Does the prophylactic administration of magnesium sulphate to patients undergoing thoracotomy prevent postoperative supraventricular arrhythmias? A randomized controlled trial

Intravenous Versus Wetting Solution Magnesium Sulphate to Counteract Epinephrine Cardiac Adverse Events in Abdominal Liposuction: A Randomized Controlled Trial

Background

The increased frequency of liposuction has resulted in more complications being reported. Adding epinephrine to the wetting solution could induce some cardiac adverse effects, some of which may be fatal. For instance, magnesium sulfate (MgSO₄) is known for its cardioprotective effects.

Objectives

This study aimed to evaluate the efficacy of intravenous (IV) versus wetting solution containing MgSO₄ in decreasing such cardiac adverse events during abdominal liposuction.

Methods

This randomized controlled study included 129 adult cases undergoing abdominal liposuction under general anesthesia. The participants were divided into 3 groups: Group I (control group) was only subjected to the injection of the wetting fluid (1 mL 1/1000 epinephrine added to every 1000 mL of normal saline), group II was subjected to IV MgSO₄ (40 mg/kg over 1 minute) at the same time of installing the wetting solution, and group III was subjected to MgSO₄ (40 mg/kg) added to the wetting solution.

Results

Intraoperative isoflurane consumption, intraoperative heart rate (HR), mean arterial pressure (MAP), and postoperative pain scores were significantly lower in the MgSO₄ groups (groups II and III) than group I. Cardiac adverse events (sinus tachycardia and premature ventricular contractions (PVCs)) were also significantly less frequent in groups II and III compared to group I.

Conclusions

Adding MgSO₄, either through IV or subcutaneous routes, is associated with lower intraoperative HR, MAP, and postoperative pain scores and a remarkable decrease in epinephrine-induced cardiac adverse events during liposuction.

Utility of magnesium sulfate in the treatment of rapid atrial fibrillation in the emergency department: a systematic review and meta-analysis

Atrial fibrillation with rapid ventricular response (Afib/RVR) is a frequent reason for emergency department (ED) visits and can be treated with a variety of pharmacological agents. Magnesium sulfate has been used to prevent and treat postoperative Afib/RVR. We performed a systematic review and meta-analysis to assess the effectiveness of magnesium for treatment of Afib/RVR in the ED. PubMed and Scopus databases were searched up to June 2021 to identify any relevant randomized trials or observational studies. We used Cochrane's Risk-of-Bias tools to assess study qualities and random-effects meta-analysis for the difference of heart rate (HR) before and after treatment. Our search identified 395 studies; after reviewing 11 full texts, we included five randomized trials in our analysis. There were 815 patients with Afib/RVR; 487 patients (60%) received magnesium treatment, whereas 328 (40%) patients received control treatment. Magnesium treatment was associated with significant reduction in HR [standardized mean difference (SMD), 0.34; 95% CI, 0.21-0.47; P < 0.001; I2 = 4%), but not associated with higher rates of sinus conversion (OR, 1.46; 95% CI, 0.726-2.94; P = 0.29), nor higher rates of hypotension and bradycardia (OR, 2.2; 95% CI, 0.62-8.09; P = 0.22). Meta-regressions demonstrated that higher maintenance dose (corr. coeff, 0.17; P = 0.01) was positively correlated with HR reductions, respectively. We observed that magnesium infusion can be an effective rate control treatment for patients who presented to the ED with Afib/RVR. Further studies with more standardized forms of control and magnesium dosages are necessary to assess the benefit/risk ratio of magnesium treatment, besides to confirm our observations.

Examination of Electrolyte Replacements in the ICU Utilizing MIMIC-III Dataset Demonstrates Redundant Replacement Patterns

Electrolyte repletion in the ICU is one of the most ubiquitous tasks in critical care, involving significant resources while having an unclear risk/benefit ratio. Prior data indicate most replacements are administered while electrolytes are within or above reference ranges with little effect on serum post-replacement levels and potential harm. ICU electrolyte replacement patterns were analyzed using the MIMIC-III database to determine the threshold governing replacement decisions and their efficiency. The data of serum values for potassium, magnesium, and phosphate before and after repletion events were evaluated. Thresholds for when repletion was administered and temporal patterns in the repletion behaviors of ICU healthcare providers were identified. Most electrolyte replacements happened when levels were below or within reference ranges. Of the lab orders placed, a minuscule number of them were followed by repletion. Electrolyte repletion resulted in negligible (phosphate), small (potassium), and modest (magnesium) post-replacement changes in electrolyte serum levels. The repletion pattern followed hospital routine work and was anchored around shift changes. A subset of providers conducting over-repletion in the absence of clinical indication was also identified. This pattern of behavior found in this study supports previous studies and may allude to a universal pattern of over-repletion in the ICU setting.

Predictive value of preoperative echocardiographic assessment for postoperative atrial fibrillation after esophagectomy for esophageal cancer

BACKGROUND

Postoperative atrial fibrillation (POAF) after esophagectomy for esophageal cancer is not uncommon. The aim of this study is to examine whether preoperative transthoracic echocardiography is useful for predicting new-onset POAF in esophageal cancer.

METHODS

In this prospective observational study, we evaluated 200 patients with esophageal cancer who underwent esophagectomy at our hospital between January 2016 and July 2019. Conventional echocardiographic assessment and tissue Doppler imaging were performed before surgery. We investigated the utility of preoperative transthoracic echocardiography for predicting new-onset POAF in esophageal cancer.

RESULTS

New-onset POAF occurred in 51 (25.5%) of 200 patients. POAF was significantly associated with older age (p = 0.007), higher body mass index (p = 0.020), preoperative hypertensive disease (p = 0.021), and lower hemoglobin level (p = 0.028). The incidence of postoperative complications was significantly higher in patients with POAF than in patients without POAF (43.1% vs. 24.2%, p = 0.013). Transthoracic echocardiography showed that left atrial diameter (LAD) and E wave/e' wave ratio (E/e') were significantly higher in patients with POAF than in patients without POAF (34.1 vs. 31.3 mm, p < 0.001 and 11.6 vs. 10.5, p = 0.003, respectively). Multivariate analysis showed that LAD ≥ 36.0 mm, E/e' ≥ 8.4 are independent risk factors for POAF (odds ratios 2.47 and 3.64; p values 0.035 and 0.027, respectively) CONCLUSIONS: Preoperative echocardiographic evaluation is useful for predicting the onset of POAF after esophagectomy for esophageal cancer. Risk stratification using LAD and E/e' enables clinicians to identify patients at high risk for POAF before esophagectomy.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Randomized clinical trial of landiolol hydrochloride for the prevention of atrial fibrillation and postoperative complications after oesophagectomy for cancer

Background

Atrial fibrillation is common after oesophageal surgery. The aim of this study was to evaluate whether landiolol hydrochloride was effective and safe in the prevention of atrial fibrillation after oesophagectomy, and to see whether a reduction in incidence of atrial fibrillation would reduce other postoperative complications.

Methods

This single-centre study enrolled patients scheduled for transthoracic oesophagectomy in a randomized, double-blind, placebo-controlled trial between March 2013 and January 2016. Enrolled patients were randomized with a 1 : 1 parallel allocation ratio to either landiolol prophylaxis or placebo. The primary endpoint was the occurrence of atrial fibrillation after oesophagectomy. Secondary endpoints were incidence of postoperative complications, and effects on haemodynamic and inflammatory indices.

Results

One hundred patients were enrolled, 50 in each group. Postoperative atrial fibrillation occurred in 15 patients (30 per cent) receiving placebo versus five (10 per cent) receiving landiolol (P = 0·012). The overall incidence of postoperative complications was significantly lower in the landiolol group (P = 0·046). In the landiolol group, postoperative heart rate was suppressed effectively, but the decrease in BP was not harmful. The interleukin 6 level was significantly lower on days 3 and 5 after surgery in the landiolol group (P = 0·001 and P = 0·002 respectively).

Conclusion

Landiolol was effective and safe in preventing atrial fibrillation after oesophagectomy. Registration number: UMIN000010648 (http://www.umin.ac.jp/ctr/).

Epidemiology, prevention, and treatment of new-onset atrial fibrillation in critically ill: a systematic review

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia in the ICU. The aim of this review is to summarize relevant information on new-onset AF in non-cardiac critical illness with respect to epidemiology, prevention, and treatment.

METHODS

We conducted a PubMed search in June 2014 and included studies describing the epidemiology, prevention, and treatment of new-onset AF and atrial flutter during ICU stay in non-cardiac adult patients. Selected studies were divided into the three categories according to the extracted information. The methodological quality of selected studies was described according to the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

We identified 1,132 citations, and after full-text-level selection, we included 10 studies on etiology/outcome and five studies on treatment. There was no study related to prevention. Overall quality of evidence was mostly low or very low due to their observational study designs, small sample sizes, flawed diagnosis of new-onset AF, and the absence of mortality evaluation. The incidence of new-onset AF varied from 4.5% to 15.0%, excluding exceptional cases (e.g., septic shock). Severity scores of patients with new-onset AF were higher than those without new-onset AF in eight studies, in four of which the difference was statistically significant. Five studies reported risk factors for new-onset AF, all of which used multivariate analyses to extract risk factors. Multiple risk factors are reported, e.g., advanced age, the white race, severity scores, organ failures, and sepsis. Hospital mortality in new-onset AF patients was higher than that of patients without AF in all studies, four of which found statistical significance. Among the five studies on treatment, only one study was randomized controlled, and various interventions were studied.

CONCLUSIONS

New-onset AF occurred in 5%-15% of the non-cardiac critically ill patients. Patients with new-onset AF had poor outcomes compared with those without AF. Despite the high incidence of new-onset AF in the general ICU population, currently available information for AF, especially for management (prevention, treatment, and anticoagulation), is quite limited. Further research is needed to improve our understanding of new-onset AF in critically ill patients.

Anesthesia for esophagectomy

Esophagectomy is a high-risk operation with significant perioperative morbidity and mortality. Attention to detail in many areas of perioperative management should lead to an aggregation of marginal gains and improvement in postoperative outcome. This review addresses preoperative assessment and patient selection, perioperative care (focusing on pulmonary prehabilitation, ventilation strategies, goal-directed fluid therapy, analgesia, and cardiovascular complications), minimally invasive surgery, and current evidence for enhanced recovery in esophagectomy.

Perioperative Systemic Magnesium to Minimize Postoperative Pain

Background:

Systemic magnesium has been used to minimize postoperative pain with conflicting results by clinical studies. It remains unknown whether the administration of perioperative systemic magnesium can minimize postoperative pain. The objective of the current investigation was to evaluate the effect of systemic magnesium on postoperative pain outcomes.

Methods:

A wide search was performed to identify randomized controlled trials that evaluated the effects of systemic magnesium on postoperative pain outcomes in surgical procedures performed under general anesthesia. Meta-analysis was performed using a random-effect model. Publication bias was evaluated by examining the presence of asymmetric funnel plots using Egger regression.

Results:

Twenty randomized clinical trials with 1,257 subjects were included. The weighted mean difference (99% CI) of the combined effects favored magnesium over control for pain at rest (≤4 h, −0.74 [−1.08 to −0.48]; 24 h, −0.36 [−0.63 to −0.09]) and with movement at 24 h, −0.73 (−1.37 to −0.1). Opioid consumption was largely decreased in the systemic magnesium group compared with control, weighted mean difference (99% CI) of −10.52 (−13.50 to −7.54) mg morphine IV equivalents. Publication bias was not present in any of the analysis. Significant heterogeneity was present in some analysis, but it could be partially explained by the sole intraoperative administration of magnesium compared with the intraoperative and postoperative administration. None of the studies reported clinical toxicity related to toxic serum levels of magnesium.

Conclusion:

Systemic administration of perioperative magnesium reduces postoperative pain and opioid consumption. Magnesium administration should be considered as a strategy to mitigate postoperative pain in surgical patients.

Low serum magnesium concentrations are associated with a high prevalence of premature ventricular complexes in obese adults with type 2 diabetes

BACKGROUND

Premature ventricular complexes (PVC) predict cardiovascular mortality among several adult populations. Increased arrhythmia prevalence has been reported during controlled magnesium (Mg) depletion studies in adults. We thus hypothesized that serum magnesium (sMg) concentrations are inversely associated with the prevalence of PVC in adults at high cardiovascular risk.

METHODS

Anthropometric, demographic and lifestyle characteristics were assessed in 750 Cree adults, aged > 18 yrs, who participated in an age-stratified, cross-sectional health survey in Quebec, Canada. Holter electrocardiograms recorded heart rate variability and cardiac arrhythmias for two consecutive hours. Multivariate logistic regression was used to evaluate the associations between sMg and PVC.

RESULTS

PVC prevalence in adults with hypomagnesemia (sMg ≤ 0.70 mmol/L) was more than twice that of adults without hypomagnesemia (50% vs. 21%, p = 0.015); results were similar when adults with cardiovascular disease history were excluded. All hypomagnesemic adults with PVC had type 2 diabetes (T2DM). Prevalence of PVC declined across the sMg concentration gradient in adults with T2DM only (p < 0.001 for linear trend). In multivariate logistic regressions adjusted for age, sex, community, body mass index, smoking, physical activity, alcohol consumption, kidney disease, antihypertensive and cholesterol lowering drug use, and blood docosahexaenoic acid concentrations, the odds ratio of PVC among T2DM subjects with sMg > 0.70 mmol/L was 0.24 (95% CI: 0.06-0.98) p = 0.046 compared to those with sMg ≤ 0.70 mmol/L.

CONCLUSIONS

sMg concentrations were inversely associated with the prevalence of PVC in patients with T2DM in a dose response manner, indicating that suboptimal sMg may be a contributor to arrhythmias among patients with T2DM.