151
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Agrimi J, Baroni C, Anakor E, Lionetti V. Perioperative Heart-Brain Axis Protection in Obese Surgical Patients: The Nutrigenomic Approach. Curr Med Chem 2020; 27:258-281. [PMID: 30324875 DOI: 10.2174/0929867325666181015145225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/01/2018] [Accepted: 09/25/2018] [Indexed: 02/06/2023]
Abstract
The number of obese patients undergoing cardiac and noncardiac surgery is rapidly increasing because they are more prone to concomitant diseases, such as diabetes, thrombosis, sleep-disordered breathing, cardiovascular and cerebrovascular disorders. Even if guidelines are already available to manage anesthesia and surgery of obese patients, the assessment of the perioperative morbidity and mortality from heart and brain disorders in morbidly obese surgical patients will be challenging in the next years. The present review will recapitulate the new mechanisms underlying the Heart-brain Axis (HBA) vulnerability during the perioperative period in healthy and morbidly obese patients. Finally, we will describe the nutrigenomics approach, an emerging noninvasive dietary tool, to maintain a healthy body weight and to minimize the HBA propensity to injury in obese individuals undergoing all types of surgery by personalized intake of plant compounds that may regulate the switch from health to disease in an epigenetic manner. Our review provides current insights into the mechanisms underlying HBA response in obese surgical patients and how they are modulated by epigenetically active food constituents.
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Affiliation(s)
- Jacopo Agrimi
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Carlotta Baroni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Ekene Anakor
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Vincenzo Lionetti
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,UOS Anesthesiology, Fondazione Toscana G. Monasterio, Pisa, Italy
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152
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ST Elevations and Ventricular Tachycardia Secondary to Coronary Vasospasm upon Extubation. Case Rep Anesthesiol 2020; 2020:1527345. [PMID: 32099682 PMCID: PMC7037527 DOI: 10.1155/2020/1527345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/21/2020] [Indexed: 11/18/2022] Open
Abstract
ST elevations (STE) in the perioperative setting can result from a number of different etiologies, the most common and feared being acute coronary syndrome (ACS). However, other causes should be considered, as treatment may differ depending on the diagnosis. Here, we describe a case of STE and ventricular tachycardia in a patient at high risk for ACS. The patient had a prior diagnosis of coronary vasospasm; however, given pre-existing risk factors, much consideration and deliberation occurred prior to electing conservative therapy. This report provides an overview of perioperative vasospasm and other causes of STE, which anesthesiologists should be aware of.
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153
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Kouz K, Hoppe P, Briesenick L, Saugel B. Intraoperative hypotension: Pathophysiology, clinical relevance, and therapeutic approaches. Indian J Anaesth 2020; 64:90-96. [PMID: 32139925 PMCID: PMC7017666 DOI: 10.4103/ija.ija_939_19] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 12/20/2022] Open
Abstract
Intraoperative hypotension (IOH) i.e., low arterial blood pressure (AP) during surgery is common in patients having non-cardiac surgery under general anaesthesia. It has a multifactorial aetiology, and is associated with major postoperative complications including acute kidney injury, myocardial injury and death. Therefore, IOH may be a modifiable risk factor for postoperative complications. However, there is no uniform definition for IOH. IOH not only occurs during surgery but also after the induction of general anaesthesia before surgical incision. However, the optimal therapeutic approach to IOH remains elusive. There is evidence from one small randomised controlled trial that individualising AP targets may reduce the risk of postoperative organ dysfunction compared with standard care. More research is needed to define individual AP harm thresholds, to develop therapeutic strategies to treat and avoid IOH, and to integrate new technologies for continuous AP monitoring.
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Luisa Briesenick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Outcomes Research Consortium, Cleveland, Ohio, USA
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154
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Lowe MJ, Lightfoot NJ. The prognostic implication of perioperative cardiac enzyme elevation in patients with fractured neck of femur: A systematic review and meta-analysis. Injury 2020; 51:164-173. [PMID: 31879176 DOI: 10.1016/j.injury.2019.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/11/2019] [Accepted: 12/09/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Neck of Femur (NOF) fractures are a common injury in comorbid elderly patients which are associated with increased rates of morbidity and mortality following fracture. Because of their injury, patients can experience reductions in quality of life and independent living leading to transfer to nursing home or dependent levels of care. Numerous factors are associated with either complications or reductions in survival following fractured NOF. From the VISION cohort there is evidence that troponin elevation in the post-operative period following a diverse range of non-cardiac surgical procedures may lead to an increased risk of mortality in the absence of classical ischaemic or cardiac symptoms. The aim of this systematic review and meta-analysis is to validate the utility of perioperative troponin elevation as a prognostic indicator for mortality and cardiac morbidity in those with fractured NOF. METHODS The PRISMA guidelines for the conduct of meta-analyses were followed. An electronic search was conducted of the EMBASE, MEDLINE (Ovid) and Biosis databases. Studies were included for analysis if they stratified outcomes by perioperative troponin elevation in surgically managed fractured NOF and reported sufficient data on troponin elevation and mortality following surgery. Primary and secondary outcomes assessed were all-cause post-operative mortality and a composite measure of cardiac complications (myocardial infarction, cardiac failure and arrhythmia) respectively. RESULTS Eleven studies met inclusion criteria giving a total of 1363 patients. Overall, 497 patients (36.5%) experienced an elevation in troponin levels following surgery. Perioperative troponin elevation was significantly associated with all-cause mortality (OR 2.6; 95% CI 1.5 - 4.6; p <0.001) and cardiac complications (OR 7.4; 95% CI 3.5 - 15.8; p <0.001). Patient factors significantly associated with troponin elevation included pre-existing coronary artery disease, cardiac failure, hypertension, previous stroke and previous myocardial infarction. CONCLUSION Perioperative troponin elevation is significantly associated with increased mortality and post-operative cardiac complications following fractured NOF and may be a useful prognostic indicator in these patients. Future research should further stratify patients by the magnitude of troponin elevation and further refine the risk factors.
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Affiliation(s)
- Matthew J Lowe
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand.
| | - Nicholas J Lightfoot
- Department of Anaesthesia and Pain Medicine, Middlemore Hospital, Auckland, New Zealand
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155
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Bohsali F, Klimpl D, Baumgartner R, Sieber F, Eid SM. Effect of Heart Failure With Preserved Ejection Fraction on Perioperative Outcomes in Patients Undergoing Hip Fracture Surgery. J Am Acad Orthop Surg 2020; 28:e131-e138. [PMID: 31977615 DOI: 10.5435/jaaos-d-18-00731] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Heart failure is a leading cause of morbidity and mortality in hip fracture surgery. The impact of heart failure with preserved ejection fraction (HFpEF) is poorly understood in this population. We designed a study to evaluate national perioperative outcomes in hip fracture for patients with HFpEF. METHODS Patients with hip fracture undergoing total hip arthroplasty, hemiarthroplasty, or open/closed reduction with internal and external fixation from January 2005 to December 2013 were identified using the Nationwide Inpatient Sample. Inpatient outcomes during the index hospitalization were compared between patients without heart failure and with HFpEF. Heart failure with reduced ejection fraction was included as a secondary comparator. Perioperative major adverse cardiovascular and cerebrovascular events (MACCEs), defined as in-hospital all-cause death, acute myocardial infarction, and in-hospital cardiac arrest or acute ischemic stroke, were evaluated. RESULTS Among 2,020,712 hospitalizations for hip fracture surgery, perioperative MACCE occurred in 67,554 hospitalizations (3.3%), corresponding to an annual incidence of approximately 7,506 events after applying sample weights. Compared with patients without heart failure, patients with HFpEF experienced increased odds of MACCE, adjusted odds ratio [aOR], 1.69; 95% confidence interval (CI), 1.51 to 1.89. In comparison, the aOR of experiencing a MACCE event in the heart failure with reduced ejection fraction group was 1.75 (95% CI, 1.57 to 1.96). HFpEF was also associated with increased odds of acute respiratory failure (aOR, 1.71; 95% CI, 1.53 to 1.91) and acute renal failure (aOR, 1.52; 95% CI, 1.41 to 1.64). CONCLUSION HFpEF confers a significant perioperative risk of MACCE in patients undergoing hip fracture surgery.
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Affiliation(s)
- Fuad Bohsali
- From the Department of Medicine, Duke University School of Medicine, Durham, NC (Dr. Bohsali), the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Klimpl and Dr. Eid), the Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC (Dr. Baumgartner), and the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Sieber)
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156
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Smilowitz NR, Banco D, Katz SD, Beckman JA, Berger JS. Association between heart failure and perioperative outcomes in patients undergoing non-cardiac surgery. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 7:68-75. [PMID: 31873731 DOI: 10.1093/ehjqcco/qcz066] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/17/2019] [Accepted: 12/20/2019] [Indexed: 12/13/2022]
Abstract
AIMS Heart failure (HF) affects ∼5.7 million US adults and many of these patients develop non-cardiac disease that requires surgery. The aim of this study was to determine perioperative outcomes associated with HF in a large cohort of patients undergoing in-hospital non-cardiac surgery. METHODS AND RESULTS Adults ≥18 years old undergoing non-cardiac surgery between 2012 and 2014 were identified using the Healthcare Cost and Utilization Project National Inpatient Sample. Patients with HF were identified by ICD-9 diagnosis codes. The primary outcome was all-cause in-hospital mortality. Multivariable logistic regression models were used to estimate associations between HF and outcomes. A total of 21 560 996 surgical hospitalizations were identified, of which 1 063 405 (4.9%) had a diagnosis of HF. Among hospitalizations with HF, 4.7% had acute HF, 11.3% had acute on chronic HF, 27.8% had chronic HF, and 56.2% had an indeterminate diagnosis code that did not specify temporality. In-hospital perioperative mortality was more common among patients with any diagnosis of HF compared to those without HF [4.8% vs. 0.78%, P < 0.001; adjusted odds ratio (aOR) 2.15, 95% confidence interval (CI) 2.09-2.22], and the association between HF and mortality was greatest at small and non-teaching hospitals. Acute HF without chronic HF was associated with 8.0% mortality. Among patients with a chronic HF diagnosis, perioperative mortality was greater in those with acute on chronic HF compared to chronic HF alone (7.8% vs. 3.9%, P < 0.001; aOR 1.78, 95% CI 1.67-1.90). CONCLUSION In patients hospitalized for non-cardiac surgery, HF was common and was associated with increased risk of perioperative mortality. The greatest risks were in patients with acute HF.
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Affiliation(s)
- Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA.,Division of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Health Care System, 423 East 23rd Street, 12W New York, NY 10010, USA
| | - Darcy Banco
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA
| | - Joshua A Beckman
- Department of Medicine, Vanderbilt University School of Medicine, 1215 21st Ave South Nashville, TN 37232, USA
| | - Jeffery S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA.,Department of Surgery, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA
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157
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Qamar A, Bangalore S. Biomarkers to Personalize Preoperative Cardiovascular Risk Stratification: Ready for Prime Time? Ann Intern Med 2020; 172:149-150. [PMID: 31869831 DOI: 10.7326/m19-3718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Arman Qamar
- New York University Grossman School of Medicine, New York, New York (A.Q., S.B.)
| | - Sripal Bangalore
- New York University Grossman School of Medicine, New York, New York (A.Q., S.B.)
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158
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Duceppe E, Patel A, Chan MTV, Berwanger O, Ackland G, Kavsak PA, Rodseth R, Biccard B, Chow CK, Borges FK, Guyatt G, Pearse R, Sessler DI, Heels-Ansdell D, Kurz A, Wang CY, Szczeklik W, Srinathan S, Garg AX, Pettit S, Sloan EN, Januzzi JL, McQueen M, Buse GL, Mills NL, Zhang L, Sapsford R, Paré G, Walsh M, Whitlock R, Lamy A, Hill S, Thabane L, Yusuf S, Devereaux PJ. Preoperative N-Terminal Pro-B-Type Natriuretic Peptide and Cardiovascular Events After Noncardiac Surgery: A Cohort Study. Ann Intern Med 2020; 172:96-104. [PMID: 31869834 DOI: 10.7326/m19-2501] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Preliminary data suggest that preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) may improve risk prediction in patients undergoing noncardiac surgery. OBJECTIVE To determine whether preoperative NT-proBNP has additional predictive value beyond a clinical risk score for the composite of vascular death and myocardial injury after noncardiac surgery (MINS) within 30 days after surgery. DESIGN Prospective cohort study. SETTING 16 hospitals in 9 countries. PATIENTS 10 402 patients aged 45 years or older having inpatient noncardiac surgery. MEASUREMENTS All patients had NT-proBNP levels measured before surgery and troponin T levels measured daily for up to 3 days after surgery. RESULTS In multivariable analyses, compared with preoperative NT-proBNP values less than 100 pg/mL (the reference group), those of 100 to less than 200 pg/mL, 200 to less than 1500 pg/mL, and 1500 pg/mL or greater were associated with adjusted hazard ratios of 2.27 (95% CI, 1.90 to 2.70), 3.63 (CI, 3.13 to 4.21), and 5.82 (CI, 4.81 to 7.05) and corresponding incidences of the primary outcome of 12.3% (226 of 1843), 20.8% (542 of 2608), and 37.5% (223 of 595), respectively. Adding NT-proBNP thresholds to clinical stratification (that is, the Revised Cardiac Risk Index [RCRI]) resulted in a net absolute reclassification improvement of 258 per 1000 patients. Preoperative NT-proBNP values were also statistically significantly associated with 30-day all-cause mortality (less than 100 pg/mL [incidence, 0.3%], 100 to less than 200 pg/mL [incidence, 0.7%], 200 to less than 1500 pg/mL [incidence, 1.4%], and 1500 pg/mL or greater [incidence, 4.0%]). LIMITATION External validation of the identified NT-proBNP thresholds in other cohorts would reinforce our findings. CONCLUSION Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30 days after noncardiac surgery and improves cardiac risk prediction in addition to the RCRI. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Emmanuelle Duceppe
- University of Montreal, Montreal, Québec, and McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (E.D.)
| | - Ameen Patel
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.C., L.Z.)
| | - Otavio Berwanger
- Hospital Israelita Albert Einstein (Academic Research Organization-ARO), Sao Paulo, Brazil (O.B.)
| | - Gareth Ackland
- Translational Medicine & Therapeutics William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom (G.A., R.P.)
| | - Peter A Kavsak
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Reitze Rodseth
- University of KwaZulu-Natal, Glenwood, Durban, South Africa (R.R.)
| | - Bruce Biccard
- Groote Schuur Hospital and University of Cape Town, Western Cape, South Africa (B.B.)
| | - Clara K Chow
- Westmead Applied Research Centre, University of Sydney, Sydney, and Westmead Hospital, Westmead, Australia (C.K.C.)
| | - Flavia K Borges
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - Gordon Guyatt
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Rupert Pearse
- Translational Medicine & Therapeutics William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom (G.A., R.P.)
| | | | - Diane Heels-Ansdell
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Andrea Kurz
- Cleveland Clinic, Cleveland, Ohio (D.I.S., A.K.)
| | - Chew Yin Wang
- University of Malaya, Kuala Lumpur, Malaysia (C.Y.W.)
| | | | | | - Amit X Garg
- Western University, London, Ontario, Canada (A.X.G.)
| | - Shirley Pettit
- Population Health Research Institute, Hamilton, Ontario, Canada (S.P.)
| | - Erin N Sloan
- University of British Columbia, Vancouver, British Columbia, Canada (E.N.S.)
| | - James L Januzzi
- Massachusetts General Hospital, Harvard Medical School, and Baim Institute for Clinical Research, Boston, Massachusetts (J.L.J.)
| | - Matthew McQueen
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | | | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Sciences and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom (N.L.M.)
| | - Lin Zhang
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.C., L.Z.)
| | | | - Guillaume Paré
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - Michael Walsh
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - Richard Whitlock
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - Andre Lamy
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - Stephen Hill
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Lehana Thabane
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Salim Yusuf
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - P J Devereaux
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
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159
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Ruzycki SM, Prystajecky M, Driedger MR, Kachra R. Peri-operative cardiac biomarker screening: a narrative review. Anaesthesia 2020; 75 Suppl 1:e165-e173. [PMID: 31903570 DOI: 10.1111/anae.14920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2019] [Indexed: 12/26/2022]
Abstract
Peri-operative risk estimation has traditionally focused on assessing the likelihood of postoperative morbidity and mortality using pre-operative functional assessment. Although this strategy is currently recommended by most major society guidelines, contemporary evidence suggests that cardiac biomarker measurement has important advantages over pre-operative functional assessment. These advantages include superior predictive discrimination and inclusion of the postoperative course in risk estimation. In this review, we provide an overview of the evidence supporting the peri-operative utilisation, compare risk estimation methods and discuss which patients may benefit most from cardiac biomarker screening. We also discuss protocols for biomarker screening and management of patients with abnormal results.
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Affiliation(s)
- S M Ruzycki
- Department of Medicine, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - M Prystajecky
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - M R Driedger
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - R Kachra
- Division of General Internal Medicine, Department of Medicine, University of Calgary, AB, Canada
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160
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Yeh HW, Yeh LT, Chou YH, Yang SF, Ho SW, Yeh YT, Yeh YT, Wang YH, Chan CH, Yeh CB. Risk of Cardiovascular Disease Due to General Anesthesia and Neuraxial Anesthesia in Lower-Limb Fracture Patients: A Retrospective Population-Based Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 17:ijerph17010033. [PMID: 31861460 PMCID: PMC6982192 DOI: 10.3390/ijerph17010033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 11/20/2022]
Abstract
The purpose of this study was to analyze the relationship between elevated cardiovascular disease (CVD) risk and type of anesthesia by using the National Health Insurance Research Database (NHIRD) of Taiwan in a one-year follow-up period. We assessed whether general anesthesia (GA) or neuraxial anesthesia (NA) increased CVD occurrence in lower-limb fracture patients. Approximately 1 million patients were randomly sampled from the NHIRD registry. We identified and enrolled 3437 lower-limb fracture patients who had received anesthesia during operations conducted in the period from 2010 to 2012. Next, patients were divided into two groups, namely GA (n = 1504) and NA (n = 1933), based on the anesthetic technique received during surgery. Our results revealed that those receiving GA did not differ in their risk of CVD relative to those receiving NA, adjusted HR = 1.24 (95% CI: 0.80–1.92). Patients who received GA for more than 2 h also did not differ in their risk of CVD relative to those receiving NA for less than 2 h, adjusted HR = 1.43 (95% CI: 0.81–2.50). Moreover, in the GA group (i.e., patients aged ≥65 years and women), no significant difference for the risk of CVD events was observed. In conclusion, in our study, the difference in the risk of CVD between lower-limb fracture patients receiving NA and GA was not statistically significant. The incidence rate of CVD seemed to be more correlated with patients’ underlying characteristics such as old age, comorbidities, or admission to the intensive care unit. Due to the limited sample size in this study, a database which reviews a whole national population will be required to verify our results in the future.
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Affiliation(s)
- Han-Wei Yeh
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan;
| | - Liang-Tsai Yeh
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (L.-T.Y.); (Y.-H.C.); (S.-F.Y.)
- Department of Anesthesiology, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Ying-Hsiang Chou
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (L.-T.Y.); (Y.-H.C.); (S.-F.Y.)
- Department of Medical Imaging and Radiological Sciences, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Radiation Oncology, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (L.-T.Y.); (Y.-H.C.); (S.-F.Y.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
| | - Sai-Wai Ho
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Ying-Tung Yeh
- School of Dentistry, Chung Shan Medical University, Taichung 402, Taiwan; (Y.-T.Y.); (Y.-T.Y.)
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Ying-Ting Yeh
- School of Dentistry, Chung Shan Medical University, Taichung 402, Taiwan; (Y.-T.Y.); (Y.-T.Y.)
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
| | - Chi-Ho Chan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
- Department of Microbiology and Immunology, Chung Shan Medical University, Taichung 402, Taiwan
- Correspondence: (C.-H.C.); (C.-B.Y.)
| | - Chao-Bin Yeh
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Correspondence: (C.-H.C.); (C.-B.Y.)
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161
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Immature Platelets: The Heart of the Matter in Peri-Operative Cardiac Risk Assessment? Eur J Vasc Endovasc Surg 2019; 59:319. [PMID: 31812607 DOI: 10.1016/j.ejvs.2019.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 11/13/2019] [Indexed: 11/20/2022]
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Effects of Volatile versus Total Intravenous Anesthesia on Occurrence of Myocardial Injury after Non-Cardiac Surgery. J Clin Med 2019; 8:jcm8111999. [PMID: 31731805 PMCID: PMC6912591 DOI: 10.3390/jcm8111999] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/03/2019] [Accepted: 11/13/2019] [Indexed: 12/23/2022] Open
Abstract
The cardioprotective effects of volatile anesthetics versus total intravenous anesthesia (TIVA) are controversial, especially in patients undergoing non-cardiac surgery. Using current generation high-sensitivity cardiac troponin (hs-cTn), we aimed to evaluate the effect of anesthetics on the occurrence of myocardial injury after non-cardiac surgery (MINS). From February 2010 to December 2016, 3555 patients without preoperative hs-cTn elevation underwent non-cardiac surgery under general anesthesia. Patients were grouped according to anesthetic agent; 659 patients were classified into a propofol-remifentanil total intravenous anesthesia (TIVA) group, and 2896 patients were classified into a volatile group. To balance the use of remifentanil between groups, a balanced group (n = 1622) was generated with patients who received remifentanil infusion in the volatile group, and two separate comparisons were performed (TIVA vs. volatile and TIVA vs. balanced). The primary outcome was occurrence of MINS, defined as rise of hs-cTn I ≥ 0.04 ng/mL within postoperative 48 hours. The secondary outcomes were 30-day mortality, postoperative acute kidney injury (AKI), and adverse events during hospital stay (mortality, type I myocardial infarction (MI), and new-onset arrhythmia). In propensity-matched analyses, the occurrence of MINS was lower in the TIVA group compared to the volatile group (OR 0.642; 95% CI 0.450–0.914; p = 0.014). However, after balancing the use of remifentanil, there was no difference between groups in the risk of MINS (OR 0.832; 95% CI 0.554–1.251; p-value = 0.377). There were no significant associations between the two groups in type 1 MI, new-onset atrial fibrillation, in-hospital and 30-day mortality before and after balancing the use of remifentanil. However, the incidence of postoperative AKI was lower in the TIVA group (OR 0.362; 95% CI 0.194–0.675; p-value = 0.001). After balancing the use of remifentanil, volatile anesthesia and TIVA showed comparable effects on MINS in patients undergoing non-cardiac surgery without preoperative myocardial injury. Further studies are needed on the benefit of remifentanil infusion.
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163
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Wright DE, Knuesel SJ, Nagarur A, Philpotts LL, Greenwald JL. Examining Risk: A Systematic Review of Perioperative Cardiac Risk Prediction Indices. Mayo Clin Proc 2019; 94:2277-2290. [PMID: 31202481 DOI: 10.1016/j.mayocp.2019.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 03/01/2019] [Accepted: 03/12/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To conduct a systematic review of published cardiac risk indices relevant to patients undergoing noncardiac surgery and to provide clinically meaningful recommendations to physicians regarding the use of these indices. METHODS A literature search of articles published from January 1, 1999, through December 28, 2018, was conducted in Ovid (MEDLINE), PubMed, Embase, CINAHL, and Web of Science. Publications describing models predicting risk of cardiac complications after noncardiac surgery were included and citation chaining was used to identify additional studies for inclusion. RESULTS Eleven risk indices involving 2,910,297 adult patients were included in this analysis. Studies varied in size, population, quality, risk of bias, outcome event definitions, risk factors identified, index outputs, accuracy, and clinical usefulness. Studies considered 6 to 83 variables to develop their models. Among the identified models, the factors with the highest predictiveness for adverse cardiac outcomes included congestive heart failure, type of surgery, creatinine, diabetes, history of stroke or transient ischemic attack, and emergency surgery. Substantial data from the large studies also supports advancing age, American Society of Anesthesiology physical status classification, functional status, and hypertension as additional risks. CONCLUSION The risk indices identified generally fell into two groups - those with higher accuracy for predicting a narrow range of cardiac outcomes and those with lower accuracy for predicting a broader range of cardiac outcomes. Using one index from each group may be the most clinically useful approach. Risk factors identified varied widely among studies. In addition to judicious use of predictive indices, reasoned clinical judgment remains indispensable in assessing perioperative cardiac risk.
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Affiliation(s)
- Douglas E Wright
- Core Educator Faculty, Department of Medicine, Massachusetts General Hospital, Boston.
| | - Steven J Knuesel
- Core Educator Faculty, Department of Medicine, Massachusetts General Hospital, Boston
| | - Amulya Nagarur
- Core Educator Faculty, Department of Medicine, Massachusetts General Hospital, Boston
| | - Lisa L Philpotts
- Treadwell Virtual Library, Massachusetts General Hospital, Boston
| | - Jeffrey L Greenwald
- Core Educator Faculty, Department of Medicine, Massachusetts General Hospital, Boston
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Bourgon Labelle J, Audet LA, Farand P, Rochefort CM. Are hospital nurse staffing practices associated with postoperative cardiac events and death? A systematic review. PLoS One 2019; 14:e0223979. [PMID: 31622437 PMCID: PMC6797123 DOI: 10.1371/journal.pone.0223979] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 10/02/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Postoperative cardiac events are frequent complications of surgery, and their occurrence could be associated with suboptimal nurse staffing practices, but the existing evidence remains scattered. We systematically reviewed studies linking nurse staffing practices to postoperative cardiac events and two related outcomes, all-cause mortality and failure-to-rescue. METHODS A systematic search of the English/French literature was undertaken in the CINAHL, PsychInfo, and Medline databases. Studies were included if they: a) were published between 1996 and 2018; b) used a quantitative design; c) examined the association between at least one of seven staffing practices of interest (i.e., staffing levels, skill mix, work environment characteristics, levels of education and experience of the registered nurses, and overtime or temporary staff use) and postoperative cardiac events, mortality or failure-to-rescue; and d) were conducted among surgical patients. Data extraction, analysis, and synthesis, along with study methodological quality appraisal, were performed by two authors. High methodological heterogeneity precluded a formal meta-analysis. RESULTS Among 3,375 retrieved articles, 44 studies were included (39 cross-sectional, 3 longitudinal, 1 case-control, 1 interrupted time series). Existing evidence shows that higher nurse staffing levels, a higher proportion of registered nurses with an education at the baccalaureate degree level, and more supportive work environments are related to lower rates of both 30-day mortality and failure-to-rescue. Other staffing practices were less often studied and showed inconsistent associations with mortality or failure-to-rescue. Similarly, few studies (n = 10) examined the associations between nurse staffing practices and postoperative cardiac events and showed inconsistent results. CONCLUSION Higher nurse staffing levels, higher registered nurse education (baccalaureate degree level) and more supportive work environments were cross-sectionally associated with lower 30-day mortality and failure-to-rescue rates among surgical patients, but longitudinal studies are required to corroborate these associations. The existing evidence regarding postoperative cardiac events is limited, which warrants further investigation.
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Affiliation(s)
- Jonathan Bourgon Labelle
- Division of Cardiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche Charles-Le Moyne Saguenay-Lac-St-Jean sur les Innovations en Santé, Longueuil, Quebec, Canada
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- * E-mail:
| | - Li-Anne Audet
- Centre de Recherche Charles-Le Moyne Saguenay-Lac-St-Jean sur les Innovations en Santé, Longueuil, Quebec, Canada
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Paul Farand
- Division of Cardiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Christian M. Rochefort
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche Charles-Le Moyne Saguenay-Lac-St-Jean sur les Innovations en Santé, Longueuil, Quebec, Canada
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Hedenstierna G, Meyhoff CS. Oxygen toxicity in major emergency surgery-anything new? Intensive Care Med 2019; 45:1802-1805. [PMID: 31599335 PMCID: PMC6863790 DOI: 10.1007/s00134-019-05787-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 09/11/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Göran Hedenstierna
- Department of Medical Sciences, Clinical Physiology, Hedenstierna Laboratory, University Hospital, 75185, Uppsala, Sweden.
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Fronczek J, Polok K, Devereaux P, Górka J, Archbold R, Biccard B, Duceppe E, Le Manach Y, Sessler D, Duchińska M, Szczeklik W. External validation of the Revised Cardiac Risk Index and National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest calculator in noncardiac vascular surgery. Br J Anaesth 2019; 123:421-429. [DOI: 10.1016/j.bja.2019.05.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/20/2019] [Accepted: 05/03/2019] [Indexed: 12/24/2022] Open
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Blessberger H, Lewis SR, Pritchard MW, Fawcett LJ, Domanovits H, Schlager O, Wildner B, Kammler J, Steinwender C. Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery. Cochrane Database Syst Rev 2019; 9:CD013438. [PMID: 31556094 PMCID: PMC6761481 DOI: 10.1002/14651858.cd013438] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) have yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality. Thus routine prescription of these drugs in an unselected population remains a controversial issue. A previous version of this review assessing the effectiveness of perioperative beta-blockers in cardiac and non-cardiac surgery was last published in 2018. The previous review has now been split into two reviews according to type of surgery. This is an update, and assesses the evidence in non-cardiac surgery only. OBJECTIVES To assess the effectiveness of perioperatively administered beta-blockers for the prevention of surgery-related mortality and morbidity in adults undergoing non-cardiac surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Biosis Previews and Conference Proceedings Citation Index-Science on 28 June 2019. We searched clinical trials registers and grey literature, and conducted backward- and forward-citation searching of relevant articles. SELECTION CRITERIA We included RCTs and quasi-randomized studies comparing beta-blockers with a control (placebo or standard care) administered during the perioperative period to adults undergoing non-cardiac surgery. If studies included surgery with different types of anaesthesia, we included them if 70% participants, or at least 100 participants, received general anaesthesia. We excluded studies in which all participants in the standard care control group were given a pharmacological agent that was not given to participants in the intervention group, studies in which all participants in the control group were given a beta-blocker, and studies in which beta-blockers were given with an additional agent (e.g. magnesium). We excluded studies that did not measure or report review outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 83 RCTs with 14,967 participants; we found no quasi-randomized studies. All participants were undergoing non-cardiac surgery, and types of surgery ranged from low to high risk. Types of beta-blockers were: propranolol, metoprolol, esmolol, landiolol, nadolol, atenolol, labetalol, oxprenolol, and pindolol. In nine studies, beta-blockers were titrated according to heart rate or blood pressure. Duration of administration varied between studies, as did the time at which drugs were administered; in most studies, it was intraoperatively, but in 18 studies it was before surgery, in six postoperatively, one multi-arm study included groups of different timings, and one study did not report timing of drug administration. Overall, we found that more than half of the studies did not sufficiently report methods used for randomization. All studies in which the control was standard care were at high risk of performance bias because of the open-label study design. Only two studies were prospectively registered with clinical trials registers, which limited the assessment of reporting bias. In six studies, participants in the control group were given beta-blockers as rescue therapy during the study period.The evidence for all-cause mortality at 30 days was uncertain; based on the risk of death in the control group of 25 per 1000, the effect with beta-blockers was between two fewer and 13 more per 1000 (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.89 to 1.54; 16 studies, 11,446 participants; low-certainty evidence). Beta-blockers may reduce the incidence of myocardial infarction by 13 fewer incidences per 1000 (RR 0.72, 95% CI 0.60 to 0.87; 12 studies, 10,520 participants; low-certainty evidence). We found no evidence of a difference in cerebrovascular events (RR 1.65, 95% CI 0.97 to 2.81; 6 studies, 9460 participants; low-certainty evidence), or in ventricular arrhythmias (RR 0.72, 95% CI 0.35 to 1.47; 5 studies, 476 participants; very low-certainty evidence). Beta-blockers may reduce atrial fibrillation or flutter by 26 fewer incidences per 1000 (RR 0.41, 95% CI 0.21 to 0.79; 9 studies, 9080 participants; low-certainty evidence). However, beta-blockers may increase bradycardia by 55 more incidences per 1000 (RR 2.49, 95% CI 1.74 to 3.56; 49 studies, 12,239 participants; low-certainty evidence), and hypotension by 44 more per 1000 (RR 1.40, 95% CI 1.29 to 1.51; 49 studies, 12,304 participants; moderate-certainty evidence).We downgraded the certainty of the evidence owing to study limitations; some studies had high risks of bias, and the effects were sometimes altered when we excluded studies with a standard care control group (including only placebo-controlled trials showed an increase in early mortality and cerebrovascular events with beta-blockers). We also downgraded for inconsistency; one large, well-conducted, international study found a reduction in myocardial infarction, and an increase in cerebrovascular events and all-cause mortality, when beta-blockers were used, but other studies showed no evidence of a difference. We could not explain the reason for the inconsistency in the evidence for ventricular arrhythmias, and we also downgraded this outcome for imprecision because we found few studies with few participants. AUTHORS' CONCLUSIONS The evidence for early all-cause mortality with perioperative beta-blockers was uncertain. We found no evidence of a difference in cerebrovascular events or ventricular arrhythmias, and the certainty of the evidence for these outcomes was low and very low. We found low-certainty evidence that beta-blockers may reduce atrial fibrillation and myocardial infarctions. However, beta-blockers may increase bradycardia (low-certainty evidence) and probably increase hypotension (moderate-certainty evidence). Further evidence from large placebo-controlled trials is likely to increase the certainty of these findings, and we recommend the assessment of impact on quality of life. We found 18 studies awaiting classification; inclusion of these studies in future updates may also increase the certainty of the evidence.
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Affiliation(s)
- Hermann Blessberger
- Kepler University Hospital, Medical Faculty of the Johannes Kepler University LinzDepartment of Cardiology, Med Campus IIIKrankenhausstraße 9LinzAustria4020
| | - Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Lizzy J Fawcett
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Hans Domanovits
- Vienna General Hospital, Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20ViennaAustria1090
| | - Oliver Schlager
- Vienna General Hospital, Medical University of ViennaDepartment of Internal Medicine II, Division of AngiologyWähringer Gürtel 18‐20ViennaAustria1090
| | - Brigitte Wildner
- University Library of the Medical University of ViennaInformation Retrieval OfficeWähringer Gürtel 18‐20ViennaAustria1090
| | - Juergen Kammler
- Kepler University Hospital, Medical Faculty of the Johannes Kepler University LinzDepartment of Cardiology, Med Campus IIIKrankenhausstraße 9LinzAustria4020
| | - Clemens Steinwender
- Kepler University Hospital, Medical Faculty of the Johannes Kepler University LinzDepartment of Cardiology, Med Campus IIIKrankenhausstraße 9LinzAustria4020
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Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study. Lancet 2019; 394:1022-1029. [PMID: 31422895 DOI: 10.1016/s0140-6736(19)31795-7] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND In non-surgical settings, covert stroke is more common than overt stroke and is associated with cognitive decline. Although overt stroke occurs in less than 1% of adults after non-cardiac surgery and is associated with substantial morbidity, we know little about perioperative covert stroke. Therefore, our primary aim was to investigate the relationship between perioperative covert stroke (ie, an acute brain infarct detected on an MRI after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive decline 1 year after surgery. METHODS NeuroVISION was a prospective cohort study done in 12 academic centres in nine countries, in which we assessed patients aged 65 years or older who underwent inpatient, elective, non-cardiac surgery and had brain MRI after surgery. Two independent neuroradiology experts, masked to clinical data, assessed each MRI for acute brain infarction. Using multivariable regression, we explored the association between covert stroke and the primary outcome of cognitive decline, defined as a decrease of 2 points or more on the Montreal Cognitive Assessment from preoperative baseline to 1-year follow-up. Patients, health-care providers, and outcome adjudicators were masked to MRI results. FINDINGS Between March 24, 2014, and July 21, 2017, of 1114 participants recruited to the study, 78 (7%; 95% CI 6-9) had a perioperative covert stroke. Among the patients who completed the 1-year follow-up, cognitive decline 1 year after surgery occurred in 29 (42%) of 69 participants who had a perioperative covert stroke and in 274 (29%) of 932 participants who did not have a perioperative covert stroke (adjusted odds ratio 1·98, 95% CI 1·22-3·20, absolute risk increase 13%; p=0·0055). Covert stroke was also associated with an increased risk of perioperative delirium (hazard ratio [HR] 2·24, 95% CI 1·06-4·73, absolute risk increase 6%; p=0·030) and overt stroke or transient ischaemic attack at 1-year follow-up (HR 4·13, 1·14-14·99, absolute risk increase 3%; p=0·019). INTERPRETATION Perioperative covert stroke is associated with an increased risk of cognitive decline 1 year after non-cardiac surgery, and perioperative covert stroke occurred in one in 14 patients aged 65 years and older undergoing non-cardiac surgery. Research is needed to establish prevention and management strategies for perioperative covert stroke. FUNDING Canadian Institutes of Health Research; The Ontario Strategy for Patient Oriented Research support unit; The Ontario Ministry of Health and Long-Term Care; Health and Medical Research Fund, Government of the Hong Kong Special Administrative Region, China; and The Neurological Foundation of New Zealand.
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169
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Abstract
PURPOSE OF REVIEW Timely identification of high-risk surgical candidates facilitate surgical decision-making and allows appropriate tailoring of perioperative management strategies. This review aims to summarize the recent advances in perioperative risk stratification. RECENT FINDINGS Use of indices which include various combinations of preoperative and postoperative variables remain the most commonly used risk-stratification strategy. Incorporation of biomarkers (troponin and natriuretic peptides), comprehensive objective assessment of functional capacity, and frailty into the current framework enhance perioperative risk estimation. Intraoperative hemodynamic parameters can provide further signals towards identifying patients at risk of adverse postoperative outcomes. Implementation of machine-learning algorithms is showing promising results in real-time forecasting of perioperative outcomes. SUMMARY Perioperative risk estimation is multidimensional including validated indices, biomarkers, functional capacity estimation, and intraoperative hemodynamics. Identification and implementation of targeted strategies which mitigate predicted risk remains a greater challenge.
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170
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[Preconditioning of the lungs and circulation before visceral and thoracic surgical interventions]. Chirurg 2019; 90:529-536. [PMID: 30919019 DOI: 10.1007/s00104-019-0943-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Estimation of the perioperative risk plays a decisive role in the surgical indications, particularly in view of the demographic change. For this reason, prehabilitation concepts for reducing perioperative risk nowadays play an increasingly important role. OBJECTIVE Presentation of the current recommendations for preoperative diagnostics in thoracic surgical interventions as well as existing prehabilitation concepts and their practical applicability. MATERIAL AND METHODS A selective review of the literature was carried out by searching the electronic databases PubMed, Cochrane Library and ISRCTN, including the guidelines of the American College of Chest Physicians (ACCP) and the European Society of Thoracic Surgery (ESTS). RESULTS Preconditioning includes the conservative treatment of underlying diseases, smoking cessation and prehabilitation. Prehabilitation is an increasingly pressing concept in routine clinical practice, even though the evidence is limited due to the very heterogeneous study situation. Overall, however, there is a tendency for positive effects on the quality of life and postoperative complications as well as convalescence. CONCLUSION In addition to preoperative diagnostics to assess the perioperative risk, effective preconditioning of patients is also necessary. For this an interdisciplinary approach including anesthesia, pneumology, psychotherapy and physiotherapy is necessary. In addition to the conservative medicinal optimization, prehabilitation concepts are gaining in importance and will certainly become established in routine clinical practice. From the surgical perspective, minimally invasive approaches and parenchyma-sparing resections also serve to reduce risks.
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171
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Schacham YN, Cohen B, Bajracharya GR, Walters M, Zimmerman N, Mao G, Tanios MA, Sessler DI. Mild Perioperative Hypothermia and Myocardial Injury: A Retrospective Cohort Analysis. Anesth Analg 2019; 127:1335-1341. [PMID: 30300173 DOI: 10.1213/ane.0000000000003840] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We tested the primary hypothesis that final intraoperative esophageal temperature is associated with increased odds of a composite of in-hospital all-cause mortality and myocardial injury within 7 days after noncardiac surgery. Secondary exposures were time-weighted average intraoperative temperature and area <37°C threshold. METHODS Myocardial injury was defined by postoperative fourth-generation troponin T ≥0.03 ng/mL apparently due to cardiac ischemia. Data were extracted for inpatients who had noncardiac surgery with general anesthesia at the Cleveland Clinic between 2012 and 2015. All had esophageal temperature monitoring and routine postoperative troponin monitoring. We estimated the confounder-adjusted association between final intraoperative esophageal temperature and the collapsed composite with multivariable logistic regression. We similarly estimated associations with time-weighted average intraoperative temperature and area <37°C. RESULTS Two thousand two hundred ten patients were included. Nearly all final esophageal temperatures were 36°C-37°C. Ninety-seven patients (4.4%) had myocardial injury, and 7 (0.3%) died before discharge. Final intraoperative core temperature was not associated with the collapsed composite: odds ratio, 0.91 (95% confidence interval, 0.68-1.24) per 1°C decrease. Similarly, neither of the secondary exposures was associated with the composite outcome. CONCLUSIONS We did not observe an association between mild perioperative hypothermia and mortality or myocardial injury in adults having noncardiac surgery. However, the range of final intraoperative temperatures was small and largely restricted to the normothermic range (36°C-37°C). Trials are needed to further assess the effect of temperature on myocardial injury.
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Affiliation(s)
- Yehoshua N Schacham
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Internal Medicine C, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barak Cohen
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Division of Anesthesia, Critical Care and Pain Management, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gausan R Bajracharya
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Walters
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicole Zimmerman
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Guangmei Mao
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Marianne A Tanios
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Wald K, Letourneau J, Eshima-McKay R, Monks J, Mok-Lin E, Cedars M, Rosen M. Ovarian stimulation and egg retrieval in the acutely ill patient: special considerations. J Assist Reprod Genet 2019; 36:2087-2094. [PMID: 31396851 DOI: 10.1007/s10815-019-01556-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/02/2019] [Indexed: 01/28/2023] Open
Affiliation(s)
- Kaitlyn Wald
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 499 Illinois Street, 6th Floor, San Francisco, CA, 94158, USA.
| | - Joseph Letourneau
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 499 Illinois Street, 6th Floor, San Francisco, CA, 94158, USA.,University of Utah Center for Reproductive Medicine, Salt Lake City, UT, USA
| | - Rachel Eshima-McKay
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - John Monks
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Evelyn Mok-Lin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 499 Illinois Street, 6th Floor, San Francisco, CA, 94158, USA
| | - Marcelle Cedars
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 499 Illinois Street, 6th Floor, San Francisco, CA, 94158, USA
| | - Mitchell Rosen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 499 Illinois Street, 6th Floor, San Francisco, CA, 94158, USA
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Keuffel EL, Rizzo J, Stevens M, Gunnarsson C, Maheshwari K. Hospital costs associated with intraoperative hypotension among non-cardiac surgical patients in the US: a simulation model. J Med Econ 2019; 22:645-651. [PMID: 30838899 DOI: 10.1080/13696998.2019.1591147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective: Recent studies indicate intraoperative hypotension, common in non-cardiac surgical patients, is associated with myocardial injury, acute kidney injury, and mortality. This study extends on these findings by quantifying the association between intraoperative hypotension and hospital expenditures in the US. Methods: Monte Carlo simulations (10,000 trial per simulation) based on current epidemiological and cost outcomes literature were developed for both acute kidney injury (AKI) and myocardial injury in non-cardiac surgery (MINS). For AKI, three models with different epidemiological assumptions (two models based on observational studies and one model based on a randomized control trial [RCT]) estimate the marginal probability of AKI conditional on intraoperative hypotension status. Similar models are also developed for MINS (except for the RCT case). Marginal probabilities of AKI and MINS sequelae (myocardial infarction, congestive heart failure, stroke, cardiac catheterization, and percutaneous coronary intervention) are multiplied by marginal cost estimates for each outcome to evaluate costs associated with intraoperative hypotension. Results: The unadjusted (adjusted) model found hypotension control lowers the absolute probability of AKI by 2.2% (0.7%). Multiplying these probabilities by the marginal cost of AKI, the unadjusted (adjusted) AKI model estimated a cost reduction of $272 [95% CI = $223-$321] ($86 [95% CI = $47-$127]) per patient. The AKI model based on relative risks from the RCT had a mean cost reduction estimate of $281 (95% CI = -$346-$750). The unadjusted (adjusted) MINS model yielded a cost reduction of $186 [95% CI = $73-$393] ($33 [95% CI = $10-$77]) per patient. Conclusions: The model results suggest improved intraoperative hypotension control in a hospital with an annual volume of 10,000 non-cardiac surgical patients is associated with mean cost reductions ranging from $1.2-$4.6 million per year. Since the magnitude of the RCT mean estimate is similar to the unadjusted observational model, the institutional costs are likely at the upper end of this range.
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Affiliation(s)
- Eric L Keuffel
- a Health Finance & Access Initiative , Bryn Mawr , PA , USA
| | - John Rizzo
- b Stony Brook University Medical Center, Stony Brook University (New York) , Stony Brook , NY , USA
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175
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Abstract
In the future an increasing number of older patients with significant comorbidities will have to undergo major surgical procedures. Perioperative cardiovascular events account for many major complications and even fatalities. While perioperative myocardial infarction (PMI) is a generally well-known and recognized complication, the less severe myocardial injury after non-cardiac surgery (MINS) has not gained widespread scientific attention until recently; however, two large observational trials (VISION 1 and VISION 2) have shown a significantly increased mortality after MINS with even subtle increases in troponin T being associated with an increased risk of death. This review summarizes the current knowledge pertaining to PMI and MINS and proposes a diagnostic and therapeutic framework for optimally guiding patients at risk through the perioperative period.
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176
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Moldovan H, Popescu D, Buliga T, Filip A, Antoniac I, Gheorghiţӑ D, Molnar A. Gastric Adenocarcinoma Associated with Acute Endocarditis of the Aortic Valve and Coronary Artery Disease in a 61-Year-Old Male with Multiple Comorbidities-Combined Surgical Management-Case Report. ACTA ACUST UNITED AC 2019; 55:medicina55060242. [PMID: 31163703 PMCID: PMC6631313 DOI: 10.3390/medicina55060242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/16/2019] [Accepted: 05/24/2019] [Indexed: 11/16/2022]
Abstract
The case of a 61-year-old male with a recent total gastrectomy for a hemorrhagic gastric tumor is presented, with the important co-morbidities of type II diabetes mellitus requiring insulin, chronic hepatitis C with liver dysfunction, stage II essential hypertension, chronic stage III renal disease peripheral type II aorto-iliac disease with stage II ischemia of both legs, and chronic anemia. About one month following the gastrectomy, the patient presented with fever and acute inflammatory syndrome. Severe aortic insufficiency, aortic valvular vegetations, and positive blood cultures with Staphylococcus saprophytic were found. The diagnosis of infectious endocarditis on the aortic valve was established (positive blood cultures with echocardiographic features of vegetations, fever), and antibiotic treatment with Levofloxacin and Vancomycin was initiated. The evolution was favorable with the remission of the inflammatory syndrome and quick cessation of fever. However, the hemodynamic aspect showed progressive heart failure with acute pulmonary edema. The transesophageal echocardiographic examination confirmed the existence of severe aortic insufficiency and valvular vegetations with a left ventricular ejection fraction of 38%. The coronary angiography revealed double vessel disease. The calculated Euroscore II was 33.4%. Aortic valve replacement with porcine xenograft and double coronary artery bypass graft surgery was performed. The patient had a favorable postoperative course remaining afebrile and out of heart failure, with the markers of inflammation largely within normal limits. The left ventricular ejection fraction increased to 50%. The successful outcome of this case, represented by a rare association of cancer, endocarditis, and coronary disease, reveals the importance of the multidisciplinary teams involved in this case: gastroenterology, general surgery, cardiology, infectious diseases, cardiac surgery, and intensive care. Therefore, in such cases with high risk, complex patients, a strong collaboration between all specialties is needed to overcome all of the limitations of the patient's co-morbidities.
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Affiliation(s)
- Horaţiu Moldovan
- Department of Cardiovascular Surgery, Sanador Hospital, 010991 Bucharest, Romania.
- Titu Maiorescu University, Faculty of Medicine, 004051 Bucharest, Romania.
| | - Daniela Popescu
- Department of Cardiology, Sanador Hospital, 010991 Bucharest, Romania.
| | - Teodor Buliga
- Department of General Surgery, Sanador Hospital, 010991 Bucharest, Romania.
| | - Anca Filip
- Department of Intensive Care, Sanador Hospital, 010991 Bucharest, Romania.
| | - Iulian Antoniac
- University Politehnica of Bucharest, Faculty of Materials Science and Engineering, 060042 Bucharest, Romania.
| | - Daniela Gheorghiţӑ
- University Politehnica of Bucharest, Faculty of Materials Science and Engineering, 060042 Bucharest, Romania.
| | - Adrian Molnar
- Iuliu Hatieganu University of Medicine and Pharmacy, 400129 Cluj-Napoca, Romania.
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177
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A New Index for Pre-Operative Cardiovascular Evaluation. J Am Coll Cardiol 2019; 73:3067-3078. [DOI: 10.1016/j.jacc.2019.04.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 03/31/2019] [Accepted: 04/02/2019] [Indexed: 12/23/2022]
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178
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Marchioni M, Cindolo L, Di Nicola M, Schips L, De Sio M, Lima E, Mirone V, Cormio L, Liatsikos E, Porpiglia F, Autorino R. Major Acute Cardiovascular Events After Transurethral Prostate Surgery: A Population-based Analysis. Urology 2019; 131:196-203. [PMID: 31145946 DOI: 10.1016/j.urology.2019.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/12/2019] [Accepted: 05/16/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To test the prevalence and predictors of major acute cardiovascular events (MACE) after transurethral prostate surgery (TPS). MATERIAL AND METHODS The American College of Surgeons National Surgical Quality Improvement Program database (2011-2016) was queried for patients who underwent transurethral resection of the prostate, photoselective vaporization, or laser enucleation. MACE included: cerebrovascular events, cardiac arrest, myocardial infarction, deep venous thrombosis requiring therapy, and pulmonary embolism episodes occurred up to 30 days after discharge. Univariable and multivariable logistic regression models tested MACE predictors and effect of MACE on perioperative mortality. Within covariates significant at univariable analyses a stepwise selection, based on Akaike Information Criterion values, was performed to fit the most appropriate multivariable model. RESULTS Overall 44,939 patients were included in our analyses. Of these 365 (0.8%) had MACE within 30 days after surgery. The strongest MACE predictors were recent congestive heart failure (odds ratio [OR]: 2.1, 95% confidence interval [CI]: 1.2-3.7, P = .007), transfusions (OR: 2.5, 95% CI: 1.5-4.1, P <.001) and preoperative Systemic Inflammatory Response Syndrome or sepsis (OR: 2.6, 95% CI: 1.6-4.2, P <.001). Similarly, inpatient (OR: 2.0, 95% CI: 1.6-2.5, P <.001) and nonelective (OR: 1.5, 95% CI: 1.1-2.1, P = .012) patients experienced higher MACE rates. Perioperative mortality rates were statistical significantly higher in MACE patients (OR: 13.1, 95% CI: 8.2-21.0, P <.001). CONCLUSION Up to 1% of patients undergoing transurethral prostate surgery experience MACE. MACE are burdened by high mortality rates (up to 14% in MACE patients). Proper patient selection and postoperative monitoring are necessary to reduce MACE incidence and mortality rates.
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Affiliation(s)
- Michele Marchioni
- Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University of Chieti, Laboratory of Biostatistics, Chieti, Italy; Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University of Chieti, "SS. Annunziata" Hospital, Chieti, Italy.
| | - Luca Cindolo
- Department of Urology, ASL Abruzzo 2, Chieti, Italy
| | - Marta Di Nicola
- Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University of Chieti, Laboratory of Biostatistics, Chieti, Italy
| | - Luigi Schips
- Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University of Chieti, "SS. Annunziata" Hospital, Chieti, Italy
| | - Marco De Sio
- Department of Urology, Luigi Vanvitelli University of Naples, Naples, Italy
| | - Estevão Lima
- Department of Urology, Hospital of Braga, Braga, Portugal
| | - Vincenzo Mirone
- Department of Urology, Federico II University, Naples, Italy
| | - Luigi Cormio
- Department of Urology and Kidney Transplantation, University of Foggia, Foggia, Italy
| | | | - Francesco Porpiglia
- Department of Oncology, Division of Urology, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Riccardo Autorino
- Department of Surgery, Division of Urology, VCU Health, Richmond, VA
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Smilowitz NR, Gupta N, Ramakrishna H, Guo Y, Berger JS, Bangalore S. Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery. JAMA Cardiol 2019; 2:181-187. [PMID: 28030663 DOI: 10.1001/jamacardio.2016.4792] [Citation(s) in RCA: 233] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Major adverse cardiovascular and cerebrovascular events (MACCE) are a significant source of perioperative morbidity and mortality following noncardiac surgery. Objective To evaluate national trends in perioperative cardiovascular outcomes and mortality after major noncardiac surgery and to identify surgical subtypes associated with cardiovascular events using a large administrative database of United States hospital admissions. Design, Setting, Participants Patients who underwent major noncardiac surgery from January 2004 to December 2013 were identified using the National Inpatient Sample. Main Outcomes and Measures Perioperative MACCE (primary outcome), defined as in-hospital, all-cause death, acute myocardial infarction (AMI), or acute ischemic stroke, were evaluated over time. Results Among 10 581 621 hospitalizations (mean [SD] patient age, 65.74 [12.32] years; 5 975 798 female patients 56.60%]) for major noncardiac surgery, perioperative MACCE occurred in 317 479 hospitalizations (3.0%), corresponding to an annual incidence of approximately 150 000 events after applying sample weights. Major adverse cardiovascular and cerebrovascular events occurred most frequently in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant surgery (6.3%). Between 2004 and 2013, the frequency of MACCE declined from 3.1% to 2.6% (P for trend <.001; adjusted odds ratio [aOR], 0.95; 95% CI, 0.94-0.97) driven by a decline in frequency of perioperative death (aOR, 0.79; 95% CI, 0.77-0.81) and AMI (aOR, 0.87; 95% CI, 0.84-0.89) but an increase in perioperative ischemic stroke from 0.52% in 2004 to 0.77% in 2013 (P for trend <.001; aOR 1.79; CI 1.73-1.86). Conclusions and Relevance Perioperative MACCE occurs in 1 of every 33 hospitalizations for noncardiac surgery. Despite reductions in the rate of death and AMI among patients undergoing major noncardiac surgery in the United States, perioperative ischemic stroke increased over time. Additional efforts are necessary to improve cardiovascular care in the perioperative period of patients undergoing noncardiac surgery.
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Affiliation(s)
- Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York
| | - Navdeep Gupta
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | | | - Yu Guo
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York
| | - Jeffrey S Berger
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York
| | - Sripal Bangalore
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York
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180
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Peri-operative copeptin concentrations and their association with myocardial injury after vascular surgery: A prospective observational cohort study. Eur J Anaesthesiol 2019; 35:682-690. [PMID: 29750698 DOI: 10.1097/eja.0000000000000815] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Copeptin levels in conjunction with cardiac troponin may be used to rule out early myocardial infarction in patients presenting with chest pain. Raised pre-operative copeptin has been shown to be associated with postoperative cardiac events. However, very little is known about the peri-operative time course of copeptin or the feasibility of very early postoperative copeptin measurement to diagnose or rule-out myocardial injury. OBJECTIVES In this preparatory analysis for a larger trial, we sought to examine the time course of peri-operative copeptin and identify the time at which concentrations returned to pre-operative levels. Second, in an explorative analysis, we sought to examine the association of copeptin in general and at various time points with myocardial injury occurring within the first 48 h. DESIGN Preparatory analysis of a prospective, observational cohort study. SETTING Single university centre from February to July 2016. PATIENTS A total of 30 consecutive adults undergoing vascular surgery. INTERVENTION Serial peri-operative copeptin measurements. MAIN OUTCOME MEASURE We measured copeptin concentrations before and immediately after surgery (0 h), then at 2, 4, 6 and 8 h after surgery and on the first and second postoperative day. Postoperative concentrations were compared with pre-operative levels with a Wilcoxon signed-rank test. Second, we explored an association between postoperative copeptin concentrations and myocardial injury by the second postoperative day. Myocardial injury was defined as a 5 ng l increase between pre-operative and postoperative high-sensitivity cardiac troponin T with an absolute peak of at least 20 ng l. RESULTS Immediate postoperative copeptin concentrations (median [interquartile range]) increased nearly eight-fold from pre-operative values (8.5 [3.6 to 13.8] to 64.75 pmol l [29.6 to 258.7]; P < 0.001). Copeptin concentrations remained elevated until returning to baseline on the second postoperative day. Postoperative copeptin was significantly higher in patients experiencing myocardial injury than in those who did not (P = 0.02). The earliest most promising single time point for diagnosis may be immediately after surgery (0 h). The receiver-operating characteristics curve for immediate postoperative copeptin and myocardial injury by the second postoperative day was 0.743 (95% confidence interval 0.560 to 0.926). CONCLUSION Copeptin concentrations are greatly increased after vascular surgery and remain so until the 2nd postoperative day. Postoperative copeptin concentrations appear to be higher in patients who go on to exhibit myocardial injury. Immediate postoperative copeptin concentrations show promise for eliminating or identifying those at risk of myocardial injury. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02687776, Mauermann/Lurati Buse.
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181
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Devereaux PJ, Szczeklik W. Myocardial injury after non-cardiac surgery: diagnosis and management. Eur Heart J 2019; 41:3083-3091. [DOI: 10.1093/eurheartj/ehz301] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/21/2019] [Accepted: 05/06/2019] [Indexed: 01/13/2023] Open
Abstract
Abstract
Myocardial injury after non-cardiac surgery (MINS) is due to myocardial ischaemia (i.e. supply-demand mismatch or thrombus) and is associated with an increased risk of mortality and major vascular complications at 30 days and up to 2 years after non-cardiac surgery. The diagnostic criteria for MINS includes an elevated post-operative troponin measurement judged as resulting from myocardial ischaemia (i.e. no evidence of a non-ischaemic aetiology), during or within 30 days after non-cardiac surgery, and without the requirement of an ischaemic feature (e.g. ischaemic symptom, ischaemic electrocardiography finding). For patients with MINS who are not at high risk of bleeding, physicians should consider initiating dabigatran 110 mg twice daily and low-dose aspirin. Physicians should also consider initiating statin therapy in patients with MINS. Most MINS patients should only be referred to cardiac catheterization if they demonstrate recurrent instability (e.g. cardiac ischaemia, heart failure). Patients ≥65 years of age or with known atherosclerotic disease should have troponin measurements on days 1, 2, and 3 after surgery while the patient is in hospital to avoid missing >90% of MINS and the opportunity to initiate secondary prophylactic measures and follow-up.
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Affiliation(s)
- P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, David Braley Research Building, c/o Hamilton General Hospital, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
- Population Health Research Institute, David Braley Research Building, c/o Hamilton General Hospital, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, David Braley Research Building, c/o Hamilton General Hospital, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
- Outcomes Research Consortium, 109 Partridge Lane, Hunting Valley, Cleveland, OH 44022, USA
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, ul. Skawinska 8, 31-066 Krakow, Poland
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182
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Nomi T, Hirokawa F, Kaibori M, Ueno M, Tanaka S, Hokuto D, Noda T, Nakai T, Ikoma H, Iida H, Komeda K, Ishizaki M, Hayami S, Eguchi H, Matsumoto M, Morimura R, Maehira H, Sho M, Kubo S. Laparoscopic versus open liver resection for hepatocellular carcinoma in elderly patients: a multi-centre propensity score-based analysis. Surg Endosc 2019; 34:658-666. [PMID: 31093748 DOI: 10.1007/s00464-019-06812-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The frequency of liver resection in elderly patients has been increasing. However, data are limited regarding the safety of laparoscopic liver resection (LLR) compared with that of open liver resection (OLR) for hepatocellular carcinoma (HCC) in elderly patients. The present study aimed to compare short-term outcomes between LLR and OLR in elderly patients with HCC using propensity score matching. METHODS The study included 630 patients (age, ≥ 75 years) who underwent liver resection for HCC at nine liver centres between April 2010 and December 2017. Patients were divided into LLR and OLR groups, and perioperative outcomes were compared between the groups. In addition, subgroup analysis was performed according to age (75-79 and ≥ 80 years). RESULTS Of the 630 patients, 221 and 409 were included in the LLR and OLR groups, respectively. After propensity score matching, 155 patients were included in each group. Intraoperative blood loss and the transfusion, post-operative overall complication and major complication rates were lower in the matched LLR than the matched OLR group (P < 0.001, P = 0.004, P < 0.001 and P < 0.001, respectively). Moreover, post-operative pulmonary and cardiovascular complications were less frequent in the matched LLR group (P = 0.008 and P = 0.014, respectively). In subgroup analysis, among octogenarians, the post-operative major complication rate was lower and hospital stay was shorter in the matched LLR than the matched OLR group (P < 0.001 and P < 0.001, respectively). CONCLUSION LLR for HCC is associated with good short-term outcomes in patients aged ≥ 75 years compared with OLR. LLR is safe and feasible in selected octogenarians with HCC.
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Affiliation(s)
- Takeo Nomi
- Department of Surgery, Nara Medical University, 840, Shijocho, Kashihara, Nara, 634-8522, Japan.
| | - Fumitoshi Hirokawa
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Masaki Kaibori
- Department of Surgery, Hirakata Hospital, Kansai Medical University, Hirakata, Osaka, Japan
| | - Masaki Ueno
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Hokuto
- Department of Surgery, Nara Medical University, 840, Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takuya Nakai
- Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama, Osaka, Japan
| | - Hisashi Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroya Iida
- Division of Gastrointestinal, Breast, and General Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga Prefecture, Japan
| | - Koji Komeda
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Morihiko Ishizaki
- Department of Surgery, Hirakata Hospital, Kansai Medical University, Hirakata, Osaka, Japan
| | - Shinya Hayami
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masataka Matsumoto
- Department of Surgery, Faculty of Medicine, Kindai University, Osakasayama, Osaka, Japan
| | - Ryo Morimura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiromitsu Maehira
- Division of Gastrointestinal, Breast, and General Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga Prefecture, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840, Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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183
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Koshy AN, Ha FJ, Gow PJ, Han HC, Amirul-Islam FM, Lim HS, Teh AW, Farouque O. Computed tomographic coronary angiography in risk stratification prior to non-cardiac surgery: a systematic review and meta-analysis. Heart 2019; 105:1335-1342. [PMID: 31018953 DOI: 10.1136/heartjnl-2018-314649] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/25/2019] [Accepted: 03/28/2019] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Utility of CT coronary angiography (CTA) and coronary artery calcium (CAC) scoring in risk stratification prior to non-cardiac surgery is unclear. Although current guidelines recommend stress testing in intermediate-high risk individuals, over one-third of perioperative major adverse cardiovascular events (MACE) occur in patients with a negative study. This systematic review and meta-analysis evaluates the value of CTA and CAC score in preoperative risk prognostication prior to non-cardiac surgery. METHODS MEDLINE, PubMed and EMBASE databases were searched for articles published up to June 2018. Summary ORs for degree of coronary artery disease (CAD) and perioperative MACE were pooled using a random-effects model. RESULTS Eleven studies were included. Two hundred and fifty-two (7.2%) MACE occurred in 3480 patients. Risk of perioperative MACE rose with the severity and extent of CAD on CTA (no CAD 2.0%; non-obstructive 4.1%; obstructive single-vessel 7.1%; obstructive multivessel 23.1%, p<0.001). Multivessel disease (MVD) demonstrated the greatest risk (OR 8.9, 95% CI 5.1 to 15.3, p<0.001). Increasing CAC score was associated with higher perioperative MACE (CAC score: ≥100 OR 5.1, ≥1000 OR 10.4, both p<0.01). In a cohort deemed high risk by established clinical indices, absence of MVD on CTA demonstrated a negative predictive value of 96% (95% CI 92.8 to 98.4) for predicting freedom from MACE. CONCLUSIONS Severity and extent of CAD on CTA conferred incremental risk for perioperative MACE in patients undergoing non-cardiac surgery. The 'rule-out' capability of CTA is comparable to other non-invasive imaging modalities and offers a viable alternative for risk stratification of patients undergoing non-cardiac surgery. TRIAL REGISTRATION NUMBER CRD42018100883.
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Affiliation(s)
- Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia.,Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | | | - Paul J Gow
- Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia.,Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Hui-Chen Han
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - F M Amirul-Islam
- Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia
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184
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Mossanen M, Krasnow RE, Zlatev DV, Tan WS, Preston MA, Trinh QD, Kibel AS, Sonpavde G, Schrag D, Chung BI, Chang SL. Examining the relationship between complications and perioperative mortality following radical cystectomy: a population-based analysis. BJU Int 2019; 124:40-46. [DOI: 10.1111/bju.14636] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Matthew Mossanen
- Division of Urology; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
- Lank Center for Genitourinary Oncology; Dana-Farber Cancer Institute; Boston MA USA
- Center for Surgery and Public Health; Brigham and Women's Hospital; Boston MA USA
| | - Ross E. Krasnow
- Department of Urology; Georgetown University; Washington DC USA
| | - Dimitar V. Zlatev
- Division of Urology; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
| | - Wei Shen Tan
- Division of Surgery and Interventional Sciences; Department of Urology; University College London; London UK
- Department of Urology; Imperial College Healthcare; London UK
| | - Mark A. Preston
- Division of Urology; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
- Lank Center for Genitourinary Oncology; Dana-Farber Cancer Institute; Boston MA USA
| | - Quoc-Dien Trinh
- Division of Urology; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
- Lank Center for Genitourinary Oncology; Dana-Farber Cancer Institute; Boston MA USA
- Center for Surgery and Public Health; Brigham and Women's Hospital; Boston MA USA
| | - Adam S. Kibel
- Division of Urology; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
- Lank Center for Genitourinary Oncology; Dana-Farber Cancer Institute; Boston MA USA
| | - Guru Sonpavde
- Lank Center for Genitourinary Oncology; Dana-Farber Cancer Institute; Boston MA USA
| | - Deborah Schrag
- Lank Center for Genitourinary Oncology; Dana-Farber Cancer Institute; Boston MA USA
| | - Benjamin I. Chung
- Department of Urology; Stanford University Medical Center; Stanford CA USA
| | - Steven L. Chang
- Division of Urology; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
- Lank Center for Genitourinary Oncology; Dana-Farber Cancer Institute; Boston MA USA
- Department of Urology; Stanford University Medical Center; Stanford CA USA
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Sartini C, Lomivorotov V, Pisano A, Riha H, Baiardo Redaelli M, Lopez-Delgado JC, Pieri M, Hajjar L, Fominskiy E, Likhvantsev V, Cabrini L, Bradic N, Avancini D, Wang CY, Lembo R, Novikov M, Paternoster G, Gazivoda G, Alvaro G, Roasio A, Wang C, Severi L, Pasin L, Mura P, Musu M, Silvetti S, Votta CD, Belletti A, Corradi F, Brusasco C, Tamà S, Ruggeri L, Yong CY, Pasero D, Mancino G, Spadaro S, Conte M, Lobreglio R, Di Fraja D, Saporito E, D'Amico A, Sardo S, Ortalda A, Yavorovskiy A, Riefolo C, Monaco F, Bellomo R, Zangrillo A, Landoni G. A Systematic Review and International Web-Based Survey of Randomized Controlled Trials in the Perioperative and Critical Care Setting: Interventions Increasing Mortality. J Cardiothorac Vasc Anesth 2019; 33:2685-2694. [PMID: 31064730 DOI: 10.1053/j.jvca.2019.03.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings. DESIGN A systematic review of the literature followed by a consensus-based voting process. SETTING A web-based international consensus conference. PARTICIPANTS Two hundred fifty-one physicians from 46 countries. INTERVENTIONS The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines. MEASUREMENTS AND MAIN RESULTS The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed. CONCLUSION The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale.
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Affiliation(s)
- Chiara Sartini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Antonio Pisano
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | - Hynek Riha
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ludhmila Hajjar
- Instituto do Coracao do Hospital das Clinicas, Sao Paulo, Brazil
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valery Likhvantsev
- Department of Anesthesiology and Intensive Care, Sechenov First Moscow State Medical University, and Moscow Regional Clinical and Research Institute, Moscow, Russian Federation
| | - Luca Cabrini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nikola Bradic
- Department of Cardiovascular Anesthesiology and Cardiac Intensive Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Daniele Avancini
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chew Yin Wang
- Anaesthesia and Intensive Care, University of Malaya, Kuala Lumpur, Malaysia
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maxim Novikov
- Saint Petersburg State University, Saint Petersburg, Russia
| | | | - Gordana Gazivoda
- Institute of Cardiovascular Diseases "Dedinje", Belgrade, Serbia
| | | | - Agostino Roasio
- Department of Anaesthesia and Intensive Care, Ospedale Cardinal Massaia di Asti, Asti, Italy
| | - Chengbin Wang
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Luca Severi
- Anesthesia and Intensive Care, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | | | - Paolo Mura
- Department of Anesthesia and Intensive Care Unit, Policlinico Duilio Casula AOU, Cagliari, Italy
| | - Mario Musu
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Simona Silvetti
- IRCCS Istituto Giannina Gaslini, Ospedale Pediatrico, Genoa, Italy
| | - Carmine Domenico Votta
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Corradi
- E.O. Ospedali Galliera, Genova, Italy and Università degli Studi di Pisa, Italy
| | - Claudia Brusasco
- E.O. Ospedali Galliera, Genova, Italy and Università degli Studi di Pisa, Italy
| | - Simona Tamà
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chow-Yen Yong
- Anaesthesia and Intensive Care, Hospital Pulau Pinang, Georgetown, Malaysia
| | - Daniela Pasero
- Department of Anesthesia and Intensive Care, A.O.U. Cittàdella Salute e della Scienza, Turin, Italy
| | | | - Savino Spadaro
- Department Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Italy
| | | | - Rosetta Lobreglio
- Anesthesia and Intensive Care A.O.U Città della salute e della Scienza, Turin, Italy
| | - Diana Di Fraja
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | | | | | - Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, Sechenov First Moscow State Medical University, and Moscow Regional Clinical and Research Institute, Moscow, Russian Federation
| | - Claudio Riefolo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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Lalonde S, Wood GC. Short stay total joint arthroplasty program: patient factors predicting readmission. Can J Surg 2019; 62:1-7. [PMID: 30900435 PMCID: PMC6738504 DOI: 10.1503/cjs.009218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2018] [Indexed: 11/01/2022] Open
Abstract
Background The aim of this study was to evaluate the effectiveness of our short stay arthroplasty program as measured by 30-day readmission rate and the rate of transfer to inpatient care. Risk factors for readmission/transfer were also evaluated and contrasted with current patient screening criteria. Methods We retrospectively reviewed 297 charts for all primary total joint arthroplasties completed in the short stay program during an 18-month period. Data included readmission and patient characteristics such as age, sex, comorbidities, the American Society of Anesthesiologists (ASA) physical classification grade, body mass index (BMI) and the number of preoperative medications. Results The 30-day readmission rate was 2.6% (n = 8). With the inclusion of patients transferred to the inpatient hospital, the overall failure rate of our short stay program was 6.7% (n = 20). Multivariable modelling controlling for age, BMI and ASA suggested that those with an in-hospital complication were 11.4 times more likely to be readmitted or transferred to inpatient care (p < 0.001) with a trend for patients who were taking more medications (p = 0.09). Conclusion The current readmission rate from this program is comparable to previously published data in the arthroplasty literature. However, several patients required transfer to inpatient care, which significantly impacted the effectiveness of the short stay program. Risk factors for readmission/transfer are not completely accounted for by current presurgical screening criteria. Further evaluation of the Blaylock Risk Assessment Screening Score is required to determine its value for predicting hospital readmission.
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Affiliation(s)
- Sebastien Lalonde
- From the Department of Surgery, Kingston Health Sciences Centre, Queens University, Kingston, Ont
| | - Gavin C.A. Wood
- From the Department of Surgery, Kingston Health Sciences Centre, Queens University, Kingston, Ont
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187
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Luo Y, Jiang C, Krittanawong C, Arevalo Molina AB, Murray S, Huang F, Zhang J, Salgado M, Xu J. Systemic sclerosis and the risk of perioperative major adverse cardiovascular events for inpatient non-cardiac surgery. Int J Rheum Dis 2019; 22:1023-1028. [PMID: 30834657 DOI: 10.1111/1756-185x.13537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 12/31/2018] [Accepted: 02/10/2019] [Indexed: 01/03/2023]
Abstract
AIM We investigated the association between systemic sclerosis (SSc) and perioperative cardiovascular risk for inpatient non-cardiac surgical procedures. METHODS We used data from the National Inpatient Sample (NIS) for the year 2014 to identify patients undergoing inpatient non-cardiac surgery. SSc and major adverse cardiovascular events (MACE) were defined by International Classification of Diseases 9th Revision diagnosis codes. Univariate and multivariate analyses were performed. We adjusted for demographic information, socioeconomic status, cardiac comorbidities, cardiovascular risk factors and procedural category. Two models were used with different categorization strategies for surgical procedures. RESULTS A total of 8 156 379 hospitalizations for non-cardiac surgeries were included, 4385 of which had a diagnosis of SSc. Patients with SSc were older, more likely to be female and Caucasian and with higher cardiac and systemic comorbidity burden. In univariate analysis, SSc was associated with higher risk of perioperative MACE (odds ratio [OR] = 2.9; P < 0.001) and all-cause death (P = 3.07; P < 0.001). Multivariate analysis yielded conflicting results regarding the association between SSc and perioperative MACE (Model 1: OR = 1.42; P = 0.146; Model 2: OR = 1.59; P = 0.048). Subsequent analysis showed that only perioperative myocardial infarction (Model 1 OR = 1.85; P = 0.048; Model 2 OR = 1.94; P = 0.031) was independently associated with SSc. CONCLUSION We did not find consistent association between SSc and perioperative MACE in non-cardiac surgical procedures. SSc may be associated with perioperative myocardial infarction.
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Affiliation(s)
- Yiming Luo
- Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Changchuan Jiang
- Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chayakrit Krittanawong
- Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ana Belen Arevalo Molina
- Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shane Murray
- Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Feng Huang
- Department of Rheumatology and Immunology, China PLA General Hospital, Beijing, China
| | - Jianglin Zhang
- Department of Rheumatology and Immunology, China PLA General Hospital, Beijing, China
| | - Maria Salgado
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Jiehui Xu
- Mailman School of Public Health, Columbia University Medical Center, New York, New York
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188
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Impact of Approach and Hospital Volume on Cardiovascular Complications After Pulmonary Lobectomy. J Surg Res 2019; 235:202-209. [DOI: 10.1016/j.jss.2018.09.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/20/2018] [Accepted: 09/20/2018] [Indexed: 01/25/2023]
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189
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190
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Elsiwy Y, Jovanovic I, Doma K, Hazratwala K, Letson H. Risk factors associated with cardiac complication after total joint arthroplasty of the hip and knee: a systematic review. J Orthop Surg Res 2019; 14:15. [PMID: 30635012 PMCID: PMC6330438 DOI: 10.1186/s13018-018-1058-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 12/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background Cardiac complication represents a major cause of morbidity and mortality after total joint arthroplasty, thus necessitating investigation into the associated risks in total hip arthroplasty and total knee arthroplasty. There remains a lack of clarity for many risk factors in the current literature. The aim of this systematic review is to assess the most recent published literature and identify the risk factors associated with cardiac complication in total hip arthroplasty and total knee arthroplasty. Methods Scopus, PubMed, CINHAL, and Cochrane were searched to identify studies published since 2008 reporting on risk factors associated with cardiac complication in elective primary in total hip arthroplasty and total knee arthroplasty in patients ≥18 years old with osteoarthritis. Reported odds ratios, hazard ratios, and relative risk were the principal summary measures collected. The included studies were too heterogeneous to enable meta-analysis. Results Fifteen studies were included in this systematic review. Increasing age and history of cardiac disease were found by most studies to be positively associated with risk of cardiac complication. There was no strong association found between obesity and cardiac complication. The evidence for other risk factors was less clear in the examined literature, although there is suggestive evidence for male gender and cerebrovascular disease increasing risk. Conclusions Increasing age and history of cardiac disease increases the risk of cardiac complication after total hip arthroplasty and total knee arthroplasty. Other risk factors commonly attributed to increased risk in non-cardiac surgery including hypertension and obesity require further evaluation in arthroplasty. Systematic review registration A detailed protocol was published in the PROSPERO database (registration number CRD42018095887) for this systematic review. Electronic supplementary material The online version of this article (10.1186/s13018-018-1058-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yassin Elsiwy
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia.,College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| | - Ivana Jovanovic
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Kenji Doma
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia.,College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia
| | - Kaushik Hazratwala
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Hayley Letson
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia.
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191
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Goeddel LA, Hopkins AN, Fernando RJ, Núñez-Gil IJ, Ramakrishna H. Analysis of the 4th Universal Definition of Myocardial Infarction-Key Concepts and Perioperative Implications. J Cardiothorac Vasc Anesth 2019; 33:3486-3495. [PMID: 30738751 DOI: 10.1053/j.jvca.2019.01.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Indexed: 01/10/2023]
Affiliation(s)
- Lee A Goeddel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Amanda N Hopkins
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Rohesh J Fernando
- Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Iván J Núñez-Gil
- Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
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192
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Intra-operative heart rate and postoperative outcomes - rowing against the tide? Eur J Anaesthesiol 2019; 36:90-92. [PMID: 30624290 DOI: 10.1097/eja.0000000000000909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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193
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Percutaneous cholecystostomy-tube for high-risk patients with acute cholecystitis: current practice and implications for future research. Surg Endosc 2019; 33:3396-3403. [PMID: 30604258 DOI: 10.1007/s00464-018-06634-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 12/19/2018] [Indexed: 01/11/2023]
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194
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Verbree-Willemsen L, Grobben RB, van Waes JAR, Peelen LM, Nathoe HM, van Klei WA, Grobbee DE. Causes and prevention of postoperative myocardial injury. Eur J Prev Cardiol 2019; 26:59-67. [PMID: 30207484 PMCID: PMC6287250 DOI: 10.1177/2047487318798925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/14/2018] [Indexed: 01/10/2023]
Abstract
Over the past few years non-cardiac surgery has been recognised as a serious circulatory stress test which may trigger cardiovascular events such as myocardial infarction, in particular in patients at high risk. Detection of these postoperative cardiovascular events is difficult as clinical symptoms often go unnoticed. To improve detection, guidelines advise to perform routine postoperative assessment of cardiac troponin. Troponin elevation - or postoperative myocardial injury - can be caused by myocardial infarction. However, also non-coronary causes, such as cardiac arrhythmias, sepsis and pulmonary embolism, may play a role in a considerable number of patients with postoperative myocardial injury. It is crucial to acquire more knowledge about the underlying mechanisms of postoperative myocardial injury because effective prevention and treatment options are lacking. Preoperative administration of beta-blockers, aspirin, statins, clonidine, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and preoperative revascularisation have all been investigated as preventive options. Of these, only statins should be considered as the initiation or reload of statins may reduce the risk of postoperative myocardial injury. There is also not enough evidence for intraoperative measures such blood pressure optimisation or intensified medical therapy once patients have developed postoperative myocardial injury. Given the impact, better preoperative identification of patients at risk of postoperative myocardial injury, for example using preoperatively measured biomarkers, would be helpful to improve cardiac optimisation.
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Affiliation(s)
- Laura Verbree-Willemsen
- Department of Epidemiology, Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht,
Utrecht University, The Netherlands
| | - Remco B Grobben
- Department of Cardiology, University
Medical Center Utrecht, Utrecht University, The Netherlands
| | - Judith AR van Waes
- Department of Anaesthesiology,
University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Linda M Peelen
- Department of Epidemiology, Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht,
Utrecht University, The Netherlands
- Department of Anaesthesiology,
University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Hendrik M Nathoe
- Department of Cardiology, University
Medical Center Utrecht, Utrecht University, The Netherlands
| | - Wilton A van Klei
- Department of Anaesthesiology,
University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Diederick E Grobbee
- Department of Epidemiology, Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht,
Utrecht University, The Netherlands
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195
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Pappas MA, Auerbach AD. Estimating the Accuracy of Dobutamine Stress Echocardiography and Single-Photon Emission Computed Tomography among Patients Undergoing Noncardiac Surgery. J Hosp Med 2018; 13:783-786. [PMID: 30156575 DOI: 10.12788/jhm.3064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
When cardiac stress testing is ordered prior to noncardiac surgery, the optimal test modality is unknown. Therefore, we conducted this study to compare the diagnostic accuracy of dobutamine stress echocardiography (DSE) and single-photon emission computed tomography (SPECT) in a representative sample of patients undergoing noncardiac surgery without an existing diagnosis of coronary artery disease (CAD). The predicted accuracy of DSE was greater than that of SPECT in around 60.5% of cases above the current guideline-recommended risk threshold. In this population, DSE is likely to be more accurate than SPECT in the diagnosis of obstructive CAD. To the extent that making a diagnosis of obstructive CAD changes the decision to pursue noncardiac surgery, DSE likely represents a more efficient testing modality. However, in the range of pretest probabilities among this population, positive results from either test are more likely to represent false positives than true positives.
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Affiliation(s)
- Matthew A Pappas
- Cleveland Clinic, Medicine Institute, Center for Value-based Care Research, Cleveland, Ohio, USA.
- Cleveland Clinic, Medicine Institute, Department of Hospital Medicine, Cleveland, Ohio, USA
| | - Andrew D Auerbach
- University of California, San Francisco, Department of Hospital Medicine, San Francisco, California, USA
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Glance LG, Faden E, Dutton RP, Lustik SJ, Li Y, Eaton MP, Dick AW. Impact of the Choice of Risk Model for Identifying Low-risk Patients Using the 2014 American College of Cardiology/American Heart Association Perioperative Guidelines. Anesthesiology 2018; 129:889-900. [DOI: 10.1097/aln.0000000000002341] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
The 2014 American College of Cardiology Perioperative Guideline recommends risk stratifying patients scheduled to undergo noncardiac surgery using either: (1) the Revised Cardiac Index; (2) the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator; or (3) the Myocardial Infarction or Cardiac Arrest calculator. The aim of this study is to determine how often these three risk-prediction tools agree on the classification of patients as low risk (less than 1%) of major adverse cardiac event.
Methods
This is a retrospective observational study using a sample of 10,000 patient records. The risk of cardiac complications was calculated for the Revised Cardiac Index and the Myocardial Infarction or Cardiac Arrest models using published coefficients, and for the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator using the publicly available website. The authors used the intraclass correlation coefficient and kappa analysis to quantify the degree of agreement between these three risk-prediction tools.
Results
There is good agreement between the American College of Surgeons National Surgical Quality Improvement Program and Myocardial Infarction or Cardiac Arrest estimates of major adverse cardiac events (intraclass correlation coefficient = 0.68, 95% CI: 0.66 to 0.70), while only poor agreement between (1) American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator and the Revised Cardiac Index (intraclass correlation coefficient = 0.37; 95% CI: 0.34 to 0.40), and (2) Myocardial Infarction or Cardiac Arrest and Revised Cardiac Index (intraclass correlation coefficient = 0.26; 95% CI: 0.23 to 0.30). The three prediction models disagreed 29% of the time on which patients were low risk.
Conclusions
There is wide variability in the predicted risk of cardiac complications using different risk-prediction tools. Including more than one prediction tool in clinical guidelines could lead to differences in decision-making for some patients depending on which risk calculator is used.
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Affiliation(s)
- Laurent G. Glance
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Eric Faden
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Richard P. Dutton
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Stewart J. Lustik
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Yue Li
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Michael P. Eaton
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
| | - Andrew W. Dick
- From the Department of Anesthesiology (L.G.G., E.F., S.J.L., M.P.E.) and the Department of Public Health Sciences (L.G.G., Y.L.), University of Rochester School of Medicine, Rochester, New York; RAND Health, Boston, Massachusetts (L.G.G., A.W.D.); and U.S. Anesthesia Partners, Dallas, Texas (R.P.D.)
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Slagt C, Ketelaars R, Swenne M, Jan van Geffen G. Local Anesthetic Systemic Toxicity (LAST), Needs Treatment. J Emerg Med 2018; 56:107-108. [PMID: 30342862 DOI: 10.1016/j.jemermed.2018.06.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/05/2018] [Indexed: 11/20/2022]
Affiliation(s)
- Cornelis Slagt
- Department of Anaesthesia, Pain and Palliative Medicine, Radboud University Medical Center, Helicopter Emergency Medical Service, Lifeliner 3, Nijmegen, the Netherlands
| | - Rein Ketelaars
- Department of Anaesthesia, Pain and Palliative Medicine, Radboud University Medical Center, Helicopter Emergency Medical Service, Lifeliner 3, Nijmegen, the Netherlands
| | - Marlou Swenne
- Department of Anaesthesia, Pain and Palliative Medicine, Radboud University Medical Center, Helicopter Emergency Medical Service, Lifeliner 3, Nijmegen, the Netherlands
| | - Geert Jan van Geffen
- Department of Anaesthesia, Pain and Palliative Medicine, Radboud University Medical Center, Helicopter Emergency Medical Service, Lifeliner 3, Nijmegen, the Netherlands
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198
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Ferguson MT, Hofman MS, Ismail H, Melville A, Yap KSK, Hicks RJ, Wright S, Riedel B. A pilot study of cardiopulmonary exercise testing and cardiac stress positron emission tomography before major non-cardiac surgery. Anaesthesia 2018; 73:1524-1530. [PMID: 30284241 DOI: 10.1111/anae.14447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2018] [Indexed: 11/28/2022]
Abstract
Cardiac events are a common cause of peri-operative morbidity. Cardiopulmonary exercise testing can objectively assess risk, but it does not quantify myocardial ischaemia. With appropriate dietary preparation to suppress basal myocardial glucose uptake, positron emission tomography with 18 F-fluorodeoxyglucose can identify post-ischaemic myocardium, providing an attractive complement to exercise testing. We aimed to investigate the feasibility of this diagnostic algorithm. Patients referred for cardiopulmonary exercise testing before major cancer surgery were prospectively recruited. Exercise testing and positron emission tomography imaging were performed after a high fat-low carbohydrate meal. Protocol feasibility (primary end-point) included compliance with pre-test diet instructions and the completion of tests. Stress myocardial perfusion imaging was performed if either exercise testing or positron emission tomography was equivocal or positive for ischaemia. We recorded cardiac complications for 30 postoperative days. We enrolled 26 participants, 20 of whom completed protocol. Twenty-one participants proceeded to surgery: myocardial injury or infarction was diagnosed in three participants, two of whom had positive or equivocal positron emission tomography but negative myocardial perfusion imaging. We have shown that pre-operative cardiac positron emission tomography after cardiopulmonary exercise testing is feasible; protocol deviations were minor and did not affect image quality. Our findings warrant further investigation to compare the diagnostic utility of cardiac positron emission tomography imaging with standard pre-operative stress tests.
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Affiliation(s)
- M T Ferguson
- Department of Anaesthesia, Perioperative and Pain Medicine, Melbourne University, Australia
| | - M S Hofman
- Centre for Molecular Imaging, Melbourne University, Australia
| | - H Ismail
- Department of Anaesthesia, Perioperative and Pain Medicine, Melbourne University, Australia
| | - A Melville
- Department of Anaesthesia, Perioperative and Pain Medicine, Melbourne University, Australia
| | - K S K Yap
- Department of Nuclear Medicine and PET, The Alfred Hospital, Melbourne, Australia
| | - R J Hicks
- Centre for Molecular Imaging, Melbourne University, Australia
| | - S Wright
- Department of Cardiology, Peter MacCallum Cancer Centre, Melbourne University, Melbourne, Australia
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Melbourne University, Australia.,Drug Discovery Biology Theme, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
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199
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Volk ML, Sakr A, De Vera M. Cardiovascular Complications After Liver Transplant: A Shifting Clinical Presentation. Liver Transpl 2018; 24:1331-1332. [PMID: 30204937 DOI: 10.1002/lt.25324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/14/2018] [Indexed: 02/07/2023]
Affiliation(s)
| | - Antoine Sakr
- International Heart Institute, Loma Linda University Health, Loma Linda, CA
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200
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Pinto BB, Walder B. Heart rate as a predictor and a therapeutic target of cardiac ischemic complications after non-cardiac surgery. A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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