201
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Himes CP, Ganesh R, Wight EC, Simha V, Liebow M. Perioperative Evaluation and Management of Endocrine Disorders. Mayo Clin Proc 2020; 95:2760-2774. [PMID: 33168157 DOI: 10.1016/j.mayocp.2020.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 05/02/2020] [Accepted: 05/12/2020] [Indexed: 12/25/2022]
Abstract
Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and hypothalamic-pituitary-adrenal axis suppression are commonly encountered in the surgical setting and require unique consideration to optimize perioperative risk. For patients with diabetes, perioperative glycemic control has the strongest association with postsurgical outcomes. The preoperative evaluation should include recommendations for adjustment of insulin and noninsulin diabetic medications before surgery. Recommendations differ based on the type of diabetes, the type of insulin, and the patient's predisposition to hyperglycemia or hypoglycemia. Generally, patients with thyroid dysfunction can safely undergo operations unless they have untreated hyperthyroidism or severe hypothyroidism. Patients with known primary or secondary adrenal insufficiency require supplemental glucocorticoids to prevent adrenal crisis in the perioperative setting. Evidence supporting the use of high-dose supplemental corticosteroids for patients undergoing long-term glucocorticoid therapy is sparse. We discuss an approach to these patients based on the dose and duration of ongoing or recent corticosteroid therapy. As with other components of the preoperative medical evaluation, the primary objective is identification and assessment of the severity of endocrine issues before surgery so that the surgeons, anesthesiologists, and internal medicine professionals can optimize management accordingly.
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Affiliation(s)
- Carina P Himes
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Vinaya Simha
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Mark Liebow
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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202
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[Approaches to the pre-operative functional assessment of patients with lung cancer and preoperative rehabilitation]. Rev Mal Respir 2020; 37:800-810. [PMID: 33199069 DOI: 10.1016/j.rmr.2020.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/08/2020] [Indexed: 12/25/2022]
Abstract
Surgery is the best treatment for early lung cancer but requires a preoperative functional evaluation to identify patients who may be at a high risk of complications or death. Guideline algorithms include a cardiological evaluation, a cardiopulmonary assessment to calculate the predicted residual lung function, and identify patients needing exercise testing to complete the evaluation. According to most expert opinion, exercise tests have a very high predictive value of complications. However, since the publication of these guidelines, minimally-invasive surgery, sublobar resections, prehabilitation and enhanced recovery after surgery (ERAS) programmes have been developed. Implementation of these techniques and programs is associated with a decrease in postoperative mortality and complications. In addition, the current guidelines and the cut-off values they identified are based on early series of patients, and are designed to select patients before major lung resection (lobectomy-pneumonectomy) performed by thoracotomy. Therefore, after a review of the current guidelines and a brief update on prehabilitation (smoking cessation, exercise training and nutritional aspects), we will discuss the need to redefine functional criteria to select patients who will benefit from lung surgery.
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203
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Hanley C, Donahoe L, Slinger P. "Fit for Surgery? What's New in Preoperative Assessment of the High-Risk Patient Undergoing Pulmonary Resection". J Cardiothorac Vasc Anesth 2020; 35:3760-3773. [PMID: 33454169 DOI: 10.1053/j.jvca.2020.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 12/21/2022]
Abstract
Advances in perioperative assessment and diagnostics, together with developments in anesthetic and surgical techniques, have considerably expanded the pool of patients who may be suitable for pulmonary resection. Thoracic surgical patients frequently are perceived to be at high perioperative risk due to advanced age, level of comorbidity, and the risks associated with pulmonary resection, which predispose them to a significantly increased risk of perioperative complications, increased healthcare resource use, and costs. The definition of what is considered "fit for surgery" in thoracic surgery continually is being challenged. However, no internationally standardized definition of prohibitive risk exists. Perioperative assessment traditionally concentrates on the "three-legged stool" of pulmonary mechanical function, parenchymal function, and cardiopulmonary reserve. However, no single criterion should exclude a patient from surgery, and there are other perioperative factors in addition to the tripartite assessment that need to be considered in order to more accurately assess functional capacity and predict individual perioperative risk. In this review, the authors aim to address some of the more erudite concepts that are important in preoperative risk assessment of the patient at potentially prohibitive risk undergoing pulmonary resection for malignancy.
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Affiliation(s)
- Ciara Hanley
- Department of Anesthesia and Pain Management, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Laura Donahoe
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Peter Slinger
- Department of Anesthesia and Pain Management, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
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204
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Elsiwy Y, Symonds T, Doma K, Hazratwala K, Wilkinson M, Letson H. Pre-operative clinical predictors for cardiology referral prior to total joint arthroplasty: the 'asymptomatic' patient. J Orthop Surg Res 2020; 15:513. [PMID: 33168074 PMCID: PMC7654604 DOI: 10.1186/s13018-020-02042-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/28/2020] [Indexed: 11/16/2022] Open
Abstract
Background No validated pre-operative cardiac risk stratification tool exists that is specific for total hip and total knee arthroplasty (THA and TKA, respectively). To reduce the risk of post-operative cardiac complication, surgeons need clear guidance on which patients are likely to benefit from pre-operative cardiac optimisation. This is particularly important for asymptomatic patients, where the need is harder to determine. Methods Primary THA and TKA performed between January 1, 2010, and December 31, 2017, were identified from a single orthopaedic practice. Over 25 risk factors were evaluated as predictors for patients requiring additional cardiac investigation beyond an ECG and echocardiogram, and for cardiac abnormality detected upon additional investigation. A multivariate logistic regression was conducted using significant predictor variables identified from inferential statistics. A series of predictive scores were constructed and weighted to identify the influence of each variable on the ability to predict the detection of cardiac abnormality pre-operatively. Results Three hundred seventy-four patients were eligible for inclusion. Increasing age (p < 0.001), history of cerebrovascular accident (p = 0.018), family history of cardiovascular disease (FHx of CVD) (p < 0.001) and decreased ejection fraction (EF) (p < 0.001) were significant predictors of additional cardiac investigation being required. Increasing age (p = 0.003), male gender (p = 0.042), FHx of CVD (p = 0.001) and a reduced EF (p < 0.001) were significantly predictive for the detection of cardiac abnormality upon additional cardiac investigation. Conclusions Increasing age, male gender, FHx of CVD and decreased ejection fraction are important risk factors to consider for pre-operative cardiac optimisation in THA and TKA patients. These findings can be applied towards future predictive models, to determine which asymptomatic patients are likely to benefit from pre-operative cardiac referral.
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Affiliation(s)
- Yassin Elsiwy
- College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia.,Orthopaedic Research Institute of Queensland, 7 Turner Street, Townsville, QLD, 4812, Australia
| | - Tristan Symonds
- Orthopaedic Research Institute of Queensland, 7 Turner Street, Townsville, QLD, 4812, Australia
| | - Kenji Doma
- Orthopaedic Research Institute of Queensland, 7 Turner Street, Townsville, QLD, 4812, Australia.,College of Healthcare Sciences, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia
| | - Kaushik Hazratwala
- College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia.,Orthopaedic Research Institute of Queensland, 7 Turner Street, Townsville, QLD, 4812, Australia
| | - Matthew Wilkinson
- Orthopaedic Research Institute of Queensland, 7 Turner Street, Townsville, QLD, 4812, Australia.,School of Medicine, University of Tasmania, Medical Science Precinct, 17 Liverpool Street, Hobart, TAS, 7000, Australia
| | - Hayley Letson
- College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia.
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205
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Wang G, Yu Z, Zhang C, Zang H, Monti L, Jeong JY, Schmid RA, Pilegaard HK, Liu H. Pectus excavatum requiring temporary pacemaker implantation before Nuss procedure: a case report. J Thorac Dis 2020; 12:4985-4990. [PMID: 33145072 PMCID: PMC7578454 DOI: 10.21037/jtd-20-2312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Pectus excavatum is the most common chest wall deformity, and some patients also have it combined with cardiac arrhythmias. It is a rare occurrence for there to be a severe conduction block that requires a temporary pacemaker implantation before the surgical correction. Here we reported a case of pectus excavatum with a second-degree atrial-ventricular (AV) block (Mobitz II) who had temporary pacemaker implantation before the Nuss procedure. The young patient had a chest wall deformity for 6 years and it got worse with age. The Haller index was 4.21, and we evaluated that he should receive the Nuss procedure. An AV block was found during the preoperative electrocardiogram examination; furthermore, Holter monitor proved that he had first-degree AV block and a second-degree AV block (Mobitz II). After consultation with the anesthesiologist and cardiologist, we suggested that a temporary pacemaker placement should be performed under local anesthesia before the minimally invasive operation and removed as soon as the patient revived from general anesthesia. A postoperative Holter monitor was implemented, and the conduction defect disappeared shortly after the operation. However, the Holter monitor showed that the conduction defect was still existed during the follow-up period, which indicated that severe conduction defects should be originated from the conduction system itself, rather than the compression to the heart. The temporary pacemaker was essential to ensure the conducting of the operation went smoothly.
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Affiliation(s)
- Gebang Wang
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Zhanwu Yu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Chenlei Zhang
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Hongyun Zang
- Department of Cardiology, Air Force Hospital of North Military Command PLA, Shenyang, China
| | - Lorenzo Monti
- Radiology Department, Humanitas Research Hospital, Milan, Italy
| | - Jin Yong Jeong
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ralph A Schmid
- Division of General Thoracic Surgery, University Hospital Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Hans K Pilegaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hongxu Liu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
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206
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Charloux A, Matau C, Jégu J, Rouyer O, Falcoz PE, Quoix E. Should we screen patients for carotid artery disease before lung cancer resection? J Thorac Dis 2020; 12:6743-6751. [PMID: 33282375 PMCID: PMC7711380 DOI: 10.21037/jtd-20-1117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Postoperative stroke is a rare complication after lung cancer surgery but has a high mortality rate. No strategy has been recommended to detect carotid artery disease preoperatively in lung cancer patients. The main objective of this study was to evaluate whether a routine carotid duplex ultrasound (DUS) altered the preoperative management of these patients. Methods We performed a single-centre, retrospective study of all patients referred for lung cancer resection over a two-year period and reviewed the available carotid DUS results. We quantified the number of carotid artery disease diagnosis, the severity of the disease according to DUS results, and the number of treatments initiated preoperatively. We examined relationships between cardiovascular history and preoperative carotid artery disease diagnosis. Results Among the 398 consecutive lung surgery patients, 6% had a preoperative history of stroke or transient ischemic attack, and one developed a postoperative stroke, of cardioembolic origin. Three hundred and seven patients (77%) had preoperative carotid DUS. Carotid DUS results elicited anti-platelet therapy initiation or endarterectomy before lung resection in 7 out of these 307 patients (2.3%). One hundred and seventy-one carotid DUS were retrospectively reviewed by an expert, who diagnosed carotid stenosis >50% and occlusion in 2.3% and 1.2% of patients, respectively. Abnormal carotid DUS was associated with history of lower extremity artery disease (P<0.001), diabetes mellitus (P<0.05) and dyslipidemia (P<0.05). Conclusions This retrospective observational study showed that routine preoperative carotid DUS led to few carotid stenosis detection and few perioperative management alterations. Carotid artery disease diagnosis was associated with cardiovascular history and risk factors. Future studies should examine how to select patients who will benefit from a preoperative carotid DUS.
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Affiliation(s)
- Anne Charloux
- Department of Physiology and Lung Function Testing, University Hospital of Strasbourg, Strasbourg, France.,EA 3072, FMTS, Strasbourg University, Strasbourg, France
| | - Cézar Matau
- Department of Pulmonology, University Hospital of Strasbourg, Strasbourg, France
| | - Jérémie Jégu
- Department of Public Health, University Hospital of Strasbourg, Strasbourg, France.,UMR-S1113, FMTS, Strasbourg University, Strasbourg, France
| | - Olivier Rouyer
- Department of Physiology and Lung Function Testing, University Hospital of Strasbourg, Strasbourg, France
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207
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Tempe DK, Neema PK. The Challenges of Implementing the Clinical Data Standards. J Cardiothorac Vasc Anesth 2020; 34:2881-2883. [DOI: 10.1053/j.jvca.2020.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/25/2020] [Indexed: 11/11/2022]
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208
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Head-to-head comparison of prognostic accuracy in patients undergoing noncardiac surgery of dobutamine stress echocardiography versus computed tomography coronary angiography (PANDA trial): A prospective observational study. J Cardiovasc Comput Tomogr 2020; 14:471-477. [DOI: 10.1016/j.jcct.2020.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/20/2020] [Accepted: 02/03/2020] [Indexed: 12/26/2022]
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209
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Yu J, Lim B, Lee Y, Park JY, Hong B, Hwang JH, Kim YK. Risk factors and outcomes of myocardial injury after non-cardiac surgery in high-risk patients who underwent radical cystectomy. Medicine (Baltimore) 2020; 99:e22893. [PMID: 33120837 PMCID: PMC7581156 DOI: 10.1097/md.0000000000022893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Radical cystectomy is considered the standard treatment for patients with muscle-invasive bladder tumors and has high postoperative complication rates among urological surgeries. High-risk patients, defined as those ≥45 years of age with history of coronary artery disease, stroke, or peripheral artery disease or those ≥65 years of age, can have a higher incidence of cardiac complications. Therefore, we evaluated the incidence, risk factors, and outcomes of myocardial injury after non-cardiac surgery (MINS) in high-risk patients who underwent radical cystectomy.This retrospective observational study analyzed 248 high-risk patients who underwent radical cystectomy. MINS was defined as serum troponin I concentration ≥0.04 mg/L within postoperative 3 days. The risk factors for MINS were evaluated by multivariate logistic regression analysis. Postoperative outcomes were evaluated. The 1-year survival after radical cystectomy was also compared between patients who developed MINS (MINS group) and those who did not (non-MINS group) by Kaplan-Meier analysis.MINS occurred in 35 patients (14.1%). Multivariate logistic regression analysis showed that early diastolic transmitral filling velocity (E)/early diastolic septal mitral annular velocity (E') ratio (odds ratio = 1.102, 95% confidence interval [1.009-1.203], P = .031) and large volume blood transfusion (odds ratio = 2.745, 95% confidence interval [1.131-6.664], P = .026) were significantly associated with MINS in high-risk patients who underwent radical cystectomy. Major adverse cardiac events and 1-year mortality were significantly higher in the MINS group than in the non-MINS group (17.1% vs 6.1%, P = .035; 28.6% vs 12.7%, P = .021, respectively). Kaplan-Meier analysis showed significantly lower 1-year survival in the MINS group than in the non-MINS group (P = .010).MINS occurred in 14.1% of patients. High E/E' ratio and large volume blood transfusion were risk factors for MINS in high-risk patients who underwent radical cystectomy. Postoperative major adverse cardiac events and 1-year mortality were significantly higher in the MINS group than in the non-MINS group. Preoperative evaluation of risk factors for MINS may provide useful information to detect cardiovascular complications after radical cystectomy in high-risk patients.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine
| | - Bumjin Lim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yongsoo Lee
- Department of Anesthesiology and Pain Medicine
| | | | - Bumsik Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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210
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Petrakova ES, Savina NM, Molochkov AV. [Atrial Fibrillation After Coronary Artery Bypass Surgery: Risk Factors, Prevention and Treatment]. ACTA ACUST UNITED AC 2020; 60:134-148. [PMID: 33131484 DOI: 10.18087/cardio.2020.9.n1074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/29/2020] [Indexed: 11/18/2022]
Abstract
This review focuses on the issue of atrial fibrillation (AF) following coronary bypass surgery in patients with ischemic heart disease. Risk factors of this complication are discussed in detail. The authors addressed the effect of diabetes mellitus on development of postoperative AF. Data on current methods for prevention and treatment of AF are provided.
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Affiliation(s)
- E S Petrakova
- Central Clinical Hospital with Out-patient Clinic of the Department of Affairs of the President of the Russian Federation, Moscow
| | - N M Savina
- Central State Medical Academy of Department of Presidential Affairs, Moscow
| | - A V Molochkov
- Central Clinical Hospital with Out-patient Clinic of the Department of Affairs of the President of the Russian Federation, Moscow
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211
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Preoperative cardiac screening using NT-proBNP in obese patients 50 years and older undergoing bariatric surgery: a study of 310 consecutive patients. Surg Obes Relat Dis 2020; 17:64-71. [PMID: 33036941 PMCID: PMC7467016 DOI: 10.1016/j.soard.2020.08.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/14/2020] [Accepted: 08/24/2020] [Indexed: 12/28/2022]
Abstract
Background Obesity is associated with cardiovascular (CV) risk factors and diseases. Because bariatric surgery is increasingly performed in relatively elderly patients, a risk for pre- and postoperative CV complications exists. Objectives We aimed to assess the value of plasma N-terminal-probrain natriuretic peptide (NT-proBNP) as a CV screening tool. Setting High-volume bariatric center. Methods Between June 2019 and January 2020, all consecutive bariatric patients 50 years and older underwent preoperative NT-proBNP assessment in this cohort study to screen for CV disease. Patients with elevated NT-proBNP (≥125 pg/mL) were referred for further cardiac evaluation, including electrocardiography and echocardiography. Results We included 310 consecutive patients (median age, 56 years; 79% female; body mass index = 43±6.5 kg/m2). A history of CV disease was present in 21% of patients, mainly atrial fibrillation (7%) and coronary artery disease (10%). A total of 72 patients (23%) had elevated NT-proBNP levels, and 67 of them underwent further cardiac workup. Of these 67 patients, electrocardiography (ECG) showed atrial fibrillation in 7 patients (10%). On echocardiography, 3 patients had left ventricular ejection fraction (LVEF) <40%, 9 patients had LVEF 40%–49%, and 13 patients had LVEF ≥50% with structural and/or functional remodeling. In 2 patients, elevated NT-proBNP prompted workup leading to a diagnosis of coronary artery disease and consequent percutaneous coronary intervention in 1 patient. Conclusions Elevated NT-proBNP levels are present in 23% of patients 50 years and older undergoing bariatric surgery. In 37% of them, there was echocardiographic evidence for structural and/or functional remodeling. Further studies are needed to assess if these preliminary results warrant routine application of NT-proBNP to identify patients at risk for CV complications after bariatric surgery. This study assessed NT-proBNP as a cardiac screening tool in bariatric patients. Elevated NT-proBNP levels were present in 23% of patients ≥50 years. In 37% of them (n=25), echocardiography showed LV dysfunction or heart failure. NT-proBNP is a non-invasive tool that can detect new CV diseases in bariatric patients
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212
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Sharma S, Sonny A, Dalia AA, Karamchandani K. Acute heart failure after liver transplantation: A narrative review. Clin Transplant 2020; 34:e14079. [PMID: 32941661 DOI: 10.1111/ctr.14079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/06/2020] [Accepted: 08/27/2020] [Indexed: 11/27/2022]
Abstract
Acute heart failure (AHF) is an under recognized yet potentially lethal complication after liver transplantation (LT) surgery. The increase in incidence of liver transplantation amongst high-risk patients and the leniency in the criteria for transplantation, predisposes these patients to postoperative AHF and the antecedent morbidity and mortality. The inability of conventional preoperative cardiovascular testing to accurately identify patients at risk for post-LT AHF poses a considerable challenge to clinicians caring for these patients. Even if high-risk patients are identified, there is considerable ambiguity in the candidacy for transplantation as well as optimization strategies that could potentially prevent the development of AHF in the postoperative period. The intraoperative and postoperative management of patients who develop AHF is also challenging and requires a well-coordinated multidisciplinary approach. The use of mechanical circulatory support in patients with refractory heart failure has the potential to improve outcomes but its use in this complex patient population can be associated with significant complications and requires a stringent risk-benefit analysis on a case-by-case basis.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
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213
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Chang H, Rockman CB, Jacobowitz GR, Ramkhelawon B, Cayne NS, Veith FJ, Patel VI, Garg K. Contemporary outcomes of endovascular abdominal aortic aneurysm repair in patients deemed unfit for open surgical repair. J Vasc Surg 2020; 73:1583-1592.e2. [PMID: 33035595 DOI: 10.1016/j.jvs.2020.08.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/22/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Endovascular abdominal aortic aneurysm repair (EVAR) has been preferred to open surgical repair (OSR) for the treatment of abdominal aortic aneurysms (AAAs) in high-risk patients. We compared the perioperative and long-term outcomes of EVAR for patients designated as unfit for OSR using a large national dataset. METHODS The Vascular Quality Initiative database was queried for patients who had undergone elective EVAR for AAAs >5 cm from 2013 to 2019. The patients were stratified into two cohorts according to their suitability for OSR (fit vs unfit). The primary outcomes included perioperative (in-hospital) major adverse events, perioperative mortality, and mortality at 1 and 5 years. Patient demographics and postoperative outcomes were analyzed to identify the predictors of perioperative and long-term mortality. RESULTS Of 16,183 EVARs, 1782 patients had been deemed unfit for OSR. The unfit cohort was more likely to be older and female, with a greater proportion of hypertension, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and larger aneurysm diameters. Postoperatively, the unfit cohort was more likely to have experienced cardiopulmonary complications (6.5% vs 3%; P < .001), with greater perioperative mortality (1.7% vs 0.6%; P < .001) and 1- and 5-year mortality (13% and 29% for the unfit vs 5% and 14% for the fit cohorts, respectively; P < .001). A subgroup analysis of the unfit cohort revealed that those deemed unfit because of a hostile abdomen had significantly lower 1- and 5-year mortality (6% and 20%, respectively) compared with those considered unfit because of cardiopulmonary compromise and frailty (14% and 30%, respectively; P = .451). Reintervention-free survival at 1 and 5 years was significantly greater in the fit cohort (93% and 82%, respectively) compared with that for the unfit cohort (85% and 68%, respectively; P < .001). The designation as unfit for OSR was an independent predictor of both perioperative (odds ratio, 1.59; 95% confidence interval [CI], 1.03-2.46; P = .038) and long-term mortality (hazard ratio [HR], 1.92; 95% CI, 1.69-2.17; P < .001). Advanced age (odds ratio, 2.91; 95% CI, 1.28-6.66; P = .011) was the strongest determinant of perioperative mortality, and end-stage renal disease (HR, 2.51; 95% CI, 1.78-3.55; P < .001) was the strongest predictor of long-term mortality. Statin use (HR, 0.77; 95% CI, 0.69-0.87; P < .001) and angiotensin-converting enzyme inhibitor use (HR, 0.83; 95% CI, 0.75-0.93; P < .001) were protective of long-term mortality. CONCLUSIONS Despite low perioperative mortality, the long-term mortality of those designated by operating surgeons as unfit for OSR was rather high for patients undergoing elective EVAR, likely owing to the competing risk of death from medical frailty. An unfit designation because of a hostile abdomen did not confer any additional risks after EVAR. Judicious estimation of the patient's life expectancy is essential when considering the treatment options for this subset of patients deemed unfit for OSR.
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Affiliation(s)
- Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Bhama Ramkhelawon
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY.
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214
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Newman KL, Johnson KM, Cornia PB, Wu P, Itani K, Ioannou GN. Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions. Clin Gastroenterol Hepatol 2020; 18:2398-2414.e3. [PMID: 31376494 PMCID: PMC6994232 DOI: 10.1016/j.cgh.2019.07.051] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures. METHODS We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review. RESULTS Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP class A, or MELD <10) have minimal increase in operative mortality. CTP class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate. CONCLUSIONS Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management that warrant further investigation.
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Affiliation(s)
- Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, Washington.
| | - Kay M Johnson
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Paul B Cornia
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Kamal Itani
- Boston VA Health Care System and Boston University, Boston, Massachusetts
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington; Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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215
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Rishel CA, Zhang Y, Sun EC. Association Between Preoperative Benzodiazepine Use and Postoperative Opioid Use and Health Care Costs. JAMA Netw Open 2020; 3:e2018761. [PMID: 33107919 PMCID: PMC7592026 DOI: 10.1001/jamanetworkopen.2020.18761] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE The association between preoperative benzodiazepine use and long-term postoperative outcomes is not well understood. OBJECTIVE To characterize the association between preoperative benzodiazepine use and postoperative opioid use and health care costs. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, retrospective analysis of private health insurance claims data on 946 561 opioid-naive patients (no opioid prescriptions filled in the year before surgery) throughout the US was conducted. Patients underwent 1 of 11 common surgical procedures between January 1, 2004, and December 31, 2016; data analysis was performed January 9, 2020. EXPOSURES Benzodiazepine use, defined as long term (≥10 prescriptions filled or ≥120 days supplied in the year before surgery) or intermittent (any use not meeting the criteria for long term). MAIN OUTCOMES AND MEASURES The primary outcome was opioid use 91 to 365 days after surgery. Secondary outcomes included opioid use 0 to 90 days after surgery and health care costs 0 to 30 days after surgery. RESULTS In this sample of 946 561 patients, the mean age was 59.8 years (range, 18-89 years); 615 065 were women (65.0%). Of these, 23 484 patients (2.5%) met the criteria for long-term preoperative benzodiazepine use and 47 669 patients (5.0%) met the criteria for intermittent use. After adjusting for confounders, long-term (odds ratio [OR], 1.59; 95% CI, 1.54-1.65; P < .001) and intermittent (OR, 1.47; 95% CI, 1.44-1.51; P < .001) benzodiazepine use were associated with an increased probability of any opioid use during postoperative days 91 to 365. For patients who used opioids in postoperative days 91 to 365, long-term benzodiazepine use was associated with a 44% increase in opioid dose (additional 0.6 mean daily morphine milligram equivalents [MMEs]; 95% CI, 0.3-0.8 MMEs; P < .001), although intermittent benzodiazepine use was not significantly different (0.0 average daily MMEs; 95% CI, -0.2 to 0.2 MMEs; P = .65). Preoperative benzodiazepine use was also associated with increased opioid use in postoperative days 0 to 90 for both long-term (32% increase, additional 1.9 average daily MMEs; 95% CI, 1.6-2.1 MMEs; P < .001) and intermittent (9% increase, additional 0.5 average daily MMEs; 95% CI, 0.4-0.6 MMEs; P < .001) users. Intermittent benzodiazepine use was associated with an increase in 30-day health care costs ($1155; 95% CI, $938-$1372; P < .001), while no significant difference was observed for long-term benzodiazepine use. CONCLUSIONS AND RELEVANCE The findings of this study suggest that, among opioid-naive patients, preoperative benzodiazepine use may be associated with an increased risk of developing long-term opioid use and increased opioid dosages postoperatively, and also may be associated with increased health care costs.
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Affiliation(s)
- Chris A. Rishel
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Yuting Zhang
- Melbourne Institute: Applied Economic & Social Research, Faculty of Business & Economics, University of Melbourne, Melbourne, Victoria, Australia
| | - Eric C. Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
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216
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Shannon AH, de Grijs DP, Goudreau BJ, Mehaffey JH, Cullen JM, Williams C, Robinson WP. Impact of the Timing of Foot Tissue Resection on Outcomes in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia. Angiology 2020; 72:159-165. [PMID: 32945173 DOI: 10.1177/0003319720958554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study is to describe utilization of revascularization and tissue resection in patients with chronic limb-threatening ischemia (CLTI) and determine whether the timing of resection impacts outcomes. Revascularizations for CLTI were queried (ACS-NSQIP 2011-2015). Outcomes included 30-day major adverse limb events (MALE), major adverse cardiac events (MACE), length of stay (LOS), operative time, 30-day readmissions, and wound infections. Groups included revascularization alone, revascularization/tissue resection during the same procedure (concurrent), or revascularization/delayed tissue resection (delayed). Resections were debridement or transmetatarsal amputations. Multivariate logistic regression determined risk-adjusted effects of tissue resection on outcomes. There was no difference in overall 30-day MACE or MALE between groups (P = .70 and P = .35, respectively). Length of stay (6.1 days revascularization alone vs 7.8 days concurrent vs 8.7 days delayed, P < .0001) was longer in patients who underwent any tissue resection. Highest 30-day readmission and operative time was the concurrent group (P = .02 and P < .0001, respectively). Wound infection was highest in the delayed group (1.4% revascularization alone vs 1.3% concurrent vs 6.2% delayed, P < .0001). After risk adjustment, timing of resection did not impact LOS for concurrent and delayed groups compared to revascularization alone (both P < .0001). Debridement and minor amputations can be done concurrently in patients undergoing revascularization for CLTI.
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Affiliation(s)
- Alexander H Shannon
- Department of Surgery, 12350University of Virginia, Charlottesville, VA, USA
| | - Derek P de Grijs
- Division of Vascular and Endovascular Surgery, 12350University of Virginia, Charlottesville, VA, USA
| | | | - J Hunter Mehaffey
- Department of Surgery, 12350University of Virginia, Charlottesville, VA, USA
| | - J Michael Cullen
- Department of Surgery, 12350University of Virginia, Charlottesville, VA, USA
| | - Carlin Williams
- Division of Vascular and Endovascular Surgery, 12350University of Virginia, Charlottesville, VA, USA
| | - William P Robinson
- Division of Vascular Surgery, East Carolina University, Greenville, NC, USA
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217
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Cheong Y, Kim N, Kim M, Son HJ, Huh J, Kang SS, Lim SY, Hwang B. Postoperative pulmonary edema following vitrectomy in patients with ischemic heart disease and diastolic dysfunction in the post-anesthetic care unit: Two case reports. Medicine (Baltimore) 2020; 99:e22296. [PMID: 32957388 PMCID: PMC7505381 DOI: 10.1097/md.0000000000022296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE The increasing incidence of cardiac comorbidities in the elderly population has led to an increasing demand for vigilance of cardiac dysfunction induced by surgery. Favorable outcomes can be ensured in such cases by an increased awareness of cardiogenic complications, early identification of the problem, and appropriate treatment. PATIENT CONCERNS This study presents 2 cases of acute pulmonary edema (PE) that were likely caused by ischemic heart disease and diastolic dysfunction in postoperative patients, following vitrectomy, in the post-anesthetic care unit. DIAGNOSES Chest x-ray and computed tomography indicated PE. INTERVENTIONS Following the diagnosis of PE, patients were intubated and transferred to the intensive care unit where 20 mg furosemide was injected and 10 μg/kg/min dobutamine was infused intravenously. OUTCOMES On postoperative day 2, the patients' vital signs were stable and there were no signs of respiratory disturbance. LESSONS Physicians should be alert to the potential development of PE as a postoperative complication in patients with left ventricular (LV) diastolic dysfunction and ischemic heart disease, even if the patient has undergone a procedure with mild hemodynamic change and minimal surgical stimulation such as vitrectomy. We propose that physicians treating elderly patients with LV diastolic dysfunction and ischemic heart disease undergoing vitrectomy should consider the use of intraoperative transthoracic echocardiogram or transesophageal echocardiogram with continuous monitoring of blood pressure, using devices such as arterial catheter devices.
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Affiliation(s)
- Yuseon Cheong
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, School of Medicine, Kangwon National University
| | - Namyoong Kim
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, School of Medicine, Kangwon National University
| | - Minsoo Kim
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, School of Medicine, Kangwon National University
| | - Hee-Jeong Son
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, School of Medicine, Kangwon National University
| | - Jin Huh
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, School of Medicine, Kangwon National University
| | - Seong-Sik Kang
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, School of Medicine, Kangwon National University
| | - So Young Lim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
| | - Byeongmun Hwang
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, School of Medicine, Kangwon National University
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218
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Hughes DL, Rice JD, Burton JR, Jin Y, Peterson RA, Ambardekar AV, Pomposelli JJ, Pomfret EA, Kriss MS. Presence of any degree of coronary artery disease among liver transplant candidates is associated with increased rate of post-transplant major adverse cardiac events. Clin Transplant 2020; 34:e14077. [PMID: 32939833 DOI: 10.1111/ctr.14077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/24/2020] [Accepted: 08/22/2020] [Indexed: 01/14/2023]
Abstract
The impact of coronary artery disease (CAD) among liver transplant candidates (LTC) on post-LT clinical outcomes remains unclear. The aim of this study is to determine association of presence and severity of CAD on post-LT major adverse cardiac events (MACE) including cardiac-associated mortality. We conducted a retrospective cohort analysis of 231 patients who underwent diagnostic coronary angiogram (DCA) during their LT evaluation at a tertiary medical center from 2012-2017. Patients were analyzed based on degree of CAD (no CAD, non-obstructive CAD [< 50% stenosis], obstructive CAD [≥50% stenosis]) per DCA results. MACE were noted at 30 days, 1 year, 3 years, and 5 years post-LT, and Kaplan-Meier curves were used to determine post-LT MACE-free probability. LTC with any CAD, including non-obstructive CAD, had lower MACE-free probability at all post-LT time points (0.94 vs 0.65 at 30 days, P = .001; 0.87 vs 0.59 at 1 year, P = .002; 0.87 vs 0.41 at 3 years, P < .001; 0.87 vs 0.37 at 5 years, P < .001). Identification of and medical intervention for non-obstructive CAD should be considered in all LTC, though further studies are necessary to determine optimal medical interventions to mitigate MACE risk in this cohort.
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Affiliation(s)
- Dempsey L Hughes
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jonathan D Rice
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - James R Burton
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ying Jin
- Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan A Peterson
- Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amrut V Ambardekar
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - James J Pomposelli
- Division of Transplant Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth A Pomfret
- Division of Transplant Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael S Kriss
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
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219
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Komori K, Kano K, Aoyama T, Hashimoto I, Hara K, Murakawa M, Atsumi Y, Maezawa Y, Kazama K, Numata M, Tamagawa H, Yukawa N, Oshima T, Masuda M, Rino Y. The Short- and Long-term Outcomes of Gastrectomy in Elderly Patients With Gastric Cancer. In Vivo 2020; 34:2697-2703. [PMID: 32871802 DOI: 10.21873/invivo.12090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/26/2020] [Accepted: 04/29/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND The short- and long-term outcomes of gastrectomy in elderly patients with gastric cancer have not been fully evaluated. PATIENTS AND METHODS Patients who underwent gastrectomy were classified into two groups: Non-elderly patients (<80 years old) and elderly patients (≥80 years old). The surgical morbidity, overall and cancer-specific survival in the two groups were compared. RESULTS A total of 411 patients were evaluated. The rate of overall complication was 29.4% in the non-elderly and 32.4% in the elderly (p=0.699). In the elderly, the overall and cancer-specific survival rates at 5 years after surgery were inferior to those of the younger group (59.8% vs. 66.7%, p=0.103 and 67.9% vs. 78.2%, p=0.028, respectively). CONCLUSION The short-term outcomes after gastrectomy were almost equal for the two groups in the present study. The prognosis was poor in elderly patients, especially those with advanced gastric cancer.
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Affiliation(s)
- Keisuke Komori
- Department of Surgery, Yokohama City University, Yokohama, Japan.,Department of Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Kazuki Kano
- Department of Surgery, Yokohama City University, Yokohama, Japan.,Department of Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Toru Aoyama
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Itaru Hashimoto
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Kentaro Hara
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Masaaki Murakawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yosuke Atsumi
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yukio Maezawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Keisuke Kazama
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Masakatsu Numata
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Hiroshi Tamagawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Norio Yukawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Takashi Oshima
- Department of Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Munetaka Masuda
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University, Yokohama, Japan
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220
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Smit M, Coetzee A, Lochner A. The Pathophysiology of Myocardial Ischemia and Perioperative Myocardial Infarction. J Cardiothorac Vasc Anesth 2020; 34:2501-2512. [DOI: 10.1053/j.jvca.2019.10.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/10/2019] [Accepted: 10/02/2019] [Indexed: 12/28/2022]
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221
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Stenberg Y, Lindelöf L, Hultin M, Myrberg T. Pre-operative transthoracic echocardiography in ambulatory surgery-A cross-sectional study. Acta Anaesthesiol Scand 2020; 64:1055-1062. [PMID: 32407540 DOI: 10.1111/aas.13620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiac disease and aberrations in central volume status are risk factors for perioperative complications, and should be identified prior to surgery. This study investigated the benefit of transthoracic echocardiography (TTE) for pre-operative identification of cardiac disease and hypovolemia in ambulatory surgery. METHODS Ninety-six patients, with a mean age of 63.5 ± 12.2 years and body mass index of 27.0 ± 4.3 kg/m2 , scheduled for ambulatory surgery (breast, thyroid, and minor gastrointestinal), were consecutively enrolled in this prospective observational study. Pre-operative comprehensive TTE was performed in order to assess heart failure (HF), asymptomatic left ventricular dysfunction, valvular disease, and aberrations in central volume status. RESULTS Pre-operative TTE identified a total of 28 cases of HF, 13 cases of HF with reduced or moderately reduced, ejection fraction (EF), and 15 cases of HF with preserved EF. Furthermore, 46 cases of asymptomatic left ventricular (LV) dysfunction were identified. 44/96 patients were hypovolemic, 16 of whom in severe hypovolemia. Seven cases of previously unknown obstructive valvular or myocardial disease and six cases of right ventricular systolic dysfunction were identified. A total of 24% (23/96) were classified as potential critical hemodynamic findings. The number needed (NNT) to treat for pre-operative TTE in order to find one critical finding was 4.2. CONCLUSION In this ambulatory surgical cohort, a high prevalence of pre-operative LV dysfunction and aberrations in volume status was observed. The results demonstrate that pre-operative TTE contributed valuable hemodynamic information. The standard pre-operative assessment for this cohort might need to be revised.
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Affiliation(s)
- Ylva Stenberg
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Sunderby Research Unit Umeå University Umeå Sweden
| | - Linnea Lindelöf
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Sunderby Research Unit Umeå University Umeå Sweden
| | - Magnus Hultin
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Umeå University Umeå Sweden
| | - Tomi Myrberg
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Sunderby Research Unit Umeå University Umeå Sweden
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222
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Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus. Aging Clin Exp Res 2020; 32:1647-1673. [PMID: 32651902 PMCID: PMC7508736 DOI: 10.1007/s40520-020-01624-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue. AIMS To develop evidence-based recommendations for the integrated care of geriatric surgical patients. METHODS A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria. RESULTS A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items). CONCLUSIONS These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.
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223
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Systematic review and meta-analysis of postoperative troponin as a predictor of mortality and major adverse cardiac events after vascular surgery. J Vasc Surg 2020; 72:1132-1143.e1. [DOI: 10.1016/j.jvs.2020.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 03/06/2020] [Indexed: 01/11/2023]
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224
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Liu Z, Xu G, Xu L, Zhang Y, Huang Y. Perioperative Cardiac Complications in Patients Over 80 Years of Age with Coronary Artery Disease Undergoing Noncardiac Surgery: The Incidence and Risk Factors. Clin Interv Aging 2020; 15:1181-1191. [PMID: 32801670 PMCID: PMC7398882 DOI: 10.2147/cia.s252160] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/26/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Ever-increasing noncardiac surgeries are performed in patients aged 80 years or over with coronary artery disease (CAD). The objective of the study was to explore the incidence and risk factors of perioperative cardiac complications (PCCs) for the oldest-old patients with CAD undergoing noncardiac surgery, which have not been evaluated previously. Patients and Methods A total of 547 patients, aged over 80 years, with a history of CAD who underwent noncardiac surgery were enrolled in this retrospective study. Perioperative clinical variables were extracted from the electronic medical records database. The primary outcome was the occurrence of PCCs intraoperatively or within 30 days postoperatively, defined as any of the following complications: acute coronary syndrome, heart failure, new-onset severe arrhythmia, nonfatal cardiac arrest, and cardiac death. Multivariate logistic regression analysis and multivariate Cox regression model were both performed to estimate the risk factors of PCCs. The incidence of PCCs overtime was illustrated by the Kaplan-Meier curve with a stratified Log-rank test. Results One hundred six (19.4%) patients developed at least one PCC, and 15 (2.7%) patients developed cardiac death. The independent risk factors contributing to PCCs were age ≧85 years; body mass index ≧30 kg/m2; the history of angina within 6 months; metabolic equivalents <4; hypertension without regular treatment; preoperative ST-T segment abnormality; anesthesia time >3 h and drainage ≧200 mL within 24 h postoperatively. Conclusion The incidence of PCCs in elderly patients over 80 years with CAD who underwent noncardiac surgery was high. Comprehensive preoperative evaluation, skilled surgical technique, and regular postoperative monitoring may help to reduce the occurrence of PCCs in this high-risk population.
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Affiliation(s)
- Zijia Liu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Guangyan Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Yuelun Zhang
- Central Research Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
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225
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Schindler TH, Bateman TM, Berman DS, Chareonthaitawee P, De Blanche LE, Dilsizian V, Dorbala S, Gropler RJ, Shaw L, Soman P, Winchester DE, Verberne H, Ahuja S, Beanlands RS, Di Carli MF, Murthy VL, Ruddy TD, Schwartz RG. Appropriate Use Criteria for PET Myocardial Perfusion Imaging. J Nucl Med 2020; 61:1221-1265. [PMID: 32747510 DOI: 10.2967/jnumed.120.246280] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | - Daniel S Berman
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia
| | - Panithaya Chareonthaitawee
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,American Society of Nuclear Cardiology, Fairfax, Virginia
| | | | - Vasken Dilsizian
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,American Society of Nuclear Cardiology, Fairfax, Virginia
| | - Sharmila Dorbala
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia
| | - Robert J Gropler
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia
| | - Leslee Shaw
- American College of Cardiology, Washington, D.C.,Society of Cardiovascular Computed Tomography, Arlington, Virginia
| | - Prem Soman
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,American College of Cardiology, Washington, D.C
| | | | - Hein Verberne
- European Association of Nuclear Medicine, Vienna, Austria
| | - Sukhjeet Ahuja
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia
| | - Rob S Beanlands
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,American Society of Nuclear Cardiology, Fairfax, Virginia.,American College of Cardiology, Washington, D.C.,Canadian Society of Cardiovascular Nuclear and CT Imaging, Ottawa, Ontario, Canada.,Canadian Cardiovascular Society, Ottawa, Ontario, Canada; and
| | - Marcelo F Di Carli
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,American Heart Association, Dallas, Texas
| | | | - Terrence D Ruddy
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,Canadian Society of Cardiovascular Nuclear and CT Imaging, Ottawa, Ontario, Canada.,Canadian Cardiovascular Society, Ottawa, Ontario, Canada; and
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226
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Ramsingh D, Ma M, Kim JK, Knoll M, Patton JW, Cannesson M. Feasibility evaluation of non-invasive cardiac function technology during echocardiography-based cardiac stress testing. J Clin Monit Comput 2020; 34:655-661. [DOI: 10.1007/s10877-019-00354-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
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227
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Mohammad Ismail A, Borg T, Sjolin G, Pourlotfi A, Holm S, Cao Y, Wretenberg P, Ahl R, Mohseni S. β-adrenergic blockade is associated with a reduced risk of 90-day mortality after surgery for hip fractures. Trauma Surg Acute Care Open 2020; 5:e000533. [PMID: 32789190 PMCID: PMC7394016 DOI: 10.1136/tsaco-2020-000533] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 11/03/2022] Open
Abstract
Background There is a significant postoperative mortality risk in patients subjected to surgery for hip fractures. Adrenergic hyperactivity induced by trauma and subsequent surgery is thought to be an important contributor. By downregulating the effect of circulating catecholamines the increased risk of postoperative mortality may be reduced. The aim of the current study is to assess the association between regular β-blocker therapy and postoperative mortality. Methods This cohort study used the prospectively collected Swedish National Quality Registry for hip fractures to identify all patients over 40 years of age subjected to surgery for hip fractures between 2013 and 2017 in Örebro County, Sweden. Patients with ongoing β-blocker therapy at the time of surgery were allocated to the β-blocker-positive cohort. The primary outcome of interest was 90-day postoperative mortality. Risk factors for 90-day mortality were evaluated using Poisson regression analysis. Results A total of 2443 patients were included in this cohort of whom 900 (36.8%) had ongoing β-blocker therapy before surgery. The β-blocker positive group was significantly older, less fit for surgery based on their American Society of Anesthesiologists classification and had a higher prevalence of comorbidities. A significant risk reduction in 90-day mortality was detected in patients receiving β-blockers (adjusted incidence rate ratio=0.82, 95% CI 0.68 to 0.98, p=0.03). Conclusions β-blocker therapy is associated with a significant reduction in 90-day postoperative mortality after hip fracture surgery. Further investigation into this finding is warranted. Level of evidence Therapeutic study, level III; prognostic study, level II.
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Affiliation(s)
- Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Tomas Borg
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Gabriel Sjolin
- School of Medical Sciences, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Arvid Pourlotfi
- School of Medical Sciences, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Sebastian Holm
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Per Wretenberg
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Rebecka Ahl
- School of Medical Sciences, Örebro University, Örebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden
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228
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Ciapponi A, Tapia-López E, Virgilio S, Bardach A. The quality of clinical practice guidelines for preoperative care using the AGREE II instrument: a systematic review. Syst Rev 2020; 9:159. [PMID: 32660571 PMCID: PMC7359265 DOI: 10.1186/s13643-020-01404-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/01/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Our aim was to summarize and compare relevant recommendations from evidence-based CPGs (EB-CPGs). METHODS Systematic review of clinical practice guidelines. DATA SOURCES PubMed, EMBase, Cochrane Library, LILACS, Tripdatabase, and additional sources. In July 2017, we searched CPGs that were published in the last 10 years, without language restrictions, in electronic databases, and also searched specific CPG sources, reference lists, and consulted experts. Pairs of independent reviewers selected EB-CPGs and rated their methodological quality using the AGREE-II instrument. We summarized recommendations, its supporting evidence, and strength of recommendations according to the GRADE methodology. RESULTS We included 16 EB-CPGs out of 2262 references identified. Only nine of them had searches within the last 5 years and seven used GRADE. The median (percentile 25-75) AGREE-II scores for rigor of development was 49% (35-76%) and the domain "applicability" obtained the worst score 16% (9-31%). We summarized 31 risk stratification recommendations, 21.6% of which were supported by high/moderate quality of evidence (41% of them were strong recommendations), and 16 therapeutic/preventive recommendations, 59% of which were supported by high/moderate quality of evidence (75.7% strong). We found inconsistency in ratings of evidence level. "Guidelines' applicability" and "monitoring" were the most deficient domains. Only half of the EB-CPGs were updated in the past 5 years. CONCLUSIONS We present many strong recommendations that are ready to be considered for implementation as well as others to be interrupted, and we reveal opportunities to improve guidelines' quality.
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Affiliation(s)
- Agustín Ciapponi
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Emilio Ravignani 2024 (C1414CPV), Buenos Aires, Argentina.
| | - Elena Tapia-López
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Emilio Ravignani 2024 (C1414CPV), Buenos Aires, Argentina
| | - Sacha Virgilio
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Emilio Ravignani 2024 (C1414CPV), Buenos Aires, Argentina
| | - Ariel Bardach
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Emilio Ravignani 2024 (C1414CPV), Buenos Aires, Argentina
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229
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Sangalli F, Rubino A. Mirror, mirror on the wall, who's ischemic after all? Detection of preoperative myocardial injury in vascular surgery patients. Minerva Anestesiol 2020; 86:592-594. [PMID: 32605358 DOI: 10.23736/s0375-9393.20.14648-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Fabio Sangalli
- Department of Anesthesia and Intensive Care, Niguarda Hospital, Milan, Italy - .,University of Milan-Bicocca, Milan, Italy -
| | - Antonio Rubino
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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230
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Expert Opinion Regarding Appropriately Timing Dermatological Surgeries in Patients With Recent Myocardial Infarctions. Dermatol Surg 2020; 46:1560-1563. [PMID: 32604236 DOI: 10.1097/dss.0000000000002462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is limited data on the risk of perioperative myocardial infarctions (MIs) in patients with a recent MI who undergo dermatologic surgeries. OBJECTIVE Present the recommendations of dermatologic surgeons and cardiologists to determine the safety of dermatologic surgeries after a recent MI. METHODS An electronic survey was distributed to Mohs surgeons and cardiologists to infer the risk of major adverse cardiac events (MACE) inherent to dermatologic surgery and determine timing of dermatologic surgery in patients with a recent MI. RESULTS One hundred twenty Mohs surgeons and 30 cardiologists were surveyed. Ninety-seven percent of cardiologists and 87% of Mohs surgeons deemed cutaneous excisions and Mohs micrographic surgery as low-risk procedures with less than one-percent chance of MACE. Seventy-seven percent of cardiologists and 46% of Mohs surgeons stated dermatologic surgery should either not be delayed or be delayed up to 1 month after an MI. Responses between cardiologists and Mohs surgeons did not significantly differ. CONCLUSION A preponderance of surveyed experts believe that most dermatologic surgeries may be safely performed in patients with a history of an MI within 1 month. The decision to implement urgent dermatologic surgery in patients with a recent MI should account for all clinically significant factors.
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231
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Singh V, Bryant AS, Hull M, Skelley J, Walters R, Cross RC, Rozner MA, Boyd GL. Cardiorespiratory Events Associated With Ophthalmic Surgery: A Single-Center, Retrospective Records Review of 130 775 Patients, 1999–2015. JOURNAL OF VITREORETINAL DISEASES 2020; 4:280-285. [PMID: 37009178 PMCID: PMC9976108 DOI: 10.1177/2474126419896432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: The most recent study of ophthalmic surgery morbidity and mortality was published in 1995, with a patient study population from 1977 to 1988. The present study reports surgical outcomes from a single-center, retrospective analysis of patient records from 1999 to 2015. Methods: Three International Classification of Diseases–9-CM codes for cardiorespiratory events were searched in the discharge diagnoses in an eye hospital over a 16-year period. The overall mortality and preoperative risk factors were analyzed, including the type of anesthetic, type of surgery, medical comorbidities, and bradycardia preceding the cardiac events. Results: Between February 1, 1999 and October 1, 2015, a total of 130 775 patients presented for ophthalmic surgery. Fifty-nine patients (0.45 per 1000) experienced a cardiorespiratory event. Of the 59 patients, 14 patients had a cardiorespiratory arrest, 9 of whom died during the perioperative period. Of the remaining 45 patients, 29 had significant adverse events needing some form of advanced monitoring, evaluation, and/or intervention. There was a significantly greater prevalence of diabetes among patients who had a cardiorespiratory event ( P < .001). Conclusions: The major risk factor associated with ophthalmic surgery morbidity and mortality was diabetes with its associated complications of autonomic neuropathy, nephropathy, and retinopathy. Of the 9 patients who died, 8 were diabetic with proliferative diabetic retinopathy and renal insufficiency/failure. The ninth mortality was secondary to a venous air embolism during ocular air infusion. The adage that “the eye is the window to our overall health” seems to be correct.
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Affiliation(s)
- Vinodkumar Singh
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ayesha S. Bryant
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew Hull
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jason Skelley
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robin Walters
- Department of Anesthesiology, University of Kansas Medical Centre, Kansas City, MO, USA
| | - R. Clark Cross
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marc A. Rozner
- Baylor College of Medicine Education at The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gwendolyn L. Boyd
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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232
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Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries. J Vasc Surg 2020; 73:4S-52S. [PMID: 32615285 DOI: 10.1016/j.jvs.2020.06.011] [Citation(s) in RCA: 238] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/05/2020] [Indexed: 12/14/2022]
Abstract
Endovascular aortic aneurysm repair of complex aortic aneurysms requires incorporation of side branches using specially designed aortic stent grafts with fenestrations, directional branches, or parallel stent grafts. These techniques have been increasingly used and reported in the literature. The purpose of this document is to clarify and to update terminology, classification systems, measurement techniques, and end point definitions that are recommended for reports dealing with endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms involving the renal and mesenteric arteries.
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233
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Lam NN, Dipchand C, Fortin MC, Foster BJ, Ghanekar A, Houde I, Kiberd B, Klarenbach S, Knoll GA, Landsberg D, Luke PP, Mainra R, Singh SK, Storsley L, Gill J. Canadian Society of Transplantation and Canadian Society of Nephrology Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Can J Kidney Health Dis 2020; 7:2054358120918457. [PMID: 32577294 PMCID: PMC7288834 DOI: 10.1177/2054358120918457] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/25/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose of review: To review an international guideline on the evaluation and care of living
kidney donors and provide a commentary on the applicability of the
recommendations to the Canadian donor population. Sources of information: We reviewed the 2017 Kidney Disease: Improving Global Outcomes (KDIGO)
Clinical Practice Guideline on the Evaluation and Care of Living Kidney
Donors and compared this guideline to the Canadian 2014 Kidney Paired
Donation (KPD) Protocol for Participating Donors. Methods: A working group was formed consisting of members from the Canadian Society of
Transplantation and the Canadian Society of Nephrology. Members were
selected to have representation from across Canada and in various
subspecialties related to living kidney donation, including nephrology,
surgery, transplantation, pediatrics, and ethics. Key findings: Many of the KDIGO Guideline recommendations align with the KPD Protocol
recommendations. Canadian researchers have contributed to much of the
evidence on donor evaluation and outcomes used to support the KDIGO
Guideline recommendations. Limitations: Certain outcomes and risk assessment tools have yet to be validated in the
Canadian donor population. Implications: Living kidney donors should be counseled on the risks of postdonation
outcomes given recent evidence, understanding the limitations of the
literature with respect to its generalizability to the Canadian donor
population.
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Affiliation(s)
- Ngan N Lam
- Division of Nephrology, University of Calgary, AB, Canada
| | | | | | - Bethany J Foster
- Division of Pediatric Nephrology, McGill University, Montréal, QC, Canada
| | - Anand Ghanekar
- Department of Surgery, University of Toronto, ON, Canada
| | - Isabelle Houde
- Division of Nephrology, Centre Hospitalier de l'Université de Québec, Québec City, Canada
| | - Bryce Kiberd
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | | | - Greg A Knoll
- Division of Nephrology, University of Ottawa, ON, Canada
| | - David Landsberg
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Patrick P Luke
- Division of Urology, Western University, London, ON, Canada
| | - Rahul Mainra
- Division of Nephrology, University of Saskatchewan, Saskatoon, Canada
| | - Sunita K Singh
- Division of Nephrology, University of Toronto, ON, Canada
| | - Leroy Storsley
- Section of Nephrology, University of Manitoba, Winnipeg, Canada
| | - Jagbir Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada
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234
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Khanh LN, Helenowski IB, Hoel AW, Ho KJ. The Comorbidity-Polypharmacy Score is an Objective and Practical Predictor of Outcomes and Mortality after Vascular Surgery. Ann Vasc Surg 2020; 69:206-216. [PMID: 32502672 DOI: 10.1016/j.avsg.2020.05.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The comorbidity-polypharmacy score (CPPS) was developed to quantify the severity of comorbidities of patients with geriatric trauma. CPPS is the sum of the number of medications and comorbidities, and is thus objective, user-friendly, and potentially adaptable to many clinical situations. We sought to understand if CPPS associates with outcomes and mortality after common vascular surgery procedures. METHODS This is a retrospective single-center study. A total of 466 patients who underwent carotid endarterectomy, infrainguinal bypass, percutaneous lower extremity revascularization, or endovascular abdominal aortic aneurysm repair at a single medical center were included. CPPS were classified as mild, moderate, severe, and morbid based on scores of 0-7, 8-15, 15-21, and ≥21, respectively. End points were reinterventions, 30-day readmission, and mortality. We used chi-squared tests to analyze differences in categorical variables; Kruskal-Wallis tests to analyze differences in continuous variables; Kaplan-Meier estimation and Cox proportional hazard modeling to examine survival data; and receiver operator characteristic (ROC) curve analyses to assess sensitivity and specificity. RESULTS The mean preoperative CPPS was 14.1 ± 6.1. Higher CPPS were associated with longer hospital and postoperative length of stay (P < 0.001). Severe and morbid CPPS categories had higher rates of ICU admission, reintervention, and 30-day readmission which did not reach statistical significance after correction for multiple comparisons. CPPS was independently associated with 1- and 5-year mortality in a multivariable Cox model (hazard ratio = 2.2, 95% confidence interval: 1.3-3.3). ROC analysis revealed C-statistics of 0.81 and 0.72 for 1-year and 5-year all-cause mortality, respectively (P < 0.001). CONCLUSIONS CPPS is a simple and pragmatic clinical tool for quantifying risk of postoperative outcomes and mortality after common vascular surgery procedures. Further investigation is needed to validate the use of CPPS in enhancing existing predictors of patient outcomes and in serving as an adjunctive tool for determining resource allocation and discharge planning in patients who underwent vascular surgery.
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Affiliation(s)
- Linh Ngo Khanh
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Irene B Helenowski
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Andrew W Hoel
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Karen J Ho
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
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236
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Blitz J, Swisher J, Sweitzer B. Special Considerations Related to Race, Sex, Gender, and Socioeconomic Status in the Preoperative Evaluation: Part 1: Race, History of Incarceration, and Health Literacy. Anesthesiol Clin 2020; 38:247-261. [PMID: 32336382 DOI: 10.1016/j.anclin.2020.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Patients anticipating surgery and anesthesia often need preoperative care to reduce risk and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges is vital to reducing disparities in health and health care.
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Affiliation(s)
- Jeanna Blitz
- Duke University School of Medicine, DUMC 3094, Durham, NC 27710, USA
| | - Jenna Swisher
- Northwestern University Feinberg School of Medicine, 251 East Huron, Feinberg 5-704, Chicago, IL 60611, USA. https://twitter.com/Jeanna_BlitzMD
| | - BobbieJean Sweitzer
- Northwestern University Feinberg School of Medicine, 251 East Huron, Feinberg 5-704, Chicago, IL 60611, USA.
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237
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Walker KA, Gottesman RF, Coresh J, Sharrett AR, Knopman DS, Mosley TH, Alonso A, Zhou Y, Wong DF, Brown CH. Association of Surgical Hospitalization with Brain Amyloid Deposition: The Atherosclerosis Risk in Communities-Positron Emission Tomography (ARIC-PET) Study. Anesthesiology 2020; 132:1407-1418. [PMID: 32412719 PMCID: PMC7540736 DOI: 10.1097/aln.0000000000003255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND As more older adults undergo surgery, it is critical to understand the long-term effects of surgery on brain health, particularly in relation to the development of Alzheimer's disease. This study examined the association of surgical hospitalization with subsequent brain β-amyloid deposition in nondemented older adults. METHODS The Atherosclerosis Risk in Communities-Positron Emission Tomography (ARIC-PET) study is a prospective cohort study of 346 participants without dementia who underwent florbetapir PET imaging. Active surveillance of local hospitals and annual participant contact were used to gather hospitalization and surgical information (International Classification of Disease, Ninth Revision, Clinical Modification codes) over the preceding 24-yr period. Brain amyloid measured using florbetapir PET imaging was the primary outcome. Elevated amyloid was defined as a standardized uptake value ratio of more than 1.2. RESULTS Of the 313 participants included in this analysis (age at PET: 76.0 [SD 5.4]; 56% female), 72% had a prior hospitalization, and 50% had a prior surgical hospitalization. Elevated amyloid occurred in 87 of 156 (56%) participants with previous surgical hospitalization, compared with 45 of 87 (52%) participants who had no previous hospitalization. Participants with previous surgical hospitalizations did not show an increased odds of elevated brain amyloid (odds ratio, 1.32; 95% CI, 0.72 to 2.40; P = 0.370) after adjusting for confounders (primary analysis). Results were similar using the reference group of all participants without previous surgery (hospitalized and nonhospitalized; odds ratio, 1.58; 95% CI, 0.96 to 2.58; P = 0.070). In a prespecified secondary analysis, participants with previous surgical hospitalization did demonstrate increased odds of elevated amyloid when compared with participants hospitalized without surgery (odds ratio, 2.10; 95% CI, 1.09 to 4.05; P = 0.026). However, these results were attenuated and nonsignificant when alternative thresholds for amyloid-positive status were used. CONCLUSIONS The results do not support an association between surgical hospitalization and elevated brain amyloid.
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Affiliation(s)
- Keenan A Walker
- From the Departments of Neurology (K.A.W., R.F.G.) Radiology (D.F.W.) Anesthesiology (C.H.B.), Johns Hopkins School of Medicine, Baltimore, Maryland the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (R.F.G., J.C., A.R.S.) the Department of Neurology, Mayo Clinic, Rochester, Minnesota (D.S.K.) Department of Medicine, Division of Geriatrics, University of Mississippi Medical Center, Jackson, Mississippi (T.H.M.) the Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia (A.A.) the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri (Y.Z.)
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Hasan TF, Kelley RE, Cornett EM, Urman RD, Kaye AD. Cognitive impairment assessment and interventions to optimize surgical patient outcomes. Best Pract Res Clin Anaesthesiol 2020; 34:225-253. [PMID: 32711831 DOI: 10.1016/j.bpa.2020.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/20/2020] [Indexed: 12/22/2022]
Abstract
For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.
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Affiliation(s)
- Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Roger E Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, Massachussetts, 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
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Abstract
As the silver tsunami hits the world, older patients with hip fractures are expected to increase to 6.3 million by the year 2050, of which the majority will occur in Asia. The estimated global cost of hip fractures in the year 2050 is estimated to reach U.S. $130 billion. Hence, in addition to implementation of prevention strategies, it is important to develop an optimal model of care for older patients with hip fracture to minimize the huge medical and socioeconomic burden, especially in rapidly aging nations. This review summarizes the complications of hip fractures, importance of comprehensive geriatric assessment, and multidisciplinary rehabilitation, as well as predictors of rehabilitation outcome in older patients with hip fracture.
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Raghunathan D, Palaskas NL, Yusuf SW, Eagle KA. Rise and fall of preoperative coronary revascularization. Expert Rev Cardiovasc Ther 2020; 18:249-259. [DOI: 10.1080/14779072.2020.1757432] [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: 10/24/2022]
Affiliation(s)
| | - Nicolas L. Palaskas
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Syed Wamique Yusuf
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kim A. Eagle
- Department of Internal Medicine, Division of Cardiology, The University of Michigan, Ann Arbor, MI, USA
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Dakik HA, Sbaity E, Msheik A, Kaspar C, Eldirani M, Chehab O, Abou Hassan O, Mailhac A, Makki M, Tamim H. AUB-HAS2 Cardiovascular Risk Index: Performance in Surgical Subpopulations and Comparison to the Revised Cardiac Risk Index. J Am Heart Assoc 2020; 9:e016228. [PMID: 32390481 PMCID: PMC7660845 DOI: 10.1161/jaha.119.016228] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The American University of Beirut (AUB)-HAS2 Cardiovascular Risk Index is a newly derived index for preoperative cardiovascular evaluation. It is based on 6 data elements: history of heart disease; symptoms of angina or dyspnea; age ≥75 years; hemoglobin <12 mg/dL; vascular surgery; and emergency surgery. In this study we analyze the performance of this new index and compare it with that of the Revised Cardiac Risk Index in a broad spectrum of surgical subpopulations. Methods and Results The study population consisted of 1 167 278 noncardiac surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database. Each patient was given an AUB-HAS2 score of 0, 1, 2, 3, or >3, depending on the number of data elements present. The performance of the AUB-HAS2 index was studied in 9 surgical specialty groups and in 8 commonly performed site-specific surgeries. Receiver operating characteristic curves were constructed for the AUB-HAS2 and Revised Cardiac Risk Index measures, and the areas under the curve were compared. The outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. The AUB-HAS2 score was able to stratify risk in all surgical subgroups (P<0.001). In the majority of surgeries, patients with an AUB-HAS2 score of 0 had an event rate of <0.5%. The performance of the AUB-HAS2 index was superior to that of the Revised Cardiac Risk Index in all surgical subgroups (P<0.001). Conclusions This study extends the validation of the AUB-HAS2 index to a broad spectrum of surgical subpopulations and demonstrates its superior discriminatory power compared with the commonly utilized Revised Cardiac Risk Index.
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Affiliation(s)
- Habib A Dakik
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Eman Sbaity
- Department of Surgery American University of Beirut Medical Center Beirut Lebanon
| | - Ahmad Msheik
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Chris Kaspar
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Mahmoud Eldirani
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Omar Chehab
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Ossama Abou Hassan
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Aurelie Mailhac
- Department of Biostatistics Unit American University of Beirut Medical Center Beirut Lebanon
| | - Maha Makki
- Department of Biostatistics Unit American University of Beirut Medical Center Beirut Lebanon
| | - Hani Tamim
- Department of Biostatistics Unit American University of Beirut Medical Center Beirut Lebanon
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242
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Takahashi R, Fujikawa T. Impact of perioperative aspirin continuation on bleeding complications in laparoscopic colorectal cancer surgery: a propensity score-matched analysis. Surg Endosc 2020; 35:2075-2083. [PMID: 32372221 DOI: 10.1007/s00464-020-07604-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 04/28/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND In laparoscopic surgery for colorectal cancer (CRC) for patients who receive antiplatelet therapy (APT), it remains unclear whether APT should be continued or temporarily withdrawn. We investigated the safety of perioperative aspirin continuation, specifically focused on bleeding complications. METHODS We performed retrospective analysis utilizing propensity score-matching (PSM). In total, 789 patients satisfied the inclusion criteria, and were divided into two groups. Patients in the continued aspirin monotherapy (cAPT) group continued treatment perioperatively with not more than 2 days of withdrawal (n = 140). Patients with more than 3 days withdrawal of aspirin or who did not receive APT at all were assigned to the non-cAPT group (n = 649). After 1:1 PSM, 105 patients were extracted from each group. Perioperative APT management was determined based on our institutional committee-approved guidelines for antithrombotic management. RESULTS In PSM cohorts, all patient demographics were comparable between the groups. Regarding intraoperative outcomes, we found no significant difference in operation duration (p = 0.969), blood loss (p = 0.068), and blood transfusion (p = 0.517). Postoperative overall morbidity was 20.0% and 13.3% in the cAPT and non-cAPT groups, respectively (p = 0.195). The incidence of bleeding complications was also comparable between the groups (2.9% vs. 1.0%, p = 0.317). Assessing the 14 cases with bleeding complications overall in the full cohort, all 7 cases in the non-cAPT group had anastomotic bleeding, which was generally observed shortly after surgery [median postoperative day (POD) 1]. All 7 cases in the cAPT group received additional antithrombotics other than aspirin; bleeding occurred at various sites relatively later (median POD 7), mostly after reinstitution of additional antithrombotic agents. CONCLUSIONS For patients receiving APT, perioperative continuation of aspirin monotherapy could be safe in laparoscopic CRC surgery; however, careful consideration is required at reinstitution of additional antithrombotics where multiple antithrombotic agents are used.
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Affiliation(s)
- Ryo Takahashi
- Department of Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu, Fukuoka, 8028555, Japan
| | - Takahisa Fujikawa
- Department of Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu, Fukuoka, 8028555, Japan.
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243
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Winchester DE, Cagino L. A Redesigned Order Entry System for Reducing Low-Value Preprocedural Cardiology Consultations: Quality-Improvement Cohort Study. JMIR Perioper Med 2020; 3:e17669. [PMID: 33393916 PMCID: PMC7709841 DOI: 10.2196/17669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/10/2020] [Accepted: 03/22/2020] [Indexed: 11/13/2022] Open
Abstract
Background Preprocedural cardiac evaluation is a common reason for outpatient cardiology visits. Many patients who are referred to cardiology clinics for preprocedural evaluation are at low risk of perioperative events and do not require any further management. Our facility treats patients over a large geographic area; avoiding low-value consultations reduces time and travel burdens for patients. Objective Our study objective was to assess the impact of a novel algorithm in the electronic order entry system aimed to guide clinicians toward patients who may benefit from cardiovascular referral. Methods We retrospectively reviewed in-person consultations and electronic consultations (e-consults) to our cardiology service before and after implementation of the novel algorithm to assess changes in patterns of care. Data were stored in a custom electronic database on internal servers. Results We reviewed 603 consultations to our cardiology clinic and found that 89 (14.7%) were sent for preprocedural evaluation. Of these, 39 (43.8% of preprocedural consultations) were e-consults. After implementation, we reviewed 360 consultations. The proportion of consultations for preprocedural evaluation did not decrease (n=47, 13.0%; P=.39). We observed an absolute increase of 13.6% in the proportion of consultations ordered as e-consults (27/47, 57.4%). During the postintervention period, we received no remarks, concerns, or criticisms from ordering clinicians about the process change and no reports of adverse events. Conclusions Implementation of an ordering algorithm to reduce low-value preprocedural cardiology evaluations did not lead to a reduction in the number of overall preprocedural cardiology consultations. The number of patients seen electronically increased, potentially improving clinic access and reducing travel burden for patients.
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Affiliation(s)
- David E Winchester
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, United States
| | - Leigh Cagino
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, United States
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244
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Hanalioglu S, Sahin B, Sahin OS, Kozan A, Ucer M, Cikla U, Goodman SL, Baskaya MK. Effect of perioperative aspirin use on hemorrhagic complications in elective craniotomy for brain tumors: results of a single-center, retrospective cohort study. J Neurosurg 2020; 132:1529-1538. [PMID: 30952120 DOI: 10.3171/2018.12.jns182483] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/18/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In daily practice, neurosurgeons face increasing numbers of patients using aspirin (acetylsalicylic acid, ASA). While many of these patients discontinue ASA 7-10 days prior to elective intracranial surgery, there are limited data to support whether or not perioperative ASA use heightens the risk of hemorrhagic complications. In this study the authors retrospectively evaluated the safety of perioperative ASA use in patients undergoing craniotomy for brain tumors in the largest elective cranial surgery cohort reported to date. METHODS The authors retrospectively analyzed the medical records of 1291 patients who underwent elective intracranial tumor surgery by a single surgeon from 2007 to 2017. The patients were divided into three groups based on their perioperative ASA status: 1) group 1, no ASA; 2) group 2, stopped ASA (low cardiovascular risk); and 3) group 3, continued ASA (high cardiovascular risk). Data collected included demographic information, perioperative ASA status, tumor characteristics, extent of resection (EOR), operative blood loss, any hemorrhagic and thromboembolic complications, and any other complications. RESULTS A total of 1291 patients underwent 1346 operations. The no-ASA group included 1068 patients (1112 operations), the stopped-ASA group had 104 patients (108 operations), and the continued-ASA group had 119 patients (126 operations). The no-ASA patients were significantly younger (mean age 53.3 years) than those in the stopped- and continued-ASA groups (mean 64.8 and 64.0 years, respectively; p < 0.001). Sex distribution was similar across all groups (p = 0.272). Tumor locations and pathologies were also similar across the groups, except for deep tumors and schwannomas that were relatively less frequent in the continued-ASA group. There were no differences in the EOR between groups. Operative blood loss was not significantly different between the stopped- (186 ml) and continued- (220 ml) ASA groups (p = 0.183). Most importantly, neither hemorrhagic (0.6%, 0.9%, and 0.8%, respectively; p = 0.921) nor thromboembolic (1.3%, 1.9%, and 0.8%; p = 0.779) complication rates were significantly different between the groups, respectively. In addition, the multivariate model revealed no statistically significant predictor of hemorrhagic complications, whereas male sex (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.7-20.5, p = 0.005) and deep-extraaxial-benign ("skull base") tumors (OR 3.6, 95% CI 1.3-9.7, p = 0.011) were found to be independent predictors of thromboembolic complications. CONCLUSIONS In this cohort, perioperative ASA use was not associated with the increased rate of hemorrhagic complications following intracranial tumor surgery. In patients at high cardiovascular risk, ASA can safely be continued during elective brain tumor surgery to prevent potential life-threatening thromboembolic complications. Randomized clinical trials with larger sample sizes are warranted to achieve a greater statistical power.
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245
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Kraiss LW, Al-Dulaimi R, Cronenwett JL, Goodney PP, Clair DG, Hallett JJ, Rhodes R, Mills JL, Presson AP, Brooke BS. Failure on a Vascular Surgery Board-American Board of Surgery Examination does not predict cardiovascular outcomes in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2020; 72:1753-1760. [PMID: 32247698 DOI: 10.1016/j.jvs.2020.01.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 01/20/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The Vascular Surgery Board of the American Board of Surgery (VSB-ABS) Qualifying and Certifying examinations are meant to assess qualifications to independently practice vascular surgery, but it is unclear whether examination performance correlates with clinical outcomes. We assessed this relationship using clinical outcomes data for VSB-ABS diplomates from the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI). METHODS VSB-ABS examination performance for vascular surgeons participating in the SVS-VQI registry was characterized according to pass/fail status. Surgical experience was measured by number of years since completion of training. Examination performance and experience were compared with a composite clinical outcome (in-patient major adverse cardiac events or postoperative death [MACE+POD]) after arterial reconstructions (carotid stenting or endarterectomy, aortic aneurysm repair, open peripheral surgical bypasses) registered in the SVS-VQI. Multivariate mixed effects regression was performed adjusting for sex and surgery type, as well as clustering by surgeon and by hospital. RESULTS From 2003 to 2017, complete data were available for 776 vascular surgeons who performed 124,171 arterial reconstructions (carotid n = 56,650; aortic n = 34,764; peripheral n = 32,757) registered in the SVS-VQI. Patient characteristics associated with higher odds of MACE+POD were female sex (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.12; P = .006) and advancing age (OR, 1.04; 95% CI, 1.03-1.04; P < .001). Of the 776 surgeons, 149 (17%) had failed at least one VSB-ABS examination (group F). The unadjusted primary composite outcome of MACE+POD was marginally higher after operations performed by surgeons who never failed an examination (group P; 7% vs 6%; P = .03). This difference seems to be driven by higher rates of postoperative congestive heart failure in the aortic and lower extremity bypass cohorts as well as more postoperative myocardial infarctions after lower extremity bypass by group P surgeons. Following multivariable analyses, examination pass status was not associated with MACE+POD (OR, 0.98; 95% CI, 0.89-1.50; P = .517). However, increasing surgical experience correlated with significantly lower odds of MACE+POD (2% lower odds/year of experience since training [OR, 0.98; 95% CI, 0.98-0.99; P < .001]). CONCLUSIONS VSB-ABS examination performance by SVS-VQI surgeons does not correlate with registry-reported mortality or cardiovascular complications. Increasing surgical experience is strongly associated with lower odds of cardiovascular morbidity and death.
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Affiliation(s)
- Larry W Kraiss
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
| | | | - Jack L Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Daniel G Clair
- Department of Surgery, Palmetto Health University of South Carolina Medical Group, Columbia, SC
| | - John Jeb Hallett
- Division of Vascular Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | | | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
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Bierle DM, Raslau D, Regan DW, Sundsted KK, Mauck KF. Preoperative Evaluation Before Noncardiac Surgery. Mayo Clin Proc 2020; 95:807-822. [PMID: 31753535 DOI: 10.1016/j.mayocp.2019.04.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/23/2019] [Accepted: 04/30/2019] [Indexed: 01/19/2023]
Abstract
The medical complexity of surgical patients is increasing and medical specialties are frequently asked to assist with the perioperative management surgical patients. Effective pre-anesthetic medical evaluations are a valuable tool in providing high-value, patient-centered surgical care and should systematically address risk assessment and identify areas for risk modification. This review outlines a structured approach to the pre-anesthetic medical evaluation, focusing on the asymptomatic patient. It discusses the evidence supporting the use of perioperative risk calculation tools and focused preoperative testing. We also introduce important key topics that will be explored in greater detail in upcoming reviews in this series.
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Affiliation(s)
- Dennis M Bierle
- Mayo Clinic Rochester, Division of General Internal Medicine, Rochester, MN.
| | - David Raslau
- Mayo Clinic Rochester, Division of General Internal Medicine, Rochester, MN
| | - Dennis W Regan
- Mayo Clinic Rochester, Division of General Internal Medicine, Rochester, MN
| | - Karna K Sundsted
- Mayo Clinic Rochester, Division of General Internal Medicine, Rochester, MN
| | - Karen F Mauck
- Mayo Clinic Rochester, Division of General Internal Medicine, Rochester, MN
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247
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Scallan O, Novick T, Power AH, DeRose G, Duncan A, Dubois L. Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians. J Vasc Surg 2020; 71:1162-1168. [DOI: 10.1016/j.jvs.2019.06.207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/05/2019] [Indexed: 01/23/2023]
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Blanch A, Costescu F, Slinger P. Preoperative Evaluation for Lung Resection Surgery. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00376-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Odor PM, Bampoe S, Gilhooly D, Creagh-Brown B, Moonesinghe SR. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis. BMJ 2020; 368:m540. [PMID: 32161042 PMCID: PMC7190038 DOI: 10.1136/bmj.m540] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017. ELIGIBILITY CRITERIA Randomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded. DATA EXTRACTION AND SYNTHESIS Reviewers independently identified studies, extracted data, and assessed the quality of evidence. Meta-analyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared. RESULTS 117 trials enrolled 21 940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18 062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions. CONCLUSIONS Predominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions. STUDY REGISTRATION Prospero CRD42016035662.
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Affiliation(s)
- Peter M Odor
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - Sohail Bampoe
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - David Gilhooly
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - Benedict Creagh-Brown
- Surrey Perioperative Anaesthesia Critical care collaborative Research (SPACeR) Group, Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - S Ramani Moonesinghe
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
- UCL/UCLH Surgical Outcomes Research Centre, UCL Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
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