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McNamara JR, McMahon A, Griffin M. Perioperative Management of the Fontan Patient for Cardiac and Noncardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:275-285. [PMID: 34023201 DOI: 10.1053/j.jvca.2021.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 11/11/2022]
Abstract
The Fontan circulation is the single-ventricle approach to surgical palliation of complex congenital heart disease wherein biventricular separation and function cannot be safely achieved. Incremental improvements in this surgical technique, along with improvements in the long-term medical management of these patients, have led to greater survival of these patients and a remarkably steady increase in the number of adults living with this unusual circulation and physiology. This has implications for healthcare providers who now have a greater chance of encountering Fontan patients during the course of their practice. This has particularly important implications for anesthesiologists because the effects of their interventions on the finely balanced Fontan circulation may be profound. The American Heart Association and American College of Cardiology recommend that, when possible, elective surgery should be performed in an adult congenital heart disease center, although this may not be feasible in the provision of true emergency care. This review article summarizes the pathophysiology pertinent to the provision of anesthesia in this complex patient group and describes important modifications to anesthetic technique and perioperative management.
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Affiliation(s)
- John Richard McNamara
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Aisling McMahon
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Griffin
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
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Park J, Oh AR, Lee S, Lee J, Min JJ, Kwon J, Kim J, Yang K, Choi J, Lee S, Gwon H, Kim K, Ahn J, Lee SM. Associations Between Preoperative Glucose and Hemoglobin A1c Level and Myocardial Injury After Noncardiac Surgery. J Am Heart Assoc 2021; 10:e019216. [PMID: 33728934 PMCID: PMC8174354 DOI: 10.1161/jaha.120.019216] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/09/2021] [Indexed: 12/17/2022]
Abstract
Background Perioperative blood glucose level has shown an association with postoperative outcomes. We compared the incidences of myocardial injury after noncardiac surgery (MINS) and 30-day mortality, according to preoperative blood glucose and hemoglobin A1c (HbA1c) levels. Methods and Results The patients were divided according to blood glucose level within 1 day before surgery. The hyperglycemia group was defined with fasting glucose >140 mg/dL or random glucose >180 mg/dL. In addition, we compared the outcomes according to HbA1c >6.5% among patients with available HbA1c within 3 months before surgery. The primary outcome was MINS, and 30-day mortality was also compared. A total of 12 304 patients were enrolled and divided into 2 groups: 8324 (67.7%) in the normal group and 3980 (32.3%) in the hyperglycemia group. After adjustment with inverse probability of weighting, the hyperglycemia group exhibited significantly higher incidences of MINS and 30-day mortality (18.7% versus 27.6%; odds ratio, 1.29; 95% CI, 1.18-1.42; P<0.001; and 2.0% versus 5.1%; hazard ratio, 2.00; 95% CI, 1.61-2.49; P<0.001, respectively). In contrast to blood glucose, HbA1c was not associated with MINS or 30-day mortality. Conclusions Preoperative hyperglycemia was associated with MINS and 30-day mortality, whereas HbA1c was not. Immediate glucose control may be more crucial than long-term glucose control in patients undergoing noncardiac surgery. Registration URL: https://www.cris.nih.go.kr; Unique identifier: KCT0004244.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Seung‐Hwa Lee
- Division of CardiologyDepartment of MedicineHeart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Jong‐Hwan Lee
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Jeong Jin Min
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Ji‐Hye Kwon
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Jihoon Kim
- Division of CardiologyDepartment of MedicineHeart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Kwangmo Yang
- Center for Health PromotionSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Jin‐Ho Choi
- Division of CardiologyDepartment of MedicineHeart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
- Department of Emergency MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Sang‐Chol Lee
- Division of CardiologyDepartment of MedicineHeart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Hyeon‐Cheol Gwon
- Division of CardiologyDepartment of MedicineHeart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Kyunga Kim
- Statistics and Data CenterResearch Institute for Future MedicineSamsung Medical CenterSeoulKorea
- Department of Digital HealthSamsung Advanced Institute for Health Sciences & TechnologySungkyunkwan UniversitySeoulKorea
| | - Joonghyun Ahn
- Statistics and Data CenterResearch Institute for Future MedicineSamsung Medical CenterSeoulKorea
| | - Sangmin Maria Lee
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
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53
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Saladino E, Bullerwell M. Echocardiography-Guided Resuscitation in Noncardiac Surgery. AANA J 2021; 89:155-160. [PMID: 33832576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Sustained hypotension impairs perfusion, causing permanent organ damage, neurologic deficit, and cardiac arrest. Emerging evidence suggests that noncardiac anesthesia providers can use echocardiography to manage refractory hypotension. Echocardiographic findings may reveal the underlying pathology of hemodynamic compromise and can guide the selection of appropriate resuscitative measures. The current evidence was reviewed to evaluate echocardiography's impact on the cause, diagnosis, and resuscitation management of refractory hypotension during noncardiac surgery. An extensive literature search yielded 3 prospective interventional studies and 7 observational studies, which were graded and ranked by quality, consistency, and strength of recommendations according to the United States Preventive Services Task Force evidence evaluation grading system. Echocardiographic imaging was useful in all phases of perioperative care, from the preoperative clinic through the postanesthesia care unit. Focused echocardiographic examination of the heart and great vessels contributed critical diagnostic data that expedited management decisions. As a primary cardiovascular monitor, transesophageal echocardiography guided both fluid resuscitation and pharmacologic therapy. During intraoperative cardiac arrest, transesophageal echocardiography enhanced diagnostic insight and directly guided targeted, lifesaving treatment. Noninvasive transthoracic echocardiography offered providers several clinical advantages. The published literature validates echocardiography's utility in the diagnosis and treatment of patients experiencing intraoperative refractory hypotension due to hemodynamic compromise.
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Affiliation(s)
- Erin Saladino
- is a graduate of the Baylor College of Medicine Doctor of Nursing Practice (DNP) Program in Nurse Anesthesia, Houston, Texas. She is a CRNA at Houston Methodist Hospital, Houston, Texas.
| | - Megan Bullerwell
- is the associate director of the DNP-Nurse Anesthesia Program at Baylor College of Medicine. She is an assistant professor in the college's Department of Anesthesiology and School of Health Professions. Dr Bullerwell served as senior author.
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54
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Machado MN, Rodrigues FB, Nakazone MA, Martin DF, Sabbag ATR, Grigolo IH, Silva-Júnior OL, Maia LN, Jaffe AS. Prediction of Death After Noncardiac Surgery: Potential Advantage of Using High-Sensitivity Troponin T as a Continuous Variable. J Am Heart Assoc 2021; 10:e018008. [PMID: 33660524 PMCID: PMC8174224 DOI: 10.1161/jaha.120.018008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Increased high‐sensitivity cardiac troponin T (hs‐cTnT) above the upper reference limit (URL) after noncardiac surgery identifies patients at risk for mortality. Prior studies have not analyzed hs‐cTnT as a continuous variable or probed age‐ and sex‐specific URLs. This study compared the prediction of 30‐day mortality using continuous postoperative hs‐cTnT levels to the use of the overall URL and age‐ and sex‐specific URLs. Methods and Results Patients (876) >40 years of age who underwent noncardiac surgery were included. Hs‐cTnT was measured on postoperative day 1. Cox proportional hazards models were used to compare associations between 30‐day mortality and using hs‐cTnT as a continuous variable, or above the overall or age‐ and sex‐specific URLs. Comparisons were performed by the area under the receiver operating characteristic curve analysis. Mortality was 4.2%. For each 1 ng/L increase in postoperative hs‐cTnT, there was a 0.3% increase in mortality (P<0.001). Patients with postoperative hs‐cTnT >14 ng/L were 37% of the cohort, while those above age‐ and sex‐specific URLs were 25.3%. Both manifested higher mortality (hazard ratio [HR], 3.19; 95% CI, 1.20–8.49; P=0.020) and (HR, 2.76; P=0.009) than those with normal levels. The area under receiver operating characteristic curve was 0.89 using hs‐cTnT as a continuous variable, 0.87 for age‐ and sex‐specific URLs, and 0.86 for the overall URL. Conclusions Hs‐cTnT as a continuous variable was independently associated with 30‐day mortality and had the highest accuracy. Hs‐cTnT elevations using overall and/or age‐ and sex‐specific URLs were also associated with higher mortality.
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Affiliation(s)
- Mauricio N Machado
- Division of Cardiology Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Fernando B Rodrigues
- Division of Emergency and Chest Pain Center Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Marcelo A Nakazone
- Division of Cardiology Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil.,Integrated Research Center Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Danilo F Martin
- Division of Cardiology Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Amália T R Sabbag
- Division of Anesthesiology Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Ingrid H Grigolo
- Integrated Research Center Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Osvaldo L Silva-Júnior
- Integrated Research Center Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Lilia N Maia
- Division of Cardiology Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil.,Integrated Research Center Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Allan S Jaffe
- Cardiovascular Department and Department of Laboratory Medicine and Pathology Mayo Clinic MN
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55
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Liu H, Dai M, Guan H, Gao X, Zhou Y, Sun X, Zhou J, Hu X, Li X, Song Y, Han Y, Cao J. Preoperative Prognostic Nutritional Index Value is Related to Postoperative Delirium in Elderly Patients After Noncardiac Surgery: A Retrospective Cohort Study. Risk Manag Healthc Policy 2021; 14:1-8. [PMID: 33442311 PMCID: PMC7797345 DOI: 10.2147/rmhp.s280567] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/17/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose Malnutrition has been considered as a risk factor for postoperative delirium (POD). The Prognostic Nutritional Index (PNI) is a validated tool for assessing nutritional status. This study aimed to investigate the association between preoperative PNI values and the occurrence of POD in elderly surgical patients. Methods The retrospective cohort study included 361 elderly individuals who underwent noncardiac surgery between 2018 and 2019. Perioperative data were collected from the patients’ medical records. PNI was used to evaluate preoperative nutritional status. The primary outcome was the occurrence of POD. Univariate and multivariate logistic regression analyses were used to identify key factors associated with POD and assess the relationship between PNI values and the occurrence of POD. Receiver operating characteristic (ROC) curve analysis was used to assess the predictive value of PNI for POD. Results Seventy-two (19.9%) individuals developed postoperative delirium after surgery. Compared with patients of normal nutrition status (PNI ≥ 50), mild malnutrition (PNI 45–50) did not increase the risk of POD, while patients with moderate to severe malnutrition (PNI 40–45) (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.31–6.50) and serious malnutrition (PNI < 40) (OR, 3.15; 95% CI, 1.12–8.83) were more likely to develop POD. The cut-off value of PNI was 46.05 by ROC curve analysis, the area under the curve (AUC) was 0.69 (95% CI 0.62–0.77). Conclusion Preoperative PNI value is related to postoperative delirium in elderly patients after noncardiac surgery.
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Affiliation(s)
- He Liu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China.,Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou City 221004, Jiangsu Province, People's Republic of China
| | - Mingsheng Dai
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China.,Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Huilian Guan
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China
| | - Xing Gao
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China
| | - Yang Zhou
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China
| | - Xun Sun
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China
| | - Jian Zhou
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China
| | - Xiaoyi Hu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China
| | - Xiang Li
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China
| | - Yu Song
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China
| | - Yuan Han
- Department of Anesthesiology, Eye & ENT Hospital of Fudan University, Shanghai 20031, People's Republic of China
| | - Junli Cao
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City 221002, Jiangsu Province, People's Republic of China.,Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou City 221004, Jiangsu Province, People's Republic of China
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56
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Huang X, Wu D, Wu AS, Wei CW, Gao JD. The Association of Insomnia with Depression and Anxiety Symptoms in Patients Undergoing Noncardiac Surgery. Neuropsychiatr Dis Treat 2021; 17:915-924. [PMID: 33790560 PMCID: PMC8008159 DOI: 10.2147/ndt.s296986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/01/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Insomnia is common in patients undergoing surgery. It can increase the rate of postoperative complications, interfere with patient recovery, and decrease hospital satisfaction. However, there are few studies on perioperative insomnia. This study was conducted to investigate the differences in the demographic, health status, and clinical characteristics of patients with and without insomnia postoperatively, and to identify the potential risk factors of insomnia. METHODS There were 299 non-cardiac surgery patients, 165 females, and 134 males, with a mean age of 55 years, enrolled in the study. The Insomnia Severity Index (ISI), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), and Montreal Cognitive Assessment (MoCA) were administered to all the patients preoperatively. The Visual Analogue Scale (VAS) was used preoperatively, and at the end of the surgery, and then one day, two days, and three days after surgery. The PHQ-9, the GAD-7, and the ISI were repeated three days after surgery. Insomnia was diagnosed by the ISI as being a score of 8-28 (mild: 8-14; moderate-severe: 15-21; severe: 22-28). The patients were divided into group A (with insomnia, N=78) and group B (without insomnia, N=221) according to their ISI score three days after surgery. The general clinical data of the two groups were analyzed first, and then binary logistic regression analysis was conducted to assess the risk factors of insomnia. RESULTS A total of 299 non-cardiac surgery patients with a mean age of 55 years were enrolled in the study. Of the included patients, the number of females was 165 and the number of the male was 134. The incidence of insomnia at 3 days postoperatively was 26.1% (78/299). The average points that group A patients scored in the ISI, PHQ-9, and the GAD-7 were significantly higher than those in group B. The VAS score three days after surgery was significantly higher in group A. The PHQ-9 and the GAD-7 three days after surgery showed significantly higher depression and anxiety scores in group A. Logistic regression showed that the ISI (p<0.001, 95% CI=1.218-1.500) and the GAD-7 (p=0.003, 95% CI=1.041-1.218) preoperatively, and the PHQ-9 postoperatively (p<0.001, 95% CI=1.226-1.555), were risk factors of insomnia. CONCLUSION Insomnia is common and can worsen after surgery. The present study suggests that depression and anxiety are risk factors for insomnia after surgery. There is a need for further research and the development of strategies for depression and anxiety management to ensure better sleep quality for patients, which will be of significant benefit to their health. CLINICAL TRIAL REGISTRATION The study was registered at clinical trial (NCT04027751); Trial registration: clinical trial, NCT04027751. Registered 22 July 2019; https://clinicaltrials.gov/ct2/show/NCT04027751?cond=NCT04027751&cntry=CN&draw=2&rank=1.
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Affiliation(s)
- Xiao Huang
- Department of Anesthesia, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Dan Wu
- Department of Anesthesia, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - An-Shi Wu
- Department of Anesthesia, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Chang-Wei Wei
- Department of Anesthesia, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Jian-Dong Gao
- Department of Anesthesia, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
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Affiliation(s)
- Henrik Kehlet
- Rigshospitalet, Section of Surgical Pathophysiology, Copenhagen, Denmark.
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58
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Turan A, Sessler DI. Reality supported by statistics. Comment on Br J Anaesth 2021; 126: e83. Br J Anaesth 2020; 126:e83-e84. [PMID: 33342540 DOI: 10.1016/j.bja.2020.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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Sikachi RR, Anca D. Anesthetic Considerations in a Patient With LVAD and COVID-19 Undergoing Video-Assisted Thoracic Surgery. J Cardiothorac Vasc Anesth 2020; 35:3035-3038. [PMID: 33419685 PMCID: PMC7744272 DOI: 10.1053/j.jvca.2020.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 11/11/2022]
Abstract
Increased survival with left ventricular assist devices (LVAD) has led to a large number of patients with LVADs presenting for noncardiac surgeries (NCS). With studies showing that a trained noncardiac anesthesiologist can safely manage these patients when they present for NCS, it is vital that all anesthesiologists understand the LVAD physiology and its implications in various surgeries. This is even more relevant during the current pandemic in which these complex cardiopulmonary interactions may be even more challenging in patients with coronavirus disease 2019 (COVID-19). The authors describe a case of a patient with COVID-19 with an LVAD who needed thoracoscopic decortication for recurrent complex pleural effusion and briefly discuss unique challenges presented and their management.
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Affiliation(s)
- Rutuja R Sikachi
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY.
| | - Diana Anca
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
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Miller TE, Mythen M, Shaw AD, Hwang S, Shenoy AV, Bershad M, Hunley C. Association between perioperative fluid management and patient outcomes: a multicentre retrospective study. Br J Anaesth 2020; 126:720-729. [PMID: 33317803 DOI: 10.1016/j.bja.2020.10.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/09/2020] [Accepted: 10/26/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Postoperative complications increase hospital length of stay and patient mortality. Optimal perioperative fluid management should decrease patient complications. This study examined associations between fluid volume and noncardiac surgery patient outcomes within a large multicentre US surgical cohort. METHODS Adults undergoing noncardiac procedures from January 1, 2012 to December 31, 2017, with a postoperative length of stay ≥24 h, were extracted from a large US electronic health record database. Patients were segmented into quintiles based on recorded perioperative fluid volumes with Quintile 3 (Q3) serving as the reference. The primary outcome was defined as a composite of any complications during the surgical admission and a postoperative length of stay ≥7 days. Secondary outcomes included in-hospital mortality, respiratory complications, and acute kidney injury. RESULTS A total of 35 736 patients met the study criteria. There was a U-shaped pattern with highest (Q5) and lowest (Q1) quintiles of fluid volumes having increased odds of complications and a postoperative length of stay ≥7 days (Q5: odds ratio [OR] 1.51 [95% confidence interval {CI}: 1.30-1.74], P<0.001; Q1: OR 1.20 [95% CI: 1.04-1.38], P=0.011) compared with Q3. Patients in Q5 had greater odds of more severe acute kidney injury compared with Q3 (OR 1.52 [95% CI: 1.22-1.90]; P<0.001) and respiratory complications (OR 1.44 [95% CI: 1.17-1.77]; P<0.001). CONCLUSIONS Both very high and very low perioperative fluid volumes were associated with an increase in complications after noncardiac surgery.
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Affiliation(s)
- Timothy E Miller
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Monty Mythen
- University College London Hospitals, National Institute for Health Research, Biomedical Research Centre, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
| | - Seungyoung Hwang
- Department of Health Economics and Outcomes Research, Boston Strategic Partners, Inc., Boston, MA, USA
| | - Apeksha V Shenoy
- Department of Health Economics and Outcomes Research, Boston Strategic Partners, Inc., Boston, MA, USA
| | - Michael Bershad
- Global Health Economics & Reimbursement, Edwards Lifesciences, Irvine, CA, USA
| | - Charles Hunley
- Department of Critical Care Medicine, Orlando Regional Medical Center, Orlando, FL, USA.
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Huang X, Sun Y, Lin D, Wei C, Wu A. Effect of perioperative intravenous lidocaine on the incidence of short-term cognitive function after noncardiac surgery: A meta-analysis based on randomized controlled trials. Brain Behav 2020; 10:e01875. [PMID: 33044051 PMCID: PMC7749605 DOI: 10.1002/brb3.1875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Postoperative cognitive dysfunction is a debilitating postoperative complication. The perioperative neuroprotective effect of lidocaine has conflicting results. METHODS In this qualitative review of randomized controlled clinical trials on the perioperative use of lidocaine, we report the effects of intravenous lidocaine on brain function after noncardiac surgery. Studies were identified from PubMed, MEDLINE, and Cochrane Central Register. RESULTS Of the 453 retrieved studies, 4 randomized trials were included. No significant association between the use of lidocaine postoperative cognitive states was found (risk ratio 0.67; 95% CI -0.02 to 1.36; I2 89%; p = .06). CONCLUSIONS Current evidence cannot suggest that perioperative intravenous use of lidocaine has pharmacological brain neuroprotection after noncardiac surgery. All the included studies were small-scale research, and the total number of participants was small; the results should be interpreted with caution.
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Affiliation(s)
- Xiao Huang
- Anesthesia Department of Beijing Chao-Yang Hospital, Beijing, China
| | - Yuan Sun
- Pharmacy Department of Beijing Chao-Yang Hospital, Beijing, China
| | - Dandan Lin
- Anesthesia Department of Beijing Chao-Yang Hospital, Beijing, China
| | - Changwei Wei
- Anesthesia Department of Beijing Chao-Yang Hospital, Beijing, China
| | - Anshi Wu
- Anesthesia Department of Beijing Chao-Yang Hospital, Beijing, China
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Abstract
The patient with severe asymptomatic aortic stenosis presenting for elective noncardiac surgery poses a unique challenge. These patients are not traditionally offered surgical aortic valve replacement or transcatheter aortic valve replacement given their lack of symptoms; however, they are at increased risk for postsurgical complications given the severity of their aortic stenosis. The decision to proceed with elective noncardiac surgery should be based on individual and surgical risk factors. However, severity of aortic stenosis is not accounted for in current surgical risk factor assessment scoring; therefore, extensive communication with patients and surgical teams is necessary to minimize a patient's risk. A clear intraoperative plan should be designed to manage the unique hemodynamics of these patients, and a discussion should address postoperative placement.
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May SM, Abbott TEF, Del Arroyo AG, Reyes A, Martir G, Stephens RCM, Brealey D, Cuthbertson BH, Wijeysundera DN, Pearse RM, Ackland GL. MicroRNA signatures of perioperative myocardial injury after elective noncardiac surgery: a prospective observational mechanistic cohort study. Br J Anaesth 2020; 125:661-671. [PMID: 32718726 PMCID: PMC7678162 DOI: 10.1016/j.bja.2020.05.066] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/08/2020] [Accepted: 05/31/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Elevated plasma or serum troponin, indicating perioperative myocardial injury (PMI), is common after noncardiac surgery. However, underlying mechanisms remain unclear. Acute coronary syndrome (ACS) is associated with the early appearance of circulating microRNAs, which regulate post-translational gene expression. We hypothesised that if PMI and ACS share pathophysiological mechanisms, common microRNA signatures should be evident. METHODS We performed a nested case control study of samples obtained before and after noncardiac surgery from patients enrolled in two prospective observational studies of PMI (postoperative troponin I/T>99th centile). In cohort one, serum microRNAs were compared between patients with or without PMI, matched for age, gender, and comorbidity. Real-time polymerase chain reaction quantified (qRT-PCR) relative microRNA expression (cycle quantification [Cq] threshold <37) before and after surgery for microRNA signatures associated with ACS, blinded to PMI. In cohort two, we analysed (EdgeR) microRNA from plasma extracellular vesicles using next-generation sequencing (Illumina HiSeq 500). microRNA-messenger RNA-function pathway analysis was performed (DIANA miRPath v3.0/TopGO). RESULTS MicroRNAs were detectable in all 59 patients (median age 67 yr [61-75]; 42% male), who had similar clinical characteristics independent of developing PMI. In cohort one, serum microRNA expression increased after surgery (mean fold-change) hsa-miR-1-3p: 3.99 (95% confidence interval [CI: 1.95-8.19]; hsa-miR-133-3p: 5.67 [95% CI: 2.94-10.91]; P<0.001). These changes were not associated with PMI. Bioinformatic analysis of differentially expressed microRNAs from cohorts one (n=48) and two (n=11) identified pathways associated with adrenergic stress and calcium dysregulation, rather than ischaemia. CONCLUSIONS Circulating microRNAs associated with cardiac ischaemia were universally elevated in patients after surgery, independent of development of myocardial injury.
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Affiliation(s)
- Shaun M May
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Tom E F Abbott
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Ana G Del Arroyo
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Anna Reyes
- University College London NHS Hospitals Trust, London, UK
| | - Gladys Martir
- University College London NHS Hospitals Trust, London, UK
| | | | - David Brealey
- University College London NHS Hospitals Trust, London, UK
| | - Brian H Cuthbertson
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Rupert M Pearse
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Gareth L Ackland
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
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Wagner D, Hooper V, Bankieris K, Johnson A. The Relationship of Postoperative Delirium and Unplanned Perioperative Hypothermia in Surgical Patients. J Perianesth Nurs 2020; 36:41-46. [PMID: 33067117 DOI: 10.1016/j.jopan.2020.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study was to investigate associations between postoperative delirium (POD) and unplanned perioperative hypothermia (UPH) among adults undergoing noncardiac surgery. DESIGN A retrospective, exploratory design was used. METHODS A retrospective, exploratory study was conducted using electronic medical record data abstracted from a purposive convenience sample of adult patients undergoing noncardiac surgery from January 2014 to June 2017. FINDINGS The analyzed data set included 22,548 surgeries, of which 9% experienced POD. Logistic regression indicated that American Society of Anesthesiologists (ASA) class was the strongest predictor of POD (χ2 = 1,207.11, df = 4, inclusive of all ASA class terms). A significant relationship between UPH and POD (χ2 = 54.94, df = 4, inclusive of all UPH terms) and a complex relationship among UPH, patient age, ASA class, and POD were also found. CONCLUSIONS Results support a relationship between UPH and POD. Notably, there is also a complex relationship in the noncardiac surgery population among UPH, age, ASA class, and POD. Preliminary understanding of this relationship is based on the pathophysiological response to surgical stress. Further research is indicated.
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Affiliation(s)
- Doreen Wagner
- Wellstar School of Nursing, Kennesaw State University, Kennesaw, GA
| | - Vallire Hooper
- Center for Nursing Research, College of Nursing, East Tennessee State University, Johnson City, TN.
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Turan A, Cohen B, Rivas E, Liu L, Pu X, Maheshwari K, Farag E, Onal O, Wang J, Ruetzler K, Devereaux PJ, Sessler DI. Association between postoperative haemoglobin and myocardial injury after noncardiac surgery: a retrospective cohort analysis. Br J Anaesth 2020; 126:94-101. [PMID: 33039122 DOI: 10.1016/j.bja.2020.08.056] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Myocardial injury after noncardiac surgery (MINS) is common, mostly silent, and a strong predictor of postoperative mortality. MINS appears to result from myocardial supply-demand mismatch. Recent data support restrictive perioperative transfusion strategies that can result in low postoperative haemoglobin concentrations. Whether low postoperative haemoglobin is associated with myocardial injury remains unknown. We therefore tested the hypothesis that anaemia is associated with an increased risk of myocardial injury in adults having noncardiac surgery. METHODS We conducted a retrospective analysis of adults ≥45 yr old who had routine postoperative troponin T (TnT) monitoring after noncardiac surgery at the Cleverland Clinic (including those enrolled in the PeriOperative ISchemic Evaluation-2 Trial [POISE-2], the Safety of Addition of Nitrous Oxide to General Anaesthesia in At-risk Patients Having Major Non-cardiac Surgery [ENIGMA-II], Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study [VISION], and Anaesthetic Depth and Complications After Major Surgery [BALANCED] trial). Patients with baseline increase in TnT and non-ischaemic aetiologies for TnT increase were excluded. The association between postoperative haemoglobin concentration during the 3 initial postoperative days and the incidence of MINS (fourth-generation TnT ≥0.03 ng ml-1 judged as attributable to ischaemia) was assessed using a time-varying covariate Cox proportional hazards survival analysis. RESULTS Among 6141 patients, 4480 were analysed. The incidence of MINS was 155/4480 (3.5%), ranging from 0/345 (0%) among patients whose lowest postoperative haemoglobin exceeded 13 g dl-1 to 52/611 (8.5%) in patients whose minimum postoperative haemoglobin was <8 g dl-1. The confounder-adjusted hazard ratio [95% confidence interval] for having MINS was 1.29 [1.16-1.42] for every 1 g dl-1 decrease in postoperative haemoglobin in a time-varying covariate analysis. Similar associations were identified in sensitivity analyses. CONCLUSION Lower postoperative haemoglobin values are associated with MINS. Whether this association is modifiable by prevention or treatment of anaemia remains to be determined.
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Affiliation(s)
- Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, USA.
| | - Barak Cohen
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Division of Anesthesia, Critical Care, and Pain Management, Tel Aviv Medical Center, Tel Aviv University, Tel-Aviv, Israel
| | - Eva Rivas
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Liu Liu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Xuan Pu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Ehab Farag
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Ozkan Onal
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Jiayi Wang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Philip J Devereaux
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department Medicine, McMaster University, Hamilton, ON, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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Silva AR, Regueira P, Albuquerque E, Baldeiras I, Cardoso AL, Santana I, Cerejeira J. Estimates of Geriatric Delirium Frequency in Noncardiac Surgeries and Its Evaluation Across the Years: A Systematic Review and Meta-analysis. J Am Med Dir Assoc 2020; 22:613-620.e9. [PMID: 33011097 DOI: 10.1016/j.jamda.2020.08.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/26/2020] [Accepted: 08/13/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Delirium is an acute neuropsychiatric syndrome associated with poor outcomes. Older adults undergoing surgery have a higher risk of manifesting perioperative delirium, particularly those having associated comorbidities. It remains unclear whether delirium frequency varies across surgical settings and if it has remained stable across the years. We conducted a systematic review to (1) determine the overall frequency of delirium in older people undergoing noncardiac surgery; (2) explore factors explaining the variability of the estimates; and (3) determine the changing of the estimates over the past 2 decades. DESIGN Systematic review and meta-analysis. Literature search was performed in MEDLINE, PubMed, ISI Web of Science, EBSCO, ISRCTN registry, ScienceDirect, and Embase in January 2020 for studies published from 1995 to 2020. SETTING Noncardiac surgical settings. PARTICIPANTS Forty-nine studies were included with a total of 26,865 patients screened for delirium. METHODS We included observational and controlled trials reporting incidence, prevalence, or proportion of delirium in adults aged ≥60 years undergoing any noncardiac surgery requiring hospitalization. Data extracted included sample size, reported delirium frequencies, surgery type, anesthesia type, delirium diagnosis method, length of hospitalization, and year of assessment. (PROSPERO registration no.: CRD42020160045). RESULTS We found an overall pooled frequency of preoperative delirium of 17.9% and postoperative delirium (POD) of 23.8%. The POD estimates increased between 1995 and 2020 at an average rate of 3% per year. Pooled estimates of POD were significantly higher in studies not excluding patients with lower cognitive performance before surgery (28% vs 16%) and when general anesthesia was used in comparison to local, spinal, or epidural anesthesia (28% vs 20%). CONCLUSIONS AND IMPLICATIONS Type of anesthesia and preoperative cognitive status were significant moderators of delirium frequency. POD in noncardiac surgery has been increasing across the years, suggesting that more resources should be allocated to delirium prevention and management.
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Affiliation(s)
- Ana Rita Silva
- Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal
| | - Patrícia Regueira
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Elisabete Albuquerque
- Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Inês Baldeiras
- Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Ana Luísa Cardoso
- Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal
| | - Isabel Santana
- Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal; Department of Neurology, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Joaquim Cerejeira
- Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal.
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Au V, Marsh B, Benkwitz C. Resection of a Posterior Mediastinal Mass in a 4-Year-Old Child Complicated by Difficult Airway Management and Emergent Use of Extracorporeal Membrane Oxygenation. Semin Cardiothorac Vasc Anesth 2020; 24:349-354. [PMID: 32998636 DOI: 10.1177/1089253220960267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Literature on posterior mediastinal masses is limited. Furthermore, they have traditionally been described to pose lower cardiopulmonary risks compared with anterior mediastinal masses. Studies on posterior mediastinal masses are even more limited in the pediatric population. We present a case of a large posterior mediastinal mass in a 4-year-old child who presented with extremely difficult airway management during endobronchial intubation due to severe external compression that led to use of an adapted airway management technique with a rigid airway exchanger for lung isolation. Due to the pathology of the mass, a tracheal tear was encountered during surgical dissection and the patient required emergent venovenous extracorporeal membrane oxygenation to allow for successful airway repair and complete resection of the mass.
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Affiliation(s)
- Valerie Au
- University of California San Francisco, CA, USA
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68
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Bauman ZM, Cunningham R, Hodson A, Shostrom V, Evans CH, Schlitzkus LL. Emergent General Surgery Operations in Patients With Left Ventricular Assist Devices. Am Surg 2020; 87:8-14. [PMID: 32972206 DOI: 10.1177/0003134820950683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The left ventricle assist device (LVAD) patient population is rapidly expanding. Unique characteristics of these patients complicate the management of noncardiac surgical problems. Emergent general surgery (EGS) intervention is often warranted but remains poorly described. We reviewed EGS consultations in LVAD patients to better understand these patients. METHODS During a 12-year period, 301 LVAD patients were reviewed. Demographics, comorbidities, reason for EGS consultation, operative intervention, transplantation, and mortality were analyzed. Wilcoxon, Fisher's exact, and chi-square tests were used for analysis. Statistical significance was P < .05. RESULTS A total of 139 (46.2%) patients required EGS consultation. EGS consultations were older (63 vs 57 years; P = .002), primarily Caucasian (86%), and male (83%) with average preimplant cardiac index of 1.84. Comorbidities were similar between those with and without EGS consultation. Gastrointestinal (GI) bleeding was the most common reason for consultation (53%), followed by abdominal pain (22%) and bowel ischemia/obstruction (19%). Of EGS consultations, 77% were on warfarin and 60% on aspirin. Procedures were not withheld: 46% required esophagogastroduodenoscopy (EGD) and 30% required colonoscopy. Surgical intervention was performed in 28% of EGS consults-49% emergent (within 24 hours) and 44% urgent (during hospitalization). Mean time to surgery was 48 days after LVAD placement. EGS intervention precluded 7 (18%) patients from heart transplantation and 10 (26%) patients suffered perioperative mortality. Elevated lactic acid was associated with increased mortality. CONCLUSION EGS consultation is necessary in almost half of all LVAD patients, most commonly for GI bleed. EGD/colonoscopy can be safely used to manage the majority of these consultations; one-third will require surgery. High lactic acid is associated with higher mortality. Additional analysis of this population is required for improving surgical management.
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Affiliation(s)
- Zachary M Bauman
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Robert Cunningham
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Alex Hodson
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Valerie Shostrom
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Charity H Evans
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Lisa L Schlitzkus
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
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Liu Z, Xu G, Xu L, Zhang Y, Huang Y. Perioperative Cardiac Complications in Patients Over 80 Years of Age with Coronary Artery Disease Undergoing Noncardiac Surgery: The Incidence and Risk Factors. Clin Interv Aging 2020; 15:1181-1191. [PMID: 32801670 PMCID: PMC7398882 DOI: 10.2147/cia.s252160] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/26/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Ever-increasing noncardiac surgeries are performed in patients aged 80 years or over with coronary artery disease (CAD). The objective of the study was to explore the incidence and risk factors of perioperative cardiac complications (PCCs) for the oldest-old patients with CAD undergoing noncardiac surgery, which have not been evaluated previously. Patients and Methods A total of 547 patients, aged over 80 years, with a history of CAD who underwent noncardiac surgery were enrolled in this retrospective study. Perioperative clinical variables were extracted from the electronic medical records database. The primary outcome was the occurrence of PCCs intraoperatively or within 30 days postoperatively, defined as any of the following complications: acute coronary syndrome, heart failure, new-onset severe arrhythmia, nonfatal cardiac arrest, and cardiac death. Multivariate logistic regression analysis and multivariate Cox regression model were both performed to estimate the risk factors of PCCs. The incidence of PCCs overtime was illustrated by the Kaplan-Meier curve with a stratified Log-rank test. Results One hundred six (19.4%) patients developed at least one PCC, and 15 (2.7%) patients developed cardiac death. The independent risk factors contributing to PCCs were age ≧85 years; body mass index ≧30 kg/m2; the history of angina within 6 months; metabolic equivalents <4; hypertension without regular treatment; preoperative ST-T segment abnormality; anesthesia time >3 h and drainage ≧200 mL within 24 h postoperatively. Conclusion The incidence of PCCs in elderly patients over 80 years with CAD who underwent noncardiac surgery was high. Comprehensive preoperative evaluation, skilled surgical technique, and regular postoperative monitoring may help to reduce the occurrence of PCCs in this high-risk population.
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Affiliation(s)
- Zijia Liu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Guangyan Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Yuelun Zhang
- Central Research Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
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Chung M, Santer P, Raub D, Zhao Y, Zhao T, Strom J, Houle T, Shen C, Eikermann M, Yeh RW. Use of etomidate in patients with heart failure undergoing noncardiac surgery. Br J Anaesth 2020; 125:943-952. [PMID: 32807381 DOI: 10.1016/j.bja.2020.06.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/05/2020] [Accepted: 06/22/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Patients with symptomatic and asymptomatic heart failure undergoing noncardiac surgery may benefit from the haemodynamic profile of etomidate. However, the safety of etomidate in this population is unknown. We examined anaesthesiologist variation in etomidate use and assessed its safety using an instrumental variable approach to account for differences in treatment selection. METHODS A retrospective cohort study of 19 714 patients with heart failure undergoing noncardiac surgery at two tertiary care institutions from January 2006 to December 2017 was performed. The proportion of etomidate use among 294 anaesthesiologists was examined and adjusted risk differences (aRD) for in-hospital and 30-day mortality were calculated using physician preference for etomidate as an instrumental variable. RESULTS Etomidate was used in 14.3% (2821/19 714) of patients. Preference for etomidate varied substantially among individual anaesthesiologists with the lowest and highest quartile users using etomidate in 0-4.7% and 20.4-66.7% of their own heart failure patients, respectively. The adjusted instrumental variable analysis showed no significant differences in the risk of in-hospital (aRD -0.2%; 95% confidence interval, -2.4%-1.9%; P=0.83) or 30 day mortality (aRD 0.2%; 95% confidence interval, -2.5%-2.9%; P=0.90). Anaesthesiologists with higher preferences for etomidate were more experienced (greater heart failure and total case volume) than anaesthesiologists with lower preferences for etomidate. CONCLUSIONS We found substantial variability in anaesthesiologists' preference for etomidate for use in patients with heart failure undergoing noncardiac surgery. There was no association between etomidate use and in-hospital or 30-day mortality. Etomidate is not inferior to other currently used options for induction of general anaesthesia in patients with heart failure.
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Affiliation(s)
- Mabel Chung
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dana Raub
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yuansong Zhao
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, USA
| | - Tianyi Zhao
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jordan Strom
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Timothy Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Changyu Shen
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert W Yeh
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Kurnutala LN, Anand S. Perioperative Stroke in a Patient Undergoing Noncardiac, Non-Neurosurgical Procedure: A Case Report. Cureus 2020; 12:e9570. [PMID: 32913687 PMCID: PMC7474566 DOI: 10.7759/cureus.9570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Perioperative stroke is a focal or global neurological deficit lasting more than 24 hours, which occurs during the surgery or within 30 days following surgery. Medications administered during anesthesia mask the symptoms of stroke in the perioperative period and make the early diagnosis of stroke difficult. Postoperative endothelial dysfunction and surgery-induced hypercoagulable state are some of the factors contributing to perioperative stroke. This report describes a case of perioperative stroke in a patient with an unremarkable intraoperative course following otolaryngology surgery. Vigilance, early diagnosis, and prompt treatment with the help of the acute stroke team are pivotal in improving patient outcomes.
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Affiliation(s)
| | - Suwarna Anand
- Anesthesiology, University of Mississippi Medical Center, Jackson, USA
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Roshanov PS, Eikelboom JW, Sessler DI, Kearon C, Guyatt GH, Crowther M, Tandon V, Borges FK, Lamy A, Whitlock R, Biccard BM, Szczeklik W, Panju M, Spence J, Garg AX, McGillion M, VanHelder T, Kavsak PA, de Beer J, Winemaker M, Le Manach Y, Sheth T, Pinthus JH, Siegal D, Thabane L, Simunovic MRI, Mizera R, Ribas S, Devereaux PJ. Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study establishing diagnostic criteria and prognostic importance. Br J Anaesth 2020; 126:163-171. [PMID: 32768179 DOI: 10.1016/j.bja.2020.06.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/25/2020] [Accepted: 06/23/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND We aimed to establish diagnostic criteria for bleeding independently associated with mortality after noncardiac surgery (BIMS) defined as bleeding during or within 30 days after noncardiac surgery that is independently associated with mortality within 30 days of surgery, and to estimate the proportion of 30-day postoperative mortality potentially attributable to BIMS. METHODS This was a prospective cohort study of participants ≥45 yr old having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011. Cox proportional hazards models evaluated the adjusted relationship between candidate diagnostic criteria for BIMS and all-cause mortality within 30 days of surgery. RESULTS Of 16 079 participants, 2.0% (315) died and 36.1% (5810) met predefined screening criteria for bleeding. Based on independent association with 30-day mortality, BIMS was identified as bleeding leading to a postoperative haemoglobin <70 g L-1, transfusion of ≥1 unit of red blood cells, or that was judged to be the cause of death. Bleeding independently associated with mortality after noncardiac surgery occurred in 17.3% of patients (2782). Death occurred in 5.8% of patients with BIMS (161/2782), 1.3% (39/3028) who met bleeding screening criteria but not BIMS criteria, and 1.1% (115/10 269) without bleeding. BIMS was associated with mortality (adjusted hazard ratio: 1.87; 95% confidence interval: 1.42-2.47). We estimated the proportion of 30-day postoperative deaths potentially attributable to BIMS to be 20.1-31.9%. CONCLUSIONS Bleeding independently associated with mortality after noncardiac surgery (BIMS), defined as bleeding that leads to a postoperative haemoglobin <70 g L-1, blood transfusion, or that is judged to be the cause of death, is common and may account for a quarter of deaths after noncardiac surgery. CLINICAL TRIAL REGISTRATION NCT00512109.
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Affiliation(s)
- Pavel S Roshanov
- Division of Nephrology, London Health Science Centre, London, ON, Canada.
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Clive Kearon
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, Canada
| | - Gordon H Guyatt
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Flavia Kessler Borges
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Andre Lamy
- Department of Health Research Methods, Evidence, and Impact, Canada; Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Richard Whitlock
- Population Health Research Institute, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, Canada; Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Observatory, Cape Town, Western Cape, South Africa; University of Cape Town, Rondebosch, Cape Town, Western Cape, South Africa
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Mohamed Panju
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Population Health Research Institute, Hamilton, ON, Canada
| | - Amit X Garg
- Division of Nephrology, London Health Science Centre, London, ON, Canada; Institute for Clinical Evaluative Sciences at Western, London, ON, Canada
| | - Michael McGillion
- Population Health Research Institute, Hamilton, ON, Canada; School of Nursing, Faculty of Health Sciences, Canada
| | | | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Justin de Beer
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Yannick Le Manach
- Population Health Research Institute, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, Canada; Department of Anesthesia, Canada
| | - Tej Sheth
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Deborah Siegal
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Population Health Research Institute, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, Canada; Biostatistics Unit, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Marko R I Simunovic
- Department of Health Research Methods, Evidence, and Impact, Canada; Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Ryszard Mizera
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sebastian Ribas
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Philip J Devereaux
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, Canada
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Roshanov PS, Guyatt GH, Tandon V, Borges FK, Lamy A, Whitlock R, Biccard BM, Szczeklik W, Panju M, Spence J, Garg AX, McGillion M, Eikelboom JW, Sessler DI, Kearon C, Crowther M, VanHelder T, Kavsak PA, de Beer J, Winemaker M, Le Manach Y, Sheth T, Pinthus JH, Siegal D, Thabane L, Simunovic MRI, Mizera R, Ribas S, Devereaux PJ. Preoperative prediction of Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study. Br J Anaesth 2020; 126:172-180. [PMID: 32718723 DOI: 10.1016/j.bja.2020.02.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 01/14/2020] [Accepted: 02/01/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Diagnostic criteria for Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS) have been defined as bleeding that leads to a postoperative haemoglobin <70 g L-1, leads to blood transfusion, or is judged to be the direct cause of death. Preoperative prediction guides for BIMS can facilitate informed consent and planning of perioperative care. METHODS In a prospective cohort study of 16 079 participants aged ≥45 yr having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011, 17.3% (2782) experienced BIMS. An electronic risk calculator for BIMS was developed and internally validated by logistic regression with bootstrapping, and further simplified to a risk index. Decision curve analysis assessed the potential utility of each prediction guide compared with a strategy of identifying risk of BIMS based on preoperative haemoglobin <120 g L-1. RESULTS With information about the type of surgery, preoperative haemoglobin, age, sex, functional status, kidney function, history of high-risk coronary artery disease, and active cancer, the risk calculator accurately predicted BIMS (bias-corrected C-statistic, 0.84; 95% confidence interval, 0.837-0.852). A simplified index based on preoperative haemoglobin <120 g L-1, open surgery, and high-risk surgery also predicted BIMS, but less accurately (C-statistic, 0.787; 95% confidence interval, 0.779-0.796). Both prediction guides could improve decision making compared with knowledge of haemoglobin <120 g L-1 alone. CONCLUSIONS BIMS, defined as bleeding that leads to a postoperative haemoglobin <70 g L-1, leads to blood transfusion, or that is judged to be the direct cause of death, can be predicted by a simple risk index before surgery. CLINICAL TRIAL REGISTRATION NCT00512109.
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Affiliation(s)
- Pavel S Roshanov
- Division of Nephrology, London Health Science Centre, London, ON, Canada.
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Flavia K Borges
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Andre Lamy
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Richard Whitlock
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Observatory, Cape Town, Western Cape, South Africa; University of Cape Town, Rondebosch, Cape Town, Western Cape, South Africa
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Mohamed Panju
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Population Health Research Institute, Hamilton, ON, Canada
| | - Amit X Garg
- Division of Nephrology, London Health Science Centre, London, ON, Canada; Institute for Clinical Evaluative Sciences at Western, London, ON, Canada
| | - Michael McGillion
- Population Health Research Institute, Hamilton, ON, Canada; School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Clive Kearon
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tomas VanHelder
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Justin de Beer
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Yannick Le Manach
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Tej Sheth
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Deborah Siegal
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Biostatistics Unit, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Marko R I Simunovic
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Ryszard Mizera
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sebastian Ribas
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Philip J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
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Faxén UL, Hallqvist L, Benson L, Schrage B, Lund LH, Bell M. Heart Failure in Patients Undergoing Elective and Emergency Noncardiac Surgery: Still a Poorly Addressed Risk Factor. J Card Fail 2020; 26:1034-1042. [PMID: 32652244 DOI: 10.1016/j.cardfail.2020.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/29/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Noncardiac surgery is increasingly offered to an older, more comorbid population. The aim was to characterize patients with the diagnosis of heart failure (HF) undergoing elective and emergency noncardiac surgery in a broad, contemporary Swedish cohort, and to assess the short- and long-term mortality in patients with HF as compared with patients without HF. METHODS AND RESULTS Data from 200,638 and 97,129 patients undergoing elective and emergency surgical procedures at 23 Swedish university, county, and district hospitals during 2007 to 2013 were analyzed through linkage of the surgical Orbit Database to the National Patient and the Cause of Death registries. In total 7212 patients (3.6%) with a diagnosis of HF before surgery underwent elective and 6455 patients (6.6%) underwent emergency surgery. Patients with HF were older had more comorbidities, and higher mortality than patients without HF. Crude and adjusted risk ratios for 30-day mortality after elective surgery were 5.36 (95% confidence interval [CI] 4.67-6.16) and 1.79 (95% CI 1.50-2.14) (adjusted for comorbidities, surgical risk level, age, and sex). Corresponding data for emergency surgery was 3.84 (95% CI 3.58-4.12) and 1.48 (95% CI 1.31-1.62). Mortality in patients with HF after elective surgery at 30 days, 90 days, and 1 year was 3.2%, 6.5%, and 16.2% and after emergency surgery it was 13.7%, 22.4%, and 39.3%. CONCLUSIONS Patients with HF undergoing elective or emergency noncardiac surgery in a modern surgical setting have a substantial mortality risk and HF is both a risk factor and a strong marker for increasd risk. The reasons for the high mortality are not well-understood and warrant further attention.
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Affiliation(s)
- Ulrika Ljung Faxén
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden; Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Linn Hallqvist
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden; Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lina Benson
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Benedikt Schrage
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart & Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Max Bell
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden; Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Abstract
The superior cavopulmonary connection (SCPC) or "bidirectional Glenn" is an integral, intermediate stage in palliation of single ventricle patients to the Fontan procedure. The procedure, normally performed at 3 to 6 months of life, increases effective pulmonary blood flow and reduces the ventricular volume load in patients with single ventricle (parallel circulation) physiology. While the SCPC, with or without additional sources of pulmonary blood flow, cannot be considered a long-term palliation strategy, there are a subset of patients who require SCPC palliation for a longer interval than the typical patient. In this article, we will review the physiology of SCPC, the consequences of prolonged SCPC palliation, and modes of failure. We will also discuss strategies to augment pulmonary blood flow in the presence of an SCPC. The anesthetic considerations in SCPC patients will also be discussed, as these patients may present for noncardiac surgery from infancy to adulthood.
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Affiliation(s)
- Ray S Choi
- Children's Hospital Colorado, Denver, CO, USA.,Boston Children's Hospital, Boston, MA, USA
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76
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Fleisher LA. Preoperative evaluation in 2020: does exercise capacity fit into decision-making? Br J Anaesth 2020; 125:224-226. [PMID: 32654752 DOI: 10.1016/j.bja.2020.05.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 05/30/2020] [Accepted: 05/31/2020] [Indexed: 01/20/2023] Open
Affiliation(s)
- Lee A Fleisher
- Department of Anesthesiology and Critical Care, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
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77
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Yonekura H, Kamei M. Clinical utility of Duke Activity Status Index for preoperative risk assessment. Comment on Br J Anaesth 2020; 124: 261-70. Br J Anaesth 2020; 124:e198-e199. [PMID: 32081372 DOI: 10.1016/j.bja.2020.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/17/2020] [Indexed: 11/18/2022] Open
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Olafsson HB, Sigurdarson GA, Christopher KB, Karason S, Sigurdsson GH, Sigurdsson MI. A retrospective cohort study on the association between elevated preoperative red cell distribution width and all-cause mortality after noncardiac surgery. Br J Anaesth 2020; 124:718-725. [PMID: 32216958 DOI: 10.1016/j.bja.2020.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/06/2020] [Accepted: 02/07/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Elevated red cell distribution width (RDW) has been associated with worse outcomes in several medical patient populations. The aim of this study was to investigate the association of increased preoperative RDW and short- and long-term mortality after noncardiac surgery. METHODS This investigation was a retrospective cohort study including all patients undergoing noncardiac surgery between 2005 and 2015 at Landspitali-the National University Hospital in Iceland. Patients were separated into five predefined groups based on preoperative RDW (≤13.3%, 13.4-14.0%, 14.1-14.7%, 14.8-15.8%, and >15.8%). The primary outcome was all-cause long-term mortality and secondary outcomes included 30-day mortality, length of stay, and readmissions within 30 days, compared with propensity score matched (PSM) cohort from patients with RDW ≤13.3%. RESULTS There was a higher hazard of long-term mortality for patients with RDW between 14.8% and 15.8% (hazard ratio=1.33; 95% confidence interval, 1.15-1.59; P<0.001) and above 15.8% (hazard ratio=1.66; 95% confidence interval, 1.41-1.95; P<0.001), compared with matched controls with RDW ≤13.3%. This association held in multiple patient subgroups. For secondary outcomes, there was no difference in 30-day mortality, length of stay, or risk of readmission within 30 days. CONCLUSIONS Increased preoperative RDW is associated with increased long-term mortality after noncardiac surgery. RDW could be a composite biomarker of pre-existing chronic inflammation and poor nutritional status. Future studies should clarify if this is a modifiable risk factor for improved surgical outcomes.
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Affiliation(s)
| | | | - Kenneth B Christopher
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Sigurbergur Karason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Division of Anaesthesia and Intensive Care Medicine, Landspitali, National University Hospital of Iceland, Reykjavik, Iceland
| | - Gisli H Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Division of Anaesthesia and Intensive Care Medicine, Landspitali, National University Hospital of Iceland, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Division of Anaesthesia and Intensive Care Medicine, Landspitali, National University Hospital of Iceland, Reykjavik, Iceland.
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Foong TW, Ramanathan K, Chan KKM, MacLaren G. Extracorporeal Membrane Oxygenation During Adult Noncardiac Surgery and Perioperative Emergencies: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:281-297. [PMID: 32144062 DOI: 10.1053/j.jvca.2020.01.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/03/2020] [Accepted: 01/12/2020] [Indexed: 12/17/2022]
Abstract
Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has increased significantly. In some centers, ECMO has been deployed to manage perioperative emergencies and plays a role in facilitating high-risk thoracic, airway, and trauma surgery, which may not be feasible without ECMO support. General anesthesiologists who usually manage these cases may not be familiar with the initiation and management of patients on ECMO. This review discusses the use of ECMO in the operating room for thoracic, airway, and trauma surgery, as well as obstetric and perioperative emergencies.
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Affiliation(s)
- Theng Wai Foong
- Department of Anesthesia and Surgical Intensive Care Unit, National University Hospital, Singapore.
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, Department of Cardiothoracic and Vascular Surgery, National University Hospital, Singapore
| | - Kevin Kien Man Chan
- Department of Anesthesia and Surgical Intensive Care Unit, National University Hospital, Singapore
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, Department of Cardiothoracic and Vascular Surgery, National University Hospital, Singapore
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Vernooij LM, van Klei WA, Moons KGM, van Waes JA, Peelen LM. Methods to express intraoperative hypotension exposure in the anaesthesia literature. Br J Anaesth 2020; 124:e35-e37. [PMID: 31918845 DOI: 10.1016/j.bja.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 11/30/2022] Open
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May SM, Reyes A, Martir G, Reynolds J, Paredes LG, Karmali S, Stephens RCM, Brealey D, Ackland GL. Acquired loss of cardiac vagal activity is associated with myocardial injury in patients undergoing noncardiac surgery: prospective observational mechanistic cohort study. Br J Anaesth 2019; 123:758-767. [PMID: 31492527 DOI: 10.1016/j.bja.2019.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/02/2019] [Accepted: 08/03/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Myocardial injury is more frequent after noncardiac surgery in patients with preoperative cardiac vagal dysfunction, as quantified by delayed heart rate (HR) recovery after cessation of cardiopulmonary exercise testing. We hypothesised that serial and dynamic measures of cardiac vagal activity are also associated with myocardial injury after noncardiac surgery. METHODS Serial autonomic measurements were made before and after surgery in patients undergoing elective noncardiac surgery. Cardiac vagal activity was quantified by HR variability and HR recovery after orthostatic challenge (supine to sitting). Revised cardiac risk index (RCRI) was calculated for each patient. The primary outcome was myocardial injury (high-sensitivity troponin ≥15 ng L-1) within 48 h of surgery, masked to investigators. The exposure of interest was cardiac vagal activity (high-frequency power spectral analysis [HFLn]) and HR recovery 90 s from peak HR after the orthostatic challenge. RESULTS Myocardial injury occurred in 48/189 (25%) patients, in whom 41/48 (85%) RCRI was <2. In patients with myocardial injury, vagal activity (HFLn) declined from 5.15 (95% confidence interval [CI]: 4.58-5.72) before surgery to 4.33 (95% CI: 3.76-4.90; P<0.001) 24 h after surgery. In patients who remained free of myocardial injury, HFLn did not change (4.95 [95% CI: 4.64-5.26] before surgery vs 4.76 [95% CI: 4.44-5.08] after surgery). Before and after surgery, the orthostatic HR recovery was slower in patients with myocardial injury (5 beats min-1 [95% CI: 3-7]), compared with HR recovery in patients who remained free of myocardial injury (10 beats min-1 [95% CI: 7-12]; P=0.02). CONCLUSIONS Serial HR measures indicating loss of cardiac vagal activity are associated with perioperative myocardial injury in lower-risk patients undergoing noncardiac surgery.
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Affiliation(s)
- Shaun M May
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Anna Reyes
- University College London NHS Hospitals Trust, London, UK
| | - Gladys Martir
- University College London NHS Hospitals Trust, London, UK
| | - Joseph Reynolds
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | | | - Shamir Karmali
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | | | - David Brealey
- University College London NHS Hospitals Trust, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
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Gautam NK, Bober K, Pierre JA, Pawelek O, Griffin E. Deep Tracheal Extubation Using Dexmedetomidine in Children With Congenital Heart Disease Undergoing Cardiac Catheterization: Advantages and Complications. Semin Cardiothorac Vasc Anesth 2019; 23:387-392. [PMID: 31431142 DOI: 10.1177/1089253219870628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective. Deep tracheal extubation using dexmedetomidine is safe and provides smooth recovery in children with congenital heart disease undergoing cardiac catheterization. Design. Single-institution, retrospective study of prospectively collected data. Participants. All patients aged between 1 month and 5 years who underwent general endotracheal anesthesia for diagnostic and interventional cardiac catheterizations in the cardiac catheterization suite from January 2015 (change in standard operating procedure) through October 2016 (approval of institutional review board for study). Measurement and Main Results. One hundred and eighty-nine patients (81%) of the 232 patients who underwent cardiac catheterization during the study period were noted to undergo deep tracheal extubation. Cyanotic heart disease was present in 87 patients (46%), history of prematurity in 51 (27%), and pulmonary hypertension in 26 (14%) patients. A documented smooth recovery in the postoperative care unit (PACU) requiring no additional analgesics or sedatives was observed in 91% of the patients. The majority of patients required no airway support after deep extubation (n = 140, 74%, P = .136). The presence of pulmonary hypertension (odds ratio = 4.45, P = .035) and presence of a cough on the day of the procedure (odds ratio = 7.10, P = .03) were significantly associated with the use of oxygen or use of oral airway for greater than 20 minutes in the PACU. After extubation, there were no reported events of aspiration, the use of noninvasive positive pressure ventilation, reintubation, heart block, or systemic hypotension requiring treatment or cardiac arrest. Conclusions. Deep extubation using dexmedetomidine in infants and toddlers after cardiac catheterization is feasible and enables smooth postoperative recovery with minimal adverse effects.
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Affiliation(s)
| | - Kayla Bober
- University of Texas Health, Houston, TX, USA
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Wang H, Li SL, Bai J, Wang DX. Perioperative Acute Ischemic Stroke Increases Mortality After Noncardiac, Nonvascular, and Non-Neurologic Surgery: A Retrospective Case Series. J Cardiothorac Vasc Anesth 2019; 33:2231-2236. [PMID: 31060941 DOI: 10.1053/j.jvca.2019.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/01/2019] [Accepted: 02/07/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To identify the predictors of in-hospital mortality in patients who develop perioperative acute ischemic stroke (PAIS) associated with noncardiac, nonvascular, and non-neurologic surgery. DESIGN Retrospective study. SETTING University-affiliated hospital. PARTICIPANTS The study comprised 100 patients with PAIS. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The data of 351,531 patients who underwent noncardiac, nonvascular, and non-neurologic surgery in the authors' hospital between January 2003 and December 2016 were retrospectively reviewed. PAIS occurred in 100 patients. The incidence of PAIS (overall 2.8/10,000) was significantly lower in patients <45 years old (0.12/10,000) than in patients >75 years old (15.79/10,000; p < 0.001). The in-hospital mortality rate was higher among patients with PAIS (26%) than among patients without PAIS (0.34%; p < 0.01). Multiple logistic regression analysis revealed the following independent risk factors for in-hospital mortality: preoperative atrial fibrillation (odds ratio [OR] 9.013, 95% confidence interval [CI] 1.400-58.016; p = 0.021), disturbance of consciousness as the first PAIS symptom (OR 5.561, 95% CI 1.521-20.332; p = 0.009), no anticoagulant/antiplatelet therapy after PAIS (OR 8.196, 95% CI 1.017-66.065; p= 0.048), diuretic treatment (OR 4.942, 95% CI 1.233-19.818; p = 0.024), and pulmonary infection (OR 6.979, 95% CI 1.853-26.291; p = 0.004). CONCLUSIONS The risk of PAIS after noncardiac, nonvascular, and non-neurologic surgery significantly increased with age, and development of PAIS increased the mortality rate. Among these patients, the independent predictors of in-hospital mortality were preoperative atrial fibrillation, disturbance of consciousness as the first PAIS symptom, no anticoagulant/antiplatelet therapy after PAIS, diuretic treatment, and pulmonary infection.
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Affiliation(s)
- Hong Wang
- Surgical Intensive Care Unit, Peking University First Hospital, Beijing, China; Intensive Care Unit, First Hospital, Baoding City, Hebei Province, China
| | - Shuang-Ling Li
- Surgical Intensive Care Unit, Peking University First Hospital, Beijing, China.
| | - Jing Bai
- Department of Internal Neurology, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Surgical Intensive Care Unit, Peking University First Hospital, Beijing, China
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Eagle KA, McKay RE. Pre-Operative Risk Prediction: Will Better Tools Produce Better Outcomes? J Am Coll Cardiol 2019; 73:3079-3081. [PMID: 31221256 DOI: 10.1016/j.jacc.2019.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Kim A Eagle
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan.
| | - Rachel Eshima McKay
- Department of Anesthesia and Perioperative Care, PREPARE Clinic at Mission Bay Hospital, University of California San Francisco, San Francisco, California
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85
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Affiliation(s)
- Márcio Sommer Bittencourt
- Division of Internal Medicine, University Hospital, University of Sao Paulo, Sao Paulo, Brazil.,Hospital Israelita Albert Einstein, Sao Paulo, Brazil.,Diagnósticos da América (DASA), Sao Paulo, Brazil
| | - Danielle Menosi Gualandro
- Cardiology, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil.,Cardiovascular Research Institute Basel (CRIB)Department of Cardiology, University Hospital, Basel, Switzerland
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86
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Crouch C, Hendrickse A, Gilliland S, Mandell MS. Unexpected Complication of Hydroxocobalamin Administration for Refractory Vasoplegia in Orthotopic Liver Transplant: A Case Report. Semin Cardiothorac Vasc Anesth 2019; 23:409-412. [PMID: 30985242 DOI: 10.1177/1089253219842662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 40-year-old male with alcoholic cirrhosis and end-stage renal disease presented for simultaneous liver and kidney transplantation. Hemodialysis was utilized intraoperatively during liver transplantation. During the procedure, the patient developed refractory hypotension and ultimately received hydroxocobalamin for vasoplegia. Shortly after administration, the hemodialysis machine ceased working after a "blood leak" alarm developed. Without the ability to continue intraoperative dialysis, the kidney transplantation portion of his surgery was postponed. The patient was transferred to the intensive care unit, where he underwent continuous renal replacement therapy overnight, and his kidney transplant proceeded the following morning.
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Affiliation(s)
- Cara Crouch
- University of Colorado Hospital, Aurora, CO, USA
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87
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Zhang LJ, Li N, Li Y, Zeng XT, Liu MY. Cardiac Biomarkers Predicting MACE in Patients Undergoing Noncardiac Surgery: A Meta-Analysis. Front Physiol 2019; 9:1923. [PMID: 30713501 PMCID: PMC6346145 DOI: 10.3389/fphys.2018.01923] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/20/2018] [Indexed: 12/25/2022] Open
Abstract
Objective: The present meta-analysis was aimed to systematically evaluate the effectiveness and accuracy of brain natriuretic peptide (BNP), cardiac troponin (cTn), high sensitive C reactive protein (hs-CRP) and CRP for predicting postoperative major adverse cardiovascular events (MACE) in patients undergoing noncardiac surgery. Methods: A total of 26 relevant studies with 7,877 participants were collected from five databases, namely PubMed, Embase, China National Knowledge Infrastructure (CNKI), CQVIP and the Wanfang Database until August 10, 2018. And the Review Manager Version 5.3 and Stata/SE 12 software were used for data syntheses in the meta-analysis. Results: Strong relationships of BNP/NT-proBNP, cTnI/cTnT and hs-CRP with MACE were detected in patients undergoing noncardiac surgery, and the five biomarkers all increased the risk of MACE. Compared to normal levels, elevated BNP/NT-proBNP could increase the MACE risk by almost 4-fold [RR:3.92, 95%CI: 3.23–4.75, P < 0.001]; elevated BNP corresponded to a 4.5-fold risk [RR:4.57, 95%CI: 3.37–6.20, P < 0.001]; elevated NT-proBNP led to a 3-fold higher risk [RR:3.48, 95%CI: 2.71–4.46, P < 0.001]. Comparing with normal levels of cTnI/cTnT, increased cTnI/cTnT was associated with nearly 5-fold more higher risk of MACE [RR:5.52, 95%CI: 4.62–6.58, P < 0.001]; elevated cTnI faced a 5-fold risk [RR:5.21, 95%CI: 3.96–6.86, P < 0.001]; elevated cTnT resulted in nearly 6-fold higher risk [RR:5.73, 95%CI: 4.55–7.22, P < 0.001]. The elevation of hs-CRP was associated with nearly 4-fold higher risk of MACE in comparison with normal concentration [RR:3.73, 95%CI: 2.63–5.30, P < 0.001]. Conclusion: According to the results of our meta-analysis, the elevations of BNP/NT-proBNP, cTnI/cTnT, and hs-CRP, pre-operation or post-operation immediately, can predict much higher risk of postoperative MACE in patients undergoing noncardiac surgery.
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Affiliation(s)
- Li-Jun Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Na Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Li
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Center for Evidence-Based and Translational Medicine, Wuhan University, Wuhan, China
| | - Xian-Tao Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Center for Evidence-Based and Translational Medicine, Wuhan University, Wuhan, China
| | - Mei-Yan Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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88
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Wang R, Wang G, Liu Y, Zhang M. Preoperative smoking history is associated with decreased risk of early postoperative cognitive dysfunction in patients of advanced age after noncardiac surgery: a prospective observational cohort study. J Int Med Res 2018; 47:689-701. [PMID: 30417719 PMCID: PMC6381474 DOI: 10.1177/0300060518808162] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective Prevention of postoperative cognitive dysfunction (POCD) in patients of advanced age remains unclear. Studies have shown that the cholinergic anti-inflammatory pathway contributes to a decreased risk of POCD and that nicotine stimulates the cholinergic anti-inflammatory pathway. We investigated whether patients of advanced age with a preoperative smoking history have a decreased risk of POCD. Methods In total, 382 patients (190 smokers, 192 nonsmokers) aged ≥60 years who underwent major noncardiac surgery were enrolled. Cognitive function was assessed, and multivariate logistic regression analyses were performed to identify risk factors. Results On postoperative days 5 and 7, 111 (29.05%) and 90 (23.56%) patients exhibited POCD, respectively. A preoperative smoking history was significantly correlated with a decreased risk of POCD. A high serum tumor necrosis factor-α (TNF-α) level on the operative day was significantly associated with an increased risk of POCD. Early POCD was significantly associated with the sufentanil dosage, age, and education level. The hospital stay in patients with and without POCD was 10.54 ± 2.03 and 8.33 ± 1.58 days, respectively. Conclusion A preoperative smoking history was associated with a decreased risk of early POCD, and a high serum TNF-α level was significantly associated with an increased risk of POCD.
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Affiliation(s)
- Runjia Wang
- *These authors contributed equally to this work
| | | | | | - Mengyuan Zhang
- Mengyuan Zhang, Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong University, Jingwu Road No. 324, Jinan, Shandong Province 250021, China.
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89
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Dogan V, Biteker M, Özlek E, Özlek B, Başaran Ö, Yildirim B, Kayataş K, Çelik O, Doğan MM. Impact of preoperative cardiology consultation prior to intermediate-risk surgical procedures. Eur J Clin Invest 2018; 48:e12794. [PMID: 28783209 DOI: 10.1111/eci.12794] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 07/17/2017] [Accepted: 08/02/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients undergoing noncardiac, nonvascular surgery (NCNVS) are at risk of perioperative cardiovascular events. However, benefits of cardiology consultation (CC) in patients with known or suspected cardiac disease undergoing intermediate-risk NCNVS is unknown. METHODS The study group included 700 consecutive patients referred for CC before intermediate-risk NCNVS in a tertiary-care teaching hospital. The control group included 1200 age-matched and sex-matched consecutive patients proceeded to the intermediate-risk surgery without preoperative CC during the same period. Patients older than 18 years who underwent an elective, NCNVS were enrolled. Requests for consultation were made either by surgeon or an attending anaesthesiologist. All patients underwent a complete preoperative clinical evaluation. RESULTS Of the 700 patients who were referred for CC in the study group, 530 patients (75.7%) had no additional recommendations, and 170 patients (24.3%) underwent additional preoperative tests or had a change in preoperative therapy. Only 20 (2.8%) patients' NCNVS were delayed based on the cardiologists' recommendation and 680 patients eventually had their surgeries. Major cardiovascular and noncardiovascular complication rates were similar in the study and in the control groups (12.9% vs 13.6%, P = 0.273 and 25.2% vs 26%, P = 0.432 respectively). CONCLUSIONS Preoperative CC in patients who underwent intermediate-risk NCNVS does not affect either perioperative management or outcome of surgery.
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Affiliation(s)
- Volkan Dogan
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Murat Biteker
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Eda Özlek
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Bülent Özlek
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Özcan Başaran
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Birdal Yildirim
- Department of Emergency Medicine, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Kadir Kayataş
- Department of Internal Medicine, Haydarpaşa Numune Education and Research Hospital, Istanbul, Turkey
| | - Oğuzhan Çelik
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
| | - Marwa M Doğan
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
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90
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Abstract
BACKGROUND Cardiovascular complications are strongly correlated with a higher risk of mortality during follow-up after noncardiac surgery. However, controversy remains regarding whether perioperative administration of hydroxymethylglutaryl-CoA reductase inhibitors (statins) has a beneficial effect on patient outcomes. OBJECTIVE We performed a meta-analysis to validate the hypothesis that perioperative statins improve patient outcomes after noncardiac surgery. METHODS Electronic databases (PubMed, Web of Science, EMBASE, and the Cochrane Library) were searched for randomized controlled trials (RCTs) published up to 10 November 2017. RCTs were eligible for inclusion if they compared perioperative statin treatment with control treatment in patients scheduled for noncardiac surgery and reported data pertaining to clinical outcomes. RESULTS Twelve RCTs involving 4707 patients (2371 in the perioperative statin group and 2336 in the control group) were ultimately included in this meta-analysis. The incidences of postoperative myocardial infarction, composite of death/myocardial infarction/stroke and new cases of atrial fibrillation were all lower in patients treated with statins than in control group patients, as shown by the fixed-effects model (odds ratio (OR) = 0.460, 95% confidence interval (CI) = 0.324-0.653, p = 0 for myocardial infarction; OR = 0.617, 95% CI = 0.476-0.801, p = 0 for composite of death/myocardial infarction/stroke; OR = 0.406, 95% CI = 0.247-0.666, p = 0 for new atrial fibrillation). No significant differences in the incidences of stroke or transient ischemic attack, all-cause mortality and cardiovascular mortality were observed between the statin and control arms. CONCLUSIONS This meta-analysis supports the hypothesis that perioperative statins effectively reduce the incidences of postoperative myocardial infarction, composite of death/myocardial infarction/stroke and new cases of atrial fibrillation in patients undergoing noncardiac surgery. Key Messages Cardiovascular complications are strongly correlated with a higher risk of mortality during follow-up after noncardiac surgery. We performed a meta-analysis to confirm the hypothesis that perioperative statins improve patient outcomes after noncardiac surgery.
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Affiliation(s)
- Baoxin Ma
- a Department of Cardiology , The Affiliated Hospital of Binzhou Medical University , Binzhou , Shandong , China
| | - Jingwu Sun
- a Department of Cardiology , The Affiliated Hospital of Binzhou Medical University , Binzhou , Shandong , China
| | - Shuling Diao
- a Department of Cardiology , The Affiliated Hospital of Binzhou Medical University , Binzhou , Shandong , China
| | - Bo Zheng
- a Department of Cardiology , The Affiliated Hospital of Binzhou Medical University , Binzhou , Shandong , China
| | - Hua Li
- b Department of Oncology , The Affiliated Hospital of Binzhou Medical University , Binzhou , Shandong , China
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91
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Tartavoulle T, Bonanno LS, Hall S. Perioperative Considerations for Patients Diagnosed With Pulmonary Hypertension Undergoing Noncardiac Surgery. J Perianesth Nurs 2019; 34:240-9. [PMID: 30025664 DOI: 10.1016/j.jopan.2017.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/25/2017] [Accepted: 11/20/2017] [Indexed: 11/20/2022]
Abstract
The prevalence of pulmonary hypertension (PH) has risen in adults of all races, genders, and ethnicities. PH is a fatal disease that presents many challenges to the perioperative health care team. Through increased knowledge of PH pathophysiological changes and anesthesia medications' effect on PH, perioperative health care teams can conduct a detailed preoperative evaluation to determine appropriate therapies to administer. This will assist the perioperative health care team in reducing the pulmonary vascular resistance, optimizing the matching of right ventricle and pulmonary circulations, and reduce the incidence of intraoperative and postoperative complications.
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92
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Affiliation(s)
- John B Chambers
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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93
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Smilowitz NR, Beckman JA, Sherman SE, Berger JS. Hospital Readmission After Perioperative Acute Myocardial Infarction Associated With Noncardiac Surgery. Circulation 2018; 137:2332-2339. [PMID: 29525764 PMCID: PMC5995321 DOI: 10.1161/circulationaha.117.032086] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/19/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute myocardial infarction (AMI) is a major cardiovascular complication of noncardiac surgery. We aimed to evaluate the frequency, causes, and outcomes of 30-day hospital readmission after perioperative AMI. METHODS Patients who were diagnosed with AMI during hospitalization for major noncardiac surgery were identified using the 2014 US Nationwide Readmission Database. Rates, causes, and costs of 30-day readmissions after noncardiac surgery with and without perioperative AMI were identified. RESULTS Among 3 807 357 hospitalizations for major noncardiac surgery, 8085 patients with perioperative AMI were identified. A total of 1135 patients (14.0%) with perioperative AMI died in-hospital during the index admission. Survivors of perioperative AMI were more likely to be readmitted within 30 days than surgical patients without perioperative AMI (19.1% versus 6.5%, P<0.001). The most common indications for 30-day rehospitalization were management of infectious complications (30.0%), cardiovascular complications (25.3%), and bleeding (10.4%). In-hospital mortality during hospital readmission in the first 30 days after perioperative AMI was 11.3%. At 6 months, the risk of death was 17.6% and ≥1 hospital readmission was 36.2%. CONCLUSIONS Among patients undergoing noncardiac surgery who develop a perioperative MI, ≈1 in 3 suffer from in-hospital death or hospital readmission in the first 30 days after discharge. Strategies to improve outcomes of surgical patients early after perioperative AMI are warranted.
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Affiliation(s)
| | - Joshua A Beckman
- New York University School of Medicine. Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN (J.A.B.)
| | - Scott E Sherman
- Department of Population Health (S.E.S.)
- Veterans Affairs New York Harbor Healthcare System (S.E.S.)
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology (N.R.S., J.S.B.)
- Department of Surgery (J.S.B.)
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94
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Oprea AD, Lombard FW, Kertai MD. Perioperative β-Adrenergic Blockade in Noncardiac and Cardiac Surgery: A Clinical Update. J Cardiothorac Vasc Anesth 2018; 33:817-832. [PMID: 29934209 DOI: 10.1053/j.jvca.2018.04.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Adriana D Oprea
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - Frederick W Lombard
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
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95
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Yatabe T, Kubo T, Kitaoka H, Yokoyama M. Short- and Long-Term Outcomes of Patients With Hypertrophic Cardiomyopathy After Noncardiac Surgery: A Single-Center Retrospective Study. J Cardiothorac Vasc Anesth 2018; 33:109-114. [PMID: 29605142 DOI: 10.1053/j.jvca.2018.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Although several studies have demonstrated that noncardiac surgery in patients with hypertrophic cardiomyopathy (HCM) is safe, the long-term outcomes remain unclear. Therefore, the authors investigated the postoperative long-term outcomes of patients with HCM who underwent noncardiac surgery at their hospital. DESIGN Retrospective review. SETTING Single university hospital. PARTICIPANTS Seventy-two consecutive patients with HCM who underwent noncardiac surgery. INTERVENTION No intervention. MEASUREMENTS AND MAIN RESULTS The incidence of HCM-related events during the patient's hospital stay were evaluated as the short-term outcomes, and HCM-related events after discharge were evaluated as the long-term outcomes. HCM-related events were defined as sudden death, implantable cardioverter-defibrillator discharge with successful recovery from cardiopulmonary arrest, death due to heart failure, hospitalization for heart failure, myocardial infarction, and thrombosis caused by atrial fibrillation. The median postoperative follow-up was 1,382 days (3.8 years). Short-term mortality and morbidity rates were both 1.3%, whereas long-term mortality and morbidity rates were 4.2% and 15%, respectively. The 5-year event-free rate was 76%, whereas the postoperative HCM-related mortality rate was 4.2%. CONCLUSIONS This study suggests that noncardiac surgery in patients with HCM is safe in terms of both short- and long-term outcomes. To confirm the findings, additional studies, such as prospective, multicenter, observational studies, should be conducted.
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Affiliation(s)
- Tomoaki Yatabe
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kochi, Japan.
| | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi, Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi, Japan
| | - Masataka Yokoyama
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kochi, Japan
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96
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Moodley Y. HIV infection and poor renal outcomes following noncardiac surgery. Turk J Med Sci 2018; 48:46-51. [PMID: 29479953 DOI: 10.3906/sag-1507-120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background/aim: The relevance of HIV infection in perioperative renal risk stratification remains unclear. This research sought to investigate the impact of HIV infection, as well as other established preoperative risk factors for poor perioperative renal outcome (PPRO), in a population of 565,225 adult noncardiac surgery patients whose data were obtained from the 2009-2011 California State Inpatient Database. Materials and methods: HIV status, established preoperative risk factors, and the study outcome (PPRO) were determined with the Clinical Classification Software codes recorded for each patient. Data were analyzed using univariate (Mann-Whitney U test, chi-square, and Fisher′s exact test) and multivariate (binary logistic regression) statistical methods. Results: The established preoperative risk factors were independently associated with PPRO. HIV infection was not an independent risk factor for PPRO in this study (odds ratio: 1.573, 95% confidence interval: 0.998-2.480; P = 0.051). Patients with HIV infection tended to have a higher burden of certain established preoperative risk factors for PPRO than patients without HIV infection. Conclusion: HIV-infected patients should be thoroughly screened for established preoperative risk factors and carefully managed during the perioperative period to reduce their risk of PPRO.
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97
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Park J, Lee SH, Kim J, Park M, Gwon HC, Tak Lee Y, Maria Lee S. Clinical Outcome of Noncardiac Surgery in Patients With History of Coronary Artery Revascularization by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery. Jpn Clin Med 2018; 9:1179670717748945. [PMID: 29434482 PMCID: PMC5804996 DOI: 10.1177/1179670717748945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/05/2017] [Indexed: 11/23/2022]
Abstract
Objective: Although safety concerns still remain among patients undergoing unanticipated noncardiac surgery after prior percutaneous coronary intervention (PCI), it has not been directly compared with coronary artery bypass grafting (CABG). The objective of this study was to compare clinical outcomes after noncardiac surgery in patients with prior (>6 months) coronary revascularization by PCI or CABG. Methods: From February 2010 to December 2015, 413 patients with a history of coronary revascularization, scheduled for noncardiac surgery were identified. Patients were divided into PCI group and CABG group and postoperative clinical outcome was compared between 2 groups. The primary outcome was composite of all-cause death, myocardial infarction, and stroke in 1-year follow-up. Results: The 413 patients were divided according to prior coronary revascularization types: 236 (57.1%) into PCI and 177 (42.9%) into CABG group. In multivariate analysis within 1-year follow-up, there was no significant difference in clinical outcome which was composite of all-cause death, myocardial infarction, and stroke (hazard ratio [HR]: 1.50; 95% confidence interval [CI]: 0.76-2.93; P = .24). The same result was present in propensity-matched population analysis (HR: 1.43; 95% CI: 0.68-3.0; P = .34). Conclusions: In patients undergoing noncardiac surgery with prior coronary revascularization by PCI or CABG performed on an average of 42 months after PCI and 50 months after CABG, postoperative clinical outcome at 1-year follow-up is comparable.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Seung Hwa Lee
- Division of Cardiology, Heart Vascular Stroke Institute, Department of Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Myungsoo Park
- Division of Cardiology, Heart Vascular Stroke Institute, Department of Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Heart Vascular Stroke Institute, Department of Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Sangmin Maria Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
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98
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Brown TA, Kerpelman J, Wolf BJ, McSwain JR. Comparison of Clinical Outcomes Between General Anesthesiologists and Cardiac Anesthesiologists in the Management of Left Ventricular Assist Device Patients in Noncardiac Surgeries and Procedures. J Cardiothorac Vasc Anesth 2018; 32:2104-2108. [PMID: 29571640 DOI: 10.1053/j.jvca.2018.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To describe the authors' experience and comparative results after introducing noncardiac fellowship-trained anesthesiologists to a service previously managed by fellowship-trained cardiac anesthesiologists caring for left ventricular assist device (LVAD) patients undergoing low-risk noncardiac procedures with anesthesia. DESIGN A retrospective chart review. SETTING Single-site academic medical center in the United States. INTERVENTIONS Anesthesia and intraoperative therapy. MEASUREMENTS AND MAIN RESULTS After initiating a brief training period for the noncardiac fellowship-trained anesthesiologists and blending the noncardiac anesthesiologists into the care of LVAD patients, the electronic medical records of 158 patients with an LVAD who underwent noncardiac procedures were reviewed. The cases were managed by either cardiac-trained anesthesiologists or noncardiac-trained anesthesiologists. Their performance was evaluated on the basis of technique and outcome. The parameters for technique were the use of intubation and mechanical ventilation, use of vasoactive medications, type of vasoactive medications administered, use of invasive monitoring, and type and amount of intravenous fluid administration. The outcomes examined included occurrence of intraoperative mean blood pressure <55 mmHg, intraoperative cardiac arrest, intraoperative device malfunction, thromboembolic complications, inability to complete procedure due to intraoperative nonsurgical complication, unplanned postoperative intensive care unit admission, unplanned hospital readmission within 30 days, and the 30-day postoperative mortality rate. This analysis demonstrated no statistically significant associations between the type of anesthesiologist and the use of fluid, amount of fluid given, use of vasopressors, or use of invasive monitoring devices. There were no significant differences in specific patient outcomes by anesthesia provider type. CONCLUSIONS Patients with LVADs can be managed by either a noncardiac or a cardiac fellowship-trained anesthesiologist with similar technique and outcome during low-risk noncardiac procedures and surgeries.
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Affiliation(s)
- Tod A Brown
- Medical University of South Carolina, Charleston, SC.
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99
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Abstract
Stroke culminates into 6.2 million deaths annually and is thereby a leading cause of disability and death worldwide. In patients undergoing noncardiac, nonneurological surgery, perioperative stroke can eventuate into a catastropic aftermath with almost eight-fold rise in mortality. In cardiac, neurological, and carotid surgery, stroke rate accounts to be high (2.2%–5.2%) and is a significant instigator of morbidity and mortality as well. These facts kindle interest to review the predictive parameters, preventive measures, and all the possibilities in the management and protection against perioperative stroke.
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Affiliation(s)
- Amarja S Nagre
- Department of Anaesthesia, Kamalnayan Bajaj Hospital, Aurangabad, Maharashtra, India
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Ge Y, Ha ACT, Atzema CL, Abdel-Qadir HM, Fang J, Austin PC, Wijeysundera DN, Lee DS. Association of Atrial Fibrillation and Oral Anticoagulant Use With Perioperative Outcomes After Major Noncardiac Surgery. J Am Heart Assoc 2017; 6:JAHA.117.006022. [PMID: 29233826 PMCID: PMC5778996 DOI: 10.1161/jaha.117.006022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background We examined the association of atrial fibrillation (AF) and oral anticoagulant use with perioperative death and bleeding among patients undergoing major noncardiac surgery. Methods and Results A population‐based study of patients aged 66 years and older who underwent elective (n=87 257) or urgent (n=35 930) noncardiac surgery in Ontario, Canada (April 2012 to March 2015) was performed. Outcomes were compared between AF groups using inverse probability of treatment weighting using the propensity score. Of 4612 urgent surgical patients with AF, treatments before surgery included warfarin (n=1619), a direct oral anticoagulant (DOAC) (n=729), and no anticoagulation (n=2264). After urgent surgery, the death rate within 30 days was significantly higher in patients with AF compared with patients with no AF (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.12–1.45). In contrast, among 4769 elective surgical patients with AF treated with warfarin (n=1453), a DOAC (n=1165), or no anticoagulation (n=2151), prior AF was not associated with higher mortality. Comparing patients with AF who were or were not anticoagulated, there was no difference in 30‐day mortality after urgent (HR, 0.95; 95% CI, 0.79–1.14) or elective (HR, 0.65; 95% CI, 0.38–1.09) surgery. There was no difference in 30‐day mortality between patients with AF treated with a DOAC or warfarin after urgent (HR, 0.91; 95% CI, 0.70–1.18) or elective (HR, 1.64; 95% CI, 0.77–3.53) surgery. Bleeding and thromboembolic rates did not differ significantly among patients with AF prescribed a DOAC or warfarin. Conclusions Prior AF was associated with 30‐day mortality among patients undergoing urgent surgery. In patients with AF, neither the preoperative use of oral anticoagulants, nor the type of agent (either a DOAC or warfarin) were associated with the rate of 30‐day mortality.
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Affiliation(s)
- Yin Ge
- Division of Cardiology, University of Toronto, Canada
| | - Andrew C T Ha
- Division of Cardiology, University of Toronto, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Clare L Atzema
- Institute for Clinical Evaluative Sciences, Toronto, Canada.,Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, Toronto, Canada
| | - Husam M Abdel-Qadir
- Division of Cardiology, University of Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, Toronto, Canada
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, Toronto, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesia, University Health Network, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Douglas S Lee
- Division of Cardiology, University of Toronto, Canada .,Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Joint Department of Medical Imaging, University Health Network, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, Toronto, Canada
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