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Saugel B, Fletcher N, Gan TJ, Grocott MPW, Myles PS, Sessler DI. PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management. Br J Anaesth 2024; 133:264-276. [PMID: 38839472 PMCID: PMC11282474 DOI: 10.1016/j.bja.2024.04.046] [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: 12/19/2023] [Revised: 03/09/2024] [Accepted: 04/05/2024] [Indexed: 06/07/2024] Open
Abstract
Arterial pressure monitoring and management are mainstays of haemodynamic therapy in patients having surgery. This article presents updated consensus statements and recommendations on perioperative arterial pressure management developed during the 11th POQI PeriOperative Quality Initiative (POQI) consensus conference held in London, UK, on June 4-6, 2023, which included a diverse group of international experts. Based on a modified Delphi approach, we recommend keeping intraoperative mean arterial pressure ≥60 mm Hg in at-risk patients. We further recommend increasing mean arterial pressure targets when venous or compartment pressures are elevated and treating hypotension based on presumed underlying causes. When intraoperative hypertension is treated, we recommend doing so carefully to avoid hypotension. Clinicians should consider continuous intraoperative arterial pressure monitoring as it can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring. Postoperative hypotension is often unrecognised and might be more important than intraoperative hypotension because it is often prolonged and untreated. Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension including choice of vasopressors. Research is also needed to guide monitoring and management strategies for recognising, preventing, and treating postoperative hypotension.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, UK
| | - Tong J Gan
- Division of Anesthesiology and Perioperative Medicine, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
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Smith A, Turoczi Z, Al-Subaie N, Zilahi G. Postoperative Hypotension After Cardiac Surgery Is Associated With Acute Kidney Injury. J Cardiothorac Vasc Anesth 2024; 38:1683-1688. [PMID: 38879370 DOI: 10.1053/j.jvca.2024.04.024] [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: 02/13/2024] [Revised: 03/30/2024] [Accepted: 04/17/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVES To describe the incidence of postoperative hypotension in patients undergoing cardiac surgery during the first 12 hours in the intensive care unit (ICU) and any relationship between hypotension and the development of acute kidney injury (AKI). DESIGN This was a retrospective, observational cohort study. SETTING The study took place in a single-center tertiary teaching hospital in London, UK. PARTICIPANTS Adult patients (n = 100) who underwent elective cardiac surgery requiring intraoperative cardiopulmonary bypass between May and November 2021 were enrolled. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A hypotensive event was defined as mean arterial pressure <65 mmHg lasting at least 1 minute. Invasive blood pressure data was analyzed for the first 12 hours after surgery, and any association between postoperative hypotension and AKI was assessed. A total of 91% of patients experienced hypotension in the first 12 hours postprocedure. On average, patients experienced 9 hypotensive events, with events lasting an average of 5 minutes. A total of 16 patients (16%) developed at least stage 1 AKI. The average duration of hypotension was significantly higher in the AKI group (4.6 min [IQR 3.3, 8.0] v 8.1 min [IQR 5.2, 14.2], p = 0.029). Those suffering AKI had longer ICU and hospital stays. CONCLUSIONS This study demonstrated that hypotension in the first 12 hours following cardiac surgery is common and prolonged hypotensive events are associated with developing AKI. This emphasizes the importance of treating hypotension aggressively and highlights a target for further research and intervention.
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Affiliation(s)
- Alexander Smith
- Cardiothoracic Intensive Care Unit, St George's University Hospital NHS Foundation Trust, London, United Kingdom.
| | - Zsolt Turoczi
- Cardiothoracic Intensive Care Unit, St George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Nawaf Al-Subaie
- Cardiothoracic Intensive Care Unit, St George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Gabor Zilahi
- Cardiothoracic Intensive Care Unit, St George's University Hospital NHS Foundation Trust, London, United Kingdom
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HUA Q, FAN L, WANG ZW, LI J. 2023 Guideline for the management of hypertension in the elderly population in China. J Geriatr Cardiol 2024; 21:589-630. [PMID: 38973827 PMCID: PMC11224653 DOI: 10.26599/1671-5411.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Affiliation(s)
| | - Qi HUA
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li FAN
- Chinese PLA General Hospital, Beijing, China
| | - Zeng-Wu WANG
- Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing LI
- Xuanwu Hospital, Capital Medical University, Beijing, China
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Picod A, Garcia B, Van Lier D, Pickkers P, Herpain A, Mebazaa A, Azibani F. Impaired angiotensin II signaling in septic shock. Ann Intensive Care 2024; 14:89. [PMID: 38877367 PMCID: PMC11178728 DOI: 10.1186/s13613-024-01325-y] [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: 12/20/2023] [Accepted: 05/29/2024] [Indexed: 06/16/2024] Open
Abstract
Recent years have seen a resurgence of interest for the renin-angiotensin-aldosterone system in critically ill patients. Emerging data suggest that this vital homeostatic system, which plays a crucial role in maintaining systemic and renal hemodynamics during stressful conditions, is altered in septic shock, ultimately leading to impaired angiotensin II-angiotensin II type 1 receptor signaling. Indeed, available evidence from both experimental models and human studies indicates that alterations in the renin-angiotensin-aldosterone system during septic shock can occur at three distinct levels: 1. Impaired generation of angiotensin II, possibly attributable to defects in angiotensin-converting enzyme activity; 2. Enhanced degradation of angiotensin II by peptidases; and/or 3. Unavailability of angiotensin II type 1 receptor due to internalization or reduced synthesis. These alterations can occur either independently or in combination, ultimately leading to an uncoupling between the renin-angiotensin-aldosterone system input and downstream angiotensin II type 1 receptor signaling. It remains unclear whether exogenous angiotensin II infusion can adequately address all these mechanisms, and additional interventions may be required. These observations open a new avenue of research and offer the potential for novel therapeutic strategies to improve patient prognosis. In the near future, a deeper understanding of renin-angiotensin-aldosterone system alterations in septic shock should help to decipher patients' phenotypes and to implement targeted interventions.
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Affiliation(s)
- Adrien Picod
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France.
| | - Bruno Garcia
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire de Lille, Lille, France
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Dirk Van Lier
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Antoine Herpain
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
- Department of Intensive Care Medicine, St. Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Mebazaa
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France
- Department of Anesthesiology, Burns and Critical Care, Hopitaux Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Feriel Azibani
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France
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Kim J, Lee S, Choi J, Ryu DK, Woo S, Park M. Effect of continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers on the day of surgery on myocardial injury after non-cardiac surgery: A retrospective cohort study. J Clin Anesth 2024; 94:111401. [PMID: 38330844 DOI: 10.1016/j.jclinane.2024.111401] [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: 08/08/2023] [Revised: 01/17/2024] [Accepted: 01/23/2024] [Indexed: 02/10/2024]
Abstract
STUDY OBJECTIVE To evaluate the effect of continuing of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) prescriptions 24 h before surgery on postoperative myocardial injury and blood pressure in patients undergoing non-cardiac surgery. DESIGN A single-center, retrospective study. SETTING Operating room and perioperative care area. PATIENTS 42,432 patients who had been taking chronic ACEI/ARB underwent non-cardiac surgery from January 2012 to June 2022. INTERVENTIONS Patients who discontinued ACEI/ARB 24 h before surgery (withheld group, n=31,055) and those who continued ACEI/ARB 24 h before surgery (continued group, n=11,377). MEASUREMENTS Primary outcome was myocardial injury after non-cardiac surgery (MINS) within 7 days postoperatively. MINS was defined as an elevated postoperative cardiac troponin measurement above the 99th percentile of the upper reference limit with a rise/fall pattern. Perioperative blood pressure and clinical outcomes were secondary outcomes. MAIN RESULTS Among 42,432 patients, MINS occurred in 2848 patients (6.7%) and was the all-cause of death within 30 days in 122 patients (0.3%). Incidence of MINS was significantly higher in the continued group than the withheld group (847/11,377 [7.4%] vs. 2001/31,055 [6.4%]; OR [95% CI] 1.17 [1.07-1.27]; P<0.001). After 1:1 propensity score matching, 11,373 patients were included in each group. There was still a significant difference for the occurrence of MINS between two groups in matched cohort (7.4% vs. 6.6%, OR [95% CI] 1.14 [1.03-1.26]; P=0.015). Time-average weight of mean arterial pressure <65 mmHg during surgery was significantly higher in the continued group (mean 0.11 vs. 0.09 [95% CI of mean difference] [0.01-0.03]; P<0.001). However, there was no significant difference in other clinical outcomes and mortality. CONCLUSIONS Withholding ACEI/ARB before surgery was associated with a reduced risk of intraoperative hypotension and postoperative myocardial injury, but it did not affect overall clinical outcomes in patients undergoing non-cardiac surgery.
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Affiliation(s)
- Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seungwon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jisun Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae Kyun Ryu
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seunghyeon Woo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - MiHye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Gao WD. One size does not fit all: Perioperative management of patients with heart failure with preserved ejection fraction. J Clin Anesth 2024; 94:111409. [PMID: 38340679 DOI: 10.1016/j.jclinane.2024.111409] [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: 10/09/2023] [Revised: 12/18/2023] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is recognized as an important risk factor for perioperative complications. However, anesthesia management of HFpEF patients remains a considerable challenge without clear guidance. HFpEF is heterogeneous in its pathophysiological processes, diverse clinical presentations, adverse remodeling of cardiovascular and other organs, and clinical outcomes. It is difficult to manage the disease with one fixed approach because of this. This review phenotypes HFpEF patients by combining their clinical features and anesthesia care issues. Five phenotypes of HFpEF patients are identified: A, O, P, C, and Y. The clinical features, anesthesia implications, and anesthesia management for each phenotype are highlighted and discussed. Such an approach to HFpEF patients in the operating room could deliver safe, high-quality perioperative care.
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Yuan R, Xu M, Hu C, Ma H, Meng F, Ren J, Wen J. Hemodynamic effects of withholding vs. continuing angiotensin II receptor blockers on the day of prone positioning spinal surgery in elderly patients. Front Med (Lausanne) 2024; 11:1352918. [PMID: 38765256 PMCID: PMC11100417 DOI: 10.3389/fmed.2024.1352918] [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: 12/09/2023] [Accepted: 02/26/2024] [Indexed: 05/21/2024] Open
Abstract
Introduction The hemodynamic effects of withholding vs. continuing angiotensin II receptor blockers (ARBs) before surgery in elderly patients undergoing spinal surgery in a prone position during anesthesia induction to skin incision are still unknown. Methods In this prospective study, 80 patients undergoing spinal surgery in a prone position with general anesthesia, aged 60-79 years, American Society of Anesthesiologists (ASA) II or III, were enrolled. Patients who had ARBs only in their preoperative medication list were randomly divided into two groups at a 1:1 ratio: In Group A, ARBs were continued on the morning of surgery, while in Group B, they were withhold. Norepinephrine was infused to maintain the blood pressure at the baseline level of ±20% during anesthesia induction in all patients. The primary outcome was the consumption of norepinephrine in each group from anesthesia induction to skin incision. The secondary outcomes include changes in invasive arterial blood pressure and heart rate, the fluid infusion volumes, the amounts of anesthetic drugs, and the total time from induction to skin incision. Results There were no significant differences in the demographics, the fluid infusion volumes, the amounts of anesthetic drugs, the total time from induction to skin incision, and hemodynamics at different time points (p > 0.05), while significant differences were found in norepinephrine consumption between the two groups (p < 0.001). Compared with Group B, the consumption of norepinephrine increased significantly in Group A (93.3 ± 29.8 vs. 124.1 ± 38.7 μg, p = 0.000). In addition, the same trend was illustrated in the pumping rate of norepinephrine between Group B (0.04 ± 0.01 μg·kg-1·min-1) and Group A (0.06 ± 0.02 μg·kg-1·min-1) (p = 0.004). Conclusion Our study conducted in elderly patients with hypotension undergoing prone spinal surgery demonstrated a greater pumping rate of norepinephrine during anesthesia induction in patients with ARBs continuing before surgery than those withholding, indicating that it was more difficult to maintain hemodynamic stability.Clinical Trial Registration: https://www.chictr.org.cn/showproj.html?proj=141081, ChiCTR2100053583.
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Affiliation(s)
- Ruimei Yuan
- Department of Anesthesiology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Min Xu
- Department of Endocrinology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Chunhai Hu
- Department of Urology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Huailing Ma
- Department of Anesthesiology, Shandong Provincial Third Hospital, Jinan, Shandong, China
| | - Fanjun Meng
- Department of Anesthesiology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jie Ren
- Department of Anesthesiology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jing Wen
- Department of Urology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Zöllner C. [Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. DIE ANAESTHESIOLOGIE 2024; 73:294-323. [PMID: 38700730 PMCID: PMC11076399 DOI: 10.1007/s00101-024-01408-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.
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Affiliation(s)
- Christian Zöllner
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Martinistr. 52, 20246, Hamburg, Deutschland.
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Legrand M. Should renin-angiotensin system inhibitors be held prior to major surgery? Br J Anaesth 2024; 132:831-834. [PMID: 38642964 DOI: 10.1016/j.bja.2024.03.003] [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: 01/17/2024] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/22/2024] Open
Abstract
Many patients undergoing surgical procedures have a history of hypertension, diabetes mellitus, heart failure, or a combination. Often, these conditions involve the chronic use of a renin-angiotensin system inhibitor, including angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). Observational studies have suggested that continuing ACEIs/ARBs before major noncardiac surgery can increase the risk of intraoperative hypotension, which might drive postoperative complications such as acute kidney injury, myocardial injury, or stroke. Strong recommendations on how to manage ACEIs/ARBs before surgery are, however, lacking owing to insufficient evidence, mostly limited to data from observational studies. Recently, the SPACE trial investigated the impact of preoperative management of ACEIs/ARBs on postoperative myocardial injury. Myocardial injury occurred in 48.3% patients randomised to discontinue and 41.3% patients randomised to continue ACEI/ARB (odds ratio for continuing: 0.77, 95% confidence interval 0.45-1.31). Patients randomised to the 'Stop' group experienced more postoperative hypertension. In a post hoc analysis, patients randomised to the 'Continue' group with low preoperative NT-proBNP concentrations (<100 pg ml-1) experienced less myocardial injury after surgery than the 'Stop' group, whereas no significant difference was observed in patients with elevated preoperative NT-proBNP concentrations. The SPACE trial provides important and new reassuring data on the safety of continuing ACEIs/ARBs before major surgery, challenging previous beliefs.
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA; INI-CRCT Network, Nancy, France.
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Guilleminot P, Andrei S, Nguyen M, Abou-Arab O, Besnier E, Bouhemad B, Guinot PG. Pre-operative maintenance of angiotensin-converting enzyme inhibitors is not associated with acute kidney injury in cardiac surgery patients with cardio-pulmonary bypass: a propensity-matched multicentric analysis. Front Pharmacol 2024; 15:1343647. [PMID: 38783960 PMCID: PMC11112351 DOI: 10.3389/fphar.2024.1343647] [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: 11/24/2023] [Accepted: 03/28/2024] [Indexed: 05/25/2024] Open
Abstract
Objective: We investigated the effects of the maintenance of angiotensin-converting enzyme inhibitors (ACE inhibitors) the day of the surgery on the incidence of postoperative acute kidney injury (AKI) and cardiac events in patients undergoing cardiac surgery. Methods: We performed a multicentric observational study with propensity matching on 1,072 patients treated with ACE inhibitors. We collected their baseline demographic data, comorbidities, and operative and postoperative outcomes. AKI was defined by KDIGO (Kidney Disease: Improving Global Outcome). Results: Maintenance of an ACE inhibitor was not associated with an increased risk of AKI (OR: 1.215 (CI95%:0.657-2.24), p = 0.843, 71 patients (25.1%) vs. 68 patients (24%)). Multivariate logistic regression and sensitive analysis did not demonstrate any association between ACE inhibitor maintenance and AKI, following cardiac surgery (OR: 1.03 (CI95%:0.81-1.3)). No statistically significant difference occurs in terms of incidence of cardiogenic shock (OR: 1.315 (CI95%:0.620-2.786)), stroke (OR: 3.313 (CI95%:0.356-27.523)), vasoplegia (OR: 0.741 (CI95%:0.419-1.319)), postoperative atrial fibrillation (OR: 1.710 (CI95%:0.936-3.122)), or mortality (OR: 2.989 (CI95%:0.343-26.034)). ICU and hospital length of stays did not differ (3 [2; 5] vs. 3 [2; 5] days, p = 0.963 and 9.5 [8; 12] vs. 10 [8; 14] days, p = 0.638). Conclusion: Our study revealed that maintenance of ACE inhibitors on the day of the surgery was not associated with increased postoperative AKI. ACE inhibitor maintenance was also not associated with an increased rate of postoperative major cardiovascular events (arterial hypotension, cardiogenic shock, vasopressors use, stroke and death).
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Affiliation(s)
- Pierre Guilleminot
- Department of Cardiology, Dijon University Medical Centre, Dijon, France
| | - Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, Hopital Bichat Claude Bernard, Paris, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
- University of Burgundy and Franche-Comté, LNC UMR1231, F-21000, Dijon, France
| | - Osama Abou-Arab
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Medical Centre, Amiens, France
| | - Emmanuel Besnier
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, Rouen, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
- University of Burgundy and Franche-Comté, LNC UMR1231, F-21000, Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
- University of Burgundy and Franche-Comté, LNC UMR1231, F-21000, Dijon, France
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Rajan N, Joshi GP. Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers: To Continue or Stop Preoperatively-the Debate Continues. Anesth Analg 2024; 138:760-762. [PMID: 38489795 DOI: 10.1213/ane.0000000000006825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Affiliation(s)
- Niraja Rajan
- From the Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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Ackland GL, Patel A, Abbott TEF, Begum S, Dias P, Crane DR, Somanath S, Middleditch A, Cleland S, Gutierrez del Arroyo A, Brealey D, Pearse RM. Discontinuation vs. continuation of renin-angiotensin system inhibition before non-cardiac surgery: the SPACE trial. Eur Heart J 2024; 45:1146-1155. [PMID: 37935833 PMCID: PMC10984566 DOI: 10.1093/eurheartj/ehad716] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/07/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND AND AIMS Haemodynamic instability is associated with peri-operative myocardial injury, particularly in patients receiving renin-angiotensin system (RAS) inhibitors (angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers). Whether stopping RAS inhibitors to minimise hypotension, or continuing RAS inhibitors to avoid hypertension, reduces peri-operative myocardial injury remains unclear. METHODS From 31 July 2017 to 1 October 2021, patients aged ≥60 years undergoing elective non-cardiac surgery were randomly assigned to either discontinue or continue RAS inhibitors prescribed for existing medical conditions in six UK centres. Renin-angiotensin system inhibitors were withheld for different durations (2-3 days) before surgery, according to their pharmacokinetic profile. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury [plasma high-sensitivity troponin-T (hs-TnT) ≥ 15 ng/L within 48 h after surgery, or ≥5 ng/L increase when pre-operative hs-TnT ≥15 ng/L]. Pre-specified adverse haemodynamic events occurring within 48 h of surgery included acute hypertension (>180 mmHg) and hypotension requiring vasoactive therapy. RESULTS Two hundred and sixty-two participants were randomized to continue (n = 132) or stop (n = 130) RAS inhibitors. Myocardial injury occurred in 58 (48.3%) patients randomized to discontinue, compared with 50 (41.3%) patients who continued, RAS inhibitors [odds ratio (for continuing): 0.77; 95% confidence interval (CI) 0.45-1.31]. Hypertensive adverse events were more frequent when RAS inhibitors were stopped [16 (12.4%)], compared with 7 (5.3%) who continued RAS inhibitors [odds ratio (for continuing): 0.4; 95% CI 0.16-1.00]. Hypotension rates were similar when RAS inhibitors were stopped [12 (9.3%)] or continued [11 (8.4%)]. CONCLUSIONS Discontinuing RAS inhibitors before non-cardiac surgery did not reduce myocardial injury, and could increase the risk of clinically significant acute hypertension. These findings require confirmation in future studies.
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Affiliation(s)
- Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Akshaykumar Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Salma Begum
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - David R Crane
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Sameer Somanath
- County Durham and Darlington NHS Foundation Trust, Darlington, UK
| | | | | | - Ana Gutierrez del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
- UCL Hospitals NHS Foundation Trust, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Rupert M Pearse
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
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13
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Gurunathan U, Roe A, Milligan C, Hay K, Ravichandran G, Chawla G. Preoperative Renin-Angiotensin System Antagonists Intake and Blood Pressure Responses During Ambulatory Surgical Procedures: A Prospective Cohort Study. Anesth Analg 2024; 138:763-774. [PMID: 38236756 DOI: 10.1213/ane.0000000000006728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND There is limited evidence to inform the association between the intake of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) and intraoperative blood pressure (BP) changes in an ambulatory surgery population. METHODS Adult patients who underwent ambulatory surgery and were discharged on the same day or within 24 hours of their procedure were enrolled in this prospective cohort study. The primary outcome of the study was early intraoperative hypotension (first 15 minutes of induction). Secondary outcomes included any hypotension, BP variability, and recovery. Hypotension was defined as a decrease in systolic BP of >30% from baseline for ≥5 minutes or a mean BP of <55 mm Hg. Four exposure groups were compared (no antihypertensives, ACEI/ARB intake <10 hours before surgery, ACEI/ARB intake ≥10 hours before surgery, and other antihypertensives). RESULTS Of the 537 participants, early hypotension was observed in 25% (n = 134), and any hypotension in 41.5% (n = 223). Early hypotension occurred in 30% (29 of 98) and 41% (17 of 41) with the intake of ACEI/ARBs <10 and ≥10 hours before surgery, respectively, compared to 30% (9 of 30) with other antihypertensives and 21% (79 of 368) with no antihypertensives ( P = .02). Those on antihypertensives also experienced any hypotension more frequently than those who were not on antihypertensives ( P < .001). After adjusting for age and baseline BP in a regression analysis, antihypertensive exposure groups were observed to be associated only with any intraoperative hypotension ( P = .012). In the ACEI/ARB subset, there was no evidence of an association between time since the last ACEI/ARB dose, and hypotension or minimum mean or systolic BP. Compared to normal baseline BP, BP ≥ 140/90 mm Hg increased the odds of early and any hypotension (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.1-7.1 and OR, 7.7; 95% CI, 3.7-14.9, respectively; P < .001). Intraoperative variability in systolic and diastolic BP demonstrated significant differences with age, baseline BP, and antihypertensive exposure group ( P < .001). CONCLUSIONS Early and any hypotension occurred more frequently in those on antihypertensives than those not on antihypertensives. Unadjusted associations between antihypertensive exposure and intraoperative hypotension were largely explained by baseline hypertension rather than the timing of ACEI/ARBs or type of antihypertensive exposure. Patients with hypertension and on treatment experience more intraoperative BP variability and should be monitored appropriately.
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Affiliation(s)
- Usha Gurunathan
- From the Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Adrian Roe
- Department of Urology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Caitlin Milligan
- From the Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Karen Hay
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Gowri Ravichandran
- Department of Anaesthesia, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Gunjan Chawla
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia, Caboolture Hospital, Caboolture, Queensland, Australia
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14
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Gross CR, Varghese R, Zafirova Z. Perioperative Management of Novel Pharmacotherapies for Heart Failure and Pulmonary Hypertension. Anesthesiol Clin 2024; 42:117-130. [PMID: 38278584 DOI: 10.1016/j.anclin.2023.09.004] [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
Heart failure (HF) and pulmonary hypertension (PH) are increasingly prevalent comorbidities in patients presenting for noncardiac surgery. The unique pathophysiology and pharmacotherapies associated with these syndromes have important perioperative implications. As new medications for HF and PH emerge, it is imperative that anesthesiologists and other perioperative providers understand their mechanisms of action, pharmacokinetics, and potential adverse effects. We present an overview of the novel HF and PH pharmacotherapies and strategies for their perioperative management.
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Affiliation(s)
- Caroline R Gross
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Robin Varghese
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zdravka Zafirova
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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15
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Allyn S, Bentov N, Dillon J. Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications. J Oral Maxillofac Surg 2024; 82:364-375. [PMID: 38103577 DOI: 10.1016/j.joms.2023.11.015] [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: 05/08/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE The preoperative management guidelines of surgical patients are constantly evolving as newer evidence-based research is published. Oral and maxillofacial surgeons need to be current with the increasingly more complex new drug therapies and updated national association(s) guidelines. This narrative review provides a synopsis with important reference tables for updated preoperative optimization guidelines for anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control in the preoperative period for the oral and maxillofacial surgery patient. It also includes the most current anesthesia guidelines on glucagon-like peptide receptor agonists. METHODS The search strategy utilized pubmed.gov to identify the most recent national society guidelines and review articles pertinent to perioperative anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control. RESULTS The search identified 75 articles from the American College of Surgeons, American Heart Association, American Society of Anesthesiologists, American College of Cardiologists, in addition to recent reviews discussing the standard of care for optimization of patients in the perioperative period. CONCLUSION Medical optimization prior to surgery is important for safe and efficient surgical practice and has been shown to improve overall mortality. This narrative review provides a summary of the current data with recommendations focusing on four key points.
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Affiliation(s)
- Stuart Allyn
- Resident, Department of Oral & Maxillofacial Surgery, University of Washington, Seattle, WA
| | - Nathalie Bentov
- Pre-anesthesia Clinic Medical Director, Harborview Medical Center, Department of Family Medicine, University of Washington, Seattle, WA
| | - Jasjit Dillon
- Professor & Program Director, Department of Oral & Maxillofacial Surgery, University of Washington, Chief of Service, Harborview Medical Center, Seattle, WA.
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16
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Tol JTM, Terwindt LE, Rellum SR, Wijnberge M, van der Ster BJP, Kho E, Hollmann MW, Vlaar APJ, Veelo DP, Schenk J. Performance of a Machine Learning Algorithm to Predict Hypotension in Spontaneously Breathing Non-Ventilated Post-Anesthesia and ICU Patients. J Pers Med 2024; 14:210. [PMID: 38392643 PMCID: PMC10890176 DOI: 10.3390/jpm14020210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Background: Hypotension is common in the post-anesthesia care unit (PACU) and intensive care unit (ICU), and is associated with adverse patient outcomes. The Hypotension Prediction Index (HPI) algorithm has been shown to accurately predict hypotension in mechanically ventilated patients in the OR and ICU and to reduce intraoperative hypotension (IOH). Since positive pressure ventilation significantly affects patient hemodynamics, we performed this validation study to examine the performance of the HPI algorithm in a non-ventilated PACU and ICU population. Materials & Methods: The performance of the HPI algorithm was assessed using prospectively collected blood pressure (BP) and HPI data from a PACU and a mixed ICU population. Recordings with sufficient time (≥3 h) spent without mechanical ventilation were selected using data from the electronic medical record. All HPI values were evaluated for sensitivity, specificity, predictive value, and time-to-event, and a receiver operating characteristic (ROC) curve was constructed. Results: BP and HPI data from 282 patients were eligible for analysis, of which 242 (86%) were ICU patients. The mean age (standard deviation) was 63 (13.5) years, and 186 (66%) of the patients were male. Overall, the HPI predicted hypotension accurately, with an area under the ROC curve of 0.94. The most used HPI threshold cutoff in research and clinical use, 85, showed a sensitivity of 1.00, specificity of 0.79, median time-to-event of 160 s [60-380], PPV of 0.85, and NPV of 1.00. Conclusion: The absence of positive pressure ventilation and the influence thereof on patient hemodynamics does not negatively affect the performance of the HPI algorithm in predicting hypotension in the PACU and ICU. Future research should evaluate the feasibility and influence on hypotension and outcomes following HPI implementation in non-ventilated patients at risk of hypotension.
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Affiliation(s)
- Johan T M Tol
- Department of Anesthesiology, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Lotte E Terwindt
- Department of Anesthesiology, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Santino R Rellum
- Department of Anesthesiology, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
- Department of Intensive Care Medicine, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Marije Wijnberge
- Department of Anesthesiology, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Björn J P van der Ster
- Department of Anesthesiology, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Eline Kho
- Department of Anesthesiology, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
- Department of Intensive Care Medicine, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center Location, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center Location, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Denise P Veelo
- Department of Anesthesiology, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Jimmy Schenk
- Department of Anesthesiology, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
- Department of Intensive Care Medicine, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
- Department of Epidemiology and Data Science, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
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17
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Zafari Z, Park JE, Shah CH, dosReis S, Gorman EF, Hua W, Ma Y, Tian F. The State of Use and Utility of Negative Controls in Pharmacoepidemiologic Studies. Am J Epidemiol 2024; 193:426-453. [PMID: 37851862 DOI: 10.1093/aje/kwad201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/27/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023] Open
Abstract
Uses of real-world data in drug safety and effectiveness studies are often challenged by various sources of bias. We undertook a systematic search of the published literature through September 2020 to evaluate the state of use and utility of negative controls to address bias in pharmacoepidemiologic studies. Two reviewers independently evaluated study eligibility and abstracted data. Our search identified 184 eligible studies for inclusion. Cohort studies (115, 63%) and administrative data (114, 62%) were, respectively, the most common study design and data type used. Most studies used negative control outcomes (91, 50%), and for most studies the target source of bias was unmeasured confounding (93, 51%). We identified 4 utility domains of negative controls: 1) bias detection (149, 81%), 2) bias correction (16, 9%), 3) P-value calibration (8, 4%), and 4) performance assessment of different methods used in drug safety studies (31, 17%). The most popular methodologies used were the 95% confidence interval and P-value calibration. In addition, we identified 2 reference sets with structured steps to check the causality assumption of the negative control. While negative controls are powerful tools in bias detection, we found many studies lacked checking the underlying assumptions. This article is part of a Special Collection on Pharmacoepidemiology.
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18
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Ortoleva J, Homoud M, Shapeton AD. Heart Failure With Reduced Ejection Fraction: Don't Wait, Ablate! J Cardiothorac Vasc Anesth 2024; 38:355-357. [PMID: 38042743 DOI: 10.1053/j.jvca.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 12/04/2023]
Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, MA
| | - Munther Homoud
- Section of Pacing and Electrophysiology, Tufts Medical Center, Boston, MA
| | - Alexander D Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Boston Veterans Affairs Healthcare System, Boston, MA; Tufts University School of Medicine, Boston, MA.
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19
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Wang C, Lebedeva V, Yang J, Anih J, Park LJ, Paczkowski F, Roshanov PS. Desmopressin to reduce periprocedural bleeding and transfusion: a systematic review and meta-analysis. Perioper Med (Lond) 2024; 13:5. [PMID: 38263259 PMCID: PMC10804695 DOI: 10.1186/s13741-023-00358-4] [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: 10/18/2023] [Accepted: 12/29/2023] [Indexed: 01/25/2024] Open
Abstract
We systematically reviewed the literature to investigate the effects of peri-procedural desmopressin in patients without known inherited bleeding disorders undergoing surgery or other invasive procedures. We included 63 randomized trials (4163 participants) published up to February 1, 2023. Seven trials were published after a 2017 Cochrane systematic review on this topic. There were 38 trials in cardiac surgery, 22 in noncardiac surgery, and 3 in non-surgical procedures. Meta-analyses demonstrated that desmopressin likely does not reduce the risk of receiving a red blood cell transfusion (25 trials, risk ratio [RR] 0.95, 95% confidence interval [CI] 0.86 to 1.05) and may not reduce the risk of reoperation due to bleeding (22 trials, RR 0.75, 95% CI 0.47 to 1.19) when compared to placebo or usual care. However, we demonstrated significant reductions in number of units of red blood cells transfused (25 trials, mean difference -0.55 units, 95% CI - 0.94 to - 0.15), total volume of blood loss (33 trials, standardized mean difference - 0.40 standard deviations; 95% CI - 0.56 to - 0.23), and the risk of bleeding events (2 trials, RR 0.45, 95% CI 0.24 to 0.84). The certainty of evidence of these findings was generally low. Desmopressin increased the risk of clinically significant hypotension that required intervention (19 trials, RR 2.15, 95% CI 1.36 to 3.41). Limited evidence suggests that tranexamic acid is more effective than desmopressin in reducing transfusion risk (3 trials, RR 2.38 favoring tranexamic acid, 95% CI 1.06 to 5.39) and total volume of blood loss (3 trials, mean difference 391.7 mL favoring tranexamic acid, 95% CI - 93.3 to 876.7 mL). No trials directly informed the safety and hemostatic efficacy of desmopressin in advanced kidney disease. In conclusion, desmopressin likely reduces periprocedural blood loss and the number of units of blood transfused in small trials with methodologic limitations. However, the risk of hypotension needs to be mitigated. Large trials should evaluate desmopressin alongside tranexamic acid and enroll patients with advanced kidney disease.
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Affiliation(s)
- Carol Wang
- Department of Medicine, Western University, London, ON, Canada
| | | | - Jeffy Yang
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Lily J Park
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Freeman Paczkowski
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Pavel S Roshanov
- Department of Medicine, Western University, London, ON, Canada.
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
- Population Health Research Institute, Hamilton, ON, Canada.
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20
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Thilagar BP, Mueller MR, Ganesh R. Perioperative cardiac risk reduction in non cardiac surgery. Minerva Med 2023; 114:861-877. [PMID: 37140483 DOI: 10.23736/s0026-4806.23.08474-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
For patients undergoing nonemergent noncardiac surgery, care must be taken to identify patients at increased risk of major adverse cardiovascular events, as these remain a significant source of perioperative morbidity and mortality. Identification of at-risk patients requires careful attention to risk factors including assessment of functional status, medical comorbidities, and a medication assessment. After identification, to minimize perioperative cardiac risk, care should be taken through a combination of appropriate medication management, close monitoring for cardiovascular ischemic events, and optimization of pre-existing medical conditions. There are multiple society guidelines that aim to mitigate risk of cardiovascular morbidity and mortality in patients undergoing nonemergent noncardiac surgery. However, the rapid evolution of medical literature often creates gaps between the existing evidence and best practice recommendations. In this review, we aim to reconcile the recommendations made in the guidelines from the major cardiovascular and anesthesiology societies from the USA, Canada, and Europe, and to provide updated recommendations based on new evidence.
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Affiliation(s)
- Bright P Thilagar
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael R Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA -
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21
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Baldasseroni S, Bari MD, Pratesi A, Rivasi G, Stefàno P, Olivo G, Meo MLD, Orso F, Pace SD, Ungar A, Marchionni N. Prediction of worsening postoperative renal function in older candidates to elective cardiac surgery: Choosing the best eGFR formula may not be enough. Heart Lung 2023; 62:28-34. [PMID: 37295187 DOI: 10.1016/j.hrtlng.2023.05.008] [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: 02/16/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Though renal impairment is highly prevalent in older patients and influence post-operative outcomes in cardiac surgery; its prognostic relevance is debated and not fully assessed by surgical risk scores. OBJECTIVE We investigated the predictive role of estimated glomerular filtration rate formulas for in-hospital worsening renal function (WRF) after cardiac surgery. METHODS We prospectively enrolled in single-center cohort study, patients aged ≥ 75 years candidate to elective cardiac surgery. Four creatinine-based equations were used to calculate estimated glomerular filtration rate (eGFR) formulas: Cockroft-Gault, Modification of Diet in Renal Disease, Chronic Kidney Disease Epidemiology, and Berlin Initiative Study 1 formulas. Each patient underwent geriatric and clinical evaluation before surgery with calculation of the Society of Thoracic Surgeons scores. In-hospital WRF was defined as a composite of an increase in SCr ≥0.5 mg/dl or the occurrence of grade III KDIGO acute kidney injury. The association between each eGFR equation, alone and in models including clinical variables, and WRF was analyzed using logistic regressions and ROC analysis. RESULTS WRF occurred in 69 patients (19.8%), and the predictors of WRF were previous acute myocardial infarction, hypertension, 4-mt gait speed performance, and preoperative eGFR, irrespective of the equation used. With all equations, inclusion of these additional variables in the logistic regression models improved the prediction of WRF (AUCs 0.798-0.810). CONCLUSIONS An accurate assessment of renal function and of physical performance should be incorporated into cardiac surgery risk scores to improve prediction of in-hospital WRF and, hence, risk stratification in older adults undergoing elective cardiac surgery.
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Affiliation(s)
- Samuele Baldasseroni
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Mauro Di Bari
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Alessandra Pratesi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Pierluigi Stefàno
- Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Giuseppe Olivo
- Division of Cardiac Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Maria Laura Di Meo
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Francesco Orso
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Del Pace
- Division of General Cardiology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Niccolò Marchionni
- Division of Cardiac Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
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22
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Marcucci M, Chan MTV, Smith EE, Absalom AR, Devereaux PJ. Prevention of perioperative stroke in patients undergoing non-cardiac surgery. Lancet Neurol 2023; 22:946-958. [PMID: 37739575 DOI: 10.1016/s1474-4422(23)00209-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/17/2023] [Accepted: 05/26/2023] [Indexed: 09/24/2023]
Abstract
About 300 million adults undergo non-cardiac surgery annually. Although, in this setting, the incidence of perioperative stroke is low, the absolute number of patients experiencing a stroke is substantial. Furthermore, most patients with this complication will die or end up with severe disability. Covert brain infarctions are more frequent than overt strokes and are associated with postoperative delirium, cognitive decline, and cerebrovascular events at 1 year after surgery. Evidence shows that traditional stroke risk factors including older age, hypertension, and atrial fibrillation are also associated with perioperative stroke; previous stroke is the strongest risk factor for perioperative stroke. Increasing evidence also suggests the pathogenic role of perioperative events, such as hypotension, new atrial fibrillation, paradoxical embolism, and bleeding. Clinicians involved in perioperative care should be aware of this evidence on prevention strategies to improve patient outcomes after non-cardiac surgery.
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Affiliation(s)
- Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada.
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23
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Zeng B, Liu Y, Xu J, Niu L, Wu Y, Zhang D, Tang X, Zhu Z, Chen Y, Hu L, Yu S, Yu P, Zhang J, Wang W. Future Directions in Optimizing Anesthesia to Reduce Perioperative Acute Kidney Injury. Am J Nephrol 2023; 54:434-450. [PMID: 37742618 DOI: 10.1159/000533534] [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: 05/05/2023] [Accepted: 08/01/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Perioperative acute kidney injury (AKI) is common in surgical patients and is associated with high morbidity and mortality. There are currently few options for AKI prevention and treatment. Due to its complex pathophysiology, there is no efficient medication therapy to stop the onset of the injury or repair the damage already done. Certain anesthetics, however, have been demonstrated to affect the risk of perioperative AKI in some studies. The impact of anesthetics on renal function is particularly important as it is closely related to the prognosis of patients. Some anesthetics can induce anti-inflammatory, anti-necrotic, and anti-apoptotic effects. Propofol, sevoflurane, and dexmedetomidine are a few examples of anesthetics that have protective association with AKI in the perioperative period. SUMMARY In this study, we reviewed the clinical characteristics, risk factors, and pathogenesis of AKI. Subsequently, the protective effects of various anesthetic agents against perioperative AKI and the latest research are introduced. KEY MESSAGE This work demonstrates that a thorough understanding of the reciprocal effects of anesthetic drugs and AKI is crucial for safe perioperative care and prognosis of patients. However, more complete mechanisms and pathophysiological processes still need to be further studied.
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Affiliation(s)
- Bin Zeng
- Department of Gastroenterology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yinuo Liu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China,
- The Second Clinical Medical College of Nanchang University, Nanchang, China,
| | - Jiawei Xu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Liyan Niu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Second Clinical Medical College of Nanchang University, Nanchang, China
- Huan Kui College, Nanchang University, Nanchang, China
| | - Yuting Wu
- Huan Kui College, Nanchang University, Nanchang, China
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Deju Zhang
- Huan Kui College, Nanchang University, Nanchang, China
- Food and Nutritional Sciences, School of Biological Sciences, The University of Hong Kong, Hong Kong, Hong Kong, China
| | - Xiaoyi Tang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zicheng Zhu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yixuan Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Leilei Hu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shuchun Yu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Peng Yu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jing Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenting Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Steiger K, Fuentes A, Erben Y. Medical Management of Cardiovascular Disease. Surg Clin North Am 2023; 103:565-575. [PMID: 37455025 DOI: 10.1016/j.suc.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
We offer an overview of lipid lowering, antiplatelet, antihypertensive, and glucose-lowering therapies for vascular surgeons and their respective medical teams. Further reviews should offer additional guidance on smoking cessation, exercise therapy, and nutritional optimization.
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Affiliation(s)
- Kyle Steiger
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ana Fuentes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA.
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25
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Yu Y, Gong Y, Hu B, Ouyang B, Pan A, Liu J, Liu F, Shang XL, Yang XH, Tu G, Wang C, Ma S, Fang W, Liu L, Liu J, Chen D. Expert consensus on blood pressure management in critically ill patients. JOURNAL OF INTENSIVE MEDICINE 2023; 3:185-203. [PMID: 37533806 PMCID: PMC10391579 DOI: 10.1016/j.jointm.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Ye Gong
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of SunYatsen University, Guangzhou 510080, Guangdong, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei 230001, Anhui, China
| | - Jinglun Liu
- Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou 350001 Fujian, China
| | - Xiang-Hong Yang
- Department of Intensive Care Unit, Emergency & Intensive Care Unit Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310014 Zhejiang, China
| | - Guowei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Changsong Wang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang, China
| | - Shaolin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, 250014 Shandong, China
| | - Ling Liu
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009 Jiangsu, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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26
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Mahendran S, Thiagalingam A, Hillis G, Halliwell R, Pleass HC, Chow CK. Cardiovascular risk management in the peri-operative setting. Med J Aust 2023. [PMID: 37302136 DOI: 10.5694/mja2.51988] [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: 11/29/2022] [Revised: 03/17/2023] [Accepted: 03/27/2023] [Indexed: 06/13/2023]
Abstract
Peri-operative cardiovascular events occur in up to 3% of patients undergoing non-cardiac surgery. Accurate cardiovascular risk assessment is important in the peri-operative setting, as it allows informed and shared decisions regarding the appropriateness of proceeding with surgery, guides surgical and anaesthetic approaches, and may influence the use of preventive medications and post-operative cardiac monitoring. Quantitative risk assessment may also inform a reconsideration of choosing a more limited lower risk type of surgery, or conservative management. Pre-operative cardiovascular risk assessment starts with clinical assessment and should include an estimate of functional capacity. Specialised cardiac investigations are rarely indicated specifically to assess pre-operative cardiovascular risk. The decision regarding cardiac investigations is influenced by the nature, extent and urgency of surgery. The strategy of performing pre-operative revascularisation to improve post-operative outcomes is not evidence-based and recent international guidelines recommend against this.
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Affiliation(s)
| | | | | | | | - Henry Cc Pleass
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW
| | - Clara K Chow
- Westmead Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
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27
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Marcucci M, Painter TW, Conen D, Lomivorotov V, Sessler DI, Chan MTV, Borges FK, Leslie K, Duceppe E, Martínez-Zapata MJ, Wang CY, Xavier D, Ofori SN, Wang MK, Efremov S, Landoni G, Kleinlugtenbelt YV, Szczeklik W, Schmartz D, Garg AX, Short TG, Wittmann M, Meyhoff CS, Amir M, Torres D, Patel A, Ruetzler K, Parlow JL, Tandon V, Fleischmann E, Polanczyk CA, Lamy A, Jayaram R, Astrakov SV, Wu WKK, Cheong CC, Ayad S, Kirov M, de Nadal M, Likhvantsev VV, Paniagua P, Aguado HJ, Maheshwari K, Whitlock RP, McGillion MH, Vincent J, Copland I, Balasubramanian K, Biccard BM, Srinathan S, Ismoilov S, Pettit S, Stillo D, Kurz A, Belley-Côté EP, Spence J, McIntyre WF, Bangdiwala SI, Guyatt G, Yusuf S, Devereaux PJ. Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery : An International Randomized Controlled Trial. Ann Intern Med 2023; 176:605-614. [PMID: 37094336 DOI: 10.7326/m22-3157] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Among patients having noncardiac surgery, perioperative hemodynamic abnormalities are associated with vascular complications. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively. OBJECTIVE To compare the effects of a hypotension-avoidance and a hypertension-avoidance strategy on major vascular complications after noncardiac surgery. DESIGN Partial factorial randomized trial of 2 perioperative blood pressure management strategies (reported here) and tranexamic acid versus placebo. (ClinicalTrials.gov: NCT03505723). SETTING 110 hospitals in 22 countries. PATIENTS 7490 patients having noncardiac surgery who were at risk for vascular complications and were receiving 1 or more long-term antihypertensive medications. INTERVENTION In the hypotension-avoidance strategy group, the intraoperative mean arterial pressure target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld and the other long-term antihypertensive medications were administered only for systolic blood pressures 130 mm Hg or greater, following an algorithm. In the hypertension-avoidance strategy group, the intraoperative mean arterial pressure target was 60 mm Hg or greater; all antihypertensive medications were continued before and after surgery. MEASUREMENTS The primary outcome was a composite of vascular death and nonfatal myocardial injury after noncardiac surgery, stroke, and cardiac arrest at 30 days. Outcome adjudicators were masked to treatment assignment. RESULTS The primary outcome occurred in 520 of 3742 patients (13.9%) in the hypotension-avoidance group and in 524 of 3748 patients (14.0%) in the hypertension-avoidance group (hazard ratio, 0.99 [95% CI, 0.88 to 1.12]; P = 0.92). Results were consistent for patients who used 1 or more than 1 antihypertensive medication in the long term. LIMITATION Adherence to the assigned strategies was suboptimal; however, results were consistent across different adherence levels. CONCLUSION In patients having noncardiac surgery, our hypotension-avoidance and hypertension-avoidance strategies resulted in a similar incidence of major vascular complications. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research, National Health and Medical Research Council (Australia), and Research Grant Council of Hong Kong.
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Affiliation(s)
- Maura Marcucci
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Thomas W Painter
- Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia (T.W.P.)
| | - David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia (V.L., S.I.)
| | - Daniel I Sessler
- Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.V.C., W.K.K.W.)
| | - Flavia K Borges
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Kate Leslie
- Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia (K.L.)
| | - Emmanuelle Duceppe
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (E.D.)
| | - María José Martínez-Zapata
- Iberoamerican Cochrane Centre, Public Health and Clinical Epidemiology Service, IIB Sant Pau, CIBERESP, Barcelona, Spain (M.J.M.)
| | - Chew Yin Wang
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (C.Y.W., C.C.C.)
| | - Denis Xavier
- St. John's Medical College, Bangalore, India (D.X.)
| | - Sandra N Ofori
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Michael Ke Wang
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Sergey Efremov
- Saint Petersburg State University Hospital, Saint Petersburg, Russia (S.E.)
| | - Giovanni Landoni
- Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy (G.L.)
| | - Ydo V Kleinlugtenbelt
- Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer, the Netherlands (Y.V.K.)
| | - Wojciech Szczeklik
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (W.S.)
| | - Denis Schmartz
- CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium (D.S.)
| | - Amit X Garg
- Department of Medicine, Western University, London, Ontario, Canada (A.X.G.)
| | - Timothy G Short
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand (T.G.S.)
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany (M.W.)
| | - Christian S Meyhoff
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark (C.S.M.)
| | - Mohammed Amir
- Department of Surgery, Shifa International Hospital and Shifa Tameer-e-Millat University, Islamabad, Pakistan (M.A.)
| | - David Torres
- Departamento de Epidemiología y Estudios en Salud, Universidad de Los Andes, Santiago, Chile (D.T.)
| | - Ameen Patel
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada (A.P., V.T.)
| | - Kurt Ruetzler
- Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
| | - Joel L Parlow
- Department of Anesthesiology and Perioperative Medicine, Queen's University, and Kingston Health Sciences Centre, Kingston, Ontario, Canada (J.L.P.)
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada (A.P., V.T.)
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria (E.F.)
| | - Carisi A Polanczyk
- UFRGS, Hospital de Clínicas de Porto Alegre, National Institute for Health Technology Assessment, IATS; Hospital Moinhos de Vento, Porto Alegre, Brazil (C.A.P.)
| | - Andre Lamy
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Raja Jayaram
- Department of Anaesthetics, Clinical Neurosciences, University of Oxford, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (R.J.)
| | - Sergey V Astrakov
- Department of Anesthesiology, Novosibirsk State University, Novosibirsk, Russia (S.V.A.)
| | - William Ka Kei Wu
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.V.C., W.K.K.W.)
| | - Chao Chia Cheong
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (C.Y.W., C.C.C.)
| | - Sabry Ayad
- Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
| | - Mikhail Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia (M.K.)
| | - Miriam de Nadal
- Department of Anesthesiology and Intensive Care, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M. de N.)
| | | | - Pilar Paniagua
- Anesthesiology Department, Santa Creu i Sant Pau University Hospital, Barcelona, Spain (P.P.)
| | - Hector J Aguado
- Trauma & Orthopaedic Surgery Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain (H.J.A.)
| | - Kamal Maheshwari
- Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
| | - Richard P Whitlock
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Michael H McGillion
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Jessica Vincent
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Ingrid Copland
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Kumar Balasubramanian
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Bruce M Biccard
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital, and University of Cape Town, Cape Town, South Africa (B.M.B.)
| | - Sadeesh Srinathan
- Section of Thoracic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada (S.S.)
| | - Samandar Ismoilov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia (V.L., S.I.)
| | - Shirley Pettit
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - David Stillo
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Andrea Kurz
- Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
| | - Emilie P Belley-Côté
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Jessica Spence
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Shrikant I Bangdiwala
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (G.G.)
| | - Salim Yusuf
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - P J Devereaux
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
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Cai J, Tang M, Wu H, Yuan J, Liang H, Wu X, Xing S, Yang X, Duan XD. Association of intraoperative hypotension and severe postoperative complications during non-cardiac surgery in adult patients: A systematic review and meta-analysis. Heliyon 2023; 9:e15997. [PMID: 37223701 PMCID: PMC10200862 DOI: 10.1016/j.heliyon.2023.e15997] [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: 11/19/2022] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/25/2023] Open
Abstract
Background Intraoperative hypotension (IOH) is a common side effect of non-cardiac surgery that might induce poor postoperative outcomes. The relationship between the IOH and severe postoperative complications is still unclear. Thus, we summarized the existing literature to evaluate whether IOH contributes to developing severe postoperative complications during non-cardiac surgery. Methods We conducted a comprehensive search of PubMed, Embase, Cochrane Library, Web of Science, and the CBM from inception to 15 September 2022. The primary outcomes were 30-day mortality, acute kidney injury (AKI), major adverse cardiac events (myocardial injury or myocardial infarction), postoperative cognitive dysfunction (POCD), and postoperative delirium (POD). Secondary outcomes included surgical-site infection (SSI), stroke, and 1-year mortality. Results 72 studies (3 randomized; 69 non-randomized) were included in this study. Low-quality evidence showed IOH resulted in an increased risk of 30-day mortality (OR, 1.85; 95% CI, 1.30-2.64; P < .001), AKI (OR, 2.69; 95% CI, 2.15-3.37; P < .001), and stroke (OR, 1.33; 95% CI, 1.21-1.46; P < .001) after non-cardiac surgery than non-IOH. Very low-quality evidence showed IOH was associated with a higher risk of myocardial injury (OR, 2.00; 95% CI, 1.17-3.43; P = .01), myocardial infarction (OR, 2.11; 95% CI, 1.41-3.16; P < .001), and POD (OR, 2.27; 95% CI, 1.53-3.38; P < .001). Very low-quality evidence showed IOH have a similar incidence of POCD (OR, 2.82; 95% CI, 0.83-9.50; P = .10) and 1-year-mortality (OR, 1.66; 95% CI, 0.65-4.20; P = .29) compared with non-IOH in non-cardiac surgery. Conclusion Our results suggest IOH was associated with an increased risk of severe postoperative complications after non-cardiac surgery than non-IOH. IOH is a potentially avoidable hazard that should be closely monitored during non-cardiac surgery.
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Affiliation(s)
- Jianghui Cai
- Department of Pharmacy, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Mi Tang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
- Office of Good Clinical Practice, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Huaye Wu
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Jing Yuan
- Department of Information, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, 611731, China
| | - Hua Liang
- Department of Pharmacy, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xuan Wu
- Department of Epidemiology and Biostatistics and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Shasha Xing
- Office of Good Clinical Practice, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xiao Yang
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xiao-Dong Duan
- Department of Rehabilitation Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
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Shiffermiller JF, Whinney CM. Perioperative Management of Antihypertensive Agents: More Answers or More Questions? Ann Intern Med 2023; 176:725-726. [PMID: 37094338 DOI: 10.7326/m23-0745] [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: 04/26/2023] Open
Affiliation(s)
- Jason F Shiffermiller
- Division of Hospital Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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Cardiac assessment and management in older surgical patients. Int Anesthesiol Clin 2023; 61:1-7. [PMID: 36892982 DOI: 10.1097/aia.0000000000000393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Zhang YQ, Liu XG, Ding Q, Berguson M, Morris RJ, Liu H, Goldhammer JE. Perioperative Renin-Angiotensin System Inhibitors Improve Major Outcomes of Heart Failure Patients Undergoing Cardiac Surgery: A Propensity-Adjusted Cohort Study. Ann Surg 2023; 277:e948-e954. [PMID: 35166263 DOI: 10.1097/sla.0000000000005408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to study the association of perioperative administration of renin angiotensin system inhibitors (RASi) and clinical outcomes of patients with heart failure (HF) undergoing cardiac surgery. SUMMARY BACKGROUND DATA It is controversial whether the perioperative RASi should be administered in HF patients undergoing cardiac surgery. METHODS A total of 2338 patients with HF and undergoing CABG and/or valve surgeries at multiple hospitals from 2001 to 2015 were identified from STS database. After adjustment using propensity score and instrumental variable, logistic regression was conducted to analyze the influence of preoperative continuation of RASi (PreRASi) on short-term in-hospital outcomes. Independent risk factors of 30-day mortality, major adverse cardiovascular events (MACE), and renal failure were analyzed by use of stepwise logistic regression. The effects of pre- and postoperative use of RASi (PostRASi) on long-term mortality were analyzed using survival analyses. Stepwise Cox regression was conducted to analyze the independent risk factors of 6-year mortality. The relationships of HF status and surgery type with perioperative RASi, as well as PreRASi-PostRASi, were also evaluated by subgroup analyses. RESULTS PreRASi was associated with lower incidences of 30-day mortality [ P < 0.0001, odds ratio (OR): 0.556, 95% confidence interval (CI) 0.405-0.763], stroke ( P =0.035, OR: 0.585, 95% CI: 0.355-0.962), renal failure ( P =0.007, OR: 0.663, 95% CI: 0.493-0.894). Both PreRASi ( P =0.0137) and PostRASi ( P =0.007) reduced 6-year mortality compared with the No-RASi groups. CONCLUSIONS Pre- and postoperative use of RASi was associated with better outcomes for the patients who have HF and undergo CABG and/or valve surgeries. Preoperative continuation and postoperative restoration are warranted in these patients.
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Affiliation(s)
- Yan-Qing Zhang
- Department of Anesthesiology, School of Anesthesiology, The First Hospital, Shanxi Medical University, Taiyuan, China
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Xiao-Gang Liu
- The Key Laboratory of Biomedical information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qian Ding
- Department of Anesthesiology, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Mark Berguson
- Department of Anesthesiology, Lankenau Medical Center, Wynnewood, PA
| | - Rohinton J Morris
- Division of Cardiothoracic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Hong Liu
- Department of Anesthesiology, University of California Davis Medical Center, Sacramento, CA
| | - Jordan E Goldhammer
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Payne T, Braithwaite H, McCulloch T, Paleologos M, Johnstone C, Wehrman J, Taylor J, Loadsman J, Wang AY, Sanders RD. Depth of anaesthesia and mortality after cardiac or noncardiac surgery: a systematic review and meta-analysis of randomised controlled trials. Br J Anaesth 2023; 130:e317-e329. [PMID: 36210184 DOI: 10.1016/j.bja.2022.08.034] [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: 06/08/2022] [Revised: 07/25/2022] [Accepted: 08/24/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Recent randomised controlled trials have failed to show a benefit in mortality by using processed electroencephalography (pEEG) to guide lighter anaesthesia. We performed a meta-analysis of mortality data from randomised trials of pEEG monitoring to assess the evidence of any protective effect of pEEG-guided light anaesthesia compared with deep anaesthesia in adults aged ≥18 yr. METHODS Our study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. In February 2022, we searched three databases (Cochrane CENTRAL, OVID Medline, EMBASE) for RCTs of pEEG monitoring that provided mortality data at 30 days, 90 days, and/or 1 yr or longer. RESULTS We included 16 articles from 12 RCTs with 48 827 total participants. We observed no statistically significant mortality reduction with light anaesthesia compared with deep anaesthesia in patients aged ≥18 yr when all studies were pooled (odds ratio [OR]=0.99; 95% confidence interval (CI), 0.92-1.08). This result did not change significantly when analysing mortality at 30 days, 90 days, 1 yr or longer. We observed no mortality benefit for pEEG monitoring compared with usual care (OR=1.02; 95% CI, 0.89-1.18), targeting higher pEEG index values compared with lower values (OR=0.89; 95% CI, 0.60-1.32), or low pEEG index value alerts compared with no alerts (OR=1.02; 95% CI, 0.41-2.52). CONCLUSIONS pEEG-guided lighter anaesthesia does not appear to reduce the risk of postoperative mortality. The absence of a plausible rationale for why deeper anaesthesia should increase mortality has hampered appropriate design of definitive clinical trials. CLINICAL TRIAL REGISTRATION CRD42022285195 (PROSPERO).
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Affiliation(s)
- Thomas Payne
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia.
| | - Hannah Braithwaite
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Tim McCulloch
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Michael Paleologos
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Charlotte Johnstone
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Jordan Wehrman
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jennifer Taylor
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - John Loadsman
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Andy Y Wang
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia; Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Robert D Sanders
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, New South Wales, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia.
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Brennan KA, Bhutiani M, Kingeter MA, McEvoy MD. Updates in the Management of Perioperative Vasoplegic Syndrome. Adv Anesth 2022; 40:71-92. [PMID: 36333053 DOI: 10.1016/j.aan.2022.07.010] [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: 06/16/2023]
Abstract
Vasoplegic syndrome occurs relatively frequently in cardiac surgery, liver transplant, major noncardiac surgery, in post-return of spontaneous circulation situations, and in pateints with sepsis. It is paramount for the anesthesiologist to understand both the pathophysiology of vasoplegia and the different treatment strategies available for rescuing a patient from life-threatening hypotension.
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Affiliation(s)
- Kaitlyn A Brennan
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, MAB 422, Nashville, TN 37212, USA
| | - Monica Bhutiani
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, VUH 4107, Nashville, TN 37212, USA
| | - Meredith A Kingeter
- Anesthesia Residency, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 5160 MCE NT, Nashville, TN 37212, USA
| | - Matthew D McEvoy
- VUMC Enhanced Recovery Programs, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN 37232, USA.
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Association of intraoperative dexmedetomidine use with postoperative hypotension in unilateral hip and knee arthroplasties: a historical cohort study. Can J Anaesth 2022; 69:1459-1470. [PMID: 36224507 DOI: 10.1007/s12630-022-02339-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/27/2022] [Accepted: 05/29/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Dexmedetomidine is frequently used as a sedative agent for orthopedic surgery patients undergoing total hip or knee arthroplasty. Although the benefits of dexmedetomidine are well described in the literature, there is also potential for harm, especially regarding the hemodynamic effects of dexmedetomidine in the postoperative setting. METHODS This historical cohort study included all primary unilateral total hip or knee arthroplasties conducted from April 2017 to February 2020 in a single, university-affiliated, tertiary care centre (Jewish General Hospital, Montreal, QC, Canada). We used multivariable logistic regression to analyze the predictors for postoperative hypotension, defined as a systolic blood pressure < 90 mm Hg or any systolic blood pressure while on a vasopressor infusion in the postanesthesia care unit. Models were validated using calibration and discrimination with bootstrapping technique. RESULTS One thousand five hundred and eighty-eight patients were included in this study. Postoperative hypotension occurred in 413 (26%) patients. Statistically significant predictors for postoperative hypotension included female sex (adjusted odds ratio [aOR], 3.24; 95% confidence interval [CI], 2.29 to 4.58), a history of transient ischemic attack or cerebrovascular accident (aOR, 1.97; 95% CI, 1.04 to 3.72), and intraoperative dexmedetomidine use (aOR, 2.61; 95% CI, 1.99 to 3.42). Moreover, the risk of postoperative hypotension was approximately two times higher than baseline, with a total intraoperative dexmedetomidine dose above 50 μg (relative risk, 1.99; 95% CI, 1.63 to 2.44; P < 0.001). A higher preoperative systolic blood pressure (aOR, 0.98; 95% CI, 0.97 to 0.99) was a protective factor for postoperative hypotension. CONCLUSION In this historical cohort study, dexmedetomidine was a strong risk factor for postoperative hypotension in total hip or knee arthroplasty patients. Dexmedetomidine, and particularly at high cumulative doses above 50 μg, should be administered judiciously in high-risk surgical patients to minimize the risk of postoperative hypotension.
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Hojo T, Kimura Y, Shibuya M, Fujisawa T. Predictors of hypotension during anesthesia induction in patients with hypertension on medication: a retrospective observational study. BMC Anesthesiol 2022; 22:343. [PMID: 36368916 PMCID: PMC9650866 DOI: 10.1186/s12871-022-01899-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background Hypotension during anesthesia induction is a common event, and occurs more frequently in patients with hypertension than in healthy individuals. Intraoperative hypotension in non-cardiac surgery is reportedly associated with various postoperative complications. However, the predictors of hypotension during anesthesia induction in patients with hypertension have not yet been ascertained. Therefore, we aimed to determine the predictors of hypotension during anesthesia induction in patients with hypertension on medication focusing on the half-life of the medication used. Methods In this retrospective observational study, we enrolled patients with hypertension on medication who underwent general anesthesia for oral and maxillofacial surgery between January 1, 2013, and December 31, 2019. Multivariable logistic regression analysis was conducted to test for associations between clinical factors and hypotension during anesthesia induction in patients with hypertension on medication. Results A total of 395 patients were included in this study. The risk factors for hypotension during anesthesia induction in patients with hypertension on medication were pre-induction mean arterial blood pressure (adjusted unit odds ratio, 0.96 [95% confidence interval, 0.94 to 0.98]), female sex (adjusted odds ratio [aOR], 1.63 [1.03 to 2.57]), regular use of angiotensin receptor blockers (ARBs)/angiotensin-converting enzyme inhibitors (ACE-Is) with a long half-life (vs. no regular use of ARBs/ACE-Is aOR, 4.02 [1.77 to 9.12]; vs. regular use of ARBs/ACE-Is with a short-to-middle half-life aOR, 3.17 [1.46 to 6.85]), and regular use of beta blockers (aOR, 2.45 [1.19 to 5.04]). Regular use of calcium channel blockers (aOR, 0.44 [0.25 to 0.77]) was a suppressive factor for hypotension during anesthesia induction in patients with hypertension. Conclusions In patients with hypertension on medication, regular use of ARBs/ACE-Is with a long half-life, regular use of beta blockers, low pre-induction mean arterial blood pressure, and female sex were risk factors for hypotension during anesthesia induction. Notably, regular use of ARBs/ACE-Is with a long half-life was a high-risk factor for hypotension during anesthesia induction in patients with hypertension on medication even after a 24-h preoperative withdrawal period. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01899-9.
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 274] [Impact Index Per Article: 137.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Zhang H, Gao H, Xiang Y, Li J. Maximum inferior vena cava diameter predicts post-induction hypotension in hypertensive patients undergoing non-cardiac surgery under general anesthesia: A prospective cohort study. Front Cardiovasc Med 2022; 9:958259. [PMID: 36267641 PMCID: PMC9576846 DOI: 10.3389/fcvm.2022.958259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Inferior vena cava (IVC) ultrasonography is a reliable variable that predicts post-induction hypotension (PIH) in patients undergoing surgery under general anesthesia. However, in patients with hypertension, the predictive performance of ultrasound IVC measurements needs further exploration. Methods This is a prospective cohort study. Adult patients with existing hypertension scheduled to undergo non-cardiac surgery under general anesthesia were eligible. An abdominal ultrasound examination was conducted immediately prior to anesthesia induction (0.03 mg kg–1 midazolam, 0.3 mg kg–1 etomidate, 0.4 μg kg–1 sufentanil, and 0.6 mg kg–1 rocuronium). IVC collapsibility index (IVC-CI) was calculated as (dIVCmax–dIVCmin)/dIVCmax, where dIVCmax and dIVCmin represent the maximum and minimum IVC diameters at the end of expiration and inspiration, respectively. PIH was defined as a reduction of mean arterial pressure (MAP) by >30% of the baseline or to <60 mmHg within 10 min after endotracheal intubation. The diagnostic performance of IVC-CI, dIVCmax, and dIVCmin in predicting PIH was also examined in a group of normotensive patients receiving non-cardiac surgery under the same anesthesia protocol. Results A total of 51 hypertensive patients (61 ± 13 years of age, 31 women) and 52 normotensive patients (42 ± 13 years of age, 35 women) were included in the final analysis. PIH occurred in 33 (64.7%) hypertensive patients and 19 (36.5%) normotensive patients. In normotensive patients, the area under the receiver operating curve (AUC) in predicting PIH was 0.896 (95% confidence interval [CI]: 0.804–0.987) for IVC-CI, 0.770 (95% CI: 0.633–0.908) for dIVCmax, and 0.868 (95% CI: 0.773–0.963) for dIVCmin. In hypertensive patients, the AUC in predicting PIH was 0.523 (95% CI: 0.354–0.691) for IVC-CI, 0.752 (95% CI: 0.621–0.883) for dIVCmax, and 0.715 (95% CI: 0.571–0.858) for dIVCmin. At the optimal cutoff (1.24 cm), dIVCmax had 54.5% (18/33) sensitivity and 94.4% (17/18) specificity. Conclusion In hypertensive patients, IVC-CI is unsuitable for predicting PIH, and dIVCmax is an alternative measure with promising performance. Clinical trial registration [http://www.chictr.org.cn/], identifier [ChiCTR2000034853].
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Lee C, Columbo JA, Stone DH, Creager MA, Henkin S. Preoperative evaluation and perioperative management of patients undergoing major vascular surgery. Vasc Med 2022; 27:496-512. [PMID: 36214163 PMCID: PMC9551317 DOI: 10.1177/1358863x221122552] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients' risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.
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Affiliation(s)
| | | | | | | | - Stanislav Henkin
- Stanislav Henkin, Heart and Vascular
Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at
Dartmouth, Lebanon, NH 03756, USA.
Twitter: @stanhenkin
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Sahai SK, Balonov K, Bentov N, Bierle DMM, Browning LM, Cummings KC, Dougan BM, Maxwell M, Merli GJ, Oprea AD, Sweitzer B, Mauck KF, Urman RD. Preoperative Management of Cardiovascular Medications: A Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2022; 97:1734-1751. [PMID: 36058586 DOI: 10.1016/j.mayocp.2022.03.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 01/19/2022] [Accepted: 03/21/2022] [Indexed: 10/14/2022]
Abstract
Cardiovascular conditions such as hypertension, arrhythmias, and heart failure are common in patients undergoing anesthesia for surgical or other procedures. Numerous guidelines from various specialty societies offer variable recommendations for the perioperative management of these medications. The Society for Perioperative Assessment and Quality Improvement identified a need to provide multidisciplinary evidence-based recommendations for preoperative medication management. The society convened a group of 13 members with expertise in perioperative medicine and training in anesthesiology or internal medicine. The aim of this consensus effort is to provide perioperative clinicians with guidance on the management of cardiovascular medications commonly encountered during the preoperative evaluation. We used a modified Delphi process to establish consensus. Twenty-one classes of medications were identified: α-adrenergic receptor antagonists, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, angiotensin receptor-neprilysin inhibitors, β-adrenoceptor blockers, calcium-channel blockers, centrally acting sympatholytic medications, direct-acting vasodilators, loop diuretics, thiazide diuretics, potassium-sparing diuretics, endothelin receptor antagonists, cardiac glycosides, nitrodilators, phosphodiesterase-5 inhibitors, class III antiarrhythmic agents, potassium-channel openers, renin inhibitors, class I antiarrhythmic agents, sodium-channel blockers, and sodium glucose cotransportor-2 inhibitors. We provide recommendations for the management of these medications preoperatively.
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Affiliation(s)
- Sunil K Sahai
- Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX.
| | - Konstantin Balonov
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA
| | - Nathalie Bentov
- Department of Family Medicine, University of Washington, Seattle, WA
| | | | | | | | - Brian M Dougan
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Megan Maxwell
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Geno J Merli
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Adriana D Oprea
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - BobbieJean Sweitzer
- University of Virginia School of Medicine, Charlottesville, VAkInova Health Systems, Falls Church, VA; Inova Health Systems, Falls Church, VA
| | - Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Naazie IN, Arhuidese I, Abdelgawwad MS, Unkart J, Conte MS, Malas MB. Association of Renin-Angiotensin-Aldosterone System Inhibitor Usage Patterns with Mid-Term Amputation Free Survival After Lower Extremity Bypass for Peripheral Arterial Disease. Ann Vasc Surg 2022; 88:79-89. [PMID: 36028182 DOI: 10.1016/j.avsg.2022.07.022] [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: 12/19/2021] [Revised: 06/23/2022] [Accepted: 07/17/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Different renin-angiotensin-aldosterone system inhibitor (RAASI) usage patterns exist among patients undergoing lower extremity bypass (LEB) for peripheral arterial disease (PAD). We studied the association of RAASI usage patterns with LEB outcomes to determine which pattern is associated improved survival after LEB. METHODS We evaluated PAD patients who underwent LEB between January 2014 and December 2018 in the Vascular Quality Initiative (VQI) Medicare matched database. Study cohorts included no RAASI use, preoperative RAASI use only, postoperative RAASI use only, and continuous RAASI use both pre-and postoperatively. Logistic and Cox regression was used to adjust for potential confounders. Primary outcome was 2-year amputation free survival (AFS). RESULTS Of 19,012 patients included, 1574 (8.3%) were on RAASIs preoperatively only, 1051 (5.5%) postoperatively only, and 8484 (45.2%) continuously. Compared to no RAASI use, isolated preoperative RAASI use was associated with 2.8-fold increased odds of 30-day mortality (aOR, 2.75; 95%CI, 2.15-3.51; P<0.001) whereas continuous RAASI use had 56% lower odds of 30-day mortality (aOR, 0.44; 95%CI, 0.34-0.58; P<0.001). Two-year AFS was 63.2% for no RAASI use and 60.4%, 66.2% and 73.4% for preoperative, postoperative, and continuous RAASI use respectively (P<0.001). While no RAASI use and postoperative RAASI use had comparable adjusted risks of 2-year major amputation or death (aHR, 0.94; 95%CI, 0.83-1.06; P=0.312), this risk was 14% higher for preoperative RAASI use (aHR, 1.14; 95%CI, 1.04-1.26; P=0.006) and 23% lower for continuous RAASI use (aHR, 0.77; 95%CI, 0.72-0.82; P<0.001). CONCLUSIONS Isolated preoperative RAASI use was associated with worse 30-day mortality and 2-year AFS while continuous RAASI use was associated with improved 30-day mortality and 2-year AFS. Optimum survival benefit may be derived from continuous RAAS inhibition in the pre- and postoperative periods.
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Affiliation(s)
- Isaac N Naazie
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Isibor Arhuidese
- Division of Vascular Surgery, Department of Surgery, University of South Florida, Tampa, FL
| | - Mohammad S Abdelgawwad
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Jonathan Unkart
- Department of Surgery, State University of New York Downstate University Health Sciences University, Brooklyn, NY
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA.
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The effect of continuing versus withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers on mortality and major adverse cardiovascular events in hypertensive patients undergoing elective non-cardiac surgery: study protocol for a multi-centric open-label randomised controlled trial. Trials 2022; 23:670. [PMID: 35978368 PMCID: PMC9386985 DOI: 10.1186/s13063-022-06616-y] [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] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) are commonly prescribed to patients with hypertension. These drugs are cardioprotective in addition to their blood pressure-lowering effects. However, it is debatable whether hypertensive patients who present for non-cardiac surgery should continue or discontinue these drugs preoperatively. Continuing the drugs entails the risk of perioperative refractory hypotension and/or angioneurotic oedema, while discontinuing the drugs entails the risk of rebound hypertension and myocardial ischaemia. The aim of this study is to evaluate the effect of continuation vs withholding of ACEIs/ARBs on mortality and other major outcomes in hypertensive patients undergoing elective non-cardiac surgery. METHODS The continuing vs withholding of ACEIs/ARBs in patients undergoing non-cardiac surgery is a prospective, multi-centric, open-label randomised controlled trial. Two thousand one hundred hypertensive patients receiving ACEIs/ARBs and planned for elective non-cardiac surgery will be enrolled. They will be randomised to either continue the ACEIs/ARBs including on the day of surgery (group A) or to withhold it 24-36 h before surgery (group B). The primary endpoint will be the difference in the composite outcome of all-cause in-hospital/30-day mortality and major adverse cardiovascular and non-cardiovascular events. Secondary endpoints will be to evaluate the differences in perioperative hypotension, angioneurotic oedema, myocardial injury, ICU and hospital stay. The impact of the continuation vs withholding of the ACEIs/ARBs on the incidence of case cancellation will also be studied. DISCUSSION The results of this trial should provide sufficient evidence on whether to continue or withhold ACEIs/ARBs before major non-cardiac surgery. TRIAL REGISTRATION Clinical Trials Registry of India CTRI/2021/01/030199. Registered on 4 January 2021.
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Song Q, Li J, Jiang Z. Provisional Decision-Making for Perioperative Blood Pressure Management: A Narrative Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5916040. [PMID: 35860431 PMCID: PMC9293529 DOI: 10.1155/2022/5916040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
Blood pressure (BP) is a basic determinant for organ blood flow supply. Insufficient blood supply will cause tissue hypoxia, provoke cellular oxidative stress, and to some extent lead to organ injury. Perioperative BP is labile and dynamic, and intraoperative hypotension is common. It is unclear whether there is a causal relationship between intraoperative hypotension and organ injury. However, hypotension surely compromises perfusion and causes harm to some extent. Because the harm threshold remains unknown, various guidelines for intraoperative BP management have been proposed. With the pending definitions from robust randomized trials, it is reasonable to consider observational analyses suggesting that mean arterial pressures below 65 mmHg sustained for more than 15 minutes are associated with myocardial and renal injury. Advances in machine learning and artificial intelligence may facilitate the management of hemodynamics globally, including fluid administration, rather than BP alone. The previous mounting studies concentrated on associations between BP targets and adverse complications, whereas few studies were concerned about how to treat and multiple factors for decision-making. Hence, in this narrative review, we discussed the way of BP measurement and current knowledge about baseline BP extracting for surgical patients, highlighted the decision-making process for BP management with a view to providing pragmatic guidance for BP treatment in the clinical settings, and evaluated the merits of an automated blood control system in predicting hypotension.
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Affiliation(s)
- Qiliang Song
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Jipeng Li
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Zongming Jiang
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
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Ackland GL, Abbott TEF. Hypotension as a marker or mediator of perioperative organ injury: a narrative review. Br J Anaesth 2022; 128:915-930. [PMID: 35151462 PMCID: PMC9204667 DOI: 10.1016/j.bja.2022.01.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/16/2021] [Accepted: 01/08/2022] [Indexed: 12/21/2022] Open
Abstract
Perioperative hypotension has been repeatedly associated with organ injury and worse outcome, yet many interventions to reduce morbidity by attempting to avoid or reverse hypotension have floundered. In part, this reflects uncertainty as to what threshold of hypotension is relevant in the perioperative setting. Shifting population-based definitions for hypertension, plus uncertainty regarding individualised norms before surgery, both present major challenges in constructing useful clinical guidelines that may help improve clinical outcomes. Aside from these major pragmatic challenges, a wealth of biological mechanisms that underpin the development of higher blood pressure, particularly with increasing age, suggest that hypotension (however defined) or lower blood pressure per se does not account solely for developing organ injury after major surgery. The mosaic theory of hypertension, first proposed more than 60 yr ago, incorporates multiple, complementary mechanistic pathways through which clinical (macrovascular) attempts to minimise perioperative organ injury may unintentionally subvert protective or adaptive pathways that are fundamental in shaping the integrative host response to injury and inflammation. Consideration of the mosaic framework is critical for a more complete understanding of the perioperative response to acute sterile and infectious inflammation. The largely arbitrary treatment of perioperative blood pressure remains rudimentary in the context of multiple complex adaptive hypertensive endotypes, defined by distinct functional or pathobiological mechanisms, including the regulation of reactive oxygen species, autonomic dysfunction, and inflammation. Developing coherent strategies for the management of perioperative hypotension requires smarter, mechanistically solid interventions delivered by RCTs where observer bias is minimised.
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Affiliation(s)
- Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
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Rodríguez MR, DiNardo JA. Biventricular Repair as an Alternative to Single Ventricle Palliation in the Child with Hypoplastic Left Heart Structures: What the Anesthesiologist Should Know. J Cardiothorac Vasc Anesth 2022; 36:3927-3938. [DOI: 10.1053/j.jvca.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/04/2022] [Accepted: 06/13/2022] [Indexed: 11/11/2022]
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Guarracino F, Bertini P. Perioperative hypotension: causes and remedies. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022; 2:17. [PMCID: PMC10245539 DOI: 10.1186/s44158-022-00045-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/04/2022] [Indexed: 06/24/2023]
Abstract
Background Arterial hypotension is common in patients during surgery and those admitted to the intensive care unit (ICU) postoperatively. Perioperative arterial hypotension reportedly significantly affects surgical patients’ outcomes. Blood pressure level is the most crucial factor that influences organ perfusion. Hypoperfusion and organ dysfunction are correlated based on their severity associated with hypotension. As several factors can cause intraoperative hypotension, anesthetists must promptly identify the etiology for appropriate treatment and revert the patient’s hemodynamic profile. Objectives This review discusses the concept of perioperative hypotension, identifies its effects in clinical situations, and provides remedies and techniques to predict and avoid its significant consequences. Conclusions The primary determinant of organ perfusion is blood pressure. On the other hand, profound hypotension is common in surgical patients and is connected to hypoperfusion and organ failure. Currently, hypotension is addressed once low blood pressure levels are recorded. Early detection of oncoming hypotension or its clinical prediction is of paramount importance in allowing the clinician to treat hypotension and reduce the incidence and length of hypotensive episodes promptly and aggressively.
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Affiliation(s)
- Fabio Guarracino
- Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56123 Pisa, Italy
| | - Pietro Bertini
- Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56123 Pisa, Italy
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Palla K, Hyland SL, Posner K, Ghosh P, Nair B, Bristow M, Paleva Y, Williams B, Fong C, Van Cleve W, Long DR, Pauldine R, O'Hara K, Takeda K, Vavilala MS. Intraoperative prediction of postanaesthesia care unit hypotension. Br J Anaesth 2022; 128:623-635. [PMID: 34924175 PMCID: PMC9074793 DOI: 10.1016/j.bja.2021.10.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 10/01/2021] [Accepted: 10/18/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Postoperative hypotension is associated with adverse outcomes, but intraoperative prediction of postanaesthesia care unit (PACU) hypotension is not routine in anaesthesiology workflow. Although machine learning models may support clinician prediction of PACU hypotension, clinician acceptance of prediction models is poorly understood. METHODS We developed a clinically informed gradient boosting machine learning model using preoperative and intraoperative data from 88 446 surgical patients from 2015 to 2019. Nine anaesthesiologists each made 192 predictions of PACU hypotension using a web-based visualisation tool with and without input from the machine learning model. Questionnaires and interviews were analysed using thematic content analysis for model acceptance by anaesthesiologists. RESULTS The model predicted PACU hypotension in 17 029 patients (area under the receiver operating characteristic [AUROC] 0.82 [95% confidence interval {CI}: 0.81-0.83] and average precision 0.40 [95% CI: 0.38-0.42]). On a random representative subset of 192 cases, anaesthesiologist performance improved from AUROC 0.67 (95% CI: 0.60-0.73) to AUROC 0.74 (95% CI: 0.68-0.79) with model predictions and information on risk factors. Anaesthesiologists perceived more value and expressed trust in the prediction model for prospective planning, informing PACU handoffs, and drawing attention to unexpected cases of PACU hypotension, but they doubted the model when predictions and associated features were not aligned with clinical judgement. Anaesthesiologists expressed interest in patient-specific thresholds for defining and treating postoperative hypotension. CONCLUSIONS The ability of anaesthesiologists to predict PACU hypotension was improved by exposure to machine learning model predictions. Clinicians acknowledged value and trust in machine learning technology. Increasing familiarity with clinical use of model predictions is needed for effective integration into perioperative workflows.
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Affiliation(s)
| | | | - Karen Posner
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | - Bala Nair
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | | | | | - Christine Fong
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Wil Van Cleve
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Dustin R Long
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Ronald Pauldine
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Monica S Vavilala
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
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Erdoğan G, Arslan U, Yenerçağ M, Şahin O, Arslan H, Yavuz MB, Karagöz A, Şahin İ. The association between nondipper pattern and perioperative hypertension in patients with controlled hypertension. Blood Press Monit 2022; 27:105-112. [PMID: 34855651 DOI: 10.1097/mbp.0000000000000575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perioperative hypertension is a frequent complication even in preoperatively normotensive or controlled hypertensive patients and there is a lack of data regarding the effect of nondipping pattern on perioperative hypertension. OBJECTIVE In this study, we aimed to investigate the possible effect of nondipping blood pressure pattern on the risk of perioperative hypertension. MATERIALS AND METHODS 234 hypertensive patients who underwent surgery with general anesthesia were evaluated prospectively. The study enrolled patients with well-controlled preoperative blood pressure. The 24-h ambulatory blood pressure monitoring results were used to classify patients as dippers and nondippers. Perioperative hypertension is defined as a systolic/diastolic arterial blood pressure greater than or equal to 160/90 mmHg or systolic blood pressure elevated by more than 20% from the patient's baseline level for more than 15 min perioperatively. RESULTS There were 61 (26%) nondipper patients [mean age: 62.1 ± 7.1 years, 25 (40.9%) men] and 173 (74%) dipper patients [mean age: 61.4 ± 8.1 years, 83 (47.9%) men]. In the nondipper group, perioperative hypertension was observed in 31 (51.3%) patients, whereas in the dipper group, 33 (19.3%) patients experienced a hypertensive attack (P < 0.001). The independent predictors of perioperative hypertension were the presence of the nondipping pattern [odds ratio (OR) 3.084; 95% confidence interval (CI) 1.831-5.195; P < 0.001], the presence of diabetes mellitus (OR 2.059; 95% CI 1.215-3.490; P = 0.007), and the number of drugs (OR 2.317; 95% CI 1.102-5.097; P = 0.027). CONCLUSION The frequency of perioperative hypertension was higher in preoperative normotensive and known hypertensive patients who were identified as nondippers. In addition, diabetes mellitus and number of drugs were found to be predictors of perioperative hypertension.
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Affiliation(s)
- Güney Erdoğan
- Department of Cardiology, Samsun Training and Research Hospital, Samsun University Faculty of Medicine, Samsun
| | - Uğur Arslan
- Department of Cardiology, Samsun Training and Research Hospital, Samsun University Faculty of Medicine, Samsun
| | - Mustafa Yenerçağ
- Department of Cardiology, Training and Research Hospital, Ordu University, Ordu
| | - Osman Şahin
- Department of Cardiology, Konya Seydisehir State Hospital, Konya
| | - Hande Arslan
- Department of Otorhinolaryngology, Ankara Dişkapi Training and Research Hospital, University of Health Sciences, Ankara
| | - Mustafa Baran Yavuz
- Department of Anesthesiology and Reanimation, Bağcilar Training and Research Hospital, University of Health Sciences, Istanbul
| | - Ali Karagöz
- Department of Cardiology, Kartal Kosuyolu Research and Training Hospital, University of Health Sciences, İstanbul
| | - İrfan Şahin
- Department of Cardiology, Bağcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Agerskov M, Sørensen H, Højlund J, Kjær S, Secher NH, Foss NB. The effect of vasoconstriction on intestinal perfusion is determined by preload dependency: A prospective observational study. Acta Anaesthesiol Scand 2022; 66:713-721. [PMID: 35338646 DOI: 10.1111/aas.14059] [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: 10/07/2021] [Revised: 02/21/2022] [Accepted: 03/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The effects of vasoconstriction on cardiac stroke volume (SV) and indices of peripheral and intestinal perfusion are insufficiently described. METHODS In a non-randomized clinical study, 30 patients undergoing elective rectal surgery were exposed to modulation of preload. The primary endpoint was intestinal perfusion (flux), measured by single-point laser Doppler flowmetry. Secondary endpoints were central cardiovascular variables obtained by the LiDCO rapid monitor, the peripheral perfusion index (PPI) derived from the pulse oximetry signal and muscle (StO2 ) and cerebral oxygenation (ScO2 ) determined by near-infrared spectroscopy. RESULTS For the whole cohort (n = 30), administration of Phenylephrine during HUT induced a median [IQR] increase in SV by 22% [14-41], p = .003 and in mean arterial pressure (MAP) by 54% [31-62], p < .001, with no change in PPI, StO2 and ScO2 or flux. In patients who were preload dependent during HUT (stroke volume variation; SSV >10%; n = 23), administration of phenylephrine increased SV by 29% [12-43], p = .01 and MAP by 54% [33-63], p < .001, followed by an increase in intestinal perfusion flux by 60% [15-289], p = .05, while PPI, StO2 and ScO2 remained unchanged. For non-preload dependent patients (SSV <10%; n = 7), no changes in hemodynamic indices were seen besides an increase in MAP by 54% [33-58], p = .002. CONCLUSION The reflection of vasoconstrictive modulation of preload in systemic cardiovascular variables and indices of perfusion was dependent on preload responsiveness. Administration of phenylephrine to increase preload did not appear to compromise organ perfusion.
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Affiliation(s)
- Marianne Agerskov
- Department of Anesthesiology and Intensive Care Hvidovre Hospital University of Copenhagen Copenhagen Denmark
| | - Henrik Sørensen
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Hvidovre Hospital University of Copenhagen Copenhagen Denmark
| | - Søren Kjær
- Gastroenterology Surgical Section Hvidovre Hospital University of Copenhagen Copenhagen Denmark
| | - Niels H. Secher
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Nicolai B. Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital University of Copenhagen Copenhagen Denmark
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Weinberg L, Li SY, Louis M, Karp J, Poci N, Carp BS, Miles LF, Tully P, Hahn R, Karalapillai D, Lee DK. Reported definitions of intraoperative hypotension in adults undergoing non-cardiac surgery under general anaesthesia: a review. BMC Anesthesiol 2022; 22:69. [PMID: 35277122 PMCID: PMC8915500 DOI: 10.1186/s12871-022-01605-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 02/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background Intraoperative hypotension (IOH) during non-cardiac surgery is common and associated with major adverse kidney, neurological and cardiac events and even death. Given that IOH is a modifiable risk factor for the mitigation of postoperative complications, it is imperative to generate a precise definition for IOH to facilitate strategies for avoiding or treating its occurrence. Moreover, a universal and consensus definition of IOH may also facilitate the application of novel and emerging therapeutic interventions in treating IOH. We conducted a review to systematically record the reported definitions of intraoperative hypotension in adults undergoing non-cardiac surgery under general anaesthesia. Methods In accordance with Cochrane guidelines, we searched three online databases (OVID [Medline], Embase and Cochrane Library) for all studies published from 1 January 2000 to 6 September 2020. We evaluated the number of studies that reported the absolute or relative threshold values for defining blood pressure. Secondary aims included evaluation of the threshold values for defining IOH, the methodology for accounting for the severity of hypotension, whether the type of surgical procedure influenced the definition of IOH, and whether a study whose definition of IOH aligned with the Perioperative Quality Initiative-3 workgroup (POQI) consensus statement for defining was more likely to be associated with determining an adverse postoperative outcome. Results A total of 318 studies were included in the final qualitative synthesis. Most studies (n = 249; 78.3%) used an absolute threshold to define hypotension; 150 (60.5%) reported SBP, 117 (47.2%) reported MAP, and 12 (4.8%) reported diastolic blood pressure (DBP). 126 (39.6%) used a relative threshold to define hypotension. Of the included studies, 153 (48.1%) did not include any duration variable in their definition of hypotension. Among the selected 318 studies 148 (46.5%) studies defined IOH according to the POQI statement. When studies used a “relative blood pressure change” to define IOH, there was a weaker association in detecting adverse postoperative outcomes compared to studies who reported “absolute blood pressure change” (χ2(2) = 10.508, P = 0.005, Cramér’s V = 0.182). When studies used the POQI statement definition of hypotension or defined IOH by values higher than the POQI statement definition there were statistical differences observed between IOH and adverse postoperative outcomes (χ2(1) = 6.581, P = 0.037, Cramér’s V = 0.144). When both the duration of IOH or the numbers of hypotensive epochs were evaluated, we observed a significantly stronger relationship between the definition of IOH use the development of adverse postoperative outcomes. (χ2(1) = 4.860, P = 0.027, Cramér’s V = 0.124). Conclusions Most studies defined IOH by absolute or relative changes from baseline values. There are substantial inconsistencies in how IOH was reported. Further, definitions differed across different surgical specialities. Our findings further suggest that IOH should be defined using the absolute values stated in the POQI statement i.e., MAP < 60–70 mmHg or SBP < 100 mmHg. Finally, the number of hypotensive epochs or time-weighted duration of IOH should also be reported. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01605-9.
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Takeuchi K, Hayashida M, Kudoh O, Niimi N, Kataoka K, Kakemizu-Watanabe M, Yamamoto M, Hara A, Kawagoe I, Yamaguchi K. Continuing versus withholding angiotensin receptor blocker (ARB)/calcium channel blocker (CCB) combination tablets during perioperative periods in patients undergoing minor surgery: a single-blinded randomized controlled trial. J Anesth 2022; 36:374-382. [PMID: 35247102 PMCID: PMC9156462 DOI: 10.1007/s00540-022-03053-8] [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] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
Purpose This trial was conducted to compare effects of continuing versus withholding single-pill combination tablets consisting of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) on perioperative hemodynamics and clinical outcomes. Methods Patients undergoing minor abdominal or urological surgery (n = 106) were randomly assigned to Group C, in which ARB/CCB combination tablets were continued until surgery, or Group W, in which they were withheld within 24 h of surgery. Perioperative hemodynamics and clinical outcomes were compared between the Groups. Results The incidence of hypotension during anesthesia requiring repeated treatment with vasoconstrictors was higher in Group C than Group W (p = 0.0052). Blood pressure during anesthesia was generally lower in Group C than Group W (p < 0.05) despite significantly more doses of ephedrine and phenylephrine administrated in Group C (p = 0.0246 and p = 0.0327, respectively). The incidence of postoperative hypertension did not differ between Groups (p = 0.3793). Estimated glomerular filtration rate (eGFR) on the preoperative day did not differ between Groups (p = 0.7045), while eGFR was slightly lower in Group C than Group W on the first and third postoperative days (p = 0.0400 and p = 0.0088, respectively), although clinically relevant acute kidney injury did not develop. Conclusions Continuing ARB/CCB combination tablets preoperatively in patients undergoing minor surgery increased the incidence of hypotension during anesthesia, increased requirements of vasoconstrictors to treat hypotension, and might deteriorate postoperative renal function, albeit slightly. These results suggest that withholding ARB/CCB tablets preoperatively is preferable to continuing them. Clinical trial registration This trial is registered with the Japan Registry of Clinical Trials (jRCT) at Japanese Ministry of Health, Labour, and Welfare (Trial ID: jRCT1031190027).
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Affiliation(s)
- Kazuyo Takeuchi
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Masakazu Hayashida
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Osamu Kudoh
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Naoko Niimi
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kumi Kataoka
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Maho Kakemizu-Watanabe
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Makiko Yamamoto
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsuko Hara
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Keisuke Yamaguchi
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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