Association of Time Elapsed Since Ischemic Stroke With Risk of Recurrent Stroke in Older Patients Undergoing Elective Nonneurologic, Noncardiac Surgery

Perioperative care of patients with recent stroke undergoing nonemergent, nonneurological, noncardiac, nonvascular surgery: a systematic review and meta-analysis

PURPOSE OF REVIEW

To systematically review and perform a meta-analysis of published literature regarding postoperative stroke and mortality in patients with a history of stroke and to provide a framework for preoperative, intraoperative, and postoperative care in an elective setting.

RECENT FINDINGS

Patients with nonneurological, noncardiac, and nonvascular surgery within three months after stroke have a 153-fold risk, those within 6 months have a 50-fold risk, and those within 12 months have a 20-fold risk of postoperative stroke. There is a 12-fold risk of in-hospital mortality within three months and a three-to-four-fold risk of mortality for more than 12 months after stroke. The risk of stroke and mortality continues to persist years after stroke. Recurrent stroke is common in patients in whom anticoagulation/antiplatelet therapy is discontinued. Stroke and time elapsed after stroke should be included in the preoperative assessment questionnaire, and a stroke-specific risk assessment should be performed before surgical planning is pursued.

SUMMARY

In patients with a history of a recent stroke, anesthesiology, surgery, and neurology experts should create a shared mental model in which the patient/surrogate decision-maker is informed about the risks and benefits of the proposed surgical procedure; secondary-stroke-prevention medications are reviewed; plans are made for interruptions and resumption; and intraoperative care is individualized to reduce the likelihood of postoperative stroke or death.

Stroke History and Time Elapsed are Predictors of Complications in Total Knee Arthroplasty

BACKGROUND

A consensus has not been reached regarding the optimal timing of elective total knee arthroplasty (TKA) following a stroke. The purpose of this study was to examine the optimal period between stroke and TKA to minimize complications. Specifically, we assessed: (1) medical and surgical complications; (2) timing of stroke and TKA; (3) associated risk factors.

METHODS

A national database identified 69,815 TKA patients that were separated into 6 exclusive cohorts using a stratum likelihood ratio: no stroke (n = 20,000), stroke within 6 (n = 17,764), 12 (n = 10,338), 18 (n = 8,370), 24 (n = 7,121), and 30 months (n = 6,222) prior to TKA. We analyzed 90-day, 1-year, and 2-year complications in each subgroup. Multivariate analyses were used to identify risk factors for periprosthetic joint infection (PJI).

RESULTS

The multivariate regression model identified that patients with a stroke within 6 months of TKA had increased risk of PJI at all time points (P < .001). Also, stroke 12 to 18 months before TKA elevated PJI risk at 1 and 2 years (all P < .021), while those over 18 months did not show a significant risk compared to controls (P > .067).

CONCLUSIONS

Stroke prior to TKA was associated with an increased risk of postoperative complications, specifically PJI. We recommend a minimum of 6 months between stroke and TKA, with 18 months offering the lowest risk.

Risk of Mortality Following Surgery in Patients With a Previous Cardiovascular Event

Importance

There is a lack of consensus regarding the interval of time-dependent postoperative mortality risk following acute coronary syndrome or stroke.

Objective

To determine the magnitude and duration of risk associated with the time interval between a preoperative cardiovascular event and 30-day postoperative mortality.

Design, Setting, and Participants

This is a longitudinal retrospective population-based cohort study. This study linked data from the Hospital Episode Statistics for National Health Service England, Myocardial Ischaemia National Audit Project and the Office for National Statistics mortality registry. All adults undergoing a National Health Service-funded noncardiac, nonneurologic surgery in England between April 1, 2007, and March 31, 2018, registered in Hospital Episode Statistics Admitted Patient Care were included. Data were analyzed from July 2021 to July 2022.

Exposure

The time interval between a previous cardiovascular event (acute coronary syndrome or stroke) and surgery.

Main Outcomes and Measures

The primary outcome was 30-day all-cause mortality. Secondary outcomes were postoperative mortality at 60, 90, and 365 days. Multivariable logistic regression models with restricted cubic splines were used to estimate adjusted odds ratios.

Results

There were 877 430 patients with and 20 582 717 without a prior cardiovascular event (overall mean [SD] age, 53.4 [19.4] years; 11 577 157 [54%] female). Among patients with a previous cardiovascular event, the time interval associated with increased risk of postoperative mortality was surgery within 11.3 months (95% CI, 10.8-11.7), with subgroup risks of 14.2 months before elective surgery (95% CI, 13.3-15.3) and 7.3 months for emergency surgery (95% CI, 6.8-7.8). Heterogeneity in these timings was noted across many surgical specialties. The time-dependent risk intervals following stroke and myocardial infarction were similar, but the absolute risk was greater following a stroke. Regarding surgical urgency, the risk of 30-day mortality was higher in those with a prior cardiovascular event for emergency surgery (adjusted hazard ratio, 1.35; 95% CI, 1.34-1.37) and an elective procedure (adjusted hazard ratio, 1.83; 95% CI, 1.78-1.89) than those without a prior cardiovascular event.

Conclusions and Relevance

In this study, surgery within 1 year of an acute coronary syndrome or stroke was associated with increased postoperative mortality before reaching a new baseline, particularly for elective surgery. This information may help clinicians and patients balance deferring the potential benefits of the surgery against the desire to avoid increased mortality from overly expeditious surgery after a recent cardiovascular event.

Comorbid Factors and Selection for Same-Day Total Joint Arthroplasty

Given that the number of total joint arthroplasties (TJAs) performed worldwide is expected to continue to increase, and there are significant costs associated with these procedures, selecting candidates for same-day or 23-hour discharge is important in lowering costs and providing greater access. Younger, healthier patients are excellent candidates for same-day discharge after TJA. Preoperative medical assessment can help exclude patients who may not be candidates, such as patients with 1 or more comorbidities that increase the risk of intra- and postoperative complications and who may require a longer period of monitoring.

Perioperative stroke

Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.

Association between cerebrovascular disease and perioperative neurocognitive disorders: a retrospective cohort study

BACKGROUND

Previous studies have shown that patients with cerebrovascular disease (CVD) have a significantly increased risk of cognitive decline or dementia; however, the association between preoperative CVD and perioperative neurocognitive disorders (PNDs) remains unclear. This study aimed to explore the correlation between preoperative CVD and PNDs, as well as combine logistic regression and receiver operating characteristic (ROC) curves to construct a clinical prediction PND model.

MATERIALS AND METHODS

This retrospective cohort study evaluated 13 899 surgical patients of a large-scale comprehensive hospital between January 2021 and January 2022 to explore the association between preoperative CVD and PNDs, with follow-up to monitor postoperative survival until 28 February 2023, unless the patient died. The study participants comprised all inpatients from the Bone and Joint Surgery, Spine Surgery, Urology, Hepatobiliary Surgery, Gastrointestinal Surgery, and Thoracic Surgery departments. Patients were classified into two groups: the CVD group with a confirmed diagnosis and the noncerebrovascular disease group. The incidence of PNDs was measured, and potential associations between patient demographic information, preoperative comorbidities, and CVD, as well as the correlation between preoperative CVD and PNDs, were investigated by multivariate logistic regression analysis. Next, the authors constructed a clinical prediction PND model by drawing the ROC curve. The postoperative survival of all patients was tracked, and a survival curve was constructed and incorporated into the Cox proportional hazard regression model to analyze the relationship between preoperative CVD and the overall postoperative survival rate.

RESULTS

Of the included 13 899 patients, propensity score matching yielded 1006 patient pairs. Multivariate logistic regression analysis revealed that CVD was an independent risk factor for PNDs [odds ratio: 10.193; 95% CI: 7.454-13.938; P <0.001]. Subsequently, the authors developed a clinical prediction model for PNDs by multivariate logistic regression analysis. The area under the ROC curve was 0.798 (95% CI: 0.765-0.830). The survival of 11 702 patients was followed up. Multivariate Cox hazard ratio regression analysis revealed that CVD affected the overall postoperative survival rate (hazard ratio, 1.398; 95% CI: 1.112-1.758; P <0.001).

CONCLUSION

CVD was an independent risk factor for PNDs and affected the overall postoperative survival rate of surgical patients with preoperative CVD.

Prevention of perioperative stroke in patients undergoing non-cardiac surgery

About 300 million adults undergo non-cardiac surgery annually. Although, in this setting, the incidence of perioperative stroke is low, the absolute number of patients experiencing a stroke is substantial. Furthermore, most patients with this complication will die or end up with severe disability. Covert brain infarctions are more frequent than overt strokes and are associated with postoperative delirium, cognitive decline, and cerebrovascular events at 1 year after surgery. Evidence shows that traditional stroke risk factors including older age, hypertension, and atrial fibrillation are also associated with perioperative stroke; previous stroke is the strongest risk factor for perioperative stroke. Increasing evidence also suggests the pathogenic role of perioperative events, such as hypotension, new atrial fibrillation, paradoxical embolism, and bleeding. Clinicians involved in perioperative care should be aware of this evidence on prevention strategies to improve patient outcomes after non-cardiac surgery.

Patient selection in ambulatory surgery

Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.

Practice Changing Updates in Perioperative Medicine Literature 2022. A Systematic Review

Perioperative medicine is a rapidly growing multidisciplinary field with significant advances published each year. In this review, we highlight important perioperative publications in 2022. A multi-database literature search from January to December of 2022 was undertaken. Original research articles, systematic reviews, meta-analyses, and guidelines were included. Abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature were excluded. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont, Canada). A modified Delphi technique was used to identify 8 practice-changing articles. We identified another 10 articles for tabular summaries. We highlight why these articles have the potential to change clinical perioperative practice and areas where more information is needed.

Preoperative Evaluation in the 21st Century

This review aims to provide a conceptual framework for preoperative evaluation and to highlight the clinical evidence available to support perioperative decision-making.

Complications of Vascular Disease

Vascular diseases and their sequelae increase perioperative risk for noncardiac surgical patients. In this review, the authors discuss vascular diseases, their epidemiology and pathophysiology, risk stratification, and management strategies to reduce adverse perioperative outcomes.