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Rosero EB, Rajan N, Joshi GP. Pro-Con Debate: Are Patients With Coronary Stents Suitable for Free-Standing Ambulatory Surgery Centers? Anesth Analg 2023; 136:218-226. [PMID: 36638505 DOI: 10.1213/ane.0000000000006237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
With increasing implantation of coronary artery stents over the past 2 decades, it is inevitable that anesthesiologists practicing in the outpatient setting will need to determine whether these patients are suitable for procedures at a free-standing ambulatory surgery center (ASC). Appropriate selection of patients with coronary artery stents for a procedure in an ASC requires consideration of factors that affect the balance between the risk of stent thrombosis due to interruption of antiplatelet therapy and the thrombogenic effects of surgery, and the risk of perioperative bleeding complications that may occur if antiplatelet therapy is continued. Thus, periprocedure care of these patients presents unique challenges, particularly for extensive surgical procedures that are increasingly scheduled for free-standing ASCs, where consultation and ancillary services, as well as access to percutaneous cardiac interventions, may not be readily available. Therefore, the suitability of the ambulatory setting for this patient population remains highly controversial. In this Pro-Con commentary, we discuss the arguments for and against scheduling patients with coronary artery stents in free-standing ASCs.
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Affiliation(s)
- Eric B Rosero
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
| | - Niraja Rajan
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Girish P Joshi
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
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Dai ZL, Song YF, Tian Y, Li Y, Lin M, Lin J, Wang Q, Wang P, Gao WL. Trimetazidine offers myocardial protection in elderly coronary artery disease patients undergoing non-cardiac surgery: a randomized, double-blind, placebo-controlled trial. BMC Cardiovasc Disord 2021; 21:473. [PMID: 34598676 PMCID: PMC8485575 DOI: 10.1186/s12872-021-02287-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 09/24/2021] [Indexed: 11/21/2022] Open
Abstract
Background Trimetazidine (TMZ) pretreatment protects cardiomyocytes during cardiac surgery. TMZ may protect elderly patients with ischaemic heart disease (IHD) undergoing non-cardiac surgery. Methods This was a randomized, double-blind, placebo-controlled trial (registration #ChiCTR1900025018) of patients with IHD scheduled to undergo non-cardiac surgery at Shenzhen People’s Hospital (Shenzhen, Guangdong Province, China) between June 2014 and September 2015, randomized to 60 mg TMZ or placebo 12 h before surgery. The primary endpoint was the occurrence of in-hospital cardiovascular events. The secondary endpoints were myocardial ischaemia on five-lead electrocardiogram (cECG), cardiac troponin I (cTnI) elevation, cardiac death, acute coronary events, heart failure, and arrhythmia requiring treatments. Results Compared with the placebo group, the TMZ group showed a lower occurrence of in-hospital cardiovascular events (primary endpoint, 20.0% vs. 37.5%, P = 0.02), myocardial ischaemia (15.0% vs. 32.5%, P < 0.01), cTnI elevation (2.5% vs. 10%, P < 0.01), acute coronary events (10.0% vs. 20.0%, P < 0.05), heart failure (0% vs. 2.5%, P < 0.05), and arrhythmia requiring treatment (17.5% vs. 35.0%, P < 0.05). There was no acute myocardial infarction during the 30-day postoperative period. Conclusions In elderly patients with IHD undergoing non-cardiac surgery, TMZ pretreatment was associated with myocardial protective effects. Trial registration The trial was prospectively registered at http://www.chictr.org.cn/showproj.aspx?proj=41909 with registration number [ChiCTR1900025018] (7/8/2019).
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Affiliation(s)
- Zhong-Liang Dai
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China. .,Shenzhen Engineering Research Center of Anesthesiology, No. 1017 Dongmen North Road, Shenzhen, 518020, Guangdong, China.
| | - Yi-Feng Song
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China.,Shenzhen Engineering Research Center of Anesthesiology, No. 1017 Dongmen North Road, Shenzhen, 518020, Guangdong, China
| | - Ya Tian
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China.,Shenzhen Engineering Research Center of Anesthesiology, No. 1017 Dongmen North Road, Shenzhen, 518020, Guangdong, China
| | - Yin Li
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China.,Shenzhen Engineering Research Center of Anesthesiology, No. 1017 Dongmen North Road, Shenzhen, 518020, Guangdong, China
| | - Miao Lin
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China.,Shenzhen Engineering Research Center of Anesthesiology, No. 1017 Dongmen North Road, Shenzhen, 518020, Guangdong, China
| | - Juan Lin
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China.,Shenzhen Engineering Research Center of Anesthesiology, No. 1017 Dongmen North Road, Shenzhen, 518020, Guangdong, China
| | - Qi Wang
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China.,Shenzhen Engineering Research Center of Anesthesiology, No. 1017 Dongmen North Road, Shenzhen, 518020, Guangdong, China
| | - Ping Wang
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China.,Shenzhen Engineering Research Center of Anesthesiology, No. 1017 Dongmen North Road, Shenzhen, 518020, Guangdong, China
| | - Wen-Li Gao
- Department of Anesthesiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China. .,Shenzhen Engineering Research Center of Anesthesiology, No. 1017 Dongmen North Road, Shenzhen, 518020, Guangdong, China.
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Dai ZL, Cai XT, Gao WL, Lin M, Lin J, Jiang YX, Jiang X. Etomidate vs propofol in coronary heart disease patients undergoing major noncardiac surgery: A randomized clinical trial. World J Clin Cases 2021; 9:1293-1303. [PMID: 33644196 PMCID: PMC7896684 DOI: 10.12998/wjcc.v9.i6.1293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/17/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The ideal depth of general anesthesia should achieve the required levels of hypnosis, analgesia, and muscle relaxation while minimizing physiologic responses to awareness. The choice of anesthetic strategy in patients with coronary heart disease (CHD) undergoing major noncardiac surgery is becoming an increasingly important issue as the population ages. This is because general anesthesia is associated with a risk of perioperative cardiac complications and death, and this risk is much higher in people with CHD. AIM To compare hemodynamic function and cardiovascular event rate between etomidate- and propofol-based anesthesia in patients with CHD. METHODS This prospective study enrolled consecutive patients (American Society of Anesthesiologists grade II/III) with stable CHD (New York Heart Association class I/II) undergoing major noncardiac surgery. The patients were randomly allocated to receive either etomidate/remifentanil-based or propofol/remifentanil-based general anesthesia. Randomization was performed using a computer-generated random number table and sequentially numbered, opaque, sealed envelopes. Concealment was maintained until the patient had arrived in the operating theater, at which point the consulting anesthetist opened the envelope. All patients, data collectors, and data analyzers were blinded to the type of anesthesia used. The primary endpoints were the occurrence of cardiovascular events (bradycardia, tachycardia, hypotension, ST-T segment changes, and ventricular premature beats) during anesthesia and cardiac troponin I level at 24 h. The secondary endpoints were hemodynamic parameters, bispectral index, and use of vasopressors during anesthesia. RESULTS The final analysis included 40 patients in each of the propofol and etomidate groups. The incidences of bradycardia, hypotension, ST-T segment changes, and ventricular premature beats during anesthesia were significantly higher in the propofol group than in the etomidate group (P < 0.05 for all). The incidence of tachycardia was similar between the two groups. Cardiac troponin I levels were comparable between the two groups both before the induction of anesthesia and at 24 h after surgery. When compared with the etomidate group, the propofol group had significantly lower heart rates at 3 min after the anesthetic was injected (T1) and immediately after tracheal intubation (T2), lower systolic blood pressure at T1, and lower diastolic blood pressure and mean arterial pressure at T1, T2, 3 min after tracheal intubation, and 5 min after tracheal intubation (P < 0.05 for all). Vasopressor use was significantly more in the propofol group than in the etomidate group during the induction and maintenance periods (P < 0.001). CONCLUSION In patients with CHD undergoing noncardiac major surgery, etomidate-based anesthesia is associated with fewer cardiovascular events and smaller hemodynamic changes than propofol-based anesthesia.
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Affiliation(s)
- Zhong-Liang Dai
- Department of Anesthesiology, The First Affiliated Hospital of Southern University, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Xing-Tao Cai
- Department of Anesthesiology, The First Affiliated Hospital of Southern University, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Wen-Li Gao
- Department of Anesthesiology, The First Affiliated Hospital of Southern University, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Miao Lin
- Department of Anesthesiology, The First Affiliated Hospital of Southern University, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Juan Lin
- Department of Anesthesiology, The First Affiliated Hospital of Southern University, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Yuan-Xu Jiang
- Department of Anesthesiology, The First Affiliated Hospital of Southern University, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Xin Jiang
- Department of Geriatrics, The First Affiliated Hospital of Southern University, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
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Trembach N, Zabolotskikh I. The pathophysiology of complications after laparoscopic colorectal surgery: Role of baroreflex and chemoreflex impairment. ACTA ACUST UNITED AC 2019; 26:115-120. [PMID: 31146925 DOI: 10.1016/j.pathophys.2019.05.004] [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: 01/12/2019] [Revised: 04/14/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The aim of this study was to assess the dynamics of baroreflex sensitivity (BRS) during laparoscopic colorectal surgery in patients with different chemoreflex sensitivity assessed with breath-holding test. METHODS The study included 80 patients (mean age, 68 ± 7 years) who underwent routine laparoscopic colorectal surgery under general/epidural anaesthesia. Patients were retrospectively divided into two groups: with normal (breath-holding duration ≥38 s, group N [n = 42]) or high (breath-holding duration <38 s, group H [n = 38]) chemoreflex sensitivity. BRS was initially evaluated after arterial catheter placement before induction, after induction, after pneumoperitoneum, after extubation, and 6 h and 24 h after extubation. RESULTS Average BRS was significantly lower in the group with high peripheral chemoreflex sensitivity at all time points. The use of pneumoperitoneum did not significantly influence BRS in either group. After the surgery and 6 h after extubation, no significant changes were observed. After 6 h of the surgery, 11.9% of patients in group N and 57.8% of those in group H (p < 0.05) had severe baroreflex dysfunction (BRS < 3 ms/mmHg). After 24 h, only two patients in group N (vs 13 [34.2%] in group H, p < 0.05) had this dysfunction. CONCLUSION Patients with high chemoreflex sensitivity have lower BRS, and it decreases further after anaesthesia induction. The recovery process can take up to 24 h, with an increased risk of perioperative complications in patients with high preoperative chemoreflex sensitivity. The use of pneumoperitoneum does not significantly affect BRS.
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Affiliation(s)
- Nikita Trembach
- Department of Anesthesiology, Intensive Care and Transfusiology, Kuban State Medical University, 350063, Krasnodar, Sedin str., 4, Russian Federation.
| | - Igor Zabolotskikh
- Department of Anesthesiology, Intensive Care and Transfusiology, Kuban State Medical University, 350063, Krasnodar, Sedin str., 4, Russian Federation.
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