Background: Preoperative endothelial dysfunction is a predictor of myocardial injury and major adverse cardiac events. Non-cardiac surgery is known to induce acute endothelial changes. The aim of this explorative cohort study was to assess the extent of systemic endothelial dysfunction after major emergency abdominal surgery and the potential association with postoperative myocardial injury.Methods: Patients undergoing major emergency abdominal surgery were included in this prospective cohort study. The primary outcome was the change in endothelial function expressed as the reactive hyperemia index from 4-24 h after surgery until postoperative day 3-5. The reactive hyperemia index was assessed by non-invasive digital pulse tonometry. Secondary outcomes included changes in biomarkers of nitric oxide metabolism and bioavailability. All assessments were performed at the two separate time points in the postoperative period. Clinical outcomes included myocardial injury within the third postoperative day and major adverse cardiovascular events within 30 days of surgery. Results: Between October 2016 and June 2017, 83 patients were included. The first assessment of the endothelial function, 4-24 h, was performed 15.8 (SD 6.9) hours after surgery and the second assessment, postoperative day 3-5, was performed 83.7 (SD 19.8) hours after surgery. The reactive hyperemia index was suppressed early after surgery and did not increase significantly; 1.64 (95% CI 1.52-177) at 4-24 h after surgery vs. 1.75 (95% CI 1.63-1.89) at postoperative day 3-5, p = 0.34. The L-arginine/ADMA ratio, expressing the nitric oxide production, was reduced in the perioperative period and correlated significantly with the reactive hyperemia index. A total of 16 patients (19.3%) had a major adverse cardiovascular event, of which 11 patients (13.3%) had myocardial injury. The Larginine/ADMA ratio was significantly decreased at 4-24 h after surgery in patients suffering myocardial injury.Conclusion: This explorative pathophysiological study showed that acute systemic endothelial dysfunction was present early after major emergency abdominal surgery and remained unchanged until day 3-5 after the procedure. Early postoperative disturbances in the nitric oxide bioavailability might add to the pathogenesis of myocardial injury. This pathophysiological link should be confirmed in larger studies. Trial registration: clinicaltrials.gov no. NCT03010969.
The endothelium has a central regulative role in maintaining vascular homeostasis. 1 Besides controlling the vascular tone, it has an anti-inflammatory, anti-thrombotic and anti-fibrinolytic systemic effect. 1,2 Clinical studies in non-cardiac surgery have shown that surgery causes a state of acute endothelial dysfunction lasting for days after the surgical procedure. 3,4 The extent of endothelial dysfunction after surgery seems to be influenced by perioperative factors such as type of surgery, anaesthetics and pain. 3,[5][6][7] While pre-operative endothelial dysfunction has been associated with the risk of developing perioperative major adverse cardiovascular events 8-10 the clinical consequences of endothelial dysfunction in the perioperative period remain to be established. Endothelial dysfunction early after surgery may play a role in the pathophysiology of myocardial injury. 11 Remote ischaemic preconditioning (RIPC) is a non-invasive procedure with reversible episodes of ischaemia and reperfusion
The purpose of this study was to evaluate the timewise postoperative respiratory function measured by spirometry and peak flow during the first postoperative week after major emergency abdominal surgery. Patients were tested daily with forced expiratory volume (FEV) and peak flow (PEF) from postoperative day (POD) 1 through to POD7. FEV1, FEV6, FEV1/FEV6 ratio and PEF were analysed by unadjusted linear regression with 95% confidence interval (CI) on mean values for each postoperative day. A total of 35 consecutive patients were included in the study. The FEV at 1 second was 51% of predicted at POD1, which increased to 67% at POD7 (p = 0.005), whereas FEV6 was 55% of predicted at POD1, which increased to 70% at POD7 (p = .008). Respiratory function was not significantly correlated to synchronous pain scores. In conclusion, respiratory function following major emergency abdominal surgery was reduced throughout the first postoperative week irrespective of pain scores.
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