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Barboi C, Stapelfeldt WH. Mortality following noncardiac surgery assessed by the Saint Louis University Score (SLUScore) for hypotension: a retrospective observational cohort study. Br J Anaesth 2024; 133:33-41. [PMID: 38702236 PMCID: PMC11213987 DOI: 10.1016/j.bja.2024.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/07/2024] [Accepted: 03/13/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND The Saint Louis University Score (SLUScore) was developed to quantify intraoperative blood pressure trajectories and their associated risk for adverse outcomes. This study examines the prevalence and severity of intraoperative hypotension described by the SLUScore and its relationship with 30-day mortality in surgical subtypes. METHODS This retrospective analysis of perioperative data included surgical cases performed between January 1, 2010, and December 31, 2020. The SLUScore is calculated from cumulative time-periods for which the mean arterial pressure is below a range of hypotensive thresholds. After calculating the SLUScore for each surgical procedure, we quantified the prevalence and severity of intraoperative hypotension for each surgical procedure and the association between intraoperative hypotension and 30-day mortality. We used binary logistic regression to quantify the potential contribution of intraoperative hypotension to mortality. RESULTS We analysed 490 982 cases (57.7% female; mean age 57 yr); 33.2% of cases had a SLUScore>0, a median SLUScore of 13 (inter-quartile range [IQR] 7-21), with 1.19% average mortality. The SLUScore was associated with mortality in 12/14 surgical groups. The increases in the odds ratio for death within 30 days of surgery per SLUScore increment were: all surgery types 3.5% (95% confidence interval [95% CI] 3.2-3.9); abdominal/transplant surgery 6% (95% CI 1.5-10.7); thoracic surgery1.5% (95% CI 1-3.3); vascular surgery 3.01% (95% CI 1.9-4.05); spine/neurosurgery 1.1% (95% CI 0.1-2.1); orthopaedic surgery 1.4% (95% CI 0.7-2.2); gynaecological surgery 6.3% (95% CI 2.5-10.1); genitourinary surgery 4.84% (95% CI 3.5-6.15); gastrointestinal surgery 5.2% (95% CI 3.9-6.4); gastroendoscopy 5.5% (95% CI 4.4-6.7); general surgery 6.3% (95% CI 5.5-7.1); ear, nose, and throat surgery 1.6% (95% CI 0-3.27); and cardiac electrophysiology (including pacemaker procedures) 6.6% (95% CI 1.1-12.4). CONCLUSIONS The SLUScore was independently, but variably, associated with 30-day mortality after noncardiac surgery.
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Affiliation(s)
- Cristina Barboi
- Indiana University School of Medicine, Department of Anesthesiology, Indianapolis, IN, USA.
| | - Wolf H Stapelfeldt
- Indiana University School of Medicine, Department of Anesthesiology, Indianapolis, IN, USA; Richard L. Roudebush VA Medical Centre, Department of Anesthesiology, Indianapolis, IN, USA
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Wang XJ, Xuan XC, Sun ZC, Shen S, Yu F, Li NN, Chu XC, Yin H, Hu YL. Risk factors associated with intraoperative persistent hypotension in pancreaticoduodenectomy. World J Gastrointest Surg 2024; 16:1582-1591. [PMID: 38983354 PMCID: PMC11230017 DOI: 10.4240/wjgs.v16.i6.1582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/27/2024] [Accepted: 05/16/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Intraoperative persistent hypotension (IPH) during pancreaticoduodenectomy (PD) is linked to adverse postoperative outcomes, yet its risk factors remain unclear. AIM To clarify the risk factors associated with IPH during PD, ensuring patient safety in the perioperative period. METHODS A retrospective analysis of patient records from January 2018 to December 2022 at the First Affiliated Hospital of Nanjing Medical University identified factors associated with IPH in PD. These factors included age, gender, body mass index, American Society of Anesthesiologists classification, comorbidities, medication history, operation duration, fluid balance, blood loss, urine output, and blood gas parameters. IPH was defined as sustained mean arterial pressure < 65 mmHg, requiring prolonged deoxyepinephrine infusion for > 30 min despite additional deoxyepinephrine and fluid treatments. RESULTS Among 1596 PD patients, 661 (41.42%) experienced IPH. Multivariate logistic regression identified key risk factors: increased age [odds ratio (OR): 1.20 per decade, 95% confidence interval (CI): 1.08-1.33] (P < 0.001), longer surgery duration (OR: 1.15 per additional hour, 95%CI: 1.05-1.26) (P < 0.01), and greater blood loss (OR: 1.18 per 250-mL increment, 95%CI: 1.06-1.32) (P < 0.01). A novel finding was the association of arterial blood Ca2+ < 1.05 mmol/L with IPH (OR: 2.03, 95%CI: 1.65-2.50) (P < 0.001). CONCLUSION IPH during PD is independently associated with older age, prolonged surgery, increased blood loss, and lower plasma Ca2+.
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Affiliation(s)
- Xing-Jun Wang
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Xi-Chen Xuan
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Zhao-Chu Sun
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Shi Shen
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Fan Yu
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Na-Na Li
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Xue-Chun Chu
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Hui Yin
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - You-Li Hu
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
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Li Q, Lv H, Chen Y, Shen J, Shi J, Zhou C. Development and validation of a machine learning predictive model for perioperative myocardial injury in cardiac surgery with cardiopulmonary bypass. J Cardiothorac Surg 2024; 19:384. [PMID: 38926872 PMCID: PMC11201784 DOI: 10.1186/s13019-024-02856-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Perioperative myocardial injury (PMI) with different cut-off values has showed to be associated with different prognostic effect after cardiac surgery. Machine learning (ML) method has been widely used in perioperative risk predictions during cardiac surgery. However, the utilization of ML in PMI has not been studied yet. Therefore, we sought to develop and validate the performances of ML for PMI with different cut-off values in cardiac surgery with cardiopulmonary bypass (CPB). METHODS This was a second analysis of a multicenter clinical trial (OPTIMAL) and requirement for written informed consent was waived due to the retrospective design. Patients aged 18-70 undergoing elective cardiac surgery with CPB from December 2018 to April 2021 were enrolled in China. The models were developed using the data from Fuwai Hospital and externally validated by the other three cardiac centres. Traditional logistic regression (LR) and eleven ML models were constructed. The primary outcome was PMI, defined as the postoperative maximum cardiac Troponin I beyond different times of upper reference limit (40x, 70x, 100x, 130x) We measured the model performance by examining the area under the receiver operating characteristic curve (AUROC), precision-recall curve (AUPRC), and calibration brier score. RESULTS A total of 2983 eligible patients eventually participated in both the model development (n = 2420) and external validation (n = 563). The CatboostClassifier and RandomForestClassifier emerged as potential alternatives to the LR model for predicting PMI. The AUROC demonstrated an increase with each of the four cutoffs, peaking at 100x URL in the testing dataset and at 70x URL in the external validation dataset. However, it's worth noting that the AUPRC decreased with each cutoff increment. Additionally, the Brier loss score decreased as the cutoffs increased, reaching its lowest point at 0.16 with a 130x URL cutoff. Moreover, extended CPB time, aortic duration, elevated preoperative N-terminal brain sodium peptide, reduced preoperative neutrophil count, higher body mass index, and increased high-sensitivity C-reactive protein levels were identified as risk factors for PMI across all four cutoff values. CONCLUSIONS The CatboostClassifier and RandomForestClassifer algorithms could be an alternative for LR in prediction of PMI. Furthermore, preoperative higher N-terminal brain sodium peptide and lower high-sensitivity C-reactive protein were strong risk factor for PMI, the underlying mechanism require further investigation.
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Affiliation(s)
- Qian Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong Lv
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuye Chen
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingjia Shen
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenghui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd., Chaoyang District, Beijing, 10029, China.
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Zhao X, Zhang Y, Kou M, Wang Z, He Q, Wen Z, Chen J, Song Y, Wu S, Huang C, Huang W. The exploration of perioperative hypotension subtypes: a prospective, single cohort, observational pilot study. Front Med (Lausanne) 2024; 11:1358067. [PMID: 38952866 PMCID: PMC11215119 DOI: 10.3389/fmed.2024.1358067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 06/05/2024] [Indexed: 07/03/2024] Open
Abstract
Background Hypotension is a risk factor for postoperative complications, but evidence from randomized trials does not support that a higher blood pressure target always leads to optimized outcomes. The heterogeneity of underlying hemodynamics during hypotension may contribute to these contradictory results. Exploring the subtypes of hypotension can enable optimal management of intraoperative hypotension. Methods This is a prospective, observational pilot study. Patients who were ≥ 45 years old and scheduled to undergo moderate-to-high-risk noncardiac surgery were enrolled in this study. The primary objective of this pilot study was to investigate the frequency and distribution of perioperative hypotension and its subtypes (hypotension with or without cardiac output reduction). The exposure of hypotension and its subtypes in patients with and without myocardial or acute kidney injury were also explored. Results Sixty patients were included in the analysis. 83% (50/60) of the patients experienced perioperative hypotension. The median duration of hypotension for each patient was 8.0 [interquartile range, 3.1-23.3] minutes. Reduced cardiac output was present during 77% of the hypotension duration. Patients suffering from postoperative myocardial or acute kidney injury displayed longer duration and more extensive exposure in all hypotension subtypes. However, the percentage of different hypotension subtypes did not differ in patients with or without postoperative myocardial or acute kidney injury. Conclusion Perioperative hypotension was frequently accompanied by cardiac output reduction in moderate-to-high-risk noncardiac surgical patients. However, due to the pilot nature of this study, the relationship between hypotension subtypes and postoperative myocardial or acute kidney injury still needs further exploration. Clinical trial registration https://www.chictr.org.cn/showprojEN.html?proj=134260, CTR2200055929.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Shihui Wu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chanyan Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenqi Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Upadhyay P, Hicks MH, Khanna AK. Enhanced monitoring for postoperative hospital wards - Evidence to implementation. Indian J Anaesth 2024; 68:511-513. [PMID: 38903260 PMCID: PMC11186533 DOI: 10.4103/ija.ija_360_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 06/22/2024] Open
Affiliation(s)
- Prateek Upadhyay
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Megan Henley Hicks
- Anesthesiology, Section on Cardiac Anesthesiology and Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Ashish K. Khanna
- Anesthesiology, Section on Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA and Outcomes Research Consortium, Cleveland, OH, USA
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Li Q, Lv H, Chen Y, Shen J, Shi J, Zhou C. Hybrid feature selection in a machine learning predictive model for perioperative myocardial injury in noncoronary cardiac surgery with cardiopulmonary bypass. Perfusion 2024:2676591241253459. [PMID: 38733257 DOI: 10.1177/02676591241253459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
BACKGROUND Perioperative myocardial injury (PMI) is associated with increased mobility and mortality after noncoronary cardiac surgery. However, limited studies have developed a predictive model for PMI. Therefore, we used hybrid feature selection (FS) methods to establish a predictive model for PMI in noncoronary cardiac surgery with cardiopulmonary bypass (CPB). METHODS This was a single-center retrospective study conducted at the Fuwai Hospital in China. Patients aged 18-70 years who underwent elective noncoronary surgery with CPB at our institution from December 2018 to April 2021 were enrolled. The primary outcome was PMI, defined as the postoperative cardiac troponin I (cTnI) levels exceeding 220 times of upper reference limit (URL). Statistical analyses were conducted by Python (Python Software Foundation, version 3.9.7 and integrated development environment Jupyter Notebook 1.1.0) and SPSS software version 26.0 (IBM Corp., Armonk, New York, USA). RESULTS A total of 1130 patients were eventually eligible for this study. The incidence of PMI was 20.3% (229/1130) in the overall patients, 20.6% (163/791) in the training dataset, and 19.5% (66/339) in the testing dataset. The logistic regression model performed the best AUC of 0.6893 (95 CI%: 0.6371-0.7382) by the traditional selection method, and the random forest model performed the best AUC of 0.6937 (95 CI%: 0.6416-0.7423) by the union of Wrapper and Embedded method, and the CatBoost model performed the best AUC of 0.6828 (95 CI%: 0.6304-0.7320) by the union of Embedded and forward logistic regression technique, and the Naïve Bayes model achieved the best AUC with 0.7254 (95 CI%: 0.6746-0.7723) by forwarding logistic regression method. Moreover, the decision tree, KNeighborsClassifier, and support vector machine models performed the worse AUC in all selection forms. Furthermore, the SHapley Additive exPlanations plot showed that prolonged CPB, aortic clamp time, and preoperative low platelets count were strongly related to the PMI risk. CONCLUSIONS In total, four category feature selection methods were utilized, comprising five individual selection techniques and 15 combined methods. Notably, the combination of logistic regression and embedded methods demonstrated outstanding performance in predicting PMI risk. We also concluded that the machine learning model, including random forest, catboost, and Naive Bayes, were suitable candidates for establishing PMI predictive model. Nevertheless, additional investigation and validation are imperative for substantiating these finding.
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Affiliation(s)
- Qian Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Hong Lv
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Yuye Chen
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Jingjia Shen
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Jia Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Chenghui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Mohr NL, Krannich A, Jung H, Hulde N, von Dossow V. Intraoperative Blood Pressure Management and Its Effects on Postoperative Delirium After Cardiac Surgery: A Single-Center Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:1127-1134. [PMID: 38369449 DOI: 10.1053/j.jvca.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/17/2024] [Accepted: 01/23/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES There is accumulating evidence that blood pressure management might be associated with end-organ dysfunction after cardiac surgery. This study aimed to investigate the impact of intraoperative hypotension (IOH) on adverse neurologic outcomes and mortality. DESIGN A single-center retrospective cohort study. SETTING The Heart and Diabetes Centre Bad Oeynhausen NRW, Ruhr-University Bochum. PARTICIPANTS This retrospective cohort study included 31,315 adult patients who underwent elective cardiac surgery at the authors' institution between January 2009 and December 2018. INTERVENTIONS All cardiac surgery procedures except assist device implantation, organ transplantation, and emergency surgery. MEASUREMENTS AND MAIN RESULTS Adverse neurologic outcomes were defined as postoperative delirium and stroke. IOH was defined as mean arterial pressure below 60 mmHg for >2 minutes. The frequency of IOH episodes and the cumulative IOH duration were recorded. The association between IOH and adverse neurologic outcomes was examined with unadjusted statistical analysis and multiple logistic regression analysis. Eight hundred forty-nine (2.9%) patients developed postoperative stroke, and 2,401 (7.7%) patients developed postoperative delirium. The frequency of IOH episodes was independently associated with postoperative delirium in the multiple logistic regression analysis (odds ratio 1.02, 95% CI 1.003-1.03, p < 0.001), whereas there was no association between it and stroke. CONCLUSION This large retrospective monocentric cohort study revealed that increased episodes of IOH were associated with the risk of developing postoperative delirium after cardiac surgery. This might have important clinical implications with respect to careful and precise hemodynamic monitoring and proactive treatment, especially in patients with increased risk for postoperative delirium.
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Affiliation(s)
- Niklas L Mohr
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | | | - Hilke Jung
- Institute of Congenital heart diseases, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Nikolai Hulde
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Vera von Dossow
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany.
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Scott MJ. Perioperative Patients With Hemodynamic Instability: Consensus Recommendations of the Anesthesia Patient Safety Foundation. Anesth Analg 2024; 138:713-724. [PMID: 38153876 PMCID: PMC10916753 DOI: 10.1213/ane.0000000000006789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 12/30/2023]
Abstract
In November of 2022, the Anesthesia Patient Safety Foundation held a Consensus Conference on Hemodynamic Instability with invited experts. The objective was to review the science and use expert consensus to produce best practice recommendations to address the issue of perioperative hemodynamic instability. After expert presentations, a modified Delphi process using discussions, voting, and feedback resulted in 17 recommendations regarding advancing the perioperative care of the patient at risk of, or with, hemodynamic instability. There were 17 high-level recommendations. These recommendations related to the following 7 domains: Current Knowledge (5 statements); Preventing Hemodynamic Instability-Related Harm During All Phases of Care (4 statements); Data-Driven Quality Improvement (3 statements); Informing Patients (2 statements); The Importance of Technology (1 statement); Launch a National Campaign (1 statement); and Advancing the Science (1 statement). A summary of the recommendations is presented in Table 1 .
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Affiliation(s)
- Michael J. Scott
- From the Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Anesthesia Critical Care and Pain Medicine, University College London, London, United Kingdom
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Sun Y, Guo N, Zhang M, Liu M, Gao Z, Sun T, Gao X, Xu L, Zhang H, Wei C, Liu P, Liu Y, Zhang X, Guo Y, Chen L, Zhou Z, Su Z, Hu Y, Shi X, Huang L, Wang Y. Association between preoperative frailty and myocardial injury after noncardiac surgery in geriatric patients: study protocol for a prospective, multicentre, real-world observational, cohort trial. BMC Geriatr 2024; 24:271. [PMID: 38504166 PMCID: PMC10953137 DOI: 10.1186/s12877-024-04847-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 02/24/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Frailty has become a worldwide health burden that has a large influence on public health and clinical practice. The incidence of frailty is anticipated to increase as the ageing population increases. Myocardial injury after noncardiac surgery (MINS) is associated with short-term and long-term mortality. However, the incidence of MINS in frail geriatric patients is unknown. METHODS AND ANALYSIS This prospective, multicentre, real-world observational cohort study will be conducted at 18 designated centres in China from January 2023 to December 2024, with an anticipated sample size of 856 patients aged 65 years and older who are scheduled to undergo noncardiac surgery. The primary outcome will be the incidence of MINS. MINS is defined as a fourth-generation plasma cardiac troponin T (cTnT) concentration ≥ 0.03 ng/mL exhibited at least once within 30 days after surgery, with or without symptoms of myocardial ischaemia. All data will be collected via electronic data acquisition. DISCUSSION This study will explore the incidence of MINS in frail patients. The characteristics, predictive factors and 30-day outcomes of MINS in frail patients will be further investigated to lay the foundation for identifying clinical interventions. CLINICAL TRIAL REGISTRATION https://beta. CLINICALTRIALS gov/study/NCT05635877 , NCT05635877.
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Affiliation(s)
- Yongtao Sun
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
| | - Na Guo
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
| | - Min Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
| | - Mengjie Liu
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
| | - Zhongquan Gao
- Department of Anesthesiology, Shandong Public Health Clinical Center, Shandong University, Shandong, 250013, China
| | - Tao Sun
- Department of Clinical Laboratory Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China
| | - Xiaojun Gao
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
| | - Lingling Xu
- Department of Nursing, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China
| | - Haixia Zhang
- Department of Nursing, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China
| | - Chuansong Wei
- Department of Nursing, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China
| | - Peng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Yang Liu
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
| | - Xiaoning Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
| | - Yongle Guo
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Lina Chen
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
| | - Zheng Zhou
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Zhenqiang Su
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, 250014, China
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Yanmei Hu
- Department of Nursing, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China
| | - Xin Shi
- Department of Nursing, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China
| | - Linlin Huang
- Department of Nursing, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China.
| | - Yuelan Wang
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University (Shandong Provincial Hospital), Jinan, 250021, China.
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China.
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Szrama J, Gradys A, Bartkowiak T, Woźniak A, Nowak Z, Zwoliński K, Lohani A, Jawień N, Smuszkiewicz P, Kusza K. The Incidence of Perioperative Hypotension in Patients Undergoing Major Abdominal Surgery with the Use of Arterial Waveform Analysis and the Hypotension Prediction Index Hemodynamic Monitoring-A Retrospective Analysis. J Pers Med 2024; 14:174. [PMID: 38392607 PMCID: PMC10889918 DOI: 10.3390/jpm14020174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
Intraoperative hypotension (IH) is common in patients receiving general anesthesia and can lead to serious complications such as kidney failure, myocardial injury and increased mortality. The Hypotension Prediction Index (HPI) algorithm is a machine learning system that analyzes the arterial pressure waveform and alerts the clinician of an impending hypotension event. The purpose of the study was to compare the frequency of perioperative hypotension in patients undergoing major abdominal surgery with different types of hemodynamic monitoring. The study included 61 patients who were monitored with the arterial pressure-based cardiac output (APCO) technology (FloTrac group) and 62 patients with the Hypotension Prediction Index algorithm (HPI group). Our primary outcome was the time-weighted average (TWA) of hypotension below < 65 mmHg. The median TWA of hypotension in the FloTrac group was 0.31 mmHg versus 0.09 mmHg in the HPI group (p = 0.000009). In the FloTrac group, the average time of hypotension was 27.9 min vs. 8.1 min in the HPI group (p = 0.000023). By applying the HPI algorithm in addition to an arterial waveform analysis alone, we were able to significantly decrease the frequency and duration of perioperative hypotension events in patients who underwent major abdominal surgery.
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Affiliation(s)
- Jakub Szrama
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Agata Gradys
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Tomasz Bartkowiak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Amadeusz Woźniak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Zuzanna Nowak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Krzysztof Zwoliński
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Ashish Lohani
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Natalia Jawień
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Piotr Smuszkiewicz
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Krzysztof Kusza
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
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11
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Zhang K, Wang L, Qi F, Meng T. Hypotensive Levels on Endoscopic Sinus Surgery Visibility: A Randomized Non-Inferiority Trial. Laryngoscope 2024; 134:569-576. [PMID: 37449719 DOI: 10.1002/lary.30867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/02/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Optimization of endoscopic sinus surgery (ESS) conditions is a common focus of interest for otolaryngologists and anesthesiologists. Relying on hypotension alone to achieve a bloodless field may not without risks. We sought to determine whether ESS is feasible in the context of moderate hypotension. METHODS This randomized non-inferiority trial enrolled 96 adult patients who were to undergo ESS. The patients were divided into two groups: Controlled hypotension group (n = 48, MAP reduction to 55-65 mmHg, minimum of 60% of baseline blood pressure) or Individualized hypotension group (n = 48, MAP reduction to 75-80% of baseline blood pressure). All participants were placed in 10° reverse Trendelenburg position during ESS, and cottonoid patties dammed with epinephrine was recommended to clear the operative field of bleeding. The two groups were compared according to Boezaart grading scale (BS) score, estimated blood loss, blood loss rate, arterial lactate level and postoperative recovery. RESULTS Both levels of intraoperative hypotension (62.2 ± 2.3 mmHg vs. 74.0 ± 2.8 mmHg) provided acceptable surgical conditions with no difference in mean BS scores [2.00 (1.88-2.33) vs. 2.00 (1.85-2.45), p = 0.926]. The 95% CI for median value differences in mean BS scores is lower than the preset non-inferiority margin. There were no differences in blood loss rate and estimated blood loss between two groups (p > 0.05) Postoperative arterial lactate and Ramsay sedation scores were significantly different between the two groups (p < 0.05). CONCLUSIONS In ESS, both levels of intraoperative hypotension, combined with position adjustment and low-concentration adrenaline to constrict nasal mucosal blood vessels, provided acceptable surgical conditions. LEVEL OF EVIDENCE 2 Laryngoscope, 134:569-576, 2024.
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Affiliation(s)
- Kangda Zhang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Lichun Wang
- Department of Pain Management, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Feng Qi
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Tao Meng
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
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12
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Bos EME, Tol JTM, de Boer FC, Schenk J, Hermanns H, Eberl S, Veelo DP. Differences in the Incidence of Hypotension and Hypertension between Sexes during Non-Cardiac Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:666. [PMID: 38337360 PMCID: PMC10856734 DOI: 10.3390/jcm13030666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/12/2024] [Accepted: 01/20/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Major determinants of blood pressure (BP) include sex and age. In youth, females have lower BP than males, yet in advanced age, more pronounced BP increases result in higher average BPs in females over 65. This hypothesis-generating study explored whether age-related BP divergence impacts the incidence of sex-specific intraoperative hypotension (IOH) or hypertension. Methods: We systematically searched PubMed and Embase databases for studies reporting intraoperative BP in males and females in non-cardiac surgery. We analyzed between-sex differences in the incidence of IOH and intraoperative hypertension (primary endpoint). Results: Among 793 identified studies, 14 were included in this meta-analysis, comprising 1,110,636 patients (56% female). While sex was not associated with IOH overall (females: OR 1.10, 95%CI [0.98-1.23], I2 = 99%), a subset of studies with an average age ≥65 years showed increased exposure to IOH in females (OR 1.17, 95%CI [1.01-1.35], I2 = 94%). One study reported sex-specific differences in intraoperative hypertension, with a higher incidence in females (31% vs. 28%). Conclusions: While sex-specific reporting on intraoperative BP was limited, IOH did not differ between sexes. However, an exploratory subgroup analysis offers the hypothesis that females of advanced age may face an increased risk of IOH, warranting further investigation.
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Affiliation(s)
- Elke M. E. Bos
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
| | - Johan T. M. Tol
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
| | - Fabienne C. de Boer
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
| | - Jimmy Schenk
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Henning Hermanns
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
| | - Susanne Eberl
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
| | - Denise P. Veelo
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
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13
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Kim YJ, Seo JH, Lee HC, Kim HS. Pleth variability index during preoxygenation could predict anesthesia-induced hypotension: A prospective, observational study. J Clin Anesth 2023; 90:111236. [PMID: 37639751 DOI: 10.1016/j.jclinane.2023.111236] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/10/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
STUDY OBJECTIVE To determine whether changes in the pleth variability index (PVi) during preoxygenation with forced ventilation for 1 min could predict anesthesia-induced hypotension. DESIGN Prospective, observational study. SETTING A tertiary teaching hospital. PATIENTS Ninety-six patients who underwent general anesthesia using total intravenous anesthesia were enrolled. INTERVENTIONS Upon the patient's arrival at the preoperative waiting area, a PVi sensor was affixed to their fourth fingertip. For preoxygenation, forced ventilation of 8 breaths/min in a 1:2 inspiratory-expiratory ratio was conducted using the guidance of an audio file. One minute after preoxygenation, anesthetic administration was initiated. Blood pressure was measured for the next 15 min. MEASUREMENTS We calculated the difference (dPVi) and percentage of change (%PVi) between the PVi values immediately before and after forced ventilation. Anesthesia-induced hypotension was defined as a mean arterial pressure of <60 mmHg within 15 min after the infusion of anesthetics. MAIN RESULTS Overall, 87 patients were included in the final analysis. Anesthesia-induced hypotension occurred in 31 (35.6%) of the 87 patients. Receiver operating characteristic curve analyses identified a cut-off value of -2 for dPVi, with an area under the curve of 0.691 (95% confidence interval [CI], 0.564-0.818; P < 0.001) and a cut-off value of -7.6% for %PVi, with an area under the curve of 0.711 (95% CI, 0.589-0.832; P < 0.001). Further, multivariate logistic regression analysis showed that a low %PVi with an odds ratio of 9.856 (95% CI, 3.131-31.032; P < 0.001) was a significant determinant of anesthesia-induced hypotension. CONCLUSIONS Hypotension frequently occurs during general anesthesia induction and can impact outcomes. Additionally, the percentage change in the PVi before and after preoxygenation using deep breathing can be used to predict anesthesia-induced hypotension.
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Affiliation(s)
- Yoon Jung Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
| | - Jeong-Hwa Seo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
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14
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D'Amico F, Fominskiy EV, Turi S, Pruna A, Fresilli S, Triulzi M, Zangrillo A, Landoni G. Intraoperative hypotension and postoperative outcomes: a meta-analysis of randomised trials. Br J Anaesth 2023; 131:823-831. [PMID: 37739903 DOI: 10.1016/j.bja.2023.08.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION Intraoperative hypotension is associated with adverse postoperative outcomes; however these findings are supported only by observational studies. The aim of this meta-analysis of randomised trials was to compare the postoperative effects permissive management with targeted management of intraoperative blood pressure. METHODS We searched PubMed, Cochrane, and Embase up to June 2023 for studies comparing permissive (mean arterial pressure ≤60 mm Hg) with targeted (mean arterial pressure >60 mm Hg) intraoperative blood pressure management. Primary outcome was all-cause mortality at the longest follow-up available. Secondary outcomes were atrial fibrillation, myocardial infarction, acute kidney injury, delirium, stroke, number of patients requiring transfusion, time on mechanical ventilation, and length of hospital stay. RESULTS We included 10 randomised trials including a total of 9359 patients. Mortality was similar between permissive and targeted blood pressure management groups (89/4644 [1.9%] vs 99/4643 [2.1%], odds ratio 0.88, 95% confidence interval [CI], 0.65-1.18, P=0.38, I2=0% with nine studies included). Atrial fibrillation (102/3896 [2.6%] vs 130/3887 [3.3%] odds ratio 0.71, 95% CI 0.53-0.96, P=0.03, I2=0%), and length of hospital stay (mean difference -0.20 days, 95% CI -0.26 to -0.13, P<0.001, I2=0%) were reduced in the permissive management group. No significant differences were found in subgroup analysis for cardiac and noncardiac surgery. CONCLUSION Pooled randomised evidence shows that a target intraoperative mean arterial pressure ≤60 mm Hg is not associated with increased mortality; nevertheless it is surprisingly associated with a reduced rate of atrial fibrillation and of length of hospital stay. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023393725.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny V Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Fresilli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Triulzi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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15
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Baykuziyev T, Khan MJ, Karmakar A, Baloch MA. Closed-Loop Pharmacologic Control of Blood Pressure: A Review of Existing Systems. Cureus 2023; 15:e45188. [PMID: 37842385 PMCID: PMC10576018 DOI: 10.7759/cureus.45188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Blood pressure management is a critical aspect of patient care, particularly in surgical and critical care settings. Closed-loop systems, which utilize real-time data and feedback to adjust treatment interventions, have gained attention for their potential to enhance blood pressure control. This review explores the application of closed-loop systems in blood pressure management. We discuss various closed-loop approaches, including their mechanisms, benefits, and limitations. By harnessing real-time patient data and feedback, closed-loop systems can tailor interventions dynamically, thus enhancing blood pressure regulation. Additionally, we examine the integration of advanced monitoring technologies and artificial intelligence algorithms in closed-loop systems. The review highlights recent studies and their findings, emphasizing the evolving landscape of closed-loop blood pressure management across different clinical scenarios. From the perioperative period to critical care settings, closed-loop systems hold the potential to optimize patient outcomes by precisely adjusting vasopressor administration in response to continuous blood pressure fluctuations. By providing insights into the current state of closed-loop systems for blood pressure control, this review offers a comprehensive overview of their potential contributions to improved patient outcomes and future directions for research and implementation.
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Affiliation(s)
- Temur Baykuziyev
- Anesthesiology and Critical Care, Hamad Medical Corporation, Doha, QAT
| | | | - Arunabha Karmakar
- Anesthesiology and Critical Care, Hamad Medical Corporation, Doha, QAT
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16
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Shi M, Zheng Y, Wu Y, Ren Q. Multitask Attention-Based Neural Network for Intraoperative Hypotension Prediction. Bioengineering (Basel) 2023; 10:1026. [PMID: 37760128 PMCID: PMC10525858 DOI: 10.3390/bioengineering10091026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Timely detection and response to Intraoperative Hypotension (IOH) during surgery is crucial to avoid severe postoperative complications. Although several methods have been proposed to predict IOH using machine learning, their performance still has space for improvement. In this paper, we propose a ResNet-BiLSTM model based on multitask training and attention mechanism for IOH prediction. We trained and tested our proposed model using bio-signal waveforms obtained from patient monitoring of non-cardiac surgery. We selected three models (WaveNet, CNN, and TCN) that process time-series data for comparison. The experimental results demonstrate that our proposed model has optimal MSE (43.83) and accuracy (0.9224) compared to other models, including WaveNet (51.52, 0.9087), CNN (318.52, 0.5861), and TCN (62.31, 0.9045), which suggests that our proposed model has better regression and classification performance. We conducted ablation experiments on the multitask and attention mechanisms, and the experimental results demonstrated that the multitask and attention mechanisms improved MSE and accuracy. The results demonstrate the effectiveness and superiority of our proposed model in predicting IOH.
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Affiliation(s)
- Meng Shi
- School of Electronics, Peking University, Beijing 100871, China
| | - Yu Zheng
- School of Electronics, Peking University, Beijing 100871, China
| | - Youzhen Wu
- College of Engineering, Peking University, Beijing 100871, China
| | - Quansheng Ren
- School of Electronics, Peking University, Beijing 100871, China
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17
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Rajkumar KP, Hicks MH, Marchant B, Khanna AK. Blood Pressure Goals in Critically Ill Patients. Methodist Debakey Cardiovasc J 2023; 19:24-37. [PMID: 37547901 PMCID: PMC10402811 DOI: 10.14797/mdcvj.1260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 06/08/2023] [Indexed: 08/08/2023] Open
Abstract
Blood pressure goals in the intensive care unit (ICU) have been extensively investigated in large datasets and have been associated with various harm thresholds at or greater than a mean pressure of 65 mm Hg. While it is difficult to perform interventional randomized trials of blood pressure in the ICU, important evidence does not support defense of a higher pressure, except in retrospective database analyses. Perfusion pressure may be a more important target than mean pressure, even more so in the vulnerable patient population. In the cardiac ICU, blood pressure targets are tailored to specific cardiac pathophysiology and patient characteristics. Generally, the goal is to maintain adequate blood pressure within a certain range to support cardiac function and to ensure end organ perfusion. Individualized targets demand the use of both invasive and noninvasive monitoring modalities and frequent titration of medications and/or mechanical circulatory support where necessary. In this review, we aim to identify appropriate blood pressure targets in the ICU, recognizing special patient populations and outlining the risk factors and predictors of end organ failure.
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Affiliation(s)
- Karuna Puttur Rajkumar
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Megan Henley Hicks
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Bryan Marchant
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Ashish K. Khanna
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
- Outcomes Research Consortium, Cleveland, Ohio, US
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18
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Amin SM, Hasanin A, ElSayed OS, Mostafa M, Khaled D, Arafa AS, Hassan A. Comparison of the hemodynamic effects of opioid-based versus lidocaine-based induction of anesthesia with propofol in older adults: a randomized controlled trial. Anaesth Crit Care Pain Med 2023; 42:101225. [PMID: 37030397 DOI: 10.1016/j.accpm.2023.101225] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/05/2023] [Accepted: 03/19/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND The present study aims to compare the hemodynamic profile of lidocaine and fentanyl during propofol induction of general anesthesia. METHODS This randomized controlled trial included patients aged above 60 years undergoing elective non-cardiac surgery. The included patients received either 1 mg/kg lidocaine (n = 50) or 1 mcg/kg fentanyl (n = 50) based on total body weight with propofol induction of anesthesia. Patient's hemodynamics were recorded every minute for the first 5 min then every 2 min until 15 min after induction of anesthesia. Hypotension (mean arterial pressure [MAP] <65 mmHg or >30% reduction from baseline) was treated by intravenous 4 mcg bolus of norepinephrine. Outcomes included norepinephrine requirements (primary), the incidence of postinduction hypotension, MAP, heart rate, intubation condition, and postoperative delirium via the cognitive assessment method. RESULTS Forty-seven patients in the lidocaine group and 46 patients in the fentanyl group were analyzed. None in the lidocaine group experienced hypotension, while 28/46 (61%) of patients in the fentanyl group developed at least one episode of hypotension requiring a median (25th and 75th quartiles) norepinephrine dose of 4 (0,5) mcg, p-value <0.001 for both outcomes. The average MAP was lower in the fentanyl group than in the lidocaine group at all time points after anesthesia induction. The average heart rate was comparable between the two groups nearly at all time points after anesthesia induction. The overall intubation condition was comparable between the two groups. None of the included patients developed postoperative delirium. CONCLUSION Lidocaine-based regimen for induction of anesthesia reduced the risk of postinduction hypotension in older patients compared to the fentanyl-based regimen.
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Affiliation(s)
- Sarah M Amin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Omnia S ElSayed
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Dalia Khaled
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Amany S Arafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Amany Hassan
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
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19
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Li Y, Tam WW, Yu Y, Zhuo Z, Xue Z, Tsang C, Qiao X, Wang X, Wang W, Li Y, Tu Y, Gao Y. The application of Aptamer in biomarker discovery. Biomark Res 2023; 11:70. [PMID: 37468977 DOI: 10.1186/s40364-023-00510-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023] Open
Abstract
Biomarkers are detectable molecules that can reflect specific physiological states of cells, organs, and organisms and therefore be regarded as indicators for specific diseases. And the discovery of biomarkers plays an essential role in cancer management from the initial diagnosis to the final treatment regime. Practically, reliable clinical biomarkers are still limited, restricted by the suboptimal methods in biomarker discovery. Nucleic acid aptamers nowadays could be used as a powerful tool in the discovery of protein biomarkers. Nucleic acid aptamers are single-strand oligonucleotides that can specifically bind to various targets with high affinity. As artificial ssDNA or RNA, aptamers possess unique advantages compared to conventional antibodies. They can be flexible in design, low immunogenicity, relative chemical/thermos stability, as well as modifying convenience. Several SELEX (Systematic Evolution of Ligands by Exponential Enrichment) based methods have been generated recently to construct aptamers for discovering new biomarkers in different cell locations. Secretome SELEX-based aptamers selection can facilitate the identification of secreted protein biomarkers. The aptamers developed by cell-SELEX can be used to unveil those biomarkers presented on the cell surface. The aptamers from tissue-SELEX could target intracellular biomarkers. And as a multiplexed protein biomarker detection technology, aptamer-based SOMAScan can analyze thousands of proteins in a single run. In this review, we will introduce the principle and workflow of variations of SELEX-based methods, including secretome SELEX, ADAPT, Cell-SELEX and tissue SELEX. Another powerful proteome analyzing tool, SOMAScan, will also be covered. In the second half of this review, how these methods accelerate biomarker discovery in various diseases, including cardiovascular diseases, cancer and neurodegenerative diseases, will be discussed.
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Affiliation(s)
- Yongshu Li
- Center for Advanced Measurement Science, National Institute of Metrology, Beijing, China.
- Shenzhen Institute for Technology Innovation, National Institute of Metrology, Shenzhen, China.
| | - Winnie Wailing Tam
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases (TMBJ), School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Yuanyuan Yu
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases (TMBJ), School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Zhenjian Zhuo
- State Key Laboratory of Chemical Oncogenomic, Peking University Shenzhen Graduate School, Shenzhen, China
- Laboratory Animal Center, School of Chemical Biology and Biotechnology, Peking University Shenzhen Graduate School, Shenzhen, 518055, China
| | - Zhichao Xue
- Shenzhen Institute for Technology Innovation, National Institute of Metrology, Shenzhen, China
| | - Chiman Tsang
- Department of Anatomical and Cellular Pathology, State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong, China
| | - Xiaoting Qiao
- Center for Advanced Measurement Science, National Institute of Metrology, Beijing, China
| | - Xiaokang Wang
- Department of Pharmacy, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Weijing Wang
- Shantou University Medical College, Shantou, China
| | - Yongyi Li
- Laboratory Animal Center, School of Chemical Biology and Biotechnology, Peking University Shenzhen Graduate School, Shenzhen, 518055, China
| | - Yanyang Tu
- Research Center, Huizhou Central People's Hospital, Guangdong Medical University, Huizhou City, China.
| | - Yunhua Gao
- Center for Advanced Measurement Science, National Institute of Metrology, Beijing, China.
- Shenzhen Institute for Technology Innovation, National Institute of Metrology, Shenzhen, China.
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20
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Kouz K, Monge García MI, Cerutti E, Lisanti I, Draisci G, Frassanito L, Sander M, Ali Akbari A, Frey UH, Grundmann CD, Davies SJ, Donati A, Ripolles-Melchor J, García-López D, Vojnar B, Gayat É, Noll E, Bramlage P, Saugel B. Intraoperative hypotension when using hypotension prediction index software during major noncardiac surgery: a European multicentre prospective observational registry (EU HYPROTECT). BJA OPEN 2023; 6:100140. [PMID: 37588176 PMCID: PMC10430826 DOI: 10.1016/j.bjao.2023.100140] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/19/2023] [Accepted: 03/28/2023] [Indexed: 08/18/2023]
Abstract
Background Intraoperative hypotension is associated with organ injury. Current intraoperative arterial pressure management is mainly reactive. Predictive haemodynamic monitoring may help clinicians reduce intraoperative hypotension. The Acumen™ Hypotension Prediction Index software (HPI-software) (Edwards Lifesciences, Irvine, CA, USA) was developed to predict hypotension. We built up the European multicentre, prospective, observational EU HYPROTECT Registry to describe the incidence, duration, and severity of intraoperative hypotension when using HPI-software monitoring in patients having noncardiac surgery. Methods We enrolled 749 patients having elective major noncardiac surgery in 12 medical centres in five European countries. Patients were monitored using the HPI-software. We quantified hypotension using the time-weighted average MAP <65 mm Hg (primary endpoint), the proportion of patients with at least one ≥1 min episode of a MAP <65 mm Hg, the number of ≥1 min episodes of a MAP <65 mm Hg, and duration patients spent below a MAP of 65 mm Hg. Results We included 702 patients in the final analysis. The median time-weighted average MAP <65 mm Hg was 0.03 (0.00-0.20) mm Hg. In addition, 285 patients (41%) had no ≥1 min episode of a MAP <65 mm Hg; 417 patients (59%) had at least one. The median number of ≥1 min episodes of a MAP <65 mm Hg was 1 (0-3). Patients spent a median of 2 (0-9) min below a MAP of 65 mm Hg. Conclusions The median time-weighted average MAP <65 mm Hg was very low in patients in this registry. This suggests that using HPI-software monitoring may help reduce the duration and severity of intraoperative hypotension in patients having noncardiac surgery.
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Elisabetta Cerutti
- Department of Anesthesia, Transplant and Surgical Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Ivana Lisanti
- Department of Anesthesia, Transplant and Surgical Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Gaetano Draisci
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Luciano Frassanito
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Amir Ali Akbari
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Ulrich H. Frey
- Department of Anesthesiology, Intensive Care, Pain and Palliative Care, Marien Hospital Herne, Ruhr-University Bochum, Bochum, Germany
| | - Carla Davina Grundmann
- Department of Anesthesiology, Intensive Care, Pain and Palliative Care, Marien Hospital Herne, Ruhr-University Bochum, Bochum, Germany
| | - Simon James Davies
- York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
- Centre for Health and Population Sciences, Hull York Medical School, York, UK
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Javier Ripolles-Melchor
- Anesthesia and Critical Care Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Daniel García-López
- Department of Anaesthesiology and Reanimation, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Benjamin Vojnar
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Étienne Gayat
- Université Paris Cité, INSERM, Paris, France
- Department of Anesthesia and Critical Care Medicine, Hôpital Lariboisière, Paris, France
| | - Eric Noll
- Department of Anesthesiology and Intensive Care, Hôpital de Hautepierre, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
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21
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Olsen F, Hård af Segerstad M, Dalla K, Ricksten SE, Nellgård B. Fractional spinal anesthesia and systemic hemodynamics in frail elderly hip fracture patients. F1000Res 2023; 12:210. [PMID: 37497335 PMCID: PMC10366555 DOI: 10.12688/f1000research.130387.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 07/28/2023] Open
Abstract
Background: Systemic haemodynamic effects of intrathecal anaesthesia in an aging and frail population has not been well investigated. We examined the systemic haemodynamics of fractional spinal anaesthesia following intermittent microdosing of a local anaesthetic and an opioid. Methods: We included 15 patients aged over 65 with significant comorbidities, planned for hip fracture repair. Patients received a spinal catheter and cardiac output monitoring using the LiDCOplus system. All measurements were performed prior to start of surgery. Invasive mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), heart rate and stroke volume index (SVI) were registered. Two doses of bupivacaine 2.25 mg and fentanyl 15 µg were administered with 25-minute intervals. Hypotension was defined as a fall in MAP by >30% or a MAP <65 mmHg. Results: The incidence of hypotension was 30%. Hypotensive patients (n=5) were treated with low doses of norepinephrine (0.01-0.12 µg/kg/min). MAP showed a maximum reduction of 17% at 10 minutes following the first dose. CI, systemic vascular resistance index and stroke volume index decreased by 10%, 6%, and 7%, respectively, while heart rate was unchanged over time. After the second dose, none of the systemic haemodynamic variables were affected. Conclusions: Fractional spinal anaesthesia administered prior to surgery induced a minor to moderate fall in MAP, mainly caused by a reduction in cardiac output, induced by systemic venodilation, causing a fall in venous return. Our results are contrary to the widely held belief that hypotension is mainly the result of a reduction of systemic vascular resistance.
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Affiliation(s)
- Fredrik Olsen
- Anesthesia and Critical Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Keti Dalla
- Anesthesia and Critical Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Anesthesia and Critical Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bengt Nellgård
- Anesthesia and Critical Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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22
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All intraoperative hypotension is not created equal - A call for an individualized approach. J Clin Anesth 2023; 87:111076. [PMID: 36889147 DOI: 10.1016/j.jclinane.2023.111076] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/16/2023] [Accepted: 02/03/2023] [Indexed: 03/08/2023]
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Szrama J, Gradys A, Bartkowiak T, Woźniak A, Kusza K, Molnar Z. Intraoperative Hypotension Prediction—A Proactive Perioperative Hemodynamic Management—A Literature Review. Medicina (B Aires) 2023; 59:medicina59030491. [PMID: 36984493 PMCID: PMC10057151 DOI: 10.3390/medicina59030491] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/19/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Intraoperative hypotension (IH) is a frequent phenomenon affecting a substantial number of patients undergoing general anesthesia. The occurrence of IH is related to significant perioperative complications, including kidney failure, myocardial injury, and even increased mortality. Despite advanced hemodynamic monitoring and protocols utilizing goal directed therapy, our management is still reactive; we intervene when the episode of hypotension has already occurred. This literature review evaluated the Hypotension Prediction Index (HPI), which is designed to predict and reduce the incidence of IH. The HPI algorithm is based on a machine learning algorithm that analyzes the arterial pressure waveform as an input and the occurrence of hypotension with MAP <65 mmHg for at least 1 min as an output. There are several studies, both retrospective and prospective, showing a significant reduction in IH episodes with the use of the HPI algorithm. However, the level of evidence on the use of HPI remains very low, and further studies are needed to show the benefits of this algorithm on perioperative outcomes.
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Affiliation(s)
- Jakub Szrama
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Correspondence: ; Tel.: +48-618-691-856
| | - Agata Gradys
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Tomasz Bartkowiak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Amadeusz Woźniak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Krzysztof Kusza
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Zsolt Molnar
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
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24
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Dynamic cerebral autoregulation during step-wise increases in blood pressure during anaesthesia: A nonrandomised interventional trial. Eur J Anaesthesiol 2023; 40:407-417. [PMID: 36655712 PMCID: PMC10155696 DOI: 10.1097/eja.0000000000001798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Classically, cerebral autoregulation (CA) entails cerebral blood flow (CBF) remaining constant by cerebrovascular tone adapting to fluctuations in mean arterial pressure (MAP) between ∼60 and ∼150 mmHg. However, this is not an on-off mechanism; previous work has suggested that vasomotor tone is proportionally related to CA function. During propofol-based anaesthesia, there is cerebrovascular vasoconstriction, and static CA remains intact. Sevoflurane-based anaesthesia induces cerebral vasodilation and attenuates CA dose-dependently. It is unclear how this translates to dynamic CA across a range of blood pressures in the autoregulatory range. OBJECTIVE The aim of this study was to quantify the effect of step-wise increases in MAP between 60 and 100 mmHg, using phenylephrine, on dynamic CA during propofol- and sevoflurane-based anaesthesia. DESIGN A nonrandomised interventional trial. SETTING Single centre enrolment started on 11 January 2019 and ended on 23 September 2019. PATIENTS We studied American Society of Anesthesiologists (ASA) I/II patients undergoing noncardiothoracic, nonneurosurgical and nonlaparoscopic surgery under general anaesthesia. INTERVENTION In this study, cerebrovascular tone was manipulated in the autoregulatory range by increasing MAP step-wise using phenylephrine in patients receiving either propofol- or sevoflurane-based anaesthesia. MAP and mean middle cerebral artery blood velocity (MCA Vmean ) were measured in ASA I and II patients, anaesthetised with either propofol ( n = 26) or sevoflurane ( n = 28), during 10 mmHg step-wise increments of MAP between 60 and 100 mmHg. Static CA was determined by plotting 2-min averaged MCA Vmean versus MAP. Dynamic CA was determined using transfer function analysis and expressed as the phase lead (°) between MAP and MCA Vmean oscillations, created with positive pressure ventilation with a frequency of 6 min -1 . MAIN OUTCOMES The primary outcome of this study was the response of dynamic CA during step-wise increases in MAP during propofol- and sevoflurane-based anaesthesia. RESULTS MAP levels achieved per step-wise increments were comparable between anaesthesia regiment (63 ± 3, 72 ± 2, 80 ± 2, 90 ± 2, 100 ± 3 mmHg, and 61 ± 4, 71 ± 2, 80 ± 2, 89 ± 2, 98 ± 4 mmHg for propofol and sevoflurane, respectively). MCA Vmean increased more during step-wise MAP increments for sevoflurane compared to propofol ( P ≤0.001). Dynamic CA improved during propofol (0.73° mmHg -1 , 95% CI 0.51 to 0.95; P ≤ 0.001)) and less pronounced during sevoflurane-based anaesthesia (0.21° mmHg -1 (95% CI 0.01 to 0.42, P = 0.04). CONCLUSIONS During general anaesthesia, dynamic CA is dependent on MAP, also within the autoregulatory range. This phenomenon was more pronounced during propofol anaesthesia than during sevoflurane. TRIAL REGISTRATION NCT03816072 ( https://clinicaltrials.gov/ct2/show/NCT03816072 ).
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25
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Fei M, Qin W, An G, Li D, Li C, Xiong L. Comparison of paravertebral block vs. general anesthesia for percutaneous nephrolithotomy: A retrospective study. Front Med (Lausanne) 2023; 10:1081530. [PMID: 36817763 PMCID: PMC9935603 DOI: 10.3389/fmed.2023.1081530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Background General anesthesia is used in the majority of patients undergoing percutaneous nephrolithotomy. To reduce the general anesthesia-related risks and complications, this study evaluated the efficacy and safety of the paravertebral block as a novel and alternative anesthetic method for percutaneous nephrolithotomy. Methods This was a retrospective study. A total of 198 patients under percutaneous nephrolithotomy were included. Among them, 76 patients received paravertebral block and 122 received general anesthesia. Patients' characteristics, surgical outcomes, anesthetic outcomes, and perioperative complications and the visual analog scale (VAS) were recorded to evaluate the efficacy and safety of paravertebral block compared with general anesthesia. Intergroup differences of the parameters were analyzed using an independent t-test and χ2-tests appropriate. Results Seventy-six patients who underwent paravertebral block completed the surgery successfully, three patients were supplemented with propofol for discomfort during ureteroscopy, and two patients were supplemented with remifentanil for incomplete nerve blockade. Patients who underwent paravertebral block had a higher American Society of Anesthesiologists grade and heart function grade, including patients with contraindications to general anesthesia. Intraoperative and postoperative adverse events and the anesthesia costs were less in patients who underwent paravertebral block. VAS pain scores during the postoperative period in patients who underwent paravertebral block were lower than those in patients who underwent general anesthesia without the use of patient-controlled intravenous analgesia. Conclusion In this retrospective study, paravertebral block was found to be effective and safe in providing intraoperative anesthesia for percutaneous nephrolithotomy, and had less adverse events and anesthesia costs. Paravertebral block is an attractive alternative anesthesia for patients at increased risk of comorbidities following general or neuraxial anesthesia.
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Affiliation(s)
- Miaomiao Fei
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Shanghai, China,Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Clinical Research Center for Anesthesiology and Perioperative Medicine, Tongji University, Shanghai, China
| | - Wendong Qin
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Shanghai, China,Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Clinical Research Center for Anesthesiology and Perioperative Medicine, Tongji University, Shanghai, China
| | - Guanghui An
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Shanghai, China,Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Clinical Research Center for Anesthesiology and Perioperative Medicine, Tongji University, Shanghai, China
| | - Dujian Li
- Department of Urology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Cheng Li
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Shanghai, China,Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Clinical Research Center for Anesthesiology and Perioperative Medicine, Tongji University, Shanghai, China,*Correspondence: Cheng Li,
| | - Lize Xiong
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Shanghai, China,Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Clinical Research Center for Anesthesiology and Perioperative Medicine, Tongji University, Shanghai, China,Lize Xiong, ,
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26
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Yang L, Long B, Zhou M, Yu X, Xue X, Xie M, Zhang L, Guan J. Pre-anesthesia ultrasound monitoring of subclavian vein diameter changes induced by modified passive leg raising can predict the occurrence of hypotension after general anesthesia: a prospective observational study. BMC Anesthesiol 2023; 23:35. [PMID: 36710335 PMCID: PMC9885696 DOI: 10.1186/s12871-023-01989-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/18/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Perioperative hypotension increases postoperative complication rates and prolongs postoperative recovery time. Whether Passive Leg Raising test (PLR) and Subclavian Vein Diameter (DSCV) can effectively predict post-anesthesia hypotension remains to be tested. This study aimed to identify specific predictors of General Anesthesia (GA)induced hypotension by measuring DSCV in the supine versus PLR position. METHODS A total of 110 patients who underwent elective gynecological laparoscopic surgery under general anesthesia, were enrolled in this study. Before anesthesia, DSCV and theCollapsibility Index of DSCV(DSCV-CI) were measured by ultrasound, and the difference in maximal values of DSCV between supine and PLR positions was calculated, expressed as ΔDSCV. Hypotension was defined as Mean Blood Pressure (MBP) below 60mmhg or more than 30% below the baseline. Patients were divided into two groups according to the presence (Group H) or absence (Group N) of postanesthesia hypotension. The area under the receiver operating characteristic curve (ROC) and logistic regression analyses were used to evaluate the predictability of DSCV and other parameters for predicting preincision hypotension. RESULTS Three patients were excluded due to unclear ultrasound scans, resulting in a total of 107 patients studied. Twenty-seven (25.2%) patients experienced hypotension. Area under the ROC curve of ΔDSCV was 0.75 (P < 0.001) with 95% confidence interval (0.63-0.87), while DSCV and DSCV-CI were less than 0.7. The odds ratio (OR)of ΔDSCV was 1.18 (P < 0.001, 95%CI 1.09-1.27) for predicting the development of hypotension. ΔDSCV is predictive of hypotension following induction of general anesthesia. CONCLUSIONS ΔDSCV has predictive value for hypotension after general anesthesia. TRIAL REGISTRATION The trial was registered in the Chinese Clinical Trial Registry on 04/10/2021.
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Affiliation(s)
- Lijun Yang
- grid.256112.30000 0004 1797 9307Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian, China
| | - Bo Long
- grid.411504.50000 0004 1790 1622The Second Affiliated Hospital of Fujian University of Traditional Chinese Medicine, Fujian, China
| | - Min Zhou
- grid.256112.30000 0004 1797 9307Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian, China
| | - Xiaofang Yu
- grid.415108.90000 0004 1757 9178Fujian Provincial Hospital (South Branch), Fujian, China
| | - Xiaoying Xue
- grid.256112.30000 0004 1797 9307Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian, China
| | - Min Xie
- grid.256112.30000 0004 1797 9307Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian, China
| | - Li Zhang
- grid.256112.30000 0004 1797 9307Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian, China
| | - Jinsheng Guan
- grid.256112.30000 0004 1797 9307Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian, China
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27
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Le Chevallier D, van Oostrom H, MacFarlane PD. Evaluation of urine specific gravity as a predictor of hypotension during anaesthesia in healthy dogs premedicated with dexmedetomidine. Vet Anaesth Analg 2023; 50:289-293. [PMID: 37055260 DOI: 10.1016/j.vaa.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 01/05/2023] [Accepted: 01/07/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To investigate the relationship between urine specific gravity (USG) and the risk of arterial hypotension during general anaesthesia (GA) in healthy dogs premedicated with dexmedetomidine and methadone. STUDY DESIGN Prospective clinical cohort study. ANIMALS A total of 75 healthy client-owned dogs undergoing GA for elective tibial plateau levelling osteotomy. METHODS After placing an intravenous catheter, dogs were premedicated with dexmedetomidine (5 μg kg-1) and methadone (0.3 mg kg-1) intravenously. After induction of GA with alfaxalone to effect, the bladder was expressed and USG measured. An arterial catheter was placed, and residual blood was used to measure packed cell volume (PCV) and total protein (TP). GA was maintained with isoflurane vaporised in oxygen and a femoral and sciatic nerve block were performed. Arterial blood pressure < 60 mmHg was defined as hypotension and recorded by the anaesthetist. Treatment for hypotension was performed in a stepwise manner following a flow chart. Frequency of hypotension, treatment and response to treatment were recorded. Logistic regression modelling was used to assess the association between USG, TP and PCV and incidence of perioperative hypotension; p < 0.05. RESULTS Data from 14 dogs were excluded. Of the 61 dogs, 16 (26%) were hypotensive during GA, 15 dogs needed treatment of which 12 were responsive to a decrease in inhalant vaporiser setting. The logistic regression model was not statistically significant (p = 0.8). There was no significant association between USG (p = 0.6), TP (p = 0.4), PCV (p = 0.8) and arterial hypotension during GA. CONCLUSIONS AND CLINICAL RELEVANCE In healthy dogs premedicated with dexmedetomidine and methadone and maintained under GA with isoflurane and a femoral and sciatic nerve block, there was no relationship between the specific gravity of urine collected after premedication and intraoperative arterial hypotension.
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28
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Gurunathan U, Chiang L, Hines J, Pearse B, McKenzie S, Hay K, Mullany D, Nandurkar H, Eley V. Association Between Thromboelastometry Identified Hypercoagulability and Thromboembolic Complications After Arthroplasty: A Prospective Observational Study in Patients With Obesity. Clin Appl Thromb Hemost 2023; 29:10760296231199737. [PMID: 37814542 PMCID: PMC10566273 DOI: 10.1177/10760296231199737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/09/2023] [Accepted: 08/22/2023] [Indexed: 10/11/2023] Open
Abstract
The prothrombotic state of obesity can increase the risk of thromboembolism. We aimed to investigate if there was an association between baseline hypercoagulable rotational thromboelastometry (ROTEM) profile and thromboembolic complications in arthroplasty patients with obesity. Patients with a body mass index ≥ 25 kg/m2 and/or waist circumference ≥94 cm (M) and 80 cm (F) undergoing hip and knee arthroplasty had pre- and postoperative ROTEM. ROTEM values were compared by outcome status using an independent sample equal-variance t-test. Of the 303 total participants, hypercoagulability defined as extrinsically activated thromboelastometry maximum clot firmness G score ≥ 11 K dyne/cm2, was observed in 90 (30%) of the 300 participants with preoperative ROTEM assays. Clinically significant thromboembolic complications occurred in 5 (1.7%) study participants before discharge and in 10 (3.3%) by 90 days. These included 6 with pulmonary emboli, 3 with deep venous thrombus, and 1 with myocardial infarction. We found no evidence for an association between baseline hypercoagulability and incident thromboembolic events, analysis limited by the number of events. Postoperative decrease in platelets and an increase in fibrinogen were observed. ROTEM parameter changes differed across obesity categories.
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Affiliation(s)
- Usha Gurunathan
- Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Lily Chiang
- Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Joel Hines
- Adult Intensive Care Unit, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Bronwyn Pearse
- Blood Management Unit, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Scott McKenzie
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Karen Hay
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Daniel Mullany
- Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Harshal Nandurkar
- Department of Haematology, Alfred Health, Melbourne, VIC, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Victoria Eley
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
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Perioperative troponin surveillance in major noncardiac surgery: a narrative review. Br J Anaesth 2023; 130:21-28. [PMID: 36464518 DOI: 10.1016/j.bja.2022.08.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/08/2022] [Accepted: 08/31/2022] [Indexed: 12/03/2022] Open
Abstract
Myocardial injury is now an acknowledged complication in patients undergoing noncardiac surgery. Heterogeneity in the definitions of myocardial injury contributes to difficulty in evaluating the value of cardiac troponins (cTns) measurement in perioperative care. Pre-, post-, and peri-operatively increased cTns are encompassed by the umbrella term 'myocardial injury' and are likely to reflect different pathophysiological mechanisms. Increased cTns are independently associated with cardiovascular and non-cardiovascular complications, poor short-term and long-term cardiovascular outcomes, and increased mortality. Preoperative measurement of cTns aids preoperative risk stratification beyond the Revised Cardiac Risk Index. Systematic measurement detects acute perioperative increases and allows early identification of acute myocardial injury. Common definitions and standards for reporting are a prerequisite for designing impactful future trials and perioperative management strategies.
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Cai H, Liu X, Wang D, Li W, Ma H, Zhao J. Management of Suspected Life-Threatening Perioperative Anaphylaxis and Risk Factors for Near-Fatal and Fatal Outcomes: A Retrospective Study in China. Ther Clin Risk Manag 2023; 19:383-394. [PMID: 37193306 PMCID: PMC10183184 DOI: 10.2147/tcrm.s406515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/28/2023] [Indexed: 05/18/2023] Open
Abstract
Purpose Perioperative anaphylaxis (POA) is an acute severe systemic hypersensitivity reaction characterized by life-threatening respiratory and circulatory collapse. In our previous study, we reported the epidemiology of suspected POA in China. In the present study, we aimed to elucidate the management and outcomes of these cases and further verify the risk factors for near-fatal and fatal outcomes. Patients and Methods This was a retrospective study of 447 cases of suspected life-threatening POA encountered at 112 tertiary hospitals in mainland China between September 2018 and August 2019. Patient characteristics, symptoms, duration of hypotension, treatments, and clinical outcomes were documented. Bivariate logistic regression was used to identify risk factors for near-fatal and fatal outcomes. Results Most cases of suspected POA (89.9%) were recognized and treated within 5 min. Epinephrine was administered as the initial treatment in 232 (51.9%) cases. Corticosteroids (26.6%), other vasoactive drugs (18.3%), and bronchodilators (1.6%) were also administered as the initial treatment instead of epinephrine. The initial dosage of epinephrine (median, 35 µg) was insufficient according to the anaphylaxis guidelines. On multivariable analysis, age ≥65 years (odds ratio [OR] 7.48; 95% confidence interval [CI]: 1.33-41.87, P=0.022), ASA physical status IV (OR 17.68; 95% CI: 4.53-68.94; P<0.001), and hypotension duration ≥15 min (OR 3.63; 95% CI: 1.11-11.87; P=0.033) were risk factors for fatal and near-fatal outcomes. Conclusion Most cases in this study were managed in a timely manner, but the epinephrine application should be optimized according to the guidelines. Age ≥65 years, ASA physical status IV, and long-term hypotension were risk factors for near-fatal and fatal outcomes.
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Affiliation(s)
- Huamei Cai
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Xiaowen Liu
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Dingyi Wang
- National Center for Respiratory Medicine & National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine & Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Department of Clinical Research and Data Management Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Weixia Li
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Hongli Ma
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Jing Zhao
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
- Correspondence: Jing Zhao, Department of Anesthesiology, China- Japan Friendship Hospital, No. 2 Yinghua East Road, Beijing, 100029, People’s Republic of China, Tel +86 010 8420 5876, Email
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Zhang Y, Li S, Li Z, Chen J, Tan H. Intraoperative Diastolic Hypotension-Prolonged Postoperative Hospital Stay in Patients with Gastric Cancer: A Retrospective Cohort Study with Propensity Score Matching. Int J Gen Med 2022; 15:8467-8479. [PMID: 36507249 PMCID: PMC9733627 DOI: 10.2147/ijgm.s393358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose In patients undergoing surgical resection for gastric cancer, perioperative hemodynamic fluctuations may affect organ perfusion, increase the incidence of postoperative complications, and prolong hospital stay. Patients and Methods We retrospectively identified patients who underwent resection for gastric cancer at our institution from April 1, 2015 to October 30, 2018. Demographic information, perioperative data, and information on postoperative recovery were recorded. The primary outcome was length of postoperative hospital stay; the secondary outcome was incidence of postoperative complications. Propensity score matching was performed. The associations between perioperative factors and postoperative hospital stay were analyzed using multivariable logistic regression models in the full and matched cohorts. Results In total, 933 patients were included; of these, 676 had diastolic hypotension (defined as diastolic blood pressure <60 mmHg for >10 min). In both cohorts, patients with diastolic hypotension had statistically significantly longer postoperative hospital stay (full: mean 14.5 ± standard deviation 10.2 vs 11.6 ± 6.5 days, P < 0.001; matched: 13.7 ± 9.9 vs 11.7 ± 6.6 days, P = 0.009) and a higher incidence of postoperative complications (full: 170 [25.1%] vs 27 [10.5%] cases, P < 0.001; matched: 60 [24.4%] vs 33 [13.4%] cases, P = 0.003), compared with patients without diastolic hypotension. After correction for confounding factors, intraoperative diastolic hypotension was associated with longer postoperative hospital stay in both the full and the matched cohort (full: HR, 1.535 [95% CI, 1.115-2.114], P = 0.009; matched: HR, 1.532 [95% CI, 1.032-2.273], P = 0.034). Conclusion For patients with gastric cancer, intraoperative diastolic hypotension may increase the incidence of postoperative complications and prolong postoperative hospital stay.
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Affiliation(s)
- Yunxiao Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People’s Republic of China
| | - Shuo Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People’s Republic of China
| | - Zongchao Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People’s Republic of China
| | - Jiheng Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People’s Republic of China
| | - Hongyu Tan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People’s Republic of China,Correspondence: Hongyu Tan, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, 52 Fucheng Street, Haidian District, Beijing, 100142, People’s Republic of China, Tel +86 10 88196553, Fax +86 10 88122437, Email
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Li W, Hu Z, Yuan Y, Liu J, Li K. Effect of hypotension prediction index in the prevention of intraoperative hypotension during noncardiac surgery: A systematic review. J Clin Anesth 2022; 83:110981. [PMID: 36242978 DOI: 10.1016/j.jclinane.2022.110981] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/01/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
Intraoperative hypotension (IOH) is common in noncardiac surgery and is associated with serious postoperative complications. Hypotension Prediction Index (HPI) has shown high sensitivity and specificity for predicting hypotension and may reduce IOH in noncardiac surgery. We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the applications and effects of HPI in reducing hypotension during noncardiac surgery. We comprehensively searched the PubMed, Embase, Cochrane Library, Google Scholar, and http://ClinicalTrials.gov databases to identify RCTs conducted before May 2022. The primary outcome measures were the time-weighted average (TWA) of hypotension and the area under the hypotensive threshold (65 mmHg). Secondary outcomes were the incidence and duration of hypotension and the percentage of hypotensive time during surgery. The Cochrane Risk of Bias (RoB) tool was used to assess the quality of selected studies. We conducted data synthesis for median differences and assessed the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. We included five studies with a total of 461 patients. Limited evidence suggested that HPI-guided intraoperative hemodynamics management leads to lower a) TWA of hypotension (median of difference of medians [MDM], -0.27 mmHg; 95% confidence interval [CI], -0.38, -0.01), b) area under the hypotensive threshold (MDM, -60.28 mmHg*min; 95% CI, -74.00, -1.30), c) incidence of hypotension (MDM, -4.50; 95% CI, -5.00, -4.00), d) total duration of hypotension (MDM, -12.80 min; 95% CI, -16.11, -3.39), and e) percentage of hypotension (MDM, -5.80; 95% CI, -6.65, -4.82) than routine hemodynamic management during noncardiac surgery. However, only very low- to low-quality evidence on the benefit of intraoperative HPI-based hemodynamic management is available. Our review revealed that HPI has the potential to reduce the occurrence, duration, and severity of IOH during noncardiac surgery compared to standard intraoperative care with proper adherence to the protocol. Systematic review registration PROSPERO CRD42022333834.
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Affiliation(s)
- Wangyu Li
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Zhouting Hu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Yuxin Yuan
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Jiayan Liu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Kai Li
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130033, China.
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Hypotension Prediction Index Software to Prevent Intraoperative Hypotension during Major Non-Cardiac Surgery: Protocol for a European Multicenter Prospective Observational Registry (EU-HYPROTECT). J Clin Med 2022; 11:jcm11195585. [PMID: 36233455 PMCID: PMC9571548 DOI: 10.3390/jcm11195585] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/17/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Intraoperative hypotension is common in patients having non-cardiac surgery and associated with postoperative acute myocardial injury, acute kidney injury, and mortality. Avoiding intraoperative hypotension is a complex task for anesthesiologists. Using artificial intelligence to predict hypotension from clinical and hemodynamic data is an innovative and intriguing approach. The AcumenTM Hypotension Prediction Index (HPI) software (Edwards Lifesciences; Irvine, CA, USA) was developed using artificial intelligence—specifically machine learning—and predicts hypotension from blood pressure waveform features. We aimed to describe the incidence, duration, severity, and causes of intraoperative hypotension when using HPI monitoring in patients having elective major non-cardiac surgery. Methods: We built up a European, multicenter, prospective, observational registry including at least 700 evaluable patients from five European countries. The registry includes consenting adults (≥18 years) who were scheduled for elective major non-cardiac surgery under general anesthesia that was expected to last at least 120 min and in whom arterial catheter placement and HPI monitoring was planned. The major objectives are to quantify and characterize intraoperative hypotension (defined as a mean arterial pressure [MAP] < 65 mmHg) when using HPI monitoring. This includes the time-weighted average (TWA) MAP < 65 mmHg, area under a MAP of 65 mmHg, the number of episodes of a MAP < 65 mmHg, the proportion of patients with at least one episode (1 min or more) of a MAP < 65 mmHg, and the absolute maximum decrease below a MAP of 65 mmHg. In addition, we will assess causes of intraoperative hypotension and investigate associations between intraoperative hypotension and postoperative outcomes. Discussion: There are only sparse data on the effect of using HPI monitoring on intraoperative hypotension in patients having elective major non-cardiac surgery. Therefore, we built up a European, multicenter, prospective, observational registry to describe the incidence, duration, severity, and causes of intraoperative hypotension when using HPI monitoring in patients having elective major non-cardiac surgery.
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Readmission Following Perioperative Myocardial Injury: Clinical Predictors and Impact on Mortality. Crit Care Res Pract 2022; 2022:7674962. [PMID: 35996536 PMCID: PMC9392591 DOI: 10.1155/2022/7674962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Perioperative myocardial injury (PMI) following noncardiac surgery is associated with a high risk for mortality, and readmission within 30 days of PMI increases this risk. Identifying risk factors for readmission among survivors of PMI is critical to improving outcomes in PMI. We examined risk factors for readmission following discharge after surgery complicated by PMI and the effect of readmission on 1-year mortality. Methods. The study is a retropective cohort analysis of patients diagnosed with PMI in a single health system over a 10-year period. Univariate predictors of readmission were used to construct a multivariable logistic regression model. Mortality was assessed using Kaplan–Meyer survival analysis. Results. Of the 207,729 surgical patients, 5159 (2.5%) had PMI. By 30 days following PMI, 1254 patients (24.3%) died, 1142 (22.2%) were readmitted but alive at 30 days, and 2763 patients (53.5%) were alive and had not been readmitted. Readmitted patients were older, had higher peak troponin levels, and were more likely to have prior coronary, neoplastic, lung, and kidney disease. Multivariable logistic regression revealed increasing age and peak troponin, prior cancer diagnosis, and chronic lung and kidney disease as independent predictors of readmission. Readmitted patients had higher 1-year mortality than those not readmitted (33.9% vs. 22.2%,
). Conclusions. Readmission following PMI is associated with increased mortality in the following year. Patients suffering from PMI who are at risk of readmission are older, have a greater extent of myocardial injury, and are more likely to have chronic comorbidities. Identification of patients at risk of readmission following PMI is critical to improving both outcomes and utilization of hospital resources.
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Hoppe P, Burfeindt C, Reese PC, Briesenick L, Flick M, Kouz K, Pinnschmidt H, Hapfelmeier A, Sessler DI, Saugel B. Chronic arterial hypertension and nocturnal non-dipping predict postinduction and intraoperative hypotension: A secondary analysis of a prospective study. J Clin Anesth 2022; 79:110715. [DOI: 10.1016/j.jclinane.2022.110715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 02/23/2022] [Accepted: 02/27/2022] [Indexed: 12/25/2022]
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Therapeutic Effect and Prognosis of PiCCO in the Treatment of Myocardial Injury Complicated with Septic Shock. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:2910849. [PMID: 35707040 PMCID: PMC9192277 DOI: 10.1155/2022/2910849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/22/2022] [Indexed: 11/23/2022]
Abstract
Objective To explore the effect of pulse-induced contour cardiac output (PiCCO) monitoring on the survival and prognosis of patients with myocardial injury and septic shock. Methods A total of 400 patients with MI and septic shock who were treated in our hospital from May 2018 to June 2021 were included in the study. They were randomly grouped into the PiCCO group (n = 200) and the control group (n = 200) according to whether PiCCO was used for monitoring during the treatment period. The clinical baseline characteristics of all the patients were recorded. For comparison, we recorded hemodynamic parameters including mean arterial pressure (MAP), central venous pressure (CVP), heart rate (HR), troponin I (TnI), brain natriuretic peptide (BNP), oxygen metabolism parameters including systemic central venous oxygen saturation (ScvO2), and lactate before and 6 h after intervention. In addition, white blood cell count (WBC) and C-reactive protein (CPR) levels before and 6 h, 24 h, 48 h, and 72 h after intervention were measured in both groups. Finally, the survival and prognostic parameters were compared between the two groups. Results At 6 h after monitoring intervention, the hemodynamic parameters of the patients in the PiCCO group were significantly increased. Additionally, compared with the control group, the ScvO2 level was higher while the lactate level was lower in the PiCCO group. An intergroup comparison on inflammation also showed that WBC and CPR levels recovered better in the PiCCO group than in the control group. Moreover, patients with PiCCO monitoring showed better performance in outcome measures such as mortality, duration of invasive mechanical ventilation, length of hospital stay, duration of ventilator use, acute physiology and chronic health scores, and postoperative complications. Conclusion With the monitoring and guidance of the PiCCO technique, the nursing outcomes, survival rate, and prognosis of patients with myocardial injury and septic shock can be improved.
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Patient- and procedure-related factors in the pathophysiology of perioperative myocardial infarction/injury. Int J Cardiol 2022; 353:15-21. [PMID: 35026340 DOI: 10.1016/j.ijcard.2022.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 11/24/2021] [Accepted: 01/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Perioperative myocardial infarction/injury (PMI) is a frequent, often missed and incompletely understood complication of noncardiac surgery. The aim of this study was to evaluate whether patient- or procedure-related factors are more strongly associated to the development of PMI in patients undergoing repeated noncardiac surgery. METHODS In this prospective observational study, patient- and procedure-related factors were evaluated for contribution to PMI using: 1) logistic regression modelling with PMI as primary endpoint, 2) evaluation of concordance of PMI occurrence in the first and the second noncardiac surgery (surgery 1 and 2). and 3) the correlation of the extent of cardiomyocyte injury quantified by high-sensitivity cardiac troponin T between surgery 1 and 2. The secondary endpoint was all-cause mortality associated with PMI reoccurrence in surgery 2. RESULTS Among 784 patients undergoing repeated noncardiac surgery (in total 1'923 surgical procedures), 116 patients (14.8%) experienced PMI during surgery 1. Among these, PMI occurred again in surgery 2 in 35/116 (30.2%) patients. However, the vast majority of patients developing PMI during surgery 2 (96/131, 73.3%) had not developed PMI during surgery 1 (phi-coefficient 0.150, p < 0.001). The correlation between the extent of cardiomyocyte injury occurring during surgery 1 and 2 was 0.153. All-cause mortality following a second PMI in surgery 2 was dependent on time since surgery (adjusted hazard ratio 5.6 within 30 days and 2.4 within 360 days). CONCLUSIONS In high-risk patients, procedural factors are more strongly associated with occurrence of PMI than patient factors, but patient factors are also contributors to the occurrence of PMI.
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Palla K, Hyland SL, Posner K, Ghosh P, Nair B, Bristow M, Paleva Y, Williams B, Fong C, Van Cleve W, Long DR, Pauldine R, O'Hara K, Takeda K, Vavilala MS. Intraoperative prediction of postanaesthesia care unit hypotension. Br J Anaesth 2022; 128:623-635. [PMID: 34924175 PMCID: PMC9074793 DOI: 10.1016/j.bja.2021.10.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 10/01/2021] [Accepted: 10/18/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Postoperative hypotension is associated with adverse outcomes, but intraoperative prediction of postanaesthesia care unit (PACU) hypotension is not routine in anaesthesiology workflow. Although machine learning models may support clinician prediction of PACU hypotension, clinician acceptance of prediction models is poorly understood. METHODS We developed a clinically informed gradient boosting machine learning model using preoperative and intraoperative data from 88 446 surgical patients from 2015 to 2019. Nine anaesthesiologists each made 192 predictions of PACU hypotension using a web-based visualisation tool with and without input from the machine learning model. Questionnaires and interviews were analysed using thematic content analysis for model acceptance by anaesthesiologists. RESULTS The model predicted PACU hypotension in 17 029 patients (area under the receiver operating characteristic [AUROC] 0.82 [95% confidence interval {CI}: 0.81-0.83] and average precision 0.40 [95% CI: 0.38-0.42]). On a random representative subset of 192 cases, anaesthesiologist performance improved from AUROC 0.67 (95% CI: 0.60-0.73) to AUROC 0.74 (95% CI: 0.68-0.79) with model predictions and information on risk factors. Anaesthesiologists perceived more value and expressed trust in the prediction model for prospective planning, informing PACU handoffs, and drawing attention to unexpected cases of PACU hypotension, but they doubted the model when predictions and associated features were not aligned with clinical judgement. Anaesthesiologists expressed interest in patient-specific thresholds for defining and treating postoperative hypotension. CONCLUSIONS The ability of anaesthesiologists to predict PACU hypotension was improved by exposure to machine learning model predictions. Clinicians acknowledged value and trust in machine learning technology. Increasing familiarity with clinical use of model predictions is needed for effective integration into perioperative workflows.
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Affiliation(s)
| | | | - Karen Posner
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | - Bala Nair
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | | | | | - Christine Fong
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Wil Van Cleve
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Dustin R Long
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Ronald Pauldine
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Monica S Vavilala
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
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Hu Y, Lim A. MAP 65-is it enough? Curr Opin Anaesthesiol 2022; 35:242-247. [PMID: 35125394 DOI: 10.1097/aco.0000000000001115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to look at the current evidence on the consequences of intraoperative hypotension and discuss improvements that can be implemented for its prevention. RECENT FINDINGS Literature continues to supply convincing evidence that even brief periods of intraoperative hypotension are associated with increased perioperative morbidity and mortality. Recent randomized controlled trial showed intraoperative early use of vasopressor and maintaining blood pressure within tight ranges improves outcomes. SUMMARY There should be a shift in paradigm in focusing on the prevention of intraoperative hypotension instead treatment. The suggested goals to help maintaining hemodynamic stability during anesthesia include ensure adequate blood pressure and flow; hypotension prevention; and ensure adequate anesthetic depth without overdose.
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Affiliation(s)
- Yaqi Hu
- Virginia Commonwealth University, Department of Anesthesiology, 1250 East Marshall St, Richmond, Virginia, USA
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Increased risk of hip fracture mortality associated with intraoperative hypotension in elderly hip fracture patients is related to under resuscitation. J Clin Orthop Trauma 2022; 26:101783. [PMID: 35242530 PMCID: PMC8857490 DOI: 10.1016/j.jcot.2022.101783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND As the US and world population ages, hip fractures are increasingly more common. The mortality associated with these fractures remains high both in the immediate postoperative period and at one year. Perioperative resuscitation in this population is of key interest to prevent organ injury and mortality. Our objectives were to evaluate the effect of fluid resuscitation and hemodynamic status in the form of mean arterial pressure (MAP) on inpatient mortality of hip fracture patients. METHODS An institutional database was queried to compare elderly hip fracture patients that sustained in-hospital mortality to a matched control cohort. Pre-, intra-, and post-operative intravenous fluid (IVF) administration and MAP were extracted from the electronic medical record. Time from hospital presentation to the OR was also recorded. RESULTS 1,114 total hip fractures were identified during the two-year study period, 16 of which suffered inpatient mortalities. The mortality cohort was then matched with a control of 394 hip fracture patients for the same period based on age, sex, and Charlson Comorbidity Index (CCI). Conditional logistical regression analysis found odds ratios (OR) indicating that longer time between presentation and surgery (OR per additional hour: 1.05; 95% CI: 1.01-1.08) and lower intraoperative minimum MAP (OR per 5 mmHg decrease: 0.77; 95% CI: 0.61-0.97) were associated with significantly increased odds of mortality. There was also a marginal relationship between greater intraoperative IVF administration and reduced odds of mortality (OR per 500 cc additional fluid: 0.61; 95% CI: 0.37-1.00). CONCLUSION Extended time from presentation to surgery and intraoperative hypotension were associated with increased likelihood of inpatient mortality in an elderly hip fracture cohort, with a possible additional effect of under-resuscitation. Further investigation into a safe intraoperative minimum MAP should be pursued. LEVEL OF EVIDENCE Level III.
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Turan A, Cohen B, Elsharkawy H, Maheshwari K, Soliman LM, Babazade R, Ayad S, Hassan M, Elkassabany N, Essber HA, Kessler H, Mao G, Esa WAS, Sessler DI. Transversus abdominis plane block with liposomal bupivacaine versus continuous epidural analgesia for major abdominal surgery: The EXPLANE randomized trial. J Clin Anesth 2021; 77:110640. [PMID: 34969004 DOI: 10.1016/j.jclinane.2021.110640] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Compare transversus abdominis plane (TAP) blocks with liposomal bupivacaine were to epidural analgesia for pain at rest and opioid consumption in patients recovering from abdominal surgery. BACKGROUND ERAS pathways suggest TAP blocks in preference to epidural analgesia for abdominal surgery. However, the relative efficacies of TAP blocks and epidural analgesia remains unknown. METHODS Patients having major abdominal surgery were enrolled at six sites and randomly assigned 1:1 to thoracic epidural analgesia or bilateral/4-quadrant TAP blocks with liposomal bupivacaine. Intravenous opioids were used as needed. Non-inferiority margins were a priori set at 1 point on an 11-point pain numeric rating scale for pain at rest and at a 25% increase in postoperative opioid consumption. RESULTS Enrollment was stopped per protocol at 3rd interim analysis after crossing an a priori futility boundary. 498 patients were analyzed (255 had TAP blocks and 243 had epidurals). Pain scores at rest in patients assigned to TAP blocks were significantly non-inferior to those given epidurals, with an estimated difference of 0.09 points (CI: -0.12, 0.30; noninferiority P < 0.001). Opioid consumption during the initial 3 postoperative days in TAP patients was not non-inferior to epidurals, with an estimated ratio of geometric means of 1.37 (CI: 1.05, 1.79; non-inferiority P = 0.754). However, the absolute difference was only 21 mg morphine equivalents over the 3 days. Patients with epidurals were more likely to experience mean arterial pressures <65 mmHg than those given TAP blocks: 48% versus 31%, P = 0.006. CONCLUSION Pain scores at rest during the initial three days after major abdominal surgery were similar. Patients assigned to TAP blocks required more opioid then epidural patients but had less hypotension. Clinicians should reconsider epidural analgesia in patients at risk from hypotension. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02996227.
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Affiliation(s)
- Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America.
| | - Barak Cohen
- Department of Outcomes Research, Cleveland Clinic, United States of America; Division of Anesthesiology, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hesham Elsharkawy
- Department of Outcomes Research, Cleveland Clinic, United States of America; Pain Center, Anesthesiology Department, MetroHealth, Case Western Reserve University, OH, United States of America
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Loran Mounir Soliman
- Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Rovnat Babazade
- Department of Anesthesiology, University of Texas Medical Branch of Galveston, TX, United States of America
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Manal Hassan
- Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Nabil Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, United States of America
| | - Hani A Essber
- Department of Outcomes Research, Cleveland Clinic, United States of America
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic, United States of America
| | - Guangmei Mao
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic
| | - Wael Ali Sakr Esa
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, United States of America
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Chew MS, Puelacher C, Patel A, Hammarskjöld F, Lyckner S, Kollind M, Jawad M, Andersson U, Fredrikson M, Sperber J, Johnsson P, Elander L, Zeuchner J, Linhardt M, De Geer L, Rolander WG, Gagnö G, Didriksson H, Pearse R, Mueller C, Andersson H. Identification of myocardial injury using perioperative troponin surveillance in major noncardiac surgery and net benefit over the Revised Cardiac Risk Index. Br J Anaesth 2021; 128:26-36. [PMID: 34857357 DOI: 10.1016/j.bja.2021.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 09/12/2021] [Accepted: 10/05/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Patients with perioperative myocardial injury are at risk of death and major adverse cardiovascular and cerebrovascular events (MACCE). The primary aim of this study was to determine optimal thresholds of preoperative and perioperative changes in high-sensitivity cardiac troponin T (hs-cTnT) to predict MACCE and mortality. METHODS Prospective, observational, cohort study in patients ≥50 yr of age undergoing elective major noncardiac surgery at seven hospitals in Sweden. The exposures were hs-cTnT measured before and days 0-3 after surgery. Two previously published thresholds for myocardial injury and two thresholds identified using receiver operating characteristic analyses were evaluated using multivariable logistic regression models and externally validated. The weighted comparison net benefit method was applied to determine the additional value of hs-cTnT thresholds when compared with the Revised Cardiac Risk Index (RCRI). The primary outcome was a composite of 30-day all-cause mortality and MACCE. RESULTS We included 1291 patients between April 2017 and December 2020. The primary outcome occurred in 124 patients (9.6%). Perioperative increase in hs-cTnT ≥14 ng L-1 above preoperative values provided statistically optimal model performance and was associated with the highest risk for the primary outcome (adjusted odds ratio 2.9, 95% confidence interval 1.8-4.7). Validation in an independent, external cohort confirmed these findings. A net benefit over RCRI was demonstrated across a range of clinical thresholds. CONCLUSIONS Perioperative increases in hsTnT ≥14 ng L-1 above baseline values identifies acute perioperative myocardial injury and provides a net prognostic benefit when added to RCRI for the identification of patients at high risk of death and MACCE. CLINICAL TRIAL REGISTRATION NCT03436238.
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Affiliation(s)
- Michelle S Chew
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Christian Puelacher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Akshaykumar Patel
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Fredrik Hammarskjöld
- Department of Anesthesiology and Intensive Care, Ryhov County Hospital, Jönköping, Sweden
| | - Sara Lyckner
- Department of Anesthesiology, Mälarsjukhuset, Centre for Clinical Research Sörmland, Eskilstuna, Sweden
| | - Malin Kollind
- Department of Anaesthesia and Intensive Care, Centralsjukhuset Kristianstad, Kristianstad, Sweden
| | - Monir Jawad
- Department of Anaesthesia and Intensive Care, Centralsjukhuset Kristianstad, Kristianstad, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Ulrika Andersson
- Department of Clinical Sciences Lund, Anaesthesiology and Intensive Care, Skåne University Hospital Lund, Lund University, Sweden
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Jesper Sperber
- Department of Anesthesiology, Mälarsjukhuset, Centre for Clinical Research Sörmland, Eskilstuna, Sweden
| | - Patrik Johnsson
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Skåne University Hospital Malmö, Lund University, Sweden
| | - Louise Elander
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Vrinnevi Hospital, Norrköping, Sweden
| | - Jakob Zeuchner
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Vrinnevi Hospital, Norrköping, Sweden
| | - Michael Linhardt
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lina De Geer
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Wictor Gääw Rolander
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Gunilla Gagnö
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Helén Didriksson
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Rupert Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Henrik Andersson
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Brenner MJ, Boothman RC, Rushton CH, Bradford CR, Hickson GB. Honesty and Transparency, Indispensable to the Clinical Mission-Part I: How Tiered Professionalism Interventions Support Teamwork and Prevent Adverse Events. Otolaryngol Clin North Am 2021; 55:43-61. [PMID: 34823720 DOI: 10.1016/j.otc.2021.07.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
At the foundation of clinical medicine is the relationship among patients, families, and health care professionals. Implicit to that social contract, professionals pledge to bring clinical excellence to advance their patients' wellness and healing-and to prevent harm. Patients trust that those privileged to deliver care will do so unwaveringly in service of patients' best interests; however, the incentives and infrastructure surrounding health care delivery can promote or undermine individual performance, teamwork, and patient safety. Modeling professionalism and identifying slips and lapses supports pursuit of high reliability. Part 1, Promoting Professionalism, introduces the first of 3 pillars of advancing the clinical mission.
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Affiliation(s)
- Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan School of Medicine, 1500 East Medical Center Drive SPC 5312, 1904 Taubman Center, Ann Arbor, MI 48109-5312, USA; GTC Quality Improvement Collaborative, Durham, NC, USA.
| | - Richard C Boothman
- Boothman Consulting Group, LLC, Ann Arbor, MI, USA; Department of Surgery, University of Michigan Medical School, Ann Arbor; Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cynda Hylton Rushton
- Johns Hopkins University School of Nursing, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Berman Institute of Bioethics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carol R Bradford
- The College of Medicine and James Cancer Hospital and Solove Research Institute; Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Gerald B Hickson
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Quality, Safety and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN, USA
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Jiang Q, Dong X, Hu D, Chen L, Luo Y. Aquaporin 4 inhibition alleviates myocardial ischemia-reperfusion injury by restraining cardiomyocyte pyroptosis. Bioengineered 2021; 12:9021-9030. [PMID: 34657556 PMCID: PMC8806966 DOI: 10.1080/21655979.2021.1992332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Myocardial injury caused by ischemia-reperfusion is the main pathological manifestation of coronary artery disease (CAD), which is characterized by high mortality and morbidity. Thus, there’s an urgent need to develop efficacious strategies and elucidate the underlying mechanisms to prevent or alleviate myocardial ischemia-reperfusion injury to improve the clinical outcomes in patients. In this study, we took advantage of a typical myocardial cell line of mice (HL-1) and cultured with or without an aquaporin 4 inhibitor (TGN-20 denoted as AQP4i) under normal conditions (NC), ischemia (IS) and ischemia reperfusion (IR), respectively. The cytomorphology, ultrastructure, cell vitality and expression pattern of apoptotic proteins were verified with scanning electron microscope (SEM), immunofluorescence staining, flow cytometry, quantitative real-time PCR and western-blotting analysis, respectively. HL-1 under IS or IR condition revealed higher expression of Aquaporin 4 (Aqp4) compared to the NC group, whereas showed similarity in cytomorphology and ultrastructure. Aqp4 inhibition was sufficient to improve the apoptotic cells in HL-1 while showed minimal effects to the other cellular vitality. Furthermore, the expression pattern of apoptotic proteins and anti-apoptotic proteins together with proinflammatory factors in HL-1 was effectively rescued by Aqp4i treatment both at the mRNA level and protein level. Ischemia and ischemia reperfusion caused higher expression of Aqp4 and resultant increase of cardiomyocyte pyroptosis. Myocardial ischemia-reperfusion injury of HL-1 was effectively alleviated by Aqp4 and pyroptosis inhibition. Our findings provided new references for myocardial ischemia-reperfusion injury management via targeting Aqp4-mediated pyroptosis of cardiomyocyte.
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Affiliation(s)
- Qiong Jiang
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China.,Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian, P.R. China.,Fujian Heart Medical Center, Fuzhou, Fujian, P.R. China
| | - Xianfeng Dong
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China.,Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian, P.R. China.,Fujian Heart Medical Center, Fuzhou, Fujian, P.R. China
| | - Danqing Hu
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China.,Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian, P.R. China.,Fujian Heart Medical Center, Fuzhou, Fujian, P.R. China
| | - Lejun Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China.,Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian, P.R. China.,Fujian Heart Medical Center, Fuzhou, Fujian, P.R. China
| | - Yukun Luo
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China.,Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian, P.R. China.,Fujian Heart Medical Center, Fuzhou, Fujian, P.R. China
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Prevalence and risk factors of myocardial and acute kidney injury following radical nephrectomy with vena cava thrombectomy: a retrospective cohort study. BMC Anesthesiol 2021; 21:243. [PMID: 34641781 PMCID: PMC8513361 DOI: 10.1186/s12871-021-01462-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radical nephrectomy with thrombectomy is the mainstay treatment for patients with renal cell carcinoma with vena cava thrombus. But the procedure is full of challenge, with high incidence of major complications and mortality. Herein, we investigated the incidence and predictors of myocardial injury and acute kidney injury (AKI) in patients following radical nephrectomy with inferior vena cava thrombectomy. METHODS Patients who underwent nephrectomy with thrombectomy between January 2012 and June 2020 were retrospectively reviewed. Myocardial injury was diagnosed when peak cardiac troponin I was higher than 0.03 ng/ml. AKI was diagnosed according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression models were used to identify predictors of myocardial injury or AKI after surgery. RESULTS A total of 143 patients were included in the final analysis. Myocardial injury and AKI occurred in 37.8 and 42.7% of patients after this surgery, respectively. Male sex (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.10-0.71; P = 0.008) was associated with a lower risk, whereas high level Mayo classification (compared with Mayo level I + II, Mayo level III + IV: OR 4.21, 95% CI 1.42-12.4; P = 0.009), acute normovolemic hemodilution before surgery (OR 2.66, 95% CI 1.10-6.41; P = 0.029), long duration of intraoperative tachycardia (per 20 min: OR 1.49, 95% CI 1.10-2.16; P = 0.036), and long duration of surgery (per 1 h, OR 1.48, 95% CI 1.03-2.16, P = 0.009) were associated with a higher risk of myocardial injury. High body mass index (OR 1.18, 95% CI 1.06-1.33; P = 0.004) and long duration of intraoperative hypotension (per 20 min: OR 1.30, 95% CI 1.04-1.64; P = 0.024) were associated with a higher risk, whereas selective renal artery embolism before surgery (OR 0.20, 95% CI 0.07-0.59, P = 0.004) was associated with a lower risk of AKI. CONCLUSION Myocardial injury and AKI were common in patients recovering from radical nephrectomy with inferior vena cava thrombectomy. Whether interventions targeting the above modifiable factors can improve outcomes require further studies.
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Jin YN, Feng H, Wang ZY, Li J. Analysis of the Risk Factors for Hypotension in Laparoscopic Hiatal Hernia Repair. Int J Gen Med 2021; 14:5203-5208. [PMID: 34512003 PMCID: PMC8423486 DOI: 10.2147/ijgm.s327259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/16/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to investigate the risk factors for hypotension in patients undergoing laparoscopic hiatal hernia repair. Methods The clinical data of patients who underwent laparoscopic repair of a hiatal hernia in the Beijing Chao-Yang Hospital of Capital Medical University between February 2018 and January 2021 were retrospectively collected, and their perioperative data were obtained by querying the electronic medical record system. The patients were divided into two groups—a hypotension group and a normal group—based on the occurrence of intraoperative hypotension, which was defined as a mean arterial pressure <65 mmHg and lasting ≥1 minute during the operation. The variables with a P value ≤0.1 in univariate regression analysis and clinically considered relevant variables were included in multivariate regression analysis in order to screen the risk factors for hypotension in these patients. Results A total of 114 patients were included in the analysis. The incidence of hypotension was 54.4%. Old age was identified as the only risk factor for hypotension during hiatal hernia surgery. Conclusion Old age is the only risk factor for intraoperative hypotension in patients undergoing laparoscopic hiatal hernia repair.
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Affiliation(s)
- Ya-Nan Jin
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hao Feng
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhen-Yuan Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jie Li
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
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Mensel C, Eldrup N, Guldbrand V, Juhl‐Olsen P. Impact of focused cardiac ultrasound in vascular surgery patients: A prospective observational study. Health Sci Rep 2021; 4:e328. [PMID: 34386611 PMCID: PMC8339666 DOI: 10.1002/hsr2.328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/10/2021] [Accepted: 06/27/2021] [Indexed: 12/05/2022] Open
Abstract
PURPOSE We aimed to evaluate the diagnostic and logistical consequences of routine preoperative focused cardiac ultrasound (FOCUS) in patients scheduled for elective vascular surgery. METHODS In a prospective, observational study, FOCUS was performed in all patients seen in the vascular surgery outpatient clinic from January 14 to May1, 2019, unless a full echocardiography had been conducted in the preceding 12 months or the patient was already referred to an echocardiography by the vascular surgeons. FOCUS followed a stringent protocol and referrals for a full echocardiography followed predefined criteria. RESULTS Preoperative FOCUS was performed in 55 (60%) patients. Of these, 12 patients (22%) revealed cardiac pathology and were referred to a full echocardiography. Coronary angiography was subsequently performed in one of these patients but was without a further consequence. All patients underwent surgery. CONCLUSION FOCUS disclosed cardiac pathology in the outpatient clinic but with little clinical consequence. This study does not support routine FOCUS as a part of the preoperative patient cardiovascular assessment before vascular surgery. However, larger studies are warranted to further evaluate the relevance of preoperative FOCUS in a larger sample size.
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Affiliation(s)
- Camilla Mensel
- Department of AnaesthesiologyAarhus University HospitalAarhusDenmark
| | - Nikolaj Eldrup
- Department of Vascular SurgeryCopenhagen University HospitalCopenhagenDenmark
| | | | - Peter Juhl‐Olsen
- Department of AnaesthesiologyAarhus University HospitalAarhusDenmark
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Joosten A, Rinehart J, Van der Linden P, Alexander B, Penna C, De Montblanc J, Cannesson M, Vincent JL, Vicaut E, Duranteau J. Computer-assisted Individualized Hemodynamic Management Reduces Intraoperative Hypotension in Intermediate- and High-risk Surgery: A Randomized Controlled Trial. Anesthesiology 2021; 135:258-272. [PMID: 33951140 PMCID: PMC8277754 DOI: 10.1097/aln.0000000000003807] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Individualized hemodynamic management during surgery relies on accurate titration of vasopressors and fluids. In this context, computer systems have been developed to assist anesthesia providers in delivering these interventions. This study tested the hypothesis that computer-assisted individualized hemodynamic management could reduce intraoperative hypotension in patients undergoing intermediate- to high-risk surgery. METHODS This single-center, parallel, two-arm, prospective randomized controlled single blinded superiority study included 38 patients undergoing abdominal or orthopedic surgery. All included patients had a radial arterial catheter inserted after anesthesia induction and connected to an uncalibrated pulse contour monitoring device. In the manually adjusted goal-directed therapy group (N = 19), the individualized hemodynamic management consisted of manual titration of norepinephrine infusion to maintain mean arterial pressure within 10% of the patient's baseline value, and mini-fluid challenges to maximize the stroke volume index. In the computer-assisted group (N = 19), the same approach was applied using a closed-loop system for norepinephrine adjustments and a decision-support system for the infusion of mini-fluid challenges (100 ml). The primary outcome was intraoperative hypotension defined as the percentage of intraoperative case time patients spent with a mean arterial pressure of less than 90% of the patient's baseline value, measured during the preoperative screening. Secondary outcome was the incidence of minor postoperative complications. RESULTS All patients were included in the analysis. Intraoperative hypotension was 1.2% [0.4 to 2.0%] (median [25th to 75th] percentiles) in the computer-assisted group compared to 21.5% [14.5 to 31.8%] in the manually adjusted goal-directed therapy group (difference, -21.1 [95% CI, -15.9 to -27.6%]; P < 0.001). The incidence of minor postoperative complications was not different between groups (42 vs. 58%; P = 0.330). Mean stroke volume index and cardiac index were both significantly higher in the computer-assisted group than in the manually adjusted goal-directed therapy group (P < 0.001). CONCLUSIONS In patients having intermediate- to high-risk surgery, computer-assisted individualized hemodynamic management significantly reduces intraoperative hypotension compared to a manually controlled goal-directed approach. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, California, USA
| | - Philippe Van der Linden
- Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, California, USA
| | - Christophe Penna
- Department of Gastro-intestinal Surgery, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Jacques De Montblanc
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, California, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Eric Vicaut
- Unité de Recherche Clinique, Lariboisière, Paris 7 Diderot University, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
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Hallqvist L, Granath F, Fored M, Bell M. Intraoperative Hypotension and Myocardial Infarction Development Among High-Risk Patients Undergoing Noncardiac Surgery: A Nested Case-Control Study. Anesth Analg 2021; 133:6-15. [PMID: 33555690 DOI: 10.1213/ane.0000000000005391] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hemodynamic instability during anesthesia and surgery is common and associated with cardiac morbidity and mortality. Information is needed regarding optimal blood pressure (BP) threshold in the perioperative period. Therefore, the effect of intraoperative hypotension (IOH) on risk of perioperative myocardial infarction (MI) was explored. METHODS A nested case-control study with patients developing MI <30 days postsurgery matched with non-MI patients, sampled from a large surgery cohort. Study participants were adults undergoing noncardiac surgery at 3 university hospitals in Sweden, 2007-2014. Matching criteria were age, sex, American Society of Anesthesiologists (ASA) physical status, cardiovascular disease, hospital, year-, type-, and extent of surgery. Medical records were reviewed to validate MI diagnoses and retrieve information on comorbid history, baseline BP, laboratory and intraoperative data. Main exposure was IOH, defined as a decrease in systolic blood pressure (SBP), in mm Hg, from preoperative individual resting baseline lasting at least 5 minutes. Outcomes were acute MI, fulfilling the universal criteria, subclassified as type 1 and 2, occurring within 30 days and mortality beyond 30 days among case and control patients. Conditional logistic regression assessed the association between IOH, decrease in SBP from individual baseline, and perioperative MI. Mortality rates were estimated using Cox proportional hazards. Relative risk estimates are reported as are the corresponding absolute risks derived from the well-characterized source population. RESULTS A total of 326 cases met the inclusion criteria and were successfully matched with 326 controls. The distribution of MI type was 59 (18%) type 1 and 267 (82%) type 2. Median time to MI diagnosis was 2 days; 75% were detected within a week of surgery. Multivariable analysis acknowledged IOH as an independent risk factor of perioperative MI. IOH, with reduction of 41-50 mm Hg, from individual baseline SBP, was associated with a more than tripled increased odds, odds ratio (OR) = 3.42 (95% confidence interval [CI], 1.13-10.3), and a hypotensive event >50 mm Hg with considerably increased odds in respect to MI risk, OR = 22.6, (95% CI, 7.69-66.2). In patients with a very high-risk burden, the absolute risk of an MI diagnosis increased from 3.6 to 68 per 1000 surgeries. CONCLUSIONS In patients undergoing noncardiac surgery, IOH is a possible contributor to clinically significant perioperative MI. The high absolute MI risk associated with IOH, among a growing population of patients with a high-risk burden, suggests that increased vigilance of BP control in these patients may be beneficial.
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Affiliation(s)
- Linn Hallqvist
- From the Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden.,Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Granath
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Michael Fored
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Max Bell
- From the Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden.,Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
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Schenk J, Wijnberge M, Maaskant JM, Hollmann MW, Hol L, Immink RV, Vlaar AP, van der Ster BJP, Geerts BF, Veelo DP. Effect of Hypotension Prediction Index-guided intraoperative haemodynamic care on depth and duration of postoperative hypotension: a sub-study of the Hypotension Prediction trial. Br J Anaesth 2021; 127:681-688. [PMID: 34303491 DOI: 10.1016/j.bja.2021.05.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/29/2021] [Accepted: 05/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intraoperative and postoperative hypotension are associated with morbidity and mortality. The Hypotension Prediction (HYPE) trial showed that the Hypotension Prediction Index (HPI) reduced the depth and duration of intraoperative hypotension (IOH), without excess use of intravenous fluid, vasopressor, and/or inotropic therapies. Here, We hypothesised that intraoperative HPI-guided haemodynamic care would reduce the severity of postoperative hypotension in the PACU. METHODS This was a sub-study of the HYPE study, in which 60 adults undergoing elective noncardiac surgery were allocated randomly to intraoperative HPI-guided or standard haemodynamic care. Blood pressure was measured using a radial intra-arterial catheter, which was connected to a FloTracIQ sensor. Hypotension was defined as MAP <65 mm Hg, and a hypotensive event was defined as MAP <65 mm Hg for at least 1 min. The primary outcome was the time-weighted average (TWA) of postoperative hypotension. Secondary outcomes were absolute incidence, area under threshold for hypotension, and percentage of time spent with MAP <65 mm Hg. RESULTS Overall, 54/60 (90%) subjects (age 64 (8) yr; 44% female) completed the protocol, owing to failure of the FloTracIQ device in 6/60 (10%) patients. Intraoperative HPI-guided care was used in 28 subjects; 26 subjects were randomised to the control group. Postoperative hypotension occurred in 37/54 (68%) subjects. HPI-guided care did not reduce the median duration (TWA) of postoperative hypotension (adjusted median difference, vs standard of care: 0.118; 95% confidence interval [CI], 0-0.332; P=0.112). HPI-guidance reduced the percentage of time with MAP <65 mm Hg by 4.9% (adjusted median difference: -4.9; 95% CI, -11.7 to -0.01; P=0.046). CONCLUSIONS Intraoperative HPI-guided haemodynamic care did not reduce the TWA of postoperative hypotension.
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Affiliation(s)
- Jimmy Schenk
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Marije Wijnberge
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Jolanda M Maaskant
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, Location Academic Medical Centre and University of Amsterdam, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Liselotte Hol
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Rogier V Immink
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Alexander P Vlaar
- Department of Intensive Care, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands.
| | - Björn J P van der Ster
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Bart F Geerts
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Denise P Veelo
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
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