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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: 145] [Impact Index Per Article: 36.3] [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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253
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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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255
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Janssen H, Felgner L, Kummer L, Gillmann HJ, Schrimpf C, Rustum S, Lichtinghagen R, Sahlmann B, Weigand MA, Teebken OE, Theilmeier G, Larmann J. Sequential Surgical Procedures in Vascular Surgery Patients Are Associated With Perioperative Adverse Cardiac Events. Front Cardiovasc Med 2020; 7:13. [PMID: 32133374 PMCID: PMC7040239 DOI: 10.3389/fcvm.2020.00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 01/28/2020] [Indexed: 01/31/2023] Open
Abstract
Patients at elevated cardiovascular risk are prone to perioperative cardiovascular complications, like myocardial injury after non-cardiac surgery (MINS). We have demonstrated in a mouse model of atherosclerosis that perioperative stress leads to an increase in plaque volume and higher plaque vulnerability. Regulatory T cells (Tregs) play a pivotal role in development and destabilization of atherosclerotic plaques. For this exploratory post-hoc analysis we identified 40 patients recruited into a prospective perioperative biomarker study, who within the inclusion period underwent sequential open vascular surgery. On the basis of protein markers measured in the biomarker study, we evaluated the perioperative inflammatory response in patients' plasma before and after index surgery as well as before and after a second surgical procedure. We also analyzed available immunohistochemistry samples to describe plaque vulnerability in patients who underwent bilateral carotid endarterectomy (CEA) in two subsequent surgical procedures. Finally, we assessed if MINS was associated with sequential surgery. The inflammatory response of both surgeries was characterized by postoperative increases of interleukin-6,−10, Pentraxin 3 and C-reactive protein with no clear-cut difference between the two time points of surgery. Plaques from CEA extracted during the second surgery contained less Tregs, as measured by Foxp3 staining, than plaques from the first intervention. The 2nd surgical procedure was associated with MINS. In conclusion, we provide descriptive evidence that sequential surgical procedures involve repeat inflammation, and we hypothesize that elevated rates of cardiovascular complications after the second procedure could be related to reduced levels of intraplaque Tregs, a finding that deserves confirmatory testing and mechanistic exploration in future populations.
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Affiliation(s)
- Henrike Janssen
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany.,Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hanover, Germany
| | - Larissa Felgner
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Laura Kummer
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hans-Jörg Gillmann
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hanover, Germany
| | - Claudia Schrimpf
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Saad Rustum
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Ralf Lichtinghagen
- Institute for Clinical Chemistry, Medical School Hannover, Hanover, Germany
| | - Bianca Sahlmann
- Department of Human Medicine, Perioperative Inflammation and Infection, Faculty of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Omke E Teebken
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Gregor Theilmeier
- Department of Human Medicine, Perioperative Inflammation and Infection, Faculty of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany.,Department of Anesthesiology, University Medical Center Groningen, Groningen, Netherlands
| | - Jan Larmann
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany.,Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hanover, Germany
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256
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Safety of aortic aneurysm repair 8 weeks after percutaneous coronary intervention for coronary artery disease: a cohort study. Updates Surg 2020; 72:1213-1221. [DOI: 10.1007/s13304-020-00729-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/14/2020] [Indexed: 01/04/2023]
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257
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Subrata SA. Health‐related quality of life in patients undergoing TURP: Translating evidence into urological nursing practice. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2020. [DOI: 10.1111/ijun.12216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sumarno A. Subrata
- Doctoral Candidate in Doctor of Philosophy Program in NursingInternational and Collaborative Program with Foreign University Program, Mahidol University Nakhon Pathom Thailand
- Department of Nursing and Wound Research Center, Faculty of Health SciencesUniversitas Muhammadiyah Magelang Magelang Indonesia
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258
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Cardiovascular Risk Assessment in Renal and Liver Transplant Candidates: A Multidisciplinary Institutional Standardized Approach. Cardiol Rev 2020; 27:286-292. [PMID: 31584469 DOI: 10.1097/crd.0000000000000282] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the modern era, renal and liver transplant candidates present with a greater medical complexity driven in part by a higher prevalence of cardiovascular conditions, including coronary artery disease, valvular heart disease, and cardiomyopathies. In fact, cardiovascular disease is the most common cause of death after kidney transplantation worldwide. Similarly, an increase in the number of patients being listed with end-stage liver disease from nonalcoholic steatohepatitis and a rising model for end-stage liver disease scores at the time of liver transplant in the United States parallel an increasing cardiovascular disease risk profile for liver transplant candidates. A large degree of variation exists among clinical practice guidelines and transplant center practice patterns regarding patient selection for routine cardiac testing and the choice of testing modalities. Here, we review the clinical practice guidelines established at our center by a multidisciplinary group, including transplant nephrology, hepatology, and surgery, as well as general and interventional cardiology, with the goal of improving patient selection and reducing adverse cardiac events posttransplant.
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259
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Canceling dental procedures due to elevated blood pressure: Is it appropriate? J Am Dent Assoc 2020; 151:239-244. [PMID: 32067694 DOI: 10.1016/j.adaj.2019.12.010] [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: 05/29/2019] [Revised: 11/22/2019] [Accepted: 12/16/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND In 1974, the American Dental Association first considered recommending that dental offices measure blood pressure (BP) routinely, and it has been further encouraged since 2006. Investigators in several dental publications have recommended cancellation of dental procedures based solely on BP greater than 180/110 millimeters of mercury for urgent oral health care and greater than 160/100 mm Hg for elective oral health care, in the absence of prior medical consultation. METHODS The authors reviewed the evidence for cancellation of any dental or surgical procedures by using an Ovid MEDLINE search for the terms dental, elevated blood pressure, and hypertension. In addition, the authors searched resources at ebd.ada.org using the same criteria. The authors collaborated to develop recommendations in view of 2017 guidelines on this subject. RESULTS To the authors' knowledge, there are no professionally accepted criteria or study evidence indicating a specific BP elevation at which to prohibit oral health care. Researchers of a 2015 review on management of comorbidities in ambulatory anesthesia failed to find increased morbidity from hypertension in the outpatient setting. CONCLUSIONS To the authors' knowledge, there are no prospective study investigators that have addressed whether or when to cancel dental procedures due to office-measured elevated BP. The authors recommend using current anesthesiology guidelines based on functional status and past BP measurements to prevent unnecessary cancellations. PRACTICAL IMPLICATIONS It is seldom necessary to cancel dental procedures on the basis of BP measured before a planned procedure for patients under a physician's care.
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261
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Kaiser HA, Saied NN, Kokoefer AS, Saffour L, Zoller JK, Helwani MA. Incidence and prediction of intraoperative and postoperative cardiac arrest requiring cardiopulmonary resuscitation and 30-day mortality in non-cardiac surgical patients. PLoS One 2020; 15:e0225939. [PMID: 31967987 PMCID: PMC6975552 DOI: 10.1371/journal.pone.0225939] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 11/17/2019] [Indexed: 12/03/2022] Open
Abstract
Background The incidence, prediction and mortality outcomes of intraoperative and postoperative cardiac arrest requiring cardiopulmonary resuscitation (CPR) in surgical patients are under investigated and have not been studied concurrently in a single study. Methods A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program data between 2008 and 2012. Firth’s penalized logistic regression was used to study the incidence and identify risk factors for intra- and postoperative CPR and 30-day mortality. simplified prediction model was constructed and internally validated to predict the studied outcomes. Results Among about 1.86 million non-cardiac operations, the incidence rate of intraoperative CPR was 0.03%, and for postoperative CPR was 0.33%. The 30-day mortality incidence rate was 1.25%. The incidence rate of events decreased overtime between 2008–2012. Of the 29 potential predictors, 14 were significant for intraoperative CPR, 23 for postoperative CPR, and 25 for 30-day mortality. The five strongest predictors (highest odd ratios) of intraoperative CPR were the American Society of Anesthesiologists (ASA) physical status, Systemic Inflammatory Response Syndrome (SIRS)/sepsis, surgery type, urgent/emergency case and anesthesia technique. Intraoperative CPR, ASA, age, functional status and end stage renal disease were the most significant predictors for postoperative CPR. The most significant predictors of 30-day mortality were ASA, age, functional status, SIRS/sepsis, and disseminated cancer. The predictions with the simplified five-factor model performed well and was comparable to the full prediction model. Postoperative cardiac arrest requiring CPR, compared to intraoperative, was associated with much higher mortality. Conclusions The incidence of cardiac arrest requiring CPR in surgical patients decreased overtime. Risk factors for intraoperative CPR, postoperative CPR and perioperative mortality are overlapped. We proposed a simplified approach compromised of five-factor model to identify patients at high risk. Postoperative, compare to intraoperative, cardiac arrest requiring CPR was associated with much higher mortality.
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Affiliation(s)
- Heiko A. Kaiser
- Department of Anesthesiology, Washington University, St. Louis, Missouri, United States of America
- Department of Anesthesiology and Pain Medicine; Inselspital, Bern University Hospital; University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Nahel N. Saied
- Department of Anesthesiology and Critical Care, University of Arkansas Medical Sciences, Little Rock, Arkansas, United States of America
| | - Andreas S. Kokoefer
- Department of Anesthesiology, Washington University, St. Louis, Missouri, United States of America
- Department of Anesthesiology, Perioperative Care and Intensive Care Medicine, Paracelsus Medical University Salzburg, Strubergasse, Salzburg, Austria
| | - Lina Saffour
- Department of Anesthesiology, Washington University, St. Louis, Missouri, United States of America
| | - Jonathan K. Zoller
- Department of Anesthesiology, Washington University, St. Louis, Missouri, United States of America
| | - Mohammad A. Helwani
- Department of Anesthesiology, Washington University, St. Louis, Missouri, United States of America
- * E-mail:
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262
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Qamar A, Bangalore S. Biomarkers to Personalize Preoperative Cardiovascular Risk Stratification: Ready for Prime Time? Ann Intern Med 2020; 172:149-150. [PMID: 31869831 DOI: 10.7326/m19-3718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Arman Qamar
- New York University Grossman School of Medicine, New York, New York (A.Q., S.B.)
| | - Sripal Bangalore
- New York University Grossman School of Medicine, New York, New York (A.Q., S.B.)
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263
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Duceppe E, Patel A, Chan MTV, Berwanger O, Ackland G, Kavsak PA, Rodseth R, Biccard B, Chow CK, Borges FK, Guyatt G, Pearse R, Sessler DI, Heels-Ansdell D, Kurz A, Wang CY, Szczeklik W, Srinathan S, Garg AX, Pettit S, Sloan EN, Januzzi JL, McQueen M, Buse GL, Mills NL, Zhang L, Sapsford R, Paré G, Walsh M, Whitlock R, Lamy A, Hill S, Thabane L, Yusuf S, Devereaux PJ. Preoperative N-Terminal Pro-B-Type Natriuretic Peptide and Cardiovascular Events After Noncardiac Surgery: A Cohort Study. Ann Intern Med 2020; 172:96-104. [PMID: 31869834 DOI: 10.7326/m19-2501] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Preliminary data suggest that preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) may improve risk prediction in patients undergoing noncardiac surgery. OBJECTIVE To determine whether preoperative NT-proBNP has additional predictive value beyond a clinical risk score for the composite of vascular death and myocardial injury after noncardiac surgery (MINS) within 30 days after surgery. DESIGN Prospective cohort study. SETTING 16 hospitals in 9 countries. PATIENTS 10 402 patients aged 45 years or older having inpatient noncardiac surgery. MEASUREMENTS All patients had NT-proBNP levels measured before surgery and troponin T levels measured daily for up to 3 days after surgery. RESULTS In multivariable analyses, compared with preoperative NT-proBNP values less than 100 pg/mL (the reference group), those of 100 to less than 200 pg/mL, 200 to less than 1500 pg/mL, and 1500 pg/mL or greater were associated with adjusted hazard ratios of 2.27 (95% CI, 1.90 to 2.70), 3.63 (CI, 3.13 to 4.21), and 5.82 (CI, 4.81 to 7.05) and corresponding incidences of the primary outcome of 12.3% (226 of 1843), 20.8% (542 of 2608), and 37.5% (223 of 595), respectively. Adding NT-proBNP thresholds to clinical stratification (that is, the Revised Cardiac Risk Index [RCRI]) resulted in a net absolute reclassification improvement of 258 per 1000 patients. Preoperative NT-proBNP values were also statistically significantly associated with 30-day all-cause mortality (less than 100 pg/mL [incidence, 0.3%], 100 to less than 200 pg/mL [incidence, 0.7%], 200 to less than 1500 pg/mL [incidence, 1.4%], and 1500 pg/mL or greater [incidence, 4.0%]). LIMITATION External validation of the identified NT-proBNP thresholds in other cohorts would reinforce our findings. CONCLUSION Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30 days after noncardiac surgery and improves cardiac risk prediction in addition to the RCRI. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Emmanuelle Duceppe
- University of Montreal, Montreal, Québec, and McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (E.D.)
| | - Ameen Patel
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.C., L.Z.)
| | - Otavio Berwanger
- Hospital Israelita Albert Einstein (Academic Research Organization-ARO), Sao Paulo, Brazil (O.B.)
| | - Gareth Ackland
- Translational Medicine & Therapeutics William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom (G.A., R.P.)
| | - Peter A Kavsak
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Reitze Rodseth
- University of KwaZulu-Natal, Glenwood, Durban, South Africa (R.R.)
| | - Bruce Biccard
- Groote Schuur Hospital and University of Cape Town, Western Cape, South Africa (B.B.)
| | - Clara K Chow
- Westmead Applied Research Centre, University of Sydney, Sydney, and Westmead Hospital, Westmead, Australia (C.K.C.)
| | - Flavia K Borges
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - Gordon Guyatt
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Rupert Pearse
- Translational Medicine & Therapeutics William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom (G.A., R.P.)
| | | | - Diane Heels-Ansdell
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Andrea Kurz
- Cleveland Clinic, Cleveland, Ohio (D.I.S., A.K.)
| | - Chew Yin Wang
- University of Malaya, Kuala Lumpur, Malaysia (C.Y.W.)
| | | | | | - Amit X Garg
- Western University, London, Ontario, Canada (A.X.G.)
| | - Shirley Pettit
- Population Health Research Institute, Hamilton, Ontario, Canada (S.P.)
| | - Erin N Sloan
- University of British Columbia, Vancouver, British Columbia, Canada (E.N.S.)
| | - James L Januzzi
- Massachusetts General Hospital, Harvard Medical School, and Baim Institute for Clinical Research, Boston, Massachusetts (J.L.J.)
| | - Matthew McQueen
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | | | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Sciences and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom (N.L.M.)
| | - Lin Zhang
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.C., L.Z.)
| | | | - Guillaume Paré
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - Michael Walsh
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - Richard Whitlock
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - Andre Lamy
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - Stephen Hill
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Lehana Thabane
- McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.)
| | - Salim Yusuf
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
| | - P J Devereaux
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.)
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Zhao BC, Liu WF, Deng QW, Zhuang PP, Liu J, Li C, Liu KX. Meta-analysis of preoperative high-sensitivity cardiac troponin measurement in non-cardiac surgical patients at risk of cardiovascular complications. Br J Surg 2020; 107:e81-e90. [PMID: 31903596 DOI: 10.1002/bjs.11305] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 06/03/2019] [Accepted: 06/07/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Patients undergoing major non-cardiac surgery are at risk of cardiovascular complications. Raised levels of high-sensitivity troponin are frequently detected before operation among these patients. However, the prognostic value of high-sensitivity troponin in predicting postoperative outcomes remains unclear.
Methods
A systematic search of PubMed, Embase and Science Citation Index Expanded was undertaken for observational studies published before March 2018 that reported associations between raised preoperative levels of high-sensitivity troponin and postoperative major adverse cardiac events and/or mortality after non-cardiac surgery. Meta-analyses were performed, where possible, using random-effects models.
Results
Seven cohort studies with a total of 4836 patients were included. A raised preoperative high-sensitivity troponin level was associated with a higher risk of short-term major adverse cardiac events (risk ratio (RR) 2·92, 95 per cent c.i. 1·96 to 4·37; I2 = 82·6 per cent), short-term mortality (RR 5·39, 3·21 to 9·06; I2 = 0 per cent) and long-term mortality (RR 2·90, 1·83 to 4·59, I2 = 74·2 per cent). The addition of preoperative high-sensitivity troponin measurement provided improvements in cardiovascular risk discrimination (increase in C-index ranged from 0·058 to 0·109) and classification (quantified by continuous net reclassification improvement) compared with Lee's Revised Cardiac Risk Index alone. There was substantial heterogeneity and inadequate risk stratification analysis in the included studies.
Conclusion
Raised preoperative levels of high-sensitivity troponin appear to represent a risk for postoperative major adverse cardiac events and mortality. Further study is required before high-sensitivity troponin can be used to predict risk stratification in routine clinical practice.
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Affiliation(s)
- B-C Zhao
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - W-F Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Q-W Deng
- Department of Anaesthesiology, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - P-P Zhuang
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - J Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - C Li
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - K-X Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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265
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Chen X, Ma Y, Deng Z, Li Q, Liao J, Zheng Q. Prediction of Early Postoperative Major Cardiac Events and In-Hospital Mortality in Elderly Hip Fracture Patients: The Role of Different Types of Preoperative Cardiac Abnormalities on Echocardiography Report. Clin Interv Aging 2020; 15:755-762. [PMID: 32546993 PMCID: PMC7266334 DOI: 10.2147/cia.s250620] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Transthoracic echocardiography (TTE) is a common cardiac screening test before hip fracture surgery. However, the general TTE test delays surgery, so it would be meaningful if we could simplify the TTE by only assessing cardiac abnormality specifically. Therefore, we aimed to establish the most clinically relevant abnormality by comparing the predictive value of each major cardiac abnormality in postoperative cardiac complications and mortality in elderly hip fracture patients. PATIENTS AND METHODS From January 2014 to January 2019, the medical records of all surgically treated elderly patients (>65 years) with hip fracture were analyzed. The major TTE abnormalities were defined as left ventricular hypertrophy, systolic pulmonary arterial pressure >25 mm Hg, moderate-severe valve abnormality, left ventricular ejection fraction (LVEF) <50%, and pericardial effusion. The outcomes were postoperative cardiac complications and in-hospital mortality. RESULTS There were 354 patients involved finally. Postoperative cardiac complications were encountered in 7.6% (n=27) of patients. The mortality rate was 2.8% (n=10). History of coronary artery disease (CAD) (OR: 3.281, 95% CI: 1.332-8.079, p=0.010) and presence of aortic stenosis (AS) (OR:5.656, 95% CI: 1.869-17.117, p=0.002) were independent predictors of postoperative cardiac complications. In addition, age (OR: 1.264, 95% CI: 1.047-1.527, p=0.015), history of CAD (OR: 19.290, 95% CI: 2.002-185.885, p=0.010), presence of AS (OR:7.164, 95% CI: 1.988-51.413, p=0.040) and LVEF <50% (OR:8.803, 95% CI: 1.115-69.472, p=0.039) were independent predictors of mortality. However, the rest of preoperative TTE abnormalities were not associated with postoperative cardiac complications or mortality. CONCLUSION Among the TTE abnormalities presented by elderly patients with hip fracture, moderate-severe AS was the predictor of postoperative cardiac complications. Moreover, moderate-severe AS and LVEF <50% were the predictors of in-hospital mortality. Therefore, we could simplify the TTE process by assessing aortic valve and LVEF specifically on focused echocardiography, which could avoid surgery delay.
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Affiliation(s)
- Xuepan Chen
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
- Shantou University Medical College, Shantou, People’s Republic of China
| | - Yuanchen Ma
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - Zhantao Deng
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - Qingtian Li
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - JunXing Liao
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - Qiujian Zheng
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
- Correspondence: Qiujian Zheng Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, School of Medicine, South China University of Technology, No. 106, Zhongshan Second Road, Yuexiu District, Guangzhou510000, People’s Republic of China Email
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266
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Kuthiah N, Er C. Myocardial injury in non-cardiac surgery: complexities and challenges. Singapore Med J 2020; 61:6-8. [DOI: 10.11622/smedj.2020004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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267
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Ruzycki SM, Prystajecky M, Driedger MR, Kachra R. Peri-operative cardiac biomarker screening: a narrative review. Anaesthesia 2020; 75 Suppl 1:e165-e173. [PMID: 31903570 DOI: 10.1111/anae.14920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2019] [Indexed: 12/26/2022]
Abstract
Peri-operative risk estimation has traditionally focused on assessing the likelihood of postoperative morbidity and mortality using pre-operative functional assessment. Although this strategy is currently recommended by most major society guidelines, contemporary evidence suggests that cardiac biomarker measurement has important advantages over pre-operative functional assessment. These advantages include superior predictive discrimination and inclusion of the postoperative course in risk estimation. In this review, we provide an overview of the evidence supporting the peri-operative utilisation, compare risk estimation methods and discuss which patients may benefit most from cardiac biomarker screening. We also discuss protocols for biomarker screening and management of patients with abnormal results.
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Affiliation(s)
- S M Ruzycki
- Department of Medicine, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - M Prystajecky
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - M R Driedger
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - R Kachra
- Division of General Internal Medicine, Department of Medicine, University of Calgary, AB, Canada
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268
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Perioperative Assessment of High-Risk Abdominal Surgery: A Case Study. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2020; 8:374-382. [PMID: 32775620 PMCID: PMC7413206 DOI: 10.12691/ajmcr-8-10-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objectives • To outline the key components of a pre-operative cardiac risk assessment. • To review the major guidelines utilized to assess patients' surgical risks. • To discuss the perioperative management of surgical patients to prevent cardiac and pulmonary complications. • To review the utility of biomarkers in the pre- and post-operative period.
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269
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Carlesso LC, Skou ST, Tang LH, Simonÿ C, Brooks D. Multimorbidity: Making the Case for an End to Disease-Specific Rehabilitation. Physiother Can 2020; 72:1-3. [PMID: 34385742 PMCID: PMC8330980 DOI: 10.3138/ptc-72-1-gee] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Lisa C. Carlesso
- School of Rehabilitation Science, McMaster University
- Research Institute of St. Joseph’s Hospital, Hamilton, Ont
- School of Rehabilitation, Université de Montréal, Montreal, Que
| | - Søren T. Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics
- Department of Physiotherapy and Occupational Therapy
| | - Lars H. Tang
- Department of Physiotherapy and Occupational Therapy
- National Centre for Rehabilitation and Palliative Care, University of Southern Denmark and Odense University Hospital, Nyborg, Denmark
| | - Charlotte Simonÿ
- Institute of Regional Health, University of Southern Denmark, Odense
- Department of Physiotherapy and Occupational Therapy
- Department of Research, Naestved-Slagelse-Ringsted Hospitals, Region Zealand, Slagelse
| | - Dina Brooks
- School of Rehabilitation Science, McMaster University
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270
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Matsuoka T, Kobayashi K, Lefor AK, Sasaki J, Shinozaki H. Antithrombotic drugs do not increase intraoperative blood loss in emergency gastrointestinal surgery: a single-institution propensity score analysis. World J Emerg Surg 2019; 14:63. [PMID: 31892938 PMCID: PMC6938014 DOI: 10.1186/s13017-019-0284-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/18/2019] [Indexed: 12/26/2022] Open
Abstract
Background The use of antithrombotic drugs is increasing with the aging population. Prior to elective procedures, antithrombotic drugs are often discontinued. For emergency procedures in patients taking antithrombotic drugs, their effect cannot be attenuated which may lead to an increased risk of hemorrhagic events. However, there are few studies showing increased intraoperative blood loss in patients taking antithrombotic drugs who undergo emergency gastrointestinal surgery. The aim of this study is to determine whether the use of antithrombotic agents increases intraoperative blood loss in emergency gastrointestinal surgery. Methods A retrospective review of patients who underwent emergency abdominal surgery between January 2013 and December 2017 was conducted. The primary outcome measure was intraoperative blood loss. Patients were divided into the antithrombotic drug group and a control group, and a propensity score was developed using multivariate logistic regression. We use 1:1 propensity score matching analysis to compare outcomes between the two groups. Results Of 1555 patients included in this study, 1184 patients, including 170 patients taking antithrombotic drugs, were eligible for propensity score matching analysis. A 1:1 matching yielded 117 well-balanced pairs. There was no statistically significant difference in intraoperative blood loss (antithrombotic drug group vs control group, median (interquartile): 60 (225–10) vs 100 (243–10) ml, p = 0.43). Conclusions This study suggests that antithrombotic drugs do not increase intraoperative blood loss in patients undergoing emergency gastrointestinal surgery. Emergency gastrointestinal surgery for patients currently taking antithrombotic drugs can be performed safely, and the use of antithrombotic drugs is not a reason to delay surgical intervention.
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Affiliation(s)
- Tadashi Matsuoka
- 1Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan.,2Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Kenji Kobayashi
- 1Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | | | - Junichi Sasaki
- 2Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
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271
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Weyker PD, Webb CAJ. Establishing a patient centered, outpatient total joint home recovery program within an integrated healthcare system. Pain Manag 2019; 10:23-41. [PMID: 31852383 DOI: 10.2217/pmt-2019-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Outpatient total joint home recovery (HR) is a rapidly growing initiative being developed and employed at high volume orthopedic centers. Minimally invasive surgery, improved pain control and home health services have made HR possible. Multidisciplinary teams with members ranging from surgeons and anesthesiologists to hospital administrators, physical therapists, nurses and research analysts are necessary for success. Eligibility criteria for outpatient total joint arthroplasty will vary between medical centers. Surgeon preference in addition to medical comorbidities, social support, preoperative patient mobility and safety of the HR location are all factors to consider when selecting patients for outpatient total joint HR. As additional knowledge is gained, the next steps will be to establish 'best practices' and speciality society-endorsed guidelines for patients undergoing outpatient total joint arthroplasty.
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Affiliation(s)
- Paul David Weyker
- Department of Anesthesia & Perioperative Medicine, The Permanente Medical Group of Northern California, South San Francisco, CA 94080, USA.,Department of Clinical Sciences, Kaiser Permanente School of Medicine, Pasadena, CA 91101, USA
| | - Christopher Allen-John Webb
- Department of Clinical Sciences, Kaiser Permanente School of Medicine, Pasadena, CA 91101, USA.,Department of Anesthesia & Perioperative Medicine, The Permanente Medical Group of Northern California, South San Francisco, CA 94080, USA.,Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA 94143, USA
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272
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Abstract
ZusammenfassungErhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.
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273
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Tsialtas D, Bolognesi MG, Assimopoulos S, Volpi R, Bolognesi R. Electrocardiographic and echocardiographic features in patients with major arterial vascular disease assigned to surgical revascularization. Acta Cardiol 2019; 74:501-507. [PMID: 30507282 DOI: 10.1080/00015385.2018.1528665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background: We aimed to depict the electrocardiographic and echocardiographic aspects in patients before elective major vascular surgery.Methods: We evaluated through standard 12 lead electrocardiography and transthoracic echocardiography 469 patients with asymptomatic large abdominal aortic aneurysm (AAA), 334 with critical carotid stenosis (CAS), and 238 with advanced peripheral artery disease (PAD) before surgical revascularization.Results: Patients with AAA were predominantly males (p < .001) with normal sinus rhythm (p = .026), were more affected by atrioventricular block (p = .033) and left anterior fascicular block (p < .001). They also presented larger aortic root size (p < .001) and septal hypertrophy (p = .036), in addition, atrial fibrillation was less frequent in the same group (p = .023). Patients with CAS were of older age (p < .001) with a substantial number of females (p < .001). They presented less left ventricular segmental kinetic disorders and fewer dilated ventricles (p = .004 and p < .001 respectively). Finally, those with PAD had reduced septal and posterior wall thickness (p < .01, p = .009 respectively), greater mitral and aortic annular calcification (p < .001), and were more affected by previous myocardial infarction (p < .001). The PR interval, left anterior fascicular block and aortic root size were independently associated with aneurysm, previous myocardial infarction with PAD, while smaller left ventricular end systolic volumes with carotid artery stenosis.Conclusions: Patients with AAA were mostly affected by cardiac conduction disorders, septal hypertrophy, aortic root dilation and less affected by atrial fibrillation. Patients with CAS were older with more normal sized ventricles, whereas, previous myocardial infarction was most common amongst patients with peripheral artery disease.
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Affiliation(s)
- Dimitri Tsialtas
- Dipartimento di Medicina Interna e Scienze Biomediche, Sezione di Cardiologia, Università degli Studi di Parma, Parma, Italy
| | - Maria Giulia Bolognesi
- Dipartimento di Medicina Interna e Scienze Biomediche, Sezione di Cardiologia, Università degli Studi di Parma, Parma, Italy
| | - Stephania Assimopoulos
- Faculty of Medicine, Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Riccardo Volpi
- Dipartimento di Medicina Interna e Scienze Biomediche, Sezione di Cardiologia, Università degli Studi di Parma, Parma, Italy
| | - Roberto Bolognesi
- Dipartimento di Medicina Interna e Scienze Biomediche, Sezione di Cardiologia, Università degli Studi di Parma, Parma, Italy
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274
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Kim H. Pneumoperitoneum in laparoscopy and preoperative antihypertensive agents: A retrospective study. Exp Ther Med 2019; 18:4517-4522. [PMID: 31777554 DOI: 10.3892/etm.2019.8076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/29/2019] [Indexed: 11/06/2022] Open
Abstract
The purpose of the current study was to investigate the effects of preoperative antihypertensive agents on blood pressure (BP) changes after intraperitoneal CO2 insufflation during laparoscopic surgery. The medical records of patients (≥50 years old) undergoing laparoscopic colon surgery were retrospectively analyzed (n=342). The patients were divided into four groups: normotensive group (group N), monotherapy with angiotensin receptor blockers (ARBs) (group A), monotherapy with calcium channel blockers (CCBs) (group C), and combination therapy with ARBs and CCBs (group AC). The systolic BP changes were investigated, and their correlations with preoperative pulse pressure were analyzed. The degree of increase from baseline BP to that after CO2 insufflation was significantly lower in groups A [difference vs. group N, 17.8; 95% confidence interval (CI), 7.8-27.8; P=0.001) and AC (18.2; 95% CI, 8.7-27.7; P<0.001] compared with groups N and C. The incidence of intraoperative hypotension was not significantly different among the groups. In groups A and AC, the preoperative pulse pressure showed a strong correlation (r=0.73 and 0.83, respectively) with the increase in BP after CO2 insufflation. In conclusion, patients with hypertension who received ARBs before surgery showed a strong correlation between the preoperative pulse pressure and BP fluctuation immediately after CO2 insufflation. Small BP fluctuations are suggested to indicate the positive role of ARBs. Large randomized controlled trials are required to validate these results and assess the effect of each antihypertensive agent. This trial was registered (Trial registration: http://www.who.int/ictrp/network/cris2/en/; CRIS; KCT0002595) on the 23 November 2017.
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Affiliation(s)
- Hyunjee Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
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275
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Slagelse C, Gammelager H, Iversen LH, Liu KD, Sørensen HTT, Christiansen CF. Renin-angiotensin system blocker use and the risk of acute kidney injury after colorectal cancer surgery: a population-based cohort study. BMJ Open 2019; 9:e032964. [PMID: 31753901 PMCID: PMC6887015 DOI: 10.1136/bmjopen-2019-032964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES It is unknown whether preoperative use of ACE inhibitors (ACE-I) or angiotensin receptor blockers (ARBs) affects the risk of acute kidney injury (AKI) after colorectal cancer (CRC) surgery. We assessed the impact of preoperative ACE-I/ARB use on risk of AKI after CRC surgery. DESIGN Observational cohort study. Patients were divided into three exposure groups-current, former and non-users-through reimbursed prescriptions within 365 days before the surgery. AKI within 7 days after surgery was defined according to the current Kidney Disease Improving Global Outcome consensus criteria. SETTING Population-based Danish medical databases. PARTICIPANTS A total of 9932 patients undergoing incident CRC surgery during 2005-2014 in northern Denmark were included through the Danish Colorectal Cancer Group Database. OUTCOME MEASURE We computed cumulative incidence proportions (risk) of AKI with 95% CIs for current, former and non-users of ACE-I/ARB, including death as a competing risk. We compared current and former users with non-users by computing adjusted risk ratios (aRRs) using log-binomial regression adjusted for demographics, comorbidities and CRC-related characteristics. We stratified the analyses of ACE-I/ARB users to address any difference in impact within relevant subgroups. RESULTS Twenty-one per cent were ACE-I/ARB current users, 6.4% former users and 72.3% non-users. The 7-day postoperative AKI risk for current, former and non-users was 26.4% (95% CI 24.6% to 28.3%), 25.2% (21.9% to 28.6%) and 17.8% (17.0% to 18.7%), respectively. The aRRs of AKI were 1.20 (1.09 to 1.32) and 1.16 (1.01 to 1.34) for current and former users, compared with non-users. The relative risk of AKI in current compared with non-users was consistent in all subgroups, except for higher aRR in patients with a history of hypertension. CONCLUSIONS Being a current or former user of ACE-I/ARBs is associated with an increased risk of postoperative AKI compared with non-users. Although it may not be a drug effect, users of ACE-I/ARBs should be considered a risk group for postoperative AKI.
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Affiliation(s)
- Charlotte Slagelse
- Department of Clinical Epidemiology, Aarhus Universitetshospital, Aarhus N, Denmark
- Department of Anesthesiology, Regional Hospital West Jutland, Herning, Denmark
| | - H Gammelager
- Department of Clinical Epidemiology, Aarhus Universitetshospital, Aarhus N, Denmark
- Department of Intensive Care, Aarhus Universitetshospital, Aarhus N, Denmark
| | | | - Kathleen D Liu
- Department of Medicine, Division of Nephrology, School of Medicine, University of California San Francisco, San Francisco, California, USA
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276
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Effects of Volatile versus Total Intravenous Anesthesia on Occurrence of Myocardial Injury after Non-Cardiac Surgery. J Clin Med 2019; 8:jcm8111999. [PMID: 31731805 PMCID: PMC6912591 DOI: 10.3390/jcm8111999] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/03/2019] [Accepted: 11/13/2019] [Indexed: 12/23/2022] Open
Abstract
The cardioprotective effects of volatile anesthetics versus total intravenous anesthesia (TIVA) are controversial, especially in patients undergoing non-cardiac surgery. Using current generation high-sensitivity cardiac troponin (hs-cTn), we aimed to evaluate the effect of anesthetics on the occurrence of myocardial injury after non-cardiac surgery (MINS). From February 2010 to December 2016, 3555 patients without preoperative hs-cTn elevation underwent non-cardiac surgery under general anesthesia. Patients were grouped according to anesthetic agent; 659 patients were classified into a propofol-remifentanil total intravenous anesthesia (TIVA) group, and 2896 patients were classified into a volatile group. To balance the use of remifentanil between groups, a balanced group (n = 1622) was generated with patients who received remifentanil infusion in the volatile group, and two separate comparisons were performed (TIVA vs. volatile and TIVA vs. balanced). The primary outcome was occurrence of MINS, defined as rise of hs-cTn I ≥ 0.04 ng/mL within postoperative 48 hours. The secondary outcomes were 30-day mortality, postoperative acute kidney injury (AKI), and adverse events during hospital stay (mortality, type I myocardial infarction (MI), and new-onset arrhythmia). In propensity-matched analyses, the occurrence of MINS was lower in the TIVA group compared to the volatile group (OR 0.642; 95% CI 0.450–0.914; p = 0.014). However, after balancing the use of remifentanil, there was no difference between groups in the risk of MINS (OR 0.832; 95% CI 0.554–1.251; p-value = 0.377). There were no significant associations between the two groups in type 1 MI, new-onset atrial fibrillation, in-hospital and 30-day mortality before and after balancing the use of remifentanil. However, the incidence of postoperative AKI was lower in the TIVA group (OR 0.362; 95% CI 0.194–0.675; p-value = 0.001). After balancing the use of remifentanil, volatile anesthesia and TIVA showed comparable effects on MINS in patients undergoing non-cardiac surgery without preoperative myocardial injury. Further studies are needed on the benefit of remifentanil infusion.
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277
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Koutsaki M, Patoulias D, Tsinivizov P, Doumas M, Kallistratos M, Thomopoulos C, Poulimenos L, Agnelli G, Mancia G, Manolis A. Evaluation, risk stratification and management of hypertensive patients in the perioperative period. Eur J Intern Med 2019; 69:1-7. [PMID: 31606306 DOI: 10.1016/j.ejim.2019.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/18/2019] [Accepted: 09/15/2019] [Indexed: 12/19/2022]
Abstract
Uncontrolled hypertension represents an important cause for postponing a non-cardiac surgery. Perioperative management of hypertensive patients should focus on cardiovascular risk stratification, evaluation of blood pressure levels and hypertension control, registration of the ongoing antihypertensive regimen and counseling about clinical decisions related to the expected perioperative blood pressure fluctuations. To date, there is a lack of evidence on how hypertensive patients should be perioperatively treated, while an empirical clinical approach is usually pursued in the usual practice. The present review appraises the gaps in the evidence and illustrates the current empirical approach of perioperative management of hypertension in non-cardiac surgery.
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Affiliation(s)
- Maria Koutsaki
- Department of Cardiology, Asklepeion General Hospital, Athens, Greece
| | - Dimitrios Patoulias
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pavlos Tsinivizov
- Department of Cardiology, Asklepeion General Hospital, Athens, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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278
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, 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 & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, 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 healthcare 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
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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279
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Moussa Pacha H, Al-Khadra Y, Darmoch F, Soud M, Mamas MA, Moussa Pacha A, Zaitoun A, Kaki A, AlJaroudi WA, Alraies MC. In-hospital outcome of peripheral vascular intervention in dialysis-dependent end-stage renal disease patients. Catheter Cardiovasc Interv 2019; 95:E84-E95. [PMID: 31631511 DOI: 10.1002/ccd.28522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 08/26/2019] [Accepted: 09/17/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND The impact of end-stage renal disease (ESRD) on peripheral vascular intervention (PVI) outcome remains incompletely elucidated. OBJECTIVES We sought to compare the outcome of PVI in dialysis patients with those with normal kidney function. METHODS Using weighted data from the National Inpatient Sample database between 2002 and 2014, we identified all peripheral artery disease (PAD) patients aged ≥18 years that underwent PVI. Multivariate logistic regression analysis was performed to examine in-hospital outcomes. RESULTS Of 1,186,192 patients who underwent PVI, 1,066,830 had normal kidney function (89.9%) and 119,362 had ESRD requiring dialysis (10.1%). Critical limb ischemia was more prevalent in dialysis patients (63.2 vs. 34.0%, p < .001). Compared with normal kidney function group, ESRD requiring dialysis was associated with higher in-hospital mortality (1.5 vs. 4.2%, adjusted OR: 2.13 [95% CI: 2.04-2.23]) and longer length of hospital stay (median 3 days, Interquartile range [IQR] (0-6) vs. 7 days, IQR (4-18); p < .001). Dialysis patients had higher incidence of major adverse cardiovascular events (composite of death, myocardial infarction, or stroke; 14.3 vs. 9.8%, p < .001) and net adverse cardiovascular events (composite of MACE, major bleeding, or vascular complications; 40.8 vs. 29.1%, p < .001). ESRD patients less frequently underwent open bypass (5.6 vs. 8.5%, p < .001) and more frequently had major amputation (10.3 vs. 3.0%, p < .001) compared with normal kidney function group. CONCLUSION PAD patients on dialysis who underwent PVI have higher rates of mortality and adverse outcomes as compared to those with normal kidney function.
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Affiliation(s)
- Homam Moussa Pacha
- Cardiology Department, McGovern Medical School, Memorial Hermann Heart & Vascular Institute, University of Texas Health Science Center, Houston, Texas
| | - Yasser Al-Khadra
- Internal Medicine Department, Cleveland Clinic, Medicine Institute, Cleveland, Ohio
| | - Fahed Darmoch
- Internal Medicine Department, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Mohamad Soud
- Cardiology Department, Rutgers University, New Brunswick, New Jersey
| | - Mamas A Mamas
- Cardiology Department, Keele Cardiovascular Group, Centre for Prognosis Research, Institute of primary Care and Health sciences, Keele University, Stoke-on-Trent, UK
- Cardiology Department, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - Anwar Zaitoun
- Cardiology Department, St. John Hospital and Medical center, Detroit, Michigan
| | - Amir Kaki
- Cardiology Department, St. John Hospital and Medical center, Detroit, Michigan
| | - Wael A AlJaroudi
- Cardiology Department, Clemenceau Medical Center, Beirut, Lebanon
| | - M Chadi Alraies
- Cardiology Department, Detroit Medical Center, Wayne State University, Detroit Heart Hospital, Detroit, Michigan
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280
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Czobor NR, Lehot JJ, Holndonner-Kirst E, Tully PJ, Gal J, Szekely A. Frailty In Patients Undergoing Vascular Surgery: A Narrative Review Of Current Evidence. Ther Clin Risk Manag 2019; 15:1217-1232. [PMID: 31802876 PMCID: PMC6802734 DOI: 10.2147/tcrm.s217717] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/01/2019] [Indexed: 12/13/2022] Open
Abstract
Frailty is presumably associated with an elevated risk of postoperative mortality and adverse outcome in vascular surgery patients. The aim of our review was to identify possible methods for risk assessment and prehabilitation in order to improve recovery and postoperative outcome. The literature search was performed via PubMed, Embase, OvidSP, and the Cochrane Library. We collected papers published in peer-reviewed journals between 2001 and 2018. The selection criterion was the relationship between vascular surgery, frailty and postoperative outcome or mortality. A total number of 52 publications were included. Frailty increases the risk of non-home discharge independently of presence or absence of postoperative complications and it is related to a higher 30-day mortality and major morbidity. The modified Frailty Index showed significant association with elevated risk for post-interventional stroke, myocardial infarction, prolonged in-hospital stays and higher readmission rates. When adjusted for comorbidity and surgery type, frailty seems to impact medium-term survival (within 2 years). Preoperative physical exercising, avoidance of hypalbuminemia, psychological and cognitive training, maintenance of muscle strength, adequate perioperative nutrition, and management of smoking behaviours are leading to a reduced length of stay and a decreased incidence of readmission rate, thus improving the effectiveness of early rehabilitation. Pre-frailty is a dynamically changing state of the patient, capable of deteriorating or improving over time. With goal-directed preoperative interventions, the decline can be prevented.
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Affiliation(s)
- Nikoletta Rahel Czobor
- Medical Centre of Hungarian Defense Forces, Department of Anesthesiology and Intensive Care, Budapest, Hungary.,Semmelweis University, School of Doctoral Studies, Budapest, Hungary
| | - Jean-Jacques Lehot
- Claude-Bernard University, Health Services and Performance Research Lab (EA 7425 HESPER), Lyon, France.,Hôpital Neurologique Pierre Wertheimer, Department of Neuroanesthesia and Intensive Care, Hospices Civils de Lyon, Lyon, France
| | - Eniko Holndonner-Kirst
- Medical Centre of Hungarian Defense Forces, Department of Anesthesiology and Intensive Care, Budapest, Hungary
| | - Phillip J Tully
- University of Adelaide, Freemasons Foundation Centre for Men's Health, Adelaide, Australia
| | - Janos Gal
- Semmelweis University, Department of Anesthesiology and Intensive Care, Budapest, Hungary
| | - Andrea Szekely
- Semmelweis University, Department of Anesthesiology and Intensive Care, Budapest, Hungary.,Semmelweis University, Heart and Vascular Center of Városmajor, Budapest, Hungary
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281
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The Extended Postoperative Care-Score (EXPO-Score)-An Objective Tool for Early Identification of Indication for Extended Postoperative Care. J Clin Med 2019; 8:jcm8101666. [PMID: 31614741 PMCID: PMC6832365 DOI: 10.3390/jcm8101666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 11/16/2022] Open
Abstract
Extended postoperative care and intensive care unit capacity is limited and efficient patient allocation is mandatory. This study aims to develop an effective yet simple score to predict indication for extended postoperative care, as there is a lack of objective criteria for early prediction of admission to extended care in surgical patients. This prospective observational study was divided into two periods (Period 1: Extended Postoperative Care-Score (EXPO)-Score generation; Period 2: EXPO-Score validation) and it was performed at a tertiary university center in Germany. A total of 4042 (Period 1) and 2198 (Period 2) adult patients ≥ 18 years old receiving elective or emergency surgery were included in this study. After identifying patient- and surgery-related risk factors by an expert panel, the EXPO-Score was developed through logistic regression from data of Period 1 and validated in Period 2. Three risk factors are sufficient for generating a reliable predictive EXPO-Score: (1) the American Society of Anesthesiologists’ (ASA) physical status, (2) cardiopulmonary physical exercise status expressed in metabolic equivalents (MET), and (3) the type of surgery. The score threshold (0.23) has a sensitivity of 0.87, a specificity of 0.91, and an accuracy of 0.90 for predicting indication for extended postoperative care. The EXPO-Score provides a validated, early collectable, and easy-to-use tool for predicting indication of extended postoperative care in adult surgical patients.
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282
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Fronczek J, Polok K, Devereaux P, Górka J, Archbold R, Biccard B, Duceppe E, Le Manach Y, Sessler D, Duchińska M, Szczeklik W. External validation of the Revised Cardiac Risk Index and National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest calculator in noncardiac vascular surgery. Br J Anaesth 2019; 123:421-429. [DOI: 10.1016/j.bja.2019.05.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/20/2019] [Accepted: 05/03/2019] [Indexed: 12/24/2022] Open
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283
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Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 138:e484-e594. [PMID: 30354654 DOI: 10.1161/cir.0000000000000596] [Citation(s) in RCA: 220] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul K Whelton
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Robert M Carey
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Wilbert S Aronow
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Donald E Casey
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Karen J Collins
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Cheryl Dennison Himmelfarb
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sondra M DePalma
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Samuel Gidding
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Kenneth A Jamerson
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Daniel W Jones
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Eric J MacLaughlin
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Paul Muntner
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Bruce Ovbiagele
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sidney C Smith
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Crystal C Spencer
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Randall S Stafford
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Sandra J Taler
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Randal J Thomas
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Kim A Williams
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Jeff D Williamson
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
| | - Jackson T Wright
- American Society for Preventive Cardiology Representative. †ACC/AHA Representative. ‡Lay Volunteer/Patient Representative. §Preventive Cardiovascular Nurses Association Representative. ‖American Academy of Physician Assistants Representative. ¶Task Force Liaison. #Association of Black Cardiologists Representative. **American Pharmacists Association Representative. ††ACC/AHA Prevention Subcommittee Liaison. ‡‡American College of Preventive Medicine Representative. §§American Society of Hypertension Representative. ‖‖Task Force on Performance Measures Liaison. ¶¶American Geriatrics Society Representative. ##National Medical Association Representative
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284
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Worrall DM, Tanella A, DeMaria S, Miles BA. Anesthesia and Enhanced Recovery After Head and Neck Surgery. Otolaryngol Clin North Am 2019; 52:1095-1114. [PMID: 31551127 DOI: 10.1016/j.otc.2019.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Enhanced recovery protocols have been developed from gastrointestinal, colorectal, and thoracic surgery populations. The basic tenets of head and neck enhanced recovery are: a multidisciplinary team working around the patient, preoperative carbohydrate loading, multimodal analgesia, early mobilization and oral feeding, and frequent reassessment and auditing of protocols to improve patient outcomes. The implementation of enhanced recovery protocols across surgical populations appear to decrease length of stay, reduce cost, and improve patient satisfaction without sacrificing patient quality of care or changing readmission rates. This article examines evidence-based enhanced recovery interventions and tailors them to a major head and neck surgery population.
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Affiliation(s)
- Douglas M Worrall
- Department of Otolaryngology, Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1189, New York, NY 10029, USA
| | - Anthony Tanella
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - Brett A Miles
- Department of Otolaryngology, Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1189, New York, NY 10029, USA.
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285
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Mahmood E, Khabbaz KR, Bose R, Mitchell J, Zhang Q, Chaudhary O, Mahmood F, Matyal R. Immediate Preoperative Transthoracic Echocardiography for the Prediction of Postoperative Atrial Fibrillation in High-Risk Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 34:719-725. [PMID: 31635984 DOI: 10.1053/j.jvca.2019.09.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/17/2019] [Accepted: 09/18/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The present study aimed to validate the utility of bedside cardiac ultrasound to identify patients for the risk of postoperative atrial fibrillation (POAF). DESIGN A prospective cohort study of consecutive patients. SETTING Single-center tertiary referral center. PARTICIPANTS After Institutional Review Board consent, 169 patients undergoing elective cardiac surgery were enrolled in the study. INTERVENTIONS A preoperative transthoracic echocardiographic interrogation assessing diastolic function was performed. Measurements were assessed offline with experienced echocardiographers blinded to clinical outcomes. MEASUREMENTS AND MAIN RESULTS The primary outcome was POAF during the first 72 hours after surgery. A total of 169 patients completed the study, 44 of whom (26.0%) developed POAF, and 39 (25.2%) had diastolic dysfunction. Patients with POAF had a higher rate of postoperative heart failure, reintubation within 24 hours of surgery, and length of stay (p = 0.002, 0.01, and 0.0006, respectively). Predictors significant for POAF included increasing age, left atrial volume indexed to body surface area (LAVI), and diastolic dysfunction (p = 0.02, 0.0001, and 0.001, respectively). Multivariate spline regressions demonstrated a nonlinear correlation between increasing LAVI and risk of POAF. CONCLUSION Left atrial volume can be assessed efficiently preoperatively to provide superior risk stratification over clinical factors and diastolic parameters alone for the prediction of POAF. Furthermore, the present study demonstrated that the cutoffs of chamber quantification currently used do not appropriately capture the increased risk of POAF. Thus, LAVI provides a simple measure to identify patients who are in need of targeted prophylaxis for POAF.
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Affiliation(s)
- Eitezaz Mahmood
- Department of Cardiothoracic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kamal R Khabbaz
- Department of Cardiothoracic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ruma Bose
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - John Mitchell
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Qianqian Zhang
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Omar Chaudhary
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Robina Matyal
- Department of Anesthesia and Critical Care, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA.
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286
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Abstract
PURPOSE OF REVIEW The present article reviews the recent literature on the main aspects of perioperative acute kidney injury (AKI). RECENT FINDINGS AKI occurs in 1 in every 10 surgical patients, with cardiac, orthopedic, and major abdominal surgeries being the procedures associated with the highest risk. Overall, complex operations, bleeding, and hemodynamic instability are the most consistent procedure-related risk factors for AKI. AKI increases hospital stay, mortality, and chronic kidney disease, gradually with severity. Furthermore, delayed renal recovery negatively impacts on patients' outcomes. Cell cycle arrest biomarkers seem promising to identify high-risk patients who may benefit from the bundles recommended by the Kidney Disease: Improving Global Outcomes guidelines. Hemodynamic management using protocol-based administration of fluids and vasopressors helps reducing AKI. Recent studies have highlighted the benefit of personalizing the blood pressure target according to the patient's resting reference, and avoiding both hypovolemia and fluid overload. Preliminary research has reported encouraging renoprotective effects of angiotensin II and nitric oxide, which need to be confirmed. Moreover, urinary oxygenation monitoring appears feasible and a fair predictor of postoperative AKI. SUMMARY AKI remains a frequent and severe postoperative complication. A personalizedmulticomponent approach might help reducing the risk of AKI and improving patients' outcomes.
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287
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[Preconditioning of the lungs and circulation before visceral and thoracic surgical interventions]. Chirurg 2019; 90:529-536. [PMID: 30919019 DOI: 10.1007/s00104-019-0943-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Estimation of the perioperative risk plays a decisive role in the surgical indications, particularly in view of the demographic change. For this reason, prehabilitation concepts for reducing perioperative risk nowadays play an increasingly important role. OBJECTIVE Presentation of the current recommendations for preoperative diagnostics in thoracic surgical interventions as well as existing prehabilitation concepts and their practical applicability. MATERIAL AND METHODS A selective review of the literature was carried out by searching the electronic databases PubMed, Cochrane Library and ISRCTN, including the guidelines of the American College of Chest Physicians (ACCP) and the European Society of Thoracic Surgery (ESTS). RESULTS Preconditioning includes the conservative treatment of underlying diseases, smoking cessation and prehabilitation. Prehabilitation is an increasingly pressing concept in routine clinical practice, even though the evidence is limited due to the very heterogeneous study situation. Overall, however, there is a tendency for positive effects on the quality of life and postoperative complications as well as convalescence. CONCLUSION In addition to preoperative diagnostics to assess the perioperative risk, effective preconditioning of patients is also necessary. For this an interdisciplinary approach including anesthesia, pneumology, psychotherapy and physiotherapy is necessary. In addition to the conservative medicinal optimization, prehabilitation concepts are gaining in importance and will certainly become established in routine clinical practice. From the surgical perspective, minimally invasive approaches and parenchyma-sparing resections also serve to reduce risks.
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288
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Brand JW, Mackay JH. A new VISION to improve cardiac risk stratification in non-cardiac surgery. Anaesthesia 2019; 75:11-14. [PMID: 31478188 DOI: 10.1111/anae.14834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2019] [Indexed: 11/30/2022]
Affiliation(s)
- J W Brand
- Department of Anaesthesia and Critical Care, James Cook University Hospital, Middlesbrough, UK
| | - J H Mackay
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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289
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Goeddel LA, Jung YH, Patel P, Upchurch P, Fernando RJ, Ramakrishna H. Analysis of the 2018 American Heart Association/American College of Cardiology Guidelines for the Management of Adults With Congenital Heart Disease: Implications for the Cardiovascular Anesthesiologist. J Cardiothorac Vasc Anesth 2019; 34:1348-1365. [PMID: 31494006 DOI: 10.1053/j.jvca.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Lee A Goeddel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Youn Hoa Jung
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Prakash Patel
- Department of Anesthesiology and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Patrick Upchurch
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Rohesh J Fernando
- Division of Cardiothoracic Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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290
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National risk prediction model for perioperative mortality in non-cardiac surgery. Br J Surg 2019; 106:1549-1557. [DOI: 10.1002/bjs.11232] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 04/04/2019] [Accepted: 04/12/2019] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Many multivariable models to calculate mortality risk after surgery are limited by insufficient sample size at development or by application to cohorts distinct from derivation populations. The aims of this study were to validate the Surgical Outcome Risk Tool (SORT) for a New Zealand population and to develop an extended NZRISK model to calculate 1-month, 1-year and 2-year mortality after non-cardiac surgery.
Methods
Data from the New Zealand National Minimum Data Set for patients having surgery between January 2013 and December 2014 were used to validate SORT. A random 75 per cent split of the data was used to develop the NZRISK model, which was validated in the other 25 per cent of the data set.
Results
External validation of SORT in the 360 140 patients who underwent surgery in the study period showed good discrimination (area under the receiver operating characteristic curve (AUROC) value of 0·906) but poor calibration (McFadden's pseudo-R2 0·137, calibration slope 5·32), indicating it was invalid in this national surgical population. Internal validation of the NZRISK model, which incorporates sex and ethnicity in addition to the variables used in SORT for 1-month, 1-year and 2-year outcomes, demonstrated excellent discrimination with AUROC values of 0·921, 0·904 and 0·895 respectively, and excellent calibration (McFadden's pseudo-R2 0·275, 0·308 and 0·312 respectively). Calibration slopes were 1·12, 1·02 and 1·02 respectively.
Conclusion
The SORT performed poorly in this national population. However, inclusion of sex and ethnicity in the NZRISK model improved performance. Calculation of mortality risk beyond 30 days after surgery adds to the utility of this tool for shared decision-making.
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291
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Wilcox T, Smilowitz NR, Xia Y, Berger JS. Cardiovascular Risk Scores to Predict Perioperative Stroke in Noncardiac Surgery. Stroke 2019; 50:2002-2006. [PMID: 31234757 PMCID: PMC10027603 DOI: 10.1161/strokeaha.119.024995] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- Perioperative stroke is associated with significant morbidity and mortality. Conventional cardiovascular risk scores have not been compared to predict acute stroke after noncardiac surgery. Methods- Patients undergoing noncardiac surgery between 2009 and 2010 were identified from the US National Surgical Quality Improvement Program (n=540 717). Patients were prospectively followed for 30 days postoperatively for the primary outcome of stroke. Established cardiovascular and perioperative risk scores (CHADS2, CHA2DS2-VASc, Revised Cardiac Risk Index, Mashour et al risk score, Myocardial Infarction or Cardiac Arrest risk score, and National Quality Improvement Project American College of Surgeons surgical risk calculator) were assessed to predict perioperative stroke. Results- Stroke occurred in the perioperative period of 1474 noncardiac surgeries (0.27%). Patients with perioperative stroke were older, more frequently male, had lower body mass index, and were more likely to have undergone vascular surgery or neurosurgery than patients without stroke (P<0.001 for each comparison). All risk prediction models were associated with increased risk of perioperative stroke (C statistic [AUC] range, 0.743-0.836). The Myocardial Infarction or Cardiac Arrest risk score (AUC, 0.833) and American College of Surgeons surgical risk calculator (AUC, 0.836) had the most favorable test characteristics and a greater ability to discriminate perioperative stroke when compared with Revised Cardiac Risk Index, CHADS2, CHA2DS2-VASc, and Mashour risk scores (P for comparison, <0.001; Delong). Risk scores did not provide consistent discriminative ability across surgery types and were least predictive in vascular surgery (AUC range, 0.588-0.672). Conclusions- The Myocardial Infarction or Cardiac Arrest risk score and American College of Surgeons surgical risk calculator surgical risk scores provide excellent risk discrimination for perioperative stroke in most patients undergoing noncardiac surgery. Stroke prediction was less optimal in patients undergoing vascular surgery.
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Affiliation(s)
- Tanya Wilcox
- From the Leon H. Charney Division of Cardiology, Department of Medicine (T.W., N.R.S., Y.X., J.S.B.), New York University School of Medicine
| | - Nathaniel R Smilowitz
- From the Leon H. Charney Division of Cardiology, Department of Medicine (T.W., N.R.S., Y.X., J.S.B.), New York University School of Medicine
| | - Yuhe Xia
- From the Leon H. Charney Division of Cardiology, Department of Medicine (T.W., N.R.S., Y.X., J.S.B.), New York University School of Medicine
| | - Jeffrey S Berger
- From the Leon H. Charney Division of Cardiology, Department of Medicine (T.W., N.R.S., Y.X., J.S.B.), New York University School of Medicine
- Department of Surgery (J.S.B.), New York University School of Medicine
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292
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Shirasu T, Furuya T, Nagai M, Nomura Y. Learning Curve Analysis to Determine Operative Requirements for Young Vascular Surgeons Learning Open Abdominal Aortic Aneurysm Repair. Circ J 2019; 83:1868-1875. [PMID: 31353341 DOI: 10.1253/circj.cj-19-0386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Since endovascular aneurysm repair has become predominant, the issue of training young vascular surgeons in open abdominal aortic aneurysm (AAA) surgery has received significant attention. Through learning curve analysis, we aimed to determine the number of cases needed for young surgeons to achieve satisfactory open surgical skills.Methods and Results:A total of 562 consecutive patients who underwent open repair either by an attending surgeon (group A) or 6 young vascular surgeons (group Y) were included and assessed with regards to the preparation, clamp, and total operation times. Although some of the patients' characteristics were different, the surgical procedures were comparable between the 2 groups. There was a clear trend towards a decrease in each 10 successive cases in group Y. The operation times in group A were constant at 72±30 (preparation), 48±10 (clamp), and 231±59 min (total), which were achieved by young vascular surgeons in 10, 30, and 10 cases, respectively. In the cumulative sum analysis, 25-27 cases were necessary for young vascular surgeons to enhance their surgical skills. The complication rate in group Y was no higher than that in group A. CONCLUSIONS Young vascular surgeons can safely learn open AAA repair without increasing operation time or complications. Approximately 30 cases would be necessary to gain satisfactory surgical skills.
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Affiliation(s)
- Takuro Shirasu
- Department of Surgery, Asahi General Hospital.,Division of Vascular Surgery, Department of Surgery, The University of Tokyo
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293
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Kertai MD, Cooter M, Pollard RJ, Buhrman W, Aronson S, Mathew JP, Stafford-Smith M. Is Compliance With Surgical Care Improvement Project Cardiac (SCIP-Card-2) Measures for Perioperative β-Blockers Associated With Reduced Incidence of Mortality and Cardiovascular-Related Critical Quality Indicators After Noncardiac Surgery? Anesth Analg 2019; 126:1829-1838. [PMID: 29200062 DOI: 10.1213/ane.0000000000002577] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND While continuation of β-blockers (BBs) perioperatively has become a national quality improvement measure, the relationship between BB withdrawal and mortality and cardiovascular-related critical quality indicators has not been studied in a contemporary cohort of patients undergoing noncardiac surgery. METHODS For this retrospective study, the quality assurance database of a large community-based anesthesiology group practice was used to identify 410,288 surgical cases, 18 years of age or older, who underwent elective or emergent noncardiac surgical procedures between January 1, 2009, and December 31, 2014. Each surgical case that was withdrawn from BBs perioperatively was propensity matched by clinical and surgical characteristics to 4 cases that continued BBs perioperatively. Subsequently, multivariable conditional logistic regression analyses were performed in the matched cohort to determine the extent to which withdrawal of perioperative BBs was independently associated with mortality as the primary outcome and cardiovascular-related critical quality indicators as the secondary outcome (need for vasopressor, electrocardiographic changes requiring treatment, unplanned admission to intensive care unit, postanesthesia care unit stay >2 hours, and a combination of cardiac arrest and myocardial infarction) within 48 hours postoperatively. RESULTS Of the 66,755 (16%) cases in the cohort admitted on BB therapy, BBs were withdrawn in 3829 (6%) and continued in 62,926 (94%). Propensity score matching resulted in an analysis cohort of 19,145 cases. Withdrawal of perioperative BBs in the multivariable conditional logistic regression analysis was significantly associated with an increased risk for mortality (odds ratio [OR], 3.61; 95% confidence interval [CI], 1.75-7.35; P = .0003), but a significantly decreased risk for need of blood pressure support requiring vasopressor initiation (OR, 0.84; 95% CI, 0.76-0.92; P = .0003) and extended postanesthesia care unit stay (OR, 0.69; 95% CI, 0.54-0.88; P = .004) within 48 hours after noncardiac surgery. CONCLUSIONS Perioperative withdrawal of BBs was associated with increased risk for mortality within 48 hours after noncardiac surgery and with decreased risk for need of vasopressor during the early postoperative period and a shorter stay in the postanesthesia care unit.
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Affiliation(s)
- Miklos D Kertai
- From the Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter
- From the Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | | | | | - Solomon Aronson
- From the Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- From the Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mark Stafford-Smith
- From the Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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294
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McAlister FA, Youngson E, Jacka M, Graham M, Conen D, Chan M, Szczeklik W, Alonso-Coello P, Devereaux PJ. A comparison of four risk models for the prediction of cardiovascular complications in patients with a history of atrial fibrillation undergoing non-cardiac surgery. Anaesthesia 2019; 75:27-36. [PMID: 31282570 DOI: 10.1111/anae.14777] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 02/06/2023]
Abstract
It is unclear how best to predict peri-operative cardiovascular risk in patients with atrial fibrillation undergoing non-cardiac surgery. This study examined the accuracy of the revised cardiac risk index and three atrial fibrillation thrombo-embolic risk models for predicting 30-day cardiovascular events after non-cardiac surgery in patients with a pre-operative history of atrial fibrillation. We conducted a prospective cohort study in 28 centres from 2007 to 2013 of 40,004 patients ≥ 45 years of age undergoing inpatient non-cardiac surgery who were followed until 30 days after surgery for cardiovascular events (defined as myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death). The 2088 patients with a pre-operative history of atrial fibrillation were at higher risk of peri-operative cardiovascular events compared with the 34,830 patients without a history of atrial fibrillation (29% vs. 13%, respectively, adjusted odds ratio 1.30 (95%CI 1.17-1.45). Compared with the revised cardiac risk index (c-index 0.60), all atrial fibrillation thrombo-embolic risk scores were significantly better at predicting peri-operative cardiovascular events: CHADS2 (c-index 0.62); CHA2 DS2 -VASc (c-index 0.63); and R2 CHADS2 (c-index 0.65), respectively. Although the three thrombo-embolic risk prediction models were significantly better than the revised cardiac risk index for prediction of peri-operative cardiovascular events, none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri-operative risk prediction model.
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Affiliation(s)
- F A McAlister
- Alberta SPOR Support Unit, University of Alberta, Edmonton, AB, Canada.,General Internal Medicine, University of Alberta, Edmonton, AB, Canada
| | - E Youngson
- Alberta SPOR Support Unit, University of Alberta, Edmonton, AB, Canada
| | - M Jacka
- Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - M Graham
- Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - D Conen
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - M Chan
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Hong Kong
| | - W Szczeklik
- Jagiellonian University Medical College, Department of Intensive Care and Peri-operative Medicine, Kraków, Poland
| | - P Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB-Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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295
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Nakajima H, Momose T, Misawa T. Prevalence and risk factors of subclinical coronary artery disease in patients undergoing carotid endarterectomy: a retrospective cohort study. INT ANGIOL 2019; 38:312-319. [PMID: 31284706 DOI: 10.23736/s0392-9590.19.04094-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) is closely associated with carotid artery stenosis in the context of systemic arteriosclerosis, and it is a known perioperative risk factor for carotid endarterectomy (CEA). We aimed to evaluate the prevalence and risk factors of subclinical CAD in patients without known CAD undergoing CEA. METHODS This was a single-center, retrospective, observational study conducted between January 2013 and December 2016. Among the patients scheduled for elective CEA, 69 with no medical history of CAD and no clinical symptoms (mean age, 76.4±7.8 years; 71.0% men) underwent coronary computed tomography (CT). Coronary angiography (CAG) and subsequent fractional flow reserve (FFR) estimation were performed if necessary. Subclinical CAD was defined as newly found significant coronary lesions after coronary CT screening. Significant coronary lesions were defined as lesions that showed total or subtotal occlusion on coronary CT, had ≥75% stenosis on CAG, or had FFR≤0.80 in major coronary arteries. RESULTS The prevalence of subclinical CAD was 17.4% (12 of 69 patients). Among the patient characteristics assessed, only high-density lipoprotein cholesterol (HDL-C) levels were significantly different between patients with and those without subclinical CAD (45.8±10.1 vs. 59.7±16.7 mg/dL, P=0.0072). A multivariate analysis revealed that low HDL-C levels were independent risk factors for subclinical CAD after adjusting for possible confounders (adjusted odds ratio: 0.91, 95% confidence interval: 0.84-0.98, P=0.0099). CONCLUSIONS Subclinical CAD is a common finding and is associated with low HDL-C in patients without known CAD undergoing CEA.
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Affiliation(s)
- Hiroyuki Nakajima
- Department of Cardiology, Nagano Matsushiro General Hospital, Nagano, Japan -
| | - Tomoyasu Momose
- Department of Cardiology, Nagano Matsushiro General Hospital, Nagano, Japan
| | - Takuo Misawa
- Department of Cardiology, Nagano Matsushiro General Hospital, Nagano, Japan
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296
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Mamilla D, Araque KA, Brofferio A, Gonzales MK, Sullivan JN, Nilubol N, Pacak K. Postoperative Management in Patients with Pheochromocytoma and Paraganglioma. Cancers (Basel) 2019; 11:E936. [PMID: 31277296 PMCID: PMC6678461 DOI: 10.3390/cancers11070936] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 06/29/2019] [Accepted: 07/01/2019] [Indexed: 12/26/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare catecholamine-secreting neuroendocrine tumors of the adrenal medulla and sympathetic/parasympathetic ganglion cells, respectively. Excessive release of catecholamines leads to episodic symptoms and signs of PPGL, which include hypertension, headache, palpitations, and diaphoresis. Intraoperatively, large amounts of catecholamines are released into the bloodstream through handling and manipulation of the tumor(s). In contrast, there could also be an abrupt decline in catecholamine levels after tumor resection. Because of such binary manifestations of PPGL, patients may develop perplexing and substantially devastating cardiovascular complications during the perioperative period. These complications include hypertension, hypotension, arrhythmias, myocardial infarction, heart failure, and cerebrovascular accident. Other complications seen in the postoperative period include fever, hypoglycemia, cortisol deficiency, urinary retention, etc. In the interest of safe patient care, such emergencies require precise diagnosis and treatment. Surgeons, anesthesiologists, and intensivists must be aware of the clinical manifestations and complications associated with a sudden increase or decrease in catecholamine levels and should work closely together to be able to provide appropriate management to minimize morbidity and mortality associated with PPGLs.
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Affiliation(s)
- Divya Mamilla
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Katherine A Araque
- Adult Endocrinology Department, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Alessandra Brofferio
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Melissa K Gonzales
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - James N Sullivan
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Naris Nilubol
- Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
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297
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Katz M, Silverstein N, Coll P, Sullivan G, Mortensen EM, Sachs A, Gross JB, Girard E, Liang J, Ristau BT, Stevenson C, Smith PP, Shames BD, Millea R, Ali I, Poulos CM, Ramaraj AB, Otukoya AO, Nolan J, Wahla Z, Hardy C, Al-Naggar I, Bliss LA, McFadden DW. Surgical care of the geriatric patient. Curr Probl Surg 2019; 56:260-329. [DOI: 10.1067/j.cpsurg.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 03/13/2019] [Indexed: 12/15/2022]
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298
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299
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Shirasu T, Furuya T, Nagai M, Nomura Y. Factors Affecting Longer Stay and Higher Costs during Elective Open Repair for Abdominal Aortic Aneurysm: A Case-Control Study. Ann Vasc Surg 2019; 60:112-119. [PMID: 31201977 DOI: 10.1016/j.avsg.2019.03.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/05/2019] [Accepted: 03/28/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Open surgery for abdominal aortic aneurysm (AAA) has the advantage of requiring less reintervention compared with endovascular aneurysm repair. The reduction of the initial hospitalization costs can provide socioeconomic benefits. The objective of this study was to determine the factors associated with an increase in the length of hospital stay and costs of open surgery for AAA. METHODS A total of 579 consecutive patients who underwent open surgery for intact AAA and survived, between 1998 and 2015 at Asahi General Hospital in Japan, were included in the analysis. Patients' characteristics, aneurysm morphology, operative procedures, postoperative complications, and postoperative courses were analyzed in relation to the hospital length of stay and costs. Patients with longer stays or higher costs (exceeding the third quartile) were compared with those with stays or costs no more than the third quartile. RESULTS The mean patient age was 75 ± 8 years, and 492 patients (85%) were male, with a mean aortic diameter of 57 ± 10 mm. The mean operation time was 214 ± 56 min with an estimated mean blood loss of 444 ± 305 g. Transfusion was required in 28 patients (4.8%) and return to the operating room (RTOR) in 18 patients (3.1%). The median postoperative hospital stay was 7 (7-8) days. Median costs of hospitalization were 12,300 (11,800-13,100) United States Dollar. In the multivariate analysis, the major factors which increased the length of stay were transfusion, late ambulation, and prolonged fasting time. Major risk factors for higher total hospitalization costs were transfusion, RTOR, and longer fasting time. CONCLUSIONS Regardless of the patients' comorbidities or aneurysm morphology, avoidance of transfusion and RTOR, combined with early ambulation and enteral feeding in the postoperative care, can reduce the length of stay and total hospitalization costs associated with open surgery for AAA.
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Affiliation(s)
- Takuro Shirasu
- Department of Surgery, Asahi General Hospital, Chiba, Japan.
| | | | - Motoki Nagai
- Department of Surgery, Asahi General Hospital, Chiba, Japan
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Perioperative kardiovaskuläre Morbidität und Letalität bei nichtherzchirurgischen Eingriffen. Anaesthesist 2019; 68:653-664. [DOI: 10.1007/s00101-019-0616-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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