ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary

Tolerance of rapid right ventricular pacing during thoracic endovascular aortic repair

BACKGROUND

The objective of this retrospective study was to evaluate the tolerance of rapid right ventricular pacing (RRVP) compared with that of the traditional methods of hypotension used during thoracic endovascular aortic repair (TEVAR).

METHODS

From January 2002 to December 2012, we retrospectively included all the patients treated with TEVAR by comparing the 2 groups: patients operated with RRVP (RRVP+) and those operated without RRVP (RRVP-). The characteristics of the population and the procedures were recorded. The rates of complications were compared up to 1 year.

RESULTS

Sixty-one patients were operated. Treated pathologies were multiple with 19 aneurysms, 14 false aneurysms, 12 isthmic ruptures, 11 dissections, 3 coarctations, and 2 endoleaks. Twenty-four patients were RRVP+ and 37 patients were RRVP-. Mortality rates at 1 month in groups RRVP+ and RRVP- were of 0% and 2.7%, respectively (P = 1), and reintervention rates were 0% and 13.5%, respectively (P = 0.15). Three peroperative rhythm disorders (12.5%) were observed in the RRVP+ group including 2 ventricular fibrillations and 1 atrial fibrillation, both reduced without complications. One pacemaker was implanted for atrioventricular block in the RRVP- group. In the RRVP+ group, 83.3% of the patients presented a rise in troponin Ic (TnI) >0.04 ng/mL in 72 hours compared with 40.5% of the patients in the RRVP- group (P = 0.0013), with a spontaneously favorable evolution. No coronary syndrome was observed at 1 year with a mortality rate of 10.8% in the RRVP- group vs. 0% in the RRVP+ (P = 0.15).

CONCLUSIONS

In spite of a frequent moderate rise of TnI at the time of RRVP, this technique does not present more complications at 1 year than the use of a chemical hypotension. It thus seems an interesting alternative for selected patients, in trained teams.

Perioperative management of poly-trauma in a postmitral valve replacement patient with severe left ventricular systolic dysfunction

The anesthetic management of a patient with severe left ventricular (LV) dysfunction undergoing noncardiac surgery poses a challenge to the anesthesiologist as LV dysfunction is commonly complicated by progressive congestive heart failure and malignant arrhythmias. When the cause for LV dysfunction is postvalve replacement, additional complications such as intraoperative thrombosis, bleeding, and infective endocarditis need to be addressed perioperatively. In such situations, the anesthesiologist must have the knowledge hemodynamics, diagnostic evaluations, and treatment modalities, more so regarding various drugs used during anesthesia. We report a case of postmitral valve replaced patient with severe LV dysfunction posted for surgery of fracture of the femur and facial fractures managed successfully during anesthesia.

The implication of frailty on preoperative risk assessment

PURPOSE OF REVIEW

Frailty, a state of decreased homeostatic reserve, is characterized by dysregulation across multiple physiologic and molecular pathways. It is particularly relevant to the perioperative period, during which patients are subject to high levels of stress and inflammation. This review aims to familiarize the anesthesiologist with the most current concepts regarding frailty and its emerging role in preoperative assessment and risk stratification.

RECENT FINDINGS

Current literature has established frailty as a significant predictor of operative complications, institutionalization, and death among elderly surgical patients. A variety of scoring systems have been proposed to preoperatively identify and assess frail patients, though they differ in their clinical utility and prognostic ability. Additionally, evidence suggests an evolving potential for preoperative intervention and modification of the frailty syndrome.

SUMMARY

The elderly are medically complex and heterogeneous with respect to operative risk. Recent advances in the concept of frailty provide an evidence-based framework to guide the anesthesiologist in the perioperative management, evaluation, and risk stratification of older surgical patients.

Optimizing perioperative care for patients with hip fracture

Hip fracture is one of the most common orthopedic conditions associated with significant morbidity and mortality. Patients with hip fracture are usually older, with significant comorbidities. Delayed surgical treatment beyond 48 hours after admission is associated with significantly higher mortality. Hereby clinicians are presented with the challenge to optimize the complex hip fracture within a short time period. This article reviews the evidence regarding preoperative, intraoperative, and postoperative considerations, and provides insights into the best strategies with which to optimize the patient's condition and improve perioperative outcomes.

2014 korean guidelines for appropriate utilization of cardiovascular magnetic resonance imaging: a joint report of the korean society of cardiology and the korean society of radiology

Cardiac magnetic resonance (CMR) imaging is now widely used in several fields of cardiovascular disease assessment due to recent technical developments. CMR can give physicians information that cannot be found with other imaging modalities. However, there is no guideline which is suitable for Korean people for the use of CMR. Therefore, we have prepared a Korean guideline for the appropriate utilization of CMR to guide Korean physicians, imaging specialists, medical associates and patients to improve the overall medical system performances. By addressing CMR usage and creating these guidelines we hope to contribute towards the promotion of public health. This guideline is a joint report of the Korean Society of Cardiology and the Korean Society of Radiology.

Non-cardiac surgery after percutaneous coronary intervention

Perioperative management of patients after percutaneous coronary intervention presents physicians with unique challenges and dilemmas. Although newer generation drug-eluting stents, transcatheter-based therapies, and minimally invasive surgical techniques have changed the medical landscape, guidelines for managing perioperative patients after percutaneous intervention are based largely on expert opinion and inconsistent data from an earlier era. In conclusion, the aims of this review are to summarize the data pertinent to managing patients after percutaneous coronary intervention in the perioperative period and to explore future perspectives.

A case-cohort study of postoperative myocardial infarction: impact of anemia and cardioprotective medications

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.

2014 Korean guidelines for appropriate utilization of cardiovascular magnetic resonance imaging: a joint report of the Korean Society of Cardiology and the Korean Society of Radiology

Cardiac magnetic resonance (CMR) imaging is now widely used in several fields of cardiovascular disease assessment due to recent technical developments. CMR can give physicians information that cannot be found with other imaging modalities. However, there is no guideline which is suitable for Korean people for the use of CMR. Therefore, we have prepared a Korean guideline for the appropriate utilization of CMR to guide Korean physicians, imaging specialists, medical associates and patients to improve the overall medical system performances. By addressing CMR usage and creating these guidelines we hope to contribute towards the promotion of public health. This guideline is a joint report of the Korean Society of Cardiology and the Korean Society of Radiology.

Percutaneous nephrolithotomy during uninterrupted aspirin therapy in high-cardiovascular risk patients: preliminary report

OBJECTIVE

To determine the feasibility and safety of performing percutaneous nephrolithotomy (PCNL) in high-cardiovascular risk patients remaining on aspirin therapy.

METHODS

We retrospectively reviewed all PCNLs performed by 3 fellowship-trained endourologists at a single institution between July 2012 and January 2014. All patients remaining on aspirin for imperative indications through the day of surgery were evaluated for surgical outcomes and thromboembolic events.

RESULTS

Of 281 PCNL procedures performed during the study period, 16 (5.7%) were performed in 14 patients taking aspirin, uninterrupted, through surgery. Mean surgery time was 66 minutes, mean estimated blood loss was 161 mL, and mean length of hospital stay was 2.8 days. All patients were stone free. There were no intraoperative complications. A total of 5 patients experienced a postoperative complication (n = 4, Clavien grade II; n = 1, Clavien grade IIIa). No patient experienced a perioperative thromboembolic or cardiac event. Three patients required a blood transfusion postoperatively, and none experienced delayed renal bleeding.

CONCLUSION

PCNL can be performed safely and effectively in high-cardiovascular risk patients continuing aspirin perioperatively. Compared with the potential sequelae of a thromboembolic or cardiac event, PCNL is associated with an acceptably low transfusion rate, and should be considered a viable treatment option for large renal stones in this population.

Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age

Background

Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA.

Methods

We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital.

Results

Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P<0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01–1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged <70 years, 59 patients aged 70–79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008).

Conclusion

The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.

Evaluation of solid organ transplant candidates for coronary artery disease

Solid organ transplantation has increased in frequency in the United States, having evolved from an area of experimentation into accepted therapy for end-organ failure. As organ transplantation has become more common, the average age of transplant recipients has increased, thus increasing the potential for multiple comorbidities including coronary artery disease (CAD). CAD has been shown to be a major cause of morbidity and mortality in kidney, lung and liver transplant recipients. Identification of CAD in solid organ transplant candidates allows for stratification of short- and long-term risk, ensuring proper use of valuable allograft resources while guiding further patient management. Assessment of asymptomatic transplant candidates for CAD is difficult. Many patients undergo stress echocardiography or nuclear imaging, which have demonstrated inconsistent rates of sensitivity and specificity for the detection of CAD in these patient populations. Cardiac computed tomography is a potential tool for detecting CAD in these populations, but has questionable utility at this time. Coronary angiography has an important role in detecting CAD in high-risk transplant candidates, affecting their long-term management and risk.

Coronary risk in candidates for abdominal aortic aneurysm repair: a word of caution

BACKGROUND

Current guidelines do not recommend routine coronary evaluation preceding abdominal aortic aneurysms (AAA) repair in low-risk patients. The purpose of the present study is to report the incidence of coronary lesions in candidates for AAA repair with a Revised Cardiac Risk (Lee) Index (RCRI) < 2, which are usually excluded from preoperative cardiological work-up. Early-term and long-term results of prophylactic myocardial revascularization are also reported.

METHODS

A retrospective, observational, cohort study collecting clinical data on a series of 149 consecutive patients undergoing preoperative coronary angiography and myocardial revascularization (percutaneous coronary intervention, PCI; coronary artery bypass grafting, CABG) before elective open or endovascular AAA repair (January 2005-December 2012).

RESULTS

Severe coronary artery disease (CAD) was revealed in 43 patients (28.9%), who underwent successful myocardial revascularization by means of PCI (n.35) or off-pump CABG (n.8). The incidence of severe CAD in patients resulted at low risk on the basis of risk models was approximately 25%. The incidence of severe CAD in asymptomatic patients was 29.8%. Endovascular (n.52, 35.1%) and open (n.96, 64.9%) AAA repair was performed with low morbidity (0.6%) and mortality (0.6%) in 148 patients. The long-term estimated survival (freedom from fatal cardiovascular events) was 97% at 60 months and 82% at 90 months.

CONCLUSIONS

The incidence of severe correctable CAD is not negligible in low-risk patients scheduled for AAA repair. Waiting for further recommendations based on large population studies of vascular patients, a more extensive indication to coronary angiography and revascularization should be considered in many candidates for AAA repair.

Perioperative beta-blockers for preventing surgery-related mortality and morbidity

BACKGROUND

Randomized controlled trials have yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality. Thus routine prescription of these drugs in unselected patients remains a controversial issue.

OBJECTIVES

The objective of this review was to systematically analyse the effects of perioperatively administered beta-blockers for prevention of surgery-related mortality and morbidity in patients undergoing any type of surgery while under general anaesthesia.

SEARCH METHODS

We identified trials by searching the following databases from the date of their inception until June 2013: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Biosis Previews, CAB Abstracts, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Derwent Drug File, Science Citation Index Expanded, Life Sciences Collection, Global Health and PASCAL. In addition, we searched online resources to identify grey literature.

SELECTION CRITERIA

We included randomized controlled trials if participants were randomly assigned to a beta-blocker group or a control group (standard care or placebo). Surgery (any type) had to be performed with all or at least a significant proportion of participants under general anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from all studies. In cases of disagreement, we reassessed the respective studies to reach consensus. We computed summary estimates in the absence of significant clinical heterogeneity. Risk ratios (RRs) were used for dichotomous outcomes, and mean differences (MDs) were used for continuous outcomes. We performed subgroup analyses for various potential effect modifiers.

MAIN RESULTS

We included 89 randomized controlled trials with 19,211 participants. Six studies (7%) met the highest methodological quality criteria (studies with overall low risk of bias: adequate sequence generation, adequate allocation concealment, double/triple-blinded design with a placebo group, intention-to-treat analysis), whereas in the remaining trials, some form of bias was present or could not be definitively excluded (studies with overall unclear or high risk of bias). Outcomes were evaluated separately for cardiac and non-cardiac surgery. CARDIAC SURGERY (53 trials)We found no clear evidence of an effect of beta-blockers on the following outcomes.• All-cause mortality: RR 0.73, 95% CI 0.35 to 1.52, 3783 participants, moderate quality of evidence.• Acute myocardial infarction (AMI): RR 1.04, 95% CI 0.71 to 1.51, 3553 participants, moderate quality of evidence.• Myocardial ischaemia: RR 0.51, 95% CI 0.25 to 1.05, 166 participants, low quality of evidence.• Cerebrovascular events: RR 1.52, 95% CI 0.58 to 4.02, 1400 participants, low quality of evidence.• Hypotension: RR 1.54, 95% CI 0.67 to 3.51, 558 participants, low quality of evidence.• Bradycardia: RR 1.61, 95% CI 0.97 to 2.66, 660 participants, low quality of evidence.• Congestive heart failure: RR 0.22, 95% CI 0.04 to 1.34, 311 participants, low quality of evidence.Beta-blockers significantly reduced the occurrence of the following endpoints.• Ventricular arrhythmias: RR 0.37, 95% CI 0.24 to 0.58, number needed to treat for an additional beneficial outcome (NNTB) 29, 2292 participants, moderate quality of evidence.• Supraventricular arrhythmias: RR 0.44, 95% CI 0.36 to 0.53, NNTB six, 6420 participants, high quality of evidence.• On average, beta-blockers reduced length of hospital stay by 0.54 days (95% CI -0.90 to -0.19, 2450 participants, low quality of evidence). NON-CARDIAC SURGERY (36 trials)We found a potential increase in the occurrence of the following outcomes with the use of beta-blockers.• All-cause mortality: RR 1.24, 95% CI 0.99 to 1.54, 11,463 participants, low quality of evidence.Whereas no clear evidence of an effect was noted when all studies were analysed, restricting the meta-analysis to low risk of bias studies revealed a significant increase in all-cause mortality with the use of beta-blockers: RR 1.27, 95% CI 1.01 to 1.59, number needed to treat for an additional harmful outcome (NNTH) 189, 10,845 participants.• Cerebrovascular events: RR 1.59, 95% CI 0.93 to 2.71, 9150 participants, low quality of evidence.Whereas no clear evidence of an effect was found when all studies were analysed, restricting the meta-analysis to low risk of bias studies revealed a significant increase in cerebrovascular events with the use of beta-blockers: RR 2.09, 95% CI 1.14 to 3.82, NNTH 255, 8648 participants.Beta-blockers significantly reduced the occurrence of the following endpoints.• AMI: RR 0.73, 95% CI 0.61 to 0.87, NNTB 72, 10,958 participants, high quality of evidence.• Myocardial ischaemia: RR 0.43, 95% CI 0.27 to 0.70, NNTB seven, 1028 participants, moderate quality of evidence.• Supraventricular arrhythmias: RR 0.72, 95% CI 0.56 to 0.92, NNTB 111, 8794 participants, high quality of evidence.Beta-blockers significantly increased the occurrence of the following adverse events.• Hypotension: RR 1.50, 95% CI 1.38 to 1.64, NNTH 15, 10,947 participants, high quality of evidence.• Bradycardia: RR 2.24, 95% CI 1.49 to 3.35, NNTH 18, 11,083 participants, moderate quality of evidence.We found no clear evidence of an effect of beta-blockers on the following outcomes.• Ventricular arrhythmias: RR 0.64, 95% CI 0.30 to 1.33, 526 participants, moderate quality of evidence.• Congestive heart failure: RR 1.17, 95% CI 0.93 to 1.47, 9223 participants, moderate quality of evidence.• Length of hospital stay: mean difference -0.27 days, 95% CI -1.29 to 0.75, 601 participants, low quality of evidence.

AUTHORS' CONCLUSIONS

According to our findings, perioperative application of beta-blockers still plays a pivotal role in cardiac surgery , as they can substantially reduce the high burden of supraventricular and ventricular arrhythmias in the aftermath of surgery. Their influence on mortality, AMI, stroke, congestive heart failure, hypotension and bradycardia in this setting remains unclear.In non-cardiac surgery, evidence from low risk of bias trials shows an increase in all-cause mortality and stroke with the use of beta-blockers. As the quality of evidence is still low to moderate, more evidence is needed before a definitive conclusion can be drawn. The substantial reduction in supraventricular arrhythmias and AMI in this setting seems to be offset by the potential increase in mortality and stroke.

Perioperative management of lower extremity revascularization

Patients presenting for lower extremity revascularization often have multiple systemic comorbidities, making them high-risk surgical candidates. Neuraxial anesthesia and general anesthesia are equivocal in their effect on perioperative cardiac morbidity and improved graft patency. Postoperative epidural analgesia may improve perioperative cardiac morbidity. Systemic antithrombotic and anticoagulation therapy is common among this patient population and may affect anesthetic techniques.

Impact of aspirin and clopidogrel interruption on platelet function in patients undergoing major vascular surgery

Aims

To investigate functional platelet recovery after preoperative withdrawal of aspirin and clopidogrel and platelet function 5 days after treatment resumption.

Methods/Results

We conducted an observational study, which prospectively included consecutive patients taking aspirin, taking clopidogrel, and untreated controls (15 patients in each group). The antiplatelet drugs were withdrawn five days before surgery (baseline) and were reintroduced two days after surgery. Platelet function was evaluated by optical aggregation in the presence of collagen, arachidonic acid (aspirin) and ADP (clopidogrel) and by VASP assay (clopidogrel). Platelet-leukocyte complex (PLC) level was quantified at each time-point. At baseline, platelet function was efficiently inhibited by aspirin and had recovered fully in most patients 5 days after drug withdrawal. PLC levels five days after aspirin reintroduction were similar to baseline (+4±10%; p = 0.16), in line with an effective platelet inhibition. Chronic clopidogrel treatment was associated with variable platelet inhibition and its withdrawal led to variable functional recovery. PLC levels were significantly increased five days after clopidogrel reintroduction (+10±15%; p = 0.02), compared to baseline.

Conclusions

Aspirin withdrawal 5 days before high-bleeding-risk procedures was associated with functional platelet recovery, and its reintroduction two days after surgery restored antiplaletet efficacy five days later. This was not the case of clopidogrel, and further work is therefore needed to define its optimal perioperative management.

Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

OBJECTIVE

To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates.

METHODS

PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions.

RESULTS

We identified 17 studies, of which 16 were RCTs (12 043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI: 1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR: 0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded.

CONCLUSIONS

Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.

Routine pre-operative focused ultrasonography by anesthesiologists in patients undergoing urgent surgical procedures

BACKGROUND

Unexpected cardiopulmonary complications are well described during surgery and anesthesia. Pre-operative evaluation by focused cardiopulmonary ultrasonography may prevent such mishaps. The aim of this study was to determine the frequency of unexpected cardiopulmonary pathology with focused ultrasonography in patients undergoing urgent surgical procedures.

METHODS

We performed pre-operative focused cardiopulmonary ultrasonography in patients aged 18 years or above undergoing urgent surgical procedures at pre-defined study days. Known and unexpected cardiopulmonary pathology was recorded, and subsequent changes in the anesthesia technique or supportive actions were registered.

RESULTS

A total of 112 patients scheduled for urgent surgical procedures were included. Their mean age (standard deviation) was 62 (21) years. Of these patients, 24% were American Society of Anesthesiologists (ASA) class 1, 39% were ASA class 2, 32% were ASA class 3, and 4% were ASA class 4. Unexpected cardiopulmonary pathology was disclosed in 27% [95% confidence interval (CI) 19-36] of the patients and led to a change in anesthesia technique or supportive actions in 43% (95% CI 25-63) of these. Unexpected pathology leading to changes in anesthesia technique or supportive actions was only disclosed in a group of patients above the age of 60 years and/or in ASA class ≥ 3.

CONCLUSION

Focused cardiopulmonary ultrasonography disclosed unexpected pathology in patients undergoing urgent surgical procedures and induced changes in the anesthesia technique or supportive actions. Pre-operative focused ultrasonography seems feasible in patients above 60 year and/or with physical limitations but not in young, healthy individuals.

Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Perioperative management in patients with pulmonary hypertension

Patients with pulmonary hypertension (PH) are being encountered more commonly in the perioperative period and this trend is likely to increase as improvements in the recognition, management, and treatment of the disease continue to occur. Management of these patients is challenging due to their tenuous hemodynamic status. Recent advances in the understanding of the patho-physiology, risk factors, monitoring, and treatment of the disease provide an opportunity to reduce the morbidity and mortality associated with PH in the peri-operative period. Management of these patients requires a multi-disciplinary approach and meticulous care that is best provided in centers with vast experience in PH.

In this review, we provide a detailed discussion about oerioperative strategies in PH patients, and give evidence-based recommendations, when applicable.

Anaesthetic management of cytoreductive surgery followed by hyperthermic intrathoracic chemotherapy perfusion

BACKGROUND

Macroscopic cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion (HITHOC) is a new multimodal approach for selected patients with primary and secondary pleural tumors, which may provide the patient with better local tumor control and increased overall survival rate.

METHODS

We present a single-center study including 20 patients undergoing cytoreductive surgery and HITHOC between September 2008 and April 2013 at the University Medical Center Regensburg, Germany. Objective of the study was to describe the perioperative, anaesthetic management with special respect to pain and complication management.

RESULTS

Anaesthesia during this procedure is characterized by increased intrathoracic airway and central venous pressure, hemodynamic alterations and the risk of systemic hypo- and hyperthermia. Securing an adequate intravascular volume is one of the primary goals to prevent decreased cardiac output as well as pulmonary edema. Transfusion of packed red blood cells (PRBC) was necessary in seven of 20 (35%) patients. Only two patients (10%) showed an impairment of coagulation in postoperative laboratory analysis. Perioperative forced diuresis is recommended to prevent postoperative renal insufficiency. Supplementary thoracic epidural analgesia in 13 patients (65%) showed a significant reduction of post-operative pain compared with peroral administration of opioid and non-opioid analgesics.

CONCLUSION

This article summarizes important experiences of the anaesthesiological and intensive care management in patients undergoing HITHOC.

Perioperative complications after noncardiac surgery in patients with insertion of second-generation drug-eluting stents

The perioperative outcomes of noncardiac surgery in patients who have received second-generation drug-eluting stents (DESs) have received limited study. We reviewed the medical records of 1,748 consecutive patients who received DES at our institution (1,789 procedures) from January 1, 2009, to July 1, 2012, to determine the outcomes of subsequent noncardiac surgery. During a median follow-up of 43 months, 221 patients underwent 345 noncardiac surgeries (138 low risk, 130 intermediate risk, and 77 high risk), of which 278 were in patients with previous second-generation DES implantation. The incidence of noncardiac surgery in patients with previous second-generation DES implantation was 4.5% at 1 year, 11.6% at 2 years, and 15.2% at 3 years. The mean time from stent implantation to surgery was 21±12.9 months. Mean age was 66±8 years, 99% were men, and 11% had a perioperative complication, including 5.8% major bleeding, 2.5% acute kidney injury, 2.2% major adverse cardiac event, and 1.4% stroke. Perioperative stent thrombosis occurred in 2 patients (0.7%, 95% confidence interval 0.2% to 2.6%): 1 patient had received a DES 14 months before surgery and had stent thrombosis on the day of surgery and the other had a DES implanted 21 months before surgery and developed stent thrombosis the day after surgery. In conclusion, the incidence of perioperative complications with noncardiac surgery after second-generation DES implantation was 11% and consisted mainly of bleeding (5.8%). The incidence of definite stent thrombosis was 0.7%.

[Analysis of factors conditioning admission at the critical care unit of surgical patients. Prospective study of 764 patients operated for 1 year at a university and reference hospital]

OBJECTIVE

Assess what factors determine the income of surgical patients in critical care unit after surgery.

MATERIAL AND METHODS

It included a survey of the 10% of all patients operated by the services of General Surgery, Thoracic Surgery, Maxillofacial Surgery, Vascular Surgery, Urology and Otolaryngology during 2012. We performed a prospective, observational study. Pre-, intra-, and post-operative variables were analyzed. Comparisons were made between patients operated under elective and emergency surgery, and between patients admitted in critical care and admitted directly in the ward, using χ(2) of Pearson correlation with a confidence interval of 95%.

RESULTS

Seven hundred and sixty-four patients were included into the study, 304 were admitted in critical care after surgery and 460 were admitted in the ward. The medical history showed a statistically significant association with intensive care unit admission, well as the fact of being labeled with a high risk for the risk scales. Complexity and duration of the surgery showed a statistically significant association with intensive care unit admission, as well as the fact of present intra-operative complications. Emergency surgery was not significantly associated with intensive care unit admission of surgical patients, although these patients had significantly higher numbers of intra- and post-operative complications, and more exitus than those undergoing elective surgery.

CONCLUSIONS

A greater incidence of intensive care unit admission of patients undergoing emergency surgery should significantly reduce morbimortality rate. The existence of specific protocols for intensive care unit admission for urgent surgery, and greater availability of beds could be useful in this regard.

Positive end-expiratory pressure (PEEP) during anaesthesia for prevention of mortality and postoperative pulmonary complications

BACKGROUND

General anaesthesia causes atelectasis, which can lead to impaired respiratory function. Positive end-expiratory pressure (PEEP) is a mechanical manoeuvre that increases functional residual capacity (FRC) and prevents collapse of the airways, thereby reducing atelectasis. It is not known whether intraoperative PEEP alters the risks of postoperative mortality and pulmonary complications. This review was originally published in 2010 and was updated in 2013.

OBJECTIVES

To assess the benefits and harms of intraoperative PEEP in terms of postoperative mortality and pulmonary outcomes in all adult surgical patients.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 10, part of The Cochrane Library, as well as MEDLINE (via Ovid) (1966 to October 2013), EMBASE (via Ovid) (1980 to October 2013), CINAHL (via EBSCOhost) (1982 to October 2013), ISI Web of Science (1945 to October 2013) and LILACS (via BIREME interface) (1982 to October 2010). The original search was performed in January 2010.

SELECTION CRITERIA

We included randomized clinical trials assessing the effects of PEEP versus no PEEP during general anaesthesia on postoperative mortality and postoperative respiratory complications in adults, 16 years of age and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected papers, assessed trial quality and extracted data. We contacted study authors to ask for additional information, when necessary. We calculated the number of additional participants needed (information size) to make reliable conclusions.

MAIN RESULTS

This updated review includes two new randomized trials. In total, 10 randomized trials with 432 participants and four comparisons are included in this review. One trial had a low risk of bias. No differences were demonstrated in mortality, with risk ratio (RR) of 0.97 (95% confidence interval (CI) 0.20 to 4.59; P value 0.97; 268 participants, six trials, very low quality of evidence (grading of recommendations assessment, development and evaluation (GRADE)), and in pneumonia, with RR of 0.40 (95% CI 0.11 to 1.39; P value 0.15; 120 participants, three trials, very low quality of evidence (GRADE)). Statistically significant results included the following: The PEEP group had higher arterial oxygen pressure (PaO2)/fraction of inspired oxygen (FiO2) on day one postoperatively, with a mean difference of 22.98 (95% CI 4.40 to 41.55; P value 0.02; 80 participants, two trials, very low quality of evidence (GRADE)), and postoperative atelectasis (defined as an area of collapsed lung, quantified by computerized tomography scan) was less in the PEEP group (standard mean difference -1.2, 95% CI -1.78 to -0.79; P value 0.00001; 88 participants, two trials, very low quality of evidence (GRADE)). No adverse events were reported in the three trials that adequately measured these outcomes (barotrauma and cardiac complications). Using information size calculations, we estimated that a further 21,200 participants would have to be randomly assigned to allow a reliable conclusion about PEEP and mortality.

AUTHORS' CONCLUSIONS

Evidence is currently insufficient to permit conclusions about whether intraoperative PEEP alters risks of postoperative mortality and respiratory complications among undifferentiated surgical patients.

Cardiac biomarkers in the prediction of risk in the non-cardiac surgery setting

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.

Can routine preoperative data predict adverse outcomes in the elderly? Development and validation of a simple risk model incorporating a chart-derived frailty score

BACKGROUND

Frailty has emerged as an important predictor of operative risk among elderly surgical patients. However, the complexity of prospective frailty scores has limited their widespread use. Our goal was to develop two frailty-based surgical risk models using only routine preoperative data. Our hypothesis was that these models could easily integrate into an electronic medical record to predict 30-day morbidity and mortality.

STUDY DESIGN

American College of Surgeons NSQIP Participant Use Data Files from 2005 to 2010 were reviewed, and patients 65 years and older who underwent elective lower gastrointestinal surgery were identified. Two multivariate logistic regression models were constructed and internally cross-validated. The first included simple functional data, a comorbidity index based on the Charlson Comorbidity Index, demographics, BMI, and laboratory data (ie, albumin <3.4 g/dL, hematocrit <35%, and creatinine >2 mg/dL). The second model contained only parameters that can directly autopopulate from an electronic medical record (ie, demographics, laboratory data, BMI, and American Society of Anesthesiologists score). To assess diagnostic accuracy, receiver operating characteristic curves were constructed.

RESULTS

There were 76,106 patients who met criteria for inclusion. Thirty-day mortality was seen in 2,853 patients or 3.7% of the study population and 18,436 patients (24.2%) experienced a major complication. The c-statistic of the first expanded model was 0.813 for mortality and 0.629 for morbidity. The second simplified model had a c-statistic of 0.795 for mortality and 0.621 for morbidity. Both models were well calibrated per the Hosmer-Lemeshow test.

CONCLUSIONS

Our work demonstrates that routine preoperative data can approximate frailty and predict geriatric-specific surgical risk. The models' predicative powers were comparable with that of established prospective frailty scores. Our calculator could be used as a low-cost simple screen for high-risk individuals who might require additional evaluation or specialized services.

A systematic approach to the preoperative medical evaluation of adults

The number, age, and medical complexity of patients undergoing elective noncardiac surgery is rising worldwide. Internists, family physicians, and midlevel providers asked to perform preoperative medical evaluations. However, lack of consensus has led to wide variation in practice in what is included and addressed in these evaluations, and the efficacy of these assessments has been debated. The intended purpose of the evaluation seems to be universally accepted as aiming to assess and identify risks associated with the patient's comorbid medical conditions and the specific surgical procedure. The goal is to minimize those risks. Herein, we propose a systematic approach to the preoperative medical evaluation based on the best available evidence and expert opinion, with an emphasis on identifying all potentially pertinent patient- and surgery-specific risk factors.

Effectiveness of preoperative beta-blockade on intra-operative heart rate in vascular surgery cases conducted under regional or local anesthesia

BACKGROUND

Preoperative β-blockade has been posited to result in better outcomes for vascular surgery patients by attenuating acute hemodynamic changes associated with stress. However, the incremental effectiveness, if any, of β-blocker usage in blunting heart rate responsiveness for vascular surgery patients who avoid general anesthesia remains unknown.

METHODS

We reviewed an existing database and identified 213 consecutive vascular surgery cases from 2005-2011 conducted without general anesthesia (i.e., under monitored anesthesia care or regional anesthesia) at a tertiary care Veterans Administration medical center and categorized patients based on presence or absence of preoperative β-blocker prescription. For this series of patients, with the primary outcome of maximum heart rate during the interval between operating room entry to surgical incision, we examined the association of maximal heart rate and preoperative β-blocker usage by performing crude and multivariate linear regression, adjusting for relevant patient factors.

RESULTS

Of 213 eligible cases, 137 were prescribed preoperative β-blockers, and 76 were not. The two groups were comparable across baseline patient factors and intraoperative medication doses. The β-blocker group experienced lower maximal heart rates during the period of evaluation compared to the non-β-blocker group (85 ± 22 bpm vs. 98 ± 36 bpm, respectively; p = 0.002). Adjusted linear regression confirmed a statistically-significant association between lower maximal heart rate and the use of β-blockers (Beta = -11.5; 95% CI [-3.7, -19.3] p = 0.004).

CONCLUSIONS

The addition of preoperative β-blockers, even when general anesthesia is avoided, may be beneficial in further attenuating stress-induced hemodynamic changes for vascular surgery patients.

Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: a retrospective study of the Veterans Affairs Healthcare System

BACKGROUND

Angiotensin-converting enzyme inhibitors (ACE-Is) are a widely used class of cardiovascular medication. However, limited data exist on the risks of postoperative nonresumption of an ACE-I.

OBJECTIVE

To evaluate the factors and 30-day mortality risks associated with the postoperative nonresumption of an ACE-I.

DESIGN

A retrospective cohort study.

SETTING

Veterans Affairs (VA) Healthcare System.

PATIENTS

A total of 294,505 admissions in 240,978 patients with multiple preoperative prescription refills (>3) for an ACE-I who underwent inpatient surgery from calendar years 1999 to 2012.

INTERVENTION

None.

MEASUREMENTS

We classified surgical admissions based upon the timing of postoperative resumption of an ACE-I prescription from the day of surgery through postoperative days 0 to 14 and 15 to 30, and collected 30-day mortality data. We evaluated the relationship between 30-day mortality and the nonresumption of an ACE-I from postoperative day 0 to 14 using proportional hazard regression models, adjusting for patient- and hospital-level risk factors. Sensitivity analyses were conducted using more homogeneous subpopulations and propensity score models.

RESULTS

Twenty-five percent of our cohort did not resume an ACE-I during the 14 days following surgery. Nonresumption of an ACE-I within postoperative day 0 to 14 was independently associated with increased 30-day mortality (hazard ratio: 3.44; 95% confidence interval: 3.30-3.60; P < 0.001) compared to the restart group. Sensitivity analyses maintained this relationship.

CONCLUSIONS

Nonresumption of an ACE-I is common after major inpatient surgery in the large VA Health Care System. Restarting of an ACE-I within postoperative day 0 to 14 is, however, associated with decreased 30-day mortality. Careful attention to the issue of timely reinstitution of chronic medications such as an ACE-I is indicated.

Clinical impact of perioperative myocardial infarction after pancreatic surgery

BACKGROUND

The aim of this study was to evaluate the incidence, clinical impact and outcome of perioperative myocardial infarction (PMI) in patients undergoing pancreatic surgery.

METHODS

A data of 1,625 patients undergoing pancreatic resection were prospectively collected and analysed with regard to PMI. Demographic aspects, co-morbidities and clinical course were evaluated. Cardiac risk factors (ASA and NYHA), postoperative complications and mortality were compared in a match-pair analysis (1:3) with patients without PMI.

RESULTS

Twenty-nine patients with PMI after pancreatic surgery were identified. PMI occurred after all types of pancreatic operations and was observed most frequently (72.2%) within the first postoperative week. In a total of 90%, PMI fulfilled the criteria of non-STEMI. Nearly half of the patients (48%) were clinically asymptomatic. Both ASA III and heart failure were more frequent in patients with PMI. The in-hospital mortality was significantly increased after PMI (p < 0.002), with post-pancreatectomy haemorrhage (PPH) as the most relevant underlying risk factor.

CONCLUSION

PMI is a rare but severe complication after pancreatic operations, contributing significantly to in-hospital mortality. Clinical management mainly includes an anti-coagulant approach. This may be related with an increased risk for PPH. Therefore, the use of anti-coagulant drugs in the early postoperative period-especially in asymptomatic patients-should be critically evaluated.

Analysis of transthoracic echocardiographic data in major vascular surgery from a prospective randomised trial comparing sevoflurane and fentanyl with propofol and remifentanil anaesthesia

The aim of this study was to define pre-operative echocardiographic data and explore if postoperative indices of cardiac function after open abdominal aortic surgery were affected by the anaesthetic regimen. We hypothesised that volatile anaesthesia would improve indices of cardiac function compared with total intravenous anaesthesia. Transthoracic echocardiography was performed pre-operatively in 78 patients randomly assigned to volatile anaesthesia and 76 to total intravenous anaesthesia, and compared with postoperative data. Pre-operatively, 16 patients (10%) had left ventricular ejection fraction < 46%. In 138 patients with normal left ventricular ejection fraction, 5/8 (62%) with left ventricular dilatation and 41/130 (33%) without left ventricular dilatation had evidence of left ventricular diastolic dysfunction (p < 0.001). Compared with pre-operative findings, significant increases in left ventricular end-diastolic volume, left atrial maximal volume, cardiac output, velocity of early mitral flow and early myocardial relaxation occurred postoperatively (all p < 0.001). The ratio of the velocity of early mitral flow to early myocardial relaxation remained unchanged. There were no significant differences in postoperative echocardiographic findings between patients anaesthetised with volatile anaesthesia or total intravenous anaesthesia. Patients had an iatrogenic surplus of approximately 4.1 l of fluid volume by the first postoperative day. N-terminal prohormone of brain natriuretic peptide increased on the first postoperative day (p < 0.001) and remained elevated after 30 days (p < 0.001) in both groups. Although postoperative echocardiographic alterations were most likely to be related to increased preload due to a substantial iatrogenic surplus of fluid, a component of peri-operative myocardial ischaemia cannot be excluded. Our hypothesis that volatile anaesthesia improved indices of cardiac function compared with total intravenous anaesthesia could not be verified.

HIV, vascular surgery and cardiovascular outcomes: a South African cohort study

Risk factors for peri-operative cardiac morbidity are poorly described in HIV-positive patients. This prospective observational study describes cardiovascular risk factors in a cohort of vascular surgical patients of known HIV status. We recruited 225 patients with 73 (32%) being HIV-positive. When compared with HIV-negative patients, the HIV-positive patients were younger (mean (SD) 56.4 (13.3) vs 40.5 (10.4) years, respectively, p < 0.01). They had fewer Revised Cardiac Risk Index cardiovascular risk factors (median (range [IQR]) 1 (0-5 [0-2]) vs 0 (0-2 [0-0]), respectively, p < 0.001), with the exception of congestive cardiac failure (p = 0.23) and renal dysfunction (p = 0.32), and so were of a significantly lower Revised Cardiac Risk Index risk category (p < 0.01). HIV-positive and -negative patients had similar outcomes in: 30-day mortality (p = 0.78); three-day postoperative troponin leak (p = 0.66); and a composite outcome of mortality and troponin release (p = 0.69). We conclude that although HIV-positive patients have fewer cardiovascular risk factors, they have similar peri-operative major adverse cardiac events to HIV-negative patients. Research should focus on why this is the case, and if alternative clinical risk predictors can be developed for HIV patients.

Cancer in heart disease patients: what are the limitations in the treatment strategy?

Cardiovascular disease and cancer are leading causes of morbidity and mortality, and can both be present in one patient. In patients with simultaneous disease, the most threatening disease should be treated first. This is usually heart disease, but this can pose specific problems. If percutaneous coronary intervention is preferred, bleeding and thrombotic tendencies have to be taken into account in the subsequent treatment of the malignancy. With coronary artery bypass grafting, the advantages and disadvantages of one- or two-stage procedures, and the use of extracorporeal circulation have to be balanced. Development of heart disease after treatment of malignancy could be due to radiotherapy and chemotherapy. The effects of these cancer treatments have to be taken into account for the treatment options of the heart disease and the postoperative prognosis.

Prospective and systematic analysis of unexpected requests for non-cardiac surgery or other invasive procedures during the first year after drug-eluting stent implantation

PURPOSE

Unexpected requests for non-cardiac surgery requiring discontinuation of dual antiplatelet therapy (DAPT) frequently occur in daily clinical practice. The objectives of this study were to evaluate prevalence, timing and clinical outcomes of such unexpected requests for non-cardiac surgery or other invasive procedures during the first year after drug-eluting stents (DESs) implantation.

MATERIALS AND METHODS

We prospectively investigated the prevalence, timing and clinical outcomes of unexpected requests for non-cardiac surgery or other procedures during the first year after DESs implantation in 2117 patients.

RESULTS

The prevalence of requested non-cardiac surgery or invasive procedures was 14.6% in 310 requests and 12.3% in 261 patients. Among 310 requests, those were proposed in 11.3%<1 month, 30.0% between 1 and 3 months, 36.8% between 4 and 6 months and 21.9% between 7 and 12 months post-DES implantation. The rates of actual discontinuation of DAPT and non-cardiac surgery or procedure finally performed were 35.8% (111 of 310 requests) and 53.2% (165 of 310 requests), respectively. On multivariate regression analysis, the most significant determinants for actual discontinuation of DAPT were Endeavor zotarolimus-eluting stent implantation with 3-month DAPT (OR=5.54, 95% CI 2.95-10.44, p<0.001) and timing of request (OR=2.84, 95% CI 1.97-4.11, p<0.001). There were no patients with any death, myocardial infarction, or stent thrombosis related with actual discontinuation of DAPT.

CONCLUSION

Those unexpected requests with premature discontinuation of DAPT were relatively common and continuously proposed during the first year following DES implantation. No death, myocardial infarction or stent thrombosis occurred in patients with actual discontinuation of DAPT.

Relationship between asking an older adult about falls and surgical outcomes

IMPORTANCE

More than one-third of all US inpatient operations are performed on patients aged 65 years and older. Existing preoperative risk assessment strategies are not adequate to meet the needs of the aging population.

OBJECTIVES

To evaluate the relationship of a history of falls (a geriatric syndrome) to postoperative outcomes in older adults undergoing major elective operations.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, cohort study was conducted at a referral medical center. Persons aged 65 years and older undergoing elective colorectal and cardiac operations were enrolled. The predictor variable was having fallen in the 6 months prior to the operation.

MAIN OUTCOMES AND MEASURES

Postoperative outcomes measured included 30-day complications, the need for discharge institutionalization, and 30-day readmission.

RESULTS

There were 235 subjects with a mean (SD) age of 74 (6) years. Preoperative falls occurred in 33%. One or more postoperative complications occurred more frequently in the group with prior falls compared with the nonfallers following both colorectal (59% vs 25%; P = .004) and cardiac (39% vs 15%; P = .002) operations. These findings were independent of advancing chronologic age. The need for discharge to an institutional care facility occurred more frequently in the group that had fallen in comparison with the nonfallers in both the colorectal (52% vs 6%; P < .001) and cardiac (62% vs 32%; P = .001) groups. Similarly, 30-day readmission was higher in the group with prior falls following both colorectal (P = .04) and cardiac (P = .02) operations.

CONCLUSIONS AND RELEVANCE

A history of 1 or more falls in the 6 months prior to an operation forecasts increased postoperative complications, the need for discharge institutionalization, and 30-day readmission across surgical specialties. Using a history of prior falls in preoperative risk assessment for an older adult represents a shift from current preoperative assessment strategies.

Volatile anesthetics and AKI: risks, mechanisms, and a potential therapeutic window

AKI is a major clinical problem with extremely high mortality and morbidity. Kidney hypoxia or ischemia-reperfusion injury inevitably occurs during surgery involving renal or aortic vascular occlusion and is one of the leading causes of perioperative AKI. Despite the growing incidence and tremendous clinical and financial burden of AKI, there is currently no effective therapy for this condition. The pathophysiology of AKI is orchestrated by renal tubular and endothelial cell necrosis and apoptosis, leukocyte infiltration, and the production and release of proinflammatory cytokines and reactive oxygen species. Effective management strategies require multimodal inhibition of these injury processes. Despite the past theoretical concerns about the nephrotoxic effects of several clinically utilized volatile anesthetics, recent studies suggest that modern halogenated volatile anesthetics induce potent anti-inflammatory, antinecrotic, and antiapoptotic effects that protect against ischemic AKI. Therefore, the renal protective properties of volatile anesthetics may provide clinically useful therapeutic intervention to treat and/or prevent perioperative AKI. In this review, we outline the history of volatile anesthetics and their effect on kidney function, briefly review the studies on volatile anesthetic-induced renal protection, and summarize the basic cellular mechanisms of volatile anesthetic-mediated protection against ischemic AKI.