1
|
Sun X, Xu L, Li J, Tang W, Wei P. Potential for heart rate deceleration capacity in assessing perioperative autonomic function and predicting adverse cardiovascular events. Br J Anaesth 2024; 133:441-443. [PMID: 38724323 DOI: 10.1016/j.bja.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/31/2024] [Accepted: 04/07/2024] [Indexed: 07/16/2024] Open
Affiliation(s)
- Xinyi Sun
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Lin Xu
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Jianjun Li
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Wenxi Tang
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China.
| | - Penghui Wei
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China.
| |
Collapse
|
2
|
Bansal S, Chakrabarti D, Giribabu P, Sriganesh K, Shukla D. Cardiac autonomic function in post-COVID-19 patients and its impact on haemodynamics during neurosurgery - A prospective observational study. Indian J Anaesth 2024; 68:200-204. [PMID: 38435657 PMCID: PMC10903774 DOI: 10.4103/ija.ija_874_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/21/2023] [Accepted: 12/23/2023] [Indexed: 03/05/2024] Open
Affiliation(s)
- Sonia Bansal
- Department of Neuroanaesthesia and Neurocritical Care, and Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, and Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
| | - Parthiban Giribabu
- Department of Neuroanaesthesia and Neurocritical Care, and Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
| | - Kamath Sriganesh
- Department of Neuroanaesthesia and Neurocritical Care, and Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
| | - Dhaval Shukla
- Department of Neuroanaesthesia and Neurocritical Care, and Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
| |
Collapse
|
3
|
Fernandez N, Silverii H, Dangle P, Yonekawa K. Atypical clinical presentation and management of urinary stone disease in non-verbal non-ambulatory children. J Pediatr Urol 2023; 19:560.e1-560.e6. [PMID: 37344296 DOI: 10.1016/j.jpurol.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 05/26/2023] [Accepted: 06/01/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Management of kidney stones primarily depends on various factors such as the presence of urinary tract obstruction, pain, stone size, location, impact on renal function, and the existence of infection. Renal colic is the classic presentation of an obstructive kidney stone. However, in this study, we present a cohort of non-verbal non-ambulatory (NVNA) patients who exhibit a distinct and uncommon presentation of kidney stones due to their medical conditions. Information about kidney stone disease in this gropup of complex pediatric patients is, scarce and their associated risk factors are not well understood. Therefore, we aim to summarize the clinical presentation, and management challenges in this unique group of NVNA patients to identify potential variables for prospective studies. METHODS A retrospective chart review was completed for all NVNA patients seen at the pediatric multidisciplinary kidney stone clinic between July 2020 to August 2022. Demographic variables, clinical presentation data, metabolic evaluation, radiological imaging, and surgical management was included for analysis. RESULTS A total of 224 pediatric patients were referred to the multidisciplinary stone clinic. Of those, 27 were identified to be NVNA. The most common primary diagnosis was Cerebral Palsy followed by Lennox-Gastaut syndrome. Average age at first kidney stone presentation was 11.5 years ± 5.7 years. An obstructing stone was diagnosed in 18 (66%) patients, 4 (22.2%) of these presented with sepsis. Average stone burden was 9.2 mm ( ± 5.8 mm). Of the obstructing stones, 13 (72%) were in the kidney. All patients with an obstructing stone underwent surgical management with retrograde endoscopic approach. Metabolic 24-h-urine analysis was completed in 24 (89%) patients. 17 (62%) had an elevated urine density, 15 (55%) demonstrated calcium oxalate supersaturation, 12 (44%) met criteria for acidosis, and 7 (26%) had significant hypocitraturia. DISCUSSION NVNA patients represent a unique cohort whose clinical presentation is atypical. Limited ability to express symptoms makes early detection difficult to recognize. Twenty two percent of patients present with sepsis as their first manifestation of an acutely obstructing kidney stone. Pain is subjectively interpreted by caregivers and is an uncommon symptom. Our cohort demonstrates common risk factors for stones including propensity for chronic dehydration, slow urinary tract transit, ineffective bladder emptying, G-tube feeding, and lithogenic medications. CONCLUSION NVNA pediatric patients have atypical kidney stone clinical presentation. Awareness of this unique group of patients should support future collaborative studies to focus on understanding these atypical presentations and reflect on improving management.
Collapse
Affiliation(s)
- Nicolas Fernandez
- Division of Pediatric Urology, Seattle Children's Hospital, University of Washington, Seattle, USA.
| | - Hailey Silverii
- Division of Pediatric Urology, Seattle Children's Hospital, University of Washington, Seattle, USA
| | - Pankaj Dangle
- Division of Pediatric Urology, Riley Children's Hospital, Indiana University, Indianapolis USA
| | - Karyn Yonekawa
- Division of Pediatric Nephrology, Seattle Children's Hospital, University of Washington, Seattle, USA
| |
Collapse
|
4
|
Zhang Y, Gong L, Zhang Y, Dong S, Shi J, Li X, Guo Y, He S, Wu X, Liu S, Liu H, Zhang L, Yu J. Effect of Transcutaneous Acupoint Electrical Stimulation on Urinary Retention and Urinary ATP in Elderly Patients After Laparoscopic Cholecystectomy: A Prospective, Randomized, Controlled Clinical Trial. Clin Interv Aging 2022; 17:1751-1760. [PMID: 36479561 PMCID: PMC9722321 DOI: 10.2147/cia.s382912] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/21/2022] [Indexed: 08/30/2023] Open
Abstract
PURPOSE To investigate the effect of transcutaneous electrical acupoint stimulation (TEAS) on urinary retention after laparoscopic cholecystectomy in elderly patients, and to explore the relationship between TEAS and urinary ATP. PATIENTS AND METHODS The TEAS group was administered active TEAS at specific acupuncture points prior to induction of anesthesia and continued for 45 mins after surgery. In the control group, participants received sham stimulus at the same acupoints and no output current was delivered by disconnecting the device's output line. Urine samples were collected and evaluated in the first spontaneous voiding after surgery. In this study, postoperative urinary retention (POUR) was the primary outcome, which was diagnosed based on clinical symptoms, ultrasound assessments, and the need for bladder catheterization. Secondary outcomes include urinary ATP, postoperative spontaneous urination, urination symptoms, catheter-related bladder discomfort (CRBD), delirium, duration and hospitalization costs. RESULTS The study involved 598 patients recruited and randomized between August 2018 and June 2020. Among these patients, 547 (91.5%) completed the study and were analyzed. There were 64 cases of POUR, including 23 (8.4%, 95% confidence interval [CI]: 6.4-9.9%) in the TEAS group and 41 (15.0%, 95% CI: 9.3-13.4%) in the control group (p = 0.017). A significant difference was observed between the TEAS and control groups for urinary ATP concentration in the first spontaneous urine postoperatively (344 nmol/L versus 233 nmol/L, p=0.001). There was a shorter spontaneous voiding recovery time, smaller voiding threshold, less postoperative catheterization, less CRBD, and lower hospitalization costs in TEAS group compared with control group. CONCLUSION TEAS reduces the incidence of POUR in elderly patients undergoing laparoscopic cholecystectomy, which may be related to an increase in bladder ATP release.
Collapse
Affiliation(s)
- Yanfang Zhang
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Lirong Gong
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Yuan Zhang
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Shuan Dong
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Jia Shi
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Xiangyun Li
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Yan Guo
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Simeng He
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Xiaoyang Wu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Shasha Liu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Huayang Liu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Lantian Zhang
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| | - Jianbo Yu
- Department of Anesthesiology and Critical Care Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, People’s Republic of China
| |
Collapse
|
5
|
Weisel CL, Dyke CM, Klug MG, Haldis TA, Basson MD. Day-to-day blood pressure variability predicts poor outcomes following percutaneous coronary intervention: A retrospective study. World J Cardiol 2022; 14:307-318. [PMID: 35702324 PMCID: PMC9157607 DOI: 10.4330/wjc.v14.i5.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/10/2022] [Accepted: 04/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND For patients with cardiovascular disease, blood pressure variability (BPV), distinct from hypertension, is an important determinant of adverse cardiac events. Whether pre-operative BPV adversely affects outcomes after percutaneous coronary intervention (PCI) is to this point unclear.
AIM To investigate the relationship between blood pressure variability and outcomes for patients post-PCI.
METHODS Patients undergoing PCI in a single state in 2017 were studied (n = 647). Systolic and diastolic BPV, defined as both the largest change and standard deviation for the 3-60 mo prior to PCI was calculated and patients with more than ten blood pressure measurements in that time were included for analysis (n = 471). Adverse outcomes were identified up to a year following the procedure, including major adverse cardiac events (MACE), myocardial infarction, cerebrovascular accident, death, and all-cause hospitalization.
RESULTS Visit-to-visit systolic BPV, as measured by both standard deviation and largest change, was higher in patients who had myocardial infarction, were readmitted, or died within one year following PCI. Systolic BPV, as measured by largest change or standard deviation, was higher in patients who had MACE, or readmissions (P < 0.05). Diastolic BPV, as measured by largest change, was higher in patients with MACE and readmissions (P < 0.05).
CONCLUSION As BPV is easily measured and captured in the electronic medical record, these findings describe a novel method of identifying at-risk patients who undergo PCI. Aggressive risk modification for patients with elevated BPV and known coronary artery disease is indicated.
Collapse
Affiliation(s)
- Cody L Weisel
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND 58201, United States
| | - Cornelius M Dyke
- Department of Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND 58201, United States
- Department of Surgery, Sanford Medical Center, Fargo, ND 58104, United States
| | - Marilyn G Klug
- Population Health, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND 58201, United States
| | - Thomas A Haldis
- Department of Cardiology, Sanford Medical Center, Fargo, ND 58104, United States
| | - Marc D Basson
- Department of Surgery, Pathology and Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND 58202, United States
| |
Collapse
|
6
|
Day-to-day blood pressure variability predicts poor outcomes following percutaneous coronary intervention: A retrospective study. World J Cardiol 2022. [DOI: 10.4330/wjc.v14.i5.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
7
|
Ackerman RS, Muncey AR, Aldawoodi NN, Kotha R, Getting REG. Cancer Immunotherapies: What the Perioperative Physician Needs to Know. Curr Oncol Rep 2022; 24:399-414. [PMID: 35141856 PMCID: PMC9056594 DOI: 10.1007/s11912-022-01202-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/26/2022]
Abstract
Purpose of Review For patients with cancer, treatment may include combination therapy, including surgery and immunotherapy. Here, we review perioperative considerations for the patient prescribed immunotherapeutic agents. Recent Findings The perioperative period is a poignant moment in the journey of a patient with cancer, potentially deemed most influential compared to other moments in the care continuum. Several immunotherapeutic medications have been employed near the time of surgery to potentially increase effectiveness. Of the various drug classes, including immune checkpoint inhibitors, cytokines, toll-like receptor agonists, and oncolytic viruses, among others, several notable immune-related adverse effects were noted. They range from minor effects to more serious ones, such as renal failure, myocarditis, and tumor growth. Summary Surgery and immunotherapy are often employed in combination for primary treatment and prevention of cancer recurrence. Careful review and consideration of the pharmacokinetics, pharmacodynamics, and toxicities of immunotherapy benefit the perioperative physician and their patients.
Collapse
Affiliation(s)
- Robert S Ackerman
- Department of Anesthesiology, Duke University Medical Center, 134 Research Drive, Durham, NC, 27710, USA.
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Aaron R Muncey
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Nasrin N Aldawoodi
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rohini Kotha
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | |
Collapse
|
8
|
Galway U, Chahar P, Schmidt MT, Araujo-Duran JA, Shivakumar J, Turan A, Ruetzler K. Perioperative challenges in management of diabetic patients undergoing non-cardiac surgery. World J Diabetes 2021; 12:1255-1266. [PMID: 34512891 PMCID: PMC8394235 DOI: 10.4239/wjd.v12.i8.1255] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/17/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
Prediabetes and diabetes are important disease processes which have several perioperative implications. About one third of the United States population is considered to have prediabetes. The prevalence in surgical patients is even higher. This is due to the associated micro and macrovascular complications of diabetes that result in the need for subsequent surgical procedures. A careful preoperative evaluation of diabetic patients and patients at risk for prediabetes is essential to reduce perioperative mortality and morbidity. This preoperative evaluation involves an optimization of preoperative comorbidities. It also includes optimization of antidiabetic medication regimens, as the avoidance of unintentional hypoglycemic and hyperglycemic episodes during the perioperative period is crucial. The focus of the perioperative management is to ensure euglycemia and thus improve postoperative outcomes. Therefore, prolonged preoperative fasting should be avoided and close monitoring of blood glucose should be initiated and continued throughout surgery. This can be accomplished with either analysis in blood gas samples, venous phlebotomy or point-of-care testing. Although capillary and arterial whole blood glucose do not meet standard guidelines for glucose testing, they can still be used to guide insulin dosing in the operating room. Intraoperative glycemic control goals may vary slightly in different protocols but overall the guidelines suggest a glucose range in the operating room should be between 140 mg/dL to 180 mg/dL. When hyperglycemia is detected in the operating room, blood glucose management may be initiated with subcutaneous rapid-acting insulin, with intravenous infusion or boluses of regular insulin. Fluid and electrolyte management are other perioperative challenges. Notably diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic state are the two most serious acute metabolic complications of diabetes that must be recognized early and treated.
Collapse
Affiliation(s)
- Ursula Galway
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Praveen Chahar
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Marc T Schmidt
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Jorge A Araujo-Duran
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Jeevan Shivakumar
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Alparslan Turan
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Kurt Ruetzler
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| |
Collapse
|
9
|
Idiaquez JF, Idiaquez J, Casar JC, Biaggioni I. Neurogenic Orthostatic Hypotension. Lessons From Synucleinopathies. Am J Hypertens 2021; 34:125-133. [PMID: 33705537 DOI: 10.1093/ajh/hpaa131] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/04/2020] [Accepted: 08/12/2020] [Indexed: 12/15/2022] Open
Abstract
Maintenance of upright blood pressure critically depends on the autonomic nervous system and its failure leads to neurogenic orthostatic hypotension (NOH). The most severe cases are seen in neurodegenerative disorders caused by abnormal α-synuclein deposits: multiple system atrophy (MSA), Parkinson's disease, Lewy body dementia, and pure autonomic failure (PAF). The development of novel treatments for NOH derives from research in these disorders. We provide a brief review of their underlying pathophysiology relevant to understand the rationale behind treatment options for NOH. The goal of treatment is not to normalize blood pressure but rather to improve quality of life and prevent syncope and falls by reducing symptoms of cerebral hypoperfusion. Patients not able to recognize NOH symptoms are at a higher risk for falls. The first step in the management of NOH is to educate patients on how to avoid high-risk situations and providers to identify medications that trigger or worsen NOH. Conservative countermeasures, including diet and compression garments, should always precede pharmacologic therapies. Volume expanders (fludrocortisone and desmopressin) should be used with caution. Drugs that enhance residual sympathetic tone (pyridostigmine and atomoxetine) are more effective in patients with mild disease and in MSA patients with spared postganglionic fibers. Norepinephrine replacement therapy (midodrine and droxidopa) is more effective in patients with neurodegeneration of peripheral noradrenergic fibers like PAF. NOH is often associated with other cardiovascular diseases, most notably supine hypertension, and treatment should be adapted to their presence.
Collapse
Affiliation(s)
- Juan Francisco Idiaquez
- Hospital Padre Hurtado, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago de Chile, Chile
| | - Juan Idiaquez
- Departamento de Neurologia, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile
| | - Juan Carlos Casar
- Departamento de Neurologia, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
10
|
Hogan AM, Luck C, Woods S, Ortu A, Petkov S. The Effect of Orthostatic Hypotension Detected Pre-Operatively on Post-Operative Outcome. J Am Geriatr Soc 2020; 69:767-772. [PMID: 33314116 DOI: 10.1111/jgs.16966] [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: 08/18/2020] [Revised: 10/31/2020] [Accepted: 11/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Exacerbation of or new onset orthostatic hypotension in perioperative patients can occur. There is complex underlying pathophysiology with further derailment likely caused by acute cardiovascular changes associated with surgery. The implications for post-operative recovery are unclear, particularly in frail and older patients. We retrospectively explored patient notes for evidence of post-operative orthostatic intolerance in relation to pre-operative orthostatic hypotension. METHODS Supine and 1-minute and 3-minute standing blood pressure measures obtained from adult patients before mainly general, orthopedic or uro/gynecology surgery were compared to post-operative outcome, specifically, evidence in patient notes about falls, feeling dizzy/unsteady and/or fearful to stand. Orthostatic hypotension was defined as a 20 mmHg or more and/or 10 mmHg or more fall in systolic and diastolic blood pressure, respectively, within ~3 minutes of standing after lying supine for an electrocardiogram. RESULTS Whilst all patients included had a 1-minute standing blood pressure assessment (N = 170), 3-minute assessment was performed less commonly (N = 113). Nevertheless, one-quarter (23.5%; N = 40) of 170 patients had pre-operative orthostatic hypotension. This was not clearly explained by cardiac or neurological disease or by common medications, but did occur more frequently in older patients and in those aged 65 years or more with higher clinical frailty scale scores. The COVID-19 pandemic reduced the number of patients progressing to surgery within the planned study timescale (N = 143/170; 84.1%). Nevertheless, patients with orthostatic hypotension stayed longer in hospital post-operatively and were more likely to have an episode of fall, unsteadiness and/or dizziness documented (un-prompted) in their notes. CONCLUSIONS These data provide further impetus for research into modifiable perioperative risk factors associated with orthostatic hypotension. These risks are not confined to those with a pre-existing dysautonomia diagnosis.
Collapse
Affiliation(s)
- Alexandra M Hogan
- Anaesthetics Department & Pre-Operative Assessment Clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Cognitive Neuroscience, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Claire Luck
- Anaesthetics Department & Pre-Operative Assessment Clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Sarah Woods
- Anaesthetics Department & Pre-Operative Assessment Clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Andrea Ortu
- Anaesthetics Department & Pre-Operative Assessment Clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Svet Petkov
- Anaesthetics Department & Pre-Operative Assessment Clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| |
Collapse
|
11
|
Abstract
Patients with Parkinson's disease (PD) may undergo several elective and emergency surgeries. Motor fluctuations, the presence of a wide range of non-motor symptoms (NMS), and the use of several medications, often not limited to dopaminergic agents, make the perioperative management of PD challenging. However, the literature on perioperative management of PD is sparse. In this descriptive review article, we comprehensively discuss the issues in the pre-, intra-, and postoperative phases which may negatively affect the PD patients and discuss the approach to their prevention and management. The major preoperative challenges include accurate medication reconciliation and administration of the dopaminergic medications during the nil per os (NPO) state. While the former can be addressed with staff education and PD-specific admission protocols, knowledge of non-oral formulations of dopaminergic agents (apomorphine, inhalational levodopa, and rotigotine transdermal patch) is the key to the management of the Parkinsonian symptoms in NPO state. Deep brain stimulation (DBS) devices should be turned off to avert potential electromagnetic interference with surgical appliances. Choosing the appropriate anesthesia and avoiding and managing respiratory issues and dysautonomia are the major intraoperative challenges. Timely reinitiation of dopaminergic medications, adequate management of pain, nausea, and vomiting, and prevention of postoperative infections and delirium are the postoperative challenges. Overall, a multidisciplinary approach is pivotal to prevent and manage the perioperative complications in PD. Administration of anti-Parkinson medications during NPO state, prevention of anesthesia-related complications, and timely rehabilitation remain the key to healthy surgical outcomes.
Collapse
|
12
|
Basson MD, Klug MG, Newman WE, Dyke C. Preoperative outpatient blood pressure variability predicts postoperative mortality, readmission and morbidity after surgery. Am J Surg 2020; 220:1083-1092. [PMID: 32139103 DOI: 10.1016/j.amjsurg.2020.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Outpatient blood pressure variability (BPV) predicts hospitalization and death in non-surgical patients independently of hypertension. We hypothesized that preoperative BPV predicts postoperative outcomes. METHODS We assessed 22,233 veterans undergoing CABG, colectomy, hip replacement, pancreatectomy, carotid endarterectomy or AV-fistula with ≥10 outpatient BP's over three preoperative years. Calculating BPV as SD of systolic or diastolic BP, we used logistic regression considering demographics, comorbidities, and pre-admission cardiovascular medications to estimate odds ratios for 90-day mortality or readmission, MI, CVA, renal failure, and wound infection, choosing the lowest 5%ile of systolic/diastolic BPV for reference. RESULTS Covariate-adjusted ORs for adverse outcomes increased as BPV increased. For instance, the highest 5%ile of systolic BPV had covariate-adjusted ORs of 2.96 and 1.78 for 90-day mortality and readmission. Systolic and diastolic BPV trended together but affected outcomes independently. CONCLUSIONS Preoperative BPV predicts postoperative outcomes. BPV should be considered in individualized risk assessment and subgroup risk stratification.
Collapse
Affiliation(s)
- Marc D Basson
- Department of Surgery, University of North Dakota School of Medicine & Health Sciences and the Fargo VAMC, USA.
| | - Marilyn G Klug
- Department of Population Health, University of North Dakota School of Medicine & Health Sciences and the Fargo VA, USA
| | - William E Newman
- Department of Internal Medicine, University of North Dakota School of Medicine & Health Sciences and the Fargo VA, USA
| | - Cornelius Dyke
- Department of Surgery, University of North Dakota School of Medicine & Health Sciences and Sanford Health, USA
| |
Collapse
|
13
|
Reimer P, Máca J, Szturz P, Jor O, Kula R, Ševčík P, Burda M, Adamus M. Role of heart-rate variability in preoperative assessment of physiological reserves in patients undergoing major abdominal surgery. Ther Clin Risk Manag 2017; 13:1223-1231. [PMID: 29033572 PMCID: PMC5614745 DOI: 10.2147/tcrm.s143809] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Major abdominal surgery (MAS) is associated with increased morbidity and mortality. The main objective of our study was to evaluate the predictive value of heart-rate variability (HRV) concerning development of postoperative complications in patients undergoing MAS. The secondary objectives were to identify the relationship of HRV and use of vasoactive drugs during anesthesia, intensive care unit length of stay (ICU-LOS), and hospital length of stay (H-LOS). Patients and methods Sixty-five patients scheduled for elective MAS were enrolled in a prospective, single-center, observational study. HRV was measured by spectral analysis (SA) preoperatively during orthostatic load. Patients were divided according to cardiac autonomic reactivity (CAR; n=23) and non-cardiac autonomic reactivity (NCAR; n=30). Results The final analysis included 53 patients. No significant difference was observed between the two groups regarding type of surgery, use of minimally invasive techniques or epidural catheter, duration of surgery and anesthesia, or the amount of fluid administered intraoperatively. The NCAR group had significantly greater intraoperative blood loss than the CAR group (541.7±541.9 mL vs 269.6±174.3 mL, p<0.05). In the NCAR group, vasoactive drugs were used during anesthesia more frequently (n=21 vs n=4; p<0.001), and more patients had at least one postoperative complication compared to the CAR group (n=19 vs n=4; p<0.01). Furthermore, the NCAR group had more serious complications (Clavien–Dindo ≥ Grade III n=6 vs n=0; p<0.05) and a greater number of complications than the CAR group (n=57 vs n=5; p<0.001). Significant differences were found for two specific subgroups of complications: hypotension requiring vasoactive drugs (NCAR: n=10 vs CAR: n=0; p<0.01) and ileus (NCAR: n=11 vs CAR: n=2; p<0.05). Moreover, significant differences were found in the ICU-LOS (NCAR: 5.7±3.5 days vs CAR: 2.6±0.7 days; p<0.0001) and H-LOS (NCAR: 12.2±5.6 days vs CAR: 7.2±1.7 days; p<0.0001). Conclusion Preoperative HRV assessment during orthostatic load is objective and useful for identifying patients with low autonomic physiological reserves and high risk of poor post-operative course.
Collapse
Affiliation(s)
- Petr Reimer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Jan Máca
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Pavel Szturz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Ondřej Jor
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Roman Kula
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Pavel Ševčík
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Michal Burda
- Institute for Research and Applications of Fuzzy Modeling, Centre of Excellence IT4Innovations, University of Ostrava, Ostrava
| | - Milan Adamus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Olomouc, Olomouc, Czech Republic
| |
Collapse
|
14
|
Akbar U, Kurkchubasche AG, Friedman JH. Perioperative management of Parkinson’s disease. Expert Rev Neurother 2016; 17:301-308. [DOI: 10.1080/14737175.2017.1241143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Umer Akbar
- Department of Neurology, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Arlet G. Kurkchubasche
- Department of Surgery and Pediatrics, Brown University, Hasbro Children’s Hospital, Providence, RI, USA
| | - Joseph H. Friedman
- Department of Neurology, Brown University, Butler Hospital, Providence, RI, USA
| |
Collapse
|