151
|
Mohammad Ismail A, Ahl R, Forssten MP, Cao Y, Wretenberg P, Borg T, Mohseni S. The interaction between pre-admission β-blocker therapy, the Revised Cardiac Risk Index, and mortality in geriatric hip fracture patients. J Trauma Acute Care Surg 2022; 92:49-56. [PMID: 34252058 PMCID: PMC8677608 DOI: 10.1097/ta.0000000000003358] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/23/2021] [Accepted: 07/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND An association between β-blocker (BB) therapy and a reduced risk of major cardiac events and mortality in patients undergoing surgery for hip fractures has previously been demonstrated. Furthermore, a relationship between an increased Revised Cardiac Risk Index (RCRI) score and a higher risk of postoperative mortality has also been detected. The purpose of the current study was to investigate the interaction between BB therapy and RCRI in relation to 30-day postoperative mortality in geriatric patients after hip fracture surgery. METHODS All patients older than 65 years who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008, and December 31, 2017, except for pathological fractures, were included in this retrospective cohort study. Patients were divided into cohorts based on their RCRI score (RCRI 1, 2, 3, and ≥4) and whether they had ongoing BB therapy at the time of admission. A Poisson regression model with robust standard errors of variance was used, while adjusting for confounders, to evaluate the association between BB therapy, RCRI, and 30-day mortality. RESULTS A total of 126,934 cases met the study inclusion criteria. β-Blocker therapy was associated with a 65% decrease in the risk of 30-day postoperative mortality in the whole study population (adjusted incidence rate ratio [95% confidence interval], 0.35 [0.32-0.38]; p < 0.001). The use of BB also resulted in a significant reduction in 30-day postoperative mortality within all RCRI cohorts. However, the most pronounced effect of BB therapy was seen in patients with an RCRI score greater than 0. CONCLUSION β-Blocker therapy is associated with a reduction in 30-day postoperative mortality, irrespective of RCRI score. Furthermore, patients with an elevated cardiac risk appear to have a greater benefit of BB therapy. LEVEL OF EVIDENCE Therapeutic/care management, level II.
Collapse
|
152
|
Yao Y, Quirk T, French M, Dharmalingam A, Collins N. Myocardial perfusion imaging failed to improve patient risk classification compared to the revised cardiac risk index for early cardiac complications after major non-cardiac surgery. Intern Med J 2021; 52:1203-1214. [PMID: 34897922 DOI: 10.1111/imj.15662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE Cardiac evaluation is desirable before major non-cardiac surgery with myocardial perfusion imaging (MPI) frequently utilised for risk assessment. However, the prognostic utility of MPI above a simple clinical risk calculator, the Revised Cardiac Risk Index (RCRI), is unknown. METHODS AND RESULTS We conducted a retrospective cohort study of at-risk patients who underwent MPI before major non-cardiac surgery in a tertiary hospital, incorporating 635 surgical procedures in 629 patients from 2013 to 2019. Major adverse cardiac events (MACE) within 30 days of surgery, including any myocardial infarction, acute pulmonary oedema, ventricular arrhythmia or cardiac death, occurred in 47 (7.4%) cases. We analysed predictive value of MPI for MACE using multivariable logistic regression and categorical net reclassification index. MPI-identified medium or large-sized reversible perfusion defects (p=0.02, odds ratio 2.9 (95% confidence interval 1.1-7.1) and RCRI score two or more (p=0.03, odds ratio 2.3 (95% confidence interval 1.1-4.8) were significantly associated with MACE after adjusting for age, coronary revascularisation, surgical priority, need for general anaesthesia, left ventricular ejection fraction (LVEF) and fixed perfusion defects. MPI risk factors (LVEF, reversible perfusion and fixed perfusion defects) did not improve risk classification above baseline risk factors (age, RCRI and surgical priority). CONCLUSION MPI risk factors are weak predictors for early cardiac complications after major non-cardiac surgery and failed to improve patient risk classification beyond essential assessment using age, RCRI and surgical priority. Clinicians should consider alternative risk assessment strategies because of MPI's poor prognostic utility and its associated time and financial costs. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Yao Yao
- Department of General Medicine, Calvary Mater Hospital, Waratah, Australia
| | - Thomas Quirk
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, Australia
| | - Matthew French
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, Australia
| | - Ashok Dharmalingam
- Department of Anaesthesia, John Hunter Hospital, New Lambton Heights, Australia.,Department of Anaesthesia, Calvary Mater Hospital, Waratah, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Nicholas Collins
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, Australia
| |
Collapse
|
153
|
Kumar C, Singh PP, Krishna A, Kumar O. Perioperative Acute Myocardial Infarction in the First Deceased Kidney Transplantation Done in Bihar. Indian J Nephrol 2021; 31:498-499. [PMID: 34880565 PMCID: PMC8597795 DOI: 10.4103/ijn.ijn_498_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/13/2020] [Accepted: 02/03/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Chandan Kumar
- Department of Nephrology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Prit P Singh
- Department of Nephrology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Amresh Krishna
- Department of Nephrology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Om Kumar
- Department of Nephrology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| |
Collapse
|
154
|
Aykanat VM, Myles PS, Weinberg L, Burrell A, Bellomo R. Low-Concentration Norepinephrine Infusion for Major Surgery: A Safety and Feasibility Pilot Randomized Controlled Trial. Anesth Analg 2021; 134:410-418. [PMID: 34872102 DOI: 10.1213/ane.0000000000005811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prevention of hypotension during the intra- and postoperative period is an important goal. Peripheral administration of low-concentration norepinephrine may be a safe and effective strategy to reduce the risk of hypotension. METHODS We conducted a 2-center, randomized pilot feasibility trial, with a target of 60 adult patients undergoing major noncardiac surgery. We randomized patients to receive a peripheral low-concentration (10 µg/mL) norepinephrine or placebo (saline 0.9%) infusion. The study drug infusion was titrated to achieve a minimum systolic blood pressure target, preselected within 10% of baseline value and within the range limit 100 to 120 mm Hg during surgery and for up to 4 or 24 hours postoperatively. RESULTS We achieved a high consent rate (84%), successful study drug administration throughout surgery (98% of patients) and absence of unblinding. There were no important study drug-related adverse events. The average intraoperative systolic blood pressure was 120 ± 12.6 mm Hg in the norepinephrine group and 115 ± 14.9 mm Hg in the placebo group. The mean difference between the intraoperative systolic blood pressure achieved less the preselected minimum systolic blood pressure target was 10.0 ± 12.7 mm Hg in the norepinephrine group and 2.9 ± 14.7 mm Hg in the placebo group; difference in means, 7.1 (95% confidence interval, 0.2-14.0) mm Hg. CONCLUSIONS A future large trial evaluating the effectiveness and safety of peripheral administration of low-concentration norepinephrine during the perioperative period is feasible, and likely to achieve a minimum systolic blood pressure threshold.
Collapse
Affiliation(s)
- Verna M Aykanat
- From the Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - Paul S Myles
- From the Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Aidan Burrell
- Department of Intensive Care, Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Intensive Care Austin Hospital, Melbourne, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Australia
| |
Collapse
|
155
|
Hu G, Chen M, Wang X, Chen L, Wang W. The key role of pulse wave transit time to predict blood pressure variation during anaesthesia induction. J Int Med Res 2021; 49:3000605211058380. [PMID: 34846923 PMCID: PMC8647267 DOI: 10.1177/03000605211058380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To establish the relationship between pulse wave transit time (PWTT) before anaesthesia induction and blood pressure variability (BPV) during anaesthesia induction. METHODS This prospective observational cohort study enrolled consecutive patients that underwent elective surgery. Invasive arterial pressure, electrocardiography, pulse oximetry, heart rate and bispectral index were monitored. PWTT and BPV were measured with special software. Anaesthesia was induced with propofol, sufentanil and rocuronium. RESULTS A total of 54 patients were included in this study. There was no correlation between BPV and the dose of propofol, sufentanil and rocuronium during anaesthesia induction. Bivariate linear regression analysis demonstrated that PWTT (r = -0.54), age (r = 0.34) and systolic blood pressure (r = 0.31) significantly correlated with systolic blood pressure variability (SBPV). Only PWTT (r = -0.38) was significantly correlated with diastolic blood pressure variability (DBPV). Patients were stratified into high PWTT and low PWTT groups according to the mean PWTT value (96.8 ± 17.2 ms). Compared with the high PWTT group, the SBPV of the low PWTT group increased significantly by 3.4%. The DBPV of the low PWTT group increased significantly by 2.1% compared with the high PWTT group. CONCLUSIONS PWTT, assessed before anaesthesia induction, may be an effective predictor of haemodynamic fluctuations during anaesthesia induction.
Collapse
Affiliation(s)
- Guoqiang Hu
- Department of Anaesthesiology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang Province, China
| | - Minjuan Chen
- Department of Anaesthesiology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang Province, China
| | - Xiaodan Wang
- Department of Anaesthesiology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang Province, China
| | - Lingyang Chen
- Department of Anaesthesiology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang Province, China
| | - Weijian Wang
- Department of Anaesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| |
Collapse
|
156
|
Nanji KC, Shaikh SD, Jaffari A, Franz C, Bates DW. A Monte Carlo Simulation to Estimate the Additional Cost Associated With Adverse Medication Events Leading to Intraoperative Hypotension and/or Hypertension in the United States. J Patient Saf 2021; 17:e758-e764. [PMID: 34852412 PMCID: PMC8647903 DOI: 10.1097/pts.0000000000000926] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Intraoperative hypertension and hypotension are common and often related to adverse medication events (AMEs). The study objective is to estimate the annual additional fully allocated costs to the U.S. healthcare system related to AMEs associated with clinically significant intraoperative hypertension and hypotension. METHODS Using anesthesia-trained observers in randomly selected operating rooms, we estimated the rates of clinically significant intraoperative hypotension and hypertension. We conducted systematic literature reviews to estimate incidence and additional costs of acute kidney injury (AKI), acute myocardial injury, and stroke after intraoperative hypotension and hypertension. We used Monte Carlo simulation to estimate annual costs to the U.S. healthcare system. RESULTS Intraoperative hypotension (mean arterial pressure <55 mm Hg for >6 minutes) occurred in 11 of 277 operations (3.97%), hypotension (>30% drop from baseline mean arterial pressure in patients with coronary artery disease) in 9 operations (3.25%) and hypertension in 14 operations (5.05%). After hypotension, incremental incidence of AKI was 1.46% (additional cost $17,289/case), acute myocardial injury was 0.75% ($21,340/case), and stroke was 0.05% ($19,903/case). After hypertension, incremental stroke incidence was 4.76% ($28,320/case). Annually in the United States, we estimated 11,513 cases of AKI, 5914 of acute myocardial injury, 345 of stroke after intraoperative hypotension, and 47,774 cases of stroke after intraoperative hypertension, costing the U.S. $1.7 billion (90% confidence interval, $1.4-$2.0 billion), of which $923 million (90% confidence interval, $763-$1101 million) is preventable. CONCLUSIONS Adverse medication events related to blood pressure are frequent, costly, and can cause considerable patient harm. Cost estimates for these events may provide a means of prioritizing safety improvements to reduce cost of care and improve patient outcomes.
Collapse
Affiliation(s)
- Karen C. Nanji
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA, USA
- Partners Healthcare Systems, Inc., Wellesley, MA, USA
| | - Sofia D. Shaikh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Alireza Jaffari
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - David W. Bates
- Harvard Medical School, Boston, MA, USA
- Partners Healthcare Systems, Inc., Wellesley, MA, USA
- Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| |
Collapse
|
157
|
Myocardial injury after noncardiac surgery: facts, fallacies and how to approach clinically. Curr Opin Crit Care 2021; 27:670-675. [PMID: 34520410 DOI: 10.1097/mcc.0000000000000885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Acute myocardial injury occurs commonly during perioperative care. There is still considerable confusion regarding its diagnosis and definition, and a lack of consensus on who and how to screen, exacerbated by a lack of studies addressing how to manage patients with detected myocardial injury. RECENT FINDINGS Far from a benign biochemical anomaly, myocardial injury occurring perioperatively is largely a silent disease and is not necessarily because of ischaemia. Preoperative, postoperative, and perioperative changes in cardiac troponins (cTns) are independently associated with increased mortality and adverse cardiovascular outcomes. Routine screening with cTns is required for reliable detection of myocardial injury. Measurement of changes (from preoperative to postoperative) will detect acute events as well as identify patients with chronic troponin increases. SUMMARY This review aims to bring together current literature regarding myocardial injury that is detected perioperatively, identifies knowledge gaps for future research and provides suggestions for management.
Collapse
|
158
|
Metoprolol Protects Against Arginine Vasopressin-Induced Cellular Senescence in H9C2 Cardiomyocytes by Regulating the Sirt1/p53/p21 Axis. Cardiovasc Toxicol 2021; 22:99-107. [PMID: 34800264 PMCID: PMC8800877 DOI: 10.1007/s12012-021-09704-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/11/2021] [Indexed: 10/31/2022]
Abstract
Cardiomyocyte senescence is involved in the pathological mechanism of cardiac diseases. Metoprolol is a β1 receptor blocker used for the treatment of hypertension. Recent studies show that Metoprolol can protect cardiomyocytes against ischemia injury. The present study aims to investigate the protective effects of Metoprolol against arginine vasopressin (AVP)-induced cellular senescence in cultured cardiomyocytes. The cell proliferation assay and cytotoxicity lactate dehydrogenase assay showed that the highest tolerated dosage of Metoprolol in H9C2 cardiomyocytes was optimized as 10 µM. The enzyme-linked immunosorbent assay showed that Metoprolol significantly ameliorated the elevated level of the DNA oxidation product 8-hydroxy-2 deoxyguanosine. Metoprolol also decreased the percentage of senescence-associated β-galactosidase positive cells and improved the telomerase activity under AVP exposure. Moreover, treatment with Metoprolol ameliorated the decreased intracellular nicotinamide phosphoribosyltransferase activity, nicotinamide adenine dinucleotide/nicotinamide adenine dinucleotide phosphate (NAD+/NADPH) ratio, and Sirtuin1 activity in cardiomyocytes by AVP. Finally, Metoprolol was able to downregulate the AVP-induced expression of acetylated p53 and p21. Taken together, our data reveal that Metoprolol protected the cardiomyocytes from AVP-induced senescence.
Collapse
|
159
|
Tang H, Chen K, Hou J, Huang X, Liu S, Hu S. Preoperative beta-blocker in ventricular dysfunction patients: need a more granular quality metric. BMC Cardiovasc Disord 2021; 21:552. [PMID: 34798823 PMCID: PMC8603532 DOI: 10.1186/s12872-021-02371-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 10/28/2021] [Indexed: 11/25/2022] Open
Abstract
Background The use of preoperative beta-blockers has been accepted as a quality standard for patients undergoing coronary artery bypass graft (CABG) surgery. However, conflicting results from recent studies have raised questions concerning the effectiveness of this quality metric. We sought to determine the influence of preoperative beta-blocker administration before CABG in patients with left ventricular dysfunction. Methods The authors analyzed all cases of isolated CABGs in patients with left ventricular ejection fraction less than 50%, performed between 2012 January and 2017 June, at 94 centres recorded in the China Heart Failure Surgery Registry database. In addition to the use of multivariate regression models, a 1–1 propensity scores matched analysis was performed. Results Of 6116 eligible patients, 61.7% received a preoperative beta-blocker. No difference in operative mortality was found between two cohorts (3.7% for the non-beta-blockers group vs. 3.0% for the beta-blocker group; adjusted odds ratio [OR] 0.82 [95% CI 0.58–1.15]). Few differences in the incidence of other postoperative clinical end points were observed as a function of preoperative beta-blockers except in stroke (0.7% for the non-beta-blocker group vs. 0.3 for the beta-blocker group; adjusted OR 0.39 [95% CI 0.16–0.96]). Results of propensity-matched analyses were broadly consistent. Conclusions In this study, the administration of beta-blockers before CABG was not associated with improved operative mortality and complications except the incidence of postoperative stroke in patients with left ventricular dysfunction. A more granular quality metric which would guide the use of beta-blockers should be developed. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02371-1.
Collapse
Affiliation(s)
- Hanwei Tang
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A Beilishi Rd, Xi Cheng District, Beijing, 100037, People's Republic of China
| | - Kai Chen
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A Beilishi Rd, Xi Cheng District, Beijing, 100037, People's Republic of China
| | - Jianfeng Hou
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A Beilishi Rd, Xi Cheng District, Beijing, 100037, People's Republic of China
| | - Xiaohong Huang
- Department of Special Medical Treatment Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Sheng Liu
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A Beilishi Rd, Xi Cheng District, Beijing, 100037, People's Republic of China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A Beilishi Rd, Xi Cheng District, Beijing, 100037, People's Republic of China. .,Department of Special Medical Treatment Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China.
| |
Collapse
|
160
|
A systematic review and meta-analysis of real-world studies evaluating the association between beta-blocker use and postoperative adverse events of carotid endarterectomy (CEA). J Vasc Surg 2021; 75:1456-1465.e5. [PMID: 34788650 DOI: 10.1016/j.jvs.2021.10.052] [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: 05/16/2021] [Accepted: 10/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To estimate the association of beta-blocker use with postoperative adverse events of CEA based on real-world data. METHODS Electronic bibliographic sources (MEDLINE, EMBASE, and CENTRAL) were searched up to Apr. 2021 using a combination of thesaurus and free-text terms to identify the studies about the effect of beta-blockers on outcomes of CEA. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. All observational studies and randomized controlled trials investigating the effect of preoperative beta-blockers on the outcomes of CEA were included. Independent extraction of articles by two authors using predefined data fields, including study quality indicators. All pooled analyses were based on a random-effects model. RESULTS A total of seven observational studies (six case-control studies and one cohort study) were included. Of the three case-control studies that examine the association of beta-blockers with composite postoperative adverse events, two studies including three datasets totaled 24161 participants were included in the quantitative synthesis and the overall results showed a statistically significant association between beta-blocker use and composite postoperative adverse events of CEA (OR 1.35, 95%CI 1.15- 1.59, p = .0003; I2 = 13%). Publication bias was not present in the meta-analysis (Egger's test showed non-significant results: p = .453). Two of the included studies utilized indirect measures of cerebral ischemia: intraoperative EEG, intraoperative hemodynamic indicators; and found a significant association between beta-blockers and intraoperative cerebral ischemia. Another two studies were included for meta-analysis on the association between beta-blockers and 30-day strokes or death of CEA (OR 1.61, 95%CI 0.98-2.65, p = .06; I2=0%). Of all included studies, there is only one cohort study that reported the association of beta-blockers with postoperative MI by chi-squared analysis (OR 1.96, 95%CI 1.86-2.07). CONCLUSION This systematic review suggested that there was an increased risk of postoperative adverse outcomes of CEA among beta-blocker users compared to non-users in the real world.
Collapse
|
161
|
Yao Y, Dharmalingam A, Tang C, Bell H, Dj McKeown A, McGee M, Davies A, Tay T, Collins N. Cardiac risk assessment with the Revised Cardiac Risk Index index before elective non-cardiac surgery: A retrospective audit from an Australian tertiary hospital. Anaesth Intensive Care 2021; 49:448-454. [PMID: 34772298 DOI: 10.1177/0310057x211024661] [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] [Indexed: 11/15/2022]
Abstract
Clinicians assessing cardiac risk as part of a comprehensive consultation before surgery can use an expanding set of tools, including predictive risk calculators, cardiac stress tests and measuring serum natriuretic peptides. The optimal assessment strategy is unclear, with conflicting international guidelines. We investigated the prognostic accuracy of the Revised Cardiac Risk Index for risk stratification and cardiac outcomes in patients undergoing elective non-cardiac surgery in a contemporary Australian cohort. We audited the records for 1465 consecutive patients 45 years and older presenting to the perioperative clinic for elective non-cardiac surgery in our tertiary hospital. We calculated individual Revised Cardiac Risk Index scores and documented any use of preoperative cardiac tests. The primary outcome was any major adverse cardiac events within 30 days of surgery, including myocardial infarction, pulmonary oedema, complete heart block or cardiac death. Myocardial perfusion imaging was the most common preoperative stress test (4.2%, 61/1465). There was no routine investigation of natriuretic peptide levels for cardiac risk assessment before surgery. Major adverse cardiac events occurred in 1.3% (18/1366) of patients who had surgery. The Revised Cardiac Risk Index score had modest prognostic accuracy for major cardiac complications, area under receiver operator curve 0.73, 95% confidence interval 0.60 to 0.86. Stratifying major adverse cardiac events by the Revised Cardiac Risk Index scores 0, 1, 2 and 3 or greater corresponded to event rates of 0.6% (4/683), 0.8% (4/488), 4.1% (6/145) and 8.0% (4/50), respectively. The Revised Cardiac Risk Index had only modest predictive value in our single-centre experience. Patients with a revised cardiac risk index score of 2 or more had an elevated risk of early cardiac complications after elective non-cardiac surgery.
Collapse
Affiliation(s)
- Yao Yao
- Department of General Medicine, Calvary Mater Hospital, Waratah, Australia
| | - Ashok Dharmalingam
- Department of Anaesthesia, John Hunter Hospital, New Lambton Heights, Australia
| | - Cyril Tang
- John Hunter Hospital, New Lambton Heights, Australia
| | - Harrison Bell
- Department of Anaesthesia, John Hunter Hospital, New Lambton Heights, Australia
| | | | - Michael McGee
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, Australia
| | - Allan Davies
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Tracey Tay
- NSW Agency for Clinical Innovation, North Ryde, Australia
| | - Nicholas Collins
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, Australia
| |
Collapse
|
162
|
Effects of short-term bisoprolol on perioperative myocardial injury in patients undergoing non-cardiac surgery: a randomized control study. Sci Rep 2021; 11:22006. [PMID: 34759287 PMCID: PMC8581026 DOI: 10.1038/s41598-021-01365-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/27/2021] [Indexed: 11/09/2022] Open
Abstract
The protective role of preoperative beta-blocker in patients undergoing non-cardiac surgery is unknown. We aimed to evaluate the effects of beta-blocker on perioperative myocardial injury in patients undergoing non-cardiac surgery. We consecutively enrolled 112 patients undergoing non-cardiac surgery. They were randomly allocated to receive bisoprolol or placebo given at least 2 days preoperatively and continued until 30 days after surgery. The primary outcome was incidence of perioperative myocardial injury defined by a rise of high-sensitive troponin-T (hs-TnT) more than 99th percentile of upper reference limit or a rise of hs-TnT more than 20% if baseline level is abnormal. Baseline characteristics were comparable between bisoprolol and placebo in randomized cohort Mean age was 62.5 ± 11.8 years and 76 (67.8%) of 112 patients were male. Among 112 patients, 49 (43.8%) underwent vascular surgery and 63 (56.2%) underwent thoracic surgery. The median duration of assigned treatment prior to surgery was 4 days (2-6 days). We did not demonstrate the significant difference in the incidence of perioperative myocardial injury [52.6% (30 of 57 patients) vs. 49.1% (27 of 55 patients), P = 0.706]. In addition, the incidence of intraoperative hypotension was higher in bisoprolol group than placebo group in patients undergoing non-cardiac surgery [70.2% (40 of 57 patients) vs. 47.3% (26 of 55 patients), P = 0.017]. We demonstrated that there was no statistically significant difference in perioperative myocardial injury observed between patients receiving bisoprolol and placebo who had undergone non-cardiac surgery.
Collapse
|
163
|
Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e287-e305. [PMID: 34601955 DOI: 10.1161/cir.0000000000001024] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.
Collapse
|
164
|
Safi S, Sethi NJ, Korang SK, Nielsen EE, Feinberg J, Gluud C, Jakobsen JC. Beta-blockers in patients without heart failure after myocardial infarction. Cochrane Database Syst Rev 2021; 11:CD012565. [PMID: 34739733 PMCID: PMC8570410 DOI: 10.1002/14651858.cd012565.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cardiovascular disease is the number one cause of death globally. According to the World Health Organization (WHO), 7.4 million people died from ischaemic heart disease in 2012, constituting 15% of all deaths. Beta-blockers are recommended and are often used in patients with heart failure after acute myocardial infarction. However, it is currently unclear whether beta-blockers should be used in patients without heart failure after acute myocardial infarction. Previous meta-analyses on the topic have shown conflicting results. No previous systematic review using Cochrane methods has assessed the effects of beta-blockers in patients without heart failure after acute myocardial infarction. OBJECTIVES To assess the benefits and harms of beta-blockers compared with placebo or no treatment in patients without heart failure and with left ventricular ejection fraction (LVEF) greater than 40% in the non-acute phase after myocardial infarction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index - Expanded, BIOSIS Citation Index, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, European Medicines Agency, Food and Drug Administration, Turning Research Into Practice, Google Scholar, and SciSearch from their inception to February 2021. SELECTION CRITERIA We included all randomised clinical trials assessing effects of beta-blockers versus control (placebo or no treatment) in patients without heart failure after myocardial infarction, irrespective of publication type and status, date, and language. We excluded trials randomising participants with diagnosed heart failure at the time of randomisation. DATA COLLECTION AND ANALYSIS We followed our published protocol, with a few changes made, and methodological recommendations provided by Cochrane and Jakobsen and colleagues. Two review authors independently extracted data. Our primary outcomes were all-cause mortality, serious adverse events, and major cardiovascular events (composite of cardiovascular mortality and non-fatal myocardial reinfarction). Our secondary outcomes were quality of life, angina, cardiovascular mortality, and myocardial infarction during follow-up. We assessed all outcomes at maximum follow-up. We systematically assessed risks of bias using seven bias domains and we assessed the certainty of evidence using the GRADE approach. MAIN RESULTS We included 25 trials randomising a total of 22,423 participants (mean age 56.9 years). All trials and outcomes were at high risk of bias. In all, 24 of 25 trials included a mixed group of participants with ST-elevation myocardial infarction and non-ST myocardial infarction, and no trials provided separate results for each type of infarction. One trial included participants with only ST-elevation myocardial infarction. All trials except one included participants younger than 75 years of age. Methods used to exclude heart failure were various and were likely insufficient. A total of 21 trials used placebo, and four trials used no intervention, as the comparator. All patients received usual care; 24 of 25 trials were from the pre-reperfusion era (published from 1974 to 1999), and only one trial was from the reperfusion era (published in 2018). The certainty of evidence was moderate to low for all outcomes. Our meta-analyses show that beta-blockers compared with placebo or no intervention probably reduce the risks of all-cause mortality (risk ratio (RR) 0.81, 97.5% confidence interval (CI) 0.73 to 0.90; I² = 15%; 22,085 participants, 21 trials; moderate-certainty evidence) and myocardial reinfarction (RR 0.76, 98% CI 0.69 to 0.88; I² = 0%; 19,606 participants, 19 trials; moderate-certainty evidence). Our meta-analyses show that beta-blockers compared with placebo or no intervention may reduce the risks of major cardiovascular events (RR 0.72, 97.5% CI 0.69 to 0.84; 14,994 participants, 15 trials; low-certainty evidence) and cardiovascular mortality (RR 0.73, 98% CI 0.68 to 0.85; I² = 47%; 21,763 participants, 19 trials; low-certainty evidence). Hence, evidence seems to suggest that beta-blockers versus placebo or no treatment may result in a minimum reduction of 10% in RR for risks of all-cause mortality, major cardiovascular events, cardiovascular mortality, and myocardial infarction. However, beta-blockers compared with placebo or no intervention may not affect the risk of angina (RR 1.04, 98% CI 0.93 to 1.13; I² = 0%; 7115 participants, 5 trials; low-certainty evidence). No trials provided data on serious adverse events according to good clinical practice from the International Committee for Harmonization of Technical Requirements for Pharmaceuticals for Human Use (ICH-GCP), nor on quality of life. AUTHORS' CONCLUSIONS Beta-blockers probably reduce the risks of all-cause mortality and myocardial reinfarction in patients younger than 75 years of age without heart failure following acute myocardial infarction. Beta-blockers may further reduce the risks of major cardiovascular events and cardiovascular mortality compared with placebo or no intervention in patients younger than 75 years of age without heart failure following acute myocardial infarction. These effects could, however, be driven by patients with unrecognised heart failure. The effects of beta-blockers on serious adverse events, angina, and quality of life are unclear due to sparse data or no data at all. All trials and outcomes were at high risk of bias, and incomplete outcome data bias alone could account for the effect seen when major cardiovascular events, angina, and myocardial infarction are assessed. The evidence in this review is of moderate to low certainty, and the true result may depart substantially from the results presented here. Future trials should particularly focus on patients 75 years of age and older, and on assessment of serious adverse events according to ICH-GCP and quality of life. Newer randomised clinical trials at low risk of bias and at low risk of random errors are needed if the benefits and harms of beta-blockers in contemporary patients without heart failure following acute myocardial infarction are to be assessed properly. Such trials ought to be designed according to the SPIRIT statement and reported according to the CONSORT statement.
Collapse
Affiliation(s)
- Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Naqash J Sethi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil Eik Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
165
|
Targeting Higher Intraoperative Blood Pressures Does Not Reduce Adverse Cardiovascular Events Following Noncardiac Surgery. J Am Coll Cardiol 2021; 78:1753-1764. [PMID: 34711333 DOI: 10.1016/j.jacc.2021.08.048] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/02/2021] [Accepted: 08/17/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Intraoperative arterial hypotension is strongly associated with postoperative major adverse cardiovascular events (MACE); however, whether targeting higher intraoperative mean arterial blood pressures (MAPs) may prevent adverse events remains unclear. OBJECTIVES This study sought to determine whether targeting higher intraoperative MAP lowers the incidence of postoperative MACE. METHODS This single-center randomized controlled trial assigned adult patients at cardiovascular risk undergoing major noncardiac surgery to an intraoperative MAP target of ≥60 mm Hg (control) or ≥75 mm Hg (MAP ≥75). The primary outcome was acute myocardial injury on postoperative days 0-3 and/or 30-day MACE/acute kidney injury (AKI) (acute coronary syndrome, congestive heart failure, coronary revascularization, stroke, AKI, and all-cause mortality). The secondary outcome was 1-year MACE. RESULTS In total, 458 patients were randomized (intention-to-treat population: 451). The cumulative intraoperative duration with MAP <65 mm Hg was significantly shorter in the MAP ≥75 group (median 9 minutes [interquartile range: 3 to 24 minutes] vs 23 minutes [interquartile range: 8-49 minutes]; P < 0.001). The primary outcome incidence was 48% for MAP ≥75 and 52% for control (risk difference -4.2%; 95% CI: -13% to +5%), the primary contributor being AKI (incidence 44%). Acute myocardial injury occurred in 15% (MAP ≥75) and 19% (control) of patients. The secondary outcome incidence was 17% for MAP ≥75 and 15% for control (risk difference +2.7; 95% CI: -4% to +9.5%). CONCLUSIONS These findings do not support universally targeting higher intraoperative blood pressures to reduce postoperative complications. Despite a 60% reduction in hypotensive time with MAP <65 mm Hg, no significant reductions in acute myocardial injury or 30-day MACE/AKI could be found. (Biomarkers, Blood Pressure, BIS: Risk Stratification/Management of Patients at Cardiac Risk in Major Noncardiac Surgery [BBB]; NCT02533128).
Collapse
|
166
|
Mohammad Ismail A, Ahl R, Forssten MP, Cao Y, Wretenberg P, Borg T, Mohseni S. Beta-Blocker Therapy Is Associated With Increased 1-Year Survival After Hip Fracture Surgery: A Retrospective Cohort Study. Anesth Analg 2021; 133:1225-1234. [PMID: 34260428 PMCID: PMC8505142 DOI: 10.1213/ane.0000000000005659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The high mortality rates seen within the first postoperative year after hip fracture surgery have remained relatively unchanged in many countries for the past 15 years. Recent investigations have shown an association between beta-blocker (BB) therapy and a reduction in risk-adjusted mortality within the first 90 days after hip fracture surgery. We hypothesized that preoperative, and continuous postoperative, BB therapy may also be associated with a decrease in mortality within the first year after hip fracture surgery. METHODS In this retrospective cohort study, all adults who underwent primary emergency hip fracture surgery in Sweden, between January 1, 2008 and December 31, 2017, were included. Patients with pathological fractures and conservatively managed hip fractures were excluded. Patients who filled a prescription within the year before and after surgery were defined as having ongoing BB therapy. The primary outcome of interest was postoperative mortality within the first year. To reduce the effects of confounding from covariates due to nonrandomization in the current study, the inverse probability of treatment weighting (IPTW) method was used. Subsequently, Cox proportional hazards models were fitted to the weighted cohorts. These analyses were repeated while excluding patients who died within the first 30 days postoperatively. This reduces the effect of early deaths due to surgical and anesthesiologic complications as well as the higher degree of advanced directives present in the study population compared to the general population, which allowed for the evaluation of the long-term association between BB therapy and mortality in isolation. Results are reported as hazard ratios (HR) with 95% confidence intervals (CI). Statistical significance was defined as a 2-sided P value <.05. RESULTS A total of 134,915 cases were included in the study. After IPTW, BB therapy was associated with a 42% reduction the risk of mortality within the first postoperative year (adjusted HR = 0.58, 95% CI, 0.57-0.60; P < .001). After excluding patients who died within the first 30 days postoperatively, BB therapy was associated with a 27% reduction in the risk of mortality (adjusted HR = 0.73, 95% CI, 0.71-0.75; P < .001). CONCLUSIONS A significant reduction in the risk of mortality in the first year following hip fracture surgery was observed in patients with ongoing BB therapy. Further investigations into this finding are warranted.
Collapse
Affiliation(s)
- Ahmad Mohammad Ismail
- From the Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Rebecka Ahl
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Peter Forssten
- From the Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Per Wretenberg
- From the Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Tomas Borg
- From the Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| |
Collapse
|
167
|
Putowski Z, Czajka S, Krzych ŁJ. Association between Intraoperative Blood Pressure Drop and Clinically Significant Hypoperfusion in Abdominal Surgery: A Cohort Study. J Clin Med 2021; 10:5010. [PMID: 34768530 PMCID: PMC8584611 DOI: 10.3390/jcm10215010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022] Open
Abstract
The recent consensus by the Perioperative Quality Initiative (POQI) on intraoperative hypotension (IOH) stated that mean arterial pressure (MAP) below 60-70 mmHg is associated with myocardial infarction (MI), acute kidney injury (AKI), death and also that IOH is a function of not only severity but also of duration. However, most of the data come from large, heterogeneous cohorts of patients who underwent different surgical procedures and types of anaesthesia. We sought to assess how various definitions of IOH can predict clinically significant hypoperfusive outcomes in a homogenous cohort of generally anesthetised patients undergoing abdominal surgery, taking into account thresholds of MAP and their time durations. The data for this study come from a prospective cohort study in which patients who underwent abdominal surgery between 1 October 2018 and 15 July 2019 in the university hospital in Katowice were included in the analysis. We analysed perioperative data to assess how various IOH thresholds can predict hypoperfusive outcomes (defined as myocardial injury, acute kidney injury or stroke). 508 patients were included in the study. The total number of cases of clinically significant hypoperfusion was 38 (7.5%). We found that extending durations of low MAP, i.e., below 55 mmHg, 60 mmHg, 65 mmHg and 70 mmHg, were associated with the development of either AKI, MI or stroke. It was observed that for narrower and lower hypotension thresholds, the time required to induce complications is shorter. Patients who suffered from AKI/MI/Stroke experienced more episodes of any of the IOH definitions applied. Absolute IOH thresholds were superior to the relative definitions. For patients undergoing abdominal surgery, it is vital to prevent the extended durations of intraoperative mean arterial pressure below 70 mmHg. Finally, there appears to be no need to guide intraoperative haemodynamic therapy based on pre-induction values and, consequently, on relative drops of MAP.
Collapse
Affiliation(s)
- Zbigniew Putowski
- Students’ Scientific Society, Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, 14 Medyków Street, 40-752 Katowice, Poland
| | - Szymon Czajka
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, 14 Medyków Street, 40-752 Katowice, Poland; (S.C.); (Ł.J.K.)
| | - Łukasz J. Krzych
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, 14 Medyków Street, 40-752 Katowice, Poland; (S.C.); (Ł.J.K.)
| |
Collapse
|
168
|
Zhang Y, Li S, Yan C, Chen J, Shan F. Perioperative Use of Glucocorticoids and Intraoperative Hypotension May Affect the Incidence of Postoperative Infection in Patients with Gastric Cancer: A Retrospective Cohort Study. Cancer Manag Res 2021; 13:7723-7734. [PMID: 34675668 PMCID: PMC8517416 DOI: 10.2147/cmar.s333414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022] Open
Abstract
Background In patients undergoing surgical resection for gastric cancer, postoperative complications—in particular, postoperative infections—remain an important problem and can result in delayed recovery and increased postoperative mortality. Objective To investigate the association between perioperative anesthesia management and postoperative infectious complications in patients undergoing resection for gastric cancer. Design Retrospective cohort study. Setting A single-center study performed from April 1, 2015, to June 30, 2018, at Peking University Cancer Hospital. Patients Patients who underwent resection for gastric cancer. Main Outcome Measures Demographic information, perioperative data (including anesthesia-related data, surgery-related data, and cancer diagnosis), and information on postoperative recovery were recorded. The primary outcome was incidence of postoperative infection; the secondary outcome was length of hospital stay. The associations between perioperative factors and postoperative infectious complications were analyzed using multivariable logistic regression models and the classification tree method. Results A total of 880 patients were included in the study; of these, 111 (12.6%) had postoperative infectious complications during hospitalization, including 78 surgical site infections and 62 remote infections. After correction for confounding factors on logistic multivariable analysis, perioperative use of glucocorticoids was associated with a lower incidence of postoperative infection (hazard ratio 0.968, 95% confidence interval 0.939 to 0.997, P=0.029), and intraoperative systolic blood pressure <90 mmHg for >10 min was associated with a higher incidence of postoperative infection (hazard ratio 2.112, 95% confidence interval 1.174 to 3.801, P=0.013). In addition, older age, preoperative hypoproteinemia, and total gastrectomy were identified as independent predictors of postoperative infection. Conclusion For patients with gastric cancer, perioperative use of glucocorticoids and avoiding intraoperative hypotension may decrease the incidence of postoperative infectious complications.
Collapse
Affiliation(s)
- Yunxiao Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Shuo Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Chao Yan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), The First Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Jiheng Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Fei Shan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), The First Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| |
Collapse
|
169
|
Park J, Lee JH. Myocardial injury in noncardiac surgery. Korean J Anesthesiol 2021; 75:4-11. [PMID: 34657407 PMCID: PMC8831428 DOI: 10.4097/kja.21372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/17/2021] [Indexed: 11/13/2022] Open
Abstract
Myocardial injury is defined as an elevation of cardiac troponin (cTn) levels with or without associated ischemic symptoms. Robust evidence suggests that myocardial injury increases postoperative mortality after noncardiac surgery. The diagnostic criteria for myocardial injury after noncardiac surgery (MINS) include an elevation of cTn levels within 30 d of surgery without evidence of non-ischemic etiology. The majority of cases of MINS do not present with ischemic symptoms and are caused by a mismatch in oxygen supply and demand. Predictive models for general cardiac risk stratification can be considered for MINS. Risk factors include comorbidities, anemia, glucose levels, and intraoperative blood pressure. Modifiable factors may help prevent MINS; however, further studies are needed. Recent guidelines recommend routine monitoring of cTn levels during the first 48 h post-operation in high-risk patients since MINS most often occurs in the first 3 days after surgery without symptoms. The use of cardiovascular drugs, such as aspirin, antihypertensives, and statins, has had beneficial effects in patients with MINS, and direct oral anticoagulants have been shown to reduce the mortality associated with MINS in a randomized controlled trial. Myocardial injury detected before noncardiac surgery was also found to be associated with postoperative mortality, though further studies are needed.
Collapse
Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
170
|
Nejim B, Mathlouthi A, Naazie I, Malas MB. The Effect of Intravenous and Oral Beta-Blocker Use in Patients with Type B Thoracic Aortic Dissection. Ann Vasc Surg 2021; 80:170-179. [PMID: 34656722 DOI: 10.1016/j.avsg.2021.07.056] [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: 10/23/2020] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Beta-blockers have become the cornerstone for medical management in patients with chronic type B aortic dissection (TBAD). However, the effect of being on and/or receiving intravenous beta-blockers during hospitalization on outcomes of surgical repair of TBAD is not fully described. We sought to investigate this association during open surgical repair (OSR) and endovascular (Endo) intervention for nontraumatic TBAD. METHODS The Premier Healthcare Database was inquired (June/2009-March/2015). Patients with nontraumatic isolated TBAD were identified via ICD-9-CM diagnosis and procedural codes. Patients with codes that indicated TAAD were excluded. In-hospital mortality, cardiac complications (CHF, MI, arrythmia) and stroke were evaluated. Log binomial regression analyses with bootstrapping were performed to assess the relative risk of adverse outcomes. RESULTS A total of 1,752 were admitted for OSR (54.3%) and Endo (45.7%) TBAD repair. Use of oral beta blocker (BB) was 16.0% in OSR and 56.4% in Endo groups. In each arm, patients on BB were more likely to be diabetic, on aspirin or statin and more likely to receive additional IV BB than nonBB patients. There was no significant difference in age, sex, race, or prior history of CHF between BB and nonBB groups. Mortality was proportionally lower in patients on BB in OSR group (7.9% vs. 16.7%; P = 0.006) and Endo (3.3% vs. 9.2%; P < 0.001). The adjusted relative risk for mortality and stroke were significantly lower in oral BB recipients compared with none [aRR (95% CI): 0.53 (0.32-0.90) and 0.46 (0.25-0.87); both P ≤ 0.02]. IV metoprolol was the only IV BB that reduced mortality [aRR (95% CI): 0.62 (0.46-0.85); P = 0.003]. A dose of ≤10 mg was associated with significant mortality reduction: 6.3% (3.0-9.5%) compared with 8.1% (4.6-11.6%) in no IV BB group. Cardiac complications were not affected by BB use. CONCLUSIONS For patients with nontraumatic TBAD, use of oral BB was associated with significant protection against in-hospital mortality and stroke following repair. Metoprolol was the only Intravenous BB type associated with improved survival. Further research is warranted to elucidate the effect of beta-blockers on the long-term surgical outcomes of TBAD.
Collapse
Affiliation(s)
- Besma Nejim
- Department of Vascular Surgery, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA..
| |
Collapse
|
171
|
BARNETT R, AMBERT M, CAMPORESI EM. Preoperative cardiac evaluation of the vascular surgery patient. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.23736/s1824-4777.21.01520-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
172
|
Elvir-Lazo OL, White PF, Cruz Eng H, Yumul F, Chua R, Yumul R. Impact of chronic medications in the perioperative period -anesthetic implications (Part II). Postgrad Med 2021; 133:920-938. [PMID: 34551658 DOI: 10.1080/00325481.2021.1982298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: This review article discusses the pharmacodynamic effects of the most commonly used chronic medications by patients undergoing elective surgical procedures, namely cardiovascular drugs (e.g., beta blockers, alpha-2 agonist, calcium channel blockers, ACE inhibitors, diuretics, etc.), lipid-lowering drugs, gastrointestinal medications (H2-blockers, proton pump inhibitors), pulmonary medications (inhaled β-agonists, anticholinergics,), antibiotics (tetracyclines, clindamycin and macrolide, linezolid.), opioids and non-opioids analgesics (NSAIDs, COX-2 inhibitors, acetaminophen), gabapentanoids, erectile dysfunction (ED) drugs, psychotropic drugs (tricyclic antidepressants [TCAs], monoamine oxidase inhibitors [MAOI], selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], and cannabinol-containing drugs). In addition, the potential adverse drug-interactions between these chronic medications and commonly used anesthetic drugs during the perioperative period will be reviewed. Finally, recommendations regarding the management of chronic medications during the preoperative period will be provided.Materials and Methods: An online search was conducted from January 2000 through February 2021 with the Medline database through PubMed and Google Scholar using the following search terms/keywords: "chronic medications in the perioperative period", and "chronic medications and anesthetic implications." In addition, we searched for anesthetic side effects associated with the major drug groups.Results and Conclusions: An understanding of the pharmacodynamic effects of most used chronic medications is important to avoid untoward outcomes in the perioperative period. These drug interactions may result in altered efficacy and toxicity of the anesthetic medications administered during surgery. These drug-drug interactions can also affect the morbidity, mortality, recovery time of surgical patients and acute relapse of chronic illnesses which could lead to last minute cancellation of surgical procedures. Part II of this two-part review article focuses on the reported interactions between most commonly taken chronic medications by surgical patients and anesthetic and analgesic drugs, as well as recommendations regarding the handling these chronic medications during the perioperative period.
Collapse
Affiliation(s)
| | - Paul F White
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,The White Mountain Institute, The Sea Ranch, CA, USA
| | - Hillenn Cruz Eng
- Adena Health System, department of anesthesiology, Chillicothe, OH, US
| | - Firuz Yumul
- Department of family medicine, Skagit Regional Health, Family Medicine, Arlington, WA, USA
| | - Raissa Chua
- Department of Internal Medicine, Huntington Hospital, Prasadena, CA, USA
| | - Roya Yumul
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,David Geffen School of Medicine-UCLA, Charles R, Drew University of Medicine and Science, Los Angeles, CA, USA
| |
Collapse
|
173
|
Jorge AJL, Mesquita ET, Martins WDA. Myocardial Injury after Non-cardiac Surgery - State of the Art. Arq Bras Cardiol 2021; 117:544-553. [PMID: 34550241 PMCID: PMC8462967 DOI: 10.36660/abc.20200317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 11/04/2020] [Indexed: 11/18/2022] Open
Abstract
Aproximadamente 300 milhões de cirurgias não cardíacas são realizadas anualmente no mundo, e eventos cardiovasculares adversos são as principais causas de morbimortalidade no período perioperatório e pós-operatório. A lesão miocárdica após cirurgia não cardíaca (MINS, do inglês myocardial injury after non-cardiac surgery) é uma nova entidade clínica associada com desfechos cardiovasculares adversos. MINS é definida como uma lesão miocárdica que pode resultar em necrose secundária à isquemia, com elevação dos biomarcadores. A lesão tem importância prognóstica e ocorre em até 30 dias após a cirurgia não cardíaca. Os critérios diagnósticos para MINS são: níveis elevados de troponina durante ou em até 30 dias após a cirurgia não cardíaca, sem evidência de etiologia não isquêmica, sem que haja necessariamente sintomas isquêmicos ou achados eletrocardiográficos de isquemia. Recentemente, pacientes com maior risco para MINS têm sido identificados por variáveis clínicas e biomarcadores, bem como por protocolos de vigilância quanto ao monitoramento eletrocardiográfico e dosagem de troponina cardíaca. Pacientes idosos com doença aterosclerótica prévia necessitam medir troponina diariamente no período pós-operatório. O objetivo deste trabalho é descrever este novo problema de saúde pública, seu impacto clínico e a abordagem terapêutica contemporânea.
Collapse
Affiliation(s)
| | - Evandro Tinoco Mesquita
- Centro de Ensino e Treinamento Edson de Godoy Bueno / UHG, Rio de Janeiro, RJ - Brasil.,UNIALFA / Colégio Brasileiro de Executivos em Saúde CBEXs, São Paulo, SP - Brasil.,Sociedad Interamericana de Cardiología (SIAC), Cidade do México - México.,DASA Complexo Hospitalar de Niterói, Niterói, RJ - Brasil
| | - Wolney de Andrade Martins
- Universidade Federal Fluminense (UFF), Niterói, RJ - Brasil.,DASA Complexo Hospitalar de Niterói, Niterói, RJ - Brasil
| |
Collapse
|
174
|
Senussi MH. Beta-Blockers in the Critically Ill: Friend or Foe? J Am Coll Cardiol 2021; 78:1012-1014. [PMID: 34474732 PMCID: PMC9458104 DOI: 10.1016/j.jacc.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Mourad H Senussi
- Baylor St. Luke's Medical Center, Baylor College of Medicine, Houston, Texas, USA.
| |
Collapse
|
175
|
Heterogeneous impact of hypotension on organ perfusion and outcomes: a narrative review. Br J Anaesth 2021; 127:845-861. [PMID: 34392972 DOI: 10.1016/j.bja.2021.06.048] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/08/2021] [Accepted: 06/25/2021] [Indexed: 12/20/2022] Open
Abstract
Arterial blood pressure is the driving force for organ perfusion. Although hypotension is common in acute care, there is a lack of accepted criteria for its definition. Most practitioners regard hypotension as undesirable even in situations that pose no immediate threat to life, but hypotension does not always lead to unfavourable outcomes based on experience and evidence. Thus efforts are needed to better understand the causes, consequences, and treatments of hypotension. This narrative review focuses on the heterogeneous underlying pathophysiological bases of hypotension and their impact on organ perfusion and patient outcomes. We propose the iso-pressure curve with hypotension and hypertension zones as a way to visualize changes in blood pressure. We also propose a haemodynamic pyramid and a pressure-output-resistance triangle to facilitate understanding of why hypotension can have different pathophysiological mechanisms and end-organ effects. We emphasise that hypotension does not always lead to organ hypoperfusion; to the contrary, hypotension may preserve or even increase organ perfusion depending on the relative changes in perfusion pressure and regional vascular resistance and the status of blood pressure autoregulation. Evidence from RCTs does not support the notion that a higher arterial blood pressure target always leads to improved outcomes. Management of blood pressure is not about maintaining a prespecified value, but rather involves ensuring organ perfusion without undue stress on the cardiovascular system.
Collapse
|
176
|
Shah M, Rodriguez CJ, Bartz TM, Lyles MF, Kizer JR, Aurigemma GP, Gardin JM, Gottdiener JS. Incidence, Determinants and Mortality of Heart Failure Associated With Medical-Surgical Procedures in Patients ≥ 65 Years of Age (from the Cardiovascular Health Study). Am J Cardiol 2021; 153:71-78. [PMID: 34175107 PMCID: PMC8318205 DOI: 10.1016/j.amjcard.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 11/16/2022]
Abstract
Heart failure (HF) and myocardial infarction are serious complications of major noncardiac surgery in older adults. Many factors can contribute to the development of HF during the postoperative period. The incidence of, and risk factors for, procedure-associated heart failure (PHF) occurring at the time of, or shortly after, medical procedures in a population-based sample ≥ 65 years of age have not been fully characterized, particularly in comparison with HF not proximate to medical procedures. This analysis comprises 5,121 men and women free of HF at baseline from the Cardiovascular Health Study who were followed up for 12.0 years (median). HF events were documented by self-report at semi-annual contacts and confirmed by a formal adjudication committee using a review of the participants' medical records and standardized criteria for HF. Incident HF events were additionally adjudicated as either being related or unrelated to a medical procedure (PHF and non-PHF, respectively). We estimated cause-specific hazards ratios for the association of covariates with PHF and non-PHF. There were 1,728 incident HF events in the primary analysis: 168 (10%) classified as PHF, 1,526 (88%) as non-PHF, and 34 unclassified (2%). For those 1,045 participants in whom LV ejection fraction was known at the time of the HF event, it was ≥45% in 89 of 118 participants (75%) with PHF, compared to 517 of 927 participants (55%) with non-PHF (p < 0.001). Increased age, male gender, diabetes, and angina at baseline were associated with both PHF and non-PHF (range of hazard ratios (HR): 1.04-2.05]. Being Black was inversely associated with PHF [HR: 0.46, 95% confidence interval: 0.25-0.86]. Participants with increased age, without baseline angina, and with baseline LVEF<55% were at a significantly lower risk for PHF compared to non-PHF. Among those with PHF, surgical procedures-including cardiac, orthopedic, gastrointestinal, vascular, and urologic-comprised 83.3%, while percutaneous procedures comprised 8.9% (including 6.5% represented by cardiac catheterizations and pacemaker placements). Another group composed of a variety of procedures commonly requiring large fluid volume administration comprised 7.7%. There was a lower all-cause 30-day mortality in the PHF versus the non-PHF group (2.2% vs 5.7%), with a nonsignificant odds ratio of 0.39 in a minimally adjusted model. When individuals with prior myocardial infarction (MI) were excluded in a sensitivity analysis, the proportion of incident HF with concurrent MI was greater for PHF (32.9%) than for non-PHF (19.8%). In conclusion, PHF in older adults is a common entity with relatively low 30-day mortality. Baseline angina, lower age, and LVEF ≥ 55% were associated with a higher risk of PHF compared to non-PHF. Being Black was associated with a lower risk of PHF and PHF as a proportion of HF was lower in Black than in non-Black participants. Compared to non-PHF, PHF more frequently presented with concurrent MI and with preserved LV ejection fraction.
Collapse
Affiliation(s)
- Monali Shah
- Department of Medicine, Division of Cardiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Carlos J Rodriguez
- Department of Medicine, Albert Einstein College of Medicine, Bronx NY, USA
| | - Traci M Bartz
- Department of Biostatistics, University of Washington, Seattle WA, USA
| | - Mary F Lyles
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem NC, USA
| | - Jorge R Kizer
- Cardiology Section, San Francisco Veterans Affairs Health Care System and Departments of Medicine, Epidemiology and Biostatistics, University of California San Francisco, San Francisco CA, USA
| | - Gerard P Aurigemma
- Department of Medicine, University of Massachusetts Medical School, Worcester MA, USA
| | - Julius M Gardin
- Department of Medicine, Division of Cardiology, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - John S Gottdiener
- Department of Medicine (Cardiology), University of Maryland School of Medicine, Baltimore MD, USA
| |
Collapse
|
177
|
Jawad I, Rashan S, Sigera C, Salluh J, Dondorp AM, Haniffa R, Beane A. A scoping review of registry captured indicators for evaluating quality of critical care in ICU. J Intensive Care 2021; 9:48. [PMID: 34353360 PMCID: PMC8339165 DOI: 10.1186/s40560-021-00556-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/23/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Excess morbidity and mortality following critical illness is increasingly attributed to potentially avoidable complications occurring as a result of complex ICU management (Berenholtz et al., J Crit Care 17:1-2, 2002; De Vos et al., J Crit Care 22:267-74, 2007; Zimmerman J Crit Care 1:12-5, 2002). Routine measurement of quality indicators (QIs) through an Electronic Health Record (EHR) or registries are increasingly used to benchmark care and evaluate improvement interventions. However, existing indicators of quality for intensive care are derived almost exclusively from relatively narrow subsets of ICU patients from high-income healthcare systems. The aim of this scoping review is to systematically review the literature on QIs for evaluating critical care, identify QIs, map their definitions, evidence base, and describe the variances in measurement, and both the reported advantages and challenges of implementation. METHOD We searched MEDLINE, EMBASE, CINAHL, and the Cochrane libraries from the earliest available date through to January 2019. To increase the sensitivity of the search, grey literature and reference lists were reviewed. Minimum inclusion criteria were a description of one or more QIs designed to evaluate care for patients in ICU captured through a registry platform or EHR adapted for quality of care surveillance. RESULTS The search identified 4780 citations. Review of abstracts led to retrieval of 276 full-text articles, of which 123 articles were accepted. Fifty-one unique QIs in ICU were classified using the three components of health care quality proposed by the High Quality Health Systems (HQSS) framework. Adverse events including hospital acquired infections (13.7%), hospital processes (54.9%), and outcomes (31.4%) were the most common QIs identified. Patient reported outcome QIs accounted for less than 6%. Barriers to the implementation of QIs were described in 35.7% of articles and divided into operational barriers (51%) and acceptability barriers (49%). CONCLUSIONS Despite the complexity and risk associated with ICU care, there are only a small number of operational indicators used. Future selection of QIs would benefit from a stakeholder-driven approach, whereby the values of patients and communities and the priorities for actionable improvement as perceived by healthcare providers are prioritized and include greater focus on measuring discriminable processes of care.
Collapse
Affiliation(s)
- Issrah Jawad
- National Intensive Care Surveillance-MORU, Borella, Colombo, Western Province 08 Sri Lanka
| | - Sumayyah Rashan
- National Intensive Care Surveillance-MORU, Borella, Colombo, Western Province 08 Sri Lanka
| | - Chathurani Sigera
- National Intensive Care Surveillance-MORU, Borella, Colombo, Western Province 08 Sri Lanka
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D’Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Arjen M. Dondorp
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Central Thailand 10400 Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Rashan Haniffa
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Central Thailand 10400 Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Abi Beane
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Central Thailand 10400 Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
178
|
Ganesh R, Kebede E, Mueller M, Gilman E, Mauck KF. Perioperative Cardiac Risk Reduction in Noncardiac Surgery. Mayo Clin Proc 2021; 96:2260-2276. [PMID: 34226028 DOI: 10.1016/j.mayocp.2021.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 02/20/2021] [Accepted: 03/04/2021] [Indexed: 11/21/2022]
Abstract
Major adverse cardiovascular events are a significant source of morbidity and mortality in the perioperative setting, estimated to occur in approximately 5% of patients undergoing nonemergent noncardiac surgery. To minimize the incidence and impact of these events, careful attention must be paid to preoperative cardiovascular assessment to identify patients at high risk of cardiovascular complications. Once identified, cardiovascular risk reduction is achieved through optimization of medical conditions, appropriate management of medication, and careful monitoring to allow for early identification of-and intervention for-any new conditions that would increase the risk of adverse cardiovascular outcomes. The major cardiovascular and anesthesiology societies in the United States, Europe, and Canada have published guidelines for perioperative management of patients undergoing noncardiac surgery. However, since publication of these guidelines, there has been a practice-changing evolution in the medical literature. In this review, we attempt to reconcile the recommendations made in these 3 comprehensive guidelines, while updating recommendations, based on new evidence, when available.
Collapse
Affiliation(s)
- Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Esayas Kebede
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Elizabeth Gilman
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
179
|
Hanson NA, Lavallee MB, Thiele RH. Apophenia and anesthesia: how we sometimes change our practice prematurely. Can J Anaesth 2021; 68:1185-1196. [PMID: 33963519 PMCID: PMC8104920 DOI: 10.1007/s12630-021-02005-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 12/21/2022] Open
Abstract
Human beings are predisposed to identifying false patterns in statistical noise, a likely survival advantage during our evolutionary development. Moreover, humans seem to prefer "positive" results over "negative" ones. These two cognitive features lay a framework for premature adoption of falsely positive studies. Added to this predisposition is the tendency of journals to "overbid" for exciting or newsworthy manuscripts, incentives in both the academic and publishing industries that value change over truth and scientific rigour, and a growing dependence on complex statistical techniques that some reviewers do not understand. The purpose of this article is to describe the underlying causes of premature adoption and provide recommendations that may improve the quality of published science.
Collapse
Affiliation(s)
- Neil A Hanson
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, ville, VA, 22908-0710, USA.
| | - Matthew B Lavallee
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, ville, VA, 22908-0710, USA
| | - Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, ville, VA, 22908-0710, USA
| |
Collapse
|
180
|
Levels of Evidence Supporting the North American and European Perioperative Care Guidelines for Anesthesiologists between 2010 and 2020: A Systematic Review. Anesthesiology 2021; 135:31-56. [PMID: 34046679 DOI: 10.1097/aln.0000000000003808] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although there are thousands of published recommendations in anesthesiology clinical practice guidelines, the extent to which these are supported by high levels of evidence is not known. This study hypothesized that most recommendations in clinical practice guidelines are supported by a low level of evidence. METHODS A registered (Prospero CRD42020202932) systematic review was conducted of anesthesia evidence-based recommendations from the major North American and European anesthesiology societies between January 2010 and September 2020 in PubMed and EMBASE. The level of evidence A, B, or C and the strength of recommendation (strong or weak) for each recommendation was mapped using the American College of Cardiology/American Heart Association classification system or the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The outcome of interest was the proportion of recommendations supported by levels of evidence A, B, and C. Changes in the level of evidence over time were examined. Risk of bias was assessed using Appraisal of Guidelines for Research and Evaluation (AGREE) II. RESULTS In total, 60 guidelines comprising 2,280 recommendations were reviewed. Level of evidence A supported 16% (363 of 2,280) of total recommendations and 19% (288 of 1,506) of strong recommendations. Level of evidence C supported 51% (1,160 of 2,280) of all recommendations and 50% (756 of 1,506) of strong recommendations. Of all the guidelines, 73% (44 of 60) had a low risk of bias. The proportion of recommendations supported by level of evidence A versus level of evidence C (relative risk ratio, 0.93; 95% CI, 0.18 to 4.74; P = 0.933) or level of evidence B versus level of evidence C (relative risk ratio, 1.63; 95% CI, 0.72 to 3.72; P = 0.243) did not increase in guidelines that were revised. Year of publication was also not associated with increases in the proportion of recommendations supported by level of evidence A (relative risk ratio, 1.07; 95% CI, 0.93 to 1.23; P = 0.340) or level of evidence B (relative risk ratio, 1.05; 95% CI, 0.96 to 1.15; P = 0.283) compared to level of evidence C. CONCLUSIONS Half of the recommendations in anesthesiology clinical practice guidelines are based on a low level of evidence, and this did not change over time. These findings highlight the need for additional efforts to increase the quality of evidence used to guide decision-making in anesthesiology. EDITOR’S PERSPECTIVE
Collapse
|
181
|
Perioperative Care of Patients at High Risk for Stroke During or After Non-cardiac, Non-neurological Surgery: 2020 Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 32:210-226. [PMID: 32433102 DOI: 10.1097/ana.0000000000000686] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Perioperative stroke is associated with considerable morbidity and mortality. Stroke recognition and diagnosis are challenging perioperatively, and surgical patients receive therapeutic interventions less frequently compared with stroke patients in the outpatient setting. These updated guidelines from the Society for Neuroscience in Anesthesiology and Critical Care provide evidence-based recommendations regarding perioperative care of patients at high risk for stroke. Recommended areas for future investigation are also proposed.
Collapse
|
182
|
Foëx P, Higham H. Hypotension Is Associated With Perioperative Myocardial Infarction: Individualized Blood Pressure Is Important. Anesth Analg 2021; 133:2-5. [PMID: 34127584 DOI: 10.1213/ane.0000000000005543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Pierre Foëx
- From the Nuffield Division of Anaesthetics, University of Oxford, Oxford, United Kingdom
| | | |
Collapse
|
183
|
Wongtangman K, Wachtendorf LJ, Blank M, Grabitz SD, Linhardt FC, Azimaraghi O, Raub D, Pham S, Kendale SM, Low YH, Houle TT, Eikermann M, Pollard RJ. Effect of Intraoperative Arterial Hypotension on the Risk of Perioperative Stroke After Noncardiac Surgery: A Retrospective Multicenter Cohort Study. Anesth Analg 2021; 133:1000-1008. [PMID: 34252055 DOI: 10.1213/ane.0000000000005604] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intraoperative cerebral blood flow is mainly determined by cerebral perfusion pressure and cerebral autoregulation of vasomotor tone. About 1% of patients undergoing noncardiac surgery develop ischemic stroke. We hypothesized that intraoperative hypotension within a range frequently observed in clinical practice is associated with an increased risk of perioperative ischemic stroke within 7 days after surgery. METHODS Adult noncardiac surgical patients undergoing general anesthesia at Beth Israel Deaconess Medical Center and Massachusetts General Hospital between 2005 and 2017 were included in this retrospective cohort study. The primary exposure was intraoperative hypotension, defined as a decrease in mean arterial pressure (MAP) below 55 mm Hg, categorized into no intraoperative hypotension, short (<15 minutes, median [interquartile range {IQR}], 2 minutes [1-5 minutes]) and prolonged (≥15 minutes, median [IQR], 21 minutes [17-31 minutes]) durations. The primary outcome was a new diagnosis of early perioperative ischemic stroke within 7 days after surgery. In secondary analyses, we assessed the effect of a MAP decrease by >30% from baseline on perioperative stroke. Analyses were adjusted for the preoperative STRoke After Surgery (STRAS) prediction score, work relative value units, and duration of surgery. RESULTS Among 358,391 included patients, a total of 1553 (0.4%) experienced an early perioperative ischemic stroke. About 42% and 3% of patients had a MAP of below 55 mm Hg for a short and a prolonged duration, and 49% and 29% had a MAP decrease by >30% from baseline for a short and a prolonged duration, respectively. In an adjusted analysis, neither a MAP <55 mm Hg (short duration: adjusted odds ratio [ORadj], 0.95; 95% confidence interval [CI], 0.85-1.07; P = .417 and prolonged duration: ORadj, 1.18; 95% CI, 0.91-1.55; P = .220) nor a MAP decrease >30% (short duration: ORadj, 0.97; 95% CI, 0.67-1.42; P = .883 and prolonged duration: ORadj, 1.30; 95% CI, 0.89-1.90; P = .176) was associated with early perioperative stroke. A high a priori stroke risk quantified based on preoperatively available risk factors (STRAS prediction score) was associated with longer intraoperative hypotension (adjusted incidence rate ratio, 1.04; 95% CI, 1.04-1.05; P < .001 per 5 points of the STRAS prediction score). CONCLUSIONS This study found no evidence to conclude that intraoperative hypotension within the range studied was associated with early perioperative stroke within 7 days after surgery. These findings emphasize the importance of perioperative cerebral blood flow autoregulation to prevent ischemic stroke.
Collapse
Affiliation(s)
- Karuna Wongtangman
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Luca J Wachtendorf
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Michael Blank
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Stephanie D Grabitz
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Felix C Linhardt
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Omid Azimaraghi
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Dana Raub
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stephanie Pham
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samir M Kendale
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ying H Low
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthias Eikermann
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.,Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Richard J Pollard
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
184
|
Santangelo G, Faggiano A, Toriello F, Carugo S, Natalini G, Bursi F, Faggiano P. Risk of cardiovascular complications during non-cardiac surgery and preoperative cardiac evaluation. Trends Cardiovasc Med 2021; 32:271-284. [PMID: 34233205 DOI: 10.1016/j.tcm.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/21/2021] [Accepted: 06/30/2021] [Indexed: 12/21/2022]
Abstract
The preoperative evaluation of candidates to non-cardiac surgery requires a knowledge of factors related both to the type of surgery and to the risk of each patient, in order to predict the potential cardiovascular complications. Over the past several decades, the field of preoperative cardiac evaluation before non-cardiac surgery has evolved substantially on the basis of the current guidelines of international medical societies. The aim of this paper is to summarize available evidence on the risk of non-cardiac surgery, focusing on appropriate cardiovascular assessment prior to surgery.
Collapse
Affiliation(s)
- Gloria Santangelo
- San Paolo Hospital, Division of Cardiology, Department of Health Sciences, University of Milan, Italy
| | - Andrea Faggiano
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Internal Medicine, Cardiology Unit, University of Milan, Milan, Italy
| | - Filippo Toriello
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Internal Medicine, Cardiology Unit, University of Milan, Milan, Italy
| | - Stefano Carugo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Internal Medicine, Cardiology Unit, University of Milan, Milan, Italy
| | | | - Francesca Bursi
- San Paolo Hospital, Division of Cardiology, Department of Health Sciences, University of Milan, Italy
| | - Pompilio Faggiano
- Fondazione Poliambulanza, Cardiovascular Department, Brescia, Italy.
| |
Collapse
|
185
|
Söhle M, Coburn M. [Perioperative Medicine in Visceral Surgery in the Elderly Patient from an Anaesthesiological Perspective]. Zentralbl Chir 2021; 146:296-305. [PMID: 34154008 DOI: 10.1055/a-1447-1051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Demographic change is leading to an increasing number of old patients both in our society and in hospitals. With increasing age, not only the number of pre-existing conditions increases, but also the postoperative complication rate and mortality. Ultimately, however, it is not age that is decisive, but the condition of the patient and his or her capacity to face the physical and mental challenges of a surgical procedure. Frail patients are particularly at risk of complications, and an essential strategy - known as prehabilitation - is to put them in a better state pre-operatively through physical and mental training, as well as nutritional counselling. Delirium is one of the most frequent postoperative complications. Measures such as refraining from premedication with benzodiazepines, measuring the depth of anaesthesia, refraining from long-acting opioids, performing fast-track surgery, and providing glasses/hearing aids quickly postoperatively can reduce the risk of delirium. Close interdisciplinary consultation between surgeons, anaesthetists, geriatricians and physiotherapists is essential to coordinate the perioperative procedure and reduce the perioperative risk for elderly patients.
Collapse
Affiliation(s)
- Martin Söhle
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| | - Mark Coburn
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| |
Collapse
|
186
|
AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
| |
Collapse
|
187
|
Foëx P, Sear JW. Implications for perioperative practice of changes in guidelines on the management of hypertension: challenges and opportunities. Br J Anaesth 2021; 127:335-340. [PMID: 34127253 DOI: 10.1016/j.bja.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/20/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Pierre Foëx
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK.
| | - John W Sear
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
| |
Collapse
|
188
|
Smith HA, Kanji S, Tran DTT, Redpath C, Ferguson D, Lenet T, Sigler G, Gilbert S, Maziak D, Villeneuve P, Sundaresan S, Seely AJE. Prophylaxis for patients at Risk to Eliminate Post-operative Atrial Fibrillation (PREP-AF trial): a protocol for a feasibility randomized controlled study. Trials 2021; 22:384. [PMID: 34098992 PMCID: PMC8182941 DOI: 10.1186/s13063-021-05318-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/07/2021] [Indexed: 01/14/2023] Open
Abstract
Background Postoperative atrial fibrillation (POAF) is a frequent adverse event after thoracic surgery with associated morbidity, mortality, and healthcare costs. It has been shown to be preventable with prophylactic amiodarone, which is only recommended in high-risk individuals due to the potential associated side effects. Risk factors for POAF have been identified and incorporated into a prediction model to identify high-risk patients. Further evaluation in the form of a multicenter clinical trial is required to assess the effectiveness of prophylaxis specifically in this high-risk population. The feasibility of such a trial first needs to be assessed. Methods The PREP-AF trial is a double-blind randomized controlled feasibility trial. Individuals undergoing major thoracic surgery who are identified to be high-risk by the POAF prediction model will be randomized 1:1 to receive a short course of amiodarone vs. placebo in the immediate postoperative period. The primary outcome is feasibility, which will be measured by the number of eligible patients identified, consented, and randomized; intervention adherence; and measurement of future outcomes of a full trial. Discussion This study will determine the feasibility of a randomized controlled trial to assess the effectiveness of prophylactic amiodarone, in high-risk patients undergoing major thoracic surgery. This will inform the development of a multi-center trial to establish if prophylactic amiodarone is safe and effective at reducing the incidence of POAF. Preventing this adverse event will not only improve outcomes for patients but also reduce the associated health resource utilization and costs. Trial registration ClinicalTrials.gov NCT04392921. Registered on 19 May 2020.
Collapse
Affiliation(s)
- Heather A Smith
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Canada
| | - Diem T T Tran
- Division of Cardiac Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | - Calum Redpath
- University of Ottawa Heart Institute, Ottawa, Canada
| | | | - Tori Lenet
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Greg Sigler
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Donna Maziak
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Patrick Villeneuve
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sudhir Sundaresan
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Andrew J E Seely
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.,Division of Thoracic Surgery, Department of Surgery and Critical Care Medicine, University of Ottawa, Ottawa, Canada
| |
Collapse
|
189
|
Abstract
While intraoperative mortality has diminished greatly over the last several decades, the risk of death within 30 days of surgery remains stubbornly high and is ultimately related to perioperative organ failure. Perioperative strokes, while rare (<2% in noncardiac surgery), are associated with a more than 10-fold increase in mortality. Rapid identification and treatment are key to maximizing long-term outcomes. Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are separate but related perioperative neurological disorders, both of which are associated with poor long-term outcomes. To date, there are few known interventions that can ameliorate the risk of perioperative central nervous system dysfunction. Major adverse cardiac events (MACE) are a major contributor to adverse clinical outcomes following surgical procedures. Recently, advances in diagnostic strategies (eg, high-sensitivity cardiac troponin [hs-cTn] assays) have improved our understanding of MACE. Recently, the dabigatran in patients with myocardial injury after noncardiac surgery (MINS; Management of myocardial injury After NoncArdiac surGEry) trial demonstrated that a direct thrombin inhibitor could improve outcomes following MINS. While the risk of acute respiratory distress syndrome (ARDS) after surgery is approximately 0.2%, other less severe complications (eg, pneumonia, reintubation) are closer to 2%. While intensive care unit (ICU) concepts related to ARDS have migrated into the operating room, whether or not adverse pulmonary outcomes impact long-term outcomes in surgical patients remains a matter of debate. The standardization of acute kidney injury (AKI) definition has improved the ability of clinicians to measure and study the incidence of this important source of perioperative morbidity. AKI is associated with increased mortality as well as nonrenal morbidity (eg, myocardial infarction) after major surgery. Gastrointestinal complications after surgery range from ileus (common in abdominal procedures and associated with an increased length of stay) to less common complications such as mesenteric ischemia and gastrointestinal bleeding, both of which are associated with very high mortality. Outside of cardiothoracic surgery, the incidence of perioperative hepatic injury is not well described but, in this population, is associated with worsened long-term outcomes. Hyperglycemia is a common perioperative complication and occurs in patients undergoing both cardiac and noncardiac surgery. Both hyper- and hypoglycemia are associated with worsened long-term outcomes in cardiac and noncardiac surgery. Better diagnosis and increased understanding of perioperative organ injury has led to an increased appreciation for the specific role that particular organ systems play in poor long-term outcomes and has set the stage for targeted therapeutic interventions.
Collapse
|
190
|
Iwano T, Toda H, Nakamura K, Shimizu K, Ejiri K, Naito Y, Mori H, Masuda T, Miyoshi T, Yoshida M, Hikasa Y, Morimatsu H, Ito H. Preventative effects of bisoprolol transdermal patches on postoperative atrial fibrillation in high-risk patients undergoing non-cardiac surgery: A subanalysis of the MAMACARI study. J Cardiol 2021; 78:349-354. [PMID: 34083113 DOI: 10.1016/j.jjcc.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/02/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Perioperative atrial fibrillation (POAF) after non-cardiac surgery is a risk factor for cardiovascular events including stroke and death. The aim of this subanalysis of the MAMACARI study, a multicenter randomized control study on the effectiveness of a bisoprolol transdermal patch for prevention of perioperative myocardial injury in high-risk patients undergoing non-cardiac surgery, was to identify the predictors of POAF after non-cardiac surgery in high-risk patients and to determine changes in blood pressure and heart rate during bisoprolol patch administration in the perioperative period. METHODS AND RESULTS Patients aged over 60 years with hypertension and a high revised cardiac risk index (≥2) who were scheduled to undergo non-cardiac surgery were randomly assigned to a bisoprolol patch group (n = 120) or a control group (n = 120). We divided the patients into two groups: patients with POAF (POAF group; n = 16) and patients without POAF (non-POAF group; n = 206). Multivariate analysis showed that bisoprolol patch therapy (OR: 0.30, 95% CI: 0.092-0.978) and surgery time of 250 min or more (OR: 4.99, 95% CI: 1.37-18.2) were independently associated with POAF. Although systolic blood pressure did not differ significantly between the two groups throughout the perioperative period, treatment with a bisoprolol patch significantly reduced heart rate throughout the perioperative period compared with that in the control group. CONCLUSIONS Low dose of a bisoprolol patch in the perioperative period was effective for prevention of POAF after non-cardiac surgery in high-risk patients, while long surgery time was an independent risk factor for POAF. It is expected that low dose of a bisoprolol patch can prevent POAF without causing hypotension.
Collapse
Affiliation(s)
- Takayuki Iwano
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Hironobu Toda
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan.
| | - Kazuyoshi Shimizu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Yoichiro Naito
- Department of Cardiology, Fukuyama City Hospital, Fukuyama, Japan
| | - Hisatoshi Mori
- Department of Cardiology, Tsuyama Chuo Hospital, Tsuyama, Japan
| | - Takuro Masuda
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan; Department of Cardiology, Himeji Red Cross Hospital, Himeji, Japan
| | - Toru Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Masashi Yoshida
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Yukiko Hikasa
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | | |
Collapse
|
191
|
Nelson JA, Gue YX, Christensen JM, Lip GYH, Ramakrishna H. Analysis of the ESC/EACTS 2020 Atrial Fibrillation Guidelines With Perioperative Implications. J Cardiothorac Vasc Anesth 2021; 36:2177-2195. [PMID: 34130901 DOI: 10.1053/j.jvca.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide, with an individual lifetime risk of approximately 37% in the United States. Broadly defined as a supraventricular tachyarrhythmia with disorganized atrial activation, AF results in an increased risk of stroke, heart failure, valvular heart disease, and impaired quality of life, and confers a significant burden on the health of individuals and society. AF in the perioperative setting is common and a significant source of perioperative morbidity and mortality worldwide. The latest iteration of the European Society of Cardiology AF guidelines published in 2020 provide the clinician a valuable road map for the management of this arrythmia. This expert review will comprehensively analyze the 2020 European Society of Cardiology guidelines and provide perioperative management tools for the clinician.
Collapse
Affiliation(s)
- James A Nelson
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Jon M Christensen
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
192
|
Conen D, Alonso-Coello P, Douketis J, Chan MTV, Kurz A, Sigamani A, Parlow JL, Wang CY, Villar JC, Srinathan SK, Tiboni M, Malaga G, Guyatt G, Sivakumaran S, Rodriguez Funes MV, Cruz P, Yang H, Dresser GK, Alvarez-Garcia J, Schricker T, Jones PM, Drummond LW, Balasubramanian K, Yusuf S, Devereaux PJ. Risk of stroke and other adverse outcomes in patients with perioperative atrial fibrillation 1 year after non-cardiac surgery. Eur Heart J 2021; 41:645-651. [PMID: 31237939 DOI: 10.1093/eurheartj/ehz431] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 02/27/2019] [Accepted: 05/29/2019] [Indexed: 02/06/2023] Open
Abstract
AIMS To determine the 1-year risk of stroke and other adverse outcomes in patients with a new diagnosis of perioperative atrial fibrillation (POAF) after non-cardiac surgery. METHODS AND RESULTS The PeriOperative ISchemic Evaluation (POISE)-1 trial evaluated the effects of metoprolol vs. placebo in 8351 patients, and POISE-2 compared the effect of aspirin vs. placebo, and clonidine vs. placebo in 10 010 patients. These trials included patients with, or at risk of, cardiovascular disease who were undergoing non-cardiac surgery. For the purpose of this study, we combined the POISE datasets, excluding 244 patients who were in atrial fibrillation (AF) at the time of randomization. Perioperative atrial fibrillation was defined as new AF that occurred within 30 days after surgery. Our primary outcome was the incidence of stroke at 1 year of follow-up; secondary outcomes were mortality and myocardial infarction (MI). We compared outcomes among patients with and without POAF using multivariable adjusted Cox proportional hazards models. Among 18 117 patients (mean age 69 years, 57.4% male), 404 had POAF (2.2%). The stroke incidence 1 year after surgery was 5.58 vs. 1.54 per 100 patient-years in patients with and without POAF, adjusted hazard ratio (aHR) 3.43, 95% confidence interval (CI) 2.00-5.90; P < 0.001. Patients with POAF also had an increased risk of death (incidence 31.37 vs. 9.34; aHR 2.51, 95% CI 2.01-3.14; P < 0.001) and MI (incidence 26.20 vs. 8.23; aHR 5.10, 95% CI 3.91-6.64; P < 0.001). CONCLUSION Patients with POAF have a significantly increased risk of stroke, MI, and death at 1 year. Intervention studies are needed to evaluate risk reduction strategies in this high-risk population.
Collapse
Affiliation(s)
- David Conen
- Population Health Research Institute, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada
| | - Pablo Alonso-Coello
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada.,Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau-CIBERESP), Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
| | - James Douketis
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong Special administrative Region, China
| | - Andrea Kurz
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44120, USA
| | - Alben Sigamani
- Department of Clinical Research, Narayana Hrudayalaya Limited, 258/A, Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bangalore 560099, India
| | - Joel L Parlow
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre and Queen's University, 76 Stuart St, Kingston, ON K7L 2V7, Canada
| | - Chew Yin Wang
- Department of Anesthesiology, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Juan C Villar
- Departamento de Investigaciones, Fundación Cardioinfantil -Instituto de Cardiología and Facultad de Ciencias de la Salud, Universidad Autónoma de Bucaramanga, Av. 42 ##48 - 11, Bucaramanga, Santander, Colombia
| | - Sadeesh K Srinathan
- Department of Surgery, University of Manitoba, Rm. GE61, 820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada
| | - Maria Tiboni
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada
| | - German Malaga
- School of Medicine, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, San Martín de Porres 15102, Lima, Peru
| | - Gordon Guyatt
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada
| | - Soori Sivakumaran
- Department of Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, AB T6G 2R3, Canada
| | - Maria-Virginia Rodriguez Funes
- Unidad de Investigacion Cientifica, Facultad de Medicina, Universidad de El Salvador, Final 25 Ave norte, San Salvador, El Salvador
| | - Patricia Cruz
- Department of Anesthesia, Hospital General Universitario Gregorio Marañon, Calle del Dr. Esquerdo 46, 28007 Madrid, Spain
| | - Homer Yang
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, 1151 Richmond St, London, ON N6A 3K7, Canada
| | - George K Dresser
- Department of Medicine, London Health Sciences Centre, Victoria Hospital, 800 Commissioners Rd E, London, ON N6A 5W9, Canada
| | - Jesus Alvarez-Garcia
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, CIBERCV, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autonoma de Barcelona, Carrer de Sant Quintí, 89, 08041 Barcelona, Spain
| | - Thomas Schricker
- Department of Anesthesia, McGill University Health Centre, McGill University, 1001 Decarie Blvd, Montreal, QC H4A 3J1, Canada
| | - Philip M Jones
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, 1151 Richmond St, London, ON N6A 3K7, Canada.,Department of Epidemiology & Biostatistics, University of Western Ontario, 1151 Richmond St, London, ON N6A 3K7, Canada
| | - Leanne W Drummond
- Department of Anaesthesia, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, 719 Umbilo Road, Umbilo, 4001, South Africa
| | | | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton L8S 4K1, Canada
| |
Collapse
|
193
|
Larney S, Peacock A, Tran LT, Stockings E, Santomauro D, Santo T, Degenhardt L. All-Cause and Overdose Mortality Risk Among People Prescribed Opioids: A Systematic Review and Meta-analysis. PAIN MEDICINE 2021; 21:3700-3711. [PMID: 32951045 DOI: 10.1093/pm/pnaa214] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To estimate all-cause and overdose crude mortality rates and standardized mortality ratios among people prescribed opioids for chronic noncancer pain and risk of overdose death in this population relative to people with similar clinical profiles but not prescribed opioids. DESIGN Systematic review and meta-analysis. METHODS Medline, Embase, and PsycINFO were searched in February 2018 and October 2019 for articles published beginning 2009. Due to limitations in published studies, we revised our inclusion criteria to include cohort studies of people prescribed opioids, excluding those studies where people were explicitly prescribed opioids for the treatment of opioid use disorder or acute cancer or palliative pain. We estimated pooled all-cause and overdose crude mortality rates using random effects meta-analysis models. No studies reported standardized mortality ratios or relative risks. RESULTS We included 13 cohorts with 6,029,810 participants. The pooled all-cause crude mortality rate, based on 10 cohorts, was 28.8 per 1000 person-years (95% CI = 17.9-46.4), with substantial heterogeneity (I2 = 99.9%). The pooled overdose crude mortality rate, based on six cohorts, was 1.1 per 1000 person-years (95% CI = 0.4-3.4), with substantial heterogeneity (I2 = 99.5%), but indications for opioid prescribing and opioid exposure were poorly ascertained. We were unable to estimate mortality in this population relative to clinically similar populations not prescribed opioids. CONCLUSIONS Methodological limitations in the identified literature complicate efforts to determine the overdose mortality risk of people prescribed opioids. There is a need for large-scale clinical trials to assess adverse outcomes in opioid prescribing, especially for chronic noncancer pain.
Collapse
Affiliation(s)
- Sarah Larney
- Department of Family Medicine and Emergency Medicine, Université de Montréal and Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CR-CHUM), Montreal, Quebec, Canada.,National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| | - Lucy T Tran
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| | - Emily Stockings
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| | - Damian Santomauro
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia.,Queensland Centre for Mental Health Research, Brisbane, Queensland, Australia.,Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Thomas Santo
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia
| |
Collapse
|
194
|
Chronic Use of Angiotensin Converting Enzyme Inhibitors and/or Angiotensin Receptor Blockers is Not Associated With Stroke After Noncardiac Surgery: A Retrospective Cohort Analysis. J Neurosurg Anesthesiol 2021; 34:401-406. [PMID: 34569768 DOI: 10.1097/ana.0000000000000777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/30/2021] [Indexed: 11/26/2022]
Abstract
Background Inhibition of the renin-angiotensin-aldosterone pathways reduces blood pressure and proliferation of vascular smooth muscles and may therefore reduce the risk of stroke. We tested the hypothesis that patients taking angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) for at least 6 months have fewer postoperative strokes after non-neurological, noncarotid, and noncardiac surgeries than those who do not. Methods We considered adults who had noncardiac surgery at the Cleveland Clinic between January 2005 and December 2017. After excluding neurological and carotid surgeries, we assessed the confounder-adjusted association between chronic use of ACEIs/ARBs (during 6 preoperative months) and the incidence of postoperative stroke using logistic regression models. Results Postoperative strokes occurred in 0.26% (27/10,449) of patients who were chronic ACEI/ARBs users and in 0.18% (112/62,771) of those who were not. There was no significant association between ACEI/ARB use and postoperative stroke, with an adjusted odds ratio of 1.15 (95% confidence interval [CI]: 0.91-1.44; P=0.24). Secondarily, there was no association between exposures to ACEIs and postoperative stroke, versus no such exposure (adjusted odds ratio 0.88, 95% CI: 0.65-1.19; P=0.33). Similarly, there was no association between exposure to ARBs and postoperative stroke, versus no such exposure (adjusted odds ratio 1.05, 95% CI: 0.75-1.48; P=0.75). Conclusion We did not detect an effect of chronic ACEI/ARB use on postoperative strokes in patients who had non-neurological, noncarotid and noncardiac surgery; however, power was extremely limited.
Collapse
|
195
|
Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
196
|
Presepsin for pre-operative prediction of major adverse cardiovascular events in coronary heart disease patients undergoing noncardiac surgery: Post hoc analysis of the Leukocytes and Cardiovascular Peri-operative Events-2 (LeukoCAPE-2) Study. Eur J Anaesthesiol 2021; 37:908-919. [PMID: 32516228 DOI: 10.1097/eja.0000000000001243] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accurate pre-operative evaluation of cardiovascular risk is vital to identify patients at risk for major adverse cardiovascular and cerebrovascular events (MACCE) after noncardiac surgery. Elevated presepsin (sCD14-ST) is associated with peri-operative MACCE in coronary artery disease (CAD) patients after noncardiac surgery. OBJECTIVES Validating the prognostic utility of presepsin for MACCE after noncardiac surgery. DESIGN Prospective patient enrolment and blood sampling, followed by post hoc evaluation of pre-operative presepsin for prediction of MACCE. SETTING Single university centre. PATIENTS A total of 222 CAD patients undergoing elective, inpatient noncardiac surgery. INTERVENTION Pre-operative presepsin measurement. MAIN OUTCOME MEASURES MACCE (cardiovascular death, myocardial infarction, myocardial ischaemia and stroke) at 30 days postsurgery. RESULTS MACCE was diagnosed in 23 (10%) patients. MACCE patients presented with increased pre-operative presepsin (median [IQR]; 212 [163 to 358] vs. 156 [102 to 273] pgml, P = 0.023). Presepsin exceeding the previously derived threshold of 184 pg ml was associated with increased 30-day MACCE rate. After adjustment for confounders, presepsin more than 184 pg ml [OR = 2.8 (95% confidence interval 1.1 to 7.3), P = 0.03] remained an independent predictor of peri-operative MACCE. Predictive accuracy of presepsin was moderate [area under the curve (AUC) = 0.65 (0.54 to 0.75), P = 0.023]. While the basic risk model of revised cardiac risk index, high-sensitive cardiac troponin T and N-terminal fragment of pro-brain natriuretic peptide resulted in an AUC = 0.62 (0.48 to 0.75), P = 0.072, addition of presepsin to the model led to an AUC = 0.67 (0.56 to 0.78), P = 0.009 and (ΔAUC = 0.05, P = 0.438). Additive risk predictive value of presepsin was demonstrated by integrated discrimination improvement analysis (integrated discrimination improvement = 0.023, P = 0.022). Net reclassification improvement revealed that the additional strength of presepsin was attributed to the reclassification of no-MACCE patients into a lower risk group. CONCLUSION Increased pre-operative presepsin independently predicted 30-day MACCE in CAD patients undergoing major noncardiac surgery. Complementing cardiovascular risk prediction by inflammatory biomarkers, such as presepsin, offers potential to improve peri-operative care. However, as prediction accuracy of presepsin was only moderate, further validation studies are needed. TRIAL REGISTRATION Clinicaltrials.gov: NCT03105427.
Collapse
|
197
|
Abstract
Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.
Collapse
|
198
|
Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade. Eur J Trauma Emerg Surg 2021; 48:799-810. [PMID: 33847766 PMCID: PMC9001541 DOI: 10.1007/s00068-021-01647-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/11/2021] [Indexed: 12/14/2022]
Abstract
As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.
Collapse
|
199
|
Kim C, Kim JS, Kim H, Ahn SG, Cho S, Lee OH, Park JK, Shin S, Moon JY, Won H, Suh Y, Cho JR, Cho YH, Oh SJ, Lee BK, Hong SJ, Shin DH, Ahn CM, Kim BK, Ko YG, Choi D, Hong MK, Jang Y. Consensus Decision-Making for the Management of Antiplatelet Therapy before Non-Cardiac Surgery in Patients Who Underwent Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents: A Cohort Study. J Am Heart Assoc 2021; 10:e020079. [PMID: 33843258 PMCID: PMC8174156 DOI: 10.1161/jaha.120.020079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Although antiplatelet therapy (APT) has been recommended to balance ischemic‐bleeding risks, it has been left to an individualized decision‐making based on physicians' perspectives before non‐cardiac surgery. The study aimed to assess the advantages of a consensus among physicians, surgeons, and anesthesiologists on continuation and regimen of preoperative APT in patients with coronary drug‐eluting stents. Methods and Results A total of 3582 adult patients undergoing non‐cardiac surgery after percutaneous coronary intervention with second‐generation stents was retrospectively included from a multicenter cohort. Physicians determined whether APT should be continued or discontinued for a recommended period before non‐cardiac surgery. There were 3103 patients who complied with a consensus decision. Arbitrary APT, not based on a consensus decision, was associated with urgent surgery, high bleeding risk of surgery, female sex, and dual APT at the time of preoperative evaluation. Arbitrary APT independently increased the net clinical adverse event (adjusted odds ratio [ORadj], 1.98; 95% CI, 1.98–3.11), major adverse cardiac event (ORadj, 3.11; 95% CI, 1.31–7.34), and major bleeding (ORadj, 2.34; 95% CI, 1.45–3.76) risks. The association was consistently noted, irrespective of the surgical risks, recommendations, and practice on discontinuation of APT. Conclusions Most patients were treated in agreement with a consensus decision about preoperative APT based on a referral system among physicians, surgeons, and anesthesiologists. The risk of perioperative adverse events increased if complying with a consensus decision was failed. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03908463.
Collapse
Affiliation(s)
- Choongki Kim
- Department of Cardiology Ewha Womans University College of Medicine Seoul Hospital Seoul Korea
| | - Jung-Sun Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Hyeongsoo Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Sung Gyun Ahn
- Division of Cardiology Department of Internal Medicine Wonju Severance Christian Hospital Yonsei University Wonju College of Medicine Wonju Korea
| | - Sungsoo Cho
- Division of Cardiovascular Medicine Department of Internal Medicine Dankook University HospitalDankook University College of Medicine Cheonan Korea
| | - Oh-Hyun Lee
- Division of Cardiology Yongin Severance HospitalYonsei University College of Medicine Gyeonggi-do Korea
| | - Jong-Kwan Park
- Division of Cardiology National Health Insurance Service Ilsan Hospital Goyang Korea
| | - Sanghoon Shin
- Department of Cardiology Ewha Womans University College of Medicine Seoul Hospital Seoul Korea
| | - Jae Youn Moon
- Department of Cardiology CHA Bundang Medical Center CHA University Seongnam Korea
| | - Hoyoun Won
- Cardiovascular & Arrhythmia Center Chung-Ang University HospitalChung-Ang University College of Medicine Seoul Korea
| | - Yongsung Suh
- Department of Cardiology Myongji HospitalHanyang University College of Medicine Goyang Korea
| | - Jung Rae Cho
- Division of Cardiology Kangnam Sacred Heart Hospital Hallym University Medical Center Seoul South Korea
| | - Yun-Hyeong Cho
- Department of Cardiology Myongji HospitalHanyang University College of Medicine Goyang Korea
| | - Seung-Jin Oh
- Division of Cardiology National Health Insurance Service Ilsan Hospital Goyang Korea
| | - Byoung-Kwon Lee
- Division of Cardiology Gangnam Severance HospitalYonsei University College of Medicine Seoul South Korea
| | - Sung-Jin Hong
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Dong-Ho Shin
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Chul-Min Ahn
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Byeong-Keuk Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Young-Guk Ko
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Donghoon Choi
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Myeong-Ki Hong
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Yangsoo Jang
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| |
Collapse
|
200
|
Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, Mijalski C, Nelson MT, Power M, Welch BG. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association. Circulation 2021; 143:e923-e946. [PMID: 33827230 DOI: 10.1161/cir.0000000000000968] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.
Collapse
|