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White MJ, Zaccaria I, Ennahdi-Elidrissi F, Putzu A, Dimassi S, Luise S, Diaper J, Mulin S, Baudat AD, Gil-Wey B, Elia N, Walder B, Bollen Pinto B. Personalised perioperative dosing of ivabradine in noncardiac surgery: a single-centre, randomised, placebo-controlled, double-blind feasibility pilot trial. Br J Anaesth 2024; 133:738-747. [PMID: 38960832 DOI: 10.1016/j.bja.2024.05.020] [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: 01/02/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Perioperative myocardial injury after noncardiac surgery is associated with postoperative mortality. Heart rate (HR) is an independent risk factor for perioperative myocardial injury. In this pilot trial we tested the feasibility of a randomised, placebo-controlled trial of personalised HR-targeted perioperative ivabradine. METHODS This was a single-centre, randomised, placebo-controlled, double-blind, parallel group, feasibility pilot trial conducted at Geneva University Hospitals. We included patients ≥75 yr old or ≥45 yr old with cardiovascular risk factors planned for intermediate- or high-risk surgery. Patients were randomised to receive ivabradine (2.5, 5.0, or 7.5 mg) or placebo according to their HR, twice daily, from the morning of surgery until postoperative day 2. Primary outcomes were appropriate dosage and blinding success rates. RESULTS Between October 2020 and January 2022, we randomised 78 patients (recruitment rate of 1.3 patients week-1). Some 439 of 444 study drug administrations were adequate (99% appropriate dosage rate). The blinding success rate was 100%. There were 137 (31%) administrations of Pill A (placebo in both groups for HR ≤70 beats min-1). Nine (11.5%) patients had a high-sensitive cardiac troponin T elevation ≥14 ng L-1 between any two measurements. The number of bradycardia episodes was eight in the placebo group and nine in the ivabradine group. CONCLUSIONS This pilot study demonstrates the feasibility of, and provides guidance for, a future trial testing the efficacy of personalised perioperative ivabradine. Future studies should include patients at higher risk of cardiac complications. CLINICAL TRIAL REGISTRATION NCT04436016.
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Affiliation(s)
- Marion J White
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Isabelle Zaccaria
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Florence Ennahdi-Elidrissi
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Putzu
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Saoussen Dimassi
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphane Luise
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - John Diaper
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphanie Mulin
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Aurélie D Baudat
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Béatrice Gil-Wey
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nadia Elia
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernhard Walder
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernardo Bollen Pinto
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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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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Yamamura K, Murakami K, Hirata Y, Toeda Y, Kimura Y, Minemura C, Yokoe H. Assessing the Risks and Benefits of Hypotensive Anesthesia and Piezosurgical Instruments in Bimaxillary Surgery. Cureus 2024; 16:e67394. [PMID: 39310406 PMCID: PMC11414514 DOI: 10.7759/cureus.67394] [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] [Accepted: 08/21/2024] [Indexed: 09/25/2024] Open
Abstract
The challenge in bimaxillary surgery lies in significant intraoperative bleeding, prompting various strategies to minimize blood loss. Among the methods considered for controlling intraoperative bleeding, hypotensive anesthesia and the use of piezosurgical instruments (Osada, Tokyo, Japan) have been explored. However, hypotensive anesthesia may have adverse effects on cardiac function, and surgical time is likely to be prolonged when using piezosurgical instruments. This study retrospectively examined whether the combined use of hypotensive anesthesia and piezosurgical instruments reduces intraoperative bleeding and whether the combination impacts cardiac function. The combination of hypotensive anesthesia and piezosurgical instruments significantly reduced intraoperative bleeding. Furthermore, the combination was associated with a significantly higher incidence of tachycardia, particularly with the use of nicardipine. Additionally, the combination significantly lengthened the duration of the surgery and may have increased the burden on cardiac function. Landiolol was effectively employed to manage tachycardia. When selecting hypotensive anesthesia as a means to limit bleeding, proactive preparation and preventive small-dose administration of landiolol could be beneficial in managing the potential occurrence of tachycardia.
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Affiliation(s)
- Koji Yamamura
- Oral and Maxillofacial Surgery, National Defense Medical College, Tokorozawa, JPN
- Dentistry, Self-Defense Forces Central Hospital, Setagaya, JPN
| | - Kaoru Murakami
- Oral and Maxillofacial Surgery, National Defense Medical College, Tokorozawa, JPN
| | - Yosuke Hirata
- Oral and Maxillofacial Surgery, National Defense Medical College, Tokorozawa, JPN
| | - Yuriko Toeda
- Oral and Maxillofacial Surgery, National Defense Medical College, Tokorozawa, JPN
| | - Yasushi Kimura
- Oral and Maxillofacial Surgery, Fukaya Red Cross Hospital, Fukaya, JPN
- Oral and Maxillofacial Surgery, Fukaya Red Cross Hospital, Fukaya, JPN
| | - Chikashi Minemura
- Oral and Maxillofacial Surgery, National Defense Medical College, Tokorozawa, JPN
| | - Hidetaka Yokoe
- Oral and Maxillofacial Surgery, National Defense Medical College, Tokorozawa, JPN
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4
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Kampman JM, Hermanides J, Hollmann MW, Gilhuis CN, Bloem WAH, Schraag S, Pradelli L, Repping S, Sperna Weiland NH. Mortality and morbidity after total intravenous anaesthesia versus inhalational anaesthesia: a systematic review and meta-analysis. EClinicalMedicine 2024; 72:102636. [PMID: 38774674 PMCID: PMC11106536 DOI: 10.1016/j.eclinm.2024.102636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/24/2024] Open
Abstract
Background General anaesthesia is provided to more than 300 million surgical patients worldwide, every year. It is administered either through total intravenous anaesthesia, using only intravenous agents, or through inhalational anaesthesia, using volatile anaesthetic agents. The debate on how this affects postoperative patient outcome is ongoing, despite an abundance of published trials. The relevance of this topic has grown by the increasing concern about the contribution of anaesthetic gases to the environmental impact of surgery. We aimed to summarise all available evidence on relevant patient outcomes with total intravenous anaesthesia versus inhalational anaesthesia. Methods In this systematic review and meta-analysis, we searched PubMed/Medline, Embase and Cochrane Central Register of Controlled trials for works published from January 1, 1985 to August 1, 2023 for randomised controlled trials comparing total intravenous anaesthesia using propofol versus inhalational anaesthesia using the volatile anaesthetics sevoflurane, desflurane or isoflurane. Two reviewers independently screened titles, abstracts and full text articles, and assessed risk of bias using the Cochrane Collaboration tool. Outcomes were derived from a recent series of publications on consensus definitions for Standardised Endpoints for Perioperative trials (StEP). Primary outcomes covered mortality and organ-related morbidity. Secondary outcomes were related to anaesthetic and surgical morbidity. This study is registered with PROSPERO (CRD42023430492). Findings We included 317 randomised controlled trials, comprising 51,107 patients. No difference between total intravenous and inhalational anaesthesia was seen in the primary outcomes of in-hospital mortality (RR 1.05, 95% CI 0.67-1.66, 27 trials, 3846 patients), 30-day mortality (RR 0.97, 95% CI 0.70-1.36, 23 trials, 9667 patients) and one-year mortality (RR 1.14, 95% CI 0.88-1.48, 13 trials, 9317 patients). Organ-related morbidity was similar between groups except for the subgroup of elderly patients, in which total intravenous anaesthesia was associated with a lower incidence of postoperative cognitive dysfunction (RR 0.62, 95% CI 0.40-0.97, 11 trials, 3834 patients) and a better score on postoperative cognitive dysfunction tests (standardised mean difference 1.68, 95% CI 0.47-2.88, 9 trials, 4917 patients). In the secondary outcomes, total intravenous anaesthesia resulted in a lower incidence of postoperative nausea and vomiting (RR 0.61, 95% CI 0.56-0.67, 145 trials, 23,172 patients), less emergence delirium (RR 0.40, 95% CI 0.29-0.56, 32 trials, 4203 patients) and a higher quality of recovery score (QoR-40 mean difference 6.45, 95% CI 3.64-9.25, 17 trials, 1835 patients). Interpretation The results indicate that postoperative mortality and organ-related morbidity was similar for intravenous and inhalational anaesthesia. Total intravenous anaesthesia offered advantages in postoperative recovery. Funding Dutch Society for Anaesthesiology (NVA).
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Affiliation(s)
- Jasper M. Kampman
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Markus W. Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | | | | | | | - Sjoerd Repping
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Healthcare Evaluation and Appropriate Use, National Healthcare Institute, Diemen, the Netherlands
| | - Nicolaas H. Sperna Weiland
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, the Netherlands
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5
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Chohan M, Liu W, Chowdhury T. Perioperative adverse cardiac events in maxillofacial surgery: A systematic review and meta-analysis. Indian J Anaesth 2024; 68:426-438. [PMID: 38764965 PMCID: PMC11100642 DOI: 10.4103/ija.ija_1206_23] [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: 12/14/2023] [Revised: 02/29/2024] [Accepted: 03/10/2024] [Indexed: 05/21/2024] Open
Abstract
Background and Aims Maxillofacial surgeries, including procedures to the face, oral cavity, jaw, and head and neck, are common in adults. However, they impose a risk of adverse cardiac events (ACEs). While ACEs are well understood for other non-cardiac surgeries, there is a paucity of data about maxillofacial surgeries. This systematic review and meta-analysis report the incidence and presentation of perioperative ACEs during maxillofacial surgery. Methods We included primary studies that reported on perioperative ACEs in adults. To standardise reporting, ACEs were categorised as 1. heart rate and rhythm disturbances, 2. blood pressure disturbances, 3. ischaemic heart disease and 4. heart failure and other complications. The primary outcome was ACE presentation and incidence during the perioperative period. Secondary outcomes included the surgical outcome according to the Clavien-Dindo classification and trigeminocardiac reflex involvement. STATA version 17.0 and MetaProp were used to delineate proportion as effect size with a 95% confidence interval (CI). Results Twelve studies (34,227 patients) were included. The incidence of perioperative ACEs was 2.58% (95% CI 1.70, 3.45, I2 = 96.17%, P = 0.001). Heart rate and rhythm disturbances resulted in the greatest incidence at 3.84% among the four categories. Most commonly, these ACEs resulted in intensive care unit admission (i.e. Clavien-Dindo score of 4). Conclusion Despite an incidence of 2.58%, ACEs can disproportionately impact surgical outcomes. Future research should include large-scale prospective studies that may provide a better understanding of the contributory factors and long-term effects of ACEs in patients during maxillofacial surgery.
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Affiliation(s)
- Mehak Chohan
- Department of Health Science, Queen's University, Kingston, ON, Canada
| | - Winnie Liu
- Michael G. DeGroote School of Medicine, McMaster, Hamilton, ON, Canada
| | - Tumul Chowdhury
- Department of Anaesthesiology and Pain Medicine, Toronto Western Hospital, Toronto, ON, Canada
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6
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Rowland BA, Motamedi V, Michard F, Saha AK, Khanna AK. Impact of continuous and wireless monitoring of vital signs on clinical outcomes: a propensity-matched observational study of surgical ward patients. Br J Anaesth 2024; 132:519-527. [PMID: 38135523 DOI: 10.1016/j.bja.2023.11.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Continuous and wireless vital sign monitoring is superior to intermittent monitoring in detecting vital sign abnormalities; however, the impact on clinical outcomes has not been established. METHODS We performed a propensity-matched analysis of data describing patients admitted to general surgical wards between January 2018 and December 2019 at a single, tertiary medical centre in the USA. The primary outcome was a composite of in-hospital mortality or ICU transfer during hospitalisation. Secondary outcomes were the odds of individual components of the primary outcome, and heart failure, myocardial infarction, acute kidney injury, and rapid response team activations. Data are presented as odds ratios (ORs) with 95% confidence intervals (CIs) and n (%). RESULTS We initially screened a population of 34,636 patients (mean age 58.3 (Range 18-101) yr, 16,456 (47.5%) women. After propensity matching, intermittent monitoring (n=12 345) was associated with increased risk of a composite of mortality or ICU admission (OR 3.42, 95% CI 3.19-3.67; P<0.001), and heart failure (OR 1.48, 95% CI 1.21-1.81; P<0.001), myocardial infarction (OR 3.87, 95% CI 2.71-5.71; P<0.001), and acute kidney injury (OR 1.32, 95% CI 1.09-1.57; P<0.001) compared with continuous wireless monitoring (n=7955). The odds of rapid response team intervention were similar in both groups (OR 0.86, 95% CI 0.79-1.06; P=0.726). CONCLUSIONS Patients who received continuous ward monitoring were less likely to die or be admitted to ICU than those who received intermittent monitoring. These findings should be confirmed in prospective randomised trials.
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Affiliation(s)
- Bradley A Rowland
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Vida Motamedi
- Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Anesthesiology, Vanderbilt School of Medicine, Nashville, TN, USA
| | | | - Amit K Saha
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA.
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Elias M, Tateosian VS, Richman DC. What's New in Preoperative Cardiac Testing. Anesthesiol Clin 2024; 42:9-25. [PMID: 38278596 DOI: 10.1016/j.anclin.2023.10.001] [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] [Indexed: 01/28/2024]
Abstract
More than 300 million surgeries are performed annually worldwide. Patients are progressively aging and often have multiple comorbidities that put them at increased cardiovascular risk in the perioperative period. The United States published latest guidelines regarding preoperative cardiac evaluation and risk stratification for patients undergoing non-cardiac surgery in 2014. There are multiple risk stratification tools available that can help guide management. Furthermore, newer laboratory tests, such as preoperative NT-proBNP and high-sensitivity troponin assays, may aid in preventing and diagnosing perioperative myocardial injury.
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Affiliation(s)
- Murad Elias
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Health Sciences Center, Level 4, 101 Nicolls Road, Stony Brook, NY 11794-8480, USA.
| | - Vahé S Tateosian
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Health Sciences Center, Level 4, 101 Nicolls Road, Stony Brook, NY 11794-8480, USA
| | - Deborah C Richman
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Health Sciences Center, Level 4, 101 Nicolls Road, Stony Brook, NY 11794-8480, USA
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8
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Baron Shahaf D, Abergel E, Sivan Hoffmann R, Meirovitch E, Konstadt S, Feierman DE, Derman R, Shahaf G. Evaluating a Novel EEG-Based Index for Stroke Detection Under Anesthesia During Mechanical Thrombectomy. J Neurosurg Anesthesiol 2024; 36:60-68. [PMID: 36730962 DOI: 10.1097/ana.0000000000000889] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 08/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The rapid identification of acute stroke (AS) during and after anesthesia might lead to early interventions and improved outcomes. We investigated a novel 2-channel electroencephalogram (EEG)-based marker for stroke detection-the lateral interconnection ratio (LIR)-in AS patients having endovascular thrombectomy (EVT) with general anesthesia (GA) or sedation. The LIR in 2 reference groups of patients without postoperative neurological complications was used for comparison. METHODS The National Institutes of Health stroke scale score was assessed before and after thrombectomy in 100 patients having EVT with GA or sedation. The EEG was monitored during and for 4 hours following EVT in the AS group and during surgery in the 2 reference groups. We compared: (1) LIR between AS and reference groups; (2) LIR and stroke dynamics (clinical improvement or deterioration after EVT assessed by the National Institutes of Health stroke scale score); (3) the impact of stroke site (anterior vs. posterior circulation) and anesthesia type (GA vs. sedation) on the LIR. RESULTS Median (interquartile range) LIR was lower in patients with AS compared with reference patients (0.09, 0.05 to 0.16 vs. 0.39, 0.24 to 0.52, respectively; P <0.000002), and LIR increased in AS patients whose clinical status recovered after EVT compared with nonrecovered patients (0.20, 0.12 to 0.29 vs. 0.09, 0.05 to 0.11, respectively; P <0.007). The LIR might be more sensitive to anterior circulation stroke but is not impacted by anesthesia type. CONCLUSIONS We demonstrated the utility of using AS patients undergoing EVT as a platform for assessing a novel EEG marker for the identification of stroke during anesthesia. Further, large-scale studies in AS patients during EVT and in patients undergoing different surgeries and anesthesia are required to validate the LIR.
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Affiliation(s)
| | | | | | | | | | - Dennis E Feierman
- Department of Anesthesiology
- IRB, Maimonides Medical Center, Brooklyn NY
| | | | - Goded Shahaf
- Applied Neurophysiology Lab, Rambam Health Care Campus, Haifa
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Wahlstrøm KL, Ekeloef S, Gögenur I, Münster AMB. Myocardial injury after non-cardiac surgery and per operative fibrin metabolism in patients undergoing hip-fracture surgery: an observational study. Scand J Clin Lab Invest 2023; 83:299-308. [PMID: 37584362 DOI: 10.1080/00365513.2023.2220970] [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: 12/14/2022] [Revised: 05/20/2023] [Accepted: 05/29/2023] [Indexed: 08/17/2023]
Abstract
Myocardial injury after non-cardiac surgery (MINS) is associated with a 2-3-fold increased risk of subsequent major cardiovascular events and postoperative mortality. The pathological mechanism behind MINS is not fully uncovered. We hypothesized that patients with MINS following hip fracture surgery would have an altered haemostatic balance pre- and postoperative compared with patients without MINS. This was investigated in a prospective single-centre observational study including patients consecutively. The outcomes were changes in thrombin generation, fibrinogen/fibrin turnover, tissue plasminogen activator, plasminogen activator inhibitor-1 and fibrin structure measurements in patients developing MINS and patients who did not. Outcomes were measured preoperatively and two hours postoperatively. Seventy-two patients were included whereof 26 (36%) patients developed MINS. D-dimer delta values were significantly higher in patients developing MINS than in patients who did not (p = 0.01). After adjusting for age, sex, smoking, alcohol abuse, atrial fibrillation, anticoagulant medication preoperative CRP, preoperative creatinine and duration of surgery, the association remained significant (p = 0.04). There were no significant changes in thrombin generation, in markers of fibrinogen/fibrin turnover besides D-dimer, or in fibrin structure measurements pre- and postoperatively between patients with and without MINS. As such, a relationship between the coagulative and fibrinolytic activity and MINS cannot be ruled out in patients with MINS after hip fracture surgery. Registration: The study was an observational sub-study to a multicentre randomised clinical trial registered at ClinicalTrials.gov (NCT02344797).
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Affiliation(s)
- Kirsten L Wahlstrøm
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - Sarah Ekeloef
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark
- Institute for Clinical Medicine, Copenhagen University, Denmark
| | - Anna-Marie B Münster
- Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Biochemistry, Regional Hospital West Jutland, Holstebro, Denmark
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10
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Haidar S, Vazquez R, Medic G. Impact of surgical complications on hospital costs and revenues: retrospective database study of Medicare claims. J Comp Eff Res 2023; 12:e230080. [PMID: 37350467 PMCID: PMC10508298 DOI: 10.57264/cer-2023-0080] [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: 01/26/2023] [Accepted: 05/16/2023] [Indexed: 06/24/2023] Open
Abstract
Aim: To compare the length of stay, hospital costs and hospital revenues for Medicare patients with and without a subset of potentially preventable postoperative complications after major noncardiac surgery. Materials & methods: Retrospective data analysis using the Medicare Standard Analytical Files, Limited Data Set, 5% inpatient claims files for years 2016-2020. Results: In 74,103 claims selected for analysis, 71,467 claims had no complications and 2636 had one or more complications of interest. Claims with complications had significantly longer length of hospital stay (12.41 vs 3.95 days, p < 0.01), increased payments to the provider ($34,664 vs $16,641, p < 0.01) and substantially higher estimates of provider cost ($39,357 vs $16,158, p < 0.01) compared with claims without complications. This results on average in a negative difference between payments and costs for patients with complications compared with a positive difference for claims without complications (-$4693 vs $483, p < 0.01). Results were consistent across three different cost estimation methods used in the study. Conclusion: Compared with patients without postoperative complications, patients developing complications stay longer in the hospital and incur increased costs that outpace the increase in received payments. Complications are therefore costly to providers and payers, may negatively impact hospital profitability, and decrease the quality of life of patients. Quality initiatives aimed at reducing complications can be immensely valuable for both improving patient outcomes and hospital finances.
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Affiliation(s)
- Samer Haidar
- Advanced Algorithm Research Center, Philips, Cambridge, MA 02141, USA
| | - Reynaldo Vazquez
- Chief Medical Office, Philips, Eindhoven, 5656AG, The Netherlands
| | - Goran Medic
- Chief Medical Office, Philips, Eindhoven, 5656AG, The Netherlands
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11
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Maisat W, Yuki K. Narrative review of systemic inflammatory response mechanisms in cardiac surgery and immunomodulatory role of anesthetic agents. Ann Card Anaesth 2023; 26:133-142. [PMID: 37706376 PMCID: PMC10284469 DOI: 10.4103/aca.aca_147_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 12/05/2022] [Accepted: 12/18/2022] [Indexed: 09/15/2023] Open
Abstract
Although surgical techniques and perioperative care have made significant advances, perioperative mortality in cardiac surgery remains relatively high. Single- or multiple-organ failure remains the leading cause of postoperative mortality. Systemic inflammatory response syndrome (SIRS) is a common trigger for organ injury or dysfunction in surgical patients. Cardiac surgery involves major surgical dissection, the use of cardiopulmonary bypass (CPB), and frequent blood transfusions. Ischemia-reperfusion injury and contact activation from CPB are among the major triggers for SIRS. Blood transfusion can also induce proinflammatory responses. Here, we review the immunological mechanisms of organ injury and the role of anesthetic regimens in cardiac surgery.
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Affiliation(s)
- Wiriya Maisat
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
- Department of Immunology, Harvard Medical School, Boston, USA
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Koichi Yuki
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
- Department of Immunology, Harvard Medical School, Boston, USA
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Wahlstrøm KL, Hansen HF, Kvist M, Burcharth J, Lykkesfeldt J, Gögenur I, Ekeloef S. Effect of Remote Ischaemic Preconditioning on Perioperative Endothelial Dysfunction in Non-Cardiac Surgery: A Randomised Clinical Trial. Cells 2023; 12:cells12060911. [PMID: 36980253 PMCID: PMC10047371 DOI: 10.3390/cells12060911] [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: 11/14/2022] [Revised: 02/24/2023] [Accepted: 03/11/2023] [Indexed: 03/18/2023] Open
Abstract
Endothelial dysfunction result from inflammation and excessive production of reactive oxygen species as part of the surgical stress response. Remote ischemic preconditioning (RIPC) potentially exerts anti-oxidative and anti-inflammatory properties, which might stabilise the endothelial function after non-cardiac surgery. This was a single centre randomised clinical trial including 60 patients undergoing sub-acute laparoscopic cholecystectomy due to acute cholecystitis. Patients were randomised to RIPC or control. The RIPC procedure consisted of four cycles of five minutes of ischaemia and reperfusion of one upper extremity. Endothelial function was assessed as the reactive hyperaemia index (RHI) and circulating biomarkers of nitric oxide (NO) bioavailability (L-arginine, asymmetric dimethylarginine (ADMA), L-arginine/ADMA ratio, tetra- and dihydrobiopterin (BH4 and BH2), and total plasma biopterin) preoperative, 2–4 h after surgery and 24 h after surgery. RHI did not differ between the groups (p = 0.07). Neither did levels of circulating biomarkers of NO bioavailability change in response to RIPC. L-arginine and L-arginine/ADMA ratio was suppressed preoperatively and increased 24 h after surgery (p < 0.001). The BH4/BH2-ratio had a high preoperative level, decreased 2–4 h after surgery and remained low 24 h after surgery (p = 0.01). RIPC did not influence endothelial function or markers of NO bioavailability until 24 h after sub-acute laparoscopic cholecystectomy. In response to surgery, markers of NO bioavailability increased, and oxidative stress decreased. These findings support that a minimally invasive removal of the inflamed gallbladder countereffects reduced markers of NO bioavailability and increased oxidative stress caused by acute cholecystitis.
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Affiliation(s)
- Kirsten L. Wahlstrøm
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
- Correspondence:
| | - Hannah F. Hansen
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
| | - Madeline Kvist
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
| | - Jakob Burcharth
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
| | - Jens Lykkesfeldt
- Section of Experimental Animal Models, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Ridebanevej 9, 1871 Frederiksberg C, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Sarah Ekeloef
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
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13
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Oliver JB, McFarlane JL, Kunac A, Anjaria DJ. Declining Resident Surgical Autonomy and Improving Surgical Outcomes: Correlation Does Not Equal Causality. JOURNAL OF SURGICAL EDUCATION 2023; 80:434-441. [PMID: 36335032 DOI: 10.1016/j.jsurg.2022.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/06/2022] [Accepted: 10/16/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The volume of cases that residents perform independently have decreased leaving graduating chief residents less prepared for independent practice. Outcomes are not worse when residents are given autonomy with appropriate supervision, however it is unknown if outcomes are worsening with decreasing operative autonomy experience. We hypothesize that resident autonomous cases parallel the improving outcomes in surgical care over time, however, are less complex and on lower acuity patients. DESIGN Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING Operative cases performed on teaching services within the VASQIP database from July 1, 2004 to September 30, 2019, were included. PARTICIPANTS All adult patients who underwent a surgical procedure from July 1, 2004, to September 30, 2019, at a VA hospital on a service that included residents were initially included. After inclusions and exclusions, there were 1,346,461 cases. Cases were divided into 3 sequential 5 year eras (ERA 1: 2004-2008 n = 415,614, ERA 2: 2009-2013 n = 478,528, and ERA 3: 2014-2019 n = 452,319). The main exposure of interest was level of resident supervision, coded at the time of procedure as: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). We compared 30 day all-cause mortality, composite morbidity, work relative value unit (wRVU), hospital length of stay, and operative time between each ERA for RP cases, as well as within each ERA for RP cases compared to AR and AP cases. RESULTS There was a progressive decline in the rate of RP cases in each successive ERA (ERA 1: 58,249 (14.0%) vs ERA 2: 47,891 (10.0%) vs ERA 3: 35,352 (7.8%), p < 0.001). For RP cases, patients were progressively getting older (60 yrs [53-71] vs 63 yrs [54-69] vs 66 yrs [57-72], p < 0.001) and sicker (ASA 3 58.7% vs 62.5% vs 66.2% and ASA 4/5 8.4% vs 9.6% vs10.0%, p < 0.001). Odds of mortality decreased in each ERA compared to the previous (aOR 0.71 [0.62-0.80] ERA 2 vs ERA 1 and 0.82 [0.70-0.97] ERA 3 vs ERA 2) as did morbidity (0.77 [0.73-0.82] ERA 2 vs ERA 1 and 0.72 [0.68-0.77] ERA 3 vs ERA 2). Operative and length of stay also decreased while wRVU stayed unchanged. When comparing RP cases to AP and AR within each ERA, RP cases tended to be on younger and healthier patients with a lower wRVU, particularly compared to AR cases. Mortality and morbidity were no different or better in RP compared to AR and AP. CONCLUSIONS Despite resident autonomy decreasing, outcomes in cases where they are afforded autonomy are improving over time. This despite RP cases being on sicker and older patients and performing roughly the same complexity of cases. They also continue to perform no worse than cases with higher levels of supervision. Efforts to increase surgical resident operative autonomy are still needed to improve readiness for independent practice.
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Affiliation(s)
- Joseph B Oliver
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey.
| | - Jamal L McFarlane
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
| | - Anastasia Kunac
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
| | - Devashish J Anjaria
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
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14
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Ramamoorthy V, Chan K, Appunni S, Zhang Z, Ahmed MA, McGranaghan P, Saxena A, Rubens M. Prevalence and trends of perioperative major adverse cardiovascular and cerebrovascular events during cancer surgeries. Sci Rep 2023; 13:2410. [PMID: 36765154 PMCID: PMC9918731 DOI: 10.1038/s41598-023-29632-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
Major adverse cardiovascular and cerebrovascular events (MACCE) is an important cause of morbidity and mortality during perioperative period. In this study, we looked for national trends in perioperative MACCE and its components as well as cancer types associated with high rates of perioperative MACCE during major cancer surgeries. This study was a retrospective analysis of the National Inpatient Sample, 2005-2014. Hospitalizations for surgeries of prostate, bladder, esophagus, pancreas, lung, liver, colorectal, and breast among patients 40 years and greater were included in the analysis. MACCE was defined as a composite measure that included in-hospital all-cause mortality, acute myocardial infarction (AMI), and ischemic stroke. A total of 2,854,810 hospitalizations for major surgeries were included in this study. Of these, 67,316 (2.4%) had perioperative MACCE. Trends of perioperative MACCE showed that it decreased significantly for AMI, death and any MACCE, while stroke did not significantly change during the study period. Logistic regression analysis for perioperative MACCE by cancer types showed that surgeries for esophagus, pancreas, lung, liver, and colorectal cancers had significantly greater odds for perioperative MACCE. The surgeries identified to have greater risks for MACCE in this study could be risk stratified for better informed decision-making and management.
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Affiliation(s)
| | - Kelvin Chan
- Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Davie, FL, USA
| | | | - Zhenwei Zhang
- Miami Cancer Institute, Baptist Health South Florida, 8900 N Kendall Dr, Miami, FL, 33176, USA
| | - Md Ashfaq Ahmed
- Miami Cancer Institute, Baptist Health South Florida, 8900 N Kendall Dr, Miami, FL, 33176, USA
| | - Peter McGranaghan
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität Zu Berlin, 10117, Berlin, Germany.
| | - Anshul Saxena
- Miami Cancer Institute, Baptist Health South Florida, 8900 N Kendall Dr, Miami, FL, 33176, USA
| | - Muni Rubens
- Miami Cancer Institute, Baptist Health South Florida, 8900 N Kendall Dr, Miami, FL, 33176, USA.
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15
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Bartels K, Howard-Quijano K, Prin M, Shaefi S, Steppan J, Sun EC, Williams B, Fox AA, Namuyonga J, Shaw AD, Vavilala MS, Sessler DI. Meeting Report: First Cardiovascular Outcomes Research in Perioperative Medicine Conference. Anesth Analg 2023; 136:418-420. [PMID: 36638519 PMCID: PMC9846581 DOI: 10.1213/ane.0000000000006248] [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] [Indexed: 01/15/2023]
Abstract
The first Cardiovascular Outcomes Research in Perioperative Medicine (COR-PM) conference took place on May 13, 2022, in Palm Springs, CA, and online. Here, we: (1) summarize the background, objective, and aims of the COR-PM meeting; (2) describe the conduct of the meeting; and (3) outline future directions for scientific meetings aimed at fostering high-quality clinical research in the broader perioperative medicine community.
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Affiliation(s)
- Karsten Bartels
- Department of Anesthesiology, University of Nebraska
Medical Center, Omaha, NE, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | | | - Meghan Prin
- Department of Anesthesiology, University of Colorado,
School of Medicine, Aurora, CO, USA
| | - Shahzad Shaefi
- Department of Anesthesiology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine,
Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Eric C. Sun
- Department of Anesthesiology, Perioperative and Pain
Medicine, Stanford University, Palo Alto, CA, USA
| | - Brittney Williams
- Department of Anesthesiology, University of Maryland,
Baltimore, MD, USA
| | - Amanda A. Fox
- Department of Anesthesiology and Pain Management, UT
Southwestern Medical Center, Dallas, TX, USA
| | - Judith Namuyonga
- Department of Cardiology, Uganda Heart Institute, Kampala,
Uganda
| | - Andrew D. Shaw
- Department of Intensive Care and Resuscitation, Cleveland
Clinic, Cleveland, OH, USA
| | - Monica S. Vavilala
- Department of Anesthesiology, University of Washington,
Seattle, WA, USA
| | - Daniel I. Sessler
- Department of Outcomes Research, Cleveland Clinic,
Cleveland, OH, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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16
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Deep neural network architecture for automated soft surgical skills evaluation using objective structured assessment of technical skills criteria. Int J Comput Assist Radiol Surg 2023; 18:929-937. [PMID: 36694051 DOI: 10.1007/s11548-022-02827-5] [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: 04/29/2022] [Accepted: 12/22/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE Classic methods of surgery skills evaluation tend to classify the surgeon performance in multi-categorical discrete classes. If this classification scheme has proven to be effective, it does not provide in-between evaluation levels. If these intermediate scoring levels were available, they would provide more accurate evaluation of the surgeon trainee. METHODS We propose a novel approach to assess surgery skills on a continuous scale ranging from 1 to 5. We show that the proposed approach is flexible enough to be used either for scores of global performance or several sub-scores based on a surgical criteria set called Objective Structured Assessment of Technical Skills (OSATS). We established a combined CNN+BiLSTM architecture to take advantage of both temporal and spatial features of kinematic data. Our experimental validation relies on real-world data obtained from JIGSAWS database. The surgeons are evaluated on three tasks: Knot-Tying, Needle-Passing and Suturing. The proposed framework of neural networks takes as inputs a sequence of 76 kinematic variables and produces an output float score ranging from 1 to 5, reflecting the quality of the performed surgical task. RESULTS Our proposed model achieves high-quality OSATS scores predictions with means of Spearman correlation coefficients between the predicted outputs and the ground-truth outputs of 0.82, 0.60 and 0.65 for Knot-Tying, Needle-Passing and Suturing, respectively. To our knowledge, we are the first to achieve this regression performance using the OSATS criteria and the JIGSAWS kinematic data. CONCLUSION An effective deep learning tool was created for the purpose of surgical skills assessment. It was shown that our method could be a promising surgical skills evaluation tool for surgical training programs.
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17
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Kim EK, Choi HM, Lee JH, Han DW, Lee HS, Choi EY. Practical role of preoperative echocardiography in low-risk non-cardiac surgery. Front Cardiovasc Med 2023; 10:1088496. [PMID: 36755797 PMCID: PMC9899884 DOI: 10.3389/fcvm.2023.1088496] [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: 11/03/2022] [Accepted: 01/02/2023] [Indexed: 01/24/2023] Open
Abstract
Background Due to increased needs to reduce non-fatal as well as fatal cardiac events, preoperative echocardiography remains part of routine clinical practice in many hospitals. Data on the role of preoperative echocardiography in low-risk non-cardiac surgery (NCS) other than ambulatory surgeries do not exist. We aimed to investigate the role of preoperative echocardiography in predicting postoperative adverse cardiovascular events (CVEs) in asymptomatic patients undergoing low-risk NCS. Methods The study population was derived from a retrospective cohort of 1,264 patients who underwent elective low-risk surgery at three tertiary hospitals from June 1, 2021, to June 30, 2021. Breast, distal bone, thyroid, and transurethral surgeries were included. Preoperative examination data including electrocardiography, chest radiography, and echocardiography were collected. The primary outcome was a composite of postoperative adverse CVEs including all-cause death, myocardial infarction, cerebrovascular events, newly diagnosed or acutely decompensated heart failure (HF), lethal arrhythmia such as sustained ventricular tachycardia/fibrillation, and new-onset atrial fibrillation within 30 days after the index surgery. Results Preoperative echocardiography was performed in 503 patients (39.8%), most frequently in patients with breast surgery (73.5%), followed by transurethral (37.7%), distal bone (21.6%), and thyroid surgeries (11.9%). Abnormal findings were observed in 5.0% of patients with preoperative echocardiography. Postoperative adverse CVEs occurred in 10 (0.79%) patients. Although a history of previous HF was an independent predictor of postoperative CVE occurrence (adjusted odds ratio, aOR: 17.98; 95% confidence interval, CI: 1.21-266.71, P = 0.036), preoperative echocardiography did not significantly predict CVE in multivariate analysis (P = 0.097). However, in patients who underwent preoperative echocardiography, the presence of abnormal echocardiographic findings was independently associated with development of CVE after NCS (aOR: 23.93; 95% CI: 1.2.28-250.76, P = 0.008). In particular, the presence of wall motion abnormality was a strong predictor of postoperative adverse CVE. Conclusion In real-world clinical practice, preoperative echocardiography was performed in substantial number of patients with potential cardiac risk even in low-risk NCS, and abnormal findings were independently associated with postoperative CVE. Future studies should identify patients undergoing low-risk NCS for whom preoperative echocardiography would be helpful to predict adverse CVE.
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Affiliation(s)
- Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hong-Mi Choi
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Woo Han
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eui-Young Choi
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea,*Correspondence: Eui-Young Choi,
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18
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Wu X, Hu M, Zhang J, Li K, Yang X. A New Predictive Model for In-Hospital Major Adverse Cardiac and Cerebrovascular Events in Chinese Patients After Major Noncardiac Surgery. Am J Cardiol 2023; 186:196-202. [PMID: 36319502 DOI: 10.1016/j.amjcard.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/14/2022] [Accepted: 09/29/2022] [Indexed: 11/19/2022]
Abstract
Prediction tools focused on cardiovascular and cerebrovascular events after noncardiac surgery are lacking, particularly for Chinese patients. We developed and validated what we believe is a new predictive tool for postoperative major cardiovascular and cerebrovascular events (MACCEs) in Chinese patients in this study. Overall, 401 variables derived from 598 patients who received noncardiac surgery at our center were retrospectively analyzed to develop and validate the new predictive model for MACCEs during hospitalization. The 7 strongest predictors for MACCEs in the development cohort were chronic heart failure, age, atrial fibrillation, general anesthesia, history of coronary heart disease, high-risk procedures, and lymphocyte count. The area under the receiver operating characteristic curve was 0.698 (95% confidence interval 0.616 to 0.780) for the new predictive tool with the validation cohort. Receiver operating characteristic curve analysis showed the new predictive tool had better performance than the Revised Cardiac Risk Index and the American College of Surgeons National Surgical Quality Improvement Program scores. This new predictive tool is effective for the prediction of postoperative MACCEs in patients who undergo noncardiac surgery.
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Affiliation(s)
- Xuejiao Wu
- Heart Center, Beijing Chaoyang Hospital Jingxi Branch, Capital Medical University, Beijing, China
| | - Mei Hu
- Heart Center, Beijing Chaoyang Hospital Jingxi Branch, Capital Medical University, Beijing, China
| | - Jianjun Zhang
- Heart Center, Beijing Chaoyang Hospital Jingxi Branch, Capital Medical University, Beijing, China
| | - Kuibao Li
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinchun Yang
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
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19
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Harris DE. Perioperative Acute Myocardial Infarction and Ischemia After Noncardiac Surgery: Pathophysiology, Prevention, and Nursing Implications. AORN J 2022; 116:517-531. [DOI: 10.1002/aorn.13826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/10/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
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20
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Haller G. Changes in healthcare utilisation after surgical treatment: mitigating risk through multidisciplinary and collaborative care. Br J Anaesth 2022; 129:840-842. [DOI: 10.1016/j.bja.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 11/17/2022] Open
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21
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Lau D, Haddad AF, Joshi RS, Deviren V, Ames CP. Cardiac Complications After 3-Column Osteotomy for Adult Spinal Deformity Patients With Formal Cardiac Clearance: Identifying Key Risk Factors and Threshold Cutoffs Via Recursive Partitioning Analysis. Neurosurgery 2022; 91:562-569. [PMID: 35830241 DOI: 10.1227/neu.0000000000002074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Despite formal cardiac clearance, a subset of 3-column osteotomy (3CO) patients still experience cardiac complications (CCs). OBJECTIVE To define the incidence and risk factors for CC in 3CO patients who had formal cardiac clearance and assess the utility of the Revised Cardiac Risk Index (RCRI) and preoperative metabolic equivalent (MET) functional ability in predicting perioperative CC. METHODS Patients with adult spinal deformity (ASD) who underwent 3CO deformity correction from 2006 to 2019 were retrospectively reviewed. Multivariate and recursive partitioning analyses were performed to assess risk factors. RESULTS A total of 390 patients with ASD were included. The mean age was 64.6 years, and 60.3% were female. The CC rate was 9.7%. Patients with CCs were older ( P < .001), had an increased history of heart disease ( P = .001), and higher blood loss ( P = .045). RCRI score ( P = .646) or MET functional ability ( P = .493) were not associated with CC. On multivariate analysis, age ( P < .001), blood loss ( P = .008), and prior spinal fusion ( P = .025) were independent risk factors for CC. Patients age older than 81 years had a significantly higher CC rate than those younger than 81 years. In patients age 81 years and younger, if blood loss was >3900 mL, CC rate was significantly higher. Among patients age 81 years and younger and with >3900 mL blood loss, CC rate is significantly higher in patients with ejection fraction (EF) ≤54.5%. CONCLUSION RCRI and MET functional ability are limited risk assessment tools in ASD 3CO patients with formal cardiac clearance. Patients older than 81 years are at high risk for CC. In younger patients, cardiac EF and blood loss are significant components to risk stratify for CC.
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Affiliation(s)
- Darryl Lau
- Department of Neurosurgery, New York University, New York, New York, USA
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Rushikesh S Joshi
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, Michigan, USA
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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22
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Kim EK, Choi HM, Choi EY, Lee HS, Park G, Han DW, Lee SE, Park CS, Hwang JW, Choi JH, Kim MN, Kim HK, Kim DH, Shin SH, Sohn IS, Shin MS, Na JO, Cho I, Lee SH, Park YH, Park TH, Kim KH, Cho GY, Jung HO, Park DG, Hong JY, Kang DH. PRE-OPerative ECHOcardiograhy for prevention of cardiovascular events after non-cardiac surgery in intermediate- and high-risk patients: protocol for a low-interventional, mixed-cohort prospective study design (PREOP-ECHO). Trials 2022; 23:776. [PMID: 36104714 PMCID: PMC9476301 DOI: 10.1186/s13063-022-06701-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Cardiac evaluation using transthoracic echocardiography before noncardiac surgery is common in real-world practice. However, evidence supporting preoperative echocardiography is lacking. This study aims to evaluate the additional benefit of preoperative echocardiography in predicting postoperative cardiovascular events (CVE) in noncardiac surgery.
Methods
This study is designed as a multicenter, prospective study to assess the utility of preoperative echocardiography in patients undergoing intermediate- or high-risk noncardiac surgery. This trial comprises two studies: (1) a randomized controlled trial (RCT) for patients undergoing intermediate-risk surgery with fewer than three clinical risk factors from the revised cardiac risk index (intermediate-risk group) and (2) a prospective cohort study for patients undergoing intermediate-risk surgery with three or more clinical risk factors, or who undergo high-risk surgery regardless of the number of clinical risk factors (high-risk group). We hypothesize that the use of preoperative echocardiography will reduce postoperative CVEs in patients undergoing intermediate- to high-risk surgery through discovery of and further intervention for unexpected cardiac abnormalities before elective surgery. A total of 2330 and 2184 patients will be enrolled in the two studies. The primary endpoint is a composite of all-cause death; aborted sudden cardiac arrest; type I acute myocardial infarction; clinically diagnosed unstable angina; stress-induced cardiomyopathy; lethal arrhythmia, such as sustained ventricular tachycardia or ventricular fibrillation; and/or newly diagnosed or acutely decompensated heart failure within 30 days after surgery.
Discussion
This study will be the first large-scale prospective study examining the benefit of preoperative echocardiography in predicting postoperative CVE. The PREOP-ECHO trial will help doctors identify patients at risk of postoperative CVE using echocardiography and thereby reduce postoperative CVEs.
Trial registration
The Clinical Research Information Service KCT0006279 for RCT and KCT0006280 for prospective cohort study. Registered on June 21, 2021.
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23
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Nunez JM, Nellermoe J, Davis A, Ruhnke S, Gonchigjav B, Bat-Erdene N, Zorigtbaatar A, Jalali A, Bagley K, Katz M, Pioli H, Bat-Erdene B, Erdene S, Orgoi S, Price RR, Lundeg G. Establishing a baseline for surgical care in Mongolia: a situational analysis using the six indicators from the Lancet Commission on Global Surgery. BMJ Open 2022; 12:e051838. [PMID: 35863828 PMCID: PMC9316021 DOI: 10.1136/bmjopen-2021-051838] [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: 11/03/2022] Open
Abstract
OBJECTIVES To inform national planning, six indicators posed by the Lancet Commission on Global Surgery were collected for the Mongolian surgical system. This situational analysis shows one lower middle-income country's ability to collect the indicators aided by a well-developed health information system. DESIGN An 11-year retrospective analysis of the Mongolian surgical system using data from the Health Development Center, National Statistics Office and Household Socio-Economic Survey. Access estimates were based on travel time to capable hospitals. Provider density, surgical volume and postoperative mortality were calculated at national and regional levels. Protection against impoverishing and catastrophic expenditures was assessed against standard out-of-pocket expenditure at government hospitals for individual operations. SETTING Mongolia's 81 public hospitals with surgical capability, including tertiary, secondary and primary/secondary facilities. PARTICIPANTS All operative patients in Mongolia's public hospitals, 2006-2016. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes were national-level results of the indicators. Secondary outcomes include regional access; surgeons, anaesthesiologists and obstetricians (SAO) density; surgical volume; and perioperative mortality. RESULTS In 2016, 80.1% of the population had 2-hour access to essential surgery, including 60% of those outside the capital. SAO density was 47.4/100 000 population. A coding change increased surgical volume to 5784/100 000 population, and in-hospital mortality decreased from 0.27% to 0.14%. All households were financially protected from caesarean section. Appendectomy carried 99.4% and 98.4% protection, external femur fixation carried 75.4% and 50.7% protection from impoverishing and catastrophic expenditures, respectively. Laparoscopic cholecystectomy carried 42.9% protection from both. CONCLUSIONS Mongolia meets national benchmarks for access, provider density, surgical volume and postoperative mortality with notable limitations. Significant disparities exist between regions. Unequal access may be efficiently addressed by strengthening or building key district hospitals in population-dense areas. Increased financial protections are needed for operations involving hardware or technology. Ongoing monitoring and evaluation will support the development of context-specific interventions to improve surgical care in Mongolia.
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Affiliation(s)
- Jade M Nunez
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Jonathan Nellermoe
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Andrea Davis
- Department of Geography, University of Utah, Salt Lake City, Utah, USA
| | - Simon Ruhnke
- Berliner Institut für Empirische Integrations- und Migrationsforschung/BIM, Berlin, Germany
| | | | - Nomindari Bat-Erdene
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | | | - Ali Jalali
- Cornell University Joan and Sanford I Weill Medical College, New York City, New York, USA
| | - Kevin Bagley
- Southwest Memorial Hospital, Cortez, Colorado, USA
| | - Micah Katz
- Cayuga Medical Center, Ithaca, New York, USA
| | - Hannah Pioli
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Batsaikhan Bat-Erdene
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Sarnai Erdene
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Sergelen Orgoi
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Raymond R Price
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
- Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ganbold Lundeg
- Department of Critical Care and Anaesthesia, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
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Schaller SJ, Kiselev J, Loidl V, Quentin W, Schmidt K, Mörgeli R, Rombey T, Busse R, Mansmann U, Spies C. Prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO): study protocol for a randomized, controlled, outcome assessor-blinded trial. Trials 2022; 23:468. [PMID: 35668532 PMCID: PMC9167908 DOI: 10.1186/s13063-022-06401-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Frailty is expressed by a reduction in physical capacity, mobility, muscle strength, and endurance. (Pre-)frailty is present in up to 42% of the older surgical population, with an increased risk for peri- and postoperative complications. Consequently, these patients often suffer from a delayed or limited recovery, loss of autonomy and quality of life, and a decrease in functional and cognitive capacities. Since frailty is modifiable, prehabilitation may improve the physiological reserves of patients and reduce the care dependency 12 months after surgery. METHODS Patients ≥ 70 years old scheduled for elective surgery or intervention will be recruited in this multicenter, randomized controlled study, with a target of 1400 participants with an allocation ratio of 1:1. The intervention consists of (1) a shared decision-making process with the patient, relatives, and an interdisciplinary and interprofessional team and (2) a 3-week multimodal, individualized prehabilitation program including exercise therapy, nutritional intervention, mobility or balance training, and psychosocial interventions and medical assessment. The frequency of the supervised prehabilitation is 5 times/week for 3 weeks. The primary endpoint is defined as the level of care dependency 12 months after surgery or intervention. DISCUSSION Prehabilitation has been proven to be effective for different populations, including colorectal, transplant, and cardiac surgery patients. In contrast, evidence for prehabilitation in older, frail patients has not been clearly established. To the best of our knowledge, this is currently the largest prehabilitation study on older people with frailty undergoing general elective surgery. TRIAL REGISTRATION ClinicalTrials.gov NCT04418271 . Registered on 5 June 2020. Universal Trial Number (UTN): U1111-1253-4820.
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Affiliation(s)
- Stefan J Schaller
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Jörn Kiselev
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Verena Loidl
- Institute for Medical Information Processing, Biometry, and Epidemiology - IBE, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Wilm Quentin
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Katrin Schmidt
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Rudolf Mörgeli
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Tanja Rombey
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Reinhard Busse
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry, and Epidemiology - IBE, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK/CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Chariteplatz 1, 10117, Berlin, Germany.
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Samper AFG, Herrera-Almario GE, Tulloch D, Blanco D, Cardoso LL, Rocha REN, Rajan R, Gracias V, Hanna JS. A granular analysis of service delivery for surgical system strengthening: Application of the Lancet indicators for policy development in Colombia. LANCET REGIONAL HEALTH. AMERICAS 2022; 10:100217. [PMID: 36777688 PMCID: PMC9904114 DOI: 10.1016/j.lana.2022.100217] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND The Lancet Commission on Global Surgery (LCoGS) surgical indicators have given the surgical community metrics for objectively characterizing the disparity in access to surgical healthcare. However, aggregate national statistics lack sufficient specificity to inform strengthening plans at the community level. We performed a second-stage analysis of Colombian surgical system service delivery to inform the development of resource- and context-sensitive interventions to inform a revision of the Decennial Public Health Plan for access inequity resolution. METHODS Data from the year 2016 to inform total operative volume (TOV) and 30-day non-risk adjusted peri-operative mortality (POMR) were collected from the Colombian national health information system. TOV and POMR were sub-characterized by demographics, urgency, service line, disease pathology and facility location. FINDINGS In 2016, aggregate national mortality was 0·87%, while mortality attributable to elective and emergency surgery was 0·73% and 1·30%, respectively. The elderly experienced a 5·6-fold higher mortality, with 4·2% undergoing an operation within 30 days of dying. Individuals undergoing hepatobiliary, thoracic, cardiac, and neurosurgical operations experienced the highest mortality rates while obstetrics, general surgery, orthopaedics, and urology performed the largest procedure volume. Finally, analysis of operation and service line specific POMR reveals opportunities for improvement. INTERPRETATION This granular second-stage analysis provides actionable data which is fundamental to the development of resource and context-sensitive interventions to address gaps and inequities in surgical system service delivery. Furthermore, this analysis validates the modeling underlying development of the LCoGS indicators. These data will inform the assessment of implementation priorities and revision of the Colombian Decennial Public Health Plan. FUNDING None.
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Affiliation(s)
| | - Gabriel E. Herrera-Almario
- School of Medicine, Universidad de Los Andes, Bogotá, Colombia
- Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - David Tulloch
- Center for Remote Sensing and Spatial Analysis, Rutgers School of Environmental and Biological Sciences, New Brunswick, NJ, USA
| | - Daniela Blanco
- School of Medicine, Universidad de Los Andes, Bogotá, Colombia
| | | | | | - Roshni Rajan
- Rutgers Robert Wood Johnson Medical School, 125 Paterson St., Suite 6300, New Brunswick, NJ 08903, USA
| | - Vicente Gracias
- Rutgers Robert Wood Johnson Medical School, 125 Paterson St., Suite 6300, New Brunswick, NJ 08903, USA
- Rutgers Global Health Institute, New Brunswick, NJ, USA
| | - Joseph S. Hanna
- Rutgers Robert Wood Johnson Medical School, 125 Paterson St., Suite 6300, New Brunswick, NJ 08903, USA
- Rutgers Global Health Institute, New Brunswick, NJ, USA
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Dajenah M, Ahmed F, Thabet A, Ghaleb K, Nikbakht HA. Early Postoperative Complications of Gastrointestinal Surgery and Its Associated Factors in Yemeni Patients Treated in a Teaching Hospital: A Retrospective Monocentric Study. Cureus 2022; 14:e25215. [PMID: 35747041 PMCID: PMC9213070 DOI: 10.7759/cureus.25215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background Postoperative complications (POCs) are significant concerns to surgeons because of their possible fatality or long-term disabilities. This study aimed to investigate the early POCs of gastrointestinal surgery and its associated factors in Yemeni patients treated in a teaching hospital in Sana'a University referral hospital. Method A retrospective cross-sectional study from June 2016 to June 2020 was conducted at Al-Kuwait Teaching Hospital, Sana'a University, Yemen. The patients' characteristics, causative factors, primary treatment, and POCs were recorded from their medical profiles. Univariate analysis was utilized to identify the risk factors associated with gastrointestinal POCs within 30 postoperative days. Results The 30-postoperative day mortality was 3.6%, and major POCs occurred in 22 (20%) patients. There is no statistically significant relationship between POCs and age, sex, smoking, khat chewing, comorbidities (diabetes mellitus, anemia, jaundice, heart disease), emergency cases, drain insertion, and operative time (p ˃ 0.05). There was a significant relationship between POCs and preoperative poor nutritional status, high American Society of Anesthesiologists (ASA) grade, need for blood transfusion, major abdominal surgeries, iatrogenic injury, small bowel resection, reoperation, and history of the previous laparotomy (p ≤ 0.05). Conclusion There is a significant relationship between preoperative poor nutritional status, high ASA, need for blood transfusion, major abdominal surgeries, reoperation, small bowel resection, iatrogenic injury, previous laparotomy, and POCs across different gastrointestinal procedures. These factors should be assessed when auditing surgical outcomes.
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Sessler DI, Pei L, Li K, Cui S, Chan MTV, Huang Y, Wu J, He X, Bajracharya GR, Rivas E, Lam CKM. Aggressive intraoperative warming versus routine thermal management during non-cardiac surgery (PROTECT): a multicentre, parallel group, superiority trial. Lancet 2022; 399:1799-1808. [PMID: 35390321 DOI: 10.1016/s0140-6736(22)00560-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/03/2022] [Accepted: 03/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Moderate intraoperative hypothermia promotes myocardial injury, surgical site infections, and blood loss. Whether aggressive warming to a truly normothermic temperature near 37°C improves outcomes remains unknown. We aimed to test the hypothesis that aggressive intraoperative warming reduces major perioperative complications. METHODS In this multicentre, parallel group, superiority trial, patients at 12 sites in China and at the Cleveland Clinic in the USA were randomly assigned (1:1) to receive either aggressive warming to a target core temperature of 37°C (aggressively warmed group) or routine thermal management to a target of 35·5°C (routine thermal management group) during non-cardiac surgery. Randomisation was stratified by site, with computer-generated, randomly sized blocks. Eligible patients (aged ≥45 years) had at least one cardiovascular risk factor, were scheduled for inpatient non-cardiac surgery expected to last 2-6 h with general anaesthesia, and were expected to have at least half of the anterior skin surface available for warming. Patients requiring dialysis and those with a body-mass index exceeding 30 kg/m2 were excluded. The primary outcome was a composite of myocardial injury (troponin elevation, apparently of ischaemic origin), non-fatal cardiac arrest, and all-cause mortality within 30 days of surgery, as assessed in the modified intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT03111875. FINDINGS Between March 27, 2017, and March 16, 2021, 5056 participants were enrolled, of whom 5013 were included in the intention-to-treat population (2507 in the aggressively warmed group and 2506 in the routine thermal management group). Patients assigned to aggressive warming had a mean final intraoperative core temperature of 37·1°C (SD 0·3) whereas the routine thermal management group averaged 35·6°C (SD 0·3). At least one of the primary outcome components (myocardial injury after non-cardiac surgery, cardiac arrest, or mortality) occurred in 246 (9·9%) of 2497 patients in the aggressively warmed group and in 239 (9·6%) of 2490 patients in the routine thermal management group. The common effect relative risk of aggressive versus routine thermal management was an estimated 1·04 (95% CI 0·87-1·24, p=0·69). There were 39 adverse events in patients assigned to aggressive warming (17 of which were serious) and 54 in those assigned to routine thermal management (30 of which were serious). One serious adverse event, in an aggressively warmed patient, was deemed to be possibly related to thermal management. INTERPRETATION The incidence of a 30-day composite of major cardiovascular outcomes did not differ significantly in patients randomised to 35·5°C and to 37°C. At least over a 1·5°C range from very mild hypothermia to full normothermia, there was no evidence that any substantive outcome varied. Keeping core temperature at least 35·5°C in surgical patients appears sufficient. FUNDING 3M and the Health and Medical Research Fund, Food and Health Bureau, Hong Kong. TRANSLATION For the Chinese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Population Health Research Institute, McMaster University, ON, Canada.
| | - Lijian Pei
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Kai Li
- China-Japan Union Hospital of Jilin University, Jilin, China
| | - Shusen Cui
- China-Japan Union Hospital of Jilin University, Jilin, China
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China.
| | - Jingxiang Wu
- Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xuemei He
- West China Hospital, Sichuan University, Sichuan, China
| | - Gausan R Bajracharya
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eva Rivas
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Carmen K M Lam
- Tuen Mun Hospital, Hong Kong Special Administrative Region, China
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Oh AR, Park J, Lee JH, Kim H, Yang K, Choi JH, Ahn J, Sung JD, Lee SH. Association Between Perioperative Adverse Cardiac Events and Mortality During One-Year Follow-Up After Noncardiac Surgery. J Am Heart Assoc 2022; 11:e024325. [PMID: 35411778 PMCID: PMC9238468 DOI: 10.1161/jaha.121.024325] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiac complications are associated with perioperative mortality, but perioperative adverse cardiac events (PACEs) that are associated with long‐term mortality have not been clearly defined. We identified PACE as a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, or stroke during the 30‐day postoperative period and we compared mortality according to PACE occurrence. Methods and Results From January 2011 to June 2019, a total of 203 787 consecutive adult patients underwent noncardiac surgery at our institution. After excluding those with 30‐day mortality, mortality during a 1‐year follow‐up was compared. Machine learning with the extreme gradient boosting algorithm was also used to evaluate whether PACE was associated with 1‐year mortality. After excluding 1203 patients with 30‐day mortality, 202 584 patients were divided into 7994 (3.9%) patients with PACE and 194 590 (96.1%) without PACE. After an adjustment, the mortality was higher in the PACE group (2.1% versus 7.7%; hazard ratio [HR], 1.90; 95% CI, 1.74–2.09; P<0.001). Results were similar for 7839 pairs of propensity‐score‐matched patients (4.9% versus 7.9%; HR, 1.64; 95% CI, 1.44–1.87; P<0.001). PACE was significantly associated with mortality in the extreme gradient boostingmodel. Conclusions PACE as a composite outcome was associated with 1‐year mortality. Further studies are needed for PACE to be accepted as an end point in clinical studies of noncardiac surgery.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea.,Department of Anesthesiology and Pain Medicine Kangwon National University Hospital Chuncheon Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea.,Department of Biomedical Sciences Ajou University Graduate School of Medicine Suwon Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Hara Kim
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Kwangmo Yang
- Department of Biomedical Sciences Ajou University Graduate School of Medicine Suwon Korea.,Center for Health Promotion Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Jin-Ho Choi
- Department of Emergency Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Joonghyun Ahn
- Statistics and Data Center Research Institute for Future Medicine Samsung Medical Center Seoul Korea
| | - Ji Dong Sung
- Rehabilitation & Prevention Center Heart Vascular Stroke Institute Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Seung-Hwa Lee
- Rehabilitation & Prevention Center Heart Vascular Stroke Institute Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea.,Department of Biomedical Engineering Seoul National University College of Medicine Seoul Korea
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Rock KC, Newman MF, Fleisher LA. Implications of Perioperative Morbidity for Long-Term Outcomes. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00001-0] [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
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30
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Sessler DI. Anaesthesia's legacy: carpe diem. Br J Anaesth 2021; 128:413-415. [PMID: 34949440 DOI: 10.1016/j.bja.2021.11.029] [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: 11/15/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Abstract
Intraoperative mortality is now rare. In contrast, 30-day postoperative mortality remains common, with most deaths occurring during the initial hospitalisation. The legacy of anaesthesiology will be determined by our success in dealing with postoperative mortality, which is currently the major problem in perioperative medicine. Carpe diem!
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Affiliation(s)
- Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
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31
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Peterson BR, Cotton A, Foy AJ. Reevaluating the Cardiac Risk of Noncardiac Surgery Using the National Surgical Quality Improvement Program. Am J Med 2021; 134:1499-1505. [PMID: 34411519 DOI: 10.1016/j.amjmed.2021.07.016] [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] [Received: 06/02/2021] [Revised: 07/23/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND As surgical techniques evolve and patient outcomes improve over time, a renewed analysis of the cardiac risk of noncardiac surgeries is needed. The goal of this study was to investigate and categorize the cardiac risk of elective noncardiac surgeries. METHODS This was a cohort study of surgical data and outcomes from the 2018 National Surgical Quality Improvement Program Participant Use Data File; 807,413 cases were analyzed after excluding non-elective, emergent, and cardiac surgeries. Postoperative major adverse cardiac events (MACE) were defined as 30-day all-cause mortality, myocardial infarction, or cardiac arrest. According to their 95% confidence intervals (CI) for postoperative MACE, surgeries were categorized as low risk (95% CI <1%), intermediate risk (95% CI above and below 1%), or elevated risk (95% CI ≥1%). Multivariable logistic regression analyses were performed to determine differences in the odds for postoperative MACE for the intermediate- and elevated-risk categories relative to the low-risk category while controlling for several risk factors of prognostic importance. RESULTS Postoperative MACE occurred in 4047/807,413 cases (0.50%), including in 1708/667,735 (0.26%) of the low-risk category, in 516/53,499 (0.96%) of the intermediate-risk category, and in 1823/86,179 (2.12%) of the elevated-risk category. The elevated-risk category accounted for 10.7% of total procedures and 45.1% of total postoperative MACE. Compared with the low-risk category, the multivariable adjusted risk of postoperative MACE was increased in the intermediate-risk category (adjusted odds ratio 2.35; 95% CI, 2.12-2.62) and the elevated-risk category (adjusted odds ratio 3.15; 95% CI, 2.92-3.39). CONCLUSION Categorization of noncardiac surgeries according to cardiac risk may help to identify populations who are most likely to benefit from preoperative cardiac evaluation when indicated.
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Affiliation(s)
- Brandon R Peterson
- Penn State Heart and Vascular Institute, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey.
| | - Antoinette Cotton
- Eberly College of Science, Penn State University, State College, Penn
| | - Andrew J Foy
- Penn State Heart and Vascular Institute, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey
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Cho J, Park J, Jeong E, Shin J, Ahn S, Park MG, Park RW, Park Y. Machine Learning Approach Using Routine Immediate Postoperative Laboratory Values for Predicting Postoperative Mortality. J Pers Med 2021; 11:jpm11121271. [PMID: 34945743 PMCID: PMC8706001 DOI: 10.3390/jpm11121271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Several prediction models have been proposed for preoperative risk stratification for mortality. However, few studies have investigated postoperative risk factors, which have a significant influence on survival after surgery. This study aimed to develop prediction models using routine immediate postoperative laboratory values for predicting postoperative mortality. Methods: Two tertiary hospital databases were used in this research: one for model development and another for external validation of the resulting models. The following algorithms were utilized for model development: LASSO logistic regression, random forest, deep neural network, and XGBoost. We built the models on the lab values from immediate postoperative blood tests and compared them with the SASA scoring system to demonstrate their efficacy. Results: There were 3817 patients who had immediate postoperative blood test values. All models trained on immediate postoperative lab values outperformed the SASA model. Furthermore, the developed random forest model had the best AUROC of 0.82 and AUPRC of 0.13, and the phosphorus level contributed the most to the random forest model. Conclusions: Machine learning models trained on routine immediate postoperative laboratory values outperformed previously published approaches in predicting 30-day postoperative mortality, indicating that they may be beneficial in identifying patients at increased risk of postoperative death.
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Affiliation(s)
- Jaehyeong Cho
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Korea; (J.C.); (J.P.)
| | - Jimyung Park
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Korea; (J.C.); (J.P.)
| | - Eugene Jeong
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA;
| | - Jihye Shin
- Division of Cancer Control & Policy, National Cancer Control Institute, Goyang-si 10408, Korea;
| | - Sangjeong Ahn
- Department of Pathology, Catholic Kwandong University International St. Mary’s Hospital, Incheon 21431, Korea;
| | - Min Geun Park
- Department of Surgery, Catholic Kwandong University International St. Mary’s Hospital, Incheon 21431, Korea;
| | - Rae Woong Park
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Korea; (J.C.); (J.P.)
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon 16499, Korea
- Correspondence: (R.W.P.); (Y.P.)
| | - Yongkeun Park
- Department of Surgery, Catholic Kwandong University International St. Mary’s Hospital, Incheon 21431, Korea;
- Correspondence: (R.W.P.); (Y.P.)
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Dobson GP, Morris JL, Biros E, Davenport LM, Letson HL. Major surgery leads to a proinflammatory phenotype: Differential gene expression following a laparotomy. Ann Med Surg (Lond) 2021; 71:102970. [PMID: 34745602 PMCID: PMC8554464 DOI: 10.1016/j.amsu.2021.102970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 10/17/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The trauma of surgery is a neglected area of research. Our aim was to examine the differential expression of genes of stress, metabolism and inflammation in the major organs of a rat following a laparotomy. MATERIALS AND METHODS Anaesthetised Sprague-Dawley rats were randomised into baseline, 6-hr and 3-day groups (n = 6 each), catheterised and laparotomy performed. Animals were sacrificed at each timepoint and tissues collected for gene and protein analysis. Blood stress hormones, cytokines, endothelial injury markers and coagulation were measured. RESULTS Stress hormone corticosterone significantly increased and was accompanied by significant increases in inflammatory cytokines, endothelial markers, increased neutrophils (6-hr), higher lactate (3-days), and coagulopathy. In brain, there were significant increases in M1 muscarinic (31-fold) and α-1A-adrenergic (39-fold) receptor expression. Cortical expression of metabolic genes increased ∼3-fold, and IL-1β by 6-fold at 3-days. Cardiac β-1-adrenergic receptor expression increased up to 8.4-fold, and M2 and M1 muscarinic receptors by 2 to 4-fold (6-hr). At 3-days, cardiac mitochondrial gene expression (Tfam, Mtco3) and inflammation (IL-1α, IL-4, IL-6, MIP-1α, MCP-1) were significantly elevated. Haemodynamics remained stable. In liver, there was a dramatic suppression of adrenergic and muscarinic receptor expression (up to 90%) and increased inflammation. Gut also underwent autonomic suppression with 140-fold increase in IL-1β expression (3-days). CONCLUSIONS A single laparotomy led to a surgical-induced proinflammatory phenotype involving neuroendocrine stress, cortical excitability, immune activation, metabolic changes and coagulopathy. The pervasive nature of systemic and tissue inflammation was noteworthy. There is an urgent need for new therapies to prevent hyper-inflammation and restore homeostasis following major surgery.
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Affiliation(s)
- Geoffrey P. Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, 4811, Australia
| | - Jodie L. Morris
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, 4811, Australia
| | - Erik Biros
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, 4811, Australia
| | - Lisa M. Davenport
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, 4811, Australia
| | - Hayley L. Letson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, 4811, Australia
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Park J, Lee JH. Myocardial injury in noncardiac surgery. Korean J Anesthesiol 2021; 75:4-11. [PMID: 34657407 PMCID: PMC8831428 DOI: 10.4097/kja.21372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/17/2021] [Indexed: 11/13/2022] Open
Abstract
Myocardial injury is defined as an elevation of cardiac troponin (cTn) levels with or without associated ischemic symptoms. Robust evidence suggests that myocardial injury increases postoperative mortality after noncardiac surgery. The diagnostic criteria for myocardial injury after noncardiac surgery (MINS) include an elevation of cTn levels within 30 d of surgery without evidence of non-ischemic etiology. The majority of cases of MINS do not present with ischemic symptoms and are caused by a mismatch in oxygen supply and demand. Predictive models for general cardiac risk stratification can be considered for MINS. Risk factors include comorbidities, anemia, glucose levels, and intraoperative blood pressure. Modifiable factors may help prevent MINS; however, further studies are needed. Recent guidelines recommend routine monitoring of cTn levels during the first 48 h post-operation in high-risk patients since MINS most often occurs in the first 3 days after surgery without symptoms. The use of cardiovascular drugs, such as aspirin, antihypertensives, and statins, has had beneficial effects in patients with MINS, and direct oral anticoagulants have been shown to reduce the mortality associated with MINS in a randomized controlled trial. Myocardial injury detected before noncardiac surgery was also found to be associated with postoperative mortality, though further studies are needed.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Saab R, Wu BP, Rivas E, Chiu A, Lozovoskiy S, Ma C, Yang D, Turan A, Sessler DI. Failure to detect ward hypoxaemia and hypotension: contributions of insufficient assessment frequency and patient arousal during nursing assessments. Br J Anaesth 2021; 127:760-768. [PMID: 34301400 DOI: 10.1016/j.bja.2021.06.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/05/2021] [Accepted: 06/03/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Postoperative hypotension and hypoxaemia are common and often unrecognised. With intermittent nursing vital signs, hypotensive or hypoxaemic episodes might be missed because they occur between scheduled measurements, or because the process of taking vital signs arouses patients and temporarily improves arterial blood pressure and ventilation. We therefore estimated the fraction of desaturation and hypotension episodes that did not overlap nursing assessments and would therefore usually be missed. We also evaluated the effect of taking vital signs on blood pressure and oxygen saturation. METHODS We estimated the fraction of desaturated episodes (arterial oxygen saturation <90% for at least 90% of the time within 30 continuous minutes) and hypotensive episodes (MAP <70 mm Hg for 15 continuous minutes) that did not overlap nursing assessments in patients recovering from noncardiac surgery. We also evaluated changes over time before and after nursing visits. RESULTS Among 782 patients, we identified 878 hypotensive episodes and 2893 desaturation episodes, of which 79% of the hypotensive episodes and 82% of the desaturation episodes did not occur within 10 min of a nursing assessment and would therefore usually be missed. Mean BP and oxygen saturation did not improve by clinically meaningful amounts during nursing vital sign assessments. CONCLUSIONS Hypotensive and desaturation episodes are mostly missed because vital sign assessments on surgical wards are sparse, rather than being falsely negative because the assessment process itself increases blood pressure and oxygen saturation. Continuous vital sign monitoring will detect more disturbances, potentially giving clinicians time to intervene before critical events occur.
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Affiliation(s)
- Remie Saab
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Bernie P Wu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Eva Rivas
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Anesthesia, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Andrew Chiu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Sofia Lozovoskiy
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Chao Ma
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Dongsheng Yang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
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Khanna AK, Shaw AD, Stapelfeldt WH, Boero IJ, Chen Q, Stevens M, Gregory A, Smischney NJ. Postoperative Hypotension and Adverse Clinical Outcomes in Patients Without Intraoperative Hypotension, After Noncardiac Surgery. Anesth Analg 2021; 132:1410-1420. [PMID: 33626028 DOI: 10.1213/ane.0000000000005374] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative hypotension (POH) is associated with major adverse events. However, little is known about the association of blood pressure thresholds and outcomes in postoperative patients without intraoperative hypotension (IOH) on the general-care ward. We evaluated the association of POH with major adverse cardiac or cerebrovascular events (MACCE) in patients without IOH. METHODS This retrospective analysis included 67,968 noncardiac patient-procedures (2008-2017) for patients discharged to the ward with postoperative mean arterial pressure (MAP) readings, managed for ≥48 hours postsurgery, with no evidence of IOH. The primary outcome was 30-day MACCE evaluated by postoperative MAP thresholds: ≤75, ≤65, and ≤55 mm Hg (POH defined as a single measurement below threshold). Secondary outcomes included all-cause mortality (30-/90-day), 30-day acute myocardial infarction, 30-day acute ischemic stroke, 30-day readmission, 7-day acute kidney injury, and 30-day readmission. Associations between POH and adverse events were also evaluated in a cohort (#2) of 16,034 patient-procedures with IOH (intraoperative MAP ≤65 mm Hg). RESULTS In patients without IOH, exposure to POH was not associated with MACCE at any investigated MAP threshold (P < .016 was considered significant: ≤75 mm Hg, hazard ratio [HR] 1.18 [98.4% confidence interval {CI} 0.99-1.39], P = .023; ≤65 mm Hg, HR 1.18 [0.99-1.41], P = .028; ≤55 mm Hg, HR 1.23 [0.90-1.71], P = .121); however, associations were observed at all MAP thresholds for secondary outcomes of acute kidney injury and 30-day readmission, for 30-/90-day mortality for MAP ≤65 mm Hg, and 90-day mortality for MAP ≤55 mm Hg, compared to those without POH. No associations were detected between POH and secondary outcomes of acute ischemic stroke or acute myocardial infarction at any MAP threshold. No interaction between POH and IOH was found when we evaluated the association of POH on outcomes in the data set including all patients, regardless of IOH status (P values for interaction terms nonsignificant). When the interaction term was utilized, the association between POH without IOH and MACCE was significant for MAP ≤75 mm Hg (HR 1.20 [1.01-1.41]) and MAP ≤65 mm Hg (HR 1.21 [1.02-1.45]), but not MAP ≤55 mm Hg. Cohort #2 (POH with IOH) showed largely similar results for MACCE: not significant for MAP ≤75 and ≤65 mm Hg, but significant for MAP ≤55 mm Hg (HR 1.53 [1.05-2.22], P = .006). CONCLUSIONS POH in patients without IOH was not associated with MACCE at any MAP investigated. No interaction was identified between POH and IOH. Large prospective randomized trials are necessary to develop better evidence and inform clinicians the value of postoperative blood pressure management.
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Affiliation(s)
- Ashish K Khanna
- From the Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | - Andrew D Shaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta.,Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Wolf H Stapelfeldt
- Department of Anesthesiology & Critical Care Medicine, Saint Louis University, St. Louis, Missouri
| | | | | | | | - Anne Gregory
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta
| | - Nathan J Smischney
- Department of Anesthesiology & Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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Abstract
PURPOSE OF REVIEW After successfully reducing mortality in the operating room, the time has come for anesthesiologists to conquer postoperative complications. This review aims to raise awareness about myocardial injury after noncardiac surgery (MINS), its definition, diagnosis, clinical importance, and treatment. RECENT FINDINGS MINS, defined as an elevated postoperative troponin judged to be due to myocardial ischemia (with or without ischemic features), occurs in up to one in five patients having noncardiac surgery and is responsible for 16% of all postoperative deaths within 30 days of surgery. New evidence on risk factors, etiology, potential prevention strategies, treatment options, and the economic impact of MINS highlights the actionability of perioperative clinicians in caring for adult patients who are considered to be at risk of cardiovascular complications. SUMMARY Millions of patients safely going through surgery suffer MINS and die shortly after the procedure every year. Without a structured approach to predicting, preventing, diagnosing, and treating MINS, we lose the opportunity to provide our patients with the best chance of deriving benefit from noncardiac surgery. The perioperative community needs to come together, appreciate the clinical relevance of MINS, and step up with high-quality research in the future.
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Macedo F, Sequeira H, Ladeira K, Bonito N, Viana C, Martins S. Metastatic lymph node ratio as a better prognostic tool than the TNM system in colorectal cancer. Future Oncol 2021; 17:1519-1532. [PMID: 33626938 DOI: 10.2217/fon-2020-0993] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: The minimum number of lymph nodes that should be evaluated in colon cancer to adequately categorize lymph node status is still controversial. The lymph node ratio (LNR) may be a better prognostic indicator. Materials & methods: We studied 1065 patients treated from 1 January 2000 to 31 August 2012. Results: Significant differences in survival were detected according to regional lymph nodes (pN) (p < 0.001) and LNR (p < 0.001). LRN and pN are independent prognostic factors. Spearman correlation analysis showed a significant correlation between the total number of dissected lymph nodes and pN (rs = 0.167; p < 0.001), but the total number of dissected lymph nodes is not significantly correlated with LNR (rs = -0.019; p = 0.550). Interpretation: In this study, LNR seems to demonstrate a superior prognostic value compared with the pN categories, in part due to its greater independence regarding the extent of lymphadenectomy.
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Affiliation(s)
- Filipa Macedo
- Department of Medical Oncology, Portuguese Oncology Institute, Coimbra, 3000-075, Portugal.,Life & Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, 4710-057, Portugal
| | - Hugo Sequeira
- Life & Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, 4710-057, Portugal
| | - Katia Ladeira
- Life & Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, 4710-057, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Braga, 4710-057, Portugal
| | - Nuno Bonito
- Department of Medical Oncology, Portuguese Oncology Institute, Coimbra, 3000-075, Portugal
| | - Charlene Viana
- Department of Surgery, Coloproctology Unit, Braga Hospital, Braga, 4710-243, Portugal
| | - Sandra Martins
- Life & Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, 4710-057, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Braga, 4710-057, Portugal.,Department of Surgery, Coloproctology Unit, Braga Hospital, Braga, 4710-243, Portugal
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Bhatia K, Narasimhan B, Aggarwal G, Hajra A, Itagi S, Kumar S, Chakraborty S, Patel N, Jain V, Bandyopadhyay D, Amgai B, Aronow WS. Perioperative pharmacotherapy to prevent cardiac complications in patients undergoing noncardiac surgery. Expert Opin Pharmacother 2020; 22:755-767. [PMID: 33350868 DOI: 10.1080/14656566.2020.1856368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Despite advances in surgical and anesthetic techniques, perioperative cardiovascular complications are a major cause of 30-day perioperative mortality. Major cardiovascular complications after noncardiac surgery include myocardial ischemia, congestive heart failure, arrhythmias, and cardiac arrest. Along with surgical risk assessment, perioperative medical optimization can reduce the rates and clinical impact of these complications.Areas Covered: In this review, the authors discuss the pharmacological basis, existing evidence, and professional society recommendations for drug management in preventing cardiovascular complications in patients undergoing noncardiac surgery.Expert opinion: Perioperative management of cardiovascular disease is an increasingly important and growing area of clinical practice. Societal guidelines regarding the use of most routine cardiovascular medications are based on a number of large clinical studies and provide a basic foundation to guide management. However, the heterogeneous nature of patients, as well as surgeries, makes it practically impossible to devise a 'one size fits all' recommendation in this setting. Thus, the importance of a more individualized approach to perioperative risk stratification and management is being increasingly recognized. The underlying comorbidities and cardiac profile as well as the risk of cardiac complications associated with the planned surgery must be factored in to understand the nuance of the management strategies.
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Affiliation(s)
- Kirtipal Bhatia
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | - Bharat Narasimhan
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | | | - Adrija Hajra
- Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Soumya Itagi
- PSG Institute of Medical Sciences and Research, Coimbatore, India
| | - Shathish Kumar
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | | | | | - Dhrubajyoti Bandyopadhyay
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | | | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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McCormick PJ, Yeoh CB, Hannum M, Tan KS, Vicario-Feliciano RM, Mehta M, Yang G, Ervin K, Fischer GW, Tollinche LE. Institution of Monthly Anesthesia Quality Reports Does Not Reduce Postoperative Complications despite Improved Metric Compliance. J Med Syst 2020; 44:189. [PMID: 32964363 DOI: 10.1007/s10916-020-01659-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/16/2020] [Indexed: 01/15/2023]
Abstract
While quality programs have been shown to improve provider compliance, few have demonstrated conclusive improvements in patient outcomes. We hypothesized that there would be increased metric compliance and decreased postoperative complications after initiation of an anesthesiology quality improvement program at our institution. We performed a retrospective study of all adult inpatients having anesthesia for a twelve-month period that spanned six months before and after program implementation. The primary outcome was the rate of complications in the post-implementation period. Secondary outcomes included the change in proportion of complications and compliance with quality metrics. We studied a total of 9620 adult inpatient cases, subdivided into pre- and post-implementation groups (4832 vs 4788.) After multivariate model adjustment, the rate of any complication (our primary outcome) was not significantly changed (32% to 31%; adjusted P = 0.410.) Of the individual complications, only wound infection (2.0% to 1.5%; adjusted P = 0.020) showed a statistically significant decrease. Statistically and clinically significant increases in compliance were seen for the BP-02 Avoiding Monitoring Gaps metric (81% to 93%, P < 0.001), both neuromuscular blockade metrics (NMB-01 76% to 91%, P < 0.001; NMB-02 95% to 97%, P = 0.006), both tidal volume metrics (PUL-01 84% to 93%, P < 0.001; PUL-02 30% to 45%, P < 0.001), and the TEMP-02 Core Temperature Measurement metric (88% to 94%, P < 0.001). Implementation of a comprehensive quality feedback program improved metric compliance but was not associated with a change in postoperative complications.
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Affiliation(s)
- Patrick J McCormick
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA. .,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA.
| | - Cindy B Yeoh
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Margaret Hannum
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kay See Tan
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Meghana Mehta
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Gloria Yang
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Kaitlin Ervin
- University of South Alabama College of Medicine, Mobile, AL, USA
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Luis E Tollinche
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
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Dandena F, Leulseged B, Suga Y, Teklewold B. Magnitude and Pattern of Inpatient Surgical Mortality in a Tertiary Hospital in Addis Ababa, Ethiopia. Ethiop J Health Sci 2020; 30:371-377. [PMID: 32874080 PMCID: PMC7445947 DOI: 10.4314/ejhs.v30i3.8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Inpatient mortality is among regularly collected data in Key performance indicators in the Ethiopian healthcare system, and it is generally reported to the Federal Ministry of Health and is used as one of inpatient services quality indicators. This study was undertaken to identify the magnitude, causes and pattern of mortalities among patients who are admitted and treated in surgical wards in Saint Paul Hospital Millennium Medical College for a period of three years. Methods A retrospective review was done on all patients admitted and died in the Department of Surgery in St. Paul's Hospital Millennium Medical College from January 1, 2016–Dec 30, 2018. Result There were 10,259 admissions over three years and out of which there were 350 deaths between 2016–2018 making a crude mortality rate of 3.41 %. The commonest mode of admission was for emergency conditions, 195(62.7%). Out of emergency admissions, 139 mortalities were from general emergency surgery and 75 patients died from elective general surgery admissions. Eighty-four (26.9%) patients had comorbidity and the commonest comorbidity was anemia 21(25%). The commonest possible cause of death was multi-organ failure secondary to septic shock, 159(51%). Mortality rate patterns along the three years (2016, 2017, 2018) showed 3.34% (112/3360), 2.87% (102/3552) and 2.92% (98/3347) respectively. Conclusion The mortality rate of this study is much higher than global rates, but still there is a significant difference from other developing countries and also other researches in this country. Pattern of mortality did not show any difference across years of the study period.
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Affiliation(s)
- Firaol Dandena
- St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Belayneh Leulseged
- Department of Public Health, St Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Yisihak Suga
- Department of Surgery, St Paul hospital Millennium Medical College, Addis Ababa, Ethiopia
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Dobson GP. Trauma of major surgery: A global problem that is not going away. Int J Surg 2020; 81:47-54. [PMID: 32738546 PMCID: PMC7388795 DOI: 10.1016/j.ijsu.2020.07.017] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/27/2020] [Accepted: 07/03/2020] [Indexed: 12/21/2022]
Abstract
Globally, a staggering 310 million major surgeries are performed each year; around 40 to 50 million in USA and 20 million in Europe. It is estimated that 1-4% of these patients will die, up to 15% will have serious postoperative morbidity, and 5-15% will be readmitted within 30 days. An annual global mortality of around 8 million patients places major surgery comparable with the leading causes of death from cardiovascular disease and stroke, cancer and injury. If surgical complications were classified as a pandemic, like HIV/AIDS or coronavirus (COVID-19), developed countries would work together and devise an immediate action plan and allocate resources to address it. Seeking to reduce preventable deaths and post-surgical complications would save billions of dollars in healthcare costs. Part of the global problem resides in differences in institutional practice patterns in high- and low-income countries, and part from a lack of effective perioperative drug therapies to protect the patient from surgical stress. We briefly review the history of surgical stress and provide a path forward from a systems-based approach. Key to progress is recognizing that the anesthetized brain is still physiologically 'awake' and responsive to the sterile stressors of surgery. New intravenous drug therapies are urgently required after anesthesia and before the first incision to prevent the brain from switching to sympathetic overdrive and activating secondary injury progression such as hyperinflammation, coagulopathy, immune activation and metabolic dysfunction. A systems-based approach targeting central nervous system-mitochondrial coupling may help drive research to improve outcomes following major surgery in civilian and military medicine.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, 4811, Australia.
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43
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Park J, Kim J, Lee SH, Lee JH, Min JJ, Kwon JH, Oh AR, Seo W, Hyeon CW, Yang K, Choi JH, Lee SC, Kim K, Ahn J, Gwon HC. Postoperative statin treatment may be associated with improved mortality in patients with myocardial injury after noncardiac surgery. Sci Rep 2020; 10:11616. [PMID: 32669686 PMCID: PMC7363808 DOI: 10.1038/s41598-020-68511-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 06/17/2020] [Indexed: 11/09/2022] Open
Abstract
Myocardial injury after noncardiac surgery (MINS) is recently accepted as a strong predictor of mortality, regardless of symptoms. However, anticoagulation is the only established treatment. This study aimed to evaluate the association between statin treatment and mortality after MINS. From January 2010 to June 2019, a total of 5,267 adult patients who were discharged after the occurrence of MINS were enrolled. The patients were divided into two groups according to statin prescription at discharge. The outcomes were 1-year and overall mortalities. Of the total 5,109 patients, 1,331 (26.1%) patients were in the statin group and 3,778 (73.9%) patients were in the no statin group. The 1-year and overall mortalities were significantly lower in the statin group compared with the no statin group (6.1% vs. 13.3%; hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.41–0.74; p < 0.001 for 1-year mortality and 15.0% vs. 25.0%; HR, 0.62; 95% CI, 0.51–0.76; p < 0.001 for overall mortality). Analyses after inverse probability treatment weighting showed similar results (HR, 0.61; 95% CI, 0.50–0.74; p < 0.001 for 1-year mortality and HR, 0.70; 95% CI, 0.54–0.90; p = 0.006 for overall mortality), and the mortalities did not differ according to the dose of statin. Our results suggest that statin treatment may be associated with improved survival after MINS. A trial is needed to confirm this finding and establish causality.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jihoon Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
| | - Seung-Hwa Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea.
| | - Jong Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wonho Seo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Cheol Won Hyeon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
| | - Kwangmo Yang
- Centers for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea.,Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Joonghyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
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Dakik HA, Sbaity E, Msheik A, Kaspar C, Eldirani M, Chehab O, Abou Hassan O, Mailhac A, Makki M, Tamim H. AUB-HAS2 Cardiovascular Risk Index: Performance in Surgical Subpopulations and Comparison to the Revised Cardiac Risk Index. J Am Heart Assoc 2020; 9:e016228. [PMID: 32390481 PMCID: PMC7660845 DOI: 10.1161/jaha.119.016228] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The American University of Beirut (AUB)-HAS2 Cardiovascular Risk Index is a newly derived index for preoperative cardiovascular evaluation. It is based on 6 data elements: history of heart disease; symptoms of angina or dyspnea; age ≥75 years; hemoglobin <12 mg/dL; vascular surgery; and emergency surgery. In this study we analyze the performance of this new index and compare it with that of the Revised Cardiac Risk Index in a broad spectrum of surgical subpopulations. Methods and Results The study population consisted of 1 167 278 noncardiac surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database. Each patient was given an AUB-HAS2 score of 0, 1, 2, 3, or >3, depending on the number of data elements present. The performance of the AUB-HAS2 index was studied in 9 surgical specialty groups and in 8 commonly performed site-specific surgeries. Receiver operating characteristic curves were constructed for the AUB-HAS2 and Revised Cardiac Risk Index measures, and the areas under the curve were compared. The outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. The AUB-HAS2 score was able to stratify risk in all surgical subgroups (P<0.001). In the majority of surgeries, patients with an AUB-HAS2 score of 0 had an event rate of <0.5%. The performance of the AUB-HAS2 index was superior to that of the Revised Cardiac Risk Index in all surgical subgroups (P<0.001). Conclusions This study extends the validation of the AUB-HAS2 index to a broad spectrum of surgical subpopulations and demonstrates its superior discriminatory power compared with the commonly utilized Revised Cardiac Risk Index.
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Affiliation(s)
- Habib A Dakik
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Eman Sbaity
- Department of Surgery American University of Beirut Medical Center Beirut Lebanon
| | - Ahmad Msheik
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Chris Kaspar
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Mahmoud Eldirani
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Omar Chehab
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Ossama Abou Hassan
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Aurelie Mailhac
- Department of Biostatistics Unit American University of Beirut Medical Center Beirut Lebanon
| | - Maha Makki
- Department of Biostatistics Unit American University of Beirut Medical Center Beirut Lebanon
| | - Hani Tamim
- Department of Biostatistics Unit American University of Beirut Medical Center Beirut Lebanon
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Bohsali F, Klimpl D, Baumgartner R, Sieber F, Eid SM. Effect of Heart Failure With Preserved Ejection Fraction on Perioperative Outcomes in Patients Undergoing Hip Fracture Surgery. J Am Acad Orthop Surg 2020; 28:e131-e138. [PMID: 31977615 DOI: 10.5435/jaaos-d-18-00731] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Heart failure is a leading cause of morbidity and mortality in hip fracture surgery. The impact of heart failure with preserved ejection fraction (HFpEF) is poorly understood in this population. We designed a study to evaluate national perioperative outcomes in hip fracture for patients with HFpEF. METHODS Patients with hip fracture undergoing total hip arthroplasty, hemiarthroplasty, or open/closed reduction with internal and external fixation from January 2005 to December 2013 were identified using the Nationwide Inpatient Sample. Inpatient outcomes during the index hospitalization were compared between patients without heart failure and with HFpEF. Heart failure with reduced ejection fraction was included as a secondary comparator. Perioperative major adverse cardiovascular and cerebrovascular events (MACCEs), defined as in-hospital all-cause death, acute myocardial infarction, and in-hospital cardiac arrest or acute ischemic stroke, were evaluated. RESULTS Among 2,020,712 hospitalizations for hip fracture surgery, perioperative MACCE occurred in 67,554 hospitalizations (3.3%), corresponding to an annual incidence of approximately 7,506 events after applying sample weights. Compared with patients without heart failure, patients with HFpEF experienced increased odds of MACCE, adjusted odds ratio [aOR], 1.69; 95% confidence interval (CI), 1.51 to 1.89. In comparison, the aOR of experiencing a MACCE event in the heart failure with reduced ejection fraction group was 1.75 (95% CI, 1.57 to 1.96). HFpEF was also associated with increased odds of acute respiratory failure (aOR, 1.71; 95% CI, 1.53 to 1.91) and acute renal failure (aOR, 1.52; 95% CI, 1.41 to 1.64). CONCLUSION HFpEF confers a significant perioperative risk of MACCE in patients undergoing hip fracture surgery.
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Affiliation(s)
- Fuad Bohsali
- From the Department of Medicine, Duke University School of Medicine, Durham, NC (Dr. Bohsali), the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Klimpl and Dr. Eid), the Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC (Dr. Baumgartner), and the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Sieber)
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Santhirapala V, Peden CJ, Meara JG, Biccard BM, Gelb AW, Johnson WD, Lipnick MS, Makasa EM, Martin J, Maswime S, Mellin-Olsen J, McClain CD. Towards high-quality peri-operative care: a global perspective. Anaesthesia 2020; 75 Suppl 1:e18-e27. [PMID: 31903566 DOI: 10.1111/anae.14921] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2019] [Indexed: 01/22/2023]
Abstract
Article 25 of the United Nations' Universal Declaration of Human Rights enshrines the right to health and well-being for every individual. However, universal access to high-quality healthcare remains the purview of a handful of wealthy nations. This is no more apparent than in peri-operative care, where an estimated five billion individuals lack access to safe, affordable and timely surgical care. Delivery of surgery and anaesthesia in low-resource environments presents unique challenges that, when unaddressed, result in limited access to low-quality care. Current peri-operative research and clinical guidance often fail to acknowledge these system-level deficits and therefore have limited applicability in low-resource settings. In this manuscript, the authors priority-set the need for equitable access to high-quality peri-operative care and analyse the system-level contributors to excess peri-operative mortality rates, a key marker of quality of care. To provide examples of how research and investment may close the equity gap, a modified Delphi method was adopted to curate and appraise interventions which may, with subsequent research and evaluation, begin to address the barriers to high-quality peri-operative care in low- and middle-income countries.
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Affiliation(s)
- V Santhirapala
- Harvard Medical School, Boston, MA, USA.,Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - C J Peden
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - J G Meara
- Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - B M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, South Africa
| | - A W Gelb
- Department of Anesthesia and Perioperative Care, University of California San Francisco, CA, USA
| | - W D Johnson
- World Health Organization, Geneva, Switzerland
| | - M S Lipnick
- Department of Anesthesia and Perioperative Care, University of California San Francisco, CA, USA
| | - E M Makasa
- Wits Centre of Surgical Care for Primary Health and Sustainable Development, School of Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - J Martin
- Department of Anesthesia and Perioperative Medicine and Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - S Maswime
- University of Cape Town, South Africa
| | - J Mellin-Olsen
- Department of Anaesthesia and Intensive Care Medicine, Baerum Hospital, Sandvika, Norway
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Affiliation(s)
- Ashish K Khanna
- From the Center for Critical Care, Department of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Schacham YN, Cohen B, Bajracharya GR, Walters M, Zimmerman N, Mao G, Tanios MA, Sessler DI. Mild Perioperative Hypothermia and Myocardial Injury: A Retrospective Cohort Analysis. Anesth Analg 2019; 127:1335-1341. [PMID: 30300173 DOI: 10.1213/ane.0000000000003840] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We tested the primary hypothesis that final intraoperative esophageal temperature is associated with increased odds of a composite of in-hospital all-cause mortality and myocardial injury within 7 days after noncardiac surgery. Secondary exposures were time-weighted average intraoperative temperature and area <37°C threshold. METHODS Myocardial injury was defined by postoperative fourth-generation troponin T ≥0.03 ng/mL apparently due to cardiac ischemia. Data were extracted for inpatients who had noncardiac surgery with general anesthesia at the Cleveland Clinic between 2012 and 2015. All had esophageal temperature monitoring and routine postoperative troponin monitoring. We estimated the confounder-adjusted association between final intraoperative esophageal temperature and the collapsed composite with multivariable logistic regression. We similarly estimated associations with time-weighted average intraoperative temperature and area <37°C. RESULTS Two thousand two hundred ten patients were included. Nearly all final esophageal temperatures were 36°C-37°C. Ninety-seven patients (4.4%) had myocardial injury, and 7 (0.3%) died before discharge. Final intraoperative core temperature was not associated with the collapsed composite: odds ratio, 0.91 (95% confidence interval, 0.68-1.24) per 1°C decrease. Similarly, neither of the secondary exposures was associated with the composite outcome. CONCLUSIONS We did not observe an association between mild perioperative hypothermia and mortality or myocardial injury in adults having noncardiac surgery. However, the range of final intraoperative temperatures was small and largely restricted to the normothermic range (36°C-37°C). Trials are needed to further assess the effect of temperature on myocardial injury.
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Affiliation(s)
- Yehoshua N Schacham
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Internal Medicine C, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barak Cohen
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Division of Anesthesia, Critical Care and Pain Management, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gausan R Bajracharya
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Walters
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicole Zimmerman
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Guangmei Mao
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Marianne A Tanios
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Postoperative ward monitoring - Why and what now? Best Pract Res Clin Anaesthesiol 2019; 33:229-245. [PMID: 31582102 DOI: 10.1016/j.bpa.2019.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 06/11/2019] [Accepted: 06/17/2019] [Indexed: 12/20/2022]
Abstract
The postoperative ward is considered an ideal nursing environment for stable patients transitioning out of the hospital. However, approximately half of all in-hospital cardiorespiratory arrests occur here and are associated with poor outcomes. Current monitoring practices on the hospital ward mandate intermittent vital sign checks. Subtle changes in vital signs often occur at least 8-12 h before an acute event, and continuous monitoring of vital signs would allow for effective therapeutic interventions and potentially avoid an imminent cardiorespiratory arrest event. It seems tempting to apply continuous monitoring to every patient on the ward, but inherent challenges such as artifacts and alarm fatigue need to be considered. This review looks to the future where a continuous, smarter, and portable platform for monitoring of vital signs on the hospital ward will be accompanied with a central monitoring platform and machine learning-based pattern detection solutions to improve safety for hospitalized patients.
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