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Lu Y, Xiao Z, Zhao X, Ye Y, Li S, Guo F, Xue H, Zhu F. Incidence, risk factors, and outcomes of the transition of HIPEC-induced acute kidney injury to acute kidney disease: a retrospective study. Ren Fail 2024; 46:2338482. [PMID: 38604946 PMCID: PMC11011229 DOI: 10.1080/0886022x.2024.2338482] [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: 09/21/2023] [Accepted: 03/29/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is recognized as a common complication following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Characterized by prolonged renal function impairment, acute kidney disease (AKD) is associated with a higher risk of chronic kidney disease (CKD) and mortality. METHODS From January 2018 to December 2021, 158 patients undergoing CRS-HIPEC were retrospectively reviewed. Patients were separated into non-AKI, AKI, and AKD cohorts. Laboratory parameters and perioperative features were gathered to evaluate risk factors for both HIPEC-induced AKI and AKD, with the 90-day prognosis of AKD patients. RESULTS AKI developed in 21.5% of patients undergoing CRS-HIPEC, while 13.3% progressed to AKD. The multivariate analysis identified that ascites, GRAN%, estimated glomerular filtration rate (eGFR), and intraoperative (IO) hypotension duration were associated with the development of HIPEC-induced AKI. Higher uric acid, lessened eGFR, and prolonged IO hypotension duration were more predominant in patients proceeding with AKD. The AKD cohort presented a higher risk of 30 days of in-hospital mortality (14.3%) and CKD progression (42.8%). CONCLUSIONS Our study reveals a high incidence of AKI and AKI-to-AKD transition. Early identification of risk factors for HIPEC-induced AKD would assist clinicians in taking measures to mitigate the incidence.
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Affiliation(s)
- Yunwei Lu
- Department of Intensive Care Medicine, Trauma Center, Peking University People’s Hospital, Beijing, China
| | - Ziyan Xiao
- Department of Intensive Care Medicine, Trauma Center, Peking University People’s Hospital, Beijing, China
| | - Xiujuan Zhao
- Department of Intensive Care Medicine, Trauma Center, Peking University People’s Hospital, Beijing, China
| | - Yingjiang Ye
- Department of Gastrointestinal Surgery, Peking University People’s Hospital, Beijing, China
| | - Shu Li
- Department of Intensive Care Medicine, Trauma Center, Peking University People’s Hospital, Beijing, China
| | - Fuzheng Guo
- Department of Intensive Care Medicine, Trauma Center, Peking University People’s Hospital, Beijing, China
| | - Haiyan Xue
- Department of Intensive Care Medicine, Trauma Center, Peking University People’s Hospital, Beijing, China
| | - Fengxue Zhu
- Department of Intensive Care Medicine, Trauma Center, Peking University People’s Hospital, Beijing, China
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Thomsen KK, Sessler DI, Krause L, Hoppe P, Opitz B, Kessler T, Chindris V, Bergholz A, Flick M, Kouz K, Zöllner C, Schulte-Uentrop L, Saugel B. Processed electroencephalography-guided general anesthesia and norepinephrine requirements: A randomized trial in patients having vascular surgery. J Clin Anesth 2024; 95:111459. [PMID: 38599161 DOI: 10.1016/j.jclinane.2024.111459] [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: 12/21/2023] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024]
Abstract
STUDY OBJECTIVE Processed electroencephalography (pEEG) may help clinicians optimize depth of general anesthesia. Avoiding excessive depth of anesthesia may reduce intraoperative hypotension and the need for vasopressors. We tested the hypothesis that pEEG-guided - compared to non-pEEG-guided - general anesthesia reduces the amount of norepinephrine needed to keep intraoperative mean arterial pressure above 65 mmHg in patients having vascular surgery. DESIGN Randomized controlled clinical trial. SETTING University Medical Center Hamburg-Eppendorf, Hamburg, Germany. PATIENTS 110 patients having vascular surgery. INTERVENTIONS pEEG-guided general anesthesia. MEASUREMENTS Our primary endpoint was the average norepinephrine infusion rate from the beginning of induction of anesthesia until the end of surgery. MAIN RESULT 96 patients were analyzed. The mean ± standard deviation average norepinephrine infusion rate was 0.08 ± 0.04 μg kg-1 min-1 in patients assigned to pEEG-guided and 0.12 ± 0.09 μg kg-1 min-1 in patients assigned to non-pEEG-guided general anesthesia (mean difference 0.04 μg kg-1 min-1, 95% confidence interval 0.01 to 0.07 μg kg-1 min-1, p = 0.004). Patients assigned to pEEG-guided versus non-pEEG-guided general anesthesia, had a median time-weighted minimum alveolar concentration of 0.7 (0.6, 0.8) versus 0.8 (0.7, 0.8) (p = 0.006) and a median percentage of time Patient State Index was <25 of 12 (1, 41) % versus 23 (3, 49) % (p = 0.279). CONCLUSION pEEG-guided - compared to non-pEEG-guided - general anesthesia reduced the amount of norepinephrine needed to keep mean arterial pressure above 65 mmHg by about a third in patients having vascular surgery. Whether reduced intraoperative norepinephrine requirements resulting from pEEG-guided general anesthesia translate into improved patient-centered outcomes remains to be determined in larger trials.
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Affiliation(s)
- Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Daniel I Sessler
- OutcomesResearch Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Opitz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till Kessler
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Viorel Chindris
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; OutcomesResearch Consortium, Cleveland, OH, USA
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leonie Schulte-Uentrop
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; OutcomesResearch Consortium, Cleveland, OH, USA
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Wang XJ, Xuan XC, Sun ZC, Shen S, Yu F, Li NN, Chu XC, Yin H, Hu YL. Risk factors associated with intraoperative persistent hypotension in pancreaticoduodenectomy. World J Gastrointest Surg 2024; 16:1582-1591. [DOI: 10.4240/wjgs.v16.i6.1582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/27/2024] [Accepted: 05/16/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Intraoperative persistent hypotension (IPH) during pancreaticoduodenectomy (PD) is linked to adverse postoperative outcomes, yet its risk factors remain unclear.
AIM To clarify the risk factors associated with IPH during PD, ensuring patient safety in the perioperative period.
METHODS A retrospective analysis of patient records from January 2018 to December 2022 at the First Affiliated Hospital of Nanjing Medical University identified factors associated with IPH in PD. These factors included age, gender, body mass index, American Society of Anesthesiologists classification, comorbidities, medication history, operation duration, fluid balance, blood loss, urine output, and blood gas parameters. IPH was defined as sustained mean arterial pressure < 65 mmHg, requiring prolonged deoxyepinephrine infusion for > 30 min despite additional deoxyepinephrine and fluid treatments.
RESULTS Among 1596 PD patients, 661 (41.42%) experienced IPH. Multivariate logistic regression identified key risk factors: increased age [odds ratio (OR): 1.20 per decade, 95% confidence interval (CI): 1.08-1.33] (P < 0.001), longer surgery duration (OR: 1.15 per additional hour, 95%CI: 1.05-1.26) (P < 0.01), and greater blood loss (OR: 1.18 per 250-mL increment, 95%CI: 1.06-1.32) (P < 0.01). A novel finding was the association of arterial blood Ca2+ < 1.05 mmol/L with IPH (OR: 2.03, 95%CI: 1.65-2.50) (P < 0.001).
CONCLUSION IPH during PD is independently associated with older age, prolonged surgery, increased blood loss, and lower plasma Ca2+.
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Affiliation(s)
- Xing-Jun Wang
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Xi-Chen Xuan
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Zhao-Chu Sun
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Shi Shen
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Fan Yu
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Na-Na Li
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Xue-Chun Chu
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Hui Yin
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - You-Li Hu
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
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Chen Z, Wu R, Wei D, Wu X, Ma C, Shi J, Geng J, Zhao M, Guo Y, Xu H, Zhou Y, Zeng X, Huo W, Wang C, Mao Z. New findings on the risk of hypertension from organophosphorus exposure under different glycemic statuses: The key role of lipids? THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 930:172711. [PMID: 38688361 DOI: 10.1016/j.scitotenv.2024.172711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND AND OBJECTIVE Considering the widespread use of organophosphorus pesticides (OPs) and the global prevalence of hypertension (HTN), as well as studies indicating that different glycemic statuses may respond differently to the biological effects of OPs. Therefore, this study, based on the Henan rural cohort, aims to investigate the association between OPs exposure and HTN, and further explores whether lipids mediate these associations. METHODS We measured the plasma levels of OPs in 2730 participants under different glycemic statuses using gas chromatography-triple quadrupole mass spectrometry (GC-MS/MS). A generalized linear model, Quantile g-computation (QGC), adaptive elastic net (AENET), and Bayesian kernel machine regression (BKMR) models were used to assess the impact of OPs exposure on HTN, with least absolute shrinkage and selection operator (LASSO) penalty regression identifying main OPs. Mediation models were used to evaluate the intermediary role of blood lipids in the OPs-HTN relationship. RESULTS The detection rates for all OPs were high, ranging from 76.35 % to 99.17 %. In the normal glucose tolerance (NGT) population, single exposure models indicated that malathion and phenthoate were associated with an increased incidence of HTN (P-FDR < 0.05), with corresponding odds ratios (ORs) and 95 % confidence intervals (CIs) of 1.624 (1.167,2.260) and 1.290 (1.072,1.553), respectively. QGC demonstrated a positive association between OP mixtures and HTN, with malathion and phenthoate being the primary contributors. Additionally, the AENET model's Exposure Response Score (ERS) suggested that the risk of HTN increases with higher ERS (P < 0.001). Furthermore, BKMR revealed that co-exposure to OPs increases HTN risk, with phenthoate having a significant impact. Furthermore, triglycerides (TG) mediated 6.55 % of the association between phenthoate and HTN. However, no association was observed in the impaired fasting glucose (IFG) and type 2 diabetes mellitus (T2DM) populations. CONCLUSIONS Our findings suggest that in the NGT population, OPs may significantly contribute to the development of HTN, proposing TG as a potential novel target for HTN prevention.
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Affiliation(s)
- Zhiwei Chen
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Ruihong Wu
- School of Computer Science and Technology, East China Normal University; Information Department, First Affiliated Hospital of Henan University of Chinese Medicine, PR China
| | - Dandan Wei
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Xueyan Wu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Cuicui Ma
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Jiayu Shi
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Jintian Geng
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Mengzhen Zhao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Yao Guo
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Haoran Xu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Yilin Zhou
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Xin Zeng
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Wenqian Huo
- Department of Occupational and Environmental Health Sciences, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Chongjian Wang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Zhenxing Mao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China.
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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:S0007-0912(24)00264-2. [PMID: 38839472 DOI: 10.1016/j.bja.2024.04.046] [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: 12/19/2023] [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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Kouz K, Thiele R, Michard F, Saugel B. Haemodynamic monitoring during noncardiac surgery: past, present, and future. J Clin Monit Comput 2024; 38:565-580. [PMID: 38687416 PMCID: PMC11164815 DOI: 10.1007/s10877-024-01161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/02/2024] [Indexed: 05/02/2024]
Abstract
During surgery, various haemodynamic variables are monitored and optimised to maintain organ perfusion pressure and oxygen delivery - and to eventually improve outcomes. Important haemodynamic variables that provide an understanding of most pathophysiologic haemodynamic conditions during surgery include heart rate, arterial pressure, central venous pressure, pulse pressure variation/stroke volume variation, stroke volume, and cardiac output. A basic physiologic and pathophysiologic understanding of these haemodynamic variables and the corresponding monitoring methods is essential. We therefore revisit the pathophysiologic rationale for intraoperative monitoring of haemodynamic variables, describe the history, current use, and future technological developments of monitoring methods, and finally briefly summarise the evidence that haemodynamic management can improve patient-centred outcomes.
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Robert Thiele
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | | | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
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Gunaratne C, Ison R, Price CC, Modave F, Tighe P. Development of a Probabilistic Boolean network (PBN) to model intraoperative blood pressure management. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 249:108143. [PMID: 38552333 DOI: 10.1016/j.cmpb.2024.108143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/15/2024] [Accepted: 03/21/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Blood pressure is a vital sign for organ perfusion that anesthesiologists measure and modulate during surgery. However, current decision-making processes rely heavily on clinicians' experience, which can lead to variability in treatment across surgeries. With the advent of machine learning, we can now create models to predict the outcomes of interventions and guide perioperative decision-making. The first step in this process involves translating the clinical decision-making process into a framework understood by an algorithm. Probabilistic Boolean networks (PBNs) provide an information-rich approach to this problem. A PBN trends toward a steady state, and its decisions are easily understood via its Boolean predictor functions. We hypothesize that a PBN can be developed that corrects hemodynamic instability in patients by selecting clinical interventions to maintain blood pressure within a given range. METHODS Data on patients over the age of 65 undergoing surgery with general anesthesia from 2018 to 2020 were drawn from the UF Health PRECEDE data set with IRB approval (IRB201700747). Parameters examined included heart rate, blood pressure, and frequency of medications given 15 min after anesthetic induction and 15 min before awakening. The medication frequency data were truncated into a 66/33 split for the training and validation set used in the PBN. The model was coded using Python 3 and evaluated by comparing the frequency of medications chosen by the program to the values in the testing set via linear regression analysis. RESULTS The network developed successfully models a hemodynamically unstable patient and corrects the imbalance by administering medications. This is evidenced by the model achieving a stable, steady state matrix in all iterations. However, the model's ability to emulate clinical drug selection was variable. It was successful with its use of vasodilator selection but struggled with the appropriate selection of vasopressors. CONCLUSIONS The PBN has demonstrated the ability to choose appropriate interventions based on a patient's current vitals. Additional work must be done to have the network emulate the frequency at which drugs are selected from in clinical practice. In its current state, the model provides an understanding of how a PBN behaves in the context of correcting hemodynamic instability and can aid in developing more robust models in the future.
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Affiliation(s)
- Chamara Gunaratne
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA.
| | - Ron Ison
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Catherine C Price
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA; Department of Clinical and Health Psychology, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Francois Modave
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Patrick Tighe
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
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Tsumura H, Pan W, Brandon D. Exploring Differences in Intraoperative Medication Use Between African American and Non-Hispanic White Patients During General Anesthesia: Retrospective Observational Cohort Study. Clin Nurs Res 2024:10547738241253652. [PMID: 38767246 DOI: 10.1177/10547738241253652] [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: 05/22/2024]
Abstract
This study aimed to explore whether differences exist in anesthesia care providers' use of intraoperative medication between African American and non-Hispanic White patients in adult surgical patients who underwent noncardiothoracic nonobstetric surgeries with general anesthesia. A retrospective observational cohort study used electronic health records between January 1, 2018 and August 31, 2019 at a large academic health system in the southeastern United States. To evaluate the isolated impact of race on intraoperative medication use, inverse probability of treatment weighting using the propensity scores was used to balance the covariates between African American and non-Hispanic White patients. Regression analyses were then performed to evaluate the impact of race on the total dose of opioid analgesia administered, and the use of midazolam, sugammadex, antihypotensive drugs, and antihypertensive drugs. Of the 31,790 patients included in the sample, 58.9% were non-Hispanic Whites and 13.6% were African American patients. After adjusting for significant covariates, African American patients were more likely to receive midazolam premedication (p < .0001; adjusted odds ratio [aOR] = 1.17, 99.9% CI [1.06, 1.30]), and antihypertensive drugs (p = .0002; aOR = 1.15, 99.9% CI [1.02, 1.30]), and less likely to receive antihypotensive drugs (p < .0001; aOR = 0.85, 99.9% CI [0.76, 0.95]) than non-Hispanic White patients. However, we did not find significant differences in the total dose of opioid analgesia administered, or sugammadex. This study identified differences in intraoperative anesthesia care delivery between African American and non-Hispanic White patients; however, future research is needed to understand mechanisms that contribute to these differences and whether these differences are associated with patient outcomes.
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Affiliation(s)
- Hideyo Tsumura
- Duke University School of Nursing, Durham, NC, USA
- Duke University Health System, Durham, NC, USA
| | - Wei Pan
- Duke University School of Nursing, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Debra Brandon
- Duke University School of Nursing, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
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Flick M, Lohr A, Weidemann F, Naebian A, Hoppe P, Thomsen KK, Krause L, Kouz K, Saugel B. Post-anesthesia care unit hypotension in low-risk patients recovering from non-cardiac surgery: a prospective observational study. J Clin Monit Comput 2024:10.1007/s10877-024-01176-9. [PMID: 38758404 DOI: 10.1007/s10877-024-01176-9] [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: 02/08/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024]
Abstract
Intraoperative hypotension is common and associated with organ injury. Hypotension can not only occur during surgery, but also thereafter. After surgery, most patients are treated in post-anesthesia care units (PACU). The incidence of PACU hypotension is largely unknown - presumably in part because arterial pressure is usually monitored intermittently in PACU patients. We therefore aimed to evaluate the incidence, duration, and severity of PACU hypotension in low-risk patients recovering from non-cardiac surgery. In this observational study, we performed blinded continuous non-invasive arterial pressure monitoring with finger-cuffs (ClearSight system; Edwards Lifesciences, Irvine, CA, USA) in 100 patients recovering from non-cardiac surgery in the PACU. We defined PACU hypotension as a mean arterial pressure (MAP) < 65 mmHg. Patients had continuous finger-cuff monitoring for a median (25th percentile, 75th percentile) of 64 (44 to 91) minutes. Only three patients (3%) had PACU hypotension for at least one consecutive minute. These three patients had 4, 4, and 2 cumulative minutes of PACU hypotension; areas under a MAP of 65 mmHg of 17, 9, and 9 mmHg x minute; and time-weighted averages MAP less than 65 mmHg of 0.5, 0.3, and 0.2 mmHg. The median volume of crystalloid fluid patients were given during PACU treatment was 200 (100 to 400) ml. None was given colloids or a vasopressor during PACU treatment. In low-risk patients recovering from non-cardiac surgery, the incidence of PACU hypotension was very low and the few episodes of PACU hypotension were short and of modest severity.
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Affiliation(s)
- Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anneke Lohr
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Weidemann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ashkan Naebian
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - 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.
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10
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Zhou N, Ripley-Gonzalez JW, Zhang W, Xie K, You B, Shen Y, Cao Z, Qiu L, Li C, Fu S, Zhang C, Dun Y, Gao Y, Liu S. Preoperative exercise training decreases complications of minimally invasive lung cancer surgery: A randomized controlled trial. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00296-4. [PMID: 38614212 DOI: 10.1016/j.jtcvs.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 03/13/2024] [Accepted: 04/06/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE Limited evidence exists regarding the efficacy of preoperative exercise in reducing short-term complications after minimally invasive surgery in patients with non-small cell lung cancer. This study aims to investigate the impact of preoperative exercise on short-term complications after minimally invasive lung resection. METHODS In this prospective, open-label, randomized (1:1) controlled trial at Xiangya Hospital, China (September 2020 to February 2022), patients were randomly assigned to a preoperative exercise group with 16-day alternate supervised exercise or a control group. The primary outcome assessed was short-term postoperative complications, with a follow-up period of 30 days postsurgery. RESULTS A total of 124 patients were recruited (preoperative exercise group n = 62; control n = 62). Finally, 101 patients (preoperative exercise group; n = 51 and control; n = 50) with a median age of 56 years (interquartile range, 50-62 years) completed the study. Compared with the control group, the preoperative exercise group showed fewer postoperative complications (preoperative exercise 3/51 vs control 10/50; odds ratio, 0.17; 95% CI, 0.04-0.86; P = .03) and shorter hospital stays (mean difference, -2; 95% CI, -3 to -1; P = .01). Preoperative exercise significantly improved depression, stress, functional capacity, and quality of life (all P < .05) before surgery. Furthermore, preoperative exercise demonstrated a significantly lower minimum blood pressure during surgery and lower increases in body temperature on day 2 after surgery, neutrophil-to-lymphocyte ratio, and neutrophil count after surgery (all P < .05). Exploratory research on lung tissue RNA sequencing (5 in each group) showed downregulation of the tumor necrosis factor signaling pathway in the preoperative exercise group compared with the control group. CONCLUSIONS Preoperative exercise training decreased short-term postoperative complications in patients with non-small cell lung cancer.
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Affiliation(s)
- Nanjiang Zhou
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jeffrey W Ripley-Gonzalez
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Wenliang Zhang
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Kangling Xie
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Baiyang You
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yanan Shen
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zeng Cao
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ling Qiu
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Cui Li
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Siqian Fu
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Chunfang Zhang
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China; Department of Thoracic Surgery, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yaoshan Dun
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China; Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.
| | - Yang Gao
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China; Department of Thoracic Surgery, Xiangya Hospital of Central South University, Changsha, Hunan, China; Hunan Engineering Research Center for Pulmonary Nodules Precise Diagnosis & Treatment, Changsha, Hunan, China.
| | - Suixin Liu
- Division of Cardiac Rehabilitation, Department of Physical Medicine & Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China.
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11
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Krone S, Bokoch MP, Kothari R, Fong N, Tallarico RT, Sturgess-DaPrato J, Pirracchio R, Zarbock A, Legrand M. Association between peripheral perfusion index and postoperative acute kidney injury in major noncardiac surgery patients receiving continuous vasopressors: a post hoc exploratory analysis of the VEGA-1 trial. Br J Anaesth 2024; 132:685-694. [PMID: 38242802 DOI: 10.1016/j.bja.2023.11.054] [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: 05/16/2023] [Revised: 10/26/2023] [Accepted: 11/24/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The peripheral perfusion index is the ratio of pulsatile to nonpulsatile static blood flow obtained by photoplethysmography and reflects peripheral tissue perfusion. We investigated the association between intraoperative perfusion index and postoperative acute kidney injury in patients undergoing major noncardiac surgery and receiving continuous vasopressor infusions. METHODS In this exploratory post hoc analysis of a pragmatic, cluster-randomised, multicentre trial, we obtained areas and cumulative times under various thresholds of perfusion index and investigated their association with acute kidney injury in multivariable logistic regression analyses. In secondary analyses, we investigated the association of time-weighted average perfusion index with acute kidney injury. The 30-day mortality was a secondary outcome. RESULTS Of 2534 cases included, 8.9% developed postoperative acute kidney injury. Areas and cumulative times under a perfusion index of 3% and 2% were associated with an increased risk of acute kidney injury; the strongest association was observed for area under a perfusion index of 1% (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 1.00-1.74, P=0.050, per 100%∗min increase). Additionally, time-weighted average perfusion index was associated with acute kidney injury (aOR 0.82, 95% CI 0.74-0.91, P<0.001) and 30-day mortality (aOR 0.68, 95% CI 0.49-0.95, P=0.024). CONCLUSIONS Larger areas and longer cumulative times under thresholds of perfusion index and lower time-weighted average perfusion index were associated with postoperative acute kidney injury in patients undergoing major noncardiac surgery and receiving continuous vasopressor infusions. CLINICAL TRIAL REGISTRATION NCT04789330.
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Affiliation(s)
- Sina Krone
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA; Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Michael P Bokoch
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Rishi Kothari
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Nicholas Fong
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Roberta T Tallarico
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Jillene Sturgess-DaPrato
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Romain Pirracchio
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Matthieu Legrand
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA; INI-CRCT Network, Nancy, France.
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12
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Dammling CW, Weber TM, Taylor KJ, Kinard BE. Does Tranexamic Acid Reduce the Need for Hypotensive Anesthesia Within Orthognathic Surgery? A Retrospective Study. J Maxillofac Oral Surg 2024; 23:229-234. [PMID: 38601251 PMCID: PMC11001797 DOI: 10.1007/s12663-024-02119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/19/2024] [Indexed: 04/12/2024] Open
Abstract
Background Tranexamic acid (TXA) is utilized frequently in orthognathic surgery to limit blood loss and improve surgical field visualization. This antifibrinolytic has been proven effective with use of concomitant hypotensive anesthesia. Despite proven efficacy, there is a recent push to avoid perioperative hypotensive anesthesia due to risks of organ hypoperfusion, cardiac ischemia and postoperative nausea. Aims The aim is to study the efficacy and safety of utilizing TXA without controlled hypotensive anesthesia. Methods The authors identified two cohorts of subjects that underwent bimaxillary orthognathic surgery both with and without TXA administration and compared operative and perioperative variables. A retrospective analysis was completed evaluating intraoperative MAP measurements in subjects treated both with and without TXA using descriptive and bivariate analysis. Results and conclusion Sixty-three subjects met inclusion criteria. The TXA cohort experienced 11.5% less time under hypotensive anesthesia when compared to the group that did not receive TXA. Additionally, surgical length was decreased by more than 28 min when subjects received TXA. No subjects required a blood transfusion or experienced any TXA-related complications. Given the recommendations to limit hypotensive anesthesia perioperatively, TXA is a useful adjunct in orthognathic surgery to limit controlled hypotensive anesthesia.
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Affiliation(s)
- Chad W. Dammling
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham School of Dentistry, Birmingham, AL USA
| | - Timothy M. Weber
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham School of Dentistry, Birmingham, AL USA
| | - Kenneth J. Taylor
- Nursing Acute, Chronic & Continuing Care, University of Alabama at Birmingham School of Nursing, Birmingham, AL USA
| | - Brian E. Kinard
- Department of Oral and Maxillofacial Surgery, Department of Orthodontics, University of Alabama at Birmingham School of Dentistry, 1919 7th Ave S, SDB 419, Birmingham, Alabama 35294-0007 USA
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13
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Saugel B, Annecke T, Bein B, Flick M, Goepfert M, Gruenewald M, Habicher M, Jungwirth B, Koch T, Kouz K, Meidert AS, Pestel G, Renner J, Sakka SG, Sander M, Treskatsch S, Zitzmann A, Reuter DA. Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies. J Clin Monit Comput 2024:10.1007/s10877-024-01132-7. [PMID: 38381359 DOI: 10.1007/s10877-024-01132-7] [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: 01/18/2024] [Accepted: 01/25/2024] [Indexed: 02/22/2024]
Abstract
Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).
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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.
| | - Thorsten Annecke
- Department of Anesthesiology and Intensive Care Medicine, Cologne Merheim Medical Center, Hospital of the University of Witten/Herdecke, Cologne, Germany
| | - Berthold Bein
- Department for Anaesthesiology, Asklepios Hospital Hamburg St. Georg, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Goepfert
- Department of Anaesthesiology and Intensive Care Medicine, Alexianer St. Hedwigkliniken Berlin, Berlin, Germany
| | - Matthias Gruenewald
- Department of Anaesthesiology and Intensive Care Medicine, Evangelisches Amalie Sieveking Krankenhaus, Hamburg, Germany
| | - Marit Habicher
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Bettina Jungwirth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Tilo Koch
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Agnes S Meidert
- Department of Anaesthesiology, University Hospital LMU Munich, Munich, Germany
| | - Gunther Pestel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jochen Renner
- Department of Anesthesiology and Intensive Care Medicine, Municipal Hospital Kiel, Kiel, Germany
| | - Samir G Sakka
- Department of Intensive Care Medicine, Gemeinschaftsklinikum Mittelrhein gGmbH, Academic Teaching Hospital of the Johannes Gutenberg University Mainz, Koblenz, Germany
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Amelie Zitzmann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
| | - Daniel A Reuter
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
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14
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Rennert WP, Smith M J, Cormier KA, Austin AE. Supportive Care of Hematopoietic Stem Cell Donors. Clin Hematol Int 2024; 6:43-50. [PMID: 38817695 PMCID: PMC11086998 DOI: 10.46989/001c.92460] [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: 10/05/2023] [Accepted: 10/21/2023] [Indexed: 06/01/2024] Open
Abstract
Supportive care needs for hematopoietic stem cell recipients have been studied. Less is known about the care needs of stem cell donors. Care challenges arise at donor selection, preparation for the donation, the donation procedure and the immediate and long-term after-care. Care needs were analyzed for 1,831 consecutive bone marrow and peripheral stem cell donors at MedStar Georgetown University Hospital between January 2018 and August 2023 in support of a review of the current literature. During the selection, related donors may experience psychological pressures affecting their motivation, while donation centers may be willing to accept co-morbidities in these donors which might preclude donation in unrelated peers. For bone marrow donations, it is important to select donors not only according to optimal genetic matching criteria but also according to suitable donor/recipient weight ratios, to facilitate sufficient stem cell yields. During the donation preparation phase, side effects and complications related to stem cell stimulation must be anticipated and managed for peripheral cell donors, while the pros and cons of autologous blood donation should be evaluated carefully for bone marrow donors. The stem cell donation procedure itself carries potential side effects and complications as well. Peripheral cell donors may require a central line and may encounter hypocalcemia, thrombocytopenia, and anemia. Bone marrow donors face risks associated with anesthesia, blood loss and pain. Post-procedure care focusses on pain management, blood cell recovery and the psychological support necessary to regain a high quality-of-life existence. Hematopoietic stem donors are giving part of themselves to save another's life. They deserve comprehensive supportive care to accompany them throughout the donation process.
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Affiliation(s)
- Wolfgang P Rennert
- Blood and Marrow Collection ProgramMedStar Georgetown University Hospital
| | - Jenna Smith M
- Blood and Marrow Collection ProgramMedStar Georgetown University Hospital
| | - Katie A Cormier
- Blood and Marrow Collection ProgramMedStar Georgetown University Hospital
| | - Anne E Austin
- Stem Cell Transplant and Cellular TherapyVanderbilt University Medical Center
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15
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Zhang K, Wang L, Qi F, Meng T. Hypotensive Levels on Endoscopic Sinus Surgery Visibility: A Randomized Non-Inferiority Trial. Laryngoscope 2024; 134:569-576. [PMID: 37449719 DOI: 10.1002/lary.30867] [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: 04/12/2023] [Revised: 06/02/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Optimization of endoscopic sinus surgery (ESS) conditions is a common focus of interest for otolaryngologists and anesthesiologists. Relying on hypotension alone to achieve a bloodless field may not without risks. We sought to determine whether ESS is feasible in the context of moderate hypotension. METHODS This randomized non-inferiority trial enrolled 96 adult patients who were to undergo ESS. The patients were divided into two groups: Controlled hypotension group (n = 48, MAP reduction to 55-65 mmHg, minimum of 60% of baseline blood pressure) or Individualized hypotension group (n = 48, MAP reduction to 75-80% of baseline blood pressure). All participants were placed in 10° reverse Trendelenburg position during ESS, and cottonoid patties dammed with epinephrine was recommended to clear the operative field of bleeding. The two groups were compared according to Boezaart grading scale (BS) score, estimated blood loss, blood loss rate, arterial lactate level and postoperative recovery. RESULTS Both levels of intraoperative hypotension (62.2 ± 2.3 mmHg vs. 74.0 ± 2.8 mmHg) provided acceptable surgical conditions with no difference in mean BS scores [2.00 (1.88-2.33) vs. 2.00 (1.85-2.45), p = 0.926]. The 95% CI for median value differences in mean BS scores is lower than the preset non-inferiority margin. There were no differences in blood loss rate and estimated blood loss between two groups (p > 0.05) Postoperative arterial lactate and Ramsay sedation scores were significantly different between the two groups (p < 0.05). CONCLUSIONS In ESS, both levels of intraoperative hypotension, combined with position adjustment and low-concentration adrenaline to constrict nasal mucosal blood vessels, provided acceptable surgical conditions. LEVEL OF EVIDENCE 2 Laryngoscope, 134:569-576, 2024.
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Affiliation(s)
- Kangda Zhang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Lichun Wang
- Department of Pain Management, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Feng Qi
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Tao Meng
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
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16
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Petkar S, Chakole V, Nisal R, Priya V. Cerebral Perfusion Unveiled: A Comprehensive Review of Blood Pressure Management in Neurosurgical and Endovascular Aneurysm Interventions. Cureus 2024; 16:e53635. [PMID: 38449959 PMCID: PMC10917124 DOI: 10.7759/cureus.53635] [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: 12/28/2023] [Accepted: 02/05/2024] [Indexed: 03/08/2024] Open
Abstract
This comprehensive review delves into the intricate dynamics of cerebral perfusion and blood pressure management within the context of neurosurgical and endovascular aneurysm interventions. The review highlights the critical role of maintaining a delicate hemodynamic balance, given the brain's susceptibility to fluctuations in blood pressure. Emphasizing the regulatory mechanisms of cerebral perfusion, particularly autoregulation, the study advocates for a nuanced and personalized approach to blood pressure control. Key findings underscore the significance of adhering to tailored blood pressure targets to mitigate the risks of ischemic and hemorrhagic complications in both neurosurgical and endovascular procedures. The implications for clinical practice are profound, calling for heightened awareness and precision in hemodynamic management. The review concludes with recommendations for future research, urging exploration into optimal blood pressure targets, advancements in monitoring technologies, investigations into long-term outcomes, and the development of personalized approaches. By consolidating current knowledge and charting a path for future investigations, this review aims to contribute to the continual enhancement of patient outcomes in the dynamic field of neurovascular interventions.
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Affiliation(s)
- Shubham Petkar
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vivek Chakole
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Roshan Nisal
- Anaesthesiology, awaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vishnu Priya
- Anaesthesiology, awaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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17
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Flick M, Hilty MP, Duranteau J, Saugel B. The microcirculation in perioperative medicine: a narrative review. Br J Anaesth 2024; 132:25-34. [PMID: 38030549 DOI: 10.1016/j.bja.2023.10.033] [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: 06/23/2023] [Revised: 09/25/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
The microcirculation describes the network of the smallest vessels in our cardiovascular system. On a microcirculatory level, oxygen delivery is determined by the flow of oxygen-carrying red blood cells in a given single capillary (capillary red blood cell flow) and the density of the capillary network in a given tissue volume (capillary vessel density). Handheld vital videomicroscopy enables visualisation of the capillary bed on the surface of organs and tissues but currently is only used for research. Measurements are generally possible on all organ surfaces but are most often performed in the sublingual area. In patients presenting for elective surgery, the sublingual microcirculation is usually intact and functional. Induction of general anaesthesia slightly decreases capillary red blood cell flow and increases capillary vessel density. During elective, even major, noncardiac surgery, the sublingual microcirculation is preserved and remains functional, presumably because elective noncardiac surgery is scheduled trauma and haemodynamic alterations are immediately treated by anaesthesiologists, usually restoring the macrocirculation before the microcirculation is substantially impaired. Additionally, surgery is regional trauma and thus likely causes regional, rather than systemic, impairment of the microcirculation. Whether or not the sublingual microcirculation is impaired after noncardiac surgery remains a subject of ongoing research. Similarly, it remains unclear if cardiac surgery, especially with cardiopulmonary bypass, impairs the sublingual microcirculation. The effects of therapeutic interventions specifically targeting the microcirculation remain to be elucidated and tested. Future research should focus on further improving microcirculation monitoring methods and investigating how regional microcirculation monitoring can inform clinical decision-making and treatment.
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Affiliation(s)
- Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - 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
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18
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Saugel B, Hoste E, Chew MS. A global perspective on acute kidney injury after major surgery: much needed insights and sobering results. Intensive Care Med 2023; 49:1508-1510. [PMID: 37906259 PMCID: PMC10709254 DOI: 10.1007/s00134-023-07250-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/07/2023] [Indexed: 11/02/2023]
Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Eric Hoste
- Intensive Care Unit, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Michelle S Chew
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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19
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Messina A, Cortegiani A, Romagnoli S, Sotgiu G, Piccioni F, Donadello K, Girardis M, Noto A, Maggiore SM, Antonelli M, Cecconi M. High versus standard blood pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: a study protocol for the HISTAP randomized clinical trial. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:50. [PMID: 38041208 PMCID: PMC10691117 DOI: 10.1186/s44158-023-00133-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/02/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND The intraoperative period is often characterized by hemodynamic instability, and intraoperative hypotension is a common complication. The optimal mean arterial pressure (MAP) target in hypertensive patients is still not clear. We hereby describe the protocol and detailed statistical analysis plan for the high versus standard blood pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: the HISTAP randomized clinical trial. The HISTAP trial aims at addressing whether the use of a higher intraoperative MAP target in high-risk hypertensive surgical patients scheduled for elective abdominal surgery would improve postoperative outcomes, as compared to the standard and recommended perioperative MAP, by using a composite outcome including a 30-day mortality from surgical intervention and at least one major organ dysfunction or new onset of sepsis and septic shock occurring 7 days after surgery. METHODS The HISTAP trial is an investigator-initiated, pragmatic, parallel-grouped, randomized, stratified, analyst-blinded trial with adequate allocation sequence generation, and allocation concealment. We will allocate 636 patients to a MAP target ≥ 80 mmHg (treatment group) or to a MAP target ≥65 mmHg (control group). The primary outcome is a composite outcome including a 30-day mortality from the operation and major organ complications. Secondary outcomes are mortality at 30 days, intensive care unit (ICU) length of stay, ICU readmission, Sequential Organ Failure Assessment (SOFA) scores recorded up to postoperative day 7, overall intraoperative fluid balance, vasopressors use, and the need for reoperation. An unadjusted χ2 test will be used for the primary outcome analysis. A Cox proportional hazards model will be used to adjust the association between the primary outcome and baseline covariates. CONCLUSIONS The HISTAP trial results will provide important evidence to guide clinicians' choice regarding the intraoperative MAP target in high-risk hypertensive patients scheduled for elective abdominal surgery.
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Affiliation(s)
- Antonio Messina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Moltancini 4, Pieve Emanuele (MI), 20072, Italy.
- IRCCS Humanitas Research Hospital, Department of Anesthesia and Intensive Care Medicine, Via Alessandro Manzoni, 56, Rozzano (MI), 20089, Italy.
| | - Andrea Cortegiani
- Department of Surgical Oncological and Oral Science, University of Palermo, Department of Anesthesia Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Federico Piccioni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Moltancini 4, Pieve Emanuele (MI), 20072, Italy
- IRCCS Humanitas Research Hospital, Department of Anesthesia and Intensive Care Medicine, Via Alessandro Manzoni, 56, Rozzano (MI), 20089, Italy
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynecology and Paediatrics, University of Verona, Verona, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
| | - Alberto Noto
- Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", Division of Anesthesia and Intensive Care, University of Messina, Policlinico "G. Martino", Messina, Italy
| | - Salvatore Maurizio Maggiore
- University of Chieti-Pescara and Clinical, Department of Anesthesia, Critical Care and Pain Medicine, SS. Annunziata Hospital, Chieti, Italy
| | - Massimo Antonelli
- Department of Emergency, Anesthesiology and Resuscitation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Moltancini 4, Pieve Emanuele (MI), 20072, Italy
- IRCCS Humanitas Research Hospital, Department of Anesthesia and Intensive Care Medicine, Via Alessandro Manzoni, 56, Rozzano (MI), 20089, Italy
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20
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Monge García MI, Jiménez López I, Lorente Olazábal JV, García López D, Fernández López AR, Pérez Carbonell A, Ripollés Melchor J. Postoperative arterial hypotension: the unnoticed enemy. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:575-579. [PMID: 37652202 DOI: 10.1016/j.redare.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 10/17/2022] [Indexed: 09/02/2023]
Abstract
Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.
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Affiliation(s)
- M I Monge García
- Hospital Universitario SAS Jerez, Jerez de la Frontera, Cádiz, Spain.
| | | | | | - D García López
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
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21
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Wolfskeil M, Bafort V, Besard M, Moerman A, De Hert S, Vanpeteghem C. Continuous Noninvasive Blood Pressure Measurement With "ClearSight" Compared to Standard Intermittent Blood Pressure Measurement in Patients With Peripheral Arterial Disease. Are Potential Differences Influenced by Phenylephrine or Dobutamine? J Cardiothorac Vasc Anesth 2023; 37:2470-2474. [PMID: 37657998 DOI: 10.1053/j.jvca.2023.08.004] [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: 05/20/2023] [Accepted: 08/06/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES To investigate the agreement between continuous noninvasive blood pressure measurement with the ClearSight system (cNIBP-CS) and standard intermittent noninvasive blood pressure measurement (iNIBP) in patients with peripheral arterial disease (PAD). Additionally, the influence of vasoactive medication on potential measurement differences was assessed. DESIGN A secondary analysis of a randomized controlled trial. SETTING At a university hospital. PARTICIPANTS Thirty-four patients with PAD undergoing percutaneous transluminal angioplasty of the lower limbs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Continuous noninvasive blood pressures were measured with the "ClearSight" system and compared to standard iNIBPs. Bland-Altman analysis revealed a mean bias of 13 mmHg (±15) between cNIBP-CS and iNIBP, with 95% limits of agreement (LOA) ranging from -17 to 42 mmHg. When comparing both medication groups, a similar mean bias was found for phenylephrine and dobutamine (12 mmHg [±13] and 13 mmHg [±13], respectively). CONCLUSION In this study, in patients with PAD, cNIBP-CS showed an underestimation of blood pressure compared to iNIBP in phenylephrine- and dobutamine-treated patients. Compared to previous studies, a larger bias and wider 95% LOA were found.
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Affiliation(s)
- Martha Wolfskeil
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium.
| | - Vincent Bafort
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Milan Besard
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Anneliese Moerman
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Stefan De Hert
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Caroline Vanpeteghem
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
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22
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Wang J, Liu Z, Bai Y, Tian G, Hong Y, Chen G, Wan Y, Liang H. Bibliometric and visual analysis of intraoperative hypotension from 2004 to 2022. Front Cardiovasc Med 2023; 10:1270694. [PMID: 38045917 PMCID: PMC10693423 DOI: 10.3389/fcvm.2023.1270694] [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: 08/01/2023] [Accepted: 11/06/2023] [Indexed: 12/05/2023] Open
Abstract
Background Intraoperative hypotension (IOH) is a common complication occurring in surgical practice. This study aims to comprehensively review the collaboration and impact of countries, institutions, authors, journals, keywords, and critical papers on intraoperative hypotension from the perspective of bibliometric, and to evaluate the evolution of knowledge structure clustering and identify research hotspots and emerging topics. Methods Articles and reviews related to IOH published from 2004 to 2022 were retrieved from the Web of Science Core Collection. Bibliometric analyses and visualization were conducted on Excel, CiteSpace, VOSviewer, and Bibliometrix (R-Tool of R-Studio). Results A total of 1,784 articles and reviews were included from 2004 to 2022. The number of articles on IOH gradually increased in the past few years, and peaked in 2021. These publications were chiefly from 1,938 institutions in 40 countries, led by America and China in publications. Sessler Daniel I published the most papers and enjoyed the highest number of citations. Analysis of the journals with the most outputs showed that most journals concentrated on perioperative medicine and clinical anesthesiology. Delirium, acute kidney injury and vasoconstrictor agents are the current and developing research hotspots. The keywords "Acute kidney injury", "postoperative complication", "machine learning", "risk factors" and "hemodynamic instability" may also become new trends and focuses of the near future research. Conclusion This study uses bibliometrics and visualization methods to comprehensively review the research on intraoperative hypotension, which is helpful for scholars to better understand the dynamic evolution of IOH and provide directions for future research.
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Affiliation(s)
- Jieyan Wang
- Department of Urology, People's Hospital of Longhua, Shenzhen, China
| | - Zile Liu
- College of Anesthesiology, Southern Medical University, Guangzhou, China
| | - Yawen Bai
- College of Anesthesiology, Southern Medical University, Guangzhou, China
| | - Guijie Tian
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, China
| | - Yinghao Hong
- Guangdong Provincial Key Laboratory of Proteomics, Department of Pathophysiology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Guo Chen
- Tendon and Injury Department, Sichuan Provincial Orthopedics Hospital, Sichuan, China
| | - Yantong Wan
- Guangdong Provincial Key Laboratory of Proteomics, Department of Pathophysiology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Hui Liang
- Department of Urology, People's Hospital of Longhua, Shenzhen, China
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23
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Patient Assessment. J Oral Maxillofac Surg 2023; 81:E13-E34. [PMID: 37833021 DOI: 10.1016/j.joms.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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24
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Douglas N, Leslie K, Darvall JN. Vasopressors to treat postoperative hypotension after adult noncardiac, non-obstetric surgery: a systematic review. Br J Anaesth 2023; 131:813-822. [PMID: 37778937 DOI: 10.1016/j.bja.2023.08.022] [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: 05/30/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Postoperative hypotension is common after major surgery and is associated with patient harm. Vasopressors are commonly used to treat hypotension without clear evidence of benefit. We conducted a systematic review to better understand the use, impact, and rationale for vasopressor administration after noncardiac, non-obstetric surgery in adults. METHODS We conducted a prospectively registered systematic review. Cochrane CENTRAL, EMBASE, MEDBASE, and MEDLINE were searched for RCTs and cohort studies of adult patients receiving vasopressors after noncardiac, non-obstetric surgery. Study quality was critically appraised by two investigators. Findings from the review were synthesised, but formal meta-analysis was not performed because of significant variability in study populations and outcomes. RESULTS A total of 3201 articles were screened, of which seven RCTs, two prospective cohort studies, and 15 retrospective cohort studies were included in the analysis (24 in total). One study was graded as high quality, two as moderate quality, and the remaining 21 as low quality. Sixteen studies relied on clinical assessment alone to decide on therapeutic interventions. Vasodilation was the most common suggested physiological disturbance. The median proportion of patients receiving vasopressors was 42% (interquartile range: 11.5-74.7%). Norepinephrine was the most common vasopressor used. CONCLUSIONS The evidence supporting the use of vasopressors to treat postoperative hypotension is limited. Future research should focus on whether vasodilatation or other physiological disturbance is driving postoperative hypotension to allow rational decision-making.
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Affiliation(s)
- Ned Douglas
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia.
| | - Kate Leslie
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - Jai N Darvall
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
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Elsherbiny M, Hasanin A, Kasem S, Abouzeid M, Mostafa M, Fouad A, Abdelwahab Y. Comparison of different ratios of propofol-ketamine admixture in rapid-sequence induction of anesthesia for emergency laparotomy: a randomized controlled trial. BMC Anesthesiol 2023; 23:329. [PMID: 37789329 PMCID: PMC10546635 DOI: 10.1186/s12871-023-02292-w] [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: 07/11/2023] [Accepted: 09/25/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND We aimed to compare the hemodynamic effect of two ratios of propofol and ketamine (ketofol), namely 1:1 and 1:3 ratios, in rapid-sequence induction of anesthesia for emergency laparotomy. METHODS This randomized controlled study included adult patients undergoing emergency laparotomy under general anesthesia. The patients were randomized to receive either ketofol ratio of 1:1 (n = 37) or ketofol ratio of 1:3 (n = 37). Hypotension (mean arterial pressure < 70 mmHg) was managed by 5-mcg norepinephrine. The primary outcome was total norepinephrine requirements during the postinduction period. Secondary outcomes included the incidence of postinduction hypotension, and the intubation condition (excellent, good, or poor). RESULTS Thirty-seven patients in the ketofol-1:1 and 35 patients in the ketofol 1:3 group were analyzed. The total norepinephrine requirement was less in the ketofol-1:1 group than in the ketofol-1:3 group, P-values: 0.043. The incidence of postinduction hypotension was less in the ketofol-1:1 group (4 [12%]) than in ketofol-1:3 group (12 [35%]), P-value 0.022. All the included patients had excellent intubation condition. CONCLUSION In patients undergoing emergency laparotomy, the use of ketofol in 1:1 ratio for rapid-sequence induction of anesthesia was associated with less incidence of postinduction hypotension and vasopressor consumption in comparison to the 1:3 ratio with comparable intubation conditions. CLINICAL TRIAL REGISTRATION NCT05166330. URL: https://clinicaltrials.gov/ct2/show/NCT05166330 .
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Affiliation(s)
- Mona Elsherbiny
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Sahar Kasem
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Abouzeid
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Fouad
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Yaser Abdelwahab
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
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26
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Thy SA, Johansen AO, Thy A, Sørensen HH, Mølgaard J, Foss NB, Toft P, Meyhoff CS, Aasvang EK. Associations between clinical interventions and transcutaneous blood gas values in postoperative patients. J Clin Monit Comput 2023; 37:1255-1264. [PMID: 36808596 DOI: 10.1007/s10877-023-00982-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/29/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE Postoperative monitoring of circulation and respiration is pivotal to guide intervention strategies and ensure patient outcomes. Transcutaneous blood gas monitoring (TCM) may allow for noninvasive assessment of changes in cardiopulmonary function after surgery, including a more direct assessment of local micro-perfusion and metabolism. To form the basis for studies assessing the clinical impact of TCM complication detection and goal-directed-therapy, we examined the association between clinical interventions in the postoperative period and changes in transcutaneous blood gasses. METHODS Two-hundred adult patients who have had major surgery were enrolled prospectively and monitored with transcutaneous blood gas measurements (oxygen (TcPO2) and carbon dioxide (TcPCO2)) for 2 h in the post anaesthesia care unit, with recording of all clinical interventions. The primary outcome was changes in TcPO2, secondarily TcPCO2, from 5 min before a clinical intervention versus 5 min after, analysed with paired t-test. RESULTS Data from 190 patients with 686 interventions were analysed. During clinical interventions, a mean change in TcPO2 of 0.99 mmHg (95% CI-1.79-0.2, p = 0.015) and TcPCO2 of-0.67 mmHg (95% CI 0.36-0.98, p < 0.001) was detected. CONCLUSION Clinical interventions resulted in significant changes in transcutaneous oxygen and carbon dioxide. These findings suggest future studies to assess the clinical value of changes in transcutaneous PO2 and PCO2 in a postoperative setting. TRIAL REGISTRY Clinical trial number: NCT04735380. CLINICAL TRIAL REGISTRY https://clinicaltrials.gov/ct2/show/NCT04735380.
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Affiliation(s)
- Sandra A Thy
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Anesthesiology, Odense University Hospital and Faculty of Health Science, University of Southern Denmark, Odense, Denmark.
| | - Andreas O Johansen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - André Thy
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Henrik H Sørensen
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jesper Mølgaard
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital-Amager and Hvidovre, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Palle Toft
- Department of Anesthesiology, Odense University Hospital and Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Eske K Aasvang
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kim S, Kwon S, Rudas A, Pal R, Markey MK, Bovik AC, Cannesson M. Machine Learning of Physiologic Waveforms and Electronic Health Record Data: A Large Perioperative Data Set of High-Fidelity Physiologic Waveforms. Crit Care Clin 2023; 39:675-687. [PMID: 37704333 DOI: 10.1016/j.ccc.2023.03.003] [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] [Indexed: 09/15/2023]
Abstract
Perioperative morbidity and mortality are significantly associated with both static and dynamic perioperative factors. The studies investigating static perioperative factors have been reported; however, there are a limited number of previous studies and data sets analyzing dynamic perioperative factors, including physiologic waveforms, despite its clinical importance. To fill the gap, the authors introduce a novel large size perioperative data set: Machine Learning Of physiologic waveforms and electronic health Record Data (MLORD) data set. They also provide a concise tutorial on machine learning to illustrate predictive models trained on complex and diverse structures in the MLORD data set.
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Affiliation(s)
- Sungsoo Kim
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; Department of Electrical & Computer Engineering, The University of Texas at Austin, Austin, TX, USA
| | - Sohee Kwon
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Akos Rudas
- Department of Computational Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Ravi Pal
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Mia K Markey
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX, USA
| | - Alan C Bovik
- Department of Electrical & Computer Engineering, The University of Texas at Austin, Austin, TX, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA.
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Hu JH, Xu N, Bian Z, Shi HJ, Ji FH, Peng K. Protocol for development and validation of a prediction model for post-induction hypotension in elderly patients undergoing non-cardiac surgery: a prospective cohort study. BMJ Open 2023; 13:e074181. [PMID: 37734882 PMCID: PMC10514608 DOI: 10.1136/bmjopen-2023-074181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/31/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION Post-induction hypotension (PIH) is a common event in elderly surgical patients and is associated with increased postoperative morbidity and mortality. This study aims to develop and validate a PIH prediction model for elderly patients undergoing elective non-cardiac surgery to identify potential PIH in advance and help to take preventive measures. METHODS AND ANALYSIS A total of 938 elderly surgical patients (n=657 for development and internal validation, n=281 for temporal validation) will be continuously recruited at The First Affiliated Hospital of Soochow University in Suzhou, China. The main outcome is PIH during the first 15 min after anaesthesia induction or before skin incision (whichever occurs first). We select candidate predictors based on published literature, professional knowledge and clinical expertise. For model development, we will use the least absolute shrinkage and selection operator regression analysis and multivariable logistic regression. For internal validation, we will apply the bootstrapping technique. After model development and internal validation, temporal validation will be conducted in patients recruited in another time period. We will use the discrimination, calibration and max-rescaled Brier score in the temporal validation cohort. Furthermore, the clinical utility of the prediction model will be assessed using the decision curve analysis, and the results will be presented in a nomogram and a web-based risk calculator. ETHICS AND DISSEMINATION Ethical approval was obtained from the Ethics Committee of the First Affiliated Hospital of Soochow University (Approval No. 2023-012). This PIH risk prediction model will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ChiCTR2200066201.
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Affiliation(s)
- Jing-Hui Hu
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Ning Xu
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Zhen Bian
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hai-Jing Shi
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Fu-Hai Ji
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Ke Peng
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
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29
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Kouz K, Weidemann F, Naebian A, Lohr A, Bergholz A, Thomsen KK, Krause L, Petzoldt M, Moll-Khosrawi P, Sessler DI, Flick M, Saugel B. Continuous Finger-cuff versus Intermittent Oscillometric Arterial Pressure Monitoring and Hypotension during Induction of Anesthesia and Noncardiac Surgery: The DETECT Randomized Trial. Anesthesiology 2023; 139:298-308. [PMID: 37265355 DOI: 10.1097/aln.0000000000004629] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Finger-cuff methods allow noninvasive continuous arterial pressure monitoring. This study aimed to determine whether continuous finger-cuff arterial pressure monitoring helps clinicians reduce hypotension within 15 min after starting induction of anesthesia and during noncardiac surgery. Specifically, this study tested the hypotheses that continuous finger-cuff-compared to intermittent oscillometric-arterial pressure monitoring helps clinicians reduce the area under a mean arterial pressure of 65 mmHg within 15 min after starting induction of anesthesia and the time-weighted average mean arterial pressure less than 65 mmHg during noncardiac surgery. METHODS In this single-center trial, 242 noncardiac surgery patients were randomized to unblinded continuous finger-cuff arterial pressure monitoring or to intermittent oscillometric arterial pressure monitoring (with blinded continuous finger-cuff arterial pressure monitoring). The first of two hierarchical primary endpoints was the area under a mean arterial pressure of 65 mmHg within 15 min after starting induction of anesthesia; the second primary endpoint was the time-weighted average mean arterial pressure less than 65 mmHg during surgery. RESULTS Within 15 min after starting induction of anesthesia, the median (interquartile range) area under a mean arterial pressure of 65 mmHg was 7 (0, 24) mmHg × min in 109 patients assigned to continuous finger-cuff monitoring versus 19 (0.3, 60) mmHg × min in 113 patients assigned to intermittent oscillometric monitoring (P = 0.004; estimated location shift: -6 [95% CI: -15 to -0.3] mmHg × min). During surgery, the median (interquartile range) time-weighted average mean arterial pressure less than 65 mmHg was 0.04 (0, 0.27) mmHg in 112 patients assigned to continuous finger-cuff monitoring and 0.40 (0.03, 1.74) mmHg in 115 patients assigned to intermittent oscillometric monitoring (P < 0.001; estimated location shift: -0.17 [95% CI: -0.41 to -0.05] mmHg). CONCLUSIONS Continuous finger-cuff arterial pressure monitoring helps clinicians reduce hypotension within 15 min after starting induction of anesthesia and during noncardiac surgery compared to intermittent oscillometric arterial pressure monitoring. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Weidemann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ashkan Naebian
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anneke Lohr
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Parisa Moll-Khosrawi
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; and Outcomes Research Consortium, Cleveland, Ohio
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Outcomes Research Consortium, Cleveland, Ohio
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Yildirim SA, Dogan L, Sarikaya ZT, Ulugol H, Gucyetmez B, Toraman F. Hypotension after Anesthesia Induction: Target-Controlled Infusion Versus Manual Anesthesia Induction of Propofol. J Clin Med 2023; 12:5280. [PMID: 37629322 PMCID: PMC10455971 DOI: 10.3390/jcm12165280] [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: 07/25/2023] [Revised: 08/11/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Post-induction hypotension frequently occurs and can lead to adverse outcomes. As target-controlled infusion (TCI) obviates the need to calculate the infusion rate manually and helps safer dosing with prompt titration of the drug using complex pharmacokinetic models, the use of TCI may provide a better hemodynamic profile during anesthesia induction. This study aimed to compare TCI versus manual induction and to determine the hemodynamic risk factors for post-induction hypotension. METHODS A total of 200 ASA grade 1-3 patients, aged 24 to 82 years, were recruited and randomly assigned to the TCI (n = 100) or manual induction groups (n = 100). Hemodynamic parameters were monitored with the pressure-recording analytic method. The propofol dosage was adjusted to keep the Bispectral Index between 40 and 60. RESULTS Post-induction hypotension was significantly higher in the manual induction group than in the TCI group (34% vs. 13%; p < 0.001, respectively). The propofol induction dose did not differ between the groups (TCI: 155 (135-180) mg; manual: 150 (120-200) mg; p = 0.719), but the induction time was significantly longer in the TCI group (47 (35-60) s vs. 150 (105-220) s; p < 0.001, respectively). In the multivariable Cox regression model, the presence of hypertension, stroke volume index (SVI), cardiac power output (CPO), and anesthesia induction method were found to predict post-induction hypotension (p = 0.032, p = 0.013, p = 0.024, and p = 0.015, respectively). CONCLUSION TCI induction with propofol provided better hemodynamic stability than manual induction, and the presence of hypertension, a decrease in the pre-induction SVI, and the CPO could predict post-induction hypotension.
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Affiliation(s)
- Serap Aktas Yildirim
- Department of Anesthesiology and Reanimation, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul 34752, Turkey; (Z.T.S.); (H.U.); (B.G.); (F.T.)
| | - Lerzan Dogan
- Acibadem Altunizade Hospital, Istanbul 34662, Turkey;
| | - Zeynep Tugce Sarikaya
- Department of Anesthesiology and Reanimation, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul 34752, Turkey; (Z.T.S.); (H.U.); (B.G.); (F.T.)
| | - Halim Ulugol
- Department of Anesthesiology and Reanimation, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul 34752, Turkey; (Z.T.S.); (H.U.); (B.G.); (F.T.)
| | - Bulent Gucyetmez
- Department of Anesthesiology and Reanimation, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul 34752, Turkey; (Z.T.S.); (H.U.); (B.G.); (F.T.)
| | - Fevzi Toraman
- Department of Anesthesiology and Reanimation, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul 34752, Turkey; (Z.T.S.); (H.U.); (B.G.); (F.T.)
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van Klei WA, Szabo MD, Hesterberg PE. Case 22-2023: A 59-Year-Old Woman with Hypotension and Electrocardiographic Changes. N Engl J Med 2023; 389:263-272. [PMID: 37467501 DOI: 10.1056/nejmcpc2300898] [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: 07/21/2023]
Affiliation(s)
- Wilton A van Klei
- From the Department of Anesthesia and Pain Management, Toronto General Hospital, and the Department of Anesthesia and Pain Medicine, University of Toronto - both in Toronto (W.A.K.); the Division of Anesthesiology, Intensive Care, and Emergency Medicine, University Medical Center Utrecht, the Netherlands (W.A.K.); and the Departments of Anesthesia, Critical Care, and Pain Medicine (M.D.S.) and Medicine (P.E.H.), Massachusetts General Hospital, and the Departments of Anesthesia, Critical Care, and Pain Medicine (M.D.S.) and Medicine (P.E.H.), Harvard Medical School - both in Boston
| | - Michele D Szabo
- From the Department of Anesthesia and Pain Management, Toronto General Hospital, and the Department of Anesthesia and Pain Medicine, University of Toronto - both in Toronto (W.A.K.); the Division of Anesthesiology, Intensive Care, and Emergency Medicine, University Medical Center Utrecht, the Netherlands (W.A.K.); and the Departments of Anesthesia, Critical Care, and Pain Medicine (M.D.S.) and Medicine (P.E.H.), Massachusetts General Hospital, and the Departments of Anesthesia, Critical Care, and Pain Medicine (M.D.S.) and Medicine (P.E.H.), Harvard Medical School - both in Boston
| | - Paul E Hesterberg
- From the Department of Anesthesia and Pain Management, Toronto General Hospital, and the Department of Anesthesia and Pain Medicine, University of Toronto - both in Toronto (W.A.K.); the Division of Anesthesiology, Intensive Care, and Emergency Medicine, University Medical Center Utrecht, the Netherlands (W.A.K.); and the Departments of Anesthesia, Critical Care, and Pain Medicine (M.D.S.) and Medicine (P.E.H.), Massachusetts General Hospital, and the Departments of Anesthesia, Critical Care, and Pain Medicine (M.D.S.) and Medicine (P.E.H.), Harvard Medical School - both in Boston
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Bergholz A, Greiwe G, Kouz K, Saugel B. Continuous Blood Pressure Monitoring in Patients Having Surgery: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1299. [PMID: 37512110 PMCID: PMC10385393 DOI: 10.3390/medicina59071299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/11/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
Hypotension can occur before, during, and after surgery and is associated with postoperative complications. Anesthesiologists should thus avoid profound and prolonged hypotension. A crucial part of avoiding hypotension is accurate and tight blood pressure monitoring. In this narrative review, we briefly describe methods for continuous blood pressure monitoring, discuss current evidence for continuous blood pressure monitoring in patients having surgery to reduce perioperative hypotension, and expand on future directions and innovations in this field. In summary, continuous blood pressure monitoring with arterial catheters or noninvasive sensors enables clinicians to detect and treat hypotension immediately. Furthermore, advanced hemodynamic monitoring technologies and artificial intelligence-in combination with continuous blood pressure monitoring-may help clinicians identify underlying causes of hypotension or even predict hypotension before it occurs.
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Affiliation(s)
- Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Gillis Greiwe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
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Kouz K, Monge García MI, Cerutti E, Lisanti I, Draisci G, Frassanito L, Sander M, Ali Akbari A, Frey UH, Grundmann CD, Davies SJ, Donati A, Ripolles-Melchor J, García-López D, Vojnar B, Gayat É, Noll E, Bramlage P, Saugel B. Intraoperative hypotension when using hypotension prediction index software during major noncardiac surgery: a European multicentre prospective observational registry (EU HYPROTECT). BJA OPEN 2023; 6:100140. [PMID: 37588176 PMCID: PMC10430826 DOI: 10.1016/j.bjao.2023.100140] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/19/2023] [Accepted: 03/28/2023] [Indexed: 08/18/2023]
Abstract
Background Intraoperative hypotension is associated with organ injury. Current intraoperative arterial pressure management is mainly reactive. Predictive haemodynamic monitoring may help clinicians reduce intraoperative hypotension. The Acumen™ Hypotension Prediction Index software (HPI-software) (Edwards Lifesciences, Irvine, CA, USA) was developed to predict hypotension. We built up the European multicentre, prospective, observational EU HYPROTECT Registry to describe the incidence, duration, and severity of intraoperative hypotension when using HPI-software monitoring in patients having noncardiac surgery. Methods We enrolled 749 patients having elective major noncardiac surgery in 12 medical centres in five European countries. Patients were monitored using the HPI-software. We quantified hypotension using the time-weighted average MAP <65 mm Hg (primary endpoint), the proportion of patients with at least one ≥1 min episode of a MAP <65 mm Hg, the number of ≥1 min episodes of a MAP <65 mm Hg, and duration patients spent below a MAP of 65 mm Hg. Results We included 702 patients in the final analysis. The median time-weighted average MAP <65 mm Hg was 0.03 (0.00-0.20) mm Hg. In addition, 285 patients (41%) had no ≥1 min episode of a MAP <65 mm Hg; 417 patients (59%) had at least one. The median number of ≥1 min episodes of a MAP <65 mm Hg was 1 (0-3). Patients spent a median of 2 (0-9) min below a MAP of 65 mm Hg. Conclusions The median time-weighted average MAP <65 mm Hg was very low in patients in this registry. This suggests that using HPI-software monitoring may help reduce the duration and severity of intraoperative hypotension in patients having noncardiac surgery.
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Elisabetta Cerutti
- Department of Anesthesia, Transplant and Surgical Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Ivana Lisanti
- Department of Anesthesia, Transplant and Surgical Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Gaetano Draisci
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Luciano Frassanito
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Amir Ali Akbari
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Ulrich H. Frey
- Department of Anesthesiology, Intensive Care, Pain and Palliative Care, Marien Hospital Herne, Ruhr-University Bochum, Bochum, Germany
| | - Carla Davina Grundmann
- Department of Anesthesiology, Intensive Care, Pain and Palliative Care, Marien Hospital Herne, Ruhr-University Bochum, Bochum, Germany
| | - Simon James Davies
- York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
- Centre for Health and Population Sciences, Hull York Medical School, York, UK
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Javier Ripolles-Melchor
- Anesthesia and Critical Care Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Daniel García-López
- Department of Anaesthesiology and Reanimation, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Benjamin Vojnar
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Étienne Gayat
- Université Paris Cité, INSERM, Paris, France
- Department of Anesthesia and Critical Care Medicine, Hôpital Lariboisière, Paris, France
| | - Eric Noll
- Department of Anesthesiology and Intensive Care, Hôpital de Hautepierre, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - 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
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Aktas Yildirim S, Sarikaya ZT, Dogan L, Ulugol H, Gucyetmez B, Toraman F. Arterial Elastance: A Predictor of Hypotension Due to Anesthesia Induction. J Clin Med 2023; 12:jcm12093155. [PMID: 37176595 PMCID: PMC10179039 DOI: 10.3390/jcm12093155] [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: 03/24/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Hypotension is common after anesthesia induction and may have adverse outcomes. The aim of this study was to investigate whether arterial elastance (Ea) is a predictor of post-induction hypotension. METHODS Between January and June 2022, the hemodynamic parameters of 85 patients who underwent major surgery under general anesthesia were prospectively evaluated. The noncalibrated pulse contour device MostCare (Vytech, Vygon, Padua, Italy) was used to measure hemodynamic parameters before and after anesthesia induction. The duration of the measurements was determined from one minute before induction to 10 min after induction. Hypotension was defined as a greater than 30% decrease in mean arterial pressure from the pre-induction value and/or systolic arterial pressure of less than 90 mmHg. The patients were divided into post-induction hypotension (-) and (+) groups. For the likelihood of post-induction hypotension, a multivariate regression model was used by adding significantly different pre-induction parameters to the post-induction hypotension group. RESULTS The incidence of post-induction hypotension was 37.6%. The cut-off value of the pre-induction Ea for the prediction of post-induction hypotension was ≥1.08 mmHg m-2mL-1 (0.71 [0.59-0.82]). In the multivariate regression model, the likelihood of postinduction hypotension was 3.5-fold (1.4-9.1), increased by only an Ea ≥ 1.08 mmHg m-2mL-1. CONCLUSION Pre-induction Ea showed excellent predictability of hypotension during anesthetic induction and identified patients at risk of general anesthesia induction-related hypotension.
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Affiliation(s)
- Serap Aktas Yildirim
- Department of Anesthesiology and Reanimation, School of Medicine, Acibadem Mehmet Ali Aydinlar University, 34752 Istanbul, Turkey
| | - Zeynep Tugce Sarikaya
- Department of Anesthesiology and Reanimation, School of Medicine, Acibadem Mehmet Ali Aydinlar University, 34752 Istanbul, Turkey
| | - Lerzan Dogan
- Department of Anesthesiology and Reanimation, Acibadem Altunizade Hospital, 34662 Istanbul, Turkey
| | - Halim Ulugol
- Department of Anesthesiology and Reanimation, School of Medicine, Acibadem Mehmet Ali Aydinlar University, 34752 Istanbul, Turkey
| | - Bulent Gucyetmez
- Department of Anesthesiology and Reanimation, School of Medicine, Acibadem Mehmet Ali Aydinlar University, 34752 Istanbul, Turkey
| | - Fevzi Toraman
- Department of Anesthesiology and Reanimation, School of Medicine, Acibadem Mehmet Ali Aydinlar University, 34752 Istanbul, Turkey
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Saugel B, Thomsen KK, Maheshwari K. Goal-directed haemodynamic therapy: an imprecise umbrella term to avoid. Br J Anaesth 2023; 130:390-393. [PMID: 36732140 DOI: 10.1016/j.bja.2022.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/30/2022] [Accepted: 12/31/2022] [Indexed: 02/04/2023] Open
Abstract
'Goal-directed haemodynamic therapy' describes various haemodynamic treatment strategies that have in common that interventions are titrated to achieve predefined haemodynamic targets. However, the treatment strategies differ substantially regarding the underlying haemodynamic target variables and target values, and thus presumably have different effects on outcome. It is an over-simplifying approach to lump complex and substantially differing haemodynamic treatment strategies together under the term 'goal-directed haemodynamic therapy', an imprecise umbrella term that we should thus stop using.
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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.
| | - Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamal Maheshwari
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
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Nordine M, Pille M, Kraemer J, Berger C, Brandhorst P, Kaeferstein P, Kopetsch R, Wessel N, Trauzeddel RF, Treskatsch S. Intraoperative Beat-to-Beat Pulse Transit Time (PTT) Monitoring via Non-Invasive Piezoelectric/Piezocapacitive Peripheral Sensors Can Predict Changes in Invasively Acquired Blood Pressure in High-Risk Surgical Patients. SENSORS (BASEL, SWITZERLAND) 2023; 23:3304. [PMID: 36992016 PMCID: PMC10059272 DOI: 10.3390/s23063304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/14/2023] [Accepted: 03/17/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Non-invasive tracking of beat-to-beat pulse transit time (PTT) via piezoelectric/piezocapacitive sensors (PES/PCS) may expand perioperative hemodynamic monitoring. This study evaluated the ability for PTT via PES/PCS to correlate with systolic, diastolic, and mean invasive blood pressure (SBPIBP, DBPIBP, and MAPIBP, respectively) and to detect SBPIBP fluctuations. METHODS PES/PCS and IBP measurements were performed in 20 patients undergoing abdominal, urological, and cardiac surgery. A Pearson's correlation analysis (r) between 1/PTT and IBP was performed. The predictive ability of 1/PTT with changes in SBPIBP was determined by area under the curve (reported as AUC, sensitivity, specificity). RESULTS Significant correlations between 1/PTT and SBPIBP were found for PES (r = 0.64) and PCS (r = 0.55) (p < 0.01), as well as MAPIBP/DBPIBP for PES (r = 0.6/0.55) and PCS (r = 0.5/0.45) (p < 0.05). A 7% decrease in 1/PTTPES predicted a 30% SBPIBP decrease (0.82, 0.76, 0.76), while a 5.6% increase predicted a 30% SBPIBP increase (0.75, 0.7, 0.68). A 6.6% decrease in 1/PTTPCS detected a 30% SBPIBP decrease (0.81, 0.72, 0.8), while a 4.8% 1/PTTPCS increase detected a 30% SBPIBP increase (0.73, 0.64, 0.68). CONCLUSIONS Non-invasive beat-to-beat PTT via PES/PCS demonstrated significant correlations with IBP and detected significant changes in SBPIBP. Thus, PES/PCS as a novel sensor technology may augment intraoperative hemodynamic monitoring during major surgery.
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Affiliation(s)
- Michael Nordine
- Department of Anesthesiology and Intensive Care Medicine, Hindenburgdamm 30, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 12203 Berlin, Germany; (M.N.)
| | - Marius Pille
- Berlin Institute of Health at Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Physics, Humboldt University zu Berlin, 10115 Berlin, Germany
| | - Jan Kraemer
- Department of Physics, Humboldt University zu Berlin, 10115 Berlin, Germany
| | - Christian Berger
- Department of Anesthesiology and Intensive Care Medicine, Hindenburgdamm 30, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 12203 Berlin, Germany; (M.N.)
| | - Philipp Brandhorst
- Department of Anesthesiology and Intensive Care Medicine, Hindenburgdamm 30, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 12203 Berlin, Germany; (M.N.)
| | | | | | - Niels Wessel
- Department of Physics, Humboldt University zu Berlin, 10115 Berlin, Germany
- Department of Human Medicine, MSB Medical School Berlin GmbH, 14197 Berlin, Germany
| | - Ralf Felix Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine, Hindenburgdamm 30, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 12203 Berlin, Germany; (M.N.)
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Hindenburgdamm 30, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 12203 Berlin, Germany; (M.N.)
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Kouz K, Brockmann L, Timmermann LM, Bergholz A, Flick M, Maheshwari K, Sessler DI, Krause L, Saugel B. Endotypes of intraoperative hypotension during major abdominal surgery: a retrospective machine learning analysis of an observational cohort study. Br J Anaesth 2023; 130:253-261. [PMID: 36526483 DOI: 10.1016/j.bja.2022.07.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 07/27/2022] [Accepted: 07/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intraoperative hypotension is associated with myocardial injury, acute kidney injury, and death. In routine practice, specific causes of intraoperative hypotension are often unclear. A more detailed understanding of underlying haemodynamic alterations of intraoperative hypotension may identify specific treatments. We thus aimed to use machine learning - specifically, hierarchical clustering - to identify underlying haemodynamic alterations causing intraoperative hypotension in major abdominal surgery patients. Specifically, we tested the hypothesis that there are distinct endotypes of intraoperative hypotension, which may help refine therapeutic interventions. METHODS We conducted a secondary analysis of intraoperative haemodynamic measurements from a prospective observational study in 100 patients who had major abdominal surgery under general anaesthesia. We used stroke volume index, heart rate, cardiac index, systemic vascular resistance index, and pulse pressure variation measurements. Intraoperative hypotension was defined as any mean arterial pressure ≤65 mm Hg or a mean arterial pressure between 66 and 75 mm Hg requiring a norepinephrine infusion rate exceeding 0.1 μg kg-1 min-1. To identify endotypes of intraoperative hypotension, we used hierarchical clustering (Ward's method). RESULTS A total of 615 episodes of intraoperative hypotension occurred in 82 patients (46 [56%] female; median age: 64 [57, 73] yr) who had surgery of a median duration of 270 (195, 335) min. Hierarchical clustering revealed six distinct intraoperative hypotension endotypes. Based on their clinical characteristics, we labelled these endotypes as (1) myocardial depression, (2) bradycardia, (3) vasodilation with cardiac index increase, (4) vasodilation without cardiac index increase, (5) hypovolaemia, and (6) mixed type. CONCLUSION Hierarchical clustering identified six endotypes of intraoperative hypotension. If validated, considering these intraoperative hypotension endotypes may enable causal treatment of intraoperative hypotension.
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lennart Brockmann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lea Malin Timmermann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - 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.
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Hypotension and Cardiac Surgical Outcomes: Reply. Anesthesiology 2023; 138:336-337. [PMID: 36652594 DOI: 10.1097/aln.0000000000004417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Fot EV, Smetkin AA, Volkov DA, Semenkova TN, Paromov KV, Kuzkov VV, Kirov MY. The Validation of Cardiac Index and Stroke-Volume Variation Measured by the Pulse-Wave Transit Time-Analysis Versus Conventional Pulse-Contour Analysis After Off-Pump Coronary Artery Bypass Grafting: Observational Study. J Cardiothorac Vasc Anesth 2023; 37:919-926. [PMID: 36878818 DOI: 10.1053/j.jvca.2023.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
OBJECTIVE To compare the reliability of cardiac index (CI) and stroke-volume variation (SVV) measured by the pulse-wave transit-time (PWTT) method using estimated continuous cardiac output (esCCO) technique with conventional pulse-contour analysis after off-pump coronary artery bypass grafting (OPCAB). DESIGN A single-center, prospective, observational study. SETTING At a 1,000-bed university hospital. PARTICIPANTS A total of 21 patients were enrolled after elective OPCAB. INTERVENTIONS The study authors performed a method comparison study with simultaneous measurement of CI and SVV based on the esCCO technique (CIesCCO and esSVV, correspondingly) and pulse-contour analysis (CIPCA and SVVPCA, correspondingly). As a secondary analysis, they also assessed the trending ability of CIesCCO versus CIPCA. MEASUREMENTS AND MAIN RESULTS: The authors analyzed 178 measurement pairs for CI, and 174 pairs for SVV during the 10 study stages. The mean bias between CIesCCO and CIPCA was 0.06 L min/m2, with limits of agreement of ± 0.92 L min/m2 and a percentage error (PE) of 35.3%. The analysis of the trending ability of CI measured by PWTT revealed a concordance rate of 70%. The mean bias between esSVV and SVVPCA was -6.1%, with limits of agreement of ± 15.5% and a PE of 137%. CONCLUSIONS The overall performance of CIesCCO and esSVV versus CIPCA and SVVPCA is not clinically acceptable. A further improvement of the PWTT algorithm may be required for an accurate and precise assessment of CI and SVV.
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Affiliation(s)
- Evgeniia V Fot
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia; Department of Anesthesiology and Intensive Care Medicine, City Hospital #1 n.a. E.E. Volosevich, Arkhangelsk, Russia.
| | - Alexey A Smetkin
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia; Department of Anesthesiology and Intensive Care Medicine, City Hospital #1 n.a. E.E. Volosevich, Arkhangelsk, Russia
| | - Dmitriy A Volkov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia; Department of Anesthesiology and Intensive Care Medicine, City Hospital #1 n.a. E.E. Volosevich, Arkhangelsk, Russia
| | - Tatyana N Semenkova
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia; Department of Anesthesiology and Intensive Care Medicine, City Hospital #1 n.a. E.E. Volosevich, Arkhangelsk, Russia
| | - Konstantin V Paromov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Vsevolod V Kuzkov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia; Department of Anesthesiology and Intensive Care Medicine, City Hospital #1 n.a. E.E. Volosevich, Arkhangelsk, Russia
| | - Mikhail Y Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia; Department of Anesthesiology and Intensive Care Medicine, City Hospital #1 n.a. E.E. Volosevich, Arkhangelsk, Russia
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Monaghan R, Hoey M, Lavelle A. The effect of overlapping surgical scheduling on operating theatre productivity. Anaesthesia 2023; 78:264-265. [PMID: 36256735 DOI: 10.1111/anae.15893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 01/11/2023]
Affiliation(s)
| | - M Hoey
- Saint James's Hospital, Dublin, Ireland
| | - A Lavelle
- Saint James's Hospital, Dublin, Ireland
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Volcheck GW, Melchiors BB, Farooque S, Gonzalez-Estrada A, Mertes PM, Savic L, Tacquard C, Garvey LH. Perioperative Hypersensitivity Evaluation and Management: A Practical Approach. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:382-392. [PMID: 36436761 DOI: 10.1016/j.jaip.2022.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/04/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022]
Abstract
Perioperative hypersensitivity (POH) is an uncommon, potentially life-threatening event. Identification of POH can be difficult given the lack of familiarity, physiological effects of anesthesia, draping of the patient during surgery, and potential nonimmunological factors contributing to signs and symptoms. Given the unique nature and large number of medications administered in the perioperative setting, evaluation of POH can be challenging. In this paper, we present a practical approach to management with an emphasis on understanding what happens in the operating room, the overlap of signs and symptoms between nonimmunological and immunological reactions, acute management, and subsequent evaluation. In addition, we provide a strategy for further review of an initially negative evaluation and emphasize the importance of establishing management plans for the patient as well as providing recommendations to the medical, anesthesia, and surgical teams for future surgeries. A critical factor for successful management at all points in the process is a close collaboration between the anesthesia and the allergy teams.
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Affiliation(s)
- Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn.
| | | | - Sophie Farooque
- Frankland Allergy Clinic, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London, UK
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Paul Michel Mertes
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Charles Tacquard
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Schnetz MP, Danks DJ, Mahajan A. Preoperative Identification of Patient-Dependent Blood Pressure Targets Associated With Low Risk of Intraoperative Hypotension During Noncardiac Surgery. Anesth Analg 2023; 136:194-203. [PMID: 36399417 PMCID: PMC9812417 DOI: 10.1213/ane.0000000000006238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intraoperative hypotension (IOH) is strongly linked to organ system injuries and postoperative death. Blood pressure itself is a powerful predictor of IOH; however, it is unclear which pressures carry the lowest risk and may be leveraged to prevent subsequent hypotension. Our objective was to develop a model that predicts, before surgery and according to a patient's unique characteristics, which intraoperative mean arterial pressures (MAPs) between 65 and 100 mm Hg have a low risk of IOH, defined as an MAP <65 mm Hg, and may serve as testable hemodynamic targets to prevent IOH. METHODS Adult, noncardiac surgeries under general anesthesia at 2 tertiary care hospitals of the University of Pittsburgh Medical Center were divided into training and validation cohorts, then assigned into smaller subgroups according to preoperative risk factors. Primary outcome was hypotension risk, defined for each intraoperative MAP value from 65 to 100 mm Hg as the proportion of a value's total measurements followed by at least 1 MAP <65 mm Hg within 5 or 10 minutes, and calculated for all values in each subgroup. Five models depicting MAP-associated IOH risk were compared according to best fit across subgroups with proportions whose confidence interval was <0.05. For the best fitting model, (1) performance was validated, (2) low-risk MAP targets were identified according to applied benchmarks, and (3) preoperative risk factors were evaluated as predictors of model parameters. RESULTS A total of 166,091 surgeries were included, with 121,032 and 45,059 surgeries containing 5.4 million and 1.9 million MAP measurements included in the training and validation sets, respectively. Thirty-six subgroups with at least 21 eligible proportions (confidence interval <0.05) were identified, representing 92% and 94% of available MAP measurements, respectively. The exponential with theta constant model demonstrated the best fit (weighted sum of squared error 0.0005), and the mean squared error of hypotension risk per MAP did not exceed 0.01% in validation testing. MAP targets ranged between 69 and 90 mm Hg depending on the subgroup and benchmark used. Increased age, higher American Society of Anesthesiologists physical status, and female sexindependently predicted ( P < .05) hypotension risk curves with less rapid decay and higher plateaus. CONCLUSIONS We demonstrate that IOH risk specific to a given MAP is patient-dependent, but predictable before surgery. Our model can identify intraoperative MAP targets before surgery predicted to reduce a patient's exposure to IOH, potentially allowing clinicians to develop more personalized approaches for managing hemodynamics.
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Affiliation(s)
- Michael P. Schnetz
- From the Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David J. Danks
- Departments of Philosophy and Psychology, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Aman Mahajan
- From the Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
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Surgical Pharmacy for Optimizing Medication Therapy Management Services within Enhanced Recovery after Surgery (ERAS ®) Programs. J Clin Med 2023; 12:jcm12020631. [PMID: 36675560 PMCID: PMC9861533 DOI: 10.3390/jcm12020631] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/16/2022] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
Drug-related problems (DRPs) are common among surgical patients, especially older patients with polypharmacy and underlying diseases. DRPs can potentially lead to morbidity, mortality, and increased treatment costs. The enhanced recovery after surgery (ERAS) system has shown great advantages in managing surgical patients. Medication therapy management for surgical patients (established as "surgical pharmacy" by Guangdong Province Pharmaceutical Association (GDPA)) is an important part of the ERAS system. Improper medication therapy management can lead to serious consequences and even death. In order to reduce DRPs further, and promote the rapid recovery of surgical patients, the need for pharmacists in the ERAS program is even more pressing. However, the medication therapy management services of surgical pharmacy and how surgical pharmacists should participate in ERAS programs are still unclear worldwide. Therefore, this article reviews the main perioperative medical management strategies and precautions from several aspects, including antimicrobial agents, antithrombotic agents, pain medication, nutritional therapy, blood glucose monitoring, blood pressure treatment, fluid management, treatment of nausea and vomiting, and management of postoperative delirium. Additionally, the way surgical pharmacists participate in perioperative medication management, and the relevant medication pathways are explored for optimizing medication therapy management services within the ERAS programs. This study will greatly assist surgical pharmacists' work, contributing to surgeons accepting that pharmacists have an important role in the multidisciplinary team, benefitting medical workers in treating, counseling, and advocating for their patients, and further improving the effectiveness, safety and economy of medication therapy for patients and promoting patient recovery.
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Nycz BT, Chalhoub A, Patel GP, Dean CE, Papangelou A. Hemispheric Asymmetry on the Electroencephalogram during General Anesthesia Responsive to Blood Pressure Manipulations. Neurol Int 2022; 14:1018-1023. [PMID: 36548186 PMCID: PMC9782369 DOI: 10.3390/neurolint14040081] [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: 11/17/2022] [Revised: 12/03/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
The electroencephalogram (EEG) has been extensively used to detect ischemia and the need for shunting during carotid endarterectomy. Limited literature exists using EEG data to detect ischemia in other surgeries. This case report depicts a 65-year-old man, with extensive vascular history including complete left carotid occlusion and severe right carotid stenosis, who presented for left first rib resection and left subclavian vein balloon angioplasty. Following induction of general anesthesia, frontal EEG (SedLine; Masimo Corporation, Irvine, CA, USA) demonstrated hemispheric asymmetry, which nearly resolved with vasoactive support. At three distinct periods, discordance reoccurred necessitating a higher mean arterial pressure threshold. This case demonstrates EEG patterns concerning for focal spectrographic ischemia and highlights the potential use of EEG signals to capture hypoperfusion and direct vasoactive therapy.
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Deng Z, Zhang Y, Zhang Q, Li X, Zeng W, Jun C, Yuan D. Function of connexin 43 and RhoA/LIMK2/Cofilin signaling pathway in transient changes of contraction and dilation of human umbilical arterial smooth muscle cells. Int J Biochem Cell Biol 2022; 153:106326. [DOI: 10.1016/j.biocel.2022.106326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
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The Impact of Individualized Hemodynamic Management on Intraoperative Fluid Balance and Hemodynamic Interventions during Spine Surgery in the Prone Position: A Prospective Randomized Trial. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58111683. [PMID: 36422222 PMCID: PMC9698539 DOI: 10.3390/medicina58111683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/07/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
Background and Objectives: The effect of individualized hemodynamic management on the intraoperative use of fluids and other hemodynamic interventions in patients undergoing spinal surgery in the prone position is controversial. This study aimed to evaluate how the use of individualized hemodynamic management based on extended continuous non-invasive hemodynamic monitoring modifies intraoperative hemodynamic interventions compared to conventional hemodynamic monitoring with intermittent non-invasive blood pressure measurements. Methods: Fifty adult patients (American Society of Anesthesiologists physical status I−III) who underwent spinal procedures in the prone position and were then managed with a restrictive fluid strategy were prospectively randomized into intervention and control groups. In the intervention group, individualized hemodynamic management followed a goal-directed protocol based on continuously non-invasively measured blood pressure, heart rate, cardiac output, systemic vascular resistance, and stroke volume variation. In the control group, patients were monitored using intermittent non-invasive blood pressure monitoring, and the choice of hemodynamic intervention was left to the discretion of the attending anesthesiologist. Results: In the intervention group, more hypotensive episodes (3 (2−4) vs. 1 (0−2), p = 0.0001), higher intraoperative dose of ephedrine (0 (0−10) vs. 0 (0−0) mg, p = 0.0008), and more positive fluid balance (680 (510−937) vs. 270 (196−377) ml, p < 0.0001) were recorded. Intraoperative norepinephrine dose and postoperative outcomes did not differ between the groups. Conclusions: Individualized hemodynamic management based on data from extended non-invasive hemodynamic monitoring significantly modified intraoperative hemodynamic management and was associated with a higher number of hemodynamic interventions and a more positive fluid balance.
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Bergholz A, Meidert AS, Flick M, Krause L, Vettorazzi E, Zapf A, Brunkhorst FM, Meybohm P, Zacharowski K, Zarbock A, Sessler DI, Kouz K, Saugel B. Effect of personalized perioperative blood pressure management on postoperative complications and mortality in high-risk patients having major abdominal surgery: protocol for a multicenter randomized trial (IMPROVE-multi). Trials 2022; 23:946. [PMID: 36397173 PMCID: PMC9670085 DOI: 10.1186/s13063-022-06854-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intraoperative hypotension is common in patients having non-cardiac surgery and is associated with serious complications and death. However, optimal intraoperative blood pressures for individual patients remain unknown. We therefore aim to test the hypothesis that personalized perioperative blood pressure management-based on preoperative automated blood pressure monitoring-reduces the incidence of a composite outcome of acute kidney injury, acute myocardial injury, non-fatal cardiac arrest, and death within 7 days after surgery compared to routine blood pressure management in high-risk patients having major abdominal surgery. METHODS IMPROVE-multi is a multicenter randomized trial in 1272 high-risk patients having elective major abdominal surgery that we plan to conduct at 16 German university medical centers. Preoperative automated blood pressure monitoring using upper arm cuff oscillometry will be performed in all patients for one night to obtain the mean of the nighttime mean arterial pressures. Patients will then be randomized either to personalized blood pressure management or to routine blood pressure management. In patients assigned to personalized management, intraoperative mean arterial pressure will be maintained at least at the mean of the nighttime mean arterial pressures. In patients assigned to routine management, intraoperative blood pressure will be managed per routine. The primary outcome will be a composite of acute kidney injury, acute myocardial injury, non-fatal cardiac arrest, and death within 7 days after surgery. DISCUSSION Our trial will determine whether personalized perioperative blood pressure management reduces the incidence of major postoperative complications and death within 7 days after surgery compared to routine blood pressure management in high-risk patients having major abdominal surgery. TRIAL REGISTRATION ClinicalTrials.gov NCT05416944. Registered on June 14, 2022.
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Affiliation(s)
- Alina Bergholz
- grid.13648.380000 0001 2180 3484Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Agnes S. Meidert
- grid.411095.80000 0004 0477 2585Department of Anaesthesiology, University Hospital LMU Munich, Munich, Germany
| | - Moritz Flick
- grid.13648.380000 0001 2180 3484Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Linda Krause
- grid.13648.380000 0001 2180 3484Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- grid.13648.380000 0001 2180 3484Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Antonia Zapf
- grid.13648.380000 0001 2180 3484Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank M. Brunkhorst
- grid.275559.90000 0000 8517 6224Center for Clinical Studies, Jena University Hospital, Jena, Germany ,grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Patrick Meybohm
- grid.411760.50000 0001 1378 7891Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Kai Zacharowski
- grid.411088.40000 0004 0578 8220Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Alexander Zarbock
- grid.16149.3b0000 0004 0551 4246Department of Anesthesiology, Intensive Care, and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel I. Sessler
- grid.239578.20000 0001 0675 4725Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH USA ,grid.512286.aOutcomes Research Consortium, Cleveland, OH USA
| | - Karim Kouz
- grid.13648.380000 0001 2180 3484Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. .,Outcomes Research Consortium, Cleveland, OH, USA.
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Lin D, Madhok J, Bouhenguel J, Mihm F. Pheochromocytoma crisis precipitated by dexamethasone with profound lactic acidosis, but without severe hypertension. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0306. [PMID: 36511456 PMCID: PMC9716360 DOI: 10.1530/edm-22-0306] [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: 09/08/2022] [Accepted: 10/27/2022] [Indexed: 12/13/2022] Open
Abstract
Summary We describe a case of a 47-year-old patient who presented with severe lactic acidosis, troponinemia, and acute kidney injury after receiving 8 mg of intramuscular dexamethasone for seasonal allergies in the setting of an undiagnosed epinephrine-secreting pheochromocytoma. This case was atypical, however, in that the patient exhibited only mildly elevated noninvasive measured blood pressures. Following a period of alpha-adrenergic blockade, the tumor was resected successfully. Steroid administration can precipitate pheochromocytoma crisis that may present unusually as in our patient with mild hypertension but profound lactic acidosis. Learning points Steroids administered via any route can precipitate pheochromocytoma crisis, manifested by excessive catecholamine secretion and associated sequelae from vasoconstriction. Lack of moderate/severe hypertension on presentation detracts from consideration of pheochromocytoma as a diagnosis. Lactatemia after steroid administration should prompt work-up for pheochromocytoma, as it can be seen in epinephrine-secreting tumors. Noninvasive blood pressure measurements may be unreliable during pheochromocytoma crisis due to excessive peripheral vasoconstriction.
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Affiliation(s)
- David Lin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jai Madhok
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jason Bouhenguel
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Frederick Mihm
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Pinsky MR, Cecconi M, Chew MS, De Backer D, Douglas I, Edwards M, Hamzaoui O, Hernandez G, Martin G, Monnet X, Saugel B, Scheeren TWL, Teboul JL, Vincent JL. Effective hemodynamic monitoring. Crit Care 2022; 26:294. [PMID: 36171594 PMCID: PMC9520790 DOI: 10.1186/s13054-022-04173-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractHemodynamic monitoring is the centerpiece of patient monitoring in acute care settings. Its effectiveness in terms of improved patient outcomes is difficult to quantify. This review focused on effectiveness of monitoring-linked resuscitation strategies from: (1) process-specific monitoring that allows for non-specific prevention of new onset cardiovascular insufficiency (CVI) in perioperative care. Such goal-directed therapy is associated with decreased perioperative complications and length of stay in high-risk surgery patients. (2) Patient-specific personalized resuscitation approaches for CVI. These approaches including dynamic measures to define volume responsiveness and vasomotor tone, limiting less fluid administration and vasopressor duration, reduced length of care. (3) Hemodynamic monitoring to predict future CVI using machine learning approaches. These approaches presently focus on predicting hypotension. Future clinical trials assessing hemodynamic monitoring need to focus on process-specific monitoring based on modifying therapeutic interventions known to improve patient-centered outcomes.
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Hypotension Prediction Index Software to Prevent Intraoperative Hypotension during Major Non-Cardiac Surgery: Protocol for a European Multicenter Prospective Observational Registry (EU-HYPROTECT). J Clin Med 2022; 11:jcm11195585. [PMID: 36233455 PMCID: PMC9571548 DOI: 10.3390/jcm11195585] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/17/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Intraoperative hypotension is common in patients having non-cardiac surgery and associated with postoperative acute myocardial injury, acute kidney injury, and mortality. Avoiding intraoperative hypotension is a complex task for anesthesiologists. Using artificial intelligence to predict hypotension from clinical and hemodynamic data is an innovative and intriguing approach. The AcumenTM Hypotension Prediction Index (HPI) software (Edwards Lifesciences; Irvine, CA, USA) was developed using artificial intelligence—specifically machine learning—and predicts hypotension from blood pressure waveform features. We aimed to describe the incidence, duration, severity, and causes of intraoperative hypotension when using HPI monitoring in patients having elective major non-cardiac surgery. Methods: We built up a European, multicenter, prospective, observational registry including at least 700 evaluable patients from five European countries. The registry includes consenting adults (≥18 years) who were scheduled for elective major non-cardiac surgery under general anesthesia that was expected to last at least 120 min and in whom arterial catheter placement and HPI monitoring was planned. The major objectives are to quantify and characterize intraoperative hypotension (defined as a mean arterial pressure [MAP] < 65 mmHg) when using HPI monitoring. This includes the time-weighted average (TWA) MAP < 65 mmHg, area under a MAP of 65 mmHg, the number of episodes of a MAP < 65 mmHg, the proportion of patients with at least one episode (1 min or more) of a MAP < 65 mmHg, and the absolute maximum decrease below a MAP of 65 mmHg. In addition, we will assess causes of intraoperative hypotension and investigate associations between intraoperative hypotension and postoperative outcomes. Discussion: There are only sparse data on the effect of using HPI monitoring on intraoperative hypotension in patients having elective major non-cardiac surgery. Therefore, we built up a European, multicenter, prospective, observational registry to describe the incidence, duration, severity, and causes of intraoperative hypotension when using HPI monitoring in patients having elective major non-cardiac surgery.
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