injury and surgeon experi-ence.

Implication: This series touches on many of the debates current inthe management of esophageal cancer. The high mortality rate of lunginjury in association with conditions for which one-lung ventilation isrequired is shown. Most of the usual causes are mentioned, but statis-tical limitations do not allow a determination of which are actualcauses and which are not.

799LITERATURE REVIEW