1
|
Vetsch T, Eggmann S, Jardot F, von Gernler M, Engel D, Beilstein CM, Wuethrich PY, Eser P, Wilhelm M. Ventilatory efficiency as a prognostic factor for postoperative complications in patients undergoing elective major surgery: a systematic review. Br J Anaesth 2024; 133:178-189. [PMID: 38644158 DOI: 10.1016/j.bja.2024.03.013] [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: 12/29/2023] [Revised: 03/08/2024] [Accepted: 03/16/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Major surgery is associated with high complication rates. Several risk scores exist to assess individual patient risk before surgery but have limited precision. Novel prognostic factors can be included as additional building blocks in existing prediction models. A candidate prognostic factor, measured by cardiopulmonary exercise testing, is ventilatory efficiency (VE/VCO2). The aim of this systematic review was to summarise evidence regarding VE/VCO2 as a prognostic factor for postoperative complications in patients undergoing major surgery. METHODS A medical library specialist developed the search strategy. No database-provided limits, considering study types, languages, publication years, or any other formal criteria were applied to any of the sources. Two reviewers assessed eligibility of each record and rated risk of bias in included studies. RESULTS From 10,082 screened records, 65 studies were identified as eligible. We extracted adjusted associations from 32 studies and unadjusted from 33 studies. Risk of bias was a concern in the domains 'study confounding' and 'statistical analysis'. VE/VCO2 was reported as a prognostic factor for short-term complications after thoracic and abdominal surgery. VE/VCO2 was also reported as a prognostic factor for mid- to long-term mortality. Data-driven covariable selection was applied in 31 studies. Eighteen studies excluded VE/VCO2 from the final multivariable regression owing to data-driven model-building approaches. CONCLUSIONS This systematic review identifies VE/VCO2 as a predictor for short-term complications after thoracic and abdominal surgery. However, the available data do not allow conclusions about clinical decision-making. Future studies should select covariables for adjustment a priori based on external knowledge. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022369944).
Collapse
Affiliation(s)
- Thomas Vetsch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - Sabrina Eggmann
- Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, Switzerland
| | - François Jardot
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc von Gernler
- Medical Library, University Library of Bern, University of Bern, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian M Beilstein
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prisca Eser
- Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Wilhelm
- Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
2
|
Bradley NA, McGovern J, Beecroft C, Roxburgh CSD, McMillan DC, Guthrie GJK. Cardiopulmonary exercise testing, computed tomography-derived body composition, systemic inflammation and survival after elective abdominal aortic aneurysm repair: A retrospective cohort study. Eur J Anaesthesiol 2024; 41:490-499. [PMID: 38757161 DOI: 10.1097/eja.0000000000002004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
BACKGROUND Cardio-pulmonary exercise testing (CPEX) is selectively used before intervention for abdominal aortic aneurysm (AAA). Sarcopenia, a chronic condition defined by reduced skeletal muscle function and volume, can be assessed radiologically by computed tomography (CT)-derived body composition analysis (CT-BC), and is associated with systemic inflammation. OBJECTIVE The aim was to describe the association between CT-BC, CPEX, inflammation and survival in patients undergoing elective intervention for AAA. SETTING Patients were recruited retrospectively from a single, secondary-care centre-operative database. Cases undergoing elective endovascular aneurysm repair (EVAR) and open surgical repair (OSR) between 31 March 2015 and 25 June 2020 were included. PATIENTS There were 176 patients (130 EVAR, 46 OSR) available for analysis in the final study; median (interquartile range [IQR]) follow-up was 60.5 [27] months, and all completed a minimum of 2 years follow-up. MAIN OUTCOME MEASURES Preoperative CPEX tests were recorded. CT sarcopenia score [CT-SS, range 0 to 2, calculated based on normal/low SMI (0/1) and normal/low SMD (0/1)] assessed radiological sarcopenia. Preoperative modified Glasgow Prognostic score (mGPS) was used to assess systemic inflammation. RESULTS Mean [95% confidence interval (CI) survival in the CT-SS 0 vs. CT-SS 1 vs. CT-SS 2 subgroups was 80.1 (73.6 to 86.6) months vs. 70.3 (63.5 to 77.1) months vs. 63.8 (53.4 to 74.2) months] ( P = 0.01). CT-SS was not associated with CPEX results ( P > 0.05). Elevated CT-SS [hazard ratio (HR) 1.83, 95% CI, 1.16 to 2.89, P < 0.01] was independently associated with increased hazard of long-term mortality; however, CPEX results were not ( P > 0.05). CONCLUSION CPEX test results were not consistently associated with body composition and did not have significant prognostic value in patients undergoing elective treatment for AAA.
Collapse
Affiliation(s)
- Nicholas A Bradley
- From the University of Glasgow, Glasgow (NAB, JM, CSDR, DCM, GJKG) and NHS Tayside, Dundee, UK (CB)
| | | | | | | | | | | |
Collapse
|
3
|
Schmidt G, Frieling N, Schneck E, Habicher M, Koch C, Rubarth K, Balzer F, Aßmus B, Sander M. Preoperative routine measurement of NT-proBNP predicts postoperative morbidity after non-cardiac surgery with intermediate or high surgical risk: an observational study. BMC Anesthesiol 2024; 24:113. [PMID: 38521898 PMCID: PMC10960410 DOI: 10.1186/s12871-024-02488-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Chronic heart failure (HF) is a common clinical condition associated with adverse outcomes in elderly patients undergoing non-cardiac surgery. This study aimed to estimate a clinically applicable NT-proBNP cut-off that predicts postoperative 30-day morbidity in a non-cardiac surgical cohort. METHODS One hundred ninety-nine consecutive patients older than 65 years undergoing elective non-cardiac surgery with intermediate or high surgical risk were analysed. Preoperative NT-proBNP was measured, and clinical events were assessed up to postoperative day 30. The primary endpoint was the composite morbidity endpoint (CME) consisting of rehospitalisation, acute decompensated heart failure (ADHF), acute kidney injury (AKI), and infection at postoperative day 30. Secondary endpoints included perioperative fluid balance and incidence, duration, and severity of perioperative hypotension. RESULTS NT-proBNP of 443 pg/ml had the highest accuracy in predicting the composite endpoint; a clinical cut-off of 450 pg/ml was implemented to compare clinical endpoints. Although 35.2% of patients had NT-proBNP above the threshold, only 10.6% had a known history of HF. The primary endpoint was the composite morbidity endpoint (CME) consisting of rehospitalisation, acute decompensated heart failure (ADHF), acute kidney injury (AKI), and infection. Event rates were significantly increased in patients with NT-proBNP > 450 pg/ml (70.7% vs. 32.4%, p < 0.001), which was due to the incidence of cardiac rehospitalisation (4.4% vs. 0%, p = 0.018), ADHF (20.1% vs. 4.0%, p < 0.001), AKI (39.8% vs. 8.3%, p < 0.001), and infection (46.3% vs. 24.4%, p < 0.01). Perioperative fluid balance and perioperative hypotension were comparable between groups. Preoperative NT-proBNP > 450 pg/ml was an independent predictor of the CME in a multivariable Cox regression model (hazard ratio 2.92 [1.72-4.94]). CONCLUSIONS Patients with NT-proBNP > 450 pg/ml exhibited profoundly increased postoperative morbidity. Further studies should focus on interdisciplinary approaches to improve outcomes through integrated interventions in the perioperative period. TRIAL REGISTRATION German Clinical Trials Register: DRKS00027871, 17/01/2022.
Collapse
Affiliation(s)
- Götz Schmidt
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany.
| | - Nora Frieling
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Marit Habicher
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Christian Koch
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Kerstin Rubarth
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Birgit Aßmus
- Department of Cardiology and Angiology, Justus Liebig University of Giessen, Klinikstrasse 33, 35392, Giessen, Germany
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| |
Collapse
|
4
|
Arbee-Kalidas N, Moutlana HJ, Moodley Y, Kebalepile MM, Motshabi Chakane P. The association between cardiopulmonary exercise testing and postoperative outcomes in patients with lung cancer undergoing lung resection surgery: A systematic review and meta-analysis. PLoS One 2023; 18:e0295430. [PMID: 38060569 PMCID: PMC10703215 DOI: 10.1371/journal.pone.0295430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Exercise capacity should be determined in all patients undergoing lung resection for lung cancer surgery and cardiopulmonary exercise testing (CPET) remains the gold standard. The purpose of this study was to investigate associations between preoperative CPET and postoperative outcomes in patients undergoing lung resection surgery for lung cancer through a review of the existing literature. METHODS A search was conducted on PubMed, Scopus, Cochrane Library and CINAHL from inception until December 2022. Studies investigating associations between preoperative CPET and postoperative outcomes were included. Risk of bias was assessed using the QUIPS tool. A random effect model meta-analysis was performed. I2 > 40% indicated a high level of heterogeneity. RESULTS Thirty-seven studies were included with 6450 patients. Twenty-eight studies had low risk of bias. [Formula: see text] peak is the oxygen consumption at peak exercise and serves as a marker of cardiopulmonary fitness. Higher estimates of [Formula: see text] peak, measured and as a percentagege of predicted, showed significant associations with a lower risk of mortality [MD: 3.66, 95% CI: 0.88; 6.43 and MD: 16.49, 95% CI: 6.92; 26.07] and fewer complications [MD: 2.06, 95% CI: 1.12; 3.00 and MD: 9.82, 95% CI: 5.88; 13.76]. Using a previously defined cutoff value of > 15mL/kg/min for [Formula: see text] peak, showed evidence of decreased odds of mortality [OR: 0.55, 95% CI: 0.28-0.81] and but not decreased odds of postoperative morbidity [OR: 0.82, 95% CI: 0.64-1.00]. There was no relationship between [Formula: see text] slope, which depicts ventilatory efficiency, with mortality [MD: -9.60, 95% CI: -27.74; 8.54] however, patients without postoperative complications had a lower preoperative [Formula: see text] [MD: -2.36, 95% CI: -3.01; -1.71]. Exercise load and anaerobic threshold did not correlate with morbidity or mortality. There was significant heterogeneity between studies. CONCLUSIONS Estimates of cardiopulmonary fitness as evidenced by higher [Formula: see text] peak, measured and as a percentage of predicted, were associated with decreased morbidity and mortality. A cutoff value of [Formula: see text] peak > 15mL/kg/min was consistent with improved survival but not with fewer complications. Ventilatory efficiency was associated with decreased postoperative morbidity but not with improved survival. The heterogeneity in literature could be remedied with large scale, prospective, blinded, standardised research to improve preoperative risk stratification in patients with lung cancer scheduled for lung resection surgery.
Collapse
Affiliation(s)
- Nabeela Arbee-Kalidas
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Hlamatsi Jacob Moutlana
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yoshan Moodley
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Moses Mogakolodi Kebalepile
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Palesa Motshabi Chakane
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
5
|
Mesnard T, Dubosq M, Pruvot L, Azzaoui R, Patterson BO, Sobocinski J. Benefits of Prehabilitation before Complex Aortic Surgery. J Clin Med 2023; 12:jcm12113691. [PMID: 37297886 DOI: 10.3390/jcm12113691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/14/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
The purpose of this narrative review was to detail and discuss the underlying principles and benefits of preoperative interventions addressing risk factors for perioperative adverse events in open aortic surgery (OAS). The term "complex aortic disease" encompasses juxta/pararenal aortic and thoraco-abdominal aneurysms, chronic aortic dissection and occlusive aorto-iliac pathology. Although endovascular surgery has been increasingly favored, OAS remains a durable option, but by necessity involves extensive surgical approaches and aortic cross-clamping and requires a trained multidisciplinary team. The physiological stress of OAS in a fragile and comorbid patient group mandates thoughtful preoperative risk assessment and the implementation of measures dedicated to improving outcomes. Cardiac and pulmonary complications are one of the most frequent adverse events following major OAS and their incidences are correlated to the patient's functional status and previous comorbidities. Prehabilitation should be considered in patients with risk factors for pulmonary complications including advanced age, previous chronic obstructive pulmonary disease, and congestive heart failure with the aid of pulmonary function tests. It should also be combined with other measures to improve postoperative course and be included in the more general concept of enhanced recovery after surgery (ERAS). Although the current level of evidence regarding the effectiveness of ERAS in the setting of OAS remains low, an increasing body of literature has promoted its implementation in other specialties. Consequently, vascular teams should commit to improving the current evidence through studies to make ERAS the standard of care for OAS.
Collapse
Affiliation(s)
- Thomas Mesnard
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
- Univ. Lille, INSERM U1008-Advanced Drug Delivery Systems and Biomaterials, 59000 Lille, France
| | - Maxime Dubosq
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Louis Pruvot
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Richard Azzaoui
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Benjamin O Patterson
- Department of Vascular Surgery, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Jonathan Sobocinski
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
- Univ. Lille, INSERM U1008-Advanced Drug Delivery Systems and Biomaterials, 59000 Lille, France
| |
Collapse
|
6
|
Shahin Y, Dixon S, Kerr K, Cleveland T, Goode SD. Endovascular aneurysm repair offers a survival advantage and is cost-effective compared with conservative management in patients physiologically unfit for open repair. J Vasc Surg 2023; 77:386-395.e3. [PMID: 36152982 DOI: 10.1016/j.jvs.2022.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively. METHODS A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment. RESULTS Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results. CONCLUSIONS EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.
Collapse
Affiliation(s)
- Yousef Shahin
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Simon Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; SAMRC/WITS Centre for Health Economics and Decision Science-PRICELESS, Johannesburg, South Africa
| | - Karen Kerr
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
| | - Trevor Cleveland
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK
| | - Stephen D Goode
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK.
| |
Collapse
|
7
|
Sivakumar J, Forshaw MJ, Lam S, Peters CJ, Allum WH, Whibley J, Sinclair RCF, Snowden CP, Hii MW, Sivakumar H, Read M. Identifying the limitations of cardiopulmonary exercise testing prior to esophagectomy using a pooled analysis of patient-level data. Dis Esophagus 2022; 35:6524743. [PMID: 35138383 DOI: 10.1093/dote/doac005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/28/2021] [Indexed: 12/11/2022]
Abstract
Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of aerobic fitness in patients undergoing surgery. While peak oxygen uptake during exercise (VO2peak) and anaerobic threshold have demonstrated a moderate correlation with the development of complications following esophagectomy, no clinically useful threshold values have been defined. By pooling patient level data from existing studies, we aimed to define optimal thresholds for preoperative CPET parameters to predict patients at high risk of postoperative complications. Studies reporting on the relationship between preoperative CPET variables and post-esophagectomy complications were determined from a comprehensive literature search. Patient-level data were obtained from six contributing centers for pooled-analyses. Outcomes of interest included cardiopulmonary and non-cardiopulmonary complications, unplanned intensive care unit readmission, and 90-day and 12-month all-cause mortality. Receiver operating characteristic curves and logistic regression models estimated the predictive value of CPET parameters for each individual outcome of interest. This analysis comprised of 621 patients who underwent CPET prior to esophagectomy during the period from January 2004 to March 2017. For both anaerobic threshold and VO2peak, none of the receiver operating characteristic curves achieved an area under the curve value > 0.66 for the outcomes of interest. The discriminatory ability of CPET for determining high-risk patients was found to be poor in patients undergoing an esophagectomy. CPET may only carry an adjunct role to clinical decision-making.
Collapse
Affiliation(s)
- Jonathan Sivakumar
- Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Matthew J Forshaw
- Department of Upper Gastrointestinal Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Stephen Lam
- Department of Upper Gastrointestinal Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Christopher J Peters
- Department of Surgery and Cancer, Imperial College London of St Mary's Hospital, London, UK
| | | | - Jessica Whibley
- Department of Physiotherapy, Royal Marsden Hospital, London, UK
| | - Rhona C F Sinclair
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | | | - Michael W Hii
- Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Harry Sivakumar
- Department of Anaesthesia, The Alfred Hospital, Melbourne, Australia
| | - Matthew Read
- Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia
| |
Collapse
|
8
|
Ayubcha D, Grosh T, Fleisher LA. Perioperative Cardiac Risk Assessment in Noncardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00005-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
9
|
Cao D, Chandiramani R, Capodanno D, Berger JS, Levin MA, Hawn MT, Angiolillo DJ, Mehran R. Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management. Nat Rev Cardiol 2020; 18:37-57. [PMID: 32759962 DOI: 10.1038/s41569-020-0410-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 12/18/2022]
Abstract
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.
Collapse
Affiliation(s)
- Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rishi Chandiramani
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico", Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Jeffrey S Berger
- Center for the Prevention of Cardiovascular Disease, New York University Langone Health, New York, NY, USA
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| |
Collapse
|
10
|
|
11
|
Straw S, Waduud MA, Drozd M, Warman P, Bailey MA, Hammond CJ, Abdel-Rahman S, Witte KK, Scott D. The role of cardiopulmonary exercise testing and echocardiography prior to elective endovascular aneurysm repair. Ann R Coll Surg Engl 2020; 102:383-390. [PMID: 32233869 DOI: 10.1308/rcsann.2020.0045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Cardiopulmonary exercise testing (CPET) and transthoracic echocardiography (TTE) are common preparative investigations prior to elective endovascular aneurysm repair (EVAR). Whether these investigations can predict survival following EVAR and contribute to shared decision making is unknown. METHODS Patients who underwent EVAR at a tertiary centre between June 2007 and December 2014 were identified from the National Vascular Registry. Variables obtained from preoperative investigations were assessed for their association with survival at three years. Regression analysis was used to determine variables that independently predicted survival at three years. RESULTS A total of 199 patients underwent EVAR during the study period. Of these, 120 had preoperative CPET and 123 had TTE. Lower forced expiratory ventilation (FEV1), ratio of FEV1 to forced vital capacity, work at peak oxygen consumption and higher ventilatory equivalent for carbon dioxide were associated with increased mortality. Variables obtained from TTE were not associated with survival at three years although there was a low incidence of left ventricular systolic dysfunction and significant valvular disease in this cohort. CONCLUSIONS CPET might be a useful adjunct to assist in shared decision making in patients undergoing elective EVAR and may influence anaesthetic technique. TTE does not appear to be able to discriminate between high and low risk individuals. However, a low rate of significant ventricular dysfunction and valvular disease in patients undergoing elective EVAR may account for these findings.
Collapse
Affiliation(s)
| | | | | | - P Warman
- Leeds Teaching Hospitals NHS Trust, UK
| | | | | | | | | | - Dja Scott
- Leeds Teaching Hospitals NHS Trust, UK
| |
Collapse
|
12
|
Stubbs DJ, Grimes LA, Ercole A. Performance of cardiopulmonary exercise testing for the prediction of post-operative complications in non cardiopulmonary surgery: A systematic review. PLoS One 2020; 15:e0226480. [PMID: 32012165 PMCID: PMC6996804 DOI: 10.1371/journal.pone.0226480] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/24/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Cardiopulmonary exercise testing (CPET) is widely used within the United Kingdom for preoperative risk stratification. Despite this, CPET's performance in predicting adverse events has not been systematically evaluated within the framework of classifier performance. METHODS After prospective registration on PROSPERO (CRD42018095508) we systematically identified studies where CPET was used to aid in the prognostication of mortality, cardiorespiratory complications, and unplanned intensive care unit (ICU) admission in individuals undergoing non-cardiopulmonary surgery. For all included studies we extracted or calculated measures of predictive performance whilst identifying and critiquing predictive models encompassing CPET derived variables. RESULTS We identified 36 studies for qualitative review, from 27 of which measures of classifier performance could be calculated. We found studies to be highly heterogeneous in methodology and quality with high potential for bias and confounding. We found seven studies that presented risk prediction models for outcomes of interest. Of these, only four studies outlined a clear process of model development; assessment of discrimination and calibration were performed in only two and only one study undertook internal validation. No scores were externally validated. Systematically identified and calculated measures of test performance for CPET demonstrated mixed performance. Data was most complete for anaerobic threshold (AT) based predictions: calculated sensitivities ranged from 20-100% when used for predicting risk of mortality with high negative predictive values (96-100%). In contrast, positive predictive value (PPV) was poor (2.9-42.1%). PPV appeared to be generally higher for cardiorespiratory complications, with similar sensitivities. Similar patterns were seen for the association of Peak VO2 (sensitivity 85.7-100%, PPV 2.7-5.9%) and VE/VCO2 (Sensitivity 27.8%-100%, PPV 3.4-7.1%) with mortality. CONCLUSIONS In general CPET's 'rule-out' capability appears better than its ability to 'rule-in' complications. Poor PPV may reflect the frequency of complications in studied populations. Our calculated estimates of classifier performance suggest the need for a balanced interpretation of the pros and cons of CPET guided pre-operative risk stratification.
Collapse
Affiliation(s)
- Daniel J. Stubbs
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| | - Lisa A. Grimes
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| | - Ari Ercole
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| |
Collapse
|
13
|
Pouwels S, Sanches EE, Cagiltay E, Severin R, Philips SA. Perioperative Exercise Therapy in Bariatric Surgery: Improving Patient Outcomes. Diabetes Metab Syndr Obes 2020; 13:1813-1823. [PMID: 32547143 PMCID: PMC7261659 DOI: 10.2147/dmso.s215157] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 05/07/2020] [Indexed: 12/15/2022] Open
Abstract
Nowadays, obesity and related comorbidities like type 2 diabetes, hypertension, dyslipidaemia and obstructive sleep apnoea syndrome are considered one of the medical challenges of the 21st century. Even with the rise of bariatric and metabolic surgery, obesity and metabolic syndrome are reaching endemic proportions. Even in 2020, obesity is still a growing problem. There is increasing evidence that next to bariatric surgery, exercise interventions in the perioperative period could give extra beneficial effects. In this regard, effects on anthropometrics, cardiovascular risk factors and physical fitness. The aim of this review is to summarise effects of preoperative and postoperative exercise, tools for screening and directions for future research and implementations.
Collapse
Affiliation(s)
- Sjaak Pouwels
- Department of Surgery, Haaglanden Medical Center, The Hague, the Netherlands
- Correspondence: Sjaak Pouwels Department of Surgery, Haaglanden Medical Center, P.O. Box 432, 2501 CK, The Hague, the Netherlands Email
| | - Elijah E Sanches
- Department of Surgery, Haaglanden Medical Center, The Hague, the Netherlands
| | - Eylem Cagiltay
- University of Health Sciences Turkey, Sultan Abdulhamid Han Education and Research Hospital, Department of Endocrinology and Metabolic Diseases, Istanbul, Uskudar, 34668, Turkey
| | - Rich Severin
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
- Physical Therapy Program, Robbins College of Health and Human Sciences, Baylor University, Waco, TX, USA
- Graduate Program in Rehabilitation Sciences, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Shane A Philips
- Graduate Program in Rehabilitation Sciences, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
- Department of Physical Therapy, Integrative Physiologic Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
14
|
Dawkins C, Hollingsworth AC, Walker P, Milburn S, Danjoux G, Cheesman M, Mofidi R. Anaerobic threshold as an independent predictor of mid-term survival following elective endovascular repair of abdominal aortic aneurysm. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 61:596-603. [PMID: 31599146 DOI: 10.23736/s0021-9509.19.11052-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to examine the value preoperative AT as predictor of postoperative survival in patients who underwent elective EVAR for repair of asymptomatic AAA. METHODS Consecutive patients who underwent elective EVAR between 2008 and 2018 were analyzed. Cardiopulmonary exercise testing was performed. Perioperative 30-day mortality was compared between patients who had AT ≥8 mL/kg/min and those with AT<8 mL/kg/min. Risk factors for postoperative survival following EVAR were examined using Cox's regression analysis. RESULTS Between 1<sup>st</sup> January 2008 and 31<sup>st</sup> December 2017, 430 patients underwent elective EVAR (standard device: N.=374, fenestrated/branched: N.=56); their median age was 76 years (range: 53-91 years), median AT was 9.3 (range: 5.4-16.1), and 30-day mortality was 0.9%. These patients were followed up for a median of 1630 days. There was no significant difference in perioperative 30-day mortality between patients who had AT≥8 and those who had AT<8 (χ<sup>2</sup>=1.56, P=0.22). Age (HR=1.51 [CI: 1.07-1.99], P<0.05) and AT (HR=0.59 [CI: 0.45-0.76], P=0.0003) were predictors of reduced postoperative survival following elective EVAR whereas gender (HR=0.75 [CI: 0.4-1.4], P=0.37), AAA diameter (HR=0.95 [CI: 0.77-1.16], P=0.6), and AAA morphology (HR=1.23 [CI: 0.68-1.76], P=0.95) were not. CONCLUSIONS Anaerobic threshold is an independent predictor of prolonged survival following elective EVAR and can be used to identify patients who receive most benefit from elective EVAR.
Collapse
Affiliation(s)
- Claire Dawkins
- Department of Vascular Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Paul Walker
- Department of Interventional Radiology, James Cook University Hospital, Middlesbrough, UK
| | - Simon Milburn
- Department of Interventional Radiology, James Cook University Hospital, Middlesbrough, UK
| | - Gerard Danjoux
- Department of Anesthesia, James Cook University Hospital, Middlesbrough, UK
| | - Matthew Cheesman
- Department of Anesthesia, James Cook University Hospital, Middlesbrough, UK
| | - Reza Mofidi
- Department of Vascular Surgery, James Cook University Hospital, Middlesbrough, UK -
| |
Collapse
|
15
|
Topal B, Smelt HJ, Van Helden EV, Celik A, Verseveld M, Smeenk F, Pouwels S. Utility of preoperative exercise therapy in reducing postoperative morbidity after surgery; a clinical overview of current evidence. Expert Rev Cardiovasc Ther 2019; 17:395-412. [DOI: 10.1080/14779072.2019.1625771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Besir Topal
- Department of Cardiothoracic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Esmee V. Van Helden
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, The Netherlands
| | - Alper Celik
- Department of Metabolic Surgery, Metabolic Surgery Clinic, Sisli, Istanbul, Turkey
| | - Maria Verseveld
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, The Netherlands
| | - Frank Smeenk
- Department of Respiratory Medicine, Catharina Hospital, Eindhoven, The Netherlands
- SHE School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
| | - Sjaak Pouwels
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, The Netherlands
| |
Collapse
|
16
|
The association of preoperative cardiac stress testing with 30-day death and myocardial infarction among patients undergoing kidney transplantation. PLoS One 2019; 14:e0211161. [PMID: 30707723 PMCID: PMC6358073 DOI: 10.1371/journal.pone.0211161] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/08/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although periodic cardiac stress testing is commonly used to screen patients on the waiting list for kidney transplantation for ischemic heart disease, there is little evidence to support this practice. We hypothesized that cardiac stress testing in the 18 months prior to kidney transplantation would not reduce postoperative death, total myocardial infarction (MI) or fatal MI. METHODS Using the United States Renal Data System, we identified ESRD patients ≥40 years old with primary Medicare insurance who received their first kidney transplant between 7/1/2006 and 11/31/2013. Propensity matching created a 1:1 matched sample of patients with and without stress testing in the 18 months prior to kidney transplantation. The outcomes of interest were death, total (fatal and nonfatal) MI or fatal MI within 30 days of kidney transplantation. RESULTS In the propensity-matched cohort of 17,304 patients, death within 30 days occurred in 72 of 8,652 (0.83%) patients who underwent stress testing and in 65 of 8,652 (0.75%) patients who did not (OR 1.07; 95% CI: 0.79-1.45; P = 0.66). MI within 30 days occurred in 339 (3.9%) patients who had a stress test and in 333 (3.8%) patients who did not (OR 1.03; 95% CI: 0.89-1.21; P = 0.68). Fatal MI occurred in 17 (0.20%) patients who underwent stress testing and 15 (0.17%) patients who did not (OR 0.97; 95% CI: 0.71-1.32; P = 0.84). CONCLUSION Stress testing in the 18 months prior to kidney transplantation is not associated with a reduction in death, total MI or fatal MI within 30 days of kidney transplantation.
Collapse
|
17
|
Lemanska A, Poole K, Aning JJ, Griffin BA, Manders R, Saxton JM, Wainwright J, Faithfull S. The Siconolfi step test: a valid and reliable assessment of cardiopulmonary fitness in older men with prostate cancer. Eur Rev Aging Phys Act 2019; 16:1. [PMID: 30651889 PMCID: PMC6327593 DOI: 10.1186/s11556-018-0207-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/04/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Assessing fitness and promoting regular physical activity can improve health outcomes and early recovery in prostate cancer. This is however, underutilised in clinical practice. The cardiopulmonary exercise test (CPET) is increasingly being used pre-treatment to measure aerobic capacity and peak oxygen consumption (VO2peak - a gold standard in cardiopulmonary fitness assessment). However, CPET requires expensive equipment and may not always be appropriate. The Siconolfi step test (SST) is simpler and cheaper, and could provide an alternative.The aim of this study was to evaluate the validity and reliability of SST for predicting cardiopulmonary fitness in men with prostate cancer. Men were recruited to this two-centre study (Surrey and Newcastle, United Kingdom) after treatment for locally advanced prostate cancer. They had one or more of three risk factors: elevated blood pressure, overweight (BMI > 25), or androgen deprivation therapy (ADT). Cardiopulmonary fitness was measured using SST and cycle ergometry CPET, at two visits three months apart. The validity of SST was assessed by comparing it to CPET. The VO2peak predicted from SST was compared to the VO2peak directly measured with CPET. The reliability of SST was assessed by comparing repeated measures. Bland-Altman analysis was used to derive limits of agreement in validity and reliability analysis. RESULTS Sixty-six men provided data for both SST and CPET. These data were used for validity analysis. 56 men provided SST data on both visits. These data were used for reliability analysis. SST provided valid prediction of the cardiopulmonary fitness in men > 60 years old. The average difference between CPET and SST was 0.64 ml/kg/min with non-significant positive bias towards CPET (P = 0.217). Bland-Altman 95% limits of agreement of SST with CPET were ± 7.62 ml/kg/min. SST was reliable across the whole age range. Predicted VO2peak was on average 0.53 ml/kg/min higher at Visit 2 than at Visit 1 (P = 0.181). Bland-Altman 95% limits of agreement between repeated SST measures were ± 5.84 ml/kg/min. CONCLUSIONS SST provides a valid and reliable alternative to CPET for the assessment of cardiopulmonary fitness in older men with prostate cancer. Caution is advised when assessing men 60 years old or younger because the VO2peak predicted with SST was significantly lower than that measured with CPET.
Collapse
Affiliation(s)
- Agnieszka Lemanska
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Karen Poole
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Jonathan J. Aning
- Department of Urology, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Bristol Urological Institute, Southmead Hospital, Westbury-on-trym, Bristol, UK
| | - Bruce A. Griffin
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Ralph Manders
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - John M. Saxton
- Department of Sport, Exercise & Rehabilitation, Northumbria University, Newcastle Upon Tyne, UK
| | - Joe Wainwright
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Sara Faithfull
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| |
Collapse
|
18
|
Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, ESVS Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57:8-93. [DOI: 10.1016/j.ejvs.2018.09.020] [Citation(s) in RCA: 873] [Impact Index Per Article: 174.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
19
|
Timbrell D, Prabhu P. Cardiopulmonary exercise testing: valuable stratification tool or waste of time? Br J Hosp Med (Lond) 2018; 79:598. [PMID: 30290735 DOI: 10.12968/hmed.2018.79.10.598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- David Timbrell
- Fellow in Perioperative Medicine and Cardiopulmonary Exercise Testing, Department of Anaesthesia, Royal Surrey County Hospital, Guildford, Surrey GU2 7XX
| | - Pradeep Prabhu
- Consultant Anaesthetist, Department of Anaesthesia, Royal Surrey County Hospital, Guildford, Surrey
| |
Collapse
|
20
|
Wijeysundera DN, Pearse RM, Shulman MA, Abbott TEF, Torres E, Ambosta A, Croal BL, Granton JT, Thorpe KE, Grocott MPW, Farrington C, Myles PS, Cuthbertson BH. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet 2018; 391:2631-2640. [PMID: 30070222 DOI: 10.1016/s0140-6736(18)31131-0] [Citation(s) in RCA: 247] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/04/2018] [Accepted: 05/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Functional capacity is an important component of risk assessment for major surgery. Doctors' clinical subjective assessment of patients' functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery. METHODS We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor (<4), moderate (4-10), or good (>10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification. FINDINGS Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19·2% sensitivity (95% CI 14·2-25) and 94·7% specificity (93·2-95·9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0·96, 95% CI 0·83-0·99; p=0·03). INTERPRETATION Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
Collapse
Affiliation(s)
- Duminda N Wijeysundera
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | - Mark A Shulman
- Alfred Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | | | - Elizabeth Torres
- Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada
| | - Althea Ambosta
- Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada
| | | | - John T Granton
- Department of Medicine, University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Kevin E Thorpe
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Michael P W Grocott
- University Hospital Southampton, Southampton, UK; University of Southampton, Southampton, UK
| | - Catherine Farrington
- Alfred Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Paul S Myles
- Alfred Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Brian H Cuthbertson
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| |
Collapse
|
21
|
Improving the evidence-base for preoperative cardiopulmonary exercise testing. Br J Anaesth 2018; 120:419-421. [DOI: 10.1016/j.bja.2017.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 12/05/2017] [Accepted: 12/05/2017] [Indexed: 11/19/2022] Open
|
22
|
Kanakaraj M, Yates DR, Wilson RJT, Baroni ML, Davies SJ. Prognostic Markers of Outcome in Patients Undergoing Infra-inguinal Revascularisation: A Prospective Observational Pilot Study. Eur J Vasc Endovasc Surg 2017. [PMID: 28625356 DOI: 10.1016/j.ejvs.2017.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim was to investigate whether cardiopulmonary exercise testing (CPET) variables derived from cycle and arm ergonometry correlate, and whether CPET variables and pre-operative N-terminal pro-brain natriuretic peptide (NT-proBNP) have prognostic significance and if the combination of the two has incremental value. METHODS A prospective observational pilot study was conducted; 70 patients who underwent infra-inguinal bypass surgery were recruited. Pre-operatively subjects underwent CPET with both arm and leg ergonometry, to measure peak oxygen consumption, anaerobic threshold (AT), and ventilatory equivalents. In addition pre-operative serum samples of NT-proBNP were obtained. The primary endpoint was 1 year all-cause mortality; in addition, data were collected on complications, morbidity, length of stay, and major adverse cardiac events (MACE). RESULTS The 1 year mortality rate was 6%, the overall complications rate was 23%, and the combined incidence of MACE and 1 year mortality was 10%. Cycle ergonometry peak VO2 14 mL/kg/min (RR 5.5, 95% CI 1.4-22.4, p = .007) and AT < 10mL/kg/min (RR 3.0, 95% CI 1.1-7.0, p = .03) were predictors of post-operative complications. Pre-operative NT-proBNP > 320 ng/L (RR 18, 95% CI 2.5-140 p = .0003) was the sole predictor of 1 year mortality or MACE. CONCLUSION The measurement of pre-operative NT-proBNP in peripheral vascular disease patients undergoing infra-inguinal bypass can predict 1 year mortality and MACE. CPET variables from cycle ergonometry are predictors of post-operative complications in this patient group.
Collapse
Affiliation(s)
- M Kanakaraj
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - D R Yates
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - R J T Wilson
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - M L Baroni
- Department of Vascular Surgery, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - S J Davies
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK.
| |
Collapse
|
23
|
Cascella M. Preoperative cardiac evaluation and anesthetic considerations for cancer patients who underwent chemotherapy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2017. [DOI: 10.1016/j.tacc.2017.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
24
|
Masuda T, Kuramoto M, Tanimoto H, Yamamoto K, Ikeshima S, Kitano Y, Kuroda D, Shimada S, Baba H. Intraoperative baseline oxygen consumption as a prognostic factor in emergency open abdominal surgery. J Crit Care 2016; 32:42-7. [DOI: 10.1016/j.jcrc.2015.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 01/06/2023]
|
25
|
Wijeysundera DN, Pearse RM, Shulman MA, Abbott TEF, Torres E, Croal BL, Granton JT, Thorpe KE, Grocott MPW, Farrington C, Myles PS, Cuthbertson BH. Measurement of Exercise Tolerance before Surgery (METS) study: a protocol for an international multicentre prospective cohort study of cardiopulmonary exercise testing prior to major non-cardiac surgery. BMJ Open 2016; 6:e010359. [PMID: 26969643 PMCID: PMC4800144 DOI: 10.1136/bmjopen-2015-010359] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Preoperative functional capacity is considered an important risk factor for cardiovascular and other complications of major non-cardiac surgery. Nonetheless, the usual approach for estimating preoperative functional capacity, namely doctors' subjective assessment, may not accurately predict postoperative morbidity or mortality. 3 possible alternatives are cardiopulmonary exercise testing; the Duke Activity Status Index, a standardised questionnaire for estimating functional capacity; and the serum concentration of N-terminal pro-B-type natriuretic peptide (NT pro-BNP), a biomarker for heart failure and cardiac ischaemia. METHODS AND ANALYSIS The Measurement of Exercise Tolerance before Surgery (METS) Study is a multicentre prospective cohort study of patients undergoing major elective non-cardiac surgery at 25 participating study sites in Australia, Canada, New Zealand and the UK. We aim to recruit 1723 participants. Prior to surgery, participants undergo symptom-limited cardiopulmonary exercise testing on a cycle ergometer, complete the Duke Activity Status Index questionnaire, undergo blood sampling to measure serum NT pro-BNP concentration and have their functional capacity subjectively assessed by their responsible doctors. Participants are followed for 1 year after surgery to assess vital status, postoperative complications and general health utilities. The primary outcome is all-cause death or non-fatal myocardial infarction within 30 days after surgery, and the secondary outcome is all-cause death within 1 year after surgery. Both receiver-operating-characteristic curve methods and risk reclassification table methods will be used to compare the prognostic accuracy of preoperative subjective assessment, peak oxygen consumption during cardiopulmonary exercise testing, Duke Activity Status Index scores and serum NT pro-BNP concentration. ETHICS AND DISSEMINATION The METS Study has received research ethics board approval at all sites. Participant recruitment began in March 2013, and 1-year follow-up is expected to finish in 2016. Publication of the results of the METS Study is anticipated to occur in 2017.
Collapse
Affiliation(s)
- Duminda N Wijeysundera
- St. Michael's Hospital/Toronto General Hospital/University of Toronto, Toronto, Ontario, Canada
| | | | - Mark A Shulman
- Alfred Hospital/Monash University, Melbourne, Victoria, Australia
| | | | | | | | - John T Granton
- University Health Network/Mount Sinai Hospital/University of Toronto, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- University of Toronto/St. Michael's Hospital, Toronto, Ontario, Canada
| | | | | | - Paul S Myles
- Alfred Hospital/Monash University, Melbourne, Victoria, Australia
| | - Brian H Cuthbertson
- Sunnybrook Health Sciences Centre/University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
26
|
Abstract
Purpose of review Accurate and early identification of high-risk surgical patients allows for targeted use of perioperative monitoring and interventions that may improve their outcomes. This review summarizes current evidence on how information from the preoperative, operative, and immediate postoperative periods can help identify such individuals. Recent findings Simple risk indices, such as the Revised Cardiac Risk Index or American Society of Anesthesiologists Physical Status scale, and online calculators allow risk to be estimated with moderate accuracy using readily available preoperative clinical information. Both specific specialized tests (i.e., cardiopulmonary exercise testing and cardiac stress testing) and promising novel biomarkers (i.e., troponins and natriuretic peptides) can help refine these risk estimates before surgery. Estimates of perioperative risk can be further informed by information acquired during the operative and immediate postoperative periods, such as risk indices (i.e., surgical Apgar score), individual risk factors (i.e., intraoperative hypotension), or postoperative biomarkers (i.e., troponins and natriuretic peptides). Summary Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Although novel biomarkers, specialized preoperative testing, and immediate postoperative risk indices show promise as methods to refine these risk estimates, more research is needed on how best to integrate risk information from these different sources.
Collapse
|
27
|
Hollingsworth A, Danjoux G, Howell S. Cardiopulmonary exercise testing before abdominal aortic aneurysm surgery: a validated risk prediction tool? Br J Anaesth 2015; 115:494-7. [DOI: 10.1093/bja/aev150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
28
|
Affiliation(s)
- S. J. Howell
- Leeds Institute of Biomedical & Clinical Sciences; St James's University Hospital; Leeds UK
| |
Collapse
|
29
|
Grant S, Hickey G, Wisely N, Carlson E, Hartley R, Pichel A, Atkinson D, McCollum C. Cardiopulmonary exercise testing and survival after elective abdominal aortic aneurysm repair †. Br J Anaesth 2015; 114:430-6. [DOI: 10.1093/bja/aeu383] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
|
30
|
Grupo de Trabajo Conjunto sobre cirugía no cardiaca: Evaluación y manejo cardiovascular de la Sociedad Europea de Cardiología (ESC) y la European Society of Anesthesiology (ESA). Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2014.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
31
|
Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, De Hert S, Ford I, Juanatey JRG, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Luescher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Uva MS, Voudris V, Funck-Brentano C. 2014 ESC/ESA Guidelines on non-cardiac surgery. Eur J Anaesthesiol 2014; 31:517-73. [DOI: 10.1097/eja.0000000000000150] [Citation(s) in RCA: 286] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
32
|
Abstract
Patients undergoing vascular surgery present a myriad of perioperative challenges due to the complex comorbidities affecting them in conjunction with high-risk surgical procedures. Additionally, advances in endovascular technology have enabled surgical procedures to be performed on patients who would not have been considered surgical candidates in the past. This combination of increasing patient morbidity and evolving surgical technique requires a well-planned preoperative assessment and close communication with surgical and perioperative colleagues. This article outlines an appropriate approach by first considering each organ system, followed by review of considerations unique to various surgical procedures, and then an overall assessment of risk.
Collapse
|
33
|
Barakat HM, Shahin Y, Barnes R, Gohil R, Souroullas P, Khan J, McCollum PT, Chetter IC. Supervised exercise program improves aerobic fitness in patients awaiting abdominal aortic aneurysm repair. Ann Vasc Surg 2014; 28:74-9. [PMID: 24332259 DOI: 10.1016/j.avsg.2013.09.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 06/12/2013] [Accepted: 09/06/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Aerobic fitness is an important predictor of postoperative outcome in major surgery. In this study, we assess the effects of a period of preoperative exercise on aerobic fitness as measured by cardiopulmonary exercise testing (CPET) in patients scheduled for abdominal aortic aneurysm (AAA) repair. METHODS As part of a randomized trial, the first patients recruited in the intervention group were enrolled in a supervised exercise program of six week duration. Treadmill CPET parameters were measured before and after exercise preoperatively for these patients. These parameters were as follows: peak oxygen uptake (VO2 peak), anaerobic threshold (AT), and ventilator equivalents for oxygen and carbon dioxide (VE/VO2 and VE/VCO2, respectively). Total exercise time and the time at which AT was achieved were also recorded. A comparison between pre- and postexercise parameters was made to detect for a possible improvement in aerobic fitness. RESULTS Twenty patients with AAA (17 men; mean age: 74.9 ± 5.9 years) were included in this study. Thirty-five percent of patients had a history of ischemic heart disease, 25% of obstructive airway disease, and 15% of cerebral vascular events. Seventy percent were previous smokers, and 15% were current smokers. Fifty-five percent of patients were taking aspirin and 75% were undergoing statin therapy. The median (interquartile range) VO2 peak at baseline was 18.2 (15.4-19.9) mL/kg/min, and after exercise was 19.9 (17.1-21.1; P = 0.048). Median AT at baseline was 12.2 (10.5-14.9), and 14.4 (12.3-15.4) after exercise (P = 0.023). Time of exercise tolerated also improved from a median of 379 to 604 sec (P = 0.001). No significant changes were seen in VE/VO2, VE/VCO2, or the time at which AT was achieved. CONCLUSION This study shows that cardiopulmonary aerobic fitness improves after a period of supervised exercise in patients scheduled for AAA repair. This is justification for a randomized trial to assess whether this affects morbidity and mortality after AAA repair.
Collapse
Affiliation(s)
- Hashem M Barakat
- Academic Vascular Surgical Unit, University of Hull and Hull York Medical School, Hull, UK.
| | - Yousef Shahin
- Academic Vascular Surgical Unit, University of Hull and Hull York Medical School, Hull, UK
| | - Rachel Barnes
- Academic Vascular Surgical Unit, University of Hull and Hull York Medical School, Hull, UK
| | - Risha Gohil
- Academic Vascular Surgical Unit, University of Hull and Hull York Medical School, Hull, UK
| | - Panos Souroullas
- Academic Vascular Surgical Unit, University of Hull and Hull York Medical School, Hull, UK
| | - Junaid Khan
- Academic Vascular Surgical Unit, University of Hull and Hull York Medical School, Hull, UK
| | - Peter T McCollum
- Academic Vascular Surgical Unit, University of Hull and Hull York Medical School, Hull, UK
| | - Ian C Chetter
- Academic Vascular Surgical Unit, University of Hull and Hull York Medical School, Hull, UK
| |
Collapse
|
34
|
Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, Ford I, Gonzalez-Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Lüscher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Sousa-Uva M, Voudris V, Funck-Brentano C. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35:2383-431. [PMID: 25086026 DOI: 10.1093/eurheartj/ehu282] [Citation(s) in RCA: 803] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
35
|
Hubbard RE, Story DA. Patient frailty: the elephant in the operating room. Anaesthesia 2014; 69 Suppl 1:26-34. [PMID: 24303858 DOI: 10.1111/anae.12490] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2013] [Indexed: 12/21/2022]
Abstract
For most surgeons and many anaesthetists, patient frailty is currently the 'elephant in the (operating) room': it is easy to spot, but is often ignored. In this paper, we discuss different approaches to the measurement of frailty and review the evidence regarding the effect of frailty on peri-operative outcomes. We explore the limitations of 'eyeballing' patients to quantify frailty, and consider why the frail older patient, challenged by seemingly minor insults in the postoperative period, may suffer falls or delirium. Frailty represents a state of increased vulnerability to stressors, and older inpatients are exposed to multiple stressors in the peri-operative setting. Quantifying frailty is likely to increase the precision of peri-operative risk assessment. The Frailty Index derived from Comprehensive Geriatric Assessment is a simple and robust way to quantify frailty, but is yet to be systematically investigated in the pre-operative setting. Furthermore, the optimal care for frail patients and the reversibility of frailty with prehabilitation are fertile areas for future research.
Collapse
Affiliation(s)
- R E Hubbard
- Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | | |
Collapse
|
36
|
Goodyear SJ, Yow H, Saedon M, Shakespeare J, Hill CE, Watson D, Marshall C, Mahmood A, Higman D, Imray CHE. Risk stratification by pre-operative cardiopulmonary exercise testing improves outcomes following elective abdominal aortic aneurysm surgery: a cohort study. Perioper Med (Lond) 2013; 2:10. [PMID: 24472159 PMCID: PMC3964330 DOI: 10.1186/2047-0525-2-10] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 04/18/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In 2009, the NHS evidence adoption center and National Institute for Health and Care Excellence (NICE) published a review of the use of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). They recommended the development of a risk-assessment tool to help identify AAA patients with greater or lesser risk of operative mortality and to contribute to mortality prediction.A low anaerobic threshold (AT), which is a reliable, objective measure of pre-operative cardiorespiratory fitness, as determined by pre-operative cardiopulmonary exercise testing (CPET) is associated with poor surgical outcomes for major abdominal surgery. We aimed to assess the impact of a CPET-based risk-stratification strategy upon perioperative mortality, length of stay and non-operative costs for elective (open and endovascular) infra-renal AAA patients. METHODS A retrospective cohort study was undertaken. Pre-operative CPET-based selection for elective surgical intervention was introduced in 2007. An anonymized cohort of 230 consecutive infra-renal AAA patients (2007 to 2011) was studied. A historical control group of 128 consecutive infra-renal AAA patients (2003 to 2007) was identified for comparison.Comparative analysis of demographic and outcome data for CPET-pass (AT ≥ 11 ml/kg/min), CPET-fail (AT < 11 ml/kg/min) and CPET-submaximal (no AT generated) subgroups with control subjects was performed. Primary outcomes included 30-day mortality, survival and length of stay (LOS); secondary outcomes were non-operative inpatient costs. RESULTS Of 230 subjects, 188 underwent CPET: CPET-pass n = 131, CPET-fail n = 35 and CPET-submaximal n = 22. When compared to the controls, CPET-pass patients exhibited reduced median total LOS (10 vs 13 days for open surgery, n = 74, P < 0.01 and 4 vs 6 days for EVAR, n = 29, P < 0.05), intensive therapy unit requirement (3 vs 4 days for open repair only, P < 0.001), non-operative costs (£5,387 vs £9,634 for open repair, P < 0.001) and perioperative mortality (2.7% vs 12.6% (odds ratio: 0.19) for open repair only, P < 0.05). CPET-stratified (open/endovascular) patients exhibited a mid-term survival benefit (P < 0.05). CONCLUSION In this retrospective cohort study, a pre-operative AT > 11 ml/kg/min was associated with reduced perioperative mortality (open cases only), LOS, survival and inpatient costs (open and endovascular repair) for elective infra-renal AAA surgery.
Collapse
Affiliation(s)
- Stephen J Goodyear
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Heng Yow
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Mahmud Saedon
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Joanna Shakespeare
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Christopher E Hill
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Duncan Watson
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Colette Marshall
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Asif Mahmood
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Daniel Higman
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Christopher HE Imray
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| |
Collapse
|
37
|
Shah N, Hamilton M. Clinical review: Can we predict which patients are at risk of complications following surgery? Crit Care 2013; 17:226. [PMID: 23672931 PMCID: PMC3672530 DOI: 10.1186/cc11904] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
There are a vast number of operations carried out every year, with a small proportion of patients being at highest risk of mortality and morbidity. There has been considerable work to try and identify these high-risk patients. In this paper, we look in detail at the commonly used perioperative risk prediction models. Finally, we will be looking at the evolution and evidence for functional assessment and the National Surgical Quality Improvement Program (in the USA), both topical and exciting areas of perioperative prediction.
Collapse
Affiliation(s)
- Nirav Shah
- General Intensive Care Unit, St George's Hospital, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Mark Hamilton
- General Intensive Care Unit, St George's Hospital, Blackshaw Road, Tooting, London, SW17 0QT, UK
| |
Collapse
|
38
|
The Prognostic Value of Cardiopulmonary Exercise Testing in Vascular Surgery Patients. Eur J Vasc Endovasc Surg 2012; 44:457. [DOI: 10.1016/j.ejvs.2012.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 06/28/2012] [Indexed: 11/18/2022]
|
39
|
Timbrell D, Gudgeon J, Chong P, Tote S. Comment on 'A systematic review of the role of cardiopulmonary exercise testing in vascular surgery'. Eur J Vasc Endovasc Surg 2012; 44:350; author reply 350-1. [PMID: 22727061 DOI: 10.1016/j.ejvs.2012.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 05/17/2012] [Indexed: 10/28/2022]
|