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Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024:S0735-1097(24)07611-3. [PMID: 39320289 DOI: 10.1016/j.jacc.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
AIM The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.
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Wilson EA, Woodbury A, Williams KM, Coopersmith CM. OXIDATIVE study: A pilot prospective observational cohort study protocol examining the influence of peri-reperfusion hyperoxemia and immune dysregulation on early allograft dysfunction after orthotopic liver transplantation. PLoS One 2024; 19:e0301281. [PMID: 38547092 PMCID: PMC10977716 DOI: 10.1371/journal.pone.0301281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/10/2024] [Indexed: 04/02/2024] Open
Abstract
Early allograft dysfunction (EAD) is a functional hepatic insufficiency within a week of orthotopic liver transplantation (OLT) and is associated with morbidity and mortality. The etiology of EAD is multifactorial and largely driven by ischemia reperfusion injury (IRI), a phenomenon characterized by oxygen scarcity followed by paradoxical oxidative stress and inflammation. With the expanded use of marginal allografts more susceptible to IRI, the incidence of EAD may be increasing. This necessitates an in-depth understanding of the innate molecular mechanisms underlying EAD and interventions to mitigate its impact. Our central hypothesis is peri-reperfusion hyperoxemia and immune dysregulation exacerbate IRI and increase the risk of EAD. We will perform a pilot prospective single-center observational cohort study of 40 patients. The aims are to determine (1) the association between peri-reperfusion hyperoxemia and EAD and (2) whether peri-reperfusion perturbed cytokine, protein, and hypoxia inducible factor-1 alpha (HIF-1α) levels correlate with EAD after OLT. Inclusion criteria include age ≥ 18 years, liver failure, and donation after brain or circulatory death. Exclusion criteria include living donor donation, repeat OLT within a week of transplantation, multiple organ transplantation, and pregnancy. Partial pressure of arterial oxygen (PaO2) as the study measure allows for the examination of oxygen exposure within the confines of existing variability in anesthesiologist-administered fraction of inspired oxygen (FiO2) and the inclusion of patients with intrapulmonary shunting. The Olthoff et al. definition of EAD is the primary outcome. Secondary outcomes include postoperative acute kidney injury, pulmonary and biliary complications, surgical wound dehiscence and infection, and mortality. The goal of this study protocol is to identify EAD contributors that could be targeted to attenuate its impact and improve OLT outcomes. If validated, peri-reperfusion hyperoxemia and immune perturbations could be targeted via FiO2 titration to a goal PaO2 and/or administration of an immunomodulatory agent by the anesthesiologist intraoperatively.
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Affiliation(s)
- Elizabeth A Wilson
- Department of Anesthesiology, Emory University School of Medicine, Emory University Hospital, Atlanta, GA, United States of America
| | - Anna Woodbury
- Department of Anesthesiology, Emory University School of Medicine, Emory University Hospital, Atlanta, GA, United States of America
| | - Kirsten M Williams
- Department of Pediatrics, Division of Hematology and Oncology, Emory University School of Medicine, Children's Hospital of Atlanta, Atlanta, GA, United States of America
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Emory University Hospital, Atlanta, GA, United States of America
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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.
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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
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Kuh JH, Jung WS, Lim L, Yoo HK, Ju JW, Lee HJ, Kim WH. The effect of high perioperative inspiratory oxygen fraction for abdominal surgery on surgical site infection: a systematic review and meta-analysis. Sci Rep 2023; 13:15599. [PMID: 37730856 PMCID: PMC10511429 DOI: 10.1038/s41598-023-41300-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023] Open
Abstract
Guidelines from the World Health Organization strongly recommend the use of a high fraction of inspired oxygen (FiO2) in adult patients undergoing general anesthesia to reduce surgical site infection (SSI). However, previous meta-analyses reported inconsistent results. We aimed to address this controversy by focusing specifically on abdominal surgery with relatively high risk of SSI. Medline, EMBASE, and Cochrane CENTRAL databases were searched. Randomized trials of abdominal surgery comparing high to low perioperative FiO2 were included, given that the incidence of SSI was reported as an outcome. Meta-analyses of risk ratios (RR) were performed using a fixed effects model. Subgroup analysis and meta-regression were employed to explore sources of heterogeneity. We included 27 trials involving 15977 patients. The use of high FiO2 significantly reduced the incidence of SSI (n = 27, risk ratio (RR): 0.87; 95% confidence interval (CI): 0.79, 0.95; I2 = 49%, Z = 3.05). Trial sequential analysis (TSA) revealed that z-curve crossed the trial sequential boundary and data are sufficient. This finding held true for the subgroup of emergency operations (n = 2, RR: 0.54; 95% CI: 0.35, 0.84; I2 = 0%, Z = 2.75), procedures using air as carrier gas (n = 9, RR: 0.79; 95% CI: 0.69, 0.91; I2 = 60%, Z = 3.26), and when a high level of FiO2 was maintained for a postoperative 6 h or more (n = 9, RR: 0.68; 95% CI: 0.56, 0.83; I2 = 46%, Z = 3.83). Meta-regression revealed no significant interaction between SSI with any covariates including age, sex, body-mass index, diabetes mellitus, duration of surgery, and smoking. Quality of evidence was assessed to be moderate to very low. Our pooled analysis revealed that the application of high FiO2 reduced the incidence of SSI after abdominal operations. Although TSA demonstrated sufficient data and cumulative analysis crossed the TSA boundary, our results should be interpreted cautiously given the low quality of evidence.Registration: https://www.crd.york.ac.uk/prospero (CRD42022369212) on October 2022.
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Affiliation(s)
- Jae Hee Kuh
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Woo-Seok Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Leerang Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Hae Kyung Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
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Pichler A, Kurz A, Eichlseder M, Graf A, Eichinger M, Taschner A, Kabon B, Fleischmann E, Reiterer C. PerIoperative iNflammatory reSponse assessment In hiGH-risk patienTs undergoing non-cardiac surgery (INSIGHT): study protocol of a prospective non-interventional observational study. BMJ Open 2023; 13:e065469. [PMID: 37474184 PMCID: PMC10357807 DOI: 10.1136/bmjopen-2022-065469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Increased inflammatory processes after non-cardiac surgery are very common. The association between postoperative inflammation and the occurrence of cardiovascular complications after non-cardiac surgery are still not entirely clear. Therefore, we will evaluate the association between postoperative inflammation and the occurrence of major cardiovascular complications in patients at-risk for cardiovascular complications undergoing non-cardiac surgery. We will further evaluate the association of postoperative inflammation and days-at-home within 30 days after surgery (DAH30), the incidence of acute kidney injury, postoperative N-terminal probrain natriuretic peptide (NT-proBNP) concentrations and neurocognitive decline. METHODS AND ANALYSIS In this multicentre study, we will include 1400 patients at-risk for cardiovascular complications undergoing non-cardiac surgery. Our primary aim is to evaluate the association of postoperative maximum C-reactive protein concentration and the occurrence of a composite of five major cardiovascular complications (myocardial infarction, myocardial injury after non-cardiac surgery, new onset of atrial fibrillation, stroke and death) within 30 days after surgery using a Mann-Whitney-U test as well as a logistic regression model. As our secondary aim, we will evaluate the association of a composite of three inflammatory biomarkers (interleukin 6, procalcitonin and copeptin) on the occurrence of our composite of five cardiovascular complications within 30 days and 1 year after surgery, acute kidney injury, DAH30 and NT-proBNP concentrations using linear or logistic regression models. We will measure inflammatory biomarkers before surgery, and on the first, second, third and fifth postoperative day. We will check medical records and conduct a telephone survey 30 days and 1 year after surgery. We evaluate neurocognitive function, using a Montreal Cognitive Assessment, before and 1 year after surgery. ETHICS AND DISSEMINATION This study was approved by the ethics committees at the Medical University of Vienna (2458/2020) and at the Medical University of Graz (33-274 ex 20/21). TRIAL REGISTRATION NUMBER NCT04753307.
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Affiliation(s)
- Alexander Pichler
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Andrea Kurz
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Michael Eichlseder
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Alexandra Graf
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Michael Eichinger
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Alexander Taschner
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Edith Fleischmann
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Christian Reiterer
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
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Reiterer C, Fleischmann E, Kabon B, Taschner A, Kurz A, Adamowitsch N, von Sonnenburg MF, Fraunschiel M, Graf A. Hemodynamic effects of intraoperative 30% versus 80% oxygen concentrations: an exploratory analysis. Front Med (Lausanne) 2023; 10:1200223. [PMID: 37324125 PMCID: PMC10265637 DOI: 10.3389/fmed.2023.1200223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/05/2023] [Indexed: 06/17/2023] Open
Abstract
Background Supplemental oxygen leads to an increase in peripheral vascular resistance which finally increases systemic blood pressure in healthy subjects and patients with coronary artery disease, heart failure, undergoing heart surgery, and with sepsis. However, it is unknown whether this effect can also be observed in anesthetized patients having surgery. Thus, we evaluated in this exploratory analysis of a randomized controlled trial the effect of 80% versus 30% oxygen on intraoperative blood pressure and heart rate. Methods We present data from a previous study including 258 patients, who were randomized to a perioperative inspiratory FiO2 of 0.8 (128 patients) versus 0.3 (130 patients) for major abdominal surgery. Continuous arterial blood pressure values were recorded every three seconds and were exported from the electronic anesthesia record system. We calculated time-weighted average (TWA) and Average Real Variability (ARV) of mean arterial blood pressure and of heart rate. Results There was no significant difference in TWA of mean arterial pressure between the 80% (80 mmHg [76, 85]) and 30% (81 mmHg [77, 86]) oxygen group (effect estimate -0.16 mmHg, CI -1.83 to 1.51; p = 0.85). There was also no significant difference in TWA of heart rate between the 80 and 30% oxygen group (median TWA of heart rate in the 80% oxygen group: 65 beats.min-1 [58, 72], and in the 30% oxygen group: 64 beats.min-1 [58; 70]; effect estimate: 0.12 beats.min-1, CI -2.55 to 2.8, p = 0.94). Also for ARV values, no significant differences between groups could be detected. Conclusion In contrast to previous results, we did not observe a significant increase in blood pressure or a significant decrease in heart rate in patients, who received 80% oxygen as compared to patients, who received 30% oxygen during surgery and for the first two postoperative hours. Thus, hemodynamic effects of supplemental oxygen might play a negligible role in anesthetized patients. Clinical Trail Registration https://clinicaltrials.gov/ct2/show/NCT03366857?term=vienna&cond=oxygen&draw=2&rank=1.
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Affiliation(s)
- Christian Reiterer
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Outcome Research Consortium, Cleveland, OH, United States
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Outcome Research Consortium, Cleveland, OH, United States
| | - Barbara Kabon
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Outcome Research Consortium, Cleveland, OH, United States
| | - Alexander Taschner
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Outcome Research Consortium, Cleveland, OH, United States
| | - Andrea Kurz
- Outcome Research Consortium, Cleveland, OH, United States
- Department of General Anesthesiology, Cleveland Clinic, Anesthesia Institute, Cleveland, OH, United States
- Department of General Anesthesiology, Emergency Medicine and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Nikolas Adamowitsch
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Melanie Fraunschiel
- IT Systems and Communications, Medical University of Vienna, Vienna, Austria
| | - Alexandra Graf
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
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Lin S, Zhang Y, Huang X, Zhang X, Cheng E, Zhou Z, Liu J. Effects of Combined Use of Salbutamol/Budesonide in Thoracic Surgery on Postoperative Myocardial Injury (MINS) – A Prospective Randomized Clinical Trial. Drug Des Devel Ther 2023; 17:1025-1036. [PMID: 37033912 PMCID: PMC10076619 DOI: 10.2147/dddt.s403638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/24/2023] [Indexed: 04/04/2023] Open
Abstract
Purpose This study aims to investigate whether the administration of salbutamol/budesonide reduced the incidence of myocardial injury in thoracic surgery. Methods The randomized controlled trial included 298 patients over 45 and at high-risk for cardiovascular complications after lobectomy. Patients in the experimental group were treated with salbutamol/budesonide after anesthesia induction with fiberoptic bronchoscope. The primary outcome was the incidence rates of myocardial injury, assessed before and three days after the operation. The secondary outcome was respiratory function at each time point during the operation, including lung compliance and arterial partial pressure of oxygen, postoperative pulmonary and cardiovascular complications, hospital stay, pain score, and analgesic dosage. Results In the control group, the incidence of myocardial injury was 57/150 (38%), while that in the experimental group was 33/148 (22%); compared between the two groups, the difference in the incidence of myocardial injury was statistically significant. The dynamic compliance and static compliance at half an hour after the start of surgery in the experimental group were significantly improved. Before leaving the operating room, the difference in arterial oxygen partial pressure between the two groups was statistically significant. Conclusion Intraoperative administration of salbutamol/budesonide reduced the incidence of myocardial injury after thoracic surgery, improved lung function, and reduced the incidence of postoperative pulmonary complications.
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Affiliation(s)
- Shuchi Lin
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Ying Zhang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Xiaofan Huang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Xiaohan Zhang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Erhong Cheng
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Zhaoyun Zhou
- Department of Anesthesiology, The Affiliated Taian City Central Hospital of Qingdao University, Taian, Shandong, People’s Republic of China
| | - Jindong Liu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Correspondence: Jindong Liu, Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Huaihai Road West, Quanshan District, Xuzhou, Jiangsu, People’s Republic of China, Tel +86-13951355136, Email
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Bello C, Rössler J, Shehata P, Smilowitz NR, Ruetzler K. Perioperative strategies to reduce risk of myocardial injury after non-cardiac surgery (MINS): A narrative review. J Clin Anesth 2023; 87:111106. [PMID: 36931053 DOI: 10.1016/j.jclinane.2023.111106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/06/2023] [Accepted: 03/03/2023] [Indexed: 03/17/2023]
Abstract
Myocardial injury is a frequent complication of surgical patients after having non-cardiac surgery that is strongly associated with perioperative mortality. While intraoperative anesthesia-related deaths are exceedingly rare, about 1% of patients undergoing non-cardiac surgery die within the first 30 postoperative days. Given the number of surgeries performed annually, death following surgery is the second leading cause of death in the United States. Myocardial injury after non-cardiac surgery (MINS) is defined as an elevation in troponin concentrations within 30 days postoperatively. Although typically asymptomatic, patients with MINS suffer myocardial damage and have a 10% risk of death within 30 days after surgery and excess risks of mortality that persist during the first postoperative year. Many factors for the development of MINS are non-modifiable, such as preexistent coronary artery disease. Preventive measures, systematic approaches to surveillance and treatment standards are still lacking, however many factors are modifiable and should be considered in clinical practice: the importance of hemodynamic control, adequate oxygen supply, metabolic homeostasis, the use of perioperative medications such as statins, anti-thrombotic agents, beta-blockers, or anti-inflammatory agents, as well as some evidence regarding the choice of sedative and analgesic for anesthesia are discussed. Also, as age and complexity in comorbidities of the surgical patient population increase, there is an urgent need to identify patients at risk for MINS and develop prevention and treatment strategies. In this review, we provide an overview of current screening standards and promising preventive options in the perioperative setting and address knowledge gaps requiring further investigation.
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Affiliation(s)
- Corina Bello
- Department of Anaesthesiology and Pain Medicine, Inselspital Bern, University Hospital, University of Bern, Switzerland
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Peter Shehata
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, United States of America; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, New York, NY, United States of America
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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El Maleh Y, Fasquel C, Quesnel C, Garnier M. Updated meta-analysis on intraoperative inspired fraction of oxygen and the risk of surgical site infection in adults undergoing general and regional anesthesia. Sci Rep 2023; 13:2465. [PMID: 36774366 PMCID: PMC9922261 DOI: 10.1038/s41598-023-27588-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/04/2023] [Indexed: 02/13/2023] Open
Abstract
This updated meta-analysis aims at exploring whether the use of systematic high vs low intraoperative oxygen fraction (FiO2) may decrease the incidence of postoperative surgical site infection during general (GA) or regional anesthesia (RA). PubMed, Cochrane CENTRAL, ClinicalTrials.gov databases were searched from January 1st, 1999 and July, 1st 2022, for randomized and quasi-randomized controlled trials that included patients in a high and low FiO2 groups and reported the incidence of SSI. The meta-analysis was conducted with a DerSimonian and Laird random-effects model. Thirty studies (24 for GA and 6 for RA) totaling 18,055 patients (15,871 for GA and 2184 for RA) were included. We have low-to-moderate-quality evidence that high FiO2 (mainly 80%) was not associated with a reduction of SSI incidence compared to low FiO2 (mainly 30%) in all patients (RR 0.90, 95%CI 0.79-1.03). Moderate inconsistency existed between studies (I2 = 38%). Subgroup analyses showed a moderate protective effect in patients undergoing GA (RR 0.86, 95%CI 0.75-0.99) (low level of evidence), while high FiO2 was not associated with a reduction of SSI in patients undergoing RA (RR 1.17, 95%CI 0.90-1.52) (moderate level of evidence). Sensitivity analyses restricted to patients ventilated without nitrous oxide (n = 20 studies), to patients operated from abdominal surgeries (n = 21 studies), and to patients suffering from deep SSI (n = 13 studies), all showed the absence of any significant effect of high FiO2. As a conclusion there is no compelling evidence that high FiO2 can improve postoperative patient's outcome on its own when good SSI prevention practices are properly applied. Recent well-designed and adequately powered randomized controlled trials add further weight to these results.
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Affiliation(s)
- Yoann El Maleh
- Sorbonne University, GRC29, Assistance Publique-Hôpitaux de Paris (APHP), DMU DREAM, Anesthesiology and Critical Care Medicine Department, Tenon University Hospital, 4 rue de la Chine, 75020, Paris, France
| | - Charlotte Fasquel
- Centre Hospitalier Régional Universitaire de Brest, Service d'Anesthésie-Réanimation et Médecine Périopératoire, 29200, Brest, France
| | - Christophe Quesnel
- Sorbonne University, GRC29, Assistance Publique-Hôpitaux de Paris (APHP), DMU DREAM, Anesthesiology and Critical Care Medicine Department, Tenon University Hospital, 4 rue de la Chine, 75020, Paris, France
| | - Marc Garnier
- Sorbonne University, GRC29, Assistance Publique-Hôpitaux de Paris (APHP), DMU DREAM, Anesthesiology and Critical Care Medicine Department, Tenon University Hospital, 4 rue de la Chine, 75020, Paris, France.
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10
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Effect of Supplemental Oxygen on von Willebrand Factor Activity and Ristocetin Cofactor Activity in Patients at Risk for Cardiovascular Complications Undergoing Moderate-to High-Risk Major Noncardiac Surgery-A Secondary Analysis of a Randomized Trial. J Clin Med 2023; 12:jcm12031222. [PMID: 36769870 PMCID: PMC9918071 DOI: 10.3390/jcm12031222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Increased von Willebrand Factor (vWF) activity mediates platelet adhesion and might be a contributor to the development of thrombotic complications after surgery. Although in vitro studies have shown that hyperoxia induces endovascular damage, the effect of perioperative supplemental oxygen as a possible trigger for increased vWF activity has not been investigated yet. We tested our primary hypothesis that the perioperative administration of 80% oxygen concentration increases postoperative vWF activity as compared to 30% oxygen concentration in patients at risk of cardiovascular complications undergoing major noncardiac surgery. A total of 260 patients were randomly assigned to receive 80% versus 30% oxygen throughout surgery and for two hours postoperatively. We assessed vWF activity and Ristocetin cofactor activity in all patients shortly before the induction of anesthesia, within two hours after surgery and on the first and third postoperative day. Patient characteristics were similar in both groups. We found no significant difference in vWF activity in the overall perioperative time course between both randomization groups. We observed significantly increased vWF activity in the overall study population throughout the postoperative time course. Perioperative supplemental oxygen showed no significant effect on postoperative vWF and Ristocetin cofactor activity in cardiac risk patients undergoing major noncardiac surgery. In conclusion, we found no significant influence of supplemental oxygen in patients undergoing major non-cardiac surgery on postoperative vWF activity and Ristocetin cofactor activity.
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11
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Chadha R, Patel D, Bhangui P, Blasi A, Xia V, Parotto M, Wray C, Findlay J, Spiro M, Raptis DA. Optimal anesthetic conduct regarding immediate and short-term outcomes after liver transplantation - Systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14613. [PMID: 35147248 DOI: 10.1111/ctr.14613] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/06/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND In the era of enhanced recovery after surgery, there is significant discussion regarding the impact of intraoperative anesthetic management on short-term outcomes following liver transplantation (LT), with no clear consensus in the literature. OBJECTIVES To identify whether or not intraoperative anesthetic management affects short-term outcomes after liver transplantation. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review following PRISMA guidelines was undertaken. The systematic review was registered on PROSPERO (CRD42021239758). An international expert panel made recommendations for clinical practice using the GRADE approach. RESULTS After screening, 14 studies were eligible for inclusion in this systematic review. Six were prospective randomized clinical trials, three were prospective nonrandomized clinical trials, and five were retrospective studies. These manuscripts were reviewed to look at five questions regarding anesthetic care and its impact on short term outcomes following liver transplant. After review of the literature, the quality of evidence according to the following outcomes was as follows: intraoperative and postoperative morbidity and mortality (low), early allograft dysfunction (low), and hospital and ICU length of stay (moderate). CONCLUSIONS For optimal short term outcomes after liver transplantation, the panel recommends the use of volatile anesthetics in preference to total intravenous anesthesia (TIVA) (Level of Evidence: Very low; Strength of Recommendation: Weak) and minimum alveolar concentration (MAC) versus bispectral index (BIS) for depth of anesthesia monitoring (Level of Evidence: Very low; Strength of Recommendation: Weak). Regarding ventilation and oxygenation, the panel recommends a restrictive oxygenation strategy targeting a PaO2 of 70-120 mmHg (10-14 kPa), a tidal volume of 6-8 ml/kg ideal body weight (IBW), administration of positive end expiratory pressure (PEEP) tailored to patient intraoperative physiology, and recruitment maneuvers. (Level of evidence: Very low; Strength of Recommendation: Strong). Finally, the panel recommends the routine use of antiemetic prophylaxis. (Level of evidence: low; Strength of Recommendation: Strong).
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Affiliation(s)
- Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, USA
| | - Dhupal Patel
- Department of Anesthesia and Intensive Care Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Pooja Bhangui
- Department of Anesthesiology, Medanta Liver Institute, Gurgaon, India
| | - Annabel Blasi
- Department of Anesthesiology, Hospital Clinic Barcelona, Institut d'Insvestigacio Biomèdica Pi I Suner (IDIBAPS), Spain
| | - Victor Xia
- Department of Anesthesiology, University of California, Los Angeles, USA
| | - Matteo Parotto
- Department of Anesthesiology and Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Canada
| | - Christopher Wray
- Department of Anesthesiology, University of California, Los Angeles, USA
| | - James Findlay
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, UK
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12
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Valadkhani A, Henningsson R, Nordström JL, Granström A, Hallqvist L, Wahlgren CM, Peterzén B, Eriksson J, Bell M, Gupta A. Postoperative complications and myocardial injury in patients receiving air or oxygen. Acta Anaesthesiol Scand 2022; 66:1185-1192. [DOI: 10.1111/aas.14136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 07/21/2022] [Accepted: 08/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Arman Valadkhani
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
- Department of Pharmacology and Physiology Karolinska Institutet Stockholm Sweden
| | - Ragnar Henningsson
- Department of Anaesthesiology and Intensive Care Central Hospital Karlstad Karlstad Sweden
| | - Johan L. Nordström
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
| | - Anna Granström
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
| | - Linn Hallqvist
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
- Department of Pharmacology and Physiology Karolinska Institutet Stockholm Sweden
| | - Carl Magnus Wahlgren
- Department of Vascular Surgery Karolinska University Hospital, Department of Molecular Medicine and Surgery, Karolinska Institutet Stockholm Sweden
| | - Bengt Peterzén
- Department of Cardiovascular surgery Linköping University Linköping Sweden
| | - Julia Eriksson
- Division of Biostatistics Institute of Environmental Medicine, Karolinska Institutet Stockholm Sweden
| | - Max Bell
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
- Department of Pharmacology and Physiology Karolinska Institutet Stockholm Sweden
| | - Anil Gupta
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
- Department of Pharmacology and Physiology Karolinska Institutet Stockholm Sweden
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13
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Høybye M, Lind PC, Holmberg MJ, Bolther M, Jessen MK, Vallentin MF, Hansen FB, Holst JM, Magnussen A, Hansen NS, Johannsen CM, Enevoldsen J, Jensen TH, Roessler LL, Klitholm MP, Eggertsen MA, Caap P, Boye C, Dabrowski KM, Vormfenne L, Henriksen J, Karlsson CM, Balleby IR, Rasmussen MS, Paelestik K, Granfeldt A, Andersen LW. Fraction of Inspired Oxygen During General Anesthesia for Non-Cardiac Surgery: Systematic Review and Meta-Analysis. Acta Anaesthesiol Scand 2022; 66:923-933. [PMID: 35675085 PMCID: PMC9543529 DOI: 10.1111/aas.14102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 05/19/2022] [Accepted: 05/28/2022] [Indexed: 12/02/2022]
Abstract
Background Controversy exists regarding the effects of a high versus a low intraoperative fraction of inspired oxygen (FiO2) in adults undergoing general anesthesia. This systematic review and meta‐analysis investigated the effect of a high versus a low FiO2 on postoperative outcomes. Methods PubMed and Embase were searched on March 22, 2022 for randomized clinical trials investigating the effect of different FiO2 levels in adults undergoing general anesthesia for non‐cardiac surgery. Two investigators independently reviewed studies for relevance, extracted data, and assessed risk of bias. Meta‐analyses were performed for relevant outcomes, and potential effect measure modification was assessed in subgroup analyses and meta‐regression. The evidence certainty was evaluated using GRADE. Results This review included 25 original trials investigating the effect of a high (mostly 80%) versus a low (mostly 30%) FiO2. Risk of bias was intermediate for all trials. A high FiO2 did not result in a significant reduction in surgical site infections (OR: 0.91, 95% CI 0.81–1.02 [p = .10]). No effect was found for all other included outcomes, including mortality (OR = 1.27, 95% CI: 0.90–1.79 [p = .18]) and hospital length of stay (mean difference = 0.03 days, 95% CI −0.25 to 0.30 [p = .84). Results from subgroup analyses and meta‐regression did not identify any clear effect modifiers across outcomes. The certainty of evidence (GRADE) was rated as low for most outcomes. Conclusions In adults undergoing general anesthesia for non‐cardiac surgery, a high FiO2 did not improve outcomes including surgical site infections, length of stay, or mortality. However, the certainty of the evidence was assessed as low.
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Affiliation(s)
- Maria Høybye
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
| | - Peter Carøe Lind
- Department of Surgical Gastroenterology, Aalborg University Hospital, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark.,Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Maria Bolther
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Marie K Jessen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
| | - Mikael F Vallentin
- Department of Clinical Medicine, Aarhus University, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | | | - Johanne M Holst
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | | | - Niklas S Hansen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | | | | | - Thomas H Jensen
- Department of Internal Medicine, University Hospital of North Norway, Narvik, Norway
| | - Lara L Roessler
- Department of Emergency Medicine, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Maibritt P Klitholm
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | | | - Philip Caap
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Caroline Boye
- Department of Clinical Medicine, Aarhus University, Denmark
| | - Karol M Dabrowski
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | | | - Jeppe Henriksen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - C M Karlsson
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Denmark
| | - Ida R Balleby
- National Hospital of the Faroe Islands, Torshavn, Faroe Islands
| | - Marie S Rasmussen
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Denmark
| | - Kim Paelestik
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Lars W Andersen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
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14
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Taschner A, Kabon B, Graf A, Adamowitsch N, Falkner von Sonnenburg M, Fraunschiel M, Horvath K, Fleischmann E, Reiterer C. Perioperative Supplemental Oxygen and Postoperative Copeptin Concentrations in Cardiac-Risk Patients Undergoing Major Abdominal Surgery-A Secondary Analysis of a Randomized Clinical Trial. J Clin Med 2022; 11:jcm11082085. [PMID: 35456178 PMCID: PMC9025821 DOI: 10.3390/jcm11082085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 01/25/2023] Open
Abstract
Noncardiac surgery is associated with hemodynamic perturbations, fluid shifts and hypoxic events, causing stress responses. Copeptin is used to assess endogenous stress and predict myocardial injury. Myocardial injury is common after noncardiac surgery, and is often caused by myocardial oxygen demand-and-supply mismatch. In this secondary analysis, we included 173 patients at risk for cardiovascular complications undergoing moderate- to high-risk major abdominal surgery. Patients were randomly assigned to receive 80% or 30% oxygen throughout surgery and the first two postoperative hours. We evaluated the effect of supplemental oxygen on postoperative Copeptin concentrations. Copeptin concentrations were measured preoperatively, within two hours after surgery, on the first and third postoperative days. In total, 85 patients received 0.8 FiO2, and 88 patients received 0.3 FiO2. There was no significant difference in postoperative Copeptin concentrations between both study groups (p = 0.446). Copeptin increased significantly within two hours after surgery, compared with baseline in the overall study population (estimated effect: −241.7 pmol·L−1; 95% CI −264.4, −219.1; p < 0.001). Supplemental oxygen did not significantly attenuate postoperative Copeptin release. Copeptin concentrations showed a more immediate postoperative increase compared with previously established biomarkers. Nevertheless, Copeptin concentrations did not surpass Troponin T in early determination of patients at risk for developing myocardial injury after noncardiac surgery.
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Affiliation(s)
- Alexander Taschner
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
- Outcome Research Consortium, Cleveland, OH 44195, USA
| | - Alexandra Graf
- Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria;
| | - Nikolas Adamowitsch
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
| | - Markus Falkner von Sonnenburg
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
| | - Melanie Fraunschiel
- IT Systems and Communications, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria;
| | - Katharina Horvath
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
| | - Edith Fleischmann
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
- Outcome Research Consortium, Cleveland, OH 44195, USA
| | - Christian Reiterer
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
- Outcome Research Consortium, Cleveland, OH 44195, USA
- Correspondence: ; Tel.: +43-1-40400-20760
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15
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Perioperative Supplemental Oxygen and Plasma Catecholamine Concentrations after Major Abdominal Surgery-Secondary Analysis of a Randomized Clinical Trial. J Clin Med 2022; 11:jcm11071767. [PMID: 35407374 PMCID: PMC9000182 DOI: 10.3390/jcm11071767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 11/30/2022] Open
Abstract
Perioperative stress is associated with increased sympathetic activity that leads to increases in heart rate and blood pressure, which are associated with the development of perioperative myocardial ischemia. In healthy volunteers, it was shown that the administration of supplemental oxygen attenuated sympathetic nerve activity and subsequently led to lower plasma catecholamine concentrations. We therefore tested the hypothesis that perioperative supplemental oxygen attenuates sympathetic nerve in patients at risk for cardiovascular complications undergoing major abdominal surgery. We randomly assigned 81 patients to receive either 80% or 30% inspired oxygen concentration throughout surgery and the first two postoperative hours. We assessed noradrenaline, adrenaline, and dopamine plasma concentrations before the induction of anesthesia, two hours after surgery and on the third postoperative day. There was no significant difference in postoperative noradrenaline (effect estimated: −41.5 ng·L−1, 95%CI −134.3, 51.2; p = 0.38), adrenaline (effect estimated: 11.2 ng·L−1, 95%CI −7.6, 30.1; p = 0.24), and dopamine (effect estimated: −1.61 ng·L−1, 95%CI −7.2, 3.9; p = 0.57) concentrations between both groups. Based on our results, it seems unlikely that supplemental oxygen influences endogenous catecholamine release in the perioperative setting.
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16
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Reiterer C, Kabon B, Taschner A, Adamowitsch N, Graf A, Fraunschiel M, Horvath K, Kuhrn M, Clement T, Treskatsch S, Berger C, Fleischmann E. Effect of perioperative levosimendan administration on postoperative N-terminal pro-B-type natriuretic peptide concentration in patients with increased cardiovascular risk factors undergoing non-cardiac surgery: protocol for the double-blind, randomised, placebo-controlled IMPROVE trial. BMJ Open 2022; 12:e058216. [PMID: 35063963 PMCID: PMC8785196 DOI: 10.1136/bmjopen-2021-058216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Elevated N-terminal pro-brain natriuretic peptide (NT-pro-BNP) after non-cardiac surgery is a strong predictor for cardiovascular complications and reflects increased myocardial strain. NT-pro-BNP concentrations significantly rise after non-cardiac surgery within the first 3 days. Levosimendan is a potent inotropic drug that increases calcium sensitivity to cardiac myocytes, which results in improved cardiac contractility that last for approximately 7 days. Thus, we will test the effect of a pre-emptive perioperative administration of levosimendan on postoperative NT-pro-BNP concentration as compared with the administration of a placebo in patients undergoing moderate-risk to high-risk major abdominal surgery. METHODS AND ANALYSIS We will conduct a double-blinded prospective randomised trial at the Medical University of Vienna, Vienna, Austria (and potentially a second centre in Germany), including 230 patients at-risk for cardiovascular complications undergoing moderate- to high-risk major abdominal surgery. Patients will be randomly assigned to receive a single dose of 12.5 mg levosimendan versus placebo after induction of anaesthesia. The primary outcome will be the postoperative maximum NT-pro-BNP concentration between both group within the first three postoperative days. Our secondary outcomes will be the incidence of myocardial ischaemia, myocardial injury after non-cardiac surgery and a composite of myocardial infarction and death within 30 days and 1 year after surgery between both groups. Our further secondary outcome will be stratification of NT-pro-BNP values according to previously thresholds to predict mortality of myocardial infarction after surgery. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of the Medical University of Vienna on 14 July 2020 (EK 2187/2019). Written informed consent will be obtained from all patients a day before surgery. Results of this study will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04329624.
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Affiliation(s)
- Christian Reiterer
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Outcome Research Consortium, Cleveland, Ohio, USA
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Alexander Taschner
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Nikolas Adamowitsch
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Alexandra Graf
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Wien, Austria
| | - Melanie Fraunschiel
- ITSC - IT Systems & Communications, Medical University of Vienna, Wien, Austria
| | - Katharina Horvath
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Melanie Kuhrn
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Theresa Clement
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Christian Berger
- Department of Anesthesiology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
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17
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Reiterer C, Fleischmann E, Taschner A, Adamowitsch N, von Sonnenburg MF, Graf A, Fraunschiel M, Starlinger P, Goschin J, Kabon B. Perioperative supplemental oxygen and oxidative stress in patients undergoing moderate- to high-risk major abdominal surgery - A subanalysis of randomized clinical trial. J Clin Anesth 2021; 77:110614. [PMID: 34856530 DOI: 10.1016/j.jclinane.2021.110614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/31/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE Oxidative stress plays a pivotal role in the development and aggravation of cardiovascular diseases. The influence of intraoperative inspired oxygen concentrations on oxidative stress is still not entirely known. Therefore, we evaluated in this sub-study if supplemental oxygen affects the oxidation-reduction potential in patients at-risk for cardiovascular complications undergoing moderate- to high-risk major abdominal surgery. DESIGN Sub-study of a prospective parallel-arm double-blinded single-center superiority randomized trial. SETTING Operating room and postoperative recovery area. INTERVENTION Administration of 0.8 FiO2 versus 0.3 FiO2 throughout surgery and for the first two postoperative hours. MEASUREMENTS The primary outcome was the static oxidation-reduction potential (sORP) and the oxidation-reduction potential capacity (cORP) between both groups. The secondary outcome was the trend of sORP and cORP in the overall study population. We assessed sORP and cORP before induction of anesthesia, 2 h after induction of anesthesia, within 2 h after surgery and on the first and third postoperative day. MAIN RESULTS 258 patients were analyzed. 128 patients were randomly assigned to the 80% oxygen group and 130 patients were randomly assigned to the 30% oxygen group. Postoperative sORP values did not differ significantly between the 80% and 30% oxygen group (effect estimate: -1.162 mV,95% CI: -2.584 to 0.260; p = 0.109). On average, we observed a change in sORP of 5.288 mV (95% CI:4.633 to 5.913, p < 0.001) per day. cORP values did not differ significantly between the 80% and 30% oxygen group (effect estimate: -0.015μC, (95%CI: -0.062 to 0.032; p = 0.524). On average, we observed a change in cORP values of -0.170μC (95%CI: -0.194 to -0.147, p < 0.001) per day. CONCLUSION In contrast to previous reports, we could not find any evidence of an association between intraoperative supplemental oxygen and perioperative oxidative stress assessed by sORP and cORP. TRIAL REGISTRATION clinicaltrials.gov: NCT03366857https://clinicaltrials.gov/ct2/show/NCT03366857?term=vienna&cond=oxygen&draw=2&rank=1.
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Affiliation(s)
- Christian Reiterer
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria; Outcomes Research Consortium, Cleveland, OH, USA
| | - Edith Fleischmann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Alexander Taschner
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Nikolas Adamowitsch
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Markus Falkner von Sonnenburg
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Alexandra Graf
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, 1090 Vienna, Austria
| | - Melanie Fraunschiel
- IT Systems and Communications, Medical University of Vienna, 1090 Vienna, Austria
| | - Patrick Starlinger
- Department of Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Julius Goschin
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria; Outcomes Research Consortium, Cleveland, OH, USA
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Oxygen: Can you have too much of a good thing? J Clin Anesth 2021; 74:110405. [PMID: 34171714 DOI: 10.1016/j.jclinane.2021.110405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 11/20/2022]
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