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Oh MY, Jung YM, Kim WP, Lee HC, Kim TK, Ko SB, Lim J, Lee SM. Prediction for Perioperative Stroke Using Intraoperative Parameters. J Am Heart Assoc 2024; 13:e032216. [PMID: 39119968 DOI: 10.1161/jaha.123.032216] [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: 08/19/2023] [Accepted: 06/20/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Perioperative stroke is a severe complication following surgery. To identify patients at risk for perioperative stroke, several prediction models based on the preoperative factors were suggested. Prediction models often focus on preoperative patient characteristics to assess stroke risk. However, most existing models primarily base their predictions on the patient's baseline characteristics before surgery. We aimed to develop a machine-learning model incorporating both pre- and intraoperative variables to predict perioperative stroke. METHODS AND RESULTS This study included patients who underwent noncardiac surgery at 2 hospitals with the data of 15 752 patients from Seoul National University Hospital used for development and temporal internal validation, and the data of 449 patients from Boramae Medical Center used for external validation. Perioperative stroke was defined as a newly developed ischemic lesion on diffusion-weighted imaging within 30 days of surgery. We developed a prediction model composed of pre- and intraoperative factors (integrated model) and compared it with a model consisting of preoperative features alone (preoperative model). Perioperative stroke developed in 109 (0.69%) patients in the Seoul National University Hospital group and 11 patients (2.45%) in the Boramae Medical Center group. The integrated model demonstrated superior predictive performance with area under the curve values of 0.824 (95% CI, 0.762-0.880) versus 0.584 (95% CI, 0.499-0.667; P<0.001) in the internal validation; and 0.716 (95% CI, 0.560-0.859) versus 0.505 (95% CI, 0.343-0.654; P=0.018) in the external validation, compared to the preoperative model. CONCLUSIONS We suggest that incorporating intraoperative factors into perioperative stroke prediction models can improve their accuracy.
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Affiliation(s)
- Mi-Young Oh
- Department of Neurology Bucheon Sejong Hospital Bucheon-si Gyeonggi-do South Korea
| | - Young Mi Jung
- Department of Obstetrics and Gynecology Seoul National University College of Medicine Seoul South Korea
- Department of Obstetrics and Gynecology, Guro Hospital Korea University College of Medicine Seoul South Korea
| | | | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine Seoul National University College of Medicine Seoul South Korea
- Department of Anesthesiology and Pain Medicine Seoul National University Hospital Seoul South Korea
| | - Tae Kyong Kim
- Department of Anesthesiology and Pain Medicine Seoul National University College of Medicine Seoul South Korea
- Department of Anesthesiology and Pain Medicine Metropolitan Government Seoul National University Boramae Medical Center Seoul South Korea
| | - Sang-Bae Ko
- Department of Neurology Seoul National University Hospital Seoul South Korea
| | | | - Seung Mi Lee
- Department of Obstetrics and Gynecology Seoul National University College of Medicine Seoul South Korea
- Department of Obstetrics and Gynecology Seoul National University Hospital Seoul South Korea
- Innovative Medical Technology Research Institute Seoul National University Hospital Seoul South Korea
- Institute of Reproductive Medicine and Population & Medical Big Data Research Center, Medical Research Center Seoul National University Seoul South Korea
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Jin Y, Shen L, Ye R, Zhou M, Guo X. Development and validation of a novel score for predicting perioperative major adverse cardiovascular events in patients with stable coronary artery disease undergoing noncardiac surgery. Int J Cardiol 2024; 405:131982. [PMID: 38521511 DOI: 10.1016/j.ijcard.2024.131982] [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: 12/01/2023] [Revised: 02/01/2024] [Accepted: 03/17/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND A model developed specifically for stable coronary artery disease (SCAD) patients to predict perioperative major adverse cardiovascular events (MACE) has not been previously reported. METHODS The derivation cohort consisted of 5780 patients with SCAD undergoing noncardiac surgery at the First Affiliated Hospital of Zhejiang University School of Medicine, from January 1, 2013 until May 31, 2021. The validation cohort consisted of 2677 similar patients from June 1, 2021 to May 31, 2023. The primary outcome was a composite of MACEs (death, resuscitated cardiac arrest, myocardial infarction, heart failure, and stroke) intraoperatively or during hospitalization postoperatively. RESULTS Six predictors, including Creatinine >90 μmol/L, Hemoglobin <110 g/L, Albumin <40 g/L, Leukocyte >10 ×109/L, high-risk Surgery (general abdominal or vascular), and American Society of Anesthesiologists (ASA) class (III or IV), were selected in the final model (CHALSA score). Each patient was assigned a CHALSA score of 0, 1, 2, 3, or > 3 according to the number of predictors present. The incidence of perioperative MACEs increased steadily across the CHALSA score groups in both the derivation (0.5%, 1.4%, 2.9%, 6.8%, and 23.4%, respectively; p < 0.001) and validation (0.3%, 1.5%, 4.1%, 9.2%, and 29.2%, respectively; p < 0.001) cohorts. The CHALSA score had a higher discriminatory ability than the revised cardiac risk index (C statistic: 0.827 vs. 0.695 in the validation dataset; p < 0.001). CONCLUSIONS The CHALSA score showed good validity in an external dataset and will be a valuable bedside tool to guide the perioperative management of patients with SCAD undergoing noncardiac surgery.
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Affiliation(s)
- Yunpeng Jin
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; Department of Cardiology, The Fourth Affiliated Hospital of School of Medicine, International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu 322000, China
| | - Liang Shen
- Department of Information Technology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Runze Ye
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Min Zhou
- Department of Information Technology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xiaogang Guo
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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Abdulmelik A, Tila M, Tekilu T, Debalkie A, Habtu E, Sintayehu A, Dendir G, Gordie N, Daniel A, Suleiman Obsa M. Magnitude and associated factors of intraoperative cardiac complications among geriatric patients who undergo non-cardiac surgery at public hospitals in the southern region of Ethiopia: a multi-center cross-sectional study in 2022/2023. Front Med (Lausanne) 2024; 11:1325358. [PMID: 38695033 PMCID: PMC11061426 DOI: 10.3389/fmed.2024.1325358] [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: 10/21/2023] [Accepted: 03/04/2024] [Indexed: 05/04/2024] Open
Abstract
Background Intraoperative cardiac complications are a common cause of morbidity and mortality in non-cardiac surgery. The risk of these complications increased with the average age increasing from 65. In a resource-limited setting, including our study area, the magnitude and associated factors of intraoperative cardiac complications have not been adequately investigated. The aim of this study was to assess the magnitude and associated factors of intraoperative cardiac complications among geriatric patients undergoing non-cardiac surgery. Methods An institutional-based multi-center cross-sectional study was conducted on 304 geriatric patients at governmental hospitals in the southern region of Ethiopia, from 20 March 2022 to 25 August 2022. Data were collected by chart review and patient interviews. Epi Data version 4.6 and SPSS version 25 were used for analysis. The variables that had association (p < 0.25) were considered for multivariable logistic regression. A p value < 0.05 was considered significant for association. Result The overall prevalence of intraoperative cardiac complications was 24.3%. Preoperative ST-segment elevation adjusted odds ratio (AOR = 2.43, CI =2.06-3.67), history of hypertension (AOR = 3.42, CI =2.02-6.08), intraoperative hypoxia (AOR = 3.5, CI = 2.07-6.23), intraoperative hypotension (AOR = 6.2 9, CI =3.51-10.94), age > 85 years (AOR = 6.01, CI = 5.12-12.21), and anesthesia time > 3 h (AOR =2.27, CI = 2.0.2-18.25) were factors significantly associated with intraoperative cardiac complications. Conclusion The magnitude of intraoperative cardiac complications was high among geriatric patients who had undergone non-cardiac surgery. The independent risk factors of intraoperative cardiac complications for this population included age > 85, ST-segment elevation, perioperative hypertension (stage 3 with regular treatment), duration of anesthesia >3 h, intraoperative hypoxia, and intraoperative hypotension. Holistic preoperative evaluation, optimization optimal and perioperative care for preventing perioperative risk factors listed above, and knowing all possible risk factors are suggested to reduce the occurrence of complications.
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Affiliation(s)
- Amina Abdulmelik
- School of Anesthesia, College of Health Science and Medicine, Wolaita Soddo University, Wolaita Soddo, Ethiopia
| | - Mebratu Tila
- School of Anesthesia, College of Health Science and Medicine, Wolaita Soddo University, Wolaita Soddo, Ethiopia
| | - Takele Tekilu
- School of Medical Laboratory, College of Medicine and Health Science, Wolaita Soddo University, Wolaita Soddo, Ethiopia
| | - Ashebir Debalkie
- School of Anesthesia, College of Health Science and Medicine, Wolaita Soddo University, Wolaita Soddo, Ethiopia
| | - Elias Habtu
- School of Anesthesia, College of Health Science and Medicine, Wolaita Soddo University, Wolaita Soddo, Ethiopia
| | - Ashagrie Sintayehu
- School of Anesthesia, College of Health Science and Medicine, Wolaita Soddo University, Wolaita Soddo, Ethiopia
| | - Getahun Dendir
- School of Anesthesia, College of Health Science and Medicine, Wolaita Soddo University, Wolaita Soddo, Ethiopia
| | - Naol Gordie
- School of Anesthesia, College of Health Science and Medicine, Wolaita Soddo University, Wolaita Soddo, Ethiopia
| | - Abel Daniel
- School of Medicine, College of Medicine and Health Science, Wolaita Soddo University, Wolaita Soddo, Ethiopia
| | - Mohammed Suleiman Obsa
- Department of Anesthesia, College of Medicine and Health Science, Arsi University, Assela, Ethiopia
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Ran S, Wang Z, Fu M, Hou Z. Characteristics of Postoperative Heart Failure in Older Hip Fractures Patients Combined with Coronary Heart Disease and Construction of a Prediction Model of Nomogram, a Retrospective Cohort Study. Clin Interv Aging 2024; 19:599-610. [PMID: 38617097 PMCID: PMC11012631 DOI: 10.2147/cia.s450590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Older patients combined with coronary heart disease (CHD) develop acute heart failure (AHF) after hip fracture surgery is common, and this study aimed to investigate the risk factors of postoperative AHF in older hip fracture patients and to construct a nomogram prediction model. Methods We retrospectively collected older hip fracture patients with CHD who underwent hip fracture surgery at the Third Hospital of Hebei Medical University from January 2017 to December 2021. We divided them into a training set and a validation set. We collected the demographic data, laboratory indicators and imaging examination results. We identified risk factors for postoperative AHF and used R language software to establish a nomogram prediction model, plot ROC curves, calibration curves and DCA decision curves. Results We retrospectively collected 1288 older hip fractures patients with CHD. After excluding 214 patients who did not meet the criteria, 1074 patients were included in our research and we divided them into the training set and the validation set. In the training set, a total of 346 (42.8%) patients developing postoperative AHF. Through univariate and multivariate logistic regression analysis, we identified the risk factors for postoperative AHF and constructed a nomogram prediction model. The AUC of the prediction model is 0.778. The correction curve shows that the model has good consistency. The decision curve analysis shows that the model has good clinical practicality. Conclusion There were 42.8% older patients combined with CHD develop postoperative AHF. Among them, fracture type, age, anemia at admission, combined with COPD, ASA ≥ 3, and preoperative waiting time >3 days are risk factors for postoperative AHF. We constructed a nomogram prediction model that can effectively predict the risk of postoperative AHF in older hip fracture patients combined with CHD.
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Affiliation(s)
- Saidi Ran
- Department of Geriatric Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
| | - Zhiqian Wang
- Department of Geriatric Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
| | - Mingming Fu
- Department of Geriatric Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
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Zhang K, Liu C, Sha X, Yao S, Li Z, Yu Y, Lou J, Fu Q, Liu Y, Cao J, Zhang J, Yang Y, Mi W, Li H. Development and validation of a prediction model to predict major adverse cardiovascular events in elderly patients undergoing noncardiac surgery: A retrospective cohort study. Atherosclerosis 2023; 376:71-79. [PMID: 37315395 DOI: 10.1016/j.atherosclerosis.2023.06.008] [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: 12/12/2022] [Revised: 06/04/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND AIMS Current existing predictive tools have limitations in predicting major adverse cardiovascular events (MACEs) in elderly patients. We will build a new prediction model to predict MACEs in elderly patients undergoing noncardiac surgery by using traditional statistical methods and machine learning algorithms. METHODS MACEs were defined as acute myocardial infarction (AMI), ischemic stroke, heart failure and death within 30 days after surgery. Clinical data from 45,102 elderly patients (≥65 years old), who underwent noncardiac surgery from two independent cohorts, were used to develop and validate the prediction models. A traditional logistic regression and five machine learning models (decision tree, random forest, LGBM, AdaBoost, and XGBoost) were compared by the area under the receiver operating characteristic curve (AUC). In the traditional prediction model, the calibration was assessed using the calibration curve and the patients' net benefit was measured by decision curve analysis (DCA). RESULTS Among 45,102 elderly patients, 346 (0.76%) developed MACEs. The AUC of this traditional model was 0.800 (95% CI, 0.708-0.831) in the internal validation set, and 0.768 (95% CI, 0.702-0.835) in the external validation set. In the best machine learning prediction model-AdaBoost model, the AUC in the internal and external validation set was 0.778 and 0.732, respectively. Besides, for the traditional prediction model, the calibration curve of model performance accurately predicted the risk of MACEs (Hosmer and Lemeshow, p = 0.573), the DCA results showed that the nomogram had a high net benefit for predicting postoperative MACEs. CONCLUSIONS This prediction model based on the traditional method could accurately predict the risk of MACEs after noncardiac surgery in elderly patients.
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Affiliation(s)
- Kai Zhang
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Chang Liu
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiaoling Sha
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Siyi Yao
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhao Li
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yao Yu
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jingsheng Lou
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Qiang Fu
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yanhong Liu
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiangbei Cao
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yitian Yang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Weidong Mi
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
| | - Hao Li
- Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China; Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
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Zhang Z, Dong J, Lin F, Wang Q, Xu Z, He X, Yang S, Li Y, Liu L, Zhang C, Liu Z, Zhao Y, Yang H, Peng S. Hotspots and difficulties of biliary surgery in older patients. Chin Med J (Engl) 2023; 136:1037-1046. [PMID: 37052140 PMCID: PMC10228479 DOI: 10.1097/cm9.0000000000002589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Indexed: 04/14/2023] Open
Abstract
ABSTRACT With the accelerated aging society in China, the incidence of biliary surgical diseases in the elderly has increased significantly. The clinical characteristics of these patients indicate that improving treatment outcomes and realizing healthy aging are worthy of attention. How to effectively improve the treatment effect of geriatric biliary surgical diseases has attracted widespread attention. This paper reviews and comments on the hotspots and difficulties of biliary surgery in older patients from six aspects: (1) higher morbidity associated with an aging society, (2) prevention and control of pre-operative risks, (3) extending the indications of laparoscopic surgery, (4) urgent standardization of minimally invasive surgery, (5) precise technological progress in hepatobiliary surgery, and (6) guarantee of peri-operative safety. It is of great significance to fully understand the focus of controversy, actively make use of its favorable factors, and effectively avoid its unfavorable factors, for further improving the therapeutic effects of geriatric biliary surgical diseases, and thus benefits the vast older patients with biliary surgical diseases. Accordingly, a historical record with the highest age of 93 years for laparoscopic transcystic common bile duct exploration has been created by us recently.
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Affiliation(s)
- Zongming Zhang
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Jiahong Dong
- Department of Hepatopancreatobiliary Surgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing 102218, China
| | - Fangcai Lin
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Qiusheng Wang
- Department of General Surgery, Peking University People's Hospital, Beijing 100044, China
| | - Zhi Xu
- Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Xiaodong He
- Department of General Surgical, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Shizhong Yang
- Department of Hepatopancreatobiliary Surgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing 102218, China
| | - Youwei Li
- Department of Radiology, Beijing Rehabilitation Hospital, Capital Medical University, Beijing 100144, China
| | - Limin Liu
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Chong Zhang
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Zhuo Liu
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Yue Zhao
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Haiyan Yang
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Shuyou Peng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China
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Cai J, Tang M, Wu H, Yuan J, Liang H, Wu X, Xing S, Yang X, Duan XD. Association of intraoperative hypotension and severe postoperative complications during non-cardiac surgery in adult patients: A systematic review and meta-analysis. Heliyon 2023; 9:e15997. [PMID: 37223701 PMCID: PMC10200862 DOI: 10.1016/j.heliyon.2023.e15997] [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: 11/19/2022] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/25/2023] Open
Abstract
Background Intraoperative hypotension (IOH) is a common side effect of non-cardiac surgery that might induce poor postoperative outcomes. The relationship between the IOH and severe postoperative complications is still unclear. Thus, we summarized the existing literature to evaluate whether IOH contributes to developing severe postoperative complications during non-cardiac surgery. Methods We conducted a comprehensive search of PubMed, Embase, Cochrane Library, Web of Science, and the CBM from inception to 15 September 2022. The primary outcomes were 30-day mortality, acute kidney injury (AKI), major adverse cardiac events (myocardial injury or myocardial infarction), postoperative cognitive dysfunction (POCD), and postoperative delirium (POD). Secondary outcomes included surgical-site infection (SSI), stroke, and 1-year mortality. Results 72 studies (3 randomized; 69 non-randomized) were included in this study. Low-quality evidence showed IOH resulted in an increased risk of 30-day mortality (OR, 1.85; 95% CI, 1.30-2.64; P < .001), AKI (OR, 2.69; 95% CI, 2.15-3.37; P < .001), and stroke (OR, 1.33; 95% CI, 1.21-1.46; P < .001) after non-cardiac surgery than non-IOH. Very low-quality evidence showed IOH was associated with a higher risk of myocardial injury (OR, 2.00; 95% CI, 1.17-3.43; P = .01), myocardial infarction (OR, 2.11; 95% CI, 1.41-3.16; P < .001), and POD (OR, 2.27; 95% CI, 1.53-3.38; P < .001). Very low-quality evidence showed IOH have a similar incidence of POCD (OR, 2.82; 95% CI, 0.83-9.50; P = .10) and 1-year-mortality (OR, 1.66; 95% CI, 0.65-4.20; P = .29) compared with non-IOH in non-cardiac surgery. Conclusion Our results suggest IOH was associated with an increased risk of severe postoperative complications after non-cardiac surgery than non-IOH. IOH is a potentially avoidable hazard that should be closely monitored during non-cardiac surgery.
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Affiliation(s)
- Jianghui Cai
- Department of Pharmacy, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Mi Tang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
- Office of Good Clinical Practice, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Huaye Wu
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Jing Yuan
- Department of Information, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, 611731, China
| | - Hua Liang
- Department of Pharmacy, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xuan Wu
- Department of Epidemiology and Biostatistics and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Shasha Xing
- Office of Good Clinical Practice, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xiao Yang
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xiao-Dong Duan
- Department of Rehabilitation Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
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Lin DY, Woodman R, Oberai T, Brown B, Morrison C, Kroon H, Jaarsma R. Association of anesthesia and analgesia with long-term mortality after hip fracture surgery: an analysis of the Australian and New Zealand hip fracture registry. Reg Anesth Pain Med 2022; 48:14-21. [DOI: 10.1136/rapm-2022-103550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 09/13/2022] [Indexed: 11/04/2022]
Abstract
IntroductionHip fractures are a common frailty injury affecting a vulnerable geriatric population. It is debated if anesthetic and analgesic techniques are associated with altered risk for outcomes in hip fracture patients. This study aimed to determine the association of anesthesia and regional analgesia with all cause 12-month mortality and even longer-term mortality after hip fracture surgery in Australia and New Zealand.MethodsData from the Australian and New Zealand Hip Fracture Registry collected from 2016 to 2018, with a minimum follow-up of 12 months, were reviewed. Anesthesia type and use of regional nerve blocks were investigated. The primary outcome was all cause 12-month mortality.Results12-month mortality was 30.6% (n=5410) in a total of 17,635 patients. There was no difference in 12-month mortality between patients who received spinal or general anesthesia (p=0.238). The administration of a combination of general and spinal anesthesia for surgery to repair the fracture was an independent predictor of higher 12-month mortality (unadjusted complete case HR=1.17 (95% CI 1.04 to 1.31); p<0.001). Nerve blocks performed in both the emergency department (ED) and the operating theater (OT) were associated with reduced long-term mortality (median follow-up 21 months) with an unimputed unadjusted HR=0.86 (95% CI 0.77 to 0.96; p=0.043).ConclusionThere was no difference in the association of 12-month mortality between general and spinal anesthesia in patients undergoing hip fracture surgery. However, there was an association with a higher risk of 12-month mortality in patients who received both general and spinal anesthesia for the same surgery. Patients who received a regional nerve block in both the ED and the OT had a lower association of 12-month and longer-term mortality risk. The reasons for these findings remain unknown and should be the subject of further research investigation.
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Zhang ZM, Xie XY, Zhao Y, Zhang C, Liu Z, Liu LM, Zhu MW, Wan BJ, Deng H, Tian K, Guo ZT, Zhao XZ. Critical values of monitoring indexes for perioperative major adverse cardiac events in elderly patients with biliary diseases. World J Clin Cases 2022; 10:6865-6875. [PMID: 36051111 PMCID: PMC9297436 DOI: 10.12998/wjcc.v10.i20.6865] [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: 01/23/2022] [Revised: 04/06/2022] [Accepted: 05/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Major adverse cardiac events (MACE) in elderly patients with biliary diseases are the main cause of perioperative accidental death, but no widely recognized quantitative monitoring index of perioperative cardiac function so far.
AIM To investigate the critical values of monitoring indexes for perioperative MACE in elderly patients with biliary diseases.
METHODS The clinical data of 208 elderly patients with biliary diseases in our hospital from May 2016 to April 2021 were retrospectively analysed. According to whether MACE occurred during the perioperative period, they were divided into the MACE group and the non-MACE group.
RESULTS In the MACE compared with the non-MACE group, postoperative complications, mortality, hospital stay, high sensitivity troponin-I (Hs-TnI), creatine kinase isoenzyme (CK-MB), myoglobin (MYO), B-type natriuretic peptide (BNP), and D-dimer (D-D) levels were significantly increased (P < 0.05). Multivariate logistic regression showed that postoperative BNP and D-D were independent risk factors for perioperative MACE, and their cut-off values in the receiver operating characteristic (ROC) curve were 382.65 pg/mL and 0.965 mg/L, respectively.
CONCLUSION The postoperative BNP and D-D were independent risk factors for perioperative MACE, with the critical values of 382.65 pg/mL and 0.965 mg/L respectively. Consequently, timely monitoring and effective maintenance of perioperative cardiac function stability are of great clinical significance to further improve the perioperative safety of elderly patients with biliary diseases.
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Affiliation(s)
- Zong-Ming Zhang
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Xi-Yuan Xie
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Yue Zhao
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Chong Zhang
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Zhuo Liu
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Li-Min Liu
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Ming-Wen Zhu
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Bai-Jiang Wan
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Hai Deng
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Kun Tian
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Zhen-Tian Guo
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Xi-Zhe Zhao
- Department of Cardiology, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
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10
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The Effect of Intermittent versus Continuous Non-Invasive Blood Pressure Monitoring on the Detection of Intraoperative Hypotension, a Sub-Study. J Clin Med 2022; 11:jcm11144083. [PMID: 35887844 PMCID: PMC9321987 DOI: 10.3390/jcm11144083] [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: 05/30/2022] [Revised: 06/26/2022] [Accepted: 07/01/2022] [Indexed: 02/01/2023] Open
Abstract
Intraoperative hypotension is associated with postoperative complications. However, in the majority of surgical patients, blood pressure (BP) is measured intermittently with a non-invasive cuff around the upper arm (NIBP-arm). We hypothesized that NIBP-arm, compared with a non-invasive continuous alternative, would result in missed events and in delayed recognition of hypotensive events. This was a sub-study of a previously published cohort study in adult patients undergoing surgery. The detection of hypotension (mean arterial pressure below 65 mmHg) was compared using two non-invasive methods; intermittent oscillometric NIBP-arm versus continuous NIBP measured with a finger cuff (cNIBP-finger) (Nexfin, Edwards Lifesciences). cNIBP-finger was used as the reference standard. Out of 350 patients, 268 patients (77%) had one or more hypotensive events during surgery. Out of the 286 patients, 72 (27%) had one or more missed hypotensive events. The majority of hypotensive events (92%) were detected with NIBP-arm, but were recognized at a median of 1.2 (0.6–2.2) minutes later. Intermittent BP monitoring resulted in missed hypotensive events and the hypotensive events that were detected were recognized with a delay. This study highlights the advantage of continuous monitoring. Future studies are needed to understand the effect on patient outcomes.
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11
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Weinberg L, Li SY, Louis M, Karp J, Poci N, Carp BS, Miles LF, Tully P, Hahn R, Karalapillai D, Lee DK. Reported definitions of intraoperative hypotension in adults undergoing non-cardiac surgery under general anaesthesia: a review. BMC Anesthesiol 2022; 22:69. [PMID: 35277122 PMCID: PMC8915500 DOI: 10.1186/s12871-022-01605-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 02/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background Intraoperative hypotension (IOH) during non-cardiac surgery is common and associated with major adverse kidney, neurological and cardiac events and even death. Given that IOH is a modifiable risk factor for the mitigation of postoperative complications, it is imperative to generate a precise definition for IOH to facilitate strategies for avoiding or treating its occurrence. Moreover, a universal and consensus definition of IOH may also facilitate the application of novel and emerging therapeutic interventions in treating IOH. We conducted a review to systematically record the reported definitions of intraoperative hypotension in adults undergoing non-cardiac surgery under general anaesthesia. Methods In accordance with Cochrane guidelines, we searched three online databases (OVID [Medline], Embase and Cochrane Library) for all studies published from 1 January 2000 to 6 September 2020. We evaluated the number of studies that reported the absolute or relative threshold values for defining blood pressure. Secondary aims included evaluation of the threshold values for defining IOH, the methodology for accounting for the severity of hypotension, whether the type of surgical procedure influenced the definition of IOH, and whether a study whose definition of IOH aligned with the Perioperative Quality Initiative-3 workgroup (POQI) consensus statement for defining was more likely to be associated with determining an adverse postoperative outcome. Results A total of 318 studies were included in the final qualitative synthesis. Most studies (n = 249; 78.3%) used an absolute threshold to define hypotension; 150 (60.5%) reported SBP, 117 (47.2%) reported MAP, and 12 (4.8%) reported diastolic blood pressure (DBP). 126 (39.6%) used a relative threshold to define hypotension. Of the included studies, 153 (48.1%) did not include any duration variable in their definition of hypotension. Among the selected 318 studies 148 (46.5%) studies defined IOH according to the POQI statement. When studies used a “relative blood pressure change” to define IOH, there was a weaker association in detecting adverse postoperative outcomes compared to studies who reported “absolute blood pressure change” (χ2(2) = 10.508, P = 0.005, Cramér’s V = 0.182). When studies used the POQI statement definition of hypotension or defined IOH by values higher than the POQI statement definition there were statistical differences observed between IOH and adverse postoperative outcomes (χ2(1) = 6.581, P = 0.037, Cramér’s V = 0.144). When both the duration of IOH or the numbers of hypotensive epochs were evaluated, we observed a significantly stronger relationship between the definition of IOH use the development of adverse postoperative outcomes. (χ2(1) = 4.860, P = 0.027, Cramér’s V = 0.124). Conclusions Most studies defined IOH by absolute or relative changes from baseline values. There are substantial inconsistencies in how IOH was reported. Further, definitions differed across different surgical specialities. Our findings further suggest that IOH should be defined using the absolute values stated in the POQI statement i.e., MAP < 60–70 mmHg or SBP < 100 mmHg. Finally, the number of hypotensive epochs or time-weighted duration of IOH should also be reported. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01605-9.
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12
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Feng C, Ye Y, Wang T, Xiong H. Association Between Hemoglobin and Major Adverse Cardiac Events: A Secondary Analysis from a Retrospective Cohort Study. Am J Med Sci 2021; 363:151-160. [PMID: 34302773 DOI: 10.1016/j.amjms.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 02/16/2021] [Accepted: 07/09/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND This study aims to investigate the association between hemoglobin and major adverse cardiac events (MACE) in patients with stable coronary artery disease (CAD) who were treated with percutaneous coronary intervention (PCI). METHODS This was a secondary analysis based on a retrospective cohort study involving 204 patients with stable CAD. Patients were divided into four groups according to hemoglobin levels (Q1: 6.90-12.30 g/dL; Q2: 12.40-13.80 g/dL; Q3: 13.90-14.90 g/dL; Q4: 15.00-19.00 g/dL). Lasso regression analysis was performed to select characteristic variables and reduce dimensions. Odds ratio (OR) and 95% confidence interval (CI) were used for comparing data among groups. RESULTS After an average follow-up of 783 days, 28/204 (17.72%) patients with CAD occurred MACE. Univariate analysis data showed that hemoglobin level was negatively associated with the incidence of MACE in patients with CAD treated with PCI (Q2 vs Q1: OR=0.19, P=0.005; Q3 vs Q1: OR=0.25, P=0.013; Q4 vs Q1: OR=0.13, P=0.002). The negative correlation between hemoglobin and MACE still existed after adjusting selected variables obtained from multivariate regression analysis (Q2 vs Q1: OR= 0.18, P=0.007; Q3 vs Q1: OR=0.29, P=0.038; Q4 vs Q1: OR=0.19, P=0.016). Curve fitting illustrated that hemoglobin level presented a non-linear and negative association with MACE in patients with CAD treated with PCI. CONCLUSIONS Hemoglobin level can be utilized as a prognostic indicator of MACE in patients with CAD after PCI.
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Affiliation(s)
- Caiyun Feng
- Department of Nursing, People's Hospital of Longhua Shenzhen, Shenzhen, China
| | - Yongxiu Ye
- Department of Nursing, People's Hospital of Longhua Shenzhen, Shenzhen, China
| | - Ting Wang
- Department of Nursing, People's Hospital of Longhua Shenzhen, Shenzhen, China
| | - Haiyan Xiong
- Department of Nursing, People's Hospital of Longhua Shenzhen, Shenzhen, China.
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13
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Wijnberge M, Schenk J, Bulle E, Vlaar AP, Maheshwari K, Hollmann MW, Binnekade JM, Geerts BF, Veelo DP. Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis. BJS Open 2021; 5:6073395. [PMID: 33609377 PMCID: PMC7893468 DOI: 10.1093/bjsopen/zraa018] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 09/07/2020] [Indexed: 12/21/2022] Open
Abstract
Background Intraoperative hypotension, with varying definitions in literature, may be associated with postoperative complications. The aim of this meta-analysis was to assess the association of intraoperative hypotension with postoperative morbidity and mortality. Methods MEDLINE, Embase and Cochrane databases were searched for studies published between January 1990 and August 2018. The primary endpoints were postoperative overall morbidity and mortality. Secondary endpoints were postoperative cardiac outcomes, acute kidney injury, stroke, delirium, surgical outcomes and combined outcomes. Subgroup analyses, sensitivity analyses and a meta-regression were performed to test the robustness of the results and to explore heterogeneity. Results The search identified 2931 studies, of which 29 were included in the meta-analysis, consisting of 130 862 patients. Intraoperative hypotension was associated with an increased risk of morbidity (odds ratio (OR) 2.08, 95 per cent confidence interval 1.56 to 2.77) and mortality (OR 1.94, 1.32 to 2.84). In the secondary analyses, intraoperative hypotension was associated with cardiac complications (OR 2.44, 1.52 to 3.93) and acute kidney injury (OR 2.69, 1.31 to 5.55). Overall heterogeneity was high, with an I2 value of 88 per cent. When hypotension severity, outcome severity and study population variables were added to the meta-regression, heterogeneity was reduced to 50 per cent. Conclusion Intraoperative hypotension during non-cardiac surgery is associated with postoperative cardiac and renal morbidity, and mortality. A universally accepted standard definition of hypotension would facilitate further research into this topic.
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Affiliation(s)
- M Wijnberge
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - J Schenk
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - E Bulle
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - A P Vlaar
- Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - K Maheshwari
- Department of General Anaesthesiology, Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - M W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - J M Binnekade
- Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - B F Geerts
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - D P Veelo
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
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14
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Liu Z, Xu G, Xu L, Zhang Y, Huang Y. Perioperative Cardiac Complications in Patients Over 80 Years of Age with Coronary Artery Disease Undergoing Noncardiac Surgery: The Incidence and Risk Factors. Clin Interv Aging 2020; 15:1181-1191. [PMID: 32801670 PMCID: PMC7398882 DOI: 10.2147/cia.s252160] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/26/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Ever-increasing noncardiac surgeries are performed in patients aged 80 years or over with coronary artery disease (CAD). The objective of the study was to explore the incidence and risk factors of perioperative cardiac complications (PCCs) for the oldest-old patients with CAD undergoing noncardiac surgery, which have not been evaluated previously. Patients and Methods A total of 547 patients, aged over 80 years, with a history of CAD who underwent noncardiac surgery were enrolled in this retrospective study. Perioperative clinical variables were extracted from the electronic medical records database. The primary outcome was the occurrence of PCCs intraoperatively or within 30 days postoperatively, defined as any of the following complications: acute coronary syndrome, heart failure, new-onset severe arrhythmia, nonfatal cardiac arrest, and cardiac death. Multivariate logistic regression analysis and multivariate Cox regression model were both performed to estimate the risk factors of PCCs. The incidence of PCCs overtime was illustrated by the Kaplan-Meier curve with a stratified Log-rank test. Results One hundred six (19.4%) patients developed at least one PCC, and 15 (2.7%) patients developed cardiac death. The independent risk factors contributing to PCCs were age ≧85 years; body mass index ≧30 kg/m2; the history of angina within 6 months; metabolic equivalents <4; hypertension without regular treatment; preoperative ST-T segment abnormality; anesthesia time >3 h and drainage ≧200 mL within 24 h postoperatively. Conclusion The incidence of PCCs in elderly patients over 80 years with CAD who underwent noncardiac surgery was high. Comprehensive preoperative evaluation, skilled surgical technique, and regular postoperative monitoring may help to reduce the occurrence of PCCs in this high-risk population.
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Affiliation(s)
- Zijia Liu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Guangyan Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Yuelun Zhang
- Central Research Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
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15
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Cengic S, Zuberi M, Bansal V, Ratzlaff R, Rodrigues E, Festic E. Hypotension after intensive care unit drop-off in adult cardiac surgery patients. World J Crit Care Med 2020; 9:20-30. [PMID: 32577413 PMCID: PMC7298587 DOI: 10.5492/wjccm.v9.i2.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 05/08/2020] [Accepted: 05/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypotension is a frequent complication in the intensive care unit (ICU) after adult cardiac surgery.
AIM To describe frequency of hypotension in the ICU following adult cardiac surgery and its relation to the hospital outcomes.
METHODS A retrospective study of post-cardiac adult surgical patients at a tertiary academic medical center in a two-year period. We abstracted baseline demographics, comorbidities, and all pertinent clinical variables. The primary predictor variable was the development of hypotension within the first 30 min upon arrival to the ICU from the operating room (OR). The primary outcome was hospital mortality, and other outcomes included duration of mechanical ventilation (MV) in hours, and ICU and hospital length of stay in days.
RESULTS Of 417 patients, more than half (54%) experienced hypotension within 30 min upon arrival to the ICU. Presence of OR hypotension immediately prior to ICU transfer was significantly associated with ICU hypotension (odds ratio = 1.9; 95% confidence interval: 1.21-2.98; P < 0.006). ICU hypotensive patients had longer MV, 5 (interquartile ranges 3, 15) vs 4 h (interquartile ranges 3, 6), P = 0.012. The patients who received vasopressor boluses (n = 212) were more likely to experience ICU drop-off hypotension (odds ratio = 1.45, 95% confidence interval: 0.98-2.13; P = 0.062), and they experienced longer MV, ICU and hospital length of stay (P < 0.001, for all).
CONCLUSION Hypotension upon anesthesia-to-ICU drop-off is more frequent than previously reported and may be associated with adverse clinical outcomes.
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Affiliation(s)
- Sabina Cengic
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
- Department of General Surgery, Stadtspital Triemli, Zurich 8063, Switzerland
| | - Muhammad Zuberi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Vikas Bansal
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Robert Ratzlaff
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Eduardo Rodrigues
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Emir Festic
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
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16
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Liu SH, Xue FS, Hou HJ. Determining predictive value of VESPA score for postoperative mortality and morbidity in older cancer patients. J Geriatr Oncol 2020; 11:1335-1336. [PMID: 32247665 DOI: 10.1016/j.jgo.2020.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Shao-Hua Liu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Fu-Shan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China.
| | - Hai-Jun Hou
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
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17
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Wijnberge M, Geerts BF, Hol L, Lemmers N, Mulder MP, Berge P, Schenk J, Terwindt LE, Hollmann MW, Vlaar AP, Veelo DP. Effect of a Machine Learning-Derived Early Warning System for Intraoperative Hypotension vs Standard Care on Depth and Duration of Intraoperative Hypotension During Elective Noncardiac Surgery: The HYPE Randomized Clinical Trial. JAMA 2020; 323:1052-1060. [PMID: 32065827 PMCID: PMC7078808 DOI: 10.1001/jama.2020.0592] [Citation(s) in RCA: 248] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Intraoperative hypotension is associated with increased morbidity and mortality. A machine learning-derived early warning system to predict hypotension shortly before it occurs has been developed and validated. OBJECTIVE To test whether the clinical application of the early warning system in combination with a hemodynamic diagnostic guidance and treatment protocol reduces intraoperative hypotension. DESIGN, SETTING, AND PARTICIPANTS Preliminary unblinded randomized clinical trial performed in a tertiary center in Amsterdam, the Netherlands, among adult patients scheduled for elective noncardiac surgery under general anesthesia and an indication for continuous invasive blood pressure monitoring, who were enrolled between May 2018 and March 2019. Hypotension was defined as a mean arterial pressure (MAP) below 65 mm Hg for at least 1 minute. INTERVENTIONS Patients were randomly assigned to receive either the early warning system (n = 34) or standard care (n = 34), with a goal MAP of at least 65 mm Hg in both groups. MAIN OUTCOMES AND MEASURES The primary outcome was time-weighted average of hypotension during surgery, with a unit of measure of millimeters of mercury. This was calculated as the depth of hypotension below a MAP of 65 mm Hg (in millimeters of mercury) × time spent below a MAP of 65 mm Hg (in minutes) divided by total duration of operation (in minutes). RESULTS Among 68 randomized patients, 60 (88%) completed the trial (median age, 64 [interquartile range {IQR}, 57-70] years; 26 [43%] women). The median length of surgery was 256 minutes (IQR, 213-430 minutes). The median time-weighted average of hypotension was 0.10 mm Hg (IQR, 0.01-0.43 mm Hg) in the intervention group vs 0.44 mm Hg (IQR, 0.23-0.72 mm Hg) in the control group, for a median difference of 0.38 mm Hg (95% CI, 0.14-0.43 mm Hg; P = .001). The median time of hypotension per patient was 8.0 minutes (IQR, 1.33-26.00 minutes) in the intervention group vs 32.7 minutes (IQR, 11.5-59.7 minutes) in the control group, for a median difference of 16.7 minutes (95% CI, 7.7-31.0 minutes; P < .001). In the intervention group, 0 serious adverse events resulting in death occurred vs 2 (7%) in the control group. CONCLUSIONS AND RELEVANCE In this single-center preliminary study of patients undergoing elective noncardiac surgery, the use of a machine learning-derived early warning system compared with standard care resulted in less intraoperative hypotension. Further research with larger study populations in diverse settings is needed to understand the effect on additional patient outcomes and to fully assess safety and generalizability. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03376347.
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Affiliation(s)
- Marije Wijnberge
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Bart F. Geerts
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Liselotte Hol
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Nikki Lemmers
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Marijn P. Mulder
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
- Department of Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Patrick Berge
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Jimmy Schenk
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Lotte E. Terwindt
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Alexander P. Vlaar
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Denise P. Veelo
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
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18
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Wijnberge M, Schenk J, Terwindt LE, Mulder MP, Hollmann MW, Vlaar AP, Veelo DP, Geerts BF. The use of a machine-learning algorithm that predicts hypotension during surgery in combination with personalized treatment guidance: study protocol for a randomized clinical trial. Trials 2019; 20:582. [PMID: 31601239 PMCID: PMC6788048 DOI: 10.1186/s13063-019-3637-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/08/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Intraoperative hypotension is associated with increased morbidity and mortality. Current treatment is mostly reactive. The Hypotension Prediction Index (HPI) algorithm is able to predict hypotension minutes before the blood pressure actually decreases. Internal and external validation of this algorithm has shown good sensitivity and specificity. We hypothesize that the use of this algorithm in combination with a personalized treatment protocol will reduce the time weighted average (TWA) in hypotension during surgery spent in hypotension intraoperatively. METHODS/DESIGN We aim to include 100 adult patients undergoing non-cardiac surgery with an anticipated duration of more than 2 h, necessitating the use of an arterial line, and an intraoperatively targeted mean arterial pressure (MAP) of > 65 mmHg. This study is divided into two parts; in phase A baseline TWA data from 40 patients will be collected prospectively. A device (HemoSphere) with HPI software will be connected but fully covered. Phase B is designed as a single-center, randomized controlled trial were 60 patients will be randomized with computer-generated blocks of four, six or eight, with an allocation ratio of 1:1. In the intervention arm the HemoSphere with HPI will be used to guide treatment; in the control arm the HemoSphere with HPI software will be connected but fully covered. The primary outcome is the TWA in hypotension during surgery. DISCUSSION The aim of this trial is to explore whether the use of a machine-learning algorithm intraoperatively can result in less hypotension. To test this, the treating anesthesiologist will need to change treatment behavior from reactive to proactive. TRIAL REGISTRATION This trial has been registered with the NIH, U.S. National Library of Medicine at ClinicalTrials.gov, ID: NCT03376347 . The trial was submitted on 4 November 2017 and accepted for registration on 18 December 2017.
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Affiliation(s)
- M Wijnberge
- Department of Anesthesiology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, The Netherlands
| | - J Schenk
- Department of Anesthesiology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, The Netherlands
| | - L E Terwindt
- Department of Anesthesiology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, The Netherlands
| | - M P Mulder
- Department of Anesthesiology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, The Netherlands.,Department of Technical Medicine, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands
| | - M W Hollmann
- Department of Anesthesiology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, The Netherlands
| | - A P Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, The Netherlands
| | - D P Veelo
- Department of Anesthesiology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, The Netherlands.
| | - B F Geerts
- Department of Anesthesiology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, The Netherlands
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Yu HY, Ahn EK, Seo EJ. Relationship between the frequency of nursing activities and adverse outcomes in patients with acute coronary syndrome: A retrospective cohort study. Nurs Health Sci 2019; 21:531-537. [PMID: 31523893 DOI: 10.1111/nhs.12645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 07/22/2019] [Accepted: 08/06/2019] [Indexed: 11/28/2022]
Abstract
The aim of this retrospective cohort study was to identify the relationship between the frequency of nursing activities during the first hospitalization and adverse outcomes in patients with acute coronary syndrome by using electronic health records. Patients diagnosed with acute coronary syndrome from April 2010 to April 2015 were examined for eligibility based on 36 months of major adverse cardiac events as the main outcome. Among the 652 patients who were enrolled, 66 patients experienced major adverse cardiac events. The average frequency of nursing activities was 1098.7 (±2703.8), and four variables (length of hospital stay, albumin level, hemoglobin level, and frequency of nursing activities) were significantly associated with 36 months of major adverse cardiac events. After adjusting for these variables, the frequency of nursing activities was found to be the only significant factor associated with the incidence of 36 months of major adverse cardiac events. This finding suggests that patients with acute coronary syndrome who require more frequent nursing activities during the first hospitalization could be vulnerable to adverse outcomes and should be closely monitored.
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Affiliation(s)
- Hye Yon Yu
- Department of Nursing, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Eun Kyoung Ahn
- Department of Nursing Science, Dongyang University, Yeongju, Korea
| | - Eun Ji Seo
- College of Nursing and Research Institute of Nursing Science, Ajou University, Suwon, Korea
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Zhou Y, Liu L, Cheng T, Wang DX, Yang HY, Zhang BW, Yang Y, Chen F, Li XY. Grade 3 Echocardiographic Diastolic Dysfunction Is Associated With Increased Risk of Major Adverse Cardiovascular Events After Surgery: A Retrospective Cohort Study. Anesth Analg 2019; 129:651-658. [PMID: 31425203 PMCID: PMC6693928 DOI: 10.1213/ane.0000000000003807] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Diastolic dysfunction is common and may increase the risk of cardiovascular complications. This study investigated the hypothesis that, in patients with isolated left ventricular diastolic dysfunction, higher grade diastolic dysfunction was associated with greater risk of major adverse cardiovascular events (MACEs) after surgery. METHODS This was a retrospective cohort study. Data of adult patients with isolated echocardiographic diastolic dysfunction (ejection fraction, ≥50%) who underwent noncardiac surgery from January 1, 2015 to December 31, 2015 were collected. The primary end point was the occurrence of postoperative MACEs during hospital stay, which included acute myocardial infarction, congestive heart failure, stroke, nonfatal cardiac arrest, and cardiac death. The association between the grade of diastolic dysfunction and the occurrence of MACEs was assessed with a multivariable logistic model. RESULTS A total of 2976 patients were included in the final analysis. Of these, 297 (10.0%) developed MACEs after surgery. After correction for confounding factors, grade 3 diastolic dysfunction was associated with higher risk of postoperative MACEs (odds ratio, 1.71; 95% confidence interval, 1.28-2.27; P < .001) when compared with grades 1 and 2. Patients with grade 3 diastolic dysfunction developed more non-MACE complications when compared with grades 1 and 2 (uncorrected odds ratio, 1.44; 95% confidence interval, 1.07-1.95; P = .017). CONCLUSIONS In patients with isolated diastolic dysfunction undergoing noncardiac surgery, 10.0% develop MACEs during hospital stay after surgery; grade 3 diastolic dysfunction is associated with greater risk of MACEs.
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Affiliation(s)
- Yan Zhou
- From the Departments of Anesthesiology and Critical Care Medicine
| | | | - Tong Cheng
- From the Departments of Anesthesiology and Critical Care Medicine
| | - Dong-Xin Wang
- From the Departments of Anesthesiology and Critical Care Medicine
| | | | | | | | | | - Xue-Ying Li
- Biostatistics, Peking University First Hospital, Beijing, China
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21
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Zainudheen A, Scott IA, Caney X. Association of renin angiotensin antagonists with adverse perioperative events in patients undergoing elective orthopaedic surgery: a case-control study. Intern Med J 2018; 47:999-1005. [PMID: 28509399 DOI: 10.1111/imj.13487] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 04/30/2017] [Accepted: 05/09/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Renin angiotensin antagonists (RAA) may block protective vasopressor responses during surgery. Evidence linking RAA with intraoperative hypotension and perioperative adverse events is conflicting. AIM To compare the incidence of intraoperative hypotension and adverse events between patients receiving or not receiving RAA. METHODS This is a retrospective case-control study of 258 consecutive patients who underwent elective total knee or hip replacement between 1 January 2013 and 31 August 2016 and who were chronically prescribed a single blood pressure-lowering agent up to the time of surgery. Primary outcome measures were differences between patients receiving RAA (cases; n = 129) and patients receiving non-RAA medications (controls; n = 129) in incidence of intraoperative hypotension (systolic blood pressure <90 mmHg), perioperative acute kidney injury (AKI, >30% increase in serum creatinine from baseline on Day 1 post-operatively) and new onset major adverse cardiac or cerebrovascular events (MACCE) or in-hospital death over 72 h post-operatively. RESULTS Patients receiving RAA had significantly higher preoperative systolic blood pressure, greater prevalence of hypertension and chronic kidney disease, lower prevalence of ischaemic heart disease and lower cardiac risk compared to controls. Age, gender, type of operation, operative fitness, mode and duration of anaesthesia and prevalence of other types of cardiovascular disease, dyslipidaemia and diabetes were similar between groups. Compared to controls, patients receiving RAA had higher incidence of intraoperative hypotension (76.0 vs 45.9%, P < 0.001), AKI (11.6 vs 1.6%, P = 0.002) and MACCE (6.2 vs 0%, P = 0.007), with all adverse events associated with intraoperative hypotension. CONCLUSION This study provides further observational evidence of RAA-induced harm in patients undergoing elective surgery, although determining benefits and harms of preoperative withdrawal of RRA requires prospective randomised trials.
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Affiliation(s)
- Amith Zainudheen
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Xenia Caney
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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22
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Matsuo M, Yamagami T, Higuchi A. Impact of age on postoperative complication rates among elderly patients with hip fracture: a retrospective matched study. J Anesth 2018; 32:452-456. [PMID: 29663067 DOI: 10.1007/s00540-018-2494-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 04/12/2018] [Indexed: 12/18/2022]
Abstract
This study was performed to assess the impact of age of ≥ 90 years on predicting postoperative complications. We retrospectively identified all patients aged ≥ 65 years who underwent surgical repair of hip fractures over a 4.5-year period in our hospital. In total, 261 patients were identified (mean age, 86.2 ± 6.8 years). Ninety-one patients were aged ≥ 90 years (oldest-old group), and the remaining 170 were aged < 89 years (control old group). Postoperative complications developed in 54 of 261 patients (20.7%). The oldest-old group had a significantly higher proportion of patients with a Japanese long-term care insurance need level and trochanteric fracture than the control group. Spinal anesthesia was more frequently performed in the oldest-old group. After propensity adjustment for these characteristics, postoperative complication rates in the oldest-old group remained significantly higher than those in the matched control group (odds ratio (OR) 2.76, 95% confidence interval (95% CI) 1.24-6.49; P = 0.011). Major complications also developed more frequently in the oldest-old group than control group (OR 9.78, 95% CI 1.31-4.36; P = 0.018). Anesthesiologists and surgeons should pay attention to potential complications following hip fracture surgery for patients aged ≥ 90 years regardless of American Society of Anesthesiologists class or social dependency.
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Affiliation(s)
- Mitsuhiro Matsuo
- Department of Anesthesiology, Itoigawa General Hospital, 457-1 Takegahana, Itoigawa, Niigata, 941-8502, Japan.
| | - Tohru Yamagami
- Department of Orthopedic Surgery, Itoigawa General Hospital, Itoigawa, Niigata, Japan
| | - Akiko Higuchi
- Department of Anesthesiology, Itoigawa General Hospital, 457-1 Takegahana, Itoigawa, Niigata, 941-8502, Japan
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Abstract
PURPOSE OF REVIEW Coronary artery event includes acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery. Following such an event, risk of noncardiac surgery is increased. Of major concern is what can make this surgery safer? RECENT FINDINGS High functional capacity improves cardiovascular (CV) risk; at least 4.0 metabolic equivalents (METs) on stress test are favorable. Risk scores can suggest need for further evaluation. Coronary angiography prior to surgery usually is not indicated since revascularization shows disappointing CV risk reduction results. Due to high association of peripheral arterial disease (PAD) with coronary artery disease (CAD), low ankle-brachial index (ABI) indicates increased CV risk. New perioperative beta blockade has shown disappointing benefit, but if ongoing should be continued. De novo perioperative beta blockade is for the highest CV risk patient undergoing noncardiac vascular surgery. Good evidence supports CV risk reduction from new or existing statin in the perioperative period, especially for the diabetic. Diabetics should also be on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) secondarily, during the perioperative period to decrease 30-day perioperative mortality. Optimal timing of elective noncardiac surgery following a coronary artery event appears to be 180 days with CV risk decreased by a statin and an ACEI or an ARB.
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Affiliation(s)
- Thomas F Whayne
- Gill Heart and Vascular Institute, University of Kentucky, 326 Wethington Building, 900 South Limestone Street, Lexington, KY, 40536-0200, USA.
| | - Sibu P Saha
- Gill Heart and Vascular Institute, University of Kentucky, 326 Wethington Building, 900 South Limestone Street, Lexington, KY, 40536-0200, USA
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Che L, Xu L, Huang Y, Yu C. Clinical utility of the revised cardiac risk index in older Chinese patients with known coronary artery disease. Clin Interv Aging 2018; 13:35-41. [PMID: 29317808 PMCID: PMC5743178 DOI: 10.2147/cia.s144832] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives The revised Cardiac Risk Index (RCRI) is the most widely used risk prediction tool for postoperative cardiac adverse events. We aim to explore the predictive ability of the RCRI in older Chinese patients with coronary artery disease (CAD) undergoing noncardiac surgery, which has not been previously evaluated. Methods We performed a multicenter, prospective study. We enrolled a total of 1,202 patients, aged >60 years, with a history of CAD who underwent noncardiac surgery. Perioperative data were extracted from an electronic database. The primary end point was defined as an occurrence of a postoperative major cardiac event (PoMCE) within 30 days. Logistic regression analysis was performed to evaluate the performance of the RCRI. A modified RCRI was created and compared with the original RCRI with regard to its ability to predict postoperative cardiac events. Results Of the enrolled patients, 4.3% experienced PoMCE. Most components of the RCRI were not predictive of postoperative cardiac events with the exception of insulin-dependent diabetes mellitus (odds ratio =2.38, 95% CI: 1.11-5.11; P=0.03). The RCRI performed no better than chance (area under the curve =0.53; 95% CI: 0.45-0.61) in identifying patients' cardiac risk. The modified score had a higher discriminatory ability toward PoMCE (c index, 0.69 versus 0.53; P<0.01). Conclusion The original RCRI shows poor predictive ability in Chinese patients with CAD undergoing noncardiac surgery.
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Affiliation(s)
- Lu Che
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Chunhua Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
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Development of a new risk nomogram of perioperative major adverse cardiac events for Chinese patients undergoing colorectal carcinoma surgery. Int J Colorectal Dis 2017; 32:1157-1164. [PMID: 28526942 DOI: 10.1007/s00384-017-2812-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study is to create a new risk nomogram to predict perioperative major adverse cardiac events in patients undergoing colorectal carcinoma surgery. METHODS A total of 1899 patients who underwent colorectal carcinoma surgery at a tertiary teaching hospital in China between 2007 and 2012 were recruited. Logistic regression analysis was used to define risk factors for major adverse cardiac events. A nomogram-predicting model was built based on the logistic regression model and discrimination was tested by receiver operating characteristic curves. RESULTS Fifty-six (2.9%) among 1899 included patients developed at least one cardiac event. Eight risk factors were found in the multivariate logistic regression model, which included age ≥60 years, smoking, a history of chronic kidney disease, coronary artery disease, congestive heart failure, hypertension, preoperative albumin levels ≤35 g/L, blood transfusion ≥500 mL, and intraoperative blood pressure variability. P = 0.708 in the Hosmer-Lemeshow test indicated acceptable calibration power. Based on this multivariate model, we built a risk nomogram model for these cardiac events with an area under the curve (95% confidence interval) of 0.923 (0.889, 0.957), which demonstrated good discrimination of this model. When the probability cutoff was 1.9% (total score of 83), the nomogram model had the best sensitivity and specificity in predicting cardiac events. CONCLUSIONS A new nomogram model for predicting perioperative major adverse cardiac events in patients who had colorectal carcinoma surgery was established in this study. When the total score is >83, patients undergoing colorectal carcinoma surgery should be considered at high risk of perioperative major adverse cardiac events.
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Wang L, Yu J, Fordjour PA, Xing X, Gao H, Li Y, Li L, Zhu Y, Gao X, Fan G. Danshen injection prevents heart failure by attenuating post-infarct remodeling. JOURNAL OF ETHNOPHARMACOLOGY 2017; 205:22-32. [PMID: 28465251 DOI: 10.1016/j.jep.2017.04.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 04/16/2017] [Accepted: 04/26/2017] [Indexed: 06/07/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Danshen Injection (DSI) is a traditional Chinese medicine extracted from Danshen, prepared from the dried root and rhizome of Salvia miltiorrhiza Bunge. Danshen is an ancient antipyretic traditional Chinese medicine which is mostly used to improve blood circulation and dispel blood stasis. Danshen decoction or liquor-fried Danshen (with grain-based liquor) which is cool in nature is traditionally used to 'cool the blood' and reduce the swelling of sores and abscesses. AIM OF STUDY The present study aimed to examine the effect and mechanism of DSI in LAD induced heart injury. MATERIALS AND METHODS One day after LAD surgery, adult male Sprague-Dawley rats were randomized to 3 groups: MI group; DSI group (1.5ml/kg/d, intramuscular); and Valsartan group (10mg/kg/d, intragastric). Echocardiography and hemodynamic measurements (Pressure-Volume loop) were performed to evaluate cardiac function. Pathological methods (Masson, and Sirus red staining) were used to check myocardial fibrosis. Western blotting assay was used to detect the protein expression of MMP-2. RT-PCR was used to detect the gene expression of MMP-9, MPO, iNOS, Bcl-2 and Bax. RESULTS DSI administration to LAD rats resulted in improved cardiac functions, hemodynamic parameters and normalized ventricular mass. Furthermore, DSI-treated group demonstrated potential regulation of myocardial collagen I and III deposition associated with MMP-2 expression. Also, DSI administration decreased gene expression of iNOS, MPO and MMP-9, and increased Bcl-2/Bax ratio. CONCLUSION Myocardial fibrosis, cardiac hypertrophy, hemodynamic deterioration as well as systolic and diastolic dysfunctions which characterize a failing hearts were significantly prevented by DSI. Our study may provide future directions to focus on the anti-hypertrophic mechanisms of DSI and pathological roles played by MMP-2 in myocardial hypertrophy. Meanwhile, DSI also performed the effect of anti-inflammation by the way of decreasing iNOS and MPO. The way Danshen Injection increasing Bcl-2/Bax presented the possibility that it may has the effect of inhibiting cell death.
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Affiliation(s)
- Lingyan Wang
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of traditional Chinese Medicine, Tianjin, PR China.
| | - Jiahui Yu
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of traditional Chinese Medicine, Tianjin, PR China.
| | - Patrick Asare Fordjour
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of traditional Chinese Medicine, Tianjin, PR China.
| | - Xiaoxue Xing
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of traditional Chinese Medicine, Tianjin, PR China.
| | - Hui Gao
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of traditional Chinese Medicine, Tianjin, PR China.
| | - Yanyan Li
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of traditional Chinese Medicine, Tianjin, PR China.
| | - Lingyan Li
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of traditional Chinese Medicine, Tianjin, PR China.
| | - Yan Zhu
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of traditional Chinese Medicine, Tianjin, PR China.
| | - Xiumei Gao
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of traditional Chinese Medicine, Tianjin, PR China; State Key Laboratory of Modern Chinese Medicine, Ministry of Education Key Laboratory of Pharmacology of Traditional Chinese Medical Formulae, Tianjin University of Traditional Medicine, Nankai District, Tianjin, PR China.
| | - Guanwei Fan
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of traditional Chinese Medicine, Tianjin, PR China; Medical Experiment Center, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, NanKai District, Tianjin, PR China.
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Yang H, Fayad A, Chaput A, Oake S, Chan ADC, Crossan ML. Postoperative real-time electrocardiography monitoring detects myocardial ischemia: a case report. Can J Anaesth 2017; 64:411-415. [DOI: 10.1007/s12630-017-0817-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 11/23/2016] [Accepted: 01/01/2017] [Indexed: 11/29/2022] Open
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Tsai IT, Wang CP, Lu YC, Hung WC, Wu CC, Lu LF, Chung FM, Hsu CC, Lee YJ, Yu TH. The burden of major adverse cardiac events in patients with coronary artery disease. BMC Cardiovasc Disord 2017; 17:1. [PMID: 28052754 PMCID: PMC5210314 DOI: 10.1186/s12872-016-0436-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 12/07/2016] [Indexed: 12/30/2022] Open
Abstract
Background Patients with a history of cardiovascular disease are at high risk of developing secondary major adverse cardiac events (MACE). This study aimed to identify independent predictors of MACE after hospital admission which could be used to identify of high-risk patients who may benefit from preventive strategies. Methods This study included 1,520 consecutive patients with coronary artery disease (CAD) (654 with acute coronary syndrome (ACS) and 866 with elective percutaneous coronary intervention (PCI) patients) who received PCI and/or stenting. MACE was defined as all-cause mortality or rehospitalization for a cardiovascular- related illness. Cardiovascular-related illnesses included heart failure, reinfarction (nonfatal), recurrence of angina pectoris and repeat PCI or coronary artery bypass graft. Results During a mean follow-up period of 32 months, 558 of the 1,520 patients developed at least one MACE. Cox regression analysis showed that the baseline clinical and biochemical variables which associated with MACE were age, being illiterate, a widow or widower, and/or economically dependent, having triple vessel disease, stent implantation, anemia, and/or diabetes mellitus, waist to hip ratio (WHR), diastolic blood pressure, fasting glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-C), creatinine, estimated glomerular filtration rate (eGFR), red blood cell count, hemoglobin, hematocrit, and mean corpuscular-hemoglobin concentration (MCHC) in ACS patients, and age, malnourished, and/or economically dependent, taking hypoglycemic medication, having triple vessel disease, stent implantation, anemia, diabetes mellitus, and/or hypertension, WHR, fasting glucose, HDL-C, uric acid, creatinine, eGFR, high-sensitivity C-reactive protein, mean corpuscular volume, and MCHC in elective PCI patients. Using multivariate Cox regression analysis, we found the MACE’s independent factors are triple vessel disease, stent implantation, hypertension, and eGFR in ACS patients, and having triple vessel disease, stent implantation, hypertension, and uric acid in elective PCI patients. Conclusions Having triple vessel disease, stent implantation, hypertension, and eGFR or uric acid independently predicted MACE in patients with CAD after long-term follow-up. Fortunately, these factors are modifiable and should be identified and monitored early.
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Affiliation(s)
- I-Ting Tsai
- Department of Emergency, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan.,Department of Nursing, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Chao-Ping Wang
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan.,School of Medicine for International Students, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Yung-Chuan Lu
- Division of Endocrinology and Metabolism, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan.,School of Medicine for International Students, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Wei-Chin Hung
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan
| | - Cheng-Ching Wu
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan.,Department of Biomedical Engineering, National Cheng Kung University, Tainan, 70101, Taiwan
| | - Li-Fen Lu
- Division of Cardiac Surgery, Department of Surgery, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Fu-Mei Chung
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan
| | - Chia-Chang Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | | | - Teng-Hung Yu
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan.
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Abstract
Although anesthesia-associated mortality has been significantly reduced down to 0.00068-0.00082% over the last decades, recent studies have revealed a high perioperative mortality of 0.8- 4%. Apart from anesthesia and surgery-induced major complications, perioperative mortality is primarily negatively influenced by individual patient comorbidities. These risk factors predispose for acute critical incidents (e.g., myocardial infarction); however, the majority of fatal complications are a result of slowly progressing conditions, particularly infections or the sequelae of systemic inflammation. This implicates a broad window of opportunity for the detection and treatment of slow-onset complications to improve the perioperative outcome. The term "failure to rescue" (FTR), i.e., the proportion of patients who die from major complications compared to the number of all patients with complications, has been introduced as a valid indicator for the quality of perioperative care. Growing evidence has already shown that FTR is an underestimated factor in perioperative medicine accounting for or at least being involved in the development of postoperative mortality. While the incidence of severe postoperative complications amazingly does not show much variation between hospitals, FTR shows significant differences implying a major potential for improvement. With 14 million surgical procedures per year in Germany, a postoperative mortality of approximately 1% and an avoidable FTR rate of 40% mean that there are an estimated 60,000 preventable deaths per year. Hence, in the future it will be imperative to (1) identify patients at risk, (2) to prevent the development of postoperative complications with the use of adequate adjunctive therapeutic strategies, (3) to establish surveillance and monitoring systems for the early detection of postoperative complications and (4) to treat postoperative complications efficiently and in time when they arise.
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Affiliation(s)
- O Boehm
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - M K A Pfeiffer
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - G Baumgarten
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - A Hoeft
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland.
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Kendale SM, Blitz JD. Increasing body mass index and the incidence of intraoperative hypoxemia. J Clin Anesth 2016; 33:97-104. [PMID: 27555141 DOI: 10.1016/j.jclinane.2016.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/08/2016] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Obese patients regularly present for surgery and have greater hypoxemia risk. This study aimed to identify the risk and incidence of intraoperative hypoxemia with increasing body mass index (BMI). DESIGN This was a retrospective cohort study. SETTING Operating room. PATIENTS A total of 15,238 adult patients who underwent general anesthesia for elective noncardiac surgery at a single large urban academic institution between January 2013 and December 2014. INTERVENTIONS Unadjusted and risk-adjusted logistic regression analyses explored the relationship between increasing categories of BMI and intraoperative hypoxemia, severe hypoxemia, and prolonged hypoxemia. MEASUREMENTS Intraoperative pulse oximeter readings and preoperative patient characteristics. MAIN RESULTS With normal BMI, 731 (16%) patients experienced hypoxemia compared with 1150 (28%) obese patients. Adjusted odds ratio (AOR) of intraoperative hypoxemia increased with each category of BMI from 1.27 (95% confidence interval [CI], 1.12-1.44) in overweight patients to 2.63 (95% CI, 2.15-3.23) in patients with class III obesity. AOR of severe hypoxemia was significant with class I obesity (AOR, 1.32; 95% CI, 1.08-1.60), class II obesity (AOR, 2.01; 95% CI, 1.59-2.81), and class III obesity (AOR, 2.27; 95% CI, 1.75-2.93). AOR of prolonged hypoxemia increased with BMI from 3.29 (95% CI, 1.79-6.23) with class I obesity to 9.20 (95% CI, 4.74-18) with class III obesity. CONCLUSIONS Despite existing practices to limit hypoxemia in obese patients, the odds of experiencing intraoperative hypoxemia increase significantly with increasing categories of BMI. Further practices may need to be developed to minimize the risk of intraoperative hypoxemia in obese patients.
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Affiliation(s)
- Samir M Kendale
- Department of Anesthesiology, Perioperative Care, & Pain Medicine, New York University School of Medicine, 550 First Ave, New York, NY 10016.
| | - Jeanna D Blitz
- Department of Anesthesiology, Perioperative Care, & Pain Medicine, New York University School of Medicine, 550 First Ave, New York, NY 10016
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31
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García PS, Duggan EW, McCullough IL, Lee SC, Fishman D. Postanesthesia Care for the Elderly Patient. Clin Ther 2015; 37:2651-65. [PMID: 26598176 DOI: 10.1016/j.clinthera.2015.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/20/2015] [Accepted: 10/21/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE As the general population lives longer, the perioperative physician is more likely to encounter disease states that increase in incidence in an aging population. This review focuses on anesthetic considerations for rational drug choices during the perioperative care of elderly patients. The primary aim of the review was to identify intraoperative and postanesthetic considerations for diseases associated with advancing age; it includes highlights of the commonly impaired major organs (eg, cardiovascular, pulmonary, neurologic, renal, hepatic systems). We also outline an approach to frequent issues that arise in the immediate postsurgical period while caring for these patients. METHODS A systematic review was performed on aspects of the perioperative and postoperative periods that relate to the elderly. A list of pertinent key words was derived from the authors, and a PubMed database search was performed. FINDINGS The anesthesiologist must account for changes in various organ systems that affect perioperative care, including the cardiovascular, pulmonary, renal, hepatic, and central nervous systems. The pharmacokinetic principles frequently differ and are often unpredictable because of anatomic changes and decreased renal and hepatic function. The most important pharmacodynamic consideration is that elderly patients tend to exhibit an exaggerated hypoactivity after anesthesia. IMPLICATIONS Before surgery, it is essential to identify those patients at risk for delirium and other commonly encountered postanesthesia scenarios. Failure to manage these conditions appropriately can lead to an escalation of care and prolonged hospitalization.
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Affiliation(s)
- Paul S García
- US Department of Veterans Affairs, Atlanta VA Medical Center, Decatur, Georgia; Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.
| | - Elizabeth W Duggan
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ian L McCullough
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Simon C Lee
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - David Fishman
- US Department of Veterans Affairs, Atlanta VA Medical Center, Decatur, Georgia; Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
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