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Simon NB, McCready TM, Serafin J, Assel M, Jewell E, Mehta M, Vickers AJ, Barnett KM. Transfers and anesthesia-related postoperative outcomes after 3361 same-day cancer surgeries at a freestanding surgery center: An observational retrospective study. J Surg Oncol 2024; 129:1442-1448. [PMID: 38685751 PMCID: PMC11331359 DOI: 10.1002/jso.27643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/01/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND AND OBJECTIVES Expanding outpatient surgery to the increasing number of procedures and patient populations warrants continuous evaluation of postoperative outcomes to ensure the best care and safety. We describe adverse postoperative outcomes and transfer rates related to anesthesia in a large sample of patients who underwent same-day cancer surgery at a freestanding ambulatory surgery center. METHODS Between January 2017 and June 2021, 3361 cancer surgeries, including breast and plastic, head and neck, gynecology, and urology, were performed. The surgeries were indicated for diagnosis, staging, and/or treatment. We report the incidence of transfers and adverse postoperative outcomes related to anesthesia. RESULTS Breast and plastic surgeries were the most common (1771, 53%), followed by urology (1052, 31%), gynecology (410, 12%), and head and neck surgeries (128, 4%). Based on patients' first procedure, comorbidity levels were highest for urology (75% American Society of Anesthesiologists physical status score 3, 1.7% score 4) and lowest for breast surgeries (31% score 3, 0.2% score 4). Most gynecology surgeries used general anesthesia (97.6%), whereas breast surgeries used the least (38%). A total of seven patients (0.2%; 95% CI: 0.08%-0.4%) were immediately transferred to an outside hospital; four due to anesthesia-related reasons. Only 7 (0.2%) patients needed additional postoperative care related to anesthesia-related adverse events, specifically cardiac events (4), difficult intubations (2), desaturation (1), and agitation, nausea, and headache (1). CONCLUSIONS The incidence of anesthesia-related adverse postoperative outcomes is low in cancer patients undergoing outpatient surgeries at our freestanding ambulatory surgery center. This suggests that carefully selected cancer patients, including patients with metastatic cancer, can undergo anesthesia for same-day surgery, making cancer care accessible locally and reducing stress associated with travel for treatment. More research investigating complication rates related to surgery and to cancer disease trajectory are needed to establish a complete evaluation of safety for outpatient cancer surgery.
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Affiliation(s)
| | - Taylor M. McCready
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
- New York University Grossman School of Medicine, New York, New York, USA
| | - Joanna Serafin
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Melissa Assel
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth Jewell
- Memorial Sloan Kettering Cancer Center, Middletown, New Jersey, USA
| | - Meghana Mehta
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Kara M. Barnett
- Memorial Sloan Kettering Cancer Center, Middletown, New Jersey, USA
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Mases A, Beltrán de Heredia S, Gallart L, Román L, Bosch L, Núñez M, Rueda M, Recasens L, Sabaté S. Prediction of Acute Myocardial Injury in Noncardiac Surgery in Patients at Risk for Major Adverse Cardiovascular and Cerebrovascular Events: A Multivariable Risk Model. Anesth Analg 2023; 137:1116-1126. [PMID: 37043386 DOI: 10.1213/ane.0000000000006469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND The best use of perioperative cardiac biomarkers assessment is still under discussion. Massive postoperative troponin surveillance can result in untenably high workloads and costs for health care systems and potentially harmful interventions for patients. In a cohort of patients at risk for major adverse cardiovascular and cerebrovascular events (MACCEs), we aimed to (1) determine whether preoperative biomarkers can identify patients at major risk for acute myocardial injury in noncardiac surgery, (2) develop a risk model for acute myocardial injury prediction, and (3) propose an algorithm to optimize postoperative troponin surveillance. METHODS Prospective, single-center cohort study enrolling consecutive adult patients (≥45 years) at risk for MACCE scheduled for intermediate-to-high-risk noncardiac surgery. Baseline high-sensitivity troponin T (hsTnT) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP), as well as hsTnT on the first 3 postoperative days were obtained. The main outcome was the occurrence of acute myocardial injury. Candidate predictors of acute myocardial injury were baseline concentrations of hsTnT ≥14 ng/L and NT-proBNP ≥300 pg/mL and preoperative and intraoperative variables. A multivariable risk model and a decision curve were constructed. RESULTS Of 732 patients, 42.1% had elevated hsTnT and 37.3% had elevated NT-proBNP levels at baseline. Acute myocardial injury occurred in 161 patients (22%). Elevated baseline hsTnT, found in 84% of patients with acute myocardial injury, was strongly associated with this outcome: odds ratio (OR), 12.08 (95% confidence interval [CI], 7.78-19.42). Logistic regression identified 6 other independent predictors for acute myocardial injury: age, sex, estimated glomerular filtration rate (eGFR) <45 mL·min -1 ·1.73 m -2 , functional capacity <4 METs or unknown, NT-proBNP ≥300 pg/mL, and estimated intraoperative blood loss. The c -statistic for the risk model was 77% (95% CI, 0.73-0.81). The net benefit of the model began at a risk threshold of 7%. CONCLUSIONS Baseline determination of cardiac biomarkers in patients at risk for MACCE shortly before intermediate- or high-risk noncardiac surgery helps identify those with the highest risk for acute myocardial injury. A baseline hsTnT ≥14 ng/L indicates the need for postoperative troponin surveillance. In patients with baseline hsTnT <14 ng/L, our 6-predictor model will identify additional patients at risk for acute myocardial injury who may also benefit from postoperative surveillance.
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Affiliation(s)
- Anna Mases
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Sandra Beltrán de Heredia
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Lluís Gallart
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, Spain
| | - Lorena Román
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Laia Bosch
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Maria Núñez
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Mireia Rueda
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Lluís Recasens
- Department of Cardiology, Hospital del Mar, Barcelona, Spain
| | - Sergi Sabaté
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Condliffe R, Newton R, Bauchmuller K, Bonnett T, Kerry R, Mannings A, Nair A, Selby K, Skinner PP, Wilson VJ, Kiely DG. Surgery and Anesthesia in Patients with Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:797-809. [PMID: 37729924 DOI: 10.1055/s-0043-1772753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Pulmonary hypertension is characterized by right ventricular impairment and a reduced ability to compensate for hemodynamic insults. Consequently, surgery can be challenging but is increasingly considered in view of available specific therapies and improved longer term survival. Optimal management requires a multidisciplinary patient-centered approach involving surgeons, anesthetists, pulmonary hypertension clinicians, and intensivists. The optimal pathway involves risk:benefit assessment for the proposed operation, optimization of pulmonary hypertension and any comorbidities, the appropriate anesthetic approach for the specific procedure and patient, and careful monitoring and management in the postoperative period. Where patients are carefully selected and meticulously managed, good outcomes can be achieved.
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Affiliation(s)
- Robin Condliffe
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Ruth Newton
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Kris Bauchmuller
- Department of Critical Care, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Tessa Bonnett
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Robert Kerry
- Department of Orthopaedics, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Alexa Mannings
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Amanda Nair
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Karen Selby
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Paul P Skinner
- Department of Surgery, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Victoria J Wilson
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - David G Kiely
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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Hamoudi C, Sapa MC, Facca S, Xavier F, Goetsch T, Liverneaux P. Influence of surgical performance on clinical outcome after osteosynthesis of distal radius fracture. HAND SURGERY & REHABILITATION 2023; 42:430-434. [PMID: 37356571 DOI: 10.1016/j.hansur.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/27/2023]
Abstract
INTRODUCTION Clinical outcome after surgery depends on the surgeon's level of expertise or performance. The present study of minimally invasive plate osteosynthesis (MIPO) with anterior plate for distal radius fracture assessed whether clinical outcome correlated with surgeon performance. METHODS The series included 30 distal radius fractures: 15 operated on by 4 level III surgeons (Group 1) and 15 by 4 level V surgeons (Group 2), utilizing the MIPO technique. The surgical performance of all 8 surgeons was assessed using the OSATS global rating scale. Clinical outcomes were assessed at 3 months' follow-up using the modified Mayo score (MMS), in 4 grades: 0-64 (poor), 65-79 (moderate), 80-89 (good), and 90-100 (excellent). The QuickDASH score (QDASH) was also calculated, and complications were recorded. RESULTS Median MMS was better for level V (75 = fair result) than level III surgeons (62 = poor result). Median QDASH score likewise was better in group 2 (9.1) than group 1 (22.7). In group 1, there were 2 paresthesias in the median nerve territory, 1 type-1 complex regional pain syndrome, and 1 hypoesthesia in the scar area. Mean correlation between the 2 scores was -0.68. Group 1 patients were on average 7 years older. The number of patients, number of surgeons and distribution of OA A and C fractures were almost identical in the two groups. On MMS, the overall result of the two groups was moderate (70.5), which can be explained by short mean follow-up. DISCUSSION Quality of the clinical outcome on MMS and QDASH increased with surgical performance, with fewer complications. In the patients' interest, protocols for improving surgical performance should be implemented, for example, through deliberate practice.
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Affiliation(s)
- Ceyran Hamoudi
- Department of Hand Surgery, Strasbourg University Hospitals, FMTS, 1 Avenue Molière, 67200 Strasbourg, France.
| | - Marie-Cécile Sapa
- Department of Hand Surgery, Strasbourg University Hospitals, FMTS, 1 Avenue Molière, 67200 Strasbourg, France
| | - Sybille Facca
- Department of Hand Surgery, Strasbourg University Hospitals, FMTS, 1 Avenue Molière, 67200 Strasbourg, France; ICube CNRS UMR7357, Strasbourg University, 2-4 Rue Boussingault, 67000 Strasbourg, France
| | - Fred Xavier
- Orthopedic Surgery & Biomedical Engineering, Bayside, NY 11360, USA
| | - Thibaut Goetsch
- Department of Public Health, Strasbourg University Hospital, FMTS, GMRC, 1 Avenue De l'Hôpital, 67000 Strasbourg Cedex, France
| | - Philippe Liverneaux
- Department of Hand Surgery, Strasbourg University Hospitals, FMTS, 1 Avenue Molière, 67200 Strasbourg, France; ICube CNRS UMR7357, Strasbourg University, 2-4 Rue Boussingault, 67000 Strasbourg, France
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Kaw RK. Unrecognized Pulmonary Hypertension in Non-Cardiac Surgical Patients: At-Risk Populations, Preoperative Evaluation, Intraoperative Management and Postoperative Complications. J Cardiovasc Dev Dis 2023; 10:403. [PMID: 37754832 PMCID: PMC10531561 DOI: 10.3390/jcdd10090403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/28/2023] Open
Abstract
Pulmonary hypertension is a well-established independent risk factor for perioperative complications after elective non-cardiac surgery. Patients undergoing cardiac surgery are routinely evaluated for the presence of pulmonary hypertension in the preoperative period. Better monitoring in the postoperative critical care setting leads to more efficient management of potential complications. Data among patients with pulmonary hypertension undergoing elective non-cardiac surgery are scant. Moreover, the condition may be unidentified at the time of surgery. Also, monitoring after non-cardiac surgery can be very limited in the PACU setting, as opposed to the critical care setting. All these factors can result in a higher postoperative complication rate and poor outcomes.
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Affiliation(s)
- Roop K Kaw
- Department of Hospital Medicine, Cleveland Clinic, Outcomes Research Consortium, Cleveland, OH 44195, USA
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Abraham J, Meng A, Montes de Oca A, Politi M, Wildes T, Gregory S, Henrichs B, Kannampallil T, Avidan MS. An ethnographic study on the impact of a novel telemedicine-based support system in the operating room. J Am Med Inform Assoc 2022; 29:1919-1930. [PMID: 35985294 PMCID: PMC10161534 DOI: 10.1093/jamia/ocac138] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/07/2022] [Accepted: 08/04/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The Anesthesiology Control Tower (ACT) for operating rooms (ORs) remotely assesses the progress of surgeries and provides real-time perioperative risk alerts, communicating risk mitigation recommendations to bedside clinicians. We aim to identify and map ACT-OR nonroutine events (NREs)-risk-inducing or risk-mitigating workflow deviations-and ascertain ACT's impact on clinical workflow and patient safety. MATERIALS AND METHODS We used ethnographic methods including shadowing ACT and OR clinicians during 83 surgeries, artifact collection, chart reviews for decision alerts sent to the OR, and 10 clinician interviews. We used hybrid thematic analysis informed by a human-factors systems-oriented approach to assess ACT's role and impact on safety, conducting content analysis to assess NREs. RESULTS Across 83 cases, 469 risk alerts were triggered, and the ACT sent 280 care recommendations to the OR. 135 NREs were observed. Critical factors facilitating ACT's role in supporting patient safety included providing backup support and offering a fresh-eye perspective on OR decisions. Factors impeding ACT included message timing and ACT and OR clinician cognitive lapses. Suggestions for improvement included tailoring ACT message content (structure, timing, presentation) and incorporating predictive analytics for advanced planning. DISCUSSION ACT served as a safety net with remote surveillance features and as a learning healthcare system with feedback/auditing features. Supporting strategies include adaptive coordination and harnessing clinician/patient support to improve ACT's sustainability. Study insights inform future intraoperative telemedicine design considerations to mitigate safety risks. CONCLUSION Incorporating similar remote technology enhancement into routine perioperative care could markedly improve safety and quality for millions of surgical patients.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alicia Meng
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Arianna Montes de Oca
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Mary Politi
- Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Troy Wildes
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Stephen Gregory
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Bernadette Henrichs
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Goldfarb School of Nursing, Barnes-Jewish College, St. Louis, Missouri, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Computer Science & Engineering, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
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陈 娜, 李 仁, 王 锷, 胡 德, 唐 朝. [Outcomes of patients experiencing cardiovascular adverse events within 1 year following craniotomy for intracranial aneurysm clipping: a retrospective cohort study]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2022; 42:1095-1099. [PMID: 35869776 PMCID: PMC9308867 DOI: 10.12122/j.issn.1673-4254.2022.07.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the impact of postoperative serious cardiovascular adverse events (CAE) on outcomes of patients undergoing craniotomy for intracranial aneurysm clipping. METHODS This retrospective cohort study was conducted among the patients undergoing craniotomy for intracranial aneurysm clipping during the period from December, 2016 to December, 2017, who were divided into CAE group and non-CAE group according to the occurrence of Clavien-Dindo grade ≥II CAEs after the surgery. The perioperative clinical characteristics of the patients, complications and neurological functions during hospitalization, and mortality and neurological functions at 1 year postoperatively were evaluated. The primary outcome was mortality within 1 year after the surgery. The secondary outcomes were Glasgow outcome scale (GOS) score at 1 year, lengths of postoperative hospital and intensive care unit (ICU) stay, and Glasgow coma scale (GCS) score at discharge. RESULTS A total of 361 patients were enrolled in the final analysis, including 20 (5.5%) patients in CAE group and 341 in the non-CAE group. No significant differences were found in the patients' demographic characteristics, clinical history, or other postoperative adverse events between the two groups. The 1-year mortality was significantly higher in CAE group than in the non-CAE group (20.0% vs 5.6%, P=0.01). Logistics regression analysis showed that when adjusted for age, gender, emergency hospitalization, subarachnoid hemorrhage, volume of bleeding, duration of operation, aneurysm location, and preoperative history of cardiovascular disease, postoperative CAEs of Clavien-Dindo grade≥II was independently correlated with 1-year mortality rate of the patients with an adjusted odds ratio of 3.670 (95% CI: 1.037-12.992, P=0.04). The patients with CEA also had a lower GOS score at 1 year after surgery than those without CEA (P=0.002). No significant differences were found in the occurrence of other adverse events, postoperative hospital stay, ICU stay, or GCS scores at discharge between the two groups (P > 0.05). CONCLUSION Postoperative CAEs may be a risk factor for increased 1-year mortality and disability in patients undergoing craniotomy for intracranial aneurysms.
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Affiliation(s)
- 娜 陈
- 中南大学湘雅医院麻醉科,湖南 长沙 410008Department of Anesthesiology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - 仁华 李
- 湖南省人民医院麻醉科,湖南 长沙 410005Department of Anesthesiology, Hunan Provincial People's Hospital, Changsha 410005, China
| | - 锷 王
- 中南大学湘雅医院麻醉科,湖南 长沙 410008Department of Anesthesiology, Xiangya Hospital of Central South University, Changsha 410008, China
- 国家老年疾病临床研究中心(湘雅医院),湖南 长沙 410008National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha 410008, China
| | - 德华 胡
- 中南大学生命科学学院,湖南 长沙 410008School of Life Sciences, Central South University, Changsha 410008, China
| | - 朝辉 唐
- 中南大学湘雅医院麻醉科,湖南 长沙 410008Department of Anesthesiology, Xiangya Hospital of Central South University, Changsha 410008, China
- 国家老年疾病临床研究中心(湘雅医院),湖南 长沙 410008National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha 410008, China
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Wilson AC, Jungbauer WN, Hussain FT, Lindgren BR, Lassig AAD. Characterization of Baseline Temperature Characteristics Using Thermography in The Clinical Setting. J Surg Res 2021; 272:26-36. [PMID: 34922267 DOI: 10.1016/j.jss.2021.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/16/2021] [Accepted: 11/12/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Thermography is a diagnostic method based on the ability to record infrared radiation emitted by the skin and is unique in its ability to accurately show physiological and/or pathological cutaneous temperature changes in a non-invasive way. This method can be used to indirectly assess changes or impairments in cutaneous perfusion. Significant technological advancements have allowed thermography to be more commonly utilized by clinicians, yet a basic consensus of patient characteristics that may affect temperature recordings is not established. MATERIALS AND METHODS We evaluated cutaneous temperature in a cohort of outpatients to understand what factors, including tobacco use and other high-risk characteristics, contribute to cutaneous tissue perfusion as measured by thermography. Participants were prospectively enrolled if they were a combustible cigarette smoker, an electronic cigarette (e-cigarette) user, or a never smoker. Standardized thermographic images of the subject's facial profiles, forearms, and calves were taken and demographic characteristics, medical comorbidities, and tobacco product use were assessed. These variables were statistically tested for associations with temperature at each anatomic site. RESULTS We found that gender had a significant effect on thermographic temperature that differed by anatomic site, and we found a lack of significant difference in thermographic temperature by race. Our regression analysis did not support significant differences in thermographic temperatures across smoking groups, while there was a trend for decreased perfusion in smokers relative to non-smokers and e-cigarette users relative to non-smokers. CONCLUSION Thermographic imaging is a useful tool for clinical and research use with consideration of sex and other perfusion-affecting characteristics.
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Affiliation(s)
- Anna C Wilson
- Department of Otolaryngology, Hennepin Healthcare Research Institute, Hennepin Healthcare / Hennepin County Medical Center, Minneapolis, Minnesota; Department of Otolaryngology - Head and Neck Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Walter N Jungbauer
- Department of Otolaryngology, Hennepin Healthcare Research Institute, Hennepin Healthcare / Hennepin County Medical Center, Minneapolis, Minnesota; Department of Otolaryngology - Head and Neck Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota.
| | - Fareeda T Hussain
- Department of Otolaryngology, Hennepin Healthcare Research Institute, Hennepin Healthcare / Hennepin County Medical Center, Minneapolis, Minnesota; Department of Otolaryngology - Head and Neck Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota; Department of Otorhinolaryngology, Head and Neck Surgery, Mayo Clinic Health System / Mayo Clinic College of Medicine, Mankato, Minnesota
| | - Bruce R Lindgren
- Biostatistics Core, University of Minnesota Masonic Cancer Center, Minneapolis, Minnesota
| | - Amy Anne D Lassig
- Department of Otolaryngology, Hennepin Healthcare Research Institute, Hennepin Healthcare / Hennepin County Medical Center, Minneapolis, Minnesota; Department of Otolaryngology - Head and Neck Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota
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Abraham J, Meng A, Holzer KJ, Brawer L, Casarella A, Avidan M, Politi MC. Exploring patient perspectives on telemedicine monitoring within the operating room. Int J Med Inform 2021; 156:104595. [PMID: 34627112 PMCID: PMC10627166 DOI: 10.1016/j.ijmedinf.2021.104595] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/10/2021] [Accepted: 09/24/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clinical decision support systems and telemedicine for remote monitoring can together support clinicians' intraoperative decision-making and management of surgical patients' care. However, there has been limited investigation on patient perspectives about advanced health information technology use in intraoperative settings, especially an electronic OR (eOR) for remote monitoring and management of surgical patients. PURPOSE Our study objectives were: (1) to identify participant-rated items contributing to patient attitudes, beliefs, and level of comfort with eOR monitoring; and (2) to highlight barriers and facilitators to eOR use. METHODS We surveyed 324 individuals representing surgical patients across the United States using Amazon Mechanical Turk, an online platform supporting internet-based work. The structured survey questions examined the level of agreement and comfort with eOR for remote patient monitoring. We calculated descriptive statistics for demographic variables and performed a Wilcoxon matched-pairs signed-rank test to assess whether participants were more comfortable with familiar clinicians from local hospitals or health systems monitoring their health and safety status during surgery than clinicians from hospitals or health systems in other regions or countries. We also analyzed open-ended survey responses using a thematic approach informed by an eight-dimensional socio-technical model. RESULTS Participants' average age was 34.07 (SD = 10.11). Most were white (80.9%), male (57.1%), and had a high school degree or more (88.3%). Participants reported a higher level of comfort with clinicians they knew monitoring their health and safety than clinicians they did not know, even within the same healthcare system (z = -4.012, p < .001). They reported significantly higher comfort levels with clinicians within the same hospital or health system in the United States than those in a different country (z = -10.230, p < .001). Facilitators and barriers to eOR remote monitoring were prevalent across four socio-technical dimensions: 1) organizational policies, procedures, environment, and culture; 2) people; 3) workflow and communication; and 4) hardware and software. Facilitators to eOR use included perceptions of improved patient safety through a safeguard system and perceptions of streamlined care. Barriers included fears of incorrect eOR patient assessments, decision-making conflicts between care teams, and technological malfunctions. CONCLUSIONS Participants expressed significant support for intraoperative telemedicine use and greater comfort with local telemedicine systems instead of long-distance telemedicine systems. Reservations centered on organizational policies, procedures, environment, culture; people; workflow and communication; and hardware and software. To improve the buy-in and acceptability of remote monitoring by an eOR team, we offer a few evidence-based guidelines applicable to telemedicine use within the context of OR workflow. Guidelines include backup plans for technical challenges, rigid care, and privacy standards, and patient education to increase understanding of telemedicine's potential to improve patient care.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States; Institute for Informatics, Washington University School of Medicine, St Louis, MO, United States.
| | - Alicia Meng
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States
| | - Katherine J Holzer
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States
| | - Luke Brawer
- Wallace H. Coulter Department of Biomedical Engineering Georgia Institute of Technology and Emory University, Atlanta, GA, United States
| | - Aparna Casarella
- Brown School at Washington University in St. Louis, St. Louis, MO, United States
| | - Michael Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, United States
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The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System. Anesthesiology 2021; 135:904-919. [PMID: 34491303 DOI: 10.1097/aln.0000000000003947] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The American Society of Anesthesiologists (ASA) Physical Status classification system celebrates its 80th anniversary in 2021. Its simplicity represents its greatest strength as well as a limitation in a world of comprehensive multisystem tools. It was developed for statistical purposes and not as a surgical risk predictor. However, since it correlates well with multiple outcomes, it is widely used-appropriately or not-for risk prediction and many other purposes. It is timely to review the history and development of the system. The authors describe the controversies surrounding the ASA Physical Status classification, including the problems of interrater reliability and its limitations as a risk predictor. Last, the authors reflect on the current status and potential future of the ASA Physical Status system.
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Price LC, Martinez G, Brame A, Pickworth T, Samaranayake C, Alexander D, Garfield B, Aw TC, McCabe C, Mukherjee B, Harries C, Kempny A, Gatzoulis M, Marino P, Kiely DG, Condliffe R, Howard L, Davies R, Coghlan G, Schreiber BE, Lordan J, Taboada D, Gaine S, Johnson M, Church C, Kemp SV, Wong D, Curry A, Levett D, Price S, Ledot S, Reed A, Dimopoulos K, Wort SJ. Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement. Br J Anaesth 2021; 126:774-790. [PMID: 33612249 DOI: 10.1016/j.bja.2021.01.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The risk of complications, including death, is substantially increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures, especially in those with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). Sedation also poses a risk to patients with PH. Physiological changes including tachycardia, hypotension, fluid shifts, and an increase in pulmonary vascular resistance (PH crisis) can precipitate acute right ventricular decompensation and death. METHODS A systematic literature review was performed of studies in patients with PH undergoing non-cardiac and non-obstetric surgery. The management of patients with PH requiring sedation for endoscopy was also reviewed. Using a framework of relevant clinical questions, we review the available evidence guiding operative risk, risk assessment, preoperative optimisation, and perioperative management, and identifying areas for future research. RESULTS Reported 30 day mortality after non-cardiac and non-obstetric surgery ranges between 2% and 18% in patients with PH undergoing elective procedures, and increases to 15-50% for emergency surgery, with complications and death usually relating to acute right ventricular failure. Risk factors for mortality include procedure-specific and patient-related factors, especially markers of PH severity (e.g. pulmonary haemodynamics, poor exercise performance, and right ventricular dysfunction). Most studies highlight the importance of individualised preoperative risk assessment and optimisation and advanced perioperative planning. CONCLUSIONS With an increasing number of patients requiring surgery in specialist and non-specialist PH centres, a systematic, evidence-based, multidisciplinary approach is required to minimise complications. Adequate risk stratification and a tailored-individualised perioperative plan is paramount.
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Affiliation(s)
- Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.
| | - Guillermo Martinez
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Aimee Brame
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | | | | | - David Alexander
- Department of Anaesthesia, Royal Brompton Hospital, London, UK
| | - Benjamin Garfield
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Tuan-Chen Aw
- Department of Anaesthesia, Royal Brompton Hospital, London, UK
| | - Colm McCabe
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Bhashkar Mukherjee
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | - Carl Harries
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
| | - Aleksander Kempny
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael Gatzoulis
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Philip Marino
- Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | - David G Kiely
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Robin Condliffe
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Luke Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Rachel Davies
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Gerry Coghlan
- National Pulmonary Hypertension Service, Royal Free Hospital, London, UK
| | | | - James Lordan
- National Pulmonary Hypertension Service, Freeman Hospital, Newcastle upon Tyne, UK
| | - Dolores Taboada
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, NHS Golden Jubilee, Clydebank, UK
| | - Colin Church
- Scottish Pulmonary Vascular Unit, NHS Golden Jubilee, Clydebank, UK
| | - Samuel V Kemp
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Davina Wong
- Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | - Andrew Curry
- Cardiothoracic Anaesthesia, University Hospital Southampton, Southampton, Hampshire, UK
| | - Denny Levett
- Anaesthesia and Critical Care Research Area, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Stephane Ledot
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Anna Reed
- National Heart and Lung Institute, Imperial College London, London, UK; Respiratory and Lung Transplantation, Harefield Hospital, Uxbridge, UK
| | - Konstantinos Dimopoulos
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Stephen John Wort
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
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Cardiac risk assessment calculators: utility and limitations. Int Anesthesiol Clin 2020; 59:9-14. [PMID: 33231943 DOI: 10.1097/aia.0000000000000309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Yongyukantorn K, Oofuvong M. Risk factors of intraoperative and 24-hour postoperative cardiac arrest in geriatric patients in non-cardiac surgery. JOURNAL OF GERONTOLOGY AND GERIATRICS 2020. [DOI: 10.36150/2499-6564-381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Chow WB, Merkow RP, Cohen ME, Bilimoria KY, Ko CY. Association between Postoperative Complications and Reoperation for Patients Undergoing Geriatric Surgery and the Effect of Reoperation on Mortality. Am Surg 2020. [DOI: 10.1177/000313481207801028] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Elderly patients have greater risk for postoperative adverse events (PAEs). The study examines the rates of reoperation, the association between PAEs and reoperation, and the effect of reoperation on mortality for patients 65 years of age or older undergoing colorectal resections (CRRs), pancreatic resections (PRs), and lower extremity bypass (LEB) in 2010 American College of Surgeons National Surgical Quality Improvement Program. The models evaluating associations between reoperation and preoperative factors, PAEs, and mortality were developed using multiple logistic regression. The reoperation rates were 6.41 per cent for CRR (n = 11,084), 6.79 per cent for PR (n = 1,606), and 15.04 per cent for LEB (n = 4,170). Preoperative factors predicting reoperation included indications for surgery, procedure category, emergency status, and systemic sepsis. The PAEs most strongly associated with reoperation were wound dehiscence for CRR (odds ratio [OR], 15.286; 95% confidence interval [CI], 11.035 to 21.175) and for PR (OR, 19.656; 8.677 to 44.531) and for LEB, graft failure (OR, 28.151; 18.030 to 43.954) and organ space surgical site infection (OR, 15.753; 6.938 to 35.711). Higher rates of mortality occurred with reoperation for patients undergoing CRR (16.88 vs 5.45%, P < 0.0001), PR (28.44 vs 2.14%, P < 0.0001), and LEB (6.22 vs 3.05%, P < 0.0001). For elderly patients undergoing general and vascular surgery, reoperation occurs frequently, is strongly associated with other PAEs, and may elevate risk of mortality for this vulnerable population.
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Affiliation(s)
- Warren B. Chow
- Department of Surgery, Geffen School of Medicine at UCLA, Los Angeles, California
- American College of Surgeons, Chicago, Illinois
| | | | | | | | - Clifford Y. Ko
- Department of Surgery, Geffen School of Medicine at UCLA, Los Angeles, California
- Greater West Los Angeles VA Healthcare System, Los Angeles, California
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Wright DE, Knuesel SJ, Nagarur A, Philpotts LL, Greenwald JL. Examining Risk: A Systematic Review of Perioperative Cardiac Risk Prediction Indices. Mayo Clin Proc 2019; 94:2277-2290. [PMID: 31202481 DOI: 10.1016/j.mayocp.2019.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 03/01/2019] [Accepted: 03/12/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To conduct a systematic review of published cardiac risk indices relevant to patients undergoing noncardiac surgery and to provide clinically meaningful recommendations to physicians regarding the use of these indices. METHODS A literature search of articles published from January 1, 1999, through December 28, 2018, was conducted in Ovid (MEDLINE), PubMed, Embase, CINAHL, and Web of Science. Publications describing models predicting risk of cardiac complications after noncardiac surgery were included and citation chaining was used to identify additional studies for inclusion. RESULTS Eleven risk indices involving 2,910,297 adult patients were included in this analysis. Studies varied in size, population, quality, risk of bias, outcome event definitions, risk factors identified, index outputs, accuracy, and clinical usefulness. Studies considered 6 to 83 variables to develop their models. Among the identified models, the factors with the highest predictiveness for adverse cardiac outcomes included congestive heart failure, type of surgery, creatinine, diabetes, history of stroke or transient ischemic attack, and emergency surgery. Substantial data from the large studies also supports advancing age, American Society of Anesthesiology physical status classification, functional status, and hypertension as additional risks. CONCLUSION The risk indices identified generally fell into two groups - those with higher accuracy for predicting a narrow range of cardiac outcomes and those with lower accuracy for predicting a broader range of cardiac outcomes. Using one index from each group may be the most clinically useful approach. Risk factors identified varied widely among studies. In addition to judicious use of predictive indices, reasoned clinical judgment remains indispensable in assessing perioperative cardiac risk.
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Affiliation(s)
- Douglas E Wright
- Core Educator Faculty, Department of Medicine, Massachusetts General Hospital, Boston.
| | - Steven J Knuesel
- Core Educator Faculty, Department of Medicine, Massachusetts General Hospital, Boston
| | - Amulya Nagarur
- Core Educator Faculty, Department of Medicine, Massachusetts General Hospital, Boston
| | - Lisa L Philpotts
- Treadwell Virtual Library, Massachusetts General Hospital, Boston
| | - Jeffrey L Greenwald
- Core Educator Faculty, Department of Medicine, Massachusetts General Hospital, Boston
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Ollila A, Vikatmaa L, Virolainen J, Nisula S, Lakkisto P, Vikatmaa P, Tikkanen I, Venermo M, Pettilä V. The association of endothelial injury and systemic inflammation with perioperative myocardial infarction. Ann Clin Biochem 2019; 56:674-683. [DOI: 10.1177/0004563219873357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Major surgery predisposes to endothelial glycocalyx injury. Endothelial glycocalyx injury associates with cardiac morbidity, including spontaneous myocardial infarction. However, the relation between endothelial glycocalyx injury and the development of perioperative myocardial infarction remains unknown. Methods Fifteen perioperative myocardial infarction patients and 60 propensity-matched controls were investigated in this prospective study. The diagnosis of perioperative myocardial infarction was based on repeated cardiac troponin T measurements, electrocardiographs and recordings of ischaemic signs and symptoms. We measured endothelial glycocalyx markers – soluble thrombomodulin, syndecan-1 and vascular adhesion protein 1 – and an inflammatory marker, namely interleukin-6, preoperatively and 6 h and 24 h postoperatively. We calculated the areas under the receiver operating characteristics curves (AUCs) to compare the performances of the different markers in predicting perioperative myocardial infarction. The highest value of each marker was used in the analysis. Results The interleukin-6 concentrations of perioperative myocardial infarction patients were significantly higher preoperatively and 6 and 24 h postoperatively ( P = 0.002, P = 0.002 and P = 0.001, respectively). The AUCs (95% confidence intervals) for the detection of perioperative myocardial infarction were 0.51 (0.34–0.69) for soluble thrombomodulin, 0.63 (0.47–0.79) for syndecan-1, 0.54 (0.37–0.70) for vascular adhesion protein 1 and 0.69 (0.54–0.85) for interleukin-6. Conclusions Systemic inflammation, reflected by interleukin-6, associates with cardiac troponin T release and perioperative myocardial infarction. Circulating interleukin-6 demonstrated some potential to predict perioperative myocardial infarction, whereas endothelial glycocalyx markers did not.
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Affiliation(s)
- Aino Ollila
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leena Vikatmaa
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Virolainen
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sara Nisula
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Päivi Lakkisto
- Department of Clinical Chemistry and Hematology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Minerva Foundation Institute for Medical Research, Helsinki, Finland
| | - Pirkka Vikatmaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Tikkanen
- Minerva Foundation Institute for Medical Research, Helsinki, Finland
- Helsinki Hypertension Centre of Excellence, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Doan LV, Wang J, Padjen K, Gover A, Rashid J, Osmani B, Avraham S, Kendale S. Preoperative Long-Acting Opioid Use Is Associated with Increased Length of Stay and Readmission Rates After Elective Surgeries. PAIN MEDICINE 2019; 20:2539-2551. [DOI: 10.1093/pm/pny318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractObjectives To compare postoperative outcomes in patients prescribed long-acting opioids vs opioid-naïve patients who underwent elective noncardiac surgeries.Design Retrospective cohort study.Setting Single urban academic institution.Methods and Subjects We retrospectively compared postoperative outcomes in long-acting opioid users vs opioid-naïve patients who underwent elective noncardiac surgeries. Inpatient and ambulatory surgery cohorts were separately analyzed. Preoperative medication lists were queried for the presence of long-acting opioids or absence of opioids. Multivariable logistic regression was performed to analyze the impact of long-acting opioid use on readmission rate, respiratory failure, and adverse cardiac events. Multivariable zero-truncated negative binomial regression was used to examine length of stay.Results After exclusions, there were 93,644 adult patients in the study population, 23,605 of whom underwent inpatient surgeries and 70,039 of whom underwent ambulatory surgeries. After adjusting for potential confounders and inpatient surgeries, preoperative long-acting opioid use was associated with increased risk of prolonged length of stay (incidence rate ratio = 1.1, 99% confidence interval [CI] = 1.0–1.2, P < 0.01) but not readmission. For ambulatory surgeries, preoperative long-acting opioid use was associated with increased risk of all-cause as well as pain-related readmission (odds ratio [OR] = 2.1, 99% CI = 1.5–2.9, P < 0.001; OR = 2.0, 99% CI = 0.85–4.2, P = 0.02, respectively). There were no significant differences for respiratory failure or adverse cardiac events.Conclusions The use of preoperative long-acting opioids was associated with prolonged length of stay for inpatient surgeries and increased risk of all-cause and pain-related readmission for ambulatory surgeries. Timely interventions for patients on preoperative long-acting opioids may be needed to improve these outcomes.
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Affiliation(s)
- Lisa V Doan
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Jing Wang
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Kristoffer Padjen
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Adam Gover
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Jawad Rashid
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Bijan Osmani
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Shirley Avraham
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Samir Kendale
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
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Ollila A, Vikatmaa L, Sund R, Pettilä V, Wilkman E. Efficacy and safety of intravenous esmolol for cardiac protection in non-cardiac surgery. A systematic review and meta-analysis. Ann Med 2019; 51:17-27. [PMID: 30346213 PMCID: PMC7856921 DOI: 10.1080/07853890.2018.1538565] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Haemodynamic instability predisposes patients to cardiac complications in non-cardiac surgery. Esmolol, a short-acting cardioselective beta-adrenergic blocker might be efficient in perioperative cardiac protection, but could affect other vital organs, such as the kidneys, and post-discharge survival. We performed a systematic review on the use of esmolol for perioperative cardiac protection. We searched PubMed, Ovid Medline and Cochrane Central Register for Controlled trials. Eligible randomized controlled studies (RCTs) reported a perioperative esmolol intervention with at least one of the primary (major cardiac or renal complications during the first 30 postoperative days) or secondary (postoperative adverse effects and all-cause mortality) outcomes. We included 196 adult patients from three RCTs. Esmolol significantly reduced postoperative myocardial ischaemia, RR =0.43 [95% confidence interval, CI: 0.21-0.88], p = .02. No association with clinically significant bradycardia and hypotension compared to patients receiving control treatment could be confirmed (RR =7.4 [95% CI: 0.29-139.81], p = .18 and RR =2.21 [95% CI: 0.34-14.36], p = .41, respectively). No differences regarding other outcomes were observed. No study reported postoperative renal outcomes. Esmolol seems promising for the prevention of perioperative myocardial ischaemia. However, the association with bradycardia and hypotension remains unclear. Randomized trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted. Key messages Short-acting cardioselective esmolol seems efficient in the prevention of perioperative myocardial ischaemia. The possibly increased risk of bradycardia and hypotension with short-acting intravenous beta blockade could not be confirmed or refuted by available data. Future adequately powered trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted.
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Affiliation(s)
- Aino Ollila
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Leena Vikatmaa
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Reijo Sund
- b Institute of Clinical Medicine, University of Eastern Finland , Kuopio , Finland.,c Faculty of Social Sciences , Centre for Research Methods, University of Helsinki , Helsinki , Finland
| | - Ville Pettilä
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Erika Wilkman
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
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Pattanapon N, Bootcha R, Petchdee S. The effects of anesthetic drug choice on heart rate variability in dogs. J Adv Vet Anim Res 2018; 5:485-489. [PMID: 31453162 PMCID: PMC6702903 DOI: 10.5455/javar.2018.e303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/30/2018] [Accepted: 09/27/2018] [Indexed: 01/01/2023] Open
Abstract
Objective: The objective of this study was to assess the effects of anesthetic drugs on heart rate (HR) and heart rate variability (HRV) in dogs. Materials and Methods: Twelve healthy client-owned dogs of various breeds, including five females and seven males were used for elective surgery in this study. The dogs were pre-medicated with four protocols; (1) alfaxalone [at 3 mg/kg body weight (bwt)], (2) zolazepam + tiletamine (Zoletil) (at 5 mg/kg bwt), (3) diazepam (at 0.3 mg/kg bwt) + ketamine (at 5 mg/kg bwt), and (4) diazepam (at 0.3 mg/kg bwt) + propofol (at 5 mg/kg bwt). The HR and HRV of 12 dogs were recorded 20 min before and after the administration of the anesthetic drugs. Doppler was used to obtain systolic, diastolic, and mean blood pressures. Results: After anesthetic drug administration, the dogs pre-medicated and inducted with alfaxalone had the lowest HR values as compared with those of other protocols. The HRV low frequency and high frequency power ratio decreased in the dogs pre-medicated and intubated with alfaxalone. Conclusion: This study demonstrates that alfaxalone preserves the cardiovascular function; and hence, is considered as safe to use for the surgical applicability in dogs.
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Affiliation(s)
- Nakrob Pattanapon
- Faculty of Veterinary Medicine, Kasetsart University Veterinary Teaching Hospital, Kasetsart University, Kamphaeng Saen Campus, Bangkok 73140 Thailand
| | - Ratikorn Bootcha
- Faculty of Veterinary Medicine, Kasetsart University Veterinary Teaching Hospital, Kasetsart University, Kamphaeng Saen Campus, Bangkok 73140 Thailand
| | - Soontaree Petchdee
- Department of Large Animal and Wildlife Clinical Sciences, Faculty of Veterinary Medicine, Kasetsart University, Kamphaeng Saen Campus, Bangkok 73140, Thailand
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Acheampong D, Guerrier S, Lavarias V, Pechman D, Mills C, Inabnet W, Boateng P, Leitman IM. Risk factors contributing to cardiac events following general and vascular surgery. Ann Med Surg (Lond) 2018; 33:16-23. [PMID: 30147870 PMCID: PMC6105747 DOI: 10.1016/j.amsu.2018.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/02/2018] [Accepted: 08/01/2018] [Indexed: 11/19/2022] Open
Abstract
Background Cardiac events (CE) following surgery have been associated with morbidity and mortality. Defining risk factors that contribute to CE is essential to improve surgical outcomes. Study design This was a retrospective study at a large urban teaching hospital for surgery performed from 2013 to 2015. Adult patients (≥18 years) that underwent general and vascular surgery were analyzed. Patients were grouped into those who experienced postoperative CE and those who did not. Univariate and multivariate regression analyses were used to identify predictors of postoperative CE, and association of CE with adverse postoperative outcomes. Separate subgroup analyses were also conducted for general and vascular surgery patients to assess predictors of CE. Results Out of 8441 patients, 157 (1.9%) experienced CE after major general and vascular surgery. Underlying predictors for CE included age >65 years(OR 4.9, 95%CI 3.4–6.9,p < 0.01), ASA >3(OR 12.0, 95%CI 8.5–16.9,p < 0.01), emergency surgery(OR 3.7, 95%CI 2.7–5.1,p = 0.01), CHF(OR 11.2, 95%CI 6.4–16.7,p = 0.02), COPD(OR 3.9, 95%CI 2.4–6.4,p = 0.04), acute renal failure or dialysis(OR 8.0, 95%CI 5.2–12.1,p = 0.04), weight loss(OR 3.3, 95%CI 1.7–6.7,p < 0.01), preoperative creatinine >1.2 mg/dL(OR 5.1, 95%CI 3.7–7.1,p = 0.01), hematocrit <34%(OR 4.0, 95%CI 2.8–5.7,p < 0.01), and operative time >240 min(OR 2.0, 95%CI 1.3–3.3,p = 0.02). Following surgery, CE was associated with increased mortality(OR 3.5, 95%CI 1.2–6.5,p < 0.01), pulmonary complications(OR 5.0, 95%CI 3.1–8.9,p < 0.01), renal complications(OR 2.3, 95%CI 1.9–4.5,p < 0.01), neurologic complications(OR 2.5, 95%CI 1.4–5.2,p < 0.01), systemic sepsis(OR 2.2, 95%CI 1.7–4.0,p < 0.01), postoperative RBC transfusion(OR 4.4, 95%CI 2.7–6.5,p < 0.01), unplanned return to operating room(OR 4.0, 95%CI 2.3–6.9,p < 0.01), and prolonged hospitalization (OR 5.5, 95%CI 3.1–8.8,p = 0.03). There was no statistical difference in incidence of CE between general and vascular surgery patients (p = 0.44); however, predictors of CE differed between the two surgical groups. Conclusion Postoperative CE are associated with significant morbidity and mortality. Identified predictors of CE should allow for adequate risk stratification and optimization of perioperative surgical management. Cardiac events following general and vascular surgery were associated with a mortality rate of 55%. Underlying risk factors for cardiac events following general and vascular surgery include COPD, hypertension on medication, and renal failure. Return to the OR, deep wound infection, unplanned intubation and ventilator dependence are also associated with a post-op cardiac event.
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Affiliation(s)
| | | | | | | | | | | | | | - I. Michael Leitman
- Corresponding author. Department of Surgery, Mount Sinai Beth Israel, 10 Union Square East, 2M, New York, NY 10003, USA.
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Abstract
AIM To evaluate outcomes and post-donation kidney function of older living kidney donors (LKD). METHODS Retrospective analysis of prospective database including all consecutive LKD undergoing laparoscopic nephrectomy in a single center (09/1998-12/2013). LKD aged ≥60 years were compared to younger LKD. Renal function assessed by creatinine levels and estimated glomerular filtration rates (eGFR). Surgical complications classified according to the Clavien-Dindo classification. Bivariate and multivariate analyses using linear mixed effect models were performed to determine factors (age, gender, hypertension status, BMI, choice of better functioning kidney for donation) that might impinge on renal function after donation. RESULTS 213 LKD were identified: 49 older (median age: 66 years, range: 60-79) and 164 younger (median age: 46, range: 25-59). Mean operative time (149 vs. 152 min, p = 0.69), conversion to laparotomy (n = 1 vs. 3, p = 0.92), grade III-IV complications (n = 4 vs. 2, p = 0.36) were similar. Older had more grade I-II complications (n = 18 vs. 4, p < 0.001). Despite similar pre-donation eGFR (80 vs. 84 ml/min/1.73 m2), older donors presented significantly lower eGFR during inpatient period (46 vs. 51 ml/min/1.73 m2, p = 0.0003), at 1 month (51 vs. 58 ml/min/1.73 m2, p = 0.002) and at 1 year (54 vs. 62 ml/min/1.73 m2, p = 0.001). Multivariate analysis adjusted to gender, hypertension status, BMI and choice of better functioning kidney for donation showed that at 1 year, age ≥60 affected renal function by a coefficient of 0.91 (p < 0.001). CONCLUSION Despite renal function improvement after discharge, LKD ≥ 60 years presented lower eGFR than younger at one year and had more grade I-II surgical complications.
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A systematic review on risk factors associated with sepsis in patients admitted to intensive care units. Aust Crit Care 2018; 32:155-164. [PMID: 29574007 DOI: 10.1016/j.aucc.2018.02.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/29/2018] [Accepted: 02/05/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE We sought to systematically review data on the risk factors influencing the incidence of sepsis in patients admitted to intensive care units (ICUs). REVIEW METHODS An electronic search was undertaken in PubMed, MEDLINE, Scopus, and the Cochrane Library for studies reporting the risk factors of sepsis from the earliest available date up to December 30, 2016. RESULTS Among the 2978 articles, 14 studies met the inclusion criteria with a total of 56 164 participants from nine countries. The extracted risk factors were from the following categories: demographic, critical care interventions, surgery-related factors, pre-existing comorbidities, severity of organ injury, and biomarkers and biochemical and molecular indicators. From demographic factors, older age and male gender were associated with an increased risk of sepsis among ICU-admitted patients. CONCLUSION Our analysis comprehensively summarised the risk factors of sepsis in patients admitted to medical, surgical, neurologic, trauma, and general ICUs. Age, sex, and comorbidities were non-modifiable risk factors; however, critical care interventions and surgery-related factors were modifiable factors and suggest that improving the care of surgical patients and effective management of critical care interventions may play a key role in decreasing the development of sepsis in patients admitted to the ICUs.
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Defining the Intrinsic Cardiac Risks of Operations to Improve Preoperative Cardiac Risk Assessments. Anesthesiology 2018; 128:283-292. [DOI: 10.1097/aln.0000000000002024] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
Current preoperative cardiac risk stratification practices group operations into broad categories, which might inadequately consider the intrinsic cardiac risks of individual operations. We sought to define the intrinsic cardiac risks of individual operations and to demonstrate how grouping operations might lead to imprecise estimates of perioperative cardiac risk.
Methods
Elective operations (based on Common Procedural Terminology codes) performed from January 1, 2010 to December 31, 2015 at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program were studied. A composite measure of perioperative adverse cardiac events was defined as either cardiac arrest requiring cardiopulmonary resuscitation or acute myocardial infarction. Operations’ intrinsic cardiac risks were derived from mixed-effects models while controlling for patient mix. Resultant risks were sorted into low-, intermediate-, and high-risk categories, and the most commonly performed operations within each category were identified. Intrinsic operative risks were also examined using a representative grouping of operations to portray within-group variation.
Results
Sixty-six low, 30 intermediate, and 106 high intrinsic cardiac risk operations were identified. Excisional breast biopsy had the lowest intrinsic cardiac risk (overall rate, 0.01%; odds ratio, 0.11; 95% CI, 0.02 to 0.25) relative to the average, whereas aorto-bifemoral bypass grafting had the highest (overall rate, 4.1%; odds ratio, 6.61; 95% CI, 5.54 to 7.90). There was wide variation in the intrinsic cardiac risks of operations within the representative grouping (median odds ratio, 1.40; interquartile range, 0.88 to 2.17).
Conclusions
A continuum of intrinsic cardiac risk exists among operations. Grouping operations into broad categories inadequately accounts for the intrinsic cardiac risk of individual operations.
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Abstract
Older adults undergoing elective surgical procedures suffer higher rates of morbidity and mortality than younger patients. A geriatric-focused preoperative evaluation can identify risk factors for complications and opportunities for health optimization and care coordination. Key components of a geriatric preoperative evaluation include (1) assessments of function, mobility, cognition, and mental health; (2) reviews of medical conditions and medications; and (3) discussion of risks, preferences, and goals of care. A geriatric-focused, team-based approach can improve surgical outcomes and patient experience.
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Affiliation(s)
- Julianna G Marwell
- Department of Medicine, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Mitchell T Heflin
- Division of Geriatrics, Duke University School of Medicine, DUMC Box 3003, Durham, NC 27710, USA
| | - Shelley R McDonald
- Division of Geriatrics, Duke University School of Medicine, DUMC Box 3003, Durham, NC 27710, USA.
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Araujo BLDC, Theobald D. Letter to the Editor: ASA Physical Status Classification in Surgical Oncology and the Importance of Improving Inter-Rater Reliability. J Korean Med Sci 2017; 32:1211-1212. [PMID: 28581282 PMCID: PMC5461329 DOI: 10.3346/jkms.2017.32.7.1211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 05/20/2017] [Indexed: 11/20/2022] Open
Affiliation(s)
- Bruno Luís de Castro Araujo
- Department of Anesthesiology, Hospital do Câncer II, Instituto Nacional do Câncer José Alencar Gomes da Silva, Rio de Janeiro, Brazil.
| | - Daniele Theobald
- Department of Anesthesiology, Hospital do Câncer II, Instituto Nacional do Câncer José Alencar Gomes da Silva, Rio de Janeiro, Brazil
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Galyfos G, Sianou A, Filis K. Pleiotropic effects of statins in the perioperative setting. Ann Card Anaesth 2017; 20:S43-S48. [PMID: 28074822 PMCID: PMC5299828 DOI: 10.4103/0971-9784.197796] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Statins belong to a specific group of drugs that have been described for their ability to control hyperlipidemia as well as for other pleiotropic effects such as improving vascular endothelial function, inhibition of oxidative stress pathways, and anti-inflammatory actions. Accumulating clinical evidence strongly suggests that statins also have a beneficial effect on perioperative morbidity and mortality. Therefore, this review aims to present all recent and pooled data on statin treatment in the perioperative setting as well as to highlight considerations regarding their indications and therapeutic application.
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Affiliation(s)
- George Galyfos
- Department of Propaedeutic Surgery, Division of Vascular Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Argyri Sianou
- Department of Microbiology, University of Athens Medical School, Areteion Hospital, Athens, Greece
| | - Konstantinos Filis
- Department of Propaedeutic Surgery, Division of Vascular Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
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Peacock MR, Farber A, Eslami MH, Kalish JA, Rybin D, Doros G, Shah NK, Siracuse JJ. Hypoalbuminemia Predicts Perioperative Morbidity and Mortality after Infrainguinal Lower Extremity Bypass for Critical Limb Ischemia. Ann Vasc Surg 2017; 41:169-175.e4. [PMID: 28242402 DOI: 10.1016/j.avsg.2016.08.043] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/16/2016] [Accepted: 08/17/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Poor nutritional status has been associated with a higher risk of morbidity and mortality in general surgery patients; however, outcomes in vascular surgery patients are unclear. Our goal was to determine the effect of poor nutritional status on perioperative morbidity and mortality after lower extremity bypass (LEB). METHODS The 2005-2012 National Surgical Quality Improvement Program was analyzed to determine associated complications, mortality, length of stay (LOS), and readmissions for patients with hypoalbuminemia (serum albumin <3.5 g/dL and <2.8 g/dL) undergoing infrainguinal lower extremity bypass for critical limb ischemia. Multivariable analyses were performed to assess associated risk factors while adjusting for possible confounders. RESULTS There were 5,110 LEB identified with an albumin level recorded. There were 2,327 (45.5%) patients with a low preoperative albumin. Patients with a low albumin were more likely to have diabetes, chronic obstructive pulmonary disease, congestive heart failure, previous myocardial infarction, renal failure, dialysis dependence, hypertension, history of transient ischemic attack or stroke, steroid use, impaired functional status, dyspnea at rest, anemia, prior operations within 30 days, preoperative wounds or infections, and a tibial target (P < 0.05). Multivariable analyses showed that low albumin was independently associated with increased mortality (odds ratio [OR]: 1.8, 95% confidence interval [95% CI]: 1.3-2.6, P = 0.001), return to the operating room (OR: 1.4, 95% CI: 1.2-1.6, P < 0.001), and increased LOS (MR: 1.2, 95% CI: 1.1-1.2, P < 0.001). When compared with patients with normal albumin, patients with more severe hypoalbuminemia, less than 2.8 g/dL, showed further increased risk of mortality (OR: 2.5, 95% CI: 1.6-3.8), return to the operating room (OR: 1.6, 95% CI: 1.3-2.0), and prolonged LOS (MR: 1.2, 95% CI: 1.2-1.3). CONCLUSIONS Poor preoperative hypoalbuminemia is associated with morbidity and mortality after infrainguinal lower extremity bypass for critical limb ischemia. Evaluation and optimization of nutritional status should be performed preoperatively in this high risk population.
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Affiliation(s)
- Matthew R Peacock
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA
| | - Denis Rybin
- Department of Biostatistics, Boston University, Boston, MA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University, Boston, MA
| | - Nishant K Shah
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA.
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Abstract
Geriatric patients are over-represented in hospitalizations, surgeries, and perioperative complications. Special consideration is required for this patient group in the perioperative period because of the prevalence of comorbid diseases, functional impairments, and other deficits. A comprehensive preoperative evaluation strategy is recommended to identify and address these issues. Systematic, multidomain assessments should be performed and paired with risk reduction efforts. A shared understanding of patient function and long-term health goals is also important for providing patient-centered care of the geriatric surgical patient.
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Ollila A, Virolainen J, Vanhatalo J, Vikatmaa P, Tikkanen I, Venermo M, Salmenperä M, Pettilä V, Vikatmaa L. Postoperative Cardiac Ischemia Detection by Continuous 12-Lead Electrocardiographic Monitoring in Vascular Surgery Patients: A Prospective, Observational Study. J Cardiothorac Vasc Anesth 2016; 31:950-956. [PMID: 27919716 DOI: 10.1053/j.jvca.2016.09.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Elderly patients undergoing vascular surgery are at major risk for perioperative cardiac complications. The authors investigated continuous electrocardiographic Holter monitoring in a postoperative setting to determine the degree of postoperative ischemic load and its possible associations with perioperative myocardial infarction. DESIGN A prospective, observational study. SETTING One university hospital. PARTICIPANTS The study comprised 51 patients aged 65 years or older undergoing peripheral arterial surgery. INTERVENTIONS Continuous electrocardiographic monitoring with a Holter device was started postoperatively and continued for 72 hours or until discharge. Postural changes were recorded using a 3-axis accelerometer. Standard 12-lead electrocardiography, high-sensitive troponin T measurements, and an inquiry of ischemic symptoms were performed 4 times perioperatively. MEASUREMENTS AND MAIN RESULTS The primary outcomes were ischemic load (area under the function of ischemic ST-segment deviation and ischemic time) and perioperative myocardial infarction. During 3,262.7 patient-hours of monitoring, 17 patients (33.3%) experienced 608 transient ischemic events, all denoted by ST-segment depression. Of these 17 patients, 5 experienced perioperative myocardial infarction. The mean ischemic load in all patients was 913.2±2,797.3 µV×minute. Ischemic load predicted perioperative myocardial infarction, with an area under receiver operating characteristics curve (95% confidence interval) of 0.87 (0.75-0.99). Ischemic changes occurred most frequently during hours 24 to 60 of monitoring. Ischemia was asymptomatic in 14 of 17 patients (82.4%). CONCLUSION Postoperative myocardial ischemia was common in peripheral vascular surgery patients and may progress to perioperative myocardial infarction. Ischemic load was a good predictor of perioperative myocardial infarction. Ambulatory electrocardiographic monitoring solutions for continuous postoperative ischemia detection are warranted in the surgical ward.
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Affiliation(s)
- Aino Ollila
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Virolainen
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Pirkka Vikatmaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Tikkanen
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Minerva Foundation Institute for Medical Research, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Salmenperä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leena Vikatmaa
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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30
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Ollila A, Vikatmaa L, Virolainen J, Vikatmaa P, Leppäniemi A, Albäck A, Salmenperä M, Pettilä V. Perioperative Myocardial Infarction in Non-Cardiac Surgery Patients: A Prospective Observational Study. Scand J Surg 2016; 106:180-186. [DOI: 10.1177/1457496916673585] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Aims: Perioperative myocardial infarction is an underdiagnosed complication causing morbidity, mortality, and considerable costs. However, evidence of preventive and therapeutic options is scarce. We investigated the incidence and outcome of perioperative myocardial infarction in non-cardiac surgery patients in order to define a target population for future interventional trials. Material and Methods: We conducted a prospective single-center study on non-cardiac surgery patients aged 50 years or older. High-sensitivity troponin T and electrocardiograph were obtained five times perioperatively. Perioperative myocardial infarction diagnosis required a significant troponin T release and an ischemic sign or symptom. Perioperative risk calculator was used for risk assessment. Results: Of 385 patients with systematic ischemia screening, 27 patients (7.0%) had perioperative myocardial infarction. The incidence was highest in vascular surgery—19 of 172 patients (11.0%). The 90-day mortality was 29.6% in patients with perioperative myocardial infarction and 5.6% in non–perioperative myocardial infarction patients ( p < 0.001). Perioperative risk calculator predicted perioperative myocardial infarction with an area under curve of 0.73 (95% confidence interval: 0.64–0.81). Conclusion: Perioperative myocardial infarction is a common complication associated with a 90-day mortality of 30%. The ability of the perioperative risk calculator to predict perioperative myocardial infarction was fair supporting its routine use.
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Affiliation(s)
- A. Ollila
- Department of Intensive Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Anaesthesiology and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - L. Vikatmaa
- Department of Anaesthesiology and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J. Virolainen
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P. Vikatmaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A. Leppäniemi
- Department of Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A. Albäck
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M. Salmenperä
- Department of Anaesthesiology and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - V. Pettilä
- Department of Intensive Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Fantola G, Brunaud L, Nguyen-Thi PL, Germain A, Ayav A, Bresler L. Risk factors for postoperative complications in robotic general surgery. Updates Surg 2016; 69:45-54. [PMID: 27696276 DOI: 10.1007/s13304-016-0398-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 09/19/2016] [Indexed: 12/01/2022]
Abstract
The feasibility and safety of robotically assisted procedures in general surgery have been reported from various groups worldwide. Because postoperative complications may lead to longer hospital stays and higher costs overall, analysis of risk factors for postoperative surgical complications in this subset of patients is clinically relevant. The goal of this study was to identify risk factors for postoperative morbidity after robotic surgical procedures in general surgery. We performed an observational monocentric retrospective study. All consecutive robotic surgical procedures from November 2001 to December 2013 were included. One thousand consecutive general surgery patients met the inclusion criteria. The mean overall postoperative morbidity and major postoperative morbidity (Clavien >III) rates were 20.4 and 6 %, respectively. This included a conversion rate of 4.4 %, reoperation rate of 4.5 %, and mortality rate of 0.2 %. Multivariate analysis showed that ASA score >3 [OR 1.7; 95 % CI (1.2-2.4)], hematocrit value <38 [OR 1.6; 95 % CI (1.1-2.2)], previous abdominal surgery [OR 1.5; 95 % CI (1-2)], advanced dissection [OR 5.8; 95 % CI (3.1-10.6)], and multiquadrant surgery [OR 2.5; 95 % CI (1.7-3.8)] remained independent risk factors for overall postoperative morbidity. It also showed that advanced dissection [OR 4.4; 95 % CI (1.9-9.6)] and multiquadrant surgery [OR 4.4; 95 % CI (2.3-8.5)] remained independent risk factors for major postoperative morbidity (Clavien >III). This study identifies independent risk factors for postoperative overall and major morbidity in robotic general surgery. Because these factors independently impacted postoperative complications, we believe they could be taken into account in future studies comparing conventional versus robot-assisted laparoscopic procedures in general surgery.
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Affiliation(s)
- Giovanni Fantola
- Department of Digestive, Hepato-Biliary, Endocrine, and Surgical Oncology, CHU Nancy-Hospital Brabois Adultes, University de Lorraine, 11 allee du morvan, 54511, Vandoeuvre les Nancy, France
| | - Laurent Brunaud
- Department of Digestive, Hepato-Biliary, Endocrine, and Surgical Oncology, CHU Nancy-Hospital Brabois Adultes, University de Lorraine, 11 allee du morvan, 54511, Vandoeuvre les Nancy, France. .,Faculty de medicine, INSERM U954, University de Lorraine, Nancy, France.
| | - Phi-Linh Nguyen-Thi
- Clinical Epidemiology and Evaluation Department, INSERM, CIC-EC1433, CHU Nancy, Pôle S2R, University de Lorraine, 54000, Nancy, France
| | - Adeline Germain
- Department of Digestive, Hepato-Biliary, Endocrine, and Surgical Oncology, CHU Nancy-Hospital Brabois Adultes, University de Lorraine, 11 allee du morvan, 54511, Vandoeuvre les Nancy, France
| | - Ahmet Ayav
- Department of Digestive, Hepato-Biliary, Endocrine, and Surgical Oncology, CHU Nancy-Hospital Brabois Adultes, University de Lorraine, 11 allee du morvan, 54511, Vandoeuvre les Nancy, France
| | - Laurent Bresler
- Department of Digestive, Hepato-Biliary, Endocrine, and Surgical Oncology, CHU Nancy-Hospital Brabois Adultes, University de Lorraine, 11 allee du morvan, 54511, Vandoeuvre les Nancy, France
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Heiberg J, El-Ansary D, Canty DJ, Royse AG, Royse CF. Focused echocardiography: a systematic review of diagnostic and clinical decision-making in anaesthesia and critical care. Anaesthesia 2016; 71:1091-100. [DOI: 10.1111/anae.13525] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2016] [Indexed: 01/15/2023]
Affiliation(s)
- J. Heiberg
- Department of Anaesthesia and Pain Management; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - D. El-Ansary
- Department of Physiotherapy; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - D. J. Canty
- Department of Anaesthesia and Pain Management; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - A. G. Royse
- Department of Surgery; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - C. F. Royse
- Department of Anaesthesia and Pain Management; Royal Melbourne Hospital; Melbourne Victoria Australia
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Heiberg J, El-Ansary D, Royse CF, Royse AG, Alsaddique AA, Canty DJ. Transthoracic and transoesophageal echocardiography: a systematic review of feasibility and impact on diagnosis, management and outcome after cardiac surgery. Anaesthesia 2016; 71:1210-21. [PMID: 27341788 DOI: 10.1111/anae.13545] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 11/29/2022]
Abstract
Transthoracic and transoesophageal echocardiography are increasingly used as tools to improve clinical assessment following cardiac surgery. However, most physicians are not trained in echocardiography, and there is no widespread agreement on the feasibility, indications or effect on outcome of transthoracic or transoesophageal echocardiography for patients after cardiac surgery. We performed a systematic review of electronic databases for focused transthoracic and transoesophageal echocardiography after cardiac surgery which revealed 15 full-text articles. They consistently reported that echocardiography is feasible, whether performed by a novice or expert, and frequently resulted in important changes in diagnosis of cardiac abnormalities and their management. However, most were observational studies and there were no well-designed trials investigating the impact of echocardiography on outcome. We conclude that both transthoracic and transoesophageal echocardiography are useful following cardiac surgery.
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Affiliation(s)
- J Heiberg
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia.
| | - D El-Ansary
- Department of Physiotherapy, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - C F Royse
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - A G Royse
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - A A Alsaddique
- Department of Cardiothoracic Surgery, King Fahad Cardiac Centre, Riyadh, Saudi Arabia
| | - D J Canty
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Piazza O, Miccichè V, Esposito C, Romano G, De Robertis E. Individualised prediction of postoperative cardiorespiratory complications after upper abdominal surgery. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2016. [DOI: 10.1016/j.tacc.2016.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Abstract
BACKGROUND Risk adjustment is an important component of surgical outcomes and quality analyses. Current models include numerous preoperative variables; however, the relative contribution of these variables may be limited. This research seeks to identify a model with the fewest number of variables necessary to perform an adequate risk adjustment to predict any inpatient adverse event for use in resource-limited settings. METHODS All patients from the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2010 were included. Outcomes were inpatient mortality or any surgical complication captured by NSQIP. Models were built by sequential addition of preoperative risk variables selected by their area under the receiver operator characteristic curve (AUC). RESULTS Among 863,349 patients, the single variable with the highest AUC was American Society of Anesthesiologists (ASA) classification (AUC = 0.7127). AUC values reached 0.7923 with five variables (ASA classification, wound classification, functional status prior to surgery, albumin, and age) and 0.7945 with six variables. The sixth variable was one of the following: alkaline phosphatase, weight loss, principal anesthesia technique, gender, or emergency status. The model with the highest discrimination that did not require laboratories included ASA classification, functional status prior to surgery, wound classification, and age (AUC = 0.7810). Including all 66 preoperative variables produced little additional gain (AUC = 0.8006). CONCLUSIONS Six variables are sufficient to develop a risk adjustment tool for inpatient surgical mortality and morbidity. This research has important implications for the field of surgical outcomes research by improving efficiency of data collection. This limited model can aid the expansion of risk-adjusted analyses to resource-limited settings worldwide.
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36
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Xu L, Yu C, Jiang J, Zheng H, Yao S, Pei L, Sun L, Xue F, Huang Y. Major adverse cardiac events in elderly patients with coronary artery disease undergoing noncardiac surgery: A multicenter prospective study in China. Arch Gerontol Geriatr 2015; 61:503-9. [PMID: 26272285 DOI: 10.1016/j.archger.2015.07.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/20/2015] [Accepted: 07/31/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Major adverse cardiac events (MACEs) are important causes of perioperative morbidity and mortality for elderly patients undergoing non-cardiac surgery. Treatment and control rates for coronary artery disease (CAD) in Chinese patients are poorer than rates in western countries. However, no previous prospective study has focused on perioperative MACE in this population. Our aim was to ascertain the incidence and risk factors associated with MACEs in Chinese patients. METHODS Consecutive CAD patients, aged ≥60 years, who underwent non-cardiac surgery at five medical centers in China, were prospectively enrolled. Clinical variables, including electrocardiogram and troponin I levels, were evaluated to estimate MACEs. The main outcome was occurrence of at least one perioperative MACE from admittance to 30 days after surgery, defined as any of the following complications: cardiac death, nonfatal cardiac arrest, acute myocardial infarction (MI), congestive heart failure (CHF), and angina. MACE independent risk factors were based on the Andersen-Gill multiplicative intensity model. RESULTS Of the 1422 patients recruited, 129 (9.1%) developed at least one MACE, and cardiac death occurred in 11 patients (0.8%). The independent risk factors contributing to postoperative MACE included age ≥75 years, female gender, history of MI, history of hypertension, high-risk surgery, intraoperative hypotension, and intraoperative hypoxemia. CONCLUSIONS The incidence of MACE in Chinese elderly patients with CAD who underwent non-cardiac surgery was 9.1%. Seven independent risk factors for a perioperative MACE were identified. Preventing intraoperative hypoxemia and hypotension may reduce the occurrence of MACE in these high risk patients.
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Affiliation(s)
- Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Chunhua Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jingmei Jiang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Science, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong Zheng
- Department of Anesthesiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Shanglong Yao
- Department of Anesthesiology,Union Hospital, Tong Ji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Ling Pei
- Department of Anesthesiology, First Affiliated Hospital of China Medical University Graduate School, Shenyang, Liaoning, China
| | - Li Sun
- Department of Anesthesiology, Cancer Hospital of Chinese Academy of Medical Sciences, Beijing, China
| | - Fang Xue
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Science, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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Risk factors for adverse cardiac events in hip fracture patients: an analysis of NSQIP data. INTERNATIONAL ORTHOPAEDICS 2015. [DOI: 10.1007/s00264-015-2832-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Alvarez Escudero J, Calvo Vecino JM, Veiras S, García R, González A. Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery: reducing risk of heart failure patients in noncardiac surgery. ACTA ACUST UNITED AC 2015; 62:359-419. [PMID: 26164471 DOI: 10.1016/j.redar.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 12/29/2022]
Affiliation(s)
- J Alvarez Escudero
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - J M Calvo Vecino
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain; Associated Professor and Head of the Department of Anesthesiology, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - S Veiras
- Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - R García
- Department of Anesthesiology, Puerta del Mar University Hospital. Cadiz, Spain
| | - A González
- Department of Anesthesiology, Puerta de Hierro University Hospital. Madrid, Spain
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Visser A, Geboers B, Gouma DJ, Goslings JC, Ubbink DT. Predictors of surgical complications: A systematic review. Surgery 2015; 158:58-65. [DOI: 10.1016/j.surg.2015.01.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/13/2015] [Accepted: 01/14/2015] [Indexed: 12/18/2022]
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40
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Ajaimy M, Lubetzky M, Kamal L, Gupta A, Dunn C, de Boccardo G, Akalin E, Kayler L. Kidney transplantation in patients with severe preoperative hypertension. Clin Transplant 2015; 29:781-5. [PMID: 26084790 DOI: 10.1111/ctr.12579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Severe systemic hypertension (HTN) is a risk factor for perioperative cardiovascular complications; however, its impact at the time of kidney transplantation (KTX) is not well defined. METHODS A retrospective cohort study of adult kidney-only transplant recipients between October 2009 and December 2012 was performed to examine outcomes between patients with (n = 111) and without (n = 98) severe preoperative HTN defined as SBP > 180 or DBP > 110 mmHg. RESULTS Recipients with severe HTN were older (56.7 ± 13.0 vs. 53.5 ± 12.4 yr, p = 0.07) and significantly more likely to receive an expanded criteria donor kidney (32.7% vs. 12.2%, p = 0.02). No patients developed hypertensive crisis, intracranial hemorrhage, or life threatening ventricular arrhythmias within 30 d post-transplantation; however, three patients with severe HTN had cardiac events: two with demand ischemia and one with decompensate heart failure. Two patients in the control group had decompensated heart failure. There were no differences between the groups in terms of cardiac event (2.7% vs. 2.0%, p = 0.75), one-yr patient survival (98.2% vs. 98.0%, p = 0.90) or graft survival (90.1% vs. 92.9%, p = 0.48), nadir creatinine > 2 mg/dL (4.6% vs. 6.2%, p = 0.62), length of stay > 6 d (37.8% vs. 35.7%, p = 0.75), and DGF (52.3% vs. 63.3%, p = 0.11). CONCLUSIONS Our results suggest that severe preoperative HTN should not be considered an absolute contraindication to kidney transplant in patients who are otherwise clinically stable.
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Affiliation(s)
- Maria Ajaimy
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Renal Division, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michelle Lubetzky
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Renal Division, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Layla Kamal
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Renal Division, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Anjali Gupta
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Renal Division, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Colin Dunn
- Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Graciela de Boccardo
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Renal Division, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Enver Akalin
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Renal Division, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Liise Kayler
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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41
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Moghadamyeghaneh Z, Mills SD, Carmichael JC, Pigazzi A, Stamos MJ. Risk Factors of Postoperative Myocardial Infarction after Colorectal Surgeries. Am Surg 2015. [DOI: 10.1177/000313481508100425] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are limited data regarding the specific risk factors of postoperative myocardial infarction (MI) in patients undergoing colorectal resectional surgery. We sought to identify risk factors of acute MI after colorectal resection operations. The National Inpatient Sample database was used to identify patients who had postoperative MI after colorectal resection operations between 2002 and 2010. Statistical analysis was performed to identify factors predictive of postoperative MI. We sampled a total of 2,513,124 patients undergoing colorectal resection, of whom 38,317 (1.5%) sustained a postoperative MI. Patients with postoperative MI had associated 28.5 per cent in-hospital mortality. Risk factors identified include ( P < 0.01): history of congestive heart failure (odds ratio [OR], 8.18), chronic renal failure (OR, 3.86), age 70 years or older (OR, 3.68), peripheral vascular disorders (OR, 2.93), fluid and electrolyte disorders (OR, 2.69), emergency admission (OR, 2.56), preoperative weight loss (OR, 2.49), cardiac valvular disease (OR, 2.46), chronic lung disease (OR, 1.75), deficiency anemia (OR, 1.22), colorectal cancer (OR, 1.77), and hypertension (OR, 1.14). Postoperative MI occurs in less than 2 per cent of colorectal resections. However, patients sustaining postoperative MI are over six times more likely to die. Congestive heart failure and chronic renal failure are the strongest predictors of postoperative MI.
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Affiliation(s)
- Zhobin Moghadamyeghaneh
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Steven D. Mills
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Joseph C. Carmichael
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Alessio Pigazzi
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Michael J. Stamos
- Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
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Lim S, Parsa AT, Kim BD, Rosenow JM, Kim JYS. Impact of resident involvement in neurosurgery: an analysis of 8748 patients from the 2011 American College of Surgeons National Surgical Quality Improvement Program database. J Neurosurg 2015; 122:962-70. [PMID: 25614947 DOI: 10.3171/2014.11.jns1494] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECT This study evaluates the impact of resident presence in the operating room on postoperative outcomes in neurosurgery. METHODS The authors retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified all cases treated in a neurosurgery service in 2011. Propensity scoring analysis and multiple logistic regression models were used to reduce patient bias and to assess independent effect of resident involvement. RESULTS Of the 8748 neurosurgery cases identified, residents were present in 4529 cases. Residents were more likely to be involved in complex procedures with longer operative duration. The multivariate analysis found that resident involvement was not a statistically significant factor for overall complications (OR 1.116, 95% CI 0.961-1.297), surgical complications (OR 1.132, 95% CI 0.825-1.554), medical complications (OR 1.146, 95% CI 0.979-1.343), reoperation (OR 1.250, 95% CI 0.984-1.589), mortality (OR 1.164, 95% CI 0.780-1.737), or unplanned readmission (OR 1.148, 95% CI 0.946-1.393). CONCLUSIONS In this multicenter study, the authors demonstrated that resident involvement in the operating room was not a significant factor for postoperative complications in neurosurgery service. This analysis also showed that much of the observed difference in postoperative complication rates was attributable to other confounding factors. This is a quality indicator for resident trainees and current medical education. Maintaining high standards in postgraduate training is imperative in enhancing patient care and reducing postoperative complications.
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Affiliation(s)
- Seokchun Lim
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago; and
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A case-cohort study of postoperative myocardial infarction: impact of anemia and cardioprotective medications. Surgery 2014; 156:1018-26, 1029. [PMID: 25239363 DOI: 10.1016/j.surg.2014.06.055] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/24/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Postoperative myocardial infarction (poMI) is a serious and costly complication. Multiple risk factors for poMI are known, but the effect of anemia and cardioprotective medications have not been defined in real-world surgical practice. METHODS Patients undergoing inpatient elective surgery were assessed at 17 hospitals from 2008 to 2011 for the occurrence of poMI (American Heart Association definition). Non-MI control patients were chosen randomly on the basis of case type. Descriptive, univariable, and multivariable statistical analysis were performed for primary outcomes of poMI and death at 30 days. RESULTS Compared with controls (N = 304), patients with poMI (N = 222) were older (72 ± 11 vs 60 ± 17 years, P < .0001), had a lesser preoperative hematocrit (37 ± 6 vs 39 ± 5, P < .0001), more often were smokers, had a preoperative T-wave abnormality (21% vs 9%, P < .0001), and had a preoperative stress test with a fixed deficit (26% vs 3%; P < .001). Preoperative factors associated with poMI included peripheral vascular disease (odds ratio 2.6; 95% confidence interval 1.3-5.3), tobacco use (1.7; 1.01-2.9), history of percutaneous coronary angioplasty (2.8; 1.6-5.0), and age (1.05; 1.03-1.07), whereas hematocrit >35 (0.51; 0.32-0.82) and preoperative acetylsalicylic acid, ie, aspirin (0.59; 0.4-0.97) were protective. Preoperative β-blockade, statin, and use of angiotensin-converting enzyme inhibitors were not associated with lesser rates of poMI. Non-MI complication rates were 23-fold greater in the poMI group compared with the control group (P < .0001). Mortality with poMI within 30 days was 11% compared with 0.3% in non-MI control patients (P < .0001). In patients with poMI, factors independently associated with death included use of epidurals (3.5; 1.07-11.4) and bleeding (4.2; 1.1-16), whereas preoperative use of aspirin (0.29; 0.1-0.88), and postoperative β-blockade (0.18; 0.05-0.63) were protective. Cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass grafting after poMI was performed in 34% of those alive and 20% of those who died (P = .16). CONCLUSION In the current era, poMI patients have a markedly increased risk of death. This risk is decreased with preoperative use of acetylsalicylic acid and post MI β-blockade. Further study is warranted to explore the role of anemia and cardiac interventions after poMI.
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Eachempati SR, Cocanour CS, Dultz LA, Phatak UR, Albarado R, Rob Todd S. Acute cholecystitis in the sick patient. Curr Probl Surg 2014; 51:441-66. [PMID: 25497405 DOI: 10.1067/j.cpsurg.2014.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 10/30/2014] [Indexed: 12/24/2022]
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Rodseth RN, Vasconcellos K, Naidoo P, Biccard BM. Preoperative B-type natriuretic peptide risk stratification: do postoperative indices add value? SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2013.10872893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- RN Rodseth
- Perioperative Research Group, Department of Anaesthetics, University of KwaZulu-Natal, Durban; Outcomes Research Consortium, Cleveland, Ohio
| | - K Vasconcellos
- Outcomes Research Consortium, Cleveland, Ohio; Department of Anaesthetics and Critical Care, King Edward V Hospital, Durban
| | - P Naidoo
- National Health Laboratory Services; Department of Chemical Pathology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - BM Biccard
- Perioperative Research Group, Department of Anaesthetics, University of KwaZulu-Natal, Durban
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46
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Skinner DL, Goga S, Rodseth RN, Biccard BM. A meta-analysis of intraoperative factors associated with postoperative cardiac complications. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2012.10872851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- DL Skinner
- Department of Surgery, University of Kwazulu-Natal
| | - S Goga
- Perioperative Research Unit, Department of Anaesthetics, University of Kwazulu-Natal
| | - RN Rodseth
- Perioperative Research Unit, Department of Anaesthetics, University of Kwazulu-Natal
| | - BM Biccard
- Perioperative Research Unit, Department of Anaesthetics, University of Kwazulu-Natal
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47
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Edelstein AI, Lovecchio FC, Saha S, Hsu WK, Kim JYS. Impact of Resident Involvement on Orthopaedic Surgery Outcomes: An Analysis of 30,628 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database. J Bone Joint Surg Am 2014; 96:e131. [PMID: 25100784 DOI: 10.2106/jbjs.m.00660] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Operative procedural training is a key component of orthopaedic surgery residency. The influence of intraoperative resident participation on the outcomes of surgery has not been studied extensively using large, population-based databases. METHODS We identified 30,628 patients who underwent orthopaedic procedures from the 2011 American College of Surgeons National Surgical Quality Improvement Program. Outcomes as measured by perioperative complications, readmission rates, and mortality within thirty days were compared for cases with and without intraoperative resident involvement. RESULTS Logistic regression with propensity score analysis revealed that intraoperative resident participation was associated with decreased rates of overall complications (odds ratio, 0.717 [95% confidence interval, 0.657 to 0.782]), medical complications (odds ratio, 0.723 [95% confidence interval, 0.661 to 0.790]), and mortality (odds ratio, 0.638 [95% confidence interval, 0.427 to 0.951]). Resident presence in the operating room was not predictive of wound complications (odds ratio, 0.831 [95% confidence interval, 0.656 to 1.053]), readmission (odds ratio, 0.962 [95% confidence interval, 0.830 to 1.116]), or reoperation (odds ratio, 0.938 [95% confidence interval, 0.758 to 1.161]). A second analysis by propensity score stratification into quintiles grouped by similar probability of intraoperative resident presence showed resident involvement to correlate with decreased rates of overall and medical complications in three quintiles, but increased rates of overall and medical complications in one quintile. All other outcomes were equivalent across quintiles. CONCLUSIONS Orthopaedic resident involvement during surgical procedures is associated with lower risk of perioperative complications and mortality in the National Surgical Quality Improvement Program database. The results support resident participation in the operative care of orthopaedic patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Adam I Edelstein
- Departments of Orthopaedic Surgery (A.I.E. and W.K.H.) and Surgery (F.C.L., S.S., and J.Y.S.K.), Northwestern University, Feinberg School of Medicine, 675 North Saint Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail address for J.Y.S. Kim:
| | - Francis C Lovecchio
- Departments of Orthopaedic Surgery (A.I.E. and W.K.H.) and Surgery (F.C.L., S.S., and J.Y.S.K.), Northwestern University, Feinberg School of Medicine, 675 North Saint Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail address for J.Y.S. Kim:
| | - Sujata Saha
- Departments of Orthopaedic Surgery (A.I.E. and W.K.H.) and Surgery (F.C.L., S.S., and J.Y.S.K.), Northwestern University, Feinberg School of Medicine, 675 North Saint Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail address for J.Y.S. Kim:
| | - Wellington K Hsu
- Departments of Orthopaedic Surgery (A.I.E. and W.K.H.) and Surgery (F.C.L., S.S., and J.Y.S.K.), Northwestern University, Feinberg School of Medicine, 675 North Saint Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail address for J.Y.S. Kim:
| | - John Y S Kim
- Departments of Orthopaedic Surgery (A.I.E. and W.K.H.) and Surgery (F.C.L., S.S., and J.Y.S.K.), Northwestern University, Feinberg School of Medicine, 675 North Saint Clair Street, Galter Suite 19-250, Chicago, IL 60611. E-mail address for J.Y.S. Kim:
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48
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Biccard BM, Devereaux PJ, Rodseth RN. Cardiac biomarkers in the prediction of risk in the non-cardiac surgery setting. Anaesthesia 2014; 69:484-93. [PMID: 24738805 DOI: 10.1111/anae.12635] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2014] [Indexed: 12/24/2022]
Abstract
B-Type natriuretic peptides and troponin measurements have potential in predicting risk in patients undergoing non-cardiac surgery. Using the American Heart Association framework for the evaluation of novel biomarkers, we review the current evidence supporting the peri-operative use of these two biomarkers. In patients having major non-cardiac surgery who are risk stratified using clinical risk scores, the measurement of natriuretic peptides and troponin, both before and after surgery, significantly improves risk stratification. However, only pre- and postoperative natriuretic peptide measurement and postoperative troponin measurement have shown clinical utility. It is now important for trials to be conducted to determine whether integrating pre- and postoperative natriuretic peptide and postoperative troponin measurement into clinical practice is able to improve clinical outcomes in patients undergoing non-cardiac surgery.
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Affiliation(s)
- B M Biccard
- Perioperative Research Group, Department of Anaesthetics, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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49
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Jain U, Chandra RK, Smith SS, Pilecki M, Kim JYS. Predictors of readmission after outpatient otolaryngologic surgery. Laryngoscope 2014; 124:1783-8. [PMID: 24272648 DOI: 10.1002/lary.24533] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 11/14/2013] [Accepted: 11/19/2013] [Indexed: 11/05/2022]
Abstract
OBJECTIVES/HYPOTHESIS Hospital readmissions increase costs to hospitals and patients. There is a paucity of data on benchmark rates of readmission for otolaryngological surgery. Understanding the risk factors that increase readmission rates may help enhance patient education and set system-wide expectations. We aimed to provide benchmark data on causes and predictors of readmission following outpatient otolaryngological surgery. STUDY DESIGN This study is a retrospective analysis of the 2011 National Surgical Quality Improvement Program (NSQIP) dataset. METHODS NSQIP was reviewed for outpatients with "Otolaryngology (ENT)" as their recorded surgical specialty. Readmission was tracked through the "Unplanned Readmission" variable. Patient characteristics and outcomes were compared using chi-square analysis and student t tests for categorical and continuous variables, respectively. Multivariate regression analysis investigated predictors of readmission. RESULTS A total of 6,788 outpatient otolaryngological surgery patients were isolated. The unplanned readmission rate was 2.01%. Multivariate regression analysis revealed superficial surgical site infection (odds ratio [OR] 2.672, confidence interval [CI] 1.133-6.304, P = .025) and work relative value units (RVU) (OR .972, CI .944-1, P = .049) to be significant predictors of readmission. CONCLUSION Outpatient otolaryngological surgery has an associated 2.01% unplanned readmission rate. Superficial surgical site infection and work RVUs proved to be significant positive and negative risk factors, respectively, for readmission. These findings will help to benchmark outpatient readmission rates and manage patient and hospital system expectations.
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Affiliation(s)
- Umang Jain
- Division of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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50
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Domi R, Sula H, Ohri I, Beqiri A, Kaci M, Bodeci A, Laho H. Anesthetic challenges of patients with cardiac comorbidities undergoing major urologic surgery. Int Arch Med 2014; 7:17. [PMID: 24791166 PMCID: PMC4005855 DOI: 10.1186/1755-7682-7-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 04/20/2014] [Indexed: 11/23/2022] Open
Abstract
The cardiac patient undergoing major urologic surgery is a complex case requiring a great attention by the anesthesiologist. Number of this group of patients having to go through this procedure is constantly increasing, due to prolonged life, increased agressiveness of surgery and increased anesthesia's safety. The anesthesiologist usually has to deal with several problems of the patient, such as hypertension, chronic heart failure, coronary artery disease, rhythm disturbances, intraoperative hemodymanic changes, intraoperative bleeding, perioperative fluid imbalance, and metabolic disturbances. A cardiac patient undergoing major urologic surgery is a complex case requiring a great attention by the anesthesiologist. The scope of this review article is to present the most frequent issues encountered with this group of patients, and to synthetically discuss the respective strategies and maneuvers during perioperative period, which is the major challenge for the anesthesiologist.
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Affiliation(s)
- Rudin Domi
- Department of Anesthesiology and Intensive Care, “Mother Teresa” University Hospital Center, Tirana, Albania
| | - Hektor Sula
- Department of Anesthesiology and Intensive Care, “Mother Teresa” University Hospital Center, Tirana, Albania
| | - Ilir Ohri
- Department of Anesthesiology and Intensive Care, “Mother Teresa” University Hospital Center, Tirana, Albania
| | - Arben Beqiri
- Department of General Surgery, “Mother Teresa” University Hospital Center, Tirana, Albania
| | - Myzafer Kaci
- Department of General Surgery, “Mother Teresa” University Hospital Center, Tirana, Albania
| | - Artan Bodeci
- Department of General Surgery, “Mother Teresa” University Hospital Center, Tirana, Albania
| | - Haki Laho
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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