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Coronary Computed Tomography Angiography in Combination with Coronary Artery Calcium Scoring for the Preoperative Cardiac Evaluation of Liver Transplant Recipients. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4081525. [PMID: 28164120 PMCID: PMC5259617 DOI: 10.1155/2017/4081525] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/07/2016] [Accepted: 12/18/2016] [Indexed: 02/08/2023]
Abstract
Liver transplantation is the best treatment option for early-stage hepatocellular carcinoma, liver cirrhosis, fulminant liver failure, and end-stage liver diseases. Even though advances in surgical techniques and perioperative care have improved postoperative outcomes, perioperative cardiovascular complications are a leading cause of postoperative morbidity and mortality following liver transplantation. Ischemic coronary artery disease (CAD) and cardiomyopathy are the most common cardiovascular diseases and could be negative predictors of postoperative outcomes in liver transplant recipients. Therefore, comprehensive cardiovascular evaluations are required to assess perioperative risks and prevent concomitant cardiovascular complications that would preclude good outcomes in liver transplant recipients. The two major types of cardiac computed tomography are the coronary artery calcium score (CACS) and coronary computed tomography angiography (CCTA). CCTA in combination with the CACS is a validated noninvasive alternative to coronary angiography for diagnosing and grading the severity of CAD. A CACS > 400 is associated with significant CAD and a known important predictor of posttransplant cardiovascular complications in liver transplant recipients. In this review article, we discuss the usefulness, advantages, and disadvantages of CCTA combined with CACS as a noninvasive diagnostic tool for preoperative cardiac evaluation and for maximizing the perioperative outcomes of liver transplant recipients.
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402
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Boniakowski AE, Davis FM, Phillips AR, Robinson AB, Coleman DM, Henke PK. The effects of preoperative cardiology consultation prior to elective abdominal aortic aneurysm repair on patient morbidity. Vascular 2017; 25:390-395. [DOI: 10.1177/1708538116685946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objectives The relationship between preoperative medical consultations and postoperative complications has not been extensively studied. Thus, we investigated the impact of preoperative consultation on postoperative morbidity following elective abdominal aortic aneurysm repair. Methods A retrospective review was conducted on 469 patients (mean age 72 years, 20% female) who underwent elective abdominal aortic aneurysm repair from June 2007 to July 2014. Data elements included detailed medical history, preoperative cardiology consultation, and postoperative complications. Primary outcomes included 30-day morbidity, consult-specific morbidity, and mortality. A bivariate probit regression model accounting for the endogeneity of binary preoperative medical consult and patient variability was estimated with a maximum likelihood function. Results Eighty patients had preoperative medical consults (85% cardiology); thus, our analysis focuses on the effect of cardiac-related preoperative consults. Hyperlipidemia, increased aneurysm size, and increased revised cardiac risk index increased likelihood of referral to cardiology preoperatively. Surgery type (endovascular versus open repair) was not significant in development of postoperative complications when controlling for revised cardiac risk index ( p = 0.295). After controlling for patient comorbidities, there was no difference in postoperative cardiac-related complications between patients who did and did not undergo cardiology consultation preoperatively ( p = 0.386). Conclusions When controlling for patient disease severity using revised cardiac risk index risk stratification, preoperative cardiology consultation is not associated with postoperative cardiac morbidity.
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Affiliation(s)
- Anna E Boniakowski
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Frank M Davis
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Amanda R Phillips
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Adina B Robinson
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Dawn M Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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403
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Affiliation(s)
- Christopher L Wray
- Liver Transplant Division, Liver Transplant Anesthesia Fellowship, Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA.
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404
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Duconge J, Hernandez-Suarez DF. Potential Usefulness of Clopidogrel Pharmacogenetics in Cerebral Endovascular Procedures and Carotid Artery Stenting. CURRENT CLINICAL PHARMACOLOGY 2017; 12:11-17. [PMID: 28245774 PMCID: PMC5478430 DOI: 10.2174/1574884712666170227154654] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/17/2017] [Accepted: 02/21/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Previous reports have shown inadequate response to dual antiplatelet therapy (DAPT) with aspirin and clopidogrel in 5-30% of patients undergoing percutaneous coronary interventions (PCI), due mostly to clopidogrel resistance. This prevalence increases up to 66% in patients undergoing neurointerventional procedures. However, clinical significance of CYP2C19 genotypes in neurointerventional procedures or carotid artery stenting (CAS) is unknown. OBJECTIVE The purpose of this review is to update our current knowledge and understanding of the pharmacogenetic basis for poor clopidogrel responsiveness in patients undergoing CAS and endovascular interventions as well as to explore usefulness of genotyping to reduce the rate of procedure-related thrombosis that results in ischemic complications. METHOD A literature search for pharmacogenetic studies in cerebral endovascular interventions and CAS was conducted on three databases using a list of the most relevant pharmacogenetic biomarkers. RESULTS The review included 7 papers involving 3 genetic polymorphisms on CYP2C19 and 442 subjects. Patients harboring at least one loss-of-function CYP2C19 polymorphism (e.g., CYP2C19*2 and *3) are at an increased risk of thromboembolic complications such as stent thrombosis following neurointerventional procedures. Notably, patients who carry the gain-of-function CYP2C19*17 allele may have increased risk of ischemic events following endovascular treatment, independent of clopidogrel responsiveness. CONCLUSION Studies assessing the influence of CYP2C19 polymorphisms on high on-treatment platelet reactivity in CAS and cerebrovascular disease patients are still limited and need further validation in large multicenter studies. This review covers an important topic in the field of antiplatelet therapy for cerebral endovascular procedures and CAS.
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Affiliation(s)
- Jorge Duconge
- Pharmaceutical Sciences Department, School of Pharmacy, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, PR, USA
| | - Dagmar F. Hernandez-Suarez
- Department of Medicine, School of Medicine, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, PR, USA
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405
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Preoperative Administration of Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers. Anesthesiology 2017; 126:1-3. [DOI: 10.1097/aln.0000000000001405] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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406
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Ito T, Derweesh IH, Ginzburg S, Abbosh PH, Raheem OA, Mirheydar H, Hamilton Z, Chen DY, Smaldone MC, Greenberg RE, Viterbo R, Kutikov A, Uzzo RG. Perioperative Outcomes Following Partial Nephrectomy Performed on Patients Remaining on Antiplatelet Therapy. J Urol 2017; 197:31-36. [DOI: 10.1016/j.juro.2016.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2016] [Indexed: 01/20/2023]
Affiliation(s)
- Timothy Ito
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Ithaar H. Derweesh
- Department of Urology, University of California San Diego School of Medicine, San Diego, California
| | - Serge Ginzburg
- Department of Urology, Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Philip H. Abbosh
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Omer A. Raheem
- Department of Urology, University of California San Diego School of Medicine, San Diego, California
| | - Hossein Mirheydar
- Department of Urology, University of California San Diego School of Medicine, San Diego, California
| | - Zachary Hamilton
- Department of Urology, University of California San Diego School of Medicine, San Diego, California
| | - David Y.T. Chen
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Marc C. Smaldone
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Richard E. Greenberg
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Rosalia Viterbo
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Alexander Kutikov
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Robert G. Uzzo
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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407
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Hedge J, Balajibabu PR, Sivaraman T. The patient with ischaemic heart disease undergoing non cardiac surgery. Indian J Anaesth 2017; 61:705-711. [PMID: 28970628 PMCID: PMC5613595 DOI: 10.4103/ija.ija_384_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The incidence of ischaemic heart disease (IHD) is increasing. The patients with IHD with or without interventions coming for non-cardiac surgical procedures are also increasing. These patients have increased risk of myocardial ischaemia, myocardial infarction (MI), conduction disturbances, morbidity and mortality during the peri-operative period. The risks of these events are even higher in patients with recent MI. An anaesthesiologist should be aware of the pathophysiology and the need to thoroughly evaluate the patient for peri-operative management. We searched Pubmed using combinations of terms like “ischemic heart disease” and “anaesthesia”, “perioperative”, and “anaesthetic implications”. We reviewed the current practices and guidelines regarding evaluation, risk stratification and management.
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Affiliation(s)
- Jagadish Hedge
- Department of Anaesthesiology, Sparsh Super Speciality Hospital, Sri Jayadeva Institute Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - P R Balajibabu
- Department of Anaesthesiology, Sparsh Super Speciality Hospital, Sri Jayadeva Institute Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Thirunavukkarasu Sivaraman
- Department of Anaesthesiology, Sparsh Super Speciality Hospital, Sri Jayadeva Institute Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
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408
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Dalal A. Organ transplantation and drug eluting stents: Perioperative challenges. World J Transplant 2016; 6:620-631. [PMID: 28058211 PMCID: PMC5175219 DOI: 10.5500/wjt.v6.i4.620] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/18/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Patients listed for organ transplant frequently have severe coronary artery disease (CAD), which may be treated with drug eluting stents (DES). Everolimus and zotarolimus eluting stents are commonly used. Newer generation biolimus and novolimus eluting biodegradable stents are becoming increasingly popular. Patients undergoing transplant surgery soon after the placement of DES are at increased risk of stent thrombosis (ST) in the perioperative period. Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor such as clopidogrel, prasugrel and ticagrelor is instated post stenting to decrease the incident of ST. Cangrelor has recently been approved by Food and Drug Administration and can be used as a bridging antiplatelet drug. The risk of ischemia vs bleeding must be considered when discontinuing or continuing DAPT for surgery. Though living donor transplant surgery is an elective procedure and can be optimally timed, cadaveric organ availability is unpredictable, therefore, discontinuation of antiplatelet medication cannot be optimally timed. The type of stent and timing of transplant surgery can be of utmost importance. Many platelet function point of care tests such as Light Transmittance Aggregrometry, Thromboelastography Platelet Mapping, VerifyNow, Multiple Electrode Aggregrometry are used to assess bleeding risk and guide perioperative platelet transfusion. Response to allogenic platelet transfusion to control severe intraoperative bleeding may differ with the antiplatelet drug. In stent thrombosis is an emergency where management with either a drug eluting balloon or a DES has shown superior outcomes. Post-transplant complications often involved stenosis of an important vessel that may need revascularization. DES are now used for endovascular interventions for transplant orthotropic heart CAD, hepatic artery stenosis post liver transplantation, transplant renal artery stenosis following kidney transplantation, etc. Several antiproliferative drugs used in the DES are inhibitors of mammalian target of rapamycin. Thus they are used for post-transplant immunosuppression to prevent acute rejection in recipients with heart, liver, lung and kidney transplantation. This article describes in detail the various perioperative challenges encountered in organ transplantation surgery and patients with drug eluting stents.
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409
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Sandoval Y, Zakharova M, Rector TS, Brilakis ES, Drexel T, McFalls EO, Garcia S. Frequency of Increase in Cardiac Troponin Levels After Peripheral Arterial Operations (Carotid Endarterectomy, Abdominal Aorta Procedure, Distal Bypass) and Their Effect on Medical Management. Am J Cardiol 2016; 118:1929-1934. [PMID: 27726853 DOI: 10.1016/j.amjcard.2016.08.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/23/2016] [Accepted: 08/23/2016] [Indexed: 11/25/2022]
Abstract
The utility of measuring cardiac troponins (cTn) in asymptomatic patients during the perioperative period has been controversial. In the present substudy of the Cardiac Remote Ischemic Preconditioning Prior to Elective Vascular Surgery Trial (NCT01558596), we hypothesized that surveillance of myocardial injury with cTnI in the perioperative period would lead to initiation or intensification of medical therapies for coronary artery disease. Increases in cTnI ≥0.01 μg/l in the perioperative period were considered clinically significant. Intensification of medical therapy was defined as initiation of aspirin or initiation or increases in the dose of angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers, statins, or β blockers and was left to the discretion of treating physicians. From June 2011 to April 2015, a total of 185 patients (mean age 68 ± 7 years, 100% men) were enrolled in the trial. A total of 28 patients (15%) had significant increases in cTnI after vascular surgery, and 38 (20.5%) had their medical therapies intensified in the perioperative period. Among patients with increases in cTnI, 11 (39%) had intensification of medical therapy versus 27 patients (17%) with no or smaller increases in cTnI (p = 0.02). Among those patients with ΔcTnI ≥0.01 μg/l, hospital readmissions at 3 to 6 months were 7.6% for the intensification group versus 25% for the no intensification group (p = 0.18). Mortality rate at 6 months was low in both groups (2.6% vs 0%, respectively, p = 0.13). In conclusion, among patients undergoing vascular surgery, perioperative increases in cTn were associated with initiation or intensification of medical therapies for coronary artery disease at the time of discharge.
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410
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411
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Essandoh MK, Dalia AA, George BS, Flores AS, Otey AJ, Kirtane AJ, Broderick TM, Rao SV. CASE 11—2016 Perioperative Coronary Thrombosis in a Patient With Multiple Second-Generation Drug-Eluting Stents: Is It Time for a Paradigm Shift? J Cardiothorac Vasc Anesth 2016; 30:1698-1708. [DOI: 10.1053/j.jvca.2016.03.157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Indexed: 11/11/2022]
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412
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Han H, Koh EJ, Choi H, Kim BC, Yang SY, Cho KT. The Effect of Preoperative Antiplatelet Therapy on Hemorrhagic Complications after Decompressive Craniectomy in Patients with Traumatic Brain Injury. Korean J Neurotrauma 2016; 12:61-66. [PMID: 27857909 PMCID: PMC5110920 DOI: 10.13004/kjnt.2016.12.2.61] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/30/2016] [Accepted: 09/09/2016] [Indexed: 11/30/2022] Open
Abstract
Objective Traditionally, it is generally recommended that antiplatelet agent should be discontinued before surgery. However, decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) is performed emergently in most cases. Therefore, DC cannot be delayed to the time when the effect of antiplatelet agent on bleeding tendency dissipates. In this study, we evaluated the effect of preinjury antiplatelet therapy on hemorrhagic complications after emergent DC in patients with TBI. Methods We retrospectively investigated patients with TBI who underwent emergent DC between 2006 and 2015. The patients were separated into two groups according to the use of preinjury antiplatelet agent: group 1 (patients taking antiplatelet agent) and group 2 (patients not taking antiplatelet agent). The rate of hemorrhagic complications (postoperative epidural or subdural hemorrhage, newly developed, or progression of preexisting contusion or intracerebral hemorrhage within the field of DC) and the rate of reoperation within 7 days after DC were compared between two groups. Results During the study period, DC was performed in 90 patients. Of them, 19 patients were taking antiplatelet agent before TBI. The rate of hemorrhagic complications was 52.6% (10/19) in group 1 and 46.5% (33/71) in group 2 (p=0.633). The rate of reoperation was 36.8% (7/19) in group 1 and 36.6% (26/71) in group 2 (p=0.986). No statistical difference was found between two groups. Conclusion Preinjury antiplatelet therapy did not influence the rate of hemorrhagic complications and reoperation after DC. Emergent DC in patients with TBI should not be delayed because of preinjury antiplatelet therapy.
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Affiliation(s)
- Hokyun Han
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Eun Jung Koh
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Hyunho Choi
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Byong-Cheol Kim
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Seung Yeob Yang
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Keun-Tae Cho
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
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413
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Dhillon A, Khanna A, Randhawa MS, Cywinski J, Saager L, Thamilarasan M, Lever HM, Desai MY. Perioperative outcomes of patients with hypertrophic cardiomyopathy undergoing non-cardiac surgery. Heart 2016; 102:1627-32. [PMID: 27288277 DOI: 10.1136/heartjnl-2016-309442] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/19/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Due to their unique pathophysiological profile, patients with hypertrophic cardiomyopathy (HCM) undergoing non-cardiac surgery require additional attention to perioperative management. We sought to compare perioperative outcomes of patients with HCM undergoing non-cardiac surgery with a matched group patients without HCM. METHODS This observational cohort study conducted at a tertiary care centre included patients with HCM (n=92, age 67 years, 54% men) undergoing intermediate-risk and high-risk non-cardiac surgeries between 1/2007 and 12/2013 (excluding <18 years, prior septal myectomy/alcohol ablation, low-risk surgery) who were 1:2 matched (based on age, gender, type and time of non-cardiac surgery) with patients without HCM (n=184, median age 65 years, 53% men). A composite endpoint (30-day postoperative death, myocardial infarction, stroke, in-hospital decompensated congestive heart failure (CHF) and rehospitalisation within 30 days) and postoperative atrial fibrillation (AF) were recorded. RESULTS There was a significantly lower incidence of intraoperative hypotension/tachycardia in patients with HCM versus those without HCM (p<0.001). At 30 days postoperatively, 42 (15%) patients had composite events. Rates of 30-day death, MI or stroke were very low in patients with HCM (5%). However, a significantly higher proportion of patients with HCM met the composite endpoint versus patients without HCM (20 (22%) vs 22 (12%), p=0.03), driven by decompensated CHF. On logistic regression, HCM, high-risk non-cardiac surgery, high anaesthesia risk score and intraoperative duration of hypotension were independently associated with 30-day composite events (p<0.05). CONCLUSIONS Patients with HCM undergoing high-risk and intermediate-risk non-cardiac surgeries have a low perioperative event rate, at an experienced centre. However, they have a higher risk of composite events versus matched patients without HCM.
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Affiliation(s)
- Ashwat Dhillon
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland, Ohio, USA
| | - Ashish Khanna
- Departments of Outcomes Research and General Anesthesiology, Anesthesiology Institute, Cleveland, Ohio, USA
| | | | - Jacek Cywinski
- Departments of Outcomes Research and General Anesthesiology, Anesthesiology Institute, Cleveland, Ohio, USA
| | - Leif Saager
- Departments of Outcomes Research and General Anesthesiology, Anesthesiology Institute, Cleveland, Ohio, USA
| | - Maran Thamilarasan
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland, Ohio, USA
| | - Harry M Lever
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland, Ohio, USA
| | - Milind Y Desai
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland, Ohio, USA
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414
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Gurajala I, Gopinath R. Perioperative management of patient with intracoronary stent presenting for noncardiac surgery. Ann Card Anaesth 2016; 19:122-31. [PMID: 26750683 PMCID: PMC4900389 DOI: 10.4103/0971-9784.173028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
As the number of percutaneous coronary interventions increase annually, patients with intracoronary stents (ICS) who present for noncardiac surgery (NCS) are also on the rise. ICS is associated with stent thrombosis (STH) and requires mandatory antiplatelet therapy to prevent major adverse cardiac events. The risks of bleeding and ischemia remain significant and the management of these patients, especially in the initial year of ICS is challenging. The American College of Cardiologists guidelines on the management of patients with ICS recommend dual antiplatelet therapy (DAT) for minimal 14 days after balloon angioplasty, 30 days for bare metal stents, and 365 days for drug-eluting stents. Postponement of elective surgery is advocated during this period, but guidelines concerning emergency NCS are ambiguous. The risk of STH and surgical bleeding needs to be assessed carefully and many factors which are implicated in STH, apart from the type of stent and the duration of DAT, need to be considered when decision to discontinue DAT is made. DAT management should be a multidisciplinary exercise and bridging therapy with shorter acting intravenous antiplatelet drugs should be contemplated whenever possible. Well conducted clinical trials are needed to establish guidelines as regards to the appropriate tests for platelet function monitoring in patients undergoing NCS while on DAT.
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Affiliation(s)
- Indira Gurajala
- Department of Anaesthesiology and Critical Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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415
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Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S, Graham M, Tandon V, Styles K, Bessissow A, Sessler DI, Bryson G, Devereaux PJ. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol 2016; 33:17-32. [PMID: 27865641 DOI: 10.1016/j.cjca.2016.09.008] [Citation(s) in RCA: 432] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 02/06/2023] Open
Abstract
The Canadian Cardiovascular Society Guidelines Committee and key Canadian opinion leaders believed there was a need for up to date guidelines that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for patients who undergo noncardiac surgery. Strong recommendations included: 1) measuring brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) before surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥ 1; 2) against performing preoperative resting echocardiography, coronary computed tomography angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging to enhance perioperative cardiac risk estimation; 3) against the initiation or continuation of acetylsalicylic acid for the prevention of perioperative cardiac events, except in patients with a recent coronary artery stent or who will undergo carotid endarterectomy; 4) against α2 agonist or β-blocker initiation within 24 hours before surgery; 5) withholding angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker starting 24 hours before surgery; 6) facilitating smoking cessation before surgery; 7) measuring daily troponin for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have a Revised Cardiac Risk Index score ≥1, age 45-64 years with significant cardiovascular disease, or age 65 years or older; and 8) initiating of long-term acetylsalicylic acid and statin therapy in patients who suffer myocardial injury/infarction after surgery.
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Affiliation(s)
- Emmanuelle Duceppe
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Joel Parlow
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada.
| | - Paul MacDonald
- Cape Breton Regional Hospital, Cape Breton, Nova Scotia, Canada
| | - Kristin Lyons
- Division of Cardiology, University of Calgary, Calgary, Alberta, Canada
| | - Michael McMullen
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sadeesh Srinathan
- Department of Surgery, Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michelle Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kim Styles
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amal Bessissow
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gregory Bryson
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - P J Devereaux
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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416
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Toward External Validation and Routine Clinical Use of the American College of Surgeons NSQIP Surgical Risk Calculator. J Am Coll Surg 2016; 223:674. [DOI: 10.1016/j.jamcollsurg.2016.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 06/20/2016] [Indexed: 11/24/2022]
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417
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Alabdan N, Gosmanova EO, Tran NQT, Oliphant CS, Pan H, Broyles JE, Hudson JQ. Acute Kidney Injury in Patients Continued on Renin-Angiotensin System Blockers During Hospitalization. Am J Med Sci 2016; 353:172-177. [PMID: 28183419 DOI: 10.1016/j.amjms.2016.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/19/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common in hospitalized patients and is associated with adverse outcomes. This study aimed to evaluate patient characteristics and interventions during hospitalization associated with the development of AKI in patients continued on renin-angiotensin system (RAS) blockers during hospitalization. METHODS A retrospective study of 184 adult patients admitted between January 2012 and September 2014 and continued on RAS blockers was conducted. Risk factors for AKI were compared between AKI (n = 92) and non-AKI (n = 92) groups. RESULTS Patients who developed hospital-acquired AKI had a higher baseline serum creatinine (1.2 ± 0.4 versus 1 ± 0.3mg/dL, P < 0.001) and lower estimated glomerular filtration rate (54 ± 10 versus 57 ± 7mL/minute/1.73m2, P = 0.03) compared with patients who did not develop AKI. Patients who developed AKI were also more likely to be admitted to the intensive care unit, have surgical procedures, have hypotension and be prescribed loop diuretics. The presence of chronic kidney disease and hypotension were risk factors associated with AKI development. In addition, the AKI group had a significantly longer length of stay (14 days versus 8 days, P < 0.0001) and had a higher rate of all-cause hospital mortality (9% versus 1%, P = 0.03). CONCLUSIONS Patients with chronic kidney disease, hypotension and those undergoing surgeries were more likely to develop AKI while receiving RAS blockers. During hospitalization, temporary discontinuation of these medications may be warranted in patients with these characteristics.
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Affiliation(s)
- Numan Alabdan
- Pharmaceutical Care Department, King Abdulaziz Medical City, Dammam, Saudi Arabia; Pharmacy Practice Department, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Elvira O Gosmanova
- Section of Nephrology, Stratton VA Medical Center, Albany, NY; Department of Medicine, Albany Medical College, Albany, NY
| | - Nhu Quynh T Tran
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN
| | - Carrie S Oliphant
- Department of Clinical Pharmacy, Methodist University Hospital, Memphis, TN; Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, TN
| | - Hu Pan
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN
| | - Joyce E Broyles
- Department of Clinical Pharmacy, Methodist University Hospital, Memphis, TN; Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, TN
| | - Joanna Q Hudson
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, TN; Department of Medicine (Nephrology), The University of Tennessee Health Science Center, Memphis, TN.
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418
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Perioperative β-Blockade in Noncardiac Surgery: A Cautionary Tale of Over-reliance on Small Randomized Prospective Trials. Clin Ther 2016; 38:2302-2316. [PMID: 27666127 DOI: 10.1016/j.clinthera.2016.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/26/2016] [Accepted: 08/25/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Our aim was to analyze the current scientific literature relevant to the use of β-adrenergic receptor antagonists for the prevention of cardiovascular morbidity and mortality in patients undergoing noncardiac surgery. METHODS A PubMed search was conducted for the following concepts: pre- or perioperative, β-adrenergic receptor antagonist, treatment outcome, and cardiovascular complication. Randomized clinical trials measuring the effect of β-adrenergic blocking agents against that of placebo on cardiovascular outcomes after noncardiac surgery were included in the review. FINDINGS Two small randomized controlled trials published in 1996 and 1999 reported associations between perioperative β-blockade and significant reductions in long-term and 30-day cardiac mortality, respectively. These 2 studies prompted guideline changes in 2002 encouraging perioperative β-blockade in subsets of noncardiac surgery patients. However, subsequent trials failed to validate these results. In 2008, the first large randomized controlled trial on the topic was published and found an association between perioperative β-blockade and an increase in perioperative mortality. Furthermore, in 2011, the lead author of the 1999 study was dismissed from his academic position for scientific misconduct, casting doubt on the validity of guidelines based on his work. Existing studies are highly heterogeneous, making comparisons difficult. Current literature does not support initiating perioperative β-blockade in noncardiac surgery patients not already receiving these medications. IMPLICATIONS Future research on the topic should account for the influence individual genetic variation can have on outcomes and β-blocker metabolism. Additionally, the relationship between outcomes and the β-1 selectivity of different β-blockers should be explored.
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419
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Statin-Induced Cardioprotection Against Ischemia-Reperfusion Injury: Potential Drug-Drug Interactions. Lesson to be Learnt by Translating Results from Animal Models to the Clinical Settings. Cardiovasc Drugs Ther 2016; 29:461-7. [PMID: 26303765 DOI: 10.1007/s10557-015-6615-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Numerous interventions have been shown to limit myocardial infarct size in animal models; however, most of these interventions have failed to have a significant effect in clinical trials. One potential explanation for the lack of efficacy in the clinical setting is that in bench models, a single intervention is studied without the background of other interventions or modalities. This is in contrast to the clinical setting in which new medications are added to the "standard of care" treatment that by now includes a growing number of medications. Drug-drug interaction may lead to alteration, dampening, augmenting or masking the effects of the intended intervention. We use the well described model of statin-induced myocardial protection to demonstrate potential interactions with agents which are commonly concomitantly used in patients with stable coronary artery disease and/or acute coronary syndromes. These interactions could potentially explain the reduced efficacy of statins in the clinical trials compared to the animal models. In particular, caffeine and aspirin could attenuate the infarct size limiting effects of statins; morphine could delay the onset of protection or mask the protective effect in patients with ST elevation myocardial infarction, whereas other anti-platelet agents (dipyridamole, cilostazol and ticagrelor) may augment (or mask) the effect due to their favorable effects on adenosine cell reuptake and intracellular cAMP levels. We recommend that after characterizing the effects of new modalities in single intervention bench research, studies should be repeated in the background of standard-of-care medications to assure that the magnitude of the effect is not altered before proceeding with clinical trials.
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420
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Abstract
Given the low-risk nature of cataract surgery, no preoperative testing is indicated unless the patient needs it for another reason. Although electrocardiograms may have a role in preoperative testing in patients at high risk of cardiovascular disease, or if the procedure carries with it significant operative risks, they are often unnecessary. Urinalysis and coagulation studies not should be routine because they have not shown any value in predicting complications. Although these tests are not individually expensive, the aggregate cost is substantial. As good stewards of the medical system, physicians need to use these tests more judiciously.
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Affiliation(s)
- Matthew H Rusk
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, 51 North 39th Street, Medical Arts Building, Suite 102, Philadelphia, PA 19104, USA.
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421
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Packiam VT, Nottingham CU, Cohen AJ, Pearce SM, Shalhav AL, Eggener SE. The Impact of Perioperative Aspirin on Bleeding Complications Following Robotic Partial Nephrectomy. J Endourol 2016; 30:997-1003. [DOI: 10.1089/end.2016.0290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
| | | | - Andrew J. Cohen
- Section of Urology, University of Chicago, Chicago, Illinois
| | - Shane M. Pearce
- Section of Urology, University of Chicago, Chicago, Illinois
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422
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Nazha B, Spyropoulos AC. The BRIDGE trial: What the hospitalist should know. J Hosp Med 2016; 11:652-7. [PMID: 27098835 DOI: 10.1002/jhm.2594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 03/14/2016] [Accepted: 03/24/2016] [Indexed: 11/05/2022]
Abstract
Atrial fibrillation patients often require warfarin interruption for an invasive procedure or surgery. Heparin bridging therapy has been frequently used during warfarin interruption under the premise of providing a theoretical mitigation against thromboembolism that overweighs expected higher rates of bleeding. Up until recently, little definite clinical evidence was available to guide the hospitalist on optimal perioperative anticoagulant management. The landmark BRIDGE (Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation) trial provided high-quality evidence that a simple interruption of warfarin in the average atrial fibrillation patient undergoing an elective procedure or surgery is noninferior to bridging therapy for efficacy and superior to bridging therapy in preventing major bleeding. To guide the hospitalist, we propose a treatment algorithm based on these recent data. We review the literature that led to the trial and highlight its practice-changing implications as a proof of concept that calls to question the premise of heparin bridging therapy beyond the atrial fibrillation population. Journal of Hospital Medicine 2016;11:652-657. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Bassel Nazha
- Department of Medicine, Staten Island University Hospital-Northwell Health, Staten Island, New York.
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra-Northwell Health School of Medicine, Northwell Health at Lenox Hill Hospital, New York, New York
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423
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Hsiao CH, Chen KC, Chen JS. Modified single-port non-intubated video-assisted thoracoscopic decortication in high-risk parapneumonic empyema patients. Surg Endosc 2016; 31:1719-1727. [PMID: 27519590 DOI: 10.1007/s00464-016-5164-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/30/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction are risky to receive surgical decortication under general anesthesia. Non-intubated video-assisted thoracoscopy surgery is successfully performed to avoid complications of general anesthesia. We performed single-port non-intubated video-assisted flexible thoracoscopy surgery in an endoscopic center. In this study, the possible role of our modified surgery to treat fibrinopurulent stage of parapneumonic empyema with high operative risks is investigated. METHODS We retrospectively reviewed fibrinopurulent stage of parapneumonic empyema patients between July 2011 and June 2014. Thirty-three patients with coronary artery disease and reduced left ventricular ejection fraction were included in this study. One group received tube thoracostomy, and the other group received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. Patient demographics, characteristics, laboratory findings, etiology, and treatment outcomes were compared. RESULTS Mean age of 33 patients (24 males, 9 females) was 76.2 ± 9.7 years. Twelve patients received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication, and 21 patients received tube thoracostomy. Visual analog scale scores on postoperative first hour and first day were not significantly different in two groups (p value = 0.5505 and 0.2750, respectively). Chest tube drainage days, postoperative fever subsided days, postoperative hospital days, and total length of stay were significantly short in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication (p value = 0.0027, 0.0001, 0.0009, and 0.0065, respectively). Morbidities were low, and mortality was significantly low (p value = 0.0319) in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. CONCLUSIONS Single-port non-intubated video-assisted flexible thoracoscopy surgery decortication may be suggested to be a method other than tube thoracostomy to deal with fibrinopurulent stage of parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction.
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Affiliation(s)
- Chen-Hao Hsiao
- Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan
- Genome and Systems Biology Degree Program, National Taiwan University and Academia Sinica, Taipei, Taiwan
| | - Ke-Cheng Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan S. Rd, Taipei, 10002, Taiwan
| | - Jin-Shing Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan S. Rd, Taipei, 10002, Taiwan.
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan.
- Division of Experimental Surgery, National Taiwan University Hospital, Taipei, Taiwan.
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424
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Nerlekar N, Mulley W, Rehmani H, Ramkumar S, Cheng K, Vasanthakumar SA, Rashid H, Barton T, Nasis A, Meredith IT, Moir S, Mottram PM. Feasibility of exercise stress echocardiography for cardiac risk assessment in chronic kidney disease patients prior to renal transplantation. Clin Transplant 2016; 30:1209-1215. [PMID: 27327660 DOI: 10.1111/ctr.12796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pharmacologic stress testing is utilized in preference to exercise stress echocardiography (ESE) for cardiac risk evaluation in potential renal transplant recipients due to the perceived lower feasibility of ESE for achieving adequate workload and target heart rate (THR) in this population. METHODS Consecutive patients referred for cardiac risk evaluation prior to potential kidney transplantation were evaluated. All patients attempted ESE before pharmacologic testing was considered. Treadmill ESE utilized BRUCE protocol to maximum capacity. THR was defined as >85% of the maximum predicted heart rate (220-age). Functional capacity was assessed by metabolic equivalents (METs) and the rate pressure product (RPP). RESULTS Of 535 patients (349 male, age 56±11), 372(70%) reached THR. Mean METs were 10±3 with 531(99%) achieving ≥4 METs and 87% ≥7 METs. Mean RPP was 25 821±5820 bpm×mm Hg (83% achieving >20 000 bpm×mm Hg). On multivariate analysis, independent predictors of failure to reach THR were rate-control medication and diabetes; failure to reach 7 METs: females, diabetics, age≥65, and previous cardiac disease; failure to reach RPP>20 000: rate-control medication. There were 97% of ESE completed to physiologic endpoints. CONCLUSION In unselected potential renal transplant candidates, cardiac assessment by ESE is well tolerated, with 9-in-10 exercising to satisfactory functional capacity. ESE should be considered a feasible alternative to pharmacologic testing in this population.
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Affiliation(s)
- Nitesh Nerlekar
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia.
| | - William Mulley
- Department of Nephrology, Monash Medical Centre and Department of Medicine, Monash University, Clayton, Australia
| | - Hassan Rehmani
- Department of Medicine, Monash Health, Clayton, Australia
| | | | - Kevin Cheng
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia
| | - Sheran A Vasanthakumar
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia
| | - Hashrul Rashid
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia
| | - Timothy Barton
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia
| | - Arthur Nasis
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia
| | - Ian T Meredith
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia
| | - Stuart Moir
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia
| | - Philip M Mottram
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia
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425
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Schweizer R, Godet G, Petit PY, Elia J, Guette P, Finet G, Fellahi JL, Piriou V. Adherence of French cardiologists to guidelines for non-cardiac surgery. Anaesth Crit Care Pain Med 2016; 35:249-53. [DOI: 10.1016/j.accpm.2015.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 10/13/2015] [Accepted: 12/18/2015] [Indexed: 01/15/2023]
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426
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Yasuhara T, Hishikawa T, Agari T, Kurozumi K, Ichikawa T, Kameda M, Shinko A, Ishida J, Hiramatsu M, Kobayashi M, Matsuoka Y, Sasaki T, Soga Y, Yamanaka R, Ashiwa T, Arioka A, Hashimoto Y, Misaki A, Ishihara Y, Sato M, Morimatsu H, Date I. Perioperative Management Center (PERIO) for Neurosurgical Patients. Neurol Med Chir (Tokyo) 2016; 56:574-9. [PMID: 27396396 PMCID: PMC5027240 DOI: 10.2176/nmc.oa.2016-0085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Perioperative management is critical for positive neurosurgical outcomes. In order to maintain safe and authentic perioperative management, a perioperative management center (PERIO) was introduced to patients of our Neurosurgery Department beginning in June 2014. PERIO involves a multidisciplinary team consisting of anesthesiologists, dentists/dental hygienists/technicians, nurses, physical therapists, pharmacists, and nutritionists. After neurosurgeons decide on the course of surgery, a preoperative evaluation consisting of blood sampling, electrocardiogram, chest X-ray, and lung function test was performed. The patients then visited the PERIO clinic 7–14 days before surgery. One or two days before surgery, the patients without particular issues enter the hospital and receive a mouth cleaning one day before surgery. After surgery, postoperative support involving eating/swallowing evaluation, rehabilitation, and pain control is provided. The differences in duration from admission to surgery, cancellation of surgery, and postoperative complications between PERIO and non-PERIO groups were examined. Eighty-five patients were enrolled in the PERIO group and 131 patients in the non-PERIO group. The duration from admission to surgery was significantly decreased in the PERIO group (3.6 ± 0.3 days), compared to that in the non-PERIO group (4.7 ± 0.2 days). There was one cancelled surgery in the PERIO group and six in the non-PERIO group. Postoperative complications and the overall hospital stay did not differ between the two groups. The PERIO system decreased the duration from admission to surgery, and it is useful in providing high-quality medical service, although the system should be improved so as not to increase the burden on medical staff.
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Affiliation(s)
- Takao Yasuhara
- Department of Neurological Surgery, Okayama University Graduate School of Medicine
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427
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Kumar L, Ramamurthi P, Rajan S, Surendran S. Post-operative myocardial infarction complicating donor hepatectomy: Implications for donor safety. Indian J Anaesth 2016; 60:433-5. [PMID: 27330210 PMCID: PMC4910488 DOI: 10.4103/0019-5049.183381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Lakshmi Kumar
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Pavithra Ramamurthi
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Sunil Rajan
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Sudhindran Surendran
- Department of Gastro Intestinal Surgery and Solid Organ Transplantation, Amrita Vishwa Vidyapeetham, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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428
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Switching therapy from intravenous beta blocker to bisoprolol transdermal patch for atrial fibrillation tachycardia. J Anesth 2016; 30:891-4. [PMID: 27262288 DOI: 10.1007/s00540-016-2199-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 05/29/2016] [Indexed: 10/21/2022]
Abstract
Beta-blockers are important for severe-status patients with atrial fibrillation-related tachycardia. Beta 1-selective intravenous injection are routinely used, but long-term administration is difficult due to cost-performance- or management-related issues. A bisoprolol patch, a beta-blocker to be percutaneously absorbed, recently became commercially available in Japan. As it may facilitate effective absorption and a mild elevation of the blood concentration, we retrospectively analyzed 16 patients with atrial fibrillation-related tachycardia who were admitted to the Intensive Care Unit of Hitachi General Hospital Emergency and Critical Care Center, and underwent switching therapy from landiolol to a bisoprolol patch. For switching, the bisoprolol patch (4 mg) was attached to each patient. The bisoprolol patch was introduced 88 h after the start of landiolol administration, when the rate was approximately 3 μg/kg/min. Landiolol injection was combined with bisoprolol for 15.4 ± 17.5 h. Switching therapy was successful in all subjects. The introduction of the bisoprolol patch did not induce any significant changes in the blood pressure or heart rate. After the completion of landiolol administration, there were also no significant changes in either parameter. There were no adverse events. In severe-status patients, switching therapy from landiolol injection to the bisoprolol patch can be conducted safely, and might be useful for heart-rate control.
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429
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Bhatia M, Arora H, Kumar PA. Pro: ACE Inhibitors Should Be Continued Perioperatively and Prior to Cardiovascular Operations. J Cardiothorac Vasc Anesth 2016; 30:816-9. [DOI: 10.1053/j.jvca.2016.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Indexed: 11/11/2022]
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430
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Devereaux P, Eikelboom J. Insights into myocardial infarction after noncardiac surgery in patients with a prior coronary artery stent. Br J Anaesth 2016; 116:584-6. [DOI: 10.1093/bja/aew111] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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431
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Zettervall SL, Buck DB, Soden PA, Cronenwett JL, Goodney PP, Eslami MH, Lee JT, Schermerhorn ML. Regional variation exists in patient selection and treatment of abdominal aortic aneurysms. J Vasc Surg 2016; 64:921-927.e1. [PMID: 27066949 DOI: 10.1016/j.jvs.2016.02.036] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 02/09/2016] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Significant regional variation in surgical rates has been identified following multiple surgical procedures. However, limited data have examined the regional variability in patient selection and treatment of abdominal aortic aneurysms (AAAs). This study aimed to evaluate regional variation in patient selection, perioperative management, and operative approach for the repair of AAAs. METHODS All patients undergoing open repair or endovascular aneurysm repair (EVAR) of an AAA in the Vascular Quality Initiative from 2009 to 2014 were identified. All regional groups were deidentified, and those with fewer than 100 open repairs were combined into a single region. RESULTS We identified 17,269 elective repairs (EVAR, 13,759; open, 3510) and 1462 ruptured AAAs (EVAR, 749; open, 713). There was significant regional variation in the use of EVAR for elective repair (range, 66%-88%; P < .01) and ruptured AAA repair (40%-80%; P < .01). The median diameter for elective repair was similar among regions (EVAR, 5.4 cm; open, 5.7 cm). There was wide variation in the treatment of small aneurysms in male patients (<5.5 cm) for EVAR (34%-49%; P < .01) and open repair (17%-38%; P < .01) and variation in the treatment of small aneurysms in female patients (<5 cm) for EVAR (14%-32%; P < .01) but not significant for open repair (6%-24%). For elective cases, preoperative aspirin (EVAR, 50%-75% [P < .01]; open, 49%-78% [P < .01]) and statin use (EVAR, 61%-75% [P < .01]; open, 56%-80% [P < .01]) varied widely. Among elective cardiac patients, preoperative management varied significantly, including beta-blocker use (EVAR, 66%-78% [P < .01]; open, 69%-88% [P = .01]) and the frequency of stress tests (EVAR, 33%-64% [P < .01]; open, 31%-73% [P < .01]). Among open repairs for aneurysms extending at or beyond the juxtarenal segment, there was wide variation in the use of retroperitoneal exposures (7%-70%; P < .01) and adjunctive renal protective measures (cold renal perfusion, 2%-43% [P < .01]; mannitol, 47%-92% [P < .01]). CONCLUSIONS Significant regional variation exists in patient selection, perioperative management, and operative approach for the repair of AAA. Definitive evidence is lacking in many aspects of operative care, including the use of the retroperitoneal approach and renal protective strategies. However, this variation emphasizes the importance of research to determine best practice in the areas of greatest variation. Furthermore, where current clinical process measures exist and data are clear, such as the use of statin and antiplatelet agents, the high degree of variation should serve as an impetus for regional quality improvement projects.
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Affiliation(s)
- Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, George Washington University Medical Center, Washington, D.C
| | - Dominique B Buck
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Jack L Cronenwett
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Phillip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, Mass
| | - Jason T Lee
- Vascular and Endovascular Surgery, Stanford University Medical Center, Stanford, Calif
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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432
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Kim J, Al-Mallah M, Juraschek SP, Brawner C, Keteyian SJ, Nasir K, Dardari ZA, Blumenthal RS, Blaha MJ. The association of clinical indication for exercise stress testing with all-cause mortality: the FIT Project. Arch Med Sci 2016; 12:303-9. [PMID: 27186173 PMCID: PMC4848360 DOI: 10.5114/aoms.2016.59255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/19/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION We hypothesized that the indication for stress testing provided by the referring physician would be an independent predictor of all-cause mortality. MATERIAL AND METHODS We studied 48,914 patients from The Henry Ford Exercise Testing Project (The FIT Project) without known congestive heart failure who were referred for a clinical treadmill stress test and followed for 11 ±4.7 years. The reason for stress test referral was abstracted from the clinical test order, and should be considered the primary concerning symptom or indication as stated by the ordering clinician. Hierarchical multivariable Cox proportional hazards regression was performed, after controlling for potential confounders including demographics, risk factors, and medication use as well as additional adjustment for exercise capacity in the final model. RESULTS A total of 67% of the patients were referred for chest pain, 12% for shortness of breath (SOB), 4% for palpitations, 3% for pre-operative evaluation, 6% for abnormal prior testing, and 7% for risk factors only. There were 6,211 total deaths during follow-up. Compared to chest pain, those referred for palpitations (HR = 0.72, 95% CI: 0.60-0.86) and risk factors only (HR = 0.72, 95% CI: 0.63-0.82) had a lower risk of all-cause mortality, whereas those referred for SOB (HR = 1.15, 95% CI: 1.07-1.23) and pre-operative evaluation (HR = 2.11, 95% CI: 1.94-2.30) had an increased risk. In subgroup analysis, referral for palpitations was protective only in those without coronary artery disease (CAD) (HR = 0.75, 95% CI: 0.62-0.90), while SOB increased mortality risk only in those with established CAD (HR = 1.25, 95% CI: 1.10-1.44). CONCLUSIONS The indication for stress testing is an independent predictor of mortality, showing an interaction with CAD status. Importantly, SOB may be associated with higher mortality risk than chest pain, particularly in patients with CAD.
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Affiliation(s)
- Joonseok Kim
- Division of Cardiology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Mouaz Al-Mallah
- Henry Ford Health System, Detroit, MI, USA
- King Abdul-Aziz Cardiac Center, Riyadh, Saudi Arabia
| | - Stephen P. Juraschek
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | | | | | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Zeina A. Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
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Leavitt DA, Keheila M, Siev M, Shah PH, Moreira DM, George AK, Salami SS, Schwartz MJ, Richstone L, Vira MA, Kavoussi LR. Outcomes of Laparoscopic Partial Nephrectomy in Patients Continuing Aspirin Therapy. J Urol 2016; 195:859-64. [DOI: 10.1016/j.juro.2015.10.132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2015] [Indexed: 01/20/2023]
Affiliation(s)
- David A. Leavitt
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Mohamed Keheila
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Michael Siev
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Paras H. Shah
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Daniel M. Moreira
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Arvin K. George
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Simpa S. Salami
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Michael J. Schwartz
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Lee Richstone
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Manish A. Vira
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
| | - Louis R. Kavoussi
- Department of Urology, Smith Institute for Urology, Hofstra North Shore LIJ School of Medicine, New Hyde Park, New York
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434
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Pereira KSM, Oliveira JCPD, Carvalho FCD, van Bellen B. Complicações cardíacas em cirurgia vascular. J Vasc Bras 2016. [DOI: 10.1590/1677-5449.003515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Resumo Contexto Aproximadamente 60% dos pacientes portadores de doença arterial oclusiva crônica periférica têm doença coronariana grave, sendo que a principal causa de morte no pós-operatório de cirurgia vascular de grande porte é o infarto agudo do miocárdio. Objetivos Determinar a prevalência da doença coronariana em pacientes submetidos a cirurgia vascular eletiva de grande porte e sua relação com as complicações cardiológicas pós-operatórias. Métodos Foram analisados 200 pacientes submetidos a cirurgia vascular arterial eletiva: doença obstrutiva carotídea, aortoilíaca e femoropoplítea distal e doença aneurismática de aorta abdominal e de artérias ilíacas. Os pacientes constituíram três grupos: grupo I, sem doença coronariana; grupo II, com doença coronariana assintomática; e grupo III, com doença coronariana sintomática. As complicações cardiológicas consideradas foram infarto agudo do miocárdio fatal e não fatal, insuficiência cardíaca congestiva, choque cardiogênico, fibrilação atrial aguda e outras arritmias. Resultados Complicações cardíacas ocorreram em 11 pacientes (5,5%): três infartos agudos do miocárdio não fatais (1,5%) sempre em pacientes do grupo III. A complicação cardíaca mais frequente foi arritmia (exceto fibrilação atrial) ocorrida em cinco (2,5%) pacientes, sendo três do grupo II. A mortalidade precoce foi de nove pacientes (4,5%). Apenas uma morte foi decorrente de problema cardíaco: choque cardiogênico em paciente do grupo III. Conclusões A doença coronariana não foi preditora de óbito nos pacientes submetidos a cirurgia vascular periférica de grande porte. A sobrevida dos pacientes com ou sem doença coronariana não mostrou diferenças estatísticas.
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435
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Feldheiser A, Aziz O, Baldini G, Cox BPBW, Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60:289-334. [PMID: 26514824 PMCID: PMC5061107 DOI: 10.1111/aas.12651] [Citation(s) in RCA: 382] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022]
Abstract
Background The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.
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Affiliation(s)
- A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - O. Aziz
- St. Mark's Hospital Harrow Middlesex UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - B. P. B. W. Cox
- Department of Anesthesiology and Pain Therapy University Hospital Maastricht (azM) Maastricht The Netherlands
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - R. H. Kennedy
- St. Mark's Hospital/Imperial College Harrow, Middlesex/London UK
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - D. N. Lobo
- Gastrointestinal Surgery National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK
| | - T. Miller
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - F. F. Radtke
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - T. Ruiz Garces
- Anestesiologa y Reanimacin Hospital Clinico Lozano Blesa Universidad de Zaragoza Zaragoza Spain
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada
| | - M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Surrey UK
| | - J. K. Thacker
- Department of Surgery Duke University Medical Center Durham North Carolina USA
| | - L. M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway Tromso Norway
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
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436
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Conti D, Ballo P, Boccalini R, Sarti A. Predictors of early postoperative troponin increase after noncardiac surgery: a pilot study in a real-world population admitted to the recovery room. Br J Anaesth 2016; 115:945-6. [PMID: 26582864 DOI: 10.1093/bja/aev394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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437
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Orkaby AR, Forman DE. Assessing Risks and Benefits of Invasive Cardiac Procedures in Patients with Advanced Multimorbidity. Clin Geriatr Med 2016; 32:359-71. [PMID: 27113152 DOI: 10.1016/j.cger.2016.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Age-related cardiovascular disease in older adults is more likely to occur in combination with other age-related diseases, with mounting interactive complexity as multiple morbidities accumulate. Although invasive cardiac procedures are frequently recommended for cardiovascular disease, their value is less certain in the context of age-related intricacies of care. Tools for risk assessment before invasive procedures are insensitive to risks corresponding to the unique challenges of older adults. Recognizing multimorbidity and other age-related risks provides opportunities to intervene and moderate dangers. By refocusing risk assessment in terms of patient-centered goals, the fundamental utility of invasive cardiac procedures may be reconsidered and alternative therapies prioritized.
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Affiliation(s)
- Ariela R Orkaby
- Division of Cardiology, VA Boston Healthcare System, 400 Veterans of Foreign Wars Pkwy, West Roxbury, MA 02132, USA; Division of Aging, Brigham & Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA
| | - Daniel E Forman
- Section of Geriatric Cardiology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 500, Pittsburgh, PA 15213, USA; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, University Dr C, Pittsburgh, PA 15240, USA.
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439
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Lemm H, Janusch M, Buerke M. [Special aspects of analgosedation in cardiogenic shock patients]. Med Klin Intensivmed Notfmed 2016; 111:22-8. [PMID: 26809564 DOI: 10.1007/s00063-015-0131-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 12/19/2022]
Abstract
Patients with cardiogenic shock pose a challenge to physicians due to cardiorespiratory instability in addition to the underlying medical condition. If analgosedation and ventilation are indicated, commonly administered drugs themselves often influence hemodynamics and oxygenation. The present article provides an overview of the available substances with consideration of the patients' condition, then monitoring and optimization of analgosedation.
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Affiliation(s)
- H Lemm
- Medizinische Klinik II - Kardiologie, Angiologie, Internistische Intensivmedizin, St. Marien-Krankenhaus Siegen GmbH, Kampenstraße 51, 57072, Siegen, Deutschland.
| | - M Janusch
- Medizinische Klinik II - Kardiologie, Angiologie, Internistische Intensivmedizin, St. Marien-Krankenhaus Siegen GmbH, Kampenstraße 51, 57072, Siegen, Deutschland
| | - M Buerke
- Medizinische Klinik II - Kardiologie, Angiologie, Internistische Intensivmedizin, St. Marien-Krankenhaus Siegen GmbH, Kampenstraße 51, 57072, Siegen, Deutschland
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440
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Swann MC, Hoes KS, Aoun SG, McDonagh DL. Postoperative complications of spine surgery. Best Pract Res Clin Anaesthesiol 2016; 30:103-20. [PMID: 27036607 DOI: 10.1016/j.bpa.2016.01.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/05/2016] [Accepted: 01/12/2016] [Indexed: 12/20/2022]
Abstract
A variety of surgical approaches are available for the treatment of spine diseases. Complications can arise intraoperatively, in the immediate postoperative period, or in a delayed fashion. These complications may lead to severe or even permanent morbidity if left unrecognized and untreated [1-4]. Here we review a range of complications in the early postoperative period from more benign complications such as postoperative nausea and vomiting (PONV) to more feared complications leading to permanent loss of neurological function or death [5]. Perioperative pain management is covered in a separate review (Chapter 8).
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Affiliation(s)
- Matthew C Swann
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Kathryn S Hoes
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Salah G Aoun
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - David L McDonagh
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
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441
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Duncan D, Wijeysundera DN. Preoperative Cardiac Evaluation and Management of the Patient Undergoing Major Vascular Surgery. Int Anesthesiol Clin 2016; 54:1-32. [PMID: 26967800 PMCID: PMC5087846 DOI: 10.1097/aia.0000000000000091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Dallas Duncan
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Duminda N. Wijeysundera
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, ON, Canada
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442
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Ibarra P, Zárate E, Robledo B, Arango E, Falls EB, Sarmiento Á, Rojas M, Cuccaro G, Arbeláez J, Veloza M, Fernández C, Charris H, Montes F. Manual de práctica clínica basado en la evidencia: preparación del paciente para el acto quirúrgico y traslado al quirófano. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rca.2015.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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444
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Huibers A, Halliday A, Bulbulia R, Coppi G, de Borst GJ. Antiplatelet Therapy in Carotid Artery Stenting and Carotid Endarterectomy in the Asymptomatic Carotid Surgery Trial-2. Eur J Vasc Endovasc Surg 2015; 51:336-42. [PMID: 26717867 DOI: 10.1016/j.ejvs.2015.11.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/01/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Strokes are infrequent but potentially serious complications following carotid intervention, but antiplatelet therapy can reduce these risks. There are currently no specific guidelines on dose or duration of peri-procedural antiplatelet treatment for patients undergoing carotid intervention. Within the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), this study aimed at assessing the current use of antiplatelet therapy before, during, and after CEA and CAS in patients with asymptomatic carotid stenosis. METHODS Questionnaires were sent to ACST-2 collaborators seeking information about the use of antiplatelet therapy during the pre-, peri-, and post-operative periods in patients undergoing carotid intervention at 77 participating sites and also whether sites tested for antiplatelet therapy resistance. RESULTS The response rate was 68/77 (88%). For CAS, 82% of sites used dual antiplatelet therapy (DAPT) pre-operatively and 86% post-operatively with a mean post-procedural duration of 3 months (range 1-12), while 9% continued DAPT life-long. For CEA only 31% used DAPT pre-operatively, 24% post-operatively with a mean post-procedural duration of 3 months (range 1-5), while 10% continued DAPT life-long. For those prescribing post-procedural mono antiplatelet (MAPT) therapy (76%), aspirin was more commonly prescribed (59%) than clopidogrel (6%) and 11% of centres did not show a preference for either aspirin or clopidogrel. Eleven centres (16%) tested for antiplatelet therapy resistance. CONCLUSION There appears to be broad agreement on the use of antiplatelet therapy in ACST-2 patients undergoing carotid artery stenting and surgery. Although evidence to help guide the duration of peri-procedural antiplatelet therapy is limited, long-term treatment with DAPT appears similar between both treatment arms.
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Affiliation(s)
- A Huibers
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.
| | - R Bulbulia
- Clinical Trial Service Unit, University of Oxford, Oxford, UK
| | - G Coppi
- Department of Vascular Surgery, Nuovo Ospedale S. Agostino Estense, University of Modena, Modena, Italy
| | - G J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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445
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Bartline PB, Brooke BS. Using implementation science to help integrate preoperative evidence-based measures into practice for vascular surgery patients. Semin Vasc Surg 2015; 28:68-79. [PMID: 26655049 DOI: 10.1053/j.semvascsurg.2015.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The preoperative workup is a necessary and crucial evaluation for patients undergoing major vascular surgery. It is important to assess for likelihood of perioperative adverse events and then implement evidence-based measures to reduce identified medical comorbidities and improve the quality of patient care and outcomes after surgery. Although there are numerous opportunities to implement evidence-based processes during the preoperative period, there are many barriers that can prevent vascular surgeons from achieving these goals. This review will discuss how an implementation science-based approach can be used by members of the vascular surgery team to identify appropriate preoperative evidence-based interventions for diverse practice settings and to overcome barriers and allow integration of these interventions as part of the routine preoperative workup.
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Affiliation(s)
- Peter B Bartline
- Division of Vascular Surgery, University of Utah School of Medicine, 30 N. 1900 E., Suite #3C344, Salt Lake City, UT 84132
| | - Benjamin S Brooke
- Division of Vascular Surgery, University of Utah School of Medicine, 30 N. 1900 E., Suite #3C344, Salt Lake City, UT 84132.
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446
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Bisdas T, Borowski M, Torsello G. Current practice of first-line treatment strategies in patients with critical limb ischemia. J Vasc Surg 2015; 62:965-973.e3. [PMID: 26187290 DOI: 10.1016/j.jvs.2015.04.441] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 04/28/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Theodosios Bisdas
- Clinic for Vascular and Endovascular Surgery, University Clinic of Muenster, and Department of Vascular Surgery, St. Franziskus Hospital, Muenster, Germany.
| | - Matthias Borowski
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Giovanni Torsello
- Clinic for Vascular and Endovascular Surgery, University Clinic of Muenster, and Department of Vascular Surgery, St. Franziskus Hospital, Muenster, Germany
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447
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Alyeshmerni D, Eagle K. There and back again: the story of perioperative β-blockade. Am Heart J 2015; 170:617-8. [PMID: 26386783 DOI: 10.1016/j.ahj.2015.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/20/2015] [Indexed: 11/26/2022]
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448
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Is there any adhesiogenic impact of CO2-pneumoperitoneum: Pro and contra findings. Int J Surg 2015; 23:115-7. [PMID: 26403070 DOI: 10.1016/j.ijsu.2015.09.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/03/2015] [Accepted: 09/10/2015] [Indexed: 11/21/2022]
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449
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Huo Y, Shi Z, Chen Y, Dong Y, Ge J, Han Y, He B, He Z, Huang D, Li X, Li Y, Liao Y, Liu M, Lu X, Ma C, Ning T, Sun N, Wang J, Wu X, Yan X, Yang T, Yang X, Zhang J, Zhou L, Zhu W. Expert panel of the Chinese Society of Cardiology recommendations on beta-blocker therapy in patients undergoing non-cardiac surgery. Eur Heart J Suppl 2015. [DOI: 10.1093/eurheartj/suv048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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450
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Treschan TA, Malbouisson LM, Beiderlinden M. Intraoperative mechanical ventilation strategies to prevent postoperative pulmonary complications in patients with pulmonary and extrapulmonary comorbidities. Best Pract Res Clin Anaesthesiol 2015; 29:341-55. [PMID: 26643099 DOI: 10.1016/j.bpa.2015.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/20/2015] [Accepted: 08/12/2015] [Indexed: 12/26/2022]
Abstract
A variety of patient characteristics and comorbidities have been identified, which increase the risk of postoperative pulmonary complications (PPCs), including smoking, age, chronic obstructive pulmonary disease, pulmonary hypertension, obstructive sleep apnea, cardiac and neurologic diseases as well as critical illness. In contrast to the variety of conditions, evidence for specific intraoperative ventilation strategies to reduce PPC is very limited for most comorbidities. Here, we provide an overview of and discuss possible implications for the intraoperative ventilatory management of patients with comorbidities.
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Affiliation(s)
- Tanja A Treschan
- Department of Anesthesiology, Duesseldorf University Hospital, Heinrich-Heine University, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Luiz Marcelo Malbouisson
- Divisão de Anestesiologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 155, 8th Floor, 05403-000 São Paulo, SP, Brazil.
| | - Martin Beiderlinden
- Department of Anaesthesiology, Marienhospital Osnabrück, Bischofsstraße 1, 49074 Osnabrück, Germany.
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