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Mol KHJM, Liem VGB, van Lier F, Stolker RJ, Hoeks SE. Intraoperative hypotension in noncardiac surgery patients with chronic beta-blocker therapy: A matched cohort analysis. J Clin Anesth 2023; 89:111143. [PMID: 37216803 DOI: 10.1016/j.jclinane.2023.111143] [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: 09/06/2022] [Revised: 04/19/2023] [Accepted: 05/01/2023] [Indexed: 05/24/2023]
Abstract
STUDY OBJECTIVE To explore the incidence of intraoperative hypotension in patients with chronic beta-blocker therapy, expressed as time spent, area and time-weighted average under predefined mean arterial pressure thresholds. DESIGN Retrospective analysis of a prospective observational cohort registry. SETTING Patients ≥60 years undergoing intermediate- to high-risk noncardiac surgery with routine postoperative troponin measurements on the first three days after surgery. PATIENTS 1468 matched sets of patients (1:1 ratio with replacement) with and without chronic beta-blocker treatment. INTERVENTIONS None. MEASUREMENTS The primary outcome was the exposure to intraoperative hypotension in beta-blocker users vs. non-users. Time spent, area and time-weighted average under predefined mean arterial pressure thresholds (55-75 mmHg) were calculated to express the duration and severity of exposure. Secondary outcomes included incidence of postoperative myocardial injury and thirty-day mortality, myocardial infarction (MI) and stroke. Furthermore, analyses for patient subgroup and beta-blocker subtype were conducted. MAIN RESULTS In patients with chronic beta-blocker therapy, no increased exposure to intraoperative hypotension was observed for all characteristics and thresholds calculated (all P > .05). Beta-blocker users had lower heart rate before, during and after surgery (70 vs. 74, 61 vs. 65 and 68 vs. 74 bpm, all P < .001, respectively). Postoperative myocardial injury (13.6% vs. 11.6%, P = .269) and thirty-day mortality (2.5% vs. 1.4%, P = .055), MI (1.4% vs. 1.5%, P = .944) and stroke (1.0% vs 0.7%, P = .474) rates were comparable. The results were consistent in subtype and subgroup analyses. CONCLUSIONS In this matched cohort analysis, chronic beta-blocker therapy was not associated with increased exposure to intraoperative hypotension in patients undergoing intermediate- to high-risk noncardiac surgery. Furthermore, differences in patient subgroups and postoperative adverse cardiovascular events as a function of treatment regimen could not be demonstrated.
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Affiliation(s)
- Kristin H J M Mol
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Victor G B Liem
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Felix van Lier
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Robert Jan Stolker
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Sanne E Hoeks
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
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2
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Lin JJ, Conroy PC, Romero-Hernandez F, Yilma M, Feng J, Hirose K, Nakakura E, Maker AV, Corvera C, Kirkwood K, Alseidi A, Adam MA. Hypertension Requiring Medication Use: a Silent Predictor of Poor Outcomes After Pancreaticoduodenectomy. J Gastrointest Surg 2023; 27:328-336. [PMID: 36624324 DOI: 10.1007/s11605-022-05577-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/17/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although hypertension requiring medication (HTNm) is a well-known cardiovascular comorbidity, its association with postoperative outcomes is understudied. This study aimed to evaluate whether preoperative HTNm is independently associated with specific complications after pancreaticoduodenectomy. STUDY DESIGN Adults undergoing elective pancreaticoduodenectomy were included from the 2014-2019 NSQIP-targeted pancreatectomy dataset. Multivariable regression models compared outcomes between patients with and without HTNm. Endpoints included significant complications, any complication, unplanned readmissions, length of stay (LOS), clinically relevant postoperative pancreatic fistula (CR-POPF), and cardiovascular and renal complications. A subgroup analysis excluded patients with diabetes, heart failure, chronic obstructive pulmonary disease, estimated glomerular filtration rate from serum creatinine (eGFRCr) < 60 ml/min per 1.73 m2, bleeding disorder, or steroid use. RESULTS Among 14,806 patients, 52% had HTNm. HTNm was more common among older male patients with obesity, diabetes, congestive heart failure, chronic obstructive pulmonary disease, functional dependency, hard pancreatic glands, and cancer. After adjusting for demographics, preoperative comorbidities, and laboratory values, HTNm was independently associated with higher odds of significant complications (aOR 1.12, p = 0.020), any complication (aOR 1.11, p = 0.030), cardiovascular (aOR 1.78, p = 0.002) and renal (aOR 1.60, p = 0.020) complications, and unplanned readmissions (aOR 1.14, p = 0.040). In a subgroup analysis of patients without major preoperative comorbidity, HTNm remained associated with higher odds of significant complications (aOR 1.14, p = 0.030) and cardiovascular complications (aOR 1.76, p = 0.033). CONCLUSIONS HTNm is independently associated with cardiovascular and renal complications after pancreaticoduodenectomy and may need to be considered in preoperative risk stratification. Future studies are necessary to explore associations among underlying hypertension, specific antihypertensive medications, and postoperative outcomes to investigate potential risk mitigation strategies.
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Affiliation(s)
- Jackie J Lin
- School of Medicine, University of California, San Francisco, San Francisco, USA
| | - Patricia C Conroy
- Department of Surgery, University of California, San Francisco, San Francisco, USA
| | | | - Mignote Yilma
- Department of Surgery, University of California, San Francisco, San Francisco, USA
- National Clinician Scholars Program, University of California, San Francisco, San Francisco, USA
| | - Jean Feng
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, USA
| | - Kenzo Hirose
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Eric Nakakura
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Carlos Corvera
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Kimberly Kirkwood
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Adnan Alseidi
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Mohamed A Adam
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA.
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3
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Johnson S, Haywood C. Perioperative medication management for older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Samuel Johnson
- Aged Care Services, Austin Health Heidelberg Repatriation Hospital Heidelberg Heights Australia
| | - Cilla Haywood
- Aged Care Services, Austin Health Heidelberg Repatriation Hospital Heidelberg Heights Australia
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Song Q, Li J, Jiang Z. Provisional Decision-Making for Perioperative Blood Pressure Management: A Narrative Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5916040. [PMID: 35860431 PMCID: PMC9293529 DOI: 10.1155/2022/5916040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
Blood pressure (BP) is a basic determinant for organ blood flow supply. Insufficient blood supply will cause tissue hypoxia, provoke cellular oxidative stress, and to some extent lead to organ injury. Perioperative BP is labile and dynamic, and intraoperative hypotension is common. It is unclear whether there is a causal relationship between intraoperative hypotension and organ injury. However, hypotension surely compromises perfusion and causes harm to some extent. Because the harm threshold remains unknown, various guidelines for intraoperative BP management have been proposed. With the pending definitions from robust randomized trials, it is reasonable to consider observational analyses suggesting that mean arterial pressures below 65 mmHg sustained for more than 15 minutes are associated with myocardial and renal injury. Advances in machine learning and artificial intelligence may facilitate the management of hemodynamics globally, including fluid administration, rather than BP alone. The previous mounting studies concentrated on associations between BP targets and adverse complications, whereas few studies were concerned about how to treat and multiple factors for decision-making. Hence, in this narrative review, we discussed the way of BP measurement and current knowledge about baseline BP extracting for surgical patients, highlighted the decision-making process for BP management with a view to providing pragmatic guidance for BP treatment in the clinical settings, and evaluated the merits of an automated blood control system in predicting hypotension.
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Affiliation(s)
- Qiliang Song
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Jipeng Li
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Zongming Jiang
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
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Choi SU, Rho JH, Choi YJ, Jun SW, Shin YJ, Lee YS, Shin HJ, Lim CH, Shin HW, Kim JH, Lee HW, Lim HJ. Postoperative hypoalbuminemia is an independent predictor of 1-year mortality after surgery for geriatric intertrochanteric femoral fracture: A retrospective cohort study. Medicine (Baltimore) 2021; 100:e28306. [PMID: 34941120 PMCID: PMC8701452 DOI: 10.1097/md.0000000000028306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/26/2021] [Indexed: 01/05/2023] Open
Abstract
Preoperative hypoalbuminemia from malnutrition is associated with increased morbidity and mortality after geriatric hip fracture surgery. However, little is known regarding the correlation between postoperative hypoalbuminemia and mortality. This study aimed to evaluate whether postoperative hypoalbuminemia could predict 1-year mortality after intertrochanteric femoral fracture surgery in elderly patients.The medical records of 263 geriatric patients (age ≥65 years) who underwent intertrochanteric femoral fracture surgery between January 2013 and January 2016 in a single hospital were reviewed retrospectively. The patients were allocated to 2 groups based on lowest serum albumin levels within 2 postoperative days (≥3.0 g/dL [group 1, n = 46] and <3.0 g/dL [group 2, n = 217]. Data between the non-survival and survival groups were compared. Multivariable logistic regression analysis was conducted to identify the independent predictor for 1-year mortality.The 1-year mortality rate was 16.3% after intertrochanteric femoral fracture surgery. Multivariable logistic regression analysis revealed that postoperative hypoalbuminemia was significantly associated with 1-year mortality (adjusted odds ratio, 8.03; 95% confidence interval, 1.37-47.09; P = .021). The non-survival group showed a significantly increased incidence of postoperative hypoalbuminemia (95.4% vs 80.0%, P = .015) and intensive care unit admission (11.6% vs 2.7%, P = .020), older age (82.5 ± 5.8 years vs 80.0 ± 7.2 years, P = .032), lower body mass index (20.1 ± 3.2 kg/m2 vs 22.4 ± 3.8 kg/m2, P < .001), and increased amount of transfusion of perioperative red blood cells (1.79 ± 1.47 units vs 1.43 ± 2.08 units, P = .032), compared to the survival group.This study demonstrated that postoperative hypoalbuminemia is a potent predictor of 1-year mortality in geriatric patients undergoing intertrochanteric femoral fracture surgery. Therefore, exogenous albumin administration can be considered to improve postoperative outcomes and reduce the risk of mortality after surgery for geriatric hip fracture.
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Affiliation(s)
- Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Jeong Ho Rho
- Department of Anesthesiology and Pain Medicine, Okcheon St. Mary’ Hospital, Chungcheongbuk-do, Republic of Korea
| | - Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine, Ansan Hospital, College of Medicine, Korea University, Ansan, Republic of Korea
| | - Seung Woo Jun
- Department of Anesthesiology and Pain Medicine, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Young Jae Shin
- Department of Anesthesiology and Pain Medicine, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Yoon Sook Lee
- Department of Anesthesiology and Pain Medicine, Ansan Hospital, College of Medicine, Korea University, Ansan, Republic of Korea
| | - Hyeon Ju Shin
- Department of Anesthesiology and Pain Medicine, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Choon Hak Lim
- Department of Anesthesiology and Pain Medicine, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Hye Won Shin
- Department of Anesthesiology and Pain Medicine, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Jae Hwan Kim
- Department of Anesthesiology and Pain Medicine, Ansan Hospital, College of Medicine, Korea University, Ansan, Republic of Korea
| | - Hye Won Lee
- Department of Anesthesiology and Pain Medicine, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Hye Ja Lim
- Department of Anesthesiology and Pain Medicine, Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
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Foëx P, Sear JW. Implications for perioperative practice of changes in guidelines on the management of hypertension: challenges and opportunities. Br J Anaesth 2021; 127:335-340. [PMID: 34127253 DOI: 10.1016/j.bja.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/20/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Pierre Foëx
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK.
| | - John W Sear
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
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Bhatia K, Narasimhan B, Aggarwal G, Hajra A, Itagi S, Kumar S, Chakraborty S, Patel N, Jain V, Bandyopadhyay D, Amgai B, Aronow WS. Perioperative pharmacotherapy to prevent cardiac complications in patients undergoing noncardiac surgery. Expert Opin Pharmacother 2020; 22:755-767. [PMID: 33350868 DOI: 10.1080/14656566.2020.1856368] [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] [Indexed: 12/22/2022]
Abstract
Introduction: Despite advances in surgical and anesthetic techniques, perioperative cardiovascular complications are a major cause of 30-day perioperative mortality. Major cardiovascular complications after noncardiac surgery include myocardial ischemia, congestive heart failure, arrhythmias, and cardiac arrest. Along with surgical risk assessment, perioperative medical optimization can reduce the rates and clinical impact of these complications.Areas Covered: In this review, the authors discuss the pharmacological basis, existing evidence, and professional society recommendations for drug management in preventing cardiovascular complications in patients undergoing noncardiac surgery.Expert opinion: Perioperative management of cardiovascular disease is an increasingly important and growing area of clinical practice. Societal guidelines regarding the use of most routine cardiovascular medications are based on a number of large clinical studies and provide a basic foundation to guide management. However, the heterogeneous nature of patients, as well as surgeries, makes it practically impossible to devise a 'one size fits all' recommendation in this setting. Thus, the importance of a more individualized approach to perioperative risk stratification and management is being increasingly recognized. The underlying comorbidities and cardiac profile as well as the risk of cardiac complications associated with the planned surgery must be factored in to understand the nuance of the management strategies.
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Affiliation(s)
- Kirtipal Bhatia
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | - Bharat Narasimhan
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | | | - Adrija Hajra
- Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Soumya Itagi
- PSG Institute of Medical Sciences and Research, Coimbatore, India
| | - Shathish Kumar
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | | | | | - Dhrubajyoti Bandyopadhyay
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | | | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Robert D. Sanders, B.Sc., M.B.B.S., Ph.D., F.R.C.A., Recipient of the 2020 James E. Cottrell, M.D., Presidential Scholar Award. Anesthesiology 2020; 133:720-723. [DOI: 10.1097/aln.0000000000003512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Nan Y, Jia F, Du X, Mei Z. Beta-blocker exposure for short-term outcomes following non-cardiac surgery: A meta-analysis of observational studies. Int J Surg 2020; 76:153-162. [PMID: 32169568 DOI: 10.1016/j.ijsu.2020.02.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 01/07/2023]
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12
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Ratcliffe F, Rothwell PM. The case for statin use to reduce perioperative adverse cardiovascular and cerebrovascular events. Br J Anaesth 2020; 124:525-534. [PMID: 32111371 DOI: 10.1016/j.bja.2020.01.010] [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: 09/24/2019] [Revised: 01/12/2020] [Accepted: 01/24/2020] [Indexed: 12/11/2022] Open
Abstract
Ischaemic heart disease and stroke are the leading causes of death worldwide at 119 per 100,000 and 85 per 100,000 population. For the USA, heart disease is leading cause of death at 165 per 100,000 population. In developed countries, strokes and acute myocardial infarction in the general population have fallen from smoking reduction, lifestyle modifications and therapeutic interventions including statins. In a population-based stroke study in the UK involving primary care practices, of in-hospital strokes 90% were ischaemic, and 37% occurred within 1 week of an operation. Approximately 50% of the patients were not on a statin. In the UK, there is a national screening initiative for the prevention of atherosclerotic cardiovascular disease (ASCVD) offered to people aged 40-74 yr old. The QRISK3 tool calculates the risk of developing heart disease or stroke over 10 yr, from which recommendations are made on interventions for the prevention of ASCVD up to age 84 yr, with similar screening and assessment tools in Europe and the US. If the QRISK3 score tool for calculating cardiovascular risk is considered sufficiently robust for population screening in primary care, should anaesthetists not use the same screening for secondary care? We present a case for statin use over the perioperative period, to reduce early vascular adverse events based on statins' early pleiotropic actions, using the primary care QRISK tool for screening of ASCVD risk.
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Affiliation(s)
- Fiona Ratcliffe
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Abstract
PURPOSE OF REVIEW Hemodynamic instability is common in the perioperative period because of obligate physiologic changes that occur with surgery. Despite the frequency of such hemodynamic changes and the potential harm associated with them, particularly in the elderly, guidelines to optimize perioperative blood pressure are lacking. The present review examines recent evidence for perioperative blood pressure management in the elderly. RECENT FINDINGS Hypotension has been associated with poor outcomes, particularly renal injury, myocardial injury, and increased mortality, in the perioperative period. Hypertension, tachycardia, frequency of blood pressure monitoring, and management of chronic antihypertensive medications may also affect patient outcomes. Elderly patients may be especially prone to adverse events associated with perioperative hemodynamic instability. SUMMARY Precise and intentional management of hemodynamic parameters, medication regimens, and blood pressure monitoring may reduce adverse events in elderly patients undergoing surgery. Further investigation is required to identify the exact hemodynamic parameters that mitigate risk.
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Beattie WS, Yang H. Perioperative beta-adrenergic antagonism: panacea or poison? Br J Anaesth 2019; 123:97-100. [PMID: 31248641 DOI: 10.1016/j.bja.2019.05.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 05/16/2019] [Accepted: 05/26/2019] [Indexed: 01/24/2023] Open
Affiliation(s)
- W Scott Beattie
- University Health Network Department of Anesthesia and Pain Medicine, University of Toronto Department of Anesthesia, Toronto, ON, Canada.
| | - Homer Yang
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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