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Tsukimoto S, Kitaura A, Yamamoto R, Hirase C, Nakao S, Nakajima Y, Sanuki T. Comparative Analysis of the Hemodynamic Effects of Remimazolam and Propofol During General Anesthesia: A Retrospective Study. Cureus 2024; 16:e58340. [PMID: 38752064 PMCID: PMC11095992 DOI: 10.7759/cureus.58340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 05/18/2024] Open
Abstract
PURPOSE Hypotension is common during anesthesia induction. However, minimal hemodynamic effects of remimazolam anesthesia have been reported. We hypothesized that remimazolam would have weaker hemodynamic effects than would propofol. To test this, we simultaneously evaluated the hemodynamics using the estimated continuous cardiac output (esCCO) system and heart rate variability (HRV) during anesthesia induction. METHODS This was a single-center, observational, retrospective study of patients undergoing dental surgery under general anesthesia between 2020 and 2022. Seventy patients were divided into two groups: remimazolam (R group; n=34) and propofol (P group; n=36). The information obtained from the anesthesia records, patient information, esCCO system parameters, and HRV were integrated and analyzed. The percentages of various parameters were set to 100% for the pre-induction phase as the baseline. RESULTS The %MAP (noninvasive mean arterial blood pressure) decreased over a narrower range in the R compared to the P group (-17.8% (-26.3%, -11.9%) vs. -22.6% (-32.9%, -17.0%); P=0.039). The %HR (heart rate) increased significantly in the R group and decreased in the P group (+10.7% (+6.5%, +18.6%) vs. -6.5% (-14.5%, +8.4%); P<0.01). The %SVesCCO (stroke volume calculated using the esCCO system) decreased significantly in both groups, but the R group showed a smaller difference compared to the P group (- 5.1% (-7.7%, -2.1%) vs. -10.0% (-13.8%, -5.6%); P<0.01). The rates of change in %LF nu (normalized unit of low frequency) and %HF nu (normalized unit of high frequency) were lower for the R than for the P group, although the difference was not significant (+6.8% (-14.5%, 32.4%) vs. +9.2% (-7.2%, +59.7%), P=0.30; +7.9% (-51.0%, +66.9%) vs. +22.8% (-26.1%, +61.6%), P=0.57). CONCLUSION Remimazolam demonstrated a lower MAP reduction rate than propofol. A compensatory increase in HR occurred with a decrease in stroke volume. However, the HR increase was not attributable to the autonomic nervous system.
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Affiliation(s)
- Shota Tsukimoto
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| | | | - Rina Yamamoto
- Department of Anesthesiology, Kindai University, Osaka, JPN
| | | | - Shinichi Nakao
- Perioperative Management Center, Okanami General Hospital, Mie, JPN
| | | | - Takuro Sanuki
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
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Lan H, Cao H, Liu S, Gong X, Huang X, Rong H, Xu B, Chen H, Jiao Z, Lin Y, Guan X. Efficacy of remimazolam tosilate versus propofol for total intravenous anaesthesia in urological surgery: A randomised clinical trial. Eur J Anaesthesiol 2024; 41:208-216. [PMID: 38165145 DOI: 10.1097/eja.0000000000001938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Remimazolam is a novel ultra-short-acting benzodiazepine sedative that acts on the gamma-aminobutyric acid type A receptor (GABAAR). OBJECTIVE To compare the efficacies of remimazolam (RMZ), and propofol (PROP) combined with remifentanil and cisatracurium for total intravenous anaesthesia (TIVA) in patients undergoing urological surgery. DESIGN A prospective, single-blind, randomised, noninferiority clinical trial. SETTING Single centre from 1 January 2022 to 30 March 2022. PATIENTS A total of 146 adult patients undergoing elective urological surgery. INTERVENTION Patients were randomly allocated in a 1 : 1 ratio to the PROP or RMZ groups. In the PROP group, anaesthesia was induced with propofol at 100 mg min -1 to reach a bispectral index score (BIS) of 40 to 60. After loss of consciousness (LOC), intravenous fentanyl 3 μg kg -1 was administered, followed by cisatracurium 0.3 mg kg -1 . Patients were intubated 3 min after cisatracurium administration. Anaesthesia was maintained with the combination of propofol (plasma concentration: 2.5 to 4 μg ml -1 ) and remifentanil (plasma concentration: 2.5 to 4 ng ml -1 ). In the RMZ group, anaesthesia was induced with remimazolam tosilate starting at 10 mg kg -1 h -1 to reach a BIS of 40 to 60 and maintained between 0.2 and 2 mg kg -1 h -1 . After LOC, fentanyl and cisatracurium were administered and intubation was performed as in the PROP group. Anaesthesia was maintained with a combination of remimazolam (0.2 to 2 mg kg -1 h -1 ) and remifentanil (plasma concentration: 2.5 to 4 ng ml -1 ). MAIN OUTCOME MEASURES The primary outcome was the TIVA success rate. The predefined noninferiority margin considered an absolute difference of 6% in the primary outcome between the groups. The secondary outcomes were vital signs, anaesthesia and surgery characteristics, and adverse events. RESULTS All patients completed the trial. The success rates of TIVA with remimazolam and propofol were 100 and 98.6%, respectively. The incidence of hypotension during anaesthesia was lower in the RMZ group (26%) than in the PROP group (46.6%) ( P = 0.016). The median [IQR] total consumption of ephedrine during anaesthesia was higher in the PROP group 10 [0 to 12.5] mg than in the RMZ group 0 [0 to 10] mg ( P = 0.0002). The incidence of injection pain was significantly higher in the PROP group (76.7%) than in the RMZ group (0; P < 0.001). No significant differences in the controllability of the anaesthesia depth, anaesthesia and surgery characteristics, or vital signs were observed between the groups. CONCLUSION Remimazolam demonstrated noninferior efficacy to propofol combined with remifentanil and cisatracurium for TIVA in patients undergoing urological surgery. TRIAL REGISTRATION Chictr.org.cn, identifier: ChiCTR2100050923. CLINICAL REGISTRATION The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100050923, Principal investigator: Xuehai Guan, Date of registration: 8 November 2021, https://www.chictr.org.cn/showproj.html?proj=133466 ).
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Affiliation(s)
- Hongmeng Lan
- From the Department of Anaesthesiology, The First Affiliated Hospital of Guangxi Medical University (HL, HC, SL, XG, XH, HR, ZJ, YL, XG), Department of Rehabilitation, People's Hospital of Guangxi Zhuang Autonomous Region (BX) and Department of Rehabilitation, The First Affiliated Hospital of Guangxi Medical University (HC)
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Szrama J, Gradys A, Bartkowiak T, Woźniak A, Nowak Z, Zwoliński K, Lohani A, Jawień N, Smuszkiewicz P, Kusza K. The Incidence of Perioperative Hypotension in Patients Undergoing Major Abdominal Surgery with the Use of Arterial Waveform Analysis and the Hypotension Prediction Index Hemodynamic Monitoring-A Retrospective Analysis. J Pers Med 2024; 14:174. [PMID: 38392607 PMCID: PMC10889918 DOI: 10.3390/jpm14020174] [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: 01/07/2024] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
Intraoperative hypotension (IH) is common in patients receiving general anesthesia and can lead to serious complications such as kidney failure, myocardial injury and increased mortality. The Hypotension Prediction Index (HPI) algorithm is a machine learning system that analyzes the arterial pressure waveform and alerts the clinician of an impending hypotension event. The purpose of the study was to compare the frequency of perioperative hypotension in patients undergoing major abdominal surgery with different types of hemodynamic monitoring. The study included 61 patients who were monitored with the arterial pressure-based cardiac output (APCO) technology (FloTrac group) and 62 patients with the Hypotension Prediction Index algorithm (HPI group). Our primary outcome was the time-weighted average (TWA) of hypotension below < 65 mmHg. The median TWA of hypotension in the FloTrac group was 0.31 mmHg versus 0.09 mmHg in the HPI group (p = 0.000009). In the FloTrac group, the average time of hypotension was 27.9 min vs. 8.1 min in the HPI group (p = 0.000023). By applying the HPI algorithm in addition to an arterial waveform analysis alone, we were able to significantly decrease the frequency and duration of perioperative hypotension events in patients who underwent major abdominal surgery.
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Affiliation(s)
- Jakub Szrama
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Agata Gradys
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Tomasz Bartkowiak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Amadeusz Woźniak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Zuzanna Nowak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Krzysztof Zwoliński
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Ashish Lohani
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Natalia Jawień
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Piotr Smuszkiewicz
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Krzysztof Kusza
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
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Shi M, Zheng Y, Wu Y, Ren Q. Multitask Attention-Based Neural Network for Intraoperative Hypotension Prediction. Bioengineering (Basel) 2023; 10:1026. [PMID: 37760128 PMCID: PMC10525858 DOI: 10.3390/bioengineering10091026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Timely detection and response to Intraoperative Hypotension (IOH) during surgery is crucial to avoid severe postoperative complications. Although several methods have been proposed to predict IOH using machine learning, their performance still has space for improvement. In this paper, we propose a ResNet-BiLSTM model based on multitask training and attention mechanism for IOH prediction. We trained and tested our proposed model using bio-signal waveforms obtained from patient monitoring of non-cardiac surgery. We selected three models (WaveNet, CNN, and TCN) that process time-series data for comparison. The experimental results demonstrate that our proposed model has optimal MSE (43.83) and accuracy (0.9224) compared to other models, including WaveNet (51.52, 0.9087), CNN (318.52, 0.5861), and TCN (62.31, 0.9045), which suggests that our proposed model has better regression and classification performance. We conducted ablation experiments on the multitask and attention mechanisms, and the experimental results demonstrated that the multitask and attention mechanisms improved MSE and accuracy. The results demonstrate the effectiveness and superiority of our proposed model in predicting IOH.
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Affiliation(s)
- Meng Shi
- School of Electronics, Peking University, Beijing 100871, China
| | - Yu Zheng
- School of Electronics, Peking University, Beijing 100871, China
| | - Youzhen Wu
- College of Engineering, Peking University, Beijing 100871, China
| | - Quansheng Ren
- School of Electronics, Peking University, Beijing 100871, China
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Lin S, Huang X, Zhang Y, Zhang X, Cheng E, Liu J. Intraoperative Variables Enhance the Predictive Performance of Myocardial Injury in Patients with High Cardiovascular Risk After Thoracic Surgery When Added to Baseline Prediction Model. Ther Clin Risk Manag 2023; 19:435-445. [PMID: 37252064 PMCID: PMC10225131 DOI: 10.2147/tcrm.s408135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/08/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Myocardial injury after non-cardiac surgery is closely related to major adverse cardiac and cerebrovascular event and is difficult to identify. This study aims to investigate how to predict the myocardial injury of thoracic surgery and whether intraoperative variables contribute to the prediction of myocardial injury. Methods The prospective study included adult patients with high cardiovascular risk who underwent elective thoracic surgery from May 2022 to October 2022. Multivariate logistic regression was used to establish a model with baseline variables and a model with baseline and intraoperative variables. We compare the predictive performance of two models for postoperative myocardial injury. Results In general, 31.5% (94 of 298) occurred myocardial injury. Age ≥65 years old, obesity, smoking, preoperative hsTnT, and one-lung ventilation time were independent predictors of myocardial injury. Compared with baseline model, the intraoperative variables improved model fit, modestly improved the reclassification (continuous net reclassification improvement 0.409, 95% CI, 0.169 to 0.648, P<0.001, improved integrated discrimination 0.036, 95% CI, 0.011 to 0.062, P<0.01) of myocardial injury cases, and achieved higher net benefit in decision curve analysis. Conclusion The risk stratification and anesthesia management of high-risk patients are essential. The addition of intraoperative variables to the baseline predictive model improved the performance of the overall model of myocardial injury and helped anesthesiologists screen out the patients at the greatest risk for myocardial injury and adjust anesthesia strategies.
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Affiliation(s)
- Shuchi Lin
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Xiaofan Huang
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Ying Zhang
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Xiaohan Zhang
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Erhong Cheng
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Jindong Liu
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
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Cai J, Tang M, Wu H, Yuan J, Liang H, Wu X, Xing S, Yang X, Duan XD. Association of intraoperative hypotension and severe postoperative complications during non-cardiac surgery in adult patients: A systematic review and meta-analysis. Heliyon 2023; 9:e15997. [PMID: 37223701 PMCID: PMC10200862 DOI: 10.1016/j.heliyon.2023.e15997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/25/2023] Open
Abstract
Background Intraoperative hypotension (IOH) is a common side effect of non-cardiac surgery that might induce poor postoperative outcomes. The relationship between the IOH and severe postoperative complications is still unclear. Thus, we summarized the existing literature to evaluate whether IOH contributes to developing severe postoperative complications during non-cardiac surgery. Methods We conducted a comprehensive search of PubMed, Embase, Cochrane Library, Web of Science, and the CBM from inception to 15 September 2022. The primary outcomes were 30-day mortality, acute kidney injury (AKI), major adverse cardiac events (myocardial injury or myocardial infarction), postoperative cognitive dysfunction (POCD), and postoperative delirium (POD). Secondary outcomes included surgical-site infection (SSI), stroke, and 1-year mortality. Results 72 studies (3 randomized; 69 non-randomized) were included in this study. Low-quality evidence showed IOH resulted in an increased risk of 30-day mortality (OR, 1.85; 95% CI, 1.30-2.64; P < .001), AKI (OR, 2.69; 95% CI, 2.15-3.37; P < .001), and stroke (OR, 1.33; 95% CI, 1.21-1.46; P < .001) after non-cardiac surgery than non-IOH. Very low-quality evidence showed IOH was associated with a higher risk of myocardial injury (OR, 2.00; 95% CI, 1.17-3.43; P = .01), myocardial infarction (OR, 2.11; 95% CI, 1.41-3.16; P < .001), and POD (OR, 2.27; 95% CI, 1.53-3.38; P < .001). Very low-quality evidence showed IOH have a similar incidence of POCD (OR, 2.82; 95% CI, 0.83-9.50; P = .10) and 1-year-mortality (OR, 1.66; 95% CI, 0.65-4.20; P = .29) compared with non-IOH in non-cardiac surgery. Conclusion Our results suggest IOH was associated with an increased risk of severe postoperative complications after non-cardiac surgery than non-IOH. IOH is a potentially avoidable hazard that should be closely monitored during non-cardiac surgery.
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Affiliation(s)
- Jianghui Cai
- Department of Pharmacy, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Mi Tang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
- Office of Good Clinical Practice, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Huaye Wu
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Jing Yuan
- Department of Information, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, 611731, China
| | - Hua Liang
- Department of Pharmacy, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xuan Wu
- Department of Epidemiology and Biostatistics and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Shasha Xing
- Office of Good Clinical Practice, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xiao Yang
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xiao-Dong Duan
- Department of Rehabilitation Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
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Strickland SS, Quintela EM, Wilson MJ, Lee MJ. Long-term major adverse cardiovascular events following myocardial injury after non-cardiac surgery: meta-analysis. BJS Open 2023; 7:7142743. [PMID: 37104754 PMCID: PMC10129390 DOI: 10.1093/bjsopen/zrad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/12/2022] [Accepted: 01/27/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery is diagnosed following asymptomatic troponin elevation in the perioperative interval. Myocardial injury after non-cardiac surgery is associated with high mortality rates and significant rates of major adverse cardiac events within the first 30 days following surgery. However, less is known regarding its impact on mortality and morbidity beyond this time. This systematic review and meta-analysis aimed to establish the rates of long-term morbidity and mortality associated with myocardial injury after non-cardiac surgery. METHODS MEDLINE, Embase and Cochrane CENTRAL were searched, and abstracts screened by two reviewers. Observational studies and control arms of trials, reporting mortality and cardiovascular outcomes beyond 30 days in adult patients diagnosed with myocardial injury after non-cardiac surgery, were included. Risk of bias was assessed using the Quality in Prognostic Studies tool. A random-effects model was used for the meta-analysis of outcome subgroups. RESULTS Searches identified 40 studies. The meta-analysis of 37 cohort studies found a rate of major adverse cardiac events-associated myocardial injury after non-cardiac surgery of 21 per cent and mortality following myocardial injury after non-cardiac surgery was 25 per cent at 1-year follow-up. A non-linear increase in mortality rate was observed up to 1 year after surgery. Major adverse cardiac event rates were also lower in elective surgery compared with a subgroup including emergency cases. The analysis demonstrated a wide variety of accepted myocardial injury after non-cardiac surgery and major adverse cardiac events diagnostic criteria within the included studies. CONCLUSION A diagnosis of myocardial injury after non-cardiac surgery is associated with high rates of poor cardiovascular outcomes up to 1 year after surgery. Work is needed to standardize diagnostic criteria and reporting of myocardial injury after non-cardiac surgery-related outcomes. REGISTRATION This review was prospectively registered with PROSPERO in October 2021 (CRD42021283995).
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Affiliation(s)
- Scarlett S Strickland
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - Ella M Quintela
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew J Wilson
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew J Lee
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
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Szrama J, Gradys A, Bartkowiak T, Woźniak A, Kusza K, Molnar Z. Intraoperative Hypotension Prediction—A Proactive Perioperative Hemodynamic Management—A Literature Review. Medicina (B Aires) 2023; 59:medicina59030491. [PMID: 36984493 PMCID: PMC10057151 DOI: 10.3390/medicina59030491] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/19/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Intraoperative hypotension (IH) is a frequent phenomenon affecting a substantial number of patients undergoing general anesthesia. The occurrence of IH is related to significant perioperative complications, including kidney failure, myocardial injury, and even increased mortality. Despite advanced hemodynamic monitoring and protocols utilizing goal directed therapy, our management is still reactive; we intervene when the episode of hypotension has already occurred. This literature review evaluated the Hypotension Prediction Index (HPI), which is designed to predict and reduce the incidence of IH. The HPI algorithm is based on a machine learning algorithm that analyzes the arterial pressure waveform as an input and the occurrence of hypotension with MAP <65 mmHg for at least 1 min as an output. There are several studies, both retrospective and prospective, showing a significant reduction in IH episodes with the use of the HPI algorithm. However, the level of evidence on the use of HPI remains very low, and further studies are needed to show the benefits of this algorithm on perioperative outcomes.
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Affiliation(s)
- Jakub Szrama
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Correspondence: ; Tel.: +48-618-691-856
| | - Agata Gradys
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Tomasz Bartkowiak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Amadeusz Woźniak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Krzysztof Kusza
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Zsolt Molnar
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
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Ko CC, Hung KC, Illias AM, Chiu CC, Yu CH, Lin CM, Chen IW, Sun CK. The use of remimazolam versus propofol for induction and maintenance of general anesthesia: A systematic review and meta-analysis. Front Pharmacol 2023; 14:1101728. [PMID: 36814492 PMCID: PMC9939642 DOI: 10.3389/fphar.2023.1101728] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/27/2023] [Indexed: 02/09/2023] Open
Abstract
Background: The primary objective of this study was to compare the risk of hypotension, as well as the induction and recovery characteristics between remimazolam and propofol in patients receiving surgery under general anesthesia. Methods: The Embase, Medline, Google scholar, and the Cochrane Library databases were searched from inception to March 2022 for randomized controlled trials The primary outcome was the risk of post-induction hypotension between the two agents, while the secondary outcomes included anesthetic depth, induction efficacy, time to loss of consciousness (LOC), hemodynamic profiles, time to eye opening, extubation time as well as the incidence of injection pain and postoperative nausea/vomiting (PONV). Results: Meta-analysis of eight studies published from 2020 to 2022 involving 738 patients revealed a significantly lower risk of post-induction hypotension with the use of remimazolam compared to that with propofol [risk ratio (RR) = 0.57, 95% confidence interval (CI): 0.43 to 0.75, p < 0.0001, I2 = 12%, five studies, 564 patients]. After anesthetic induction, the anesthetic depth measured by bispectral index (BIS) was lighter in the remimazolam group than that in the propofol group (MD = 9.26, 95% confidence interval: 3.06 to 15.47, p = 0.003, I2 = 94%, five studies, 490 patients). The time to loss of consciousness was also longer in the former compared to the latter (MD = 15.49 s, 95%CI: 6.53 to 24.46, p = 0.0007, I2 = 61%, three studies, 331 patients). However, the use of remimazolam correlated with a lower risk of injection pain (RR = 0.03, 95%CI: 0.01 to 0.16, p < 0.0001, I2 = 0%, three studies, 407 patients) despite comparable efficacy of anesthetic induction (RR = 0.98, 95%CI: 0.9 to 1.06, p = 0.57, I2 = 76%, two studies, 319 patients). Our results demonstrated no difference in time to eye opening, extubation time, and risk of PONV between the two groups. Conclusion: Remimazolam was associated with a lower risk of post-induction hypotension after anesthetic induction compared with propofol with similar recovery characteristics. Further studies are required to support our findings. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/; Identifier: CRD42022320658.
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Affiliation(s)
- Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan city, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan city, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Amina M. Illias
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, E-Da Cancer Hospital, I-Shou University Kaohsiung city, Kaohsiung City, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung City, Taiwan
- Department of Medical Education and Research, E-Da Cancer Hospital, Kaohsiung city, Taiwan
| | - Chia-Hung Yu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Ming Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan city, Taiwan
| | - Cheuk-Kwan Sun
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung City, Taiwan
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
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Simonin M, Delsuc C, Meuret P, Caruso L, Deleat-Besson R, Lamblin A, Huriaux L, Abraham P, Bidon C, Giai J, Riche B, Rimmelé T. Hypobaric Unilateral Spinal Anesthesia Versus General Anesthesia for Hip Fracture Surgery in the Elderly: A Randomized Controlled Trial. Anesth Analg 2022; 135:1262-1270. [PMID: 36135347 DOI: 10.1213/ane.0000000000006208] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Hypotension during surgery is frequent in the elderly population and is associated with acute kidney and myocardial injury, which are, themselves, associated with increased 30-day mortality. The present study compared the hemodynamic effects of hypobaric unilateral spinal anesthesia (HUSA) to general anesthesia (GA) in patients ≥70 years of age undergoing hip fracture surgery. METHODS We conducted a single-center, prospective, randomized study. In the HUSA group, patients were positioned with the operated hip above, and the hypobaric anesthetic solution was composed of 9 mg ropivacaine, 5 µg sufentanil, and 1 mL of sterile water. Anesthesia was adjusted for the GA group. Mean arterial pressure (MAP) was measured with a noninvasive blood pressure upper arm cuff every 3 minutes. Hypotension was treated with a bolus of ephedrine and then a continuous intravenous of norepinephrine to obtain a MAP ≥65 mm Hg. Primary outcome was the occurrence of severe hypotension, defined as a MAP <65 mm Hg for >12 consecutive minutes. RESULTS A total of 154 patients were included. Severe hypotension was more frequent in the GA group compared to the HUSA group (odds ratio, 5.6; 95% confidence interval, 2.7-11.7; P < .001). There was no significant difference regarding the short-term outcomes between the HUSA and GA groups: acute kidney injury (respectively, 5.1% vs 11.3%; P = .22), myocardial injury (18.0% vs 14.0%; P = .63), and 30-day mortality (2.4% vs 4.7%; P = .65). CONCLUSIONS HUSA leads to fewer episodes of severe intraoperative hypotension compared to GA in an elderly population undergoing hip fracture surgery.
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Affiliation(s)
- Marine Simonin
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Claire Delsuc
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Pascal Meuret
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Liana Caruso
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Robert Deleat-Besson
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Antoine Lamblin
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Laetitia Huriaux
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Paul Abraham
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Cyril Bidon
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Joris Giai
- Université de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France
- Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Benjamin Riche
- Université de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France
- Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Thomas Rimmelé
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
- Hospices Civils de Lyon-Biomérieux-Université Claude Bernard Lyon 1, Hôpital Édouard Herriot, Lyon, France
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Wesselink EM, Wagemakers SH, van Waes JAR, Wanderer JP, van Klei WA, Kappen TH. Associations between intraoperative hypotension, duration of surgery and postoperative myocardial injury after noncardiac surgery: a retrospective single-centre cohort study. Br J Anaesth 2022; 129:487-496. [PMID: 36064492 DOI: 10.1016/j.bja.2022.06.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/16/2022] [Accepted: 06/05/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Studies of intraoperative hypotension typically specify a blood pressure threshold associated with adverse outcomes. Such thresholds are likely to be study-biased, investigator-biased, or both. We hypothesised that a newly developed modelling method without a threshold, which is biologically more plausible than a threshold-based approach, would reveal a continuous association between exposure to intraoperative hypotension and adverse outcomes. METHODS Single-centre, retrospective cohort study of subjects ≥60 yr old undergoing noncardiac surgery. We modelled intraoperative hypotension using three different approaches: (1) unweighted, (2) weighted for degree of hypotension (depth), and (3) weighted for duration of hypotension. The primary outcome was myocardial injury, defined as elevated troponin I (>60 ng L-1) measured during the first 3 days after surgery. The associations between the three models, postoperative myocardial injury, and mortality (secondary outcome) were reported as penalised adjusted odds ratios (ORs) scaled between the 75th and 25th percentiles. RESULTS Myocardial injury occurred in 1812/15 452 (12%) procedures, with 554/15 452 (3.6%) procedures resulting in death before discharge from hospital. The unweighted lower blood pressure measure (OR: 0.26, 95% confidence interval [CI]: 0.12-0.53) and the depth-weighted measure (OR: 4.4, 95% CI: 2.6-7.4) were associated with myocardial injury. The duration-weighted measure was not associated with myocardial injury (OR: 0.89, 95% CI: 0.61-1.3). The unweighted measure (OR 0.08, 95% CI: 0.01-0.40) and the depth-weighted measure (OR: 12, 95% CI, 3.8-35) were associated with in-hospital mortality, but not the duration-weighted measure (OR: 1.3, 95% CI: 0.53-3.0). CONCLUSIONS Intraoperative hypotension appears to have a graded association with postoperative myocardial injury and mortality, with depth appearing to contribute more than duration.
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Affiliation(s)
- Esther M Wesselink
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sjors H Wagemakers
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jonathan P Wanderer
- Departments of Anesthesiology and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Teus H Kappen
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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Intraoperative Hypotension and Myocardial Injury After Noncardiac Surgery in Adults With or Without Chronic Hypertension: A Retrospective Cohort Analysis. Anesth Analg 2022; 135:329-340. [PMID: 35130198 DOI: 10.1213/ane.0000000000005922] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The risk of myocardial injury progressively increases at intraoperative mean arterial pressures (MAPs) ≤65 mm Hg. Higher pressures might be required in chronically hypertensive patients. We aimed to test the hypothesis that the harm threshold is higher in patients with chronic hypertension than in normotensive patients. METHODS We conducted a single-center retrospective cohort analysis of adults >45 years old who had noncardiac surgery between 2010 and 2018 and scheduled, rather than symptom-driven, postoperative troponin measurements. The MAP thresholds under which risk started to increase were compared between patients with chronic hypertension (baseline MAP ≥110 mm Hg) and normotensive patients (baseline MAP <110 mm Hg). The primary outcome was a composite of in-hospital mortality and myocardial injury within 30 days, defined by any postoperative 4th-generation troponin T measurement ≥0.03 ng/mL apparently due to cardiac ischemia. Multivariable logistic regression and moving average smoothing methods were used to evaluate confounder-adjusted associations between the composite outcome and the lowest intraoperative MAP sustained for either 5 or 10 cumulative minutes, and whether the relationship depended on baseline pressure (normotensive versus hypertensive). RESULTS Among 4576 eligible surgeries, 2066 were assigned to the normotensive group with mean (standard deviation [SD]) baseline MAP of 100 (7) mm Hg, and 2510 were assigned to the hypertensive group with mean baseline MAP of 122 (10) mm Hg. The overall incidence of the composite outcome was 5.6% in normotensive and 6.0% in hypertensive patients ( P = .55). The relationship between intraoperative hypotension and the composite outcome was not found to depend on baseline MAP in a multivariable mixed effects logistic regression model. Furthermore, no statistical change points were found for either baseline MAP group. CONCLUSIONS Baseline blood pressure of the hypertensive patients was only moderately increased on average, and the event rate was low. Nonetheless, we were not able to demonstrate a difference in the harm threshold between normotensive and chronically hypertensive patients. Our results do not support the theory that hypertensive patients should be kept at higher intraoperative pressures than normotensive patients.
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Song Q, Li J, Jiang Z. Provisional Decision-Making for Perioperative Blood Pressure Management: A Narrative Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5916040. [PMID: 35860431 PMCID: PMC9293529 DOI: 10.1155/2022/5916040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
Blood pressure (BP) is a basic determinant for organ blood flow supply. Insufficient blood supply will cause tissue hypoxia, provoke cellular oxidative stress, and to some extent lead to organ injury. Perioperative BP is labile and dynamic, and intraoperative hypotension is common. It is unclear whether there is a causal relationship between intraoperative hypotension and organ injury. However, hypotension surely compromises perfusion and causes harm to some extent. Because the harm threshold remains unknown, various guidelines for intraoperative BP management have been proposed. With the pending definitions from robust randomized trials, it is reasonable to consider observational analyses suggesting that mean arterial pressures below 65 mmHg sustained for more than 15 minutes are associated with myocardial and renal injury. Advances in machine learning and artificial intelligence may facilitate the management of hemodynamics globally, including fluid administration, rather than BP alone. The previous mounting studies concentrated on associations between BP targets and adverse complications, whereas few studies were concerned about how to treat and multiple factors for decision-making. Hence, in this narrative review, we discussed the way of BP measurement and current knowledge about baseline BP extracting for surgical patients, highlighted the decision-making process for BP management with a view to providing pragmatic guidance for BP treatment in the clinical settings, and evaluated the merits of an automated blood control system in predicting hypotension.
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Affiliation(s)
- Qiliang Song
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Jipeng Li
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Zongming Jiang
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
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Prediction of intraoperative hypotension from the linear extrapolation of mean arterial pressure. Eur J Anaesthesiol 2022; 39:574-581. [PMID: 35695749 DOI: 10.1097/eja.0000000000001693] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hypotension prediction index (HPI) software is a proprietary machine learning-based algorithm used to predict intraoperative hypotension (IOH). HPI has shown superiority in predicting IOH when compared to the predictive value of changes in mean arterial pressure (ΔMAP) alone. However, the predictive value of ΔMAP alone, with no reference to the absolute level of MAP, is counterintuitive and poor at predicting IOH. A simple linear extrapolation of mean arterial pressure (LepMAP) is closer to the clinical approach. OBJECTIVES Our primary objective was to investigate whether LepMAP better predicts IOH than ΔMAP alone. DESIGN Retrospective diagnostic accuracy study. SETTING Two tertiary University Hospitals between May 2019 and December 2019. PATIENTS A total of 83 adult patients undergoing high risk non-cardiac surgery. DATA SOURCES Arterial pressure data were automatically extracted from the anaesthesia data collection software (one value per minute). IOH was defined as MAP < 65 mmHg. ANALYSIS Correlations for repeated measurements and the area under the curve (AUC) from receiver operating characteristics (ROC) were determined for the ability of LepMAP and ΔMAP to predict IOH at 1, 2 and 5 min before its occurrence (A-analysis, using the whole dataset). Data were also analysed after exclusion of MAP values between 65 and 75 mmHg (B-analysis). RESULTS A total of 24 318 segments of ten minutes duration were analysed. In the A-analysis, ROC AUCs to predict IOH at 1, 2 and 5 min before its occurrence by LepMAP were 0.87 (95% confidence interval, CI, 0.86 to 0.88), 0.81 (95% CI, 0.79 to 0.83) and 0.69 (95% CI, 0.66 to 0.71) and for ΔMAP alone 0.59 (95% CI, 0.57 to 0.62), 0.61 (95% CI, 0.59 to 0.64), 0.57 (95% CI, 0.54 to 0.69), respectively. In the B analysis for LepMAP these were 0.97 (95% CI, 0.9 to 0.98), 0.93 (95% CI, 0.92 to 0.95) and 0.86 (95% CI, 0.84 to 0.88), respectively, and for ΔMAP alone 0.59 (95% CI, 0.53 to 0.58), 0.56 (95% CI, 0.54 to 0.59), 0.54 (95% CI, 0.51 to 0.57), respectively. LepMAP ROC AUCs were significantly higher than ΔMAP ROC AUCs in all cases. CONCLUSIONS LepMAP provides reliable real-time and continuous prediction of IOH 1 and 2 min before its occurrence. LepMAP offers better discrimination than ΔMAP at 1, 2 and 5 min before its occurrence. Future studies evaluating machine learning algorithms to predict IOH should be compared with LepMAP rather than ΔMAP.
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Gao L, Chen L, He J, Wang B, Liu C, Wang R, Fan L, Cheng R. Perioperative Myocardial Injury/Infarction After Non-cardiac Surgery in Elderly Patients. Front Cardiovasc Med 2022; 9:910879. [PMID: 35665266 PMCID: PMC9160386 DOI: 10.3389/fcvm.2022.910879] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/28/2022] [Indexed: 12/15/2022] Open
Abstract
At present, we have entered an aging society. Many diseases suffered by the elderly, such as malignant tumors, cardiovascular diseases, fractures, surgical emergencies and so on, need surgical intervention. With the improvement of Geriatrics, surgical minimally invasive technology and anesthesia level, more and more elderly patients can safely undergo surgery. Elderly surgical patients are often complicated with a variety of chronic diseases, and the risk of postoperative myocardial injury/infarction (PMI) is high. PMI is considered to be the increase of cardiac troponin caused by perioperative ischemia, which mostly occurs during operation or within 30 days after operation, which can increase the risk of short-term and long-term death. Therefore, it is suggested to screen troponin in elderly patients during perioperative period, timely identify patients with postoperative myocardial injury and give appropriate treatment, so as to improve the prognosis. The pathophysiological mechanism of PMI is mainly due to the increase of myocardial oxygen consumption and / the decrease of myocardial oxygen supply. Preoperative and postoperative risk factors of myocardial injury can be induced by mismatch of preoperative and postoperative oxygen supply. The treatment strategy should first control the risk factors and use the drugs recommended in the guidelines for treatment. Application of cardiovascular drugs, such as antiplatelet β- Receptor blockers, statins and angiotensin converting enzyme inhibitors can effectively improve postoperative myocardial ischemia. However, the risk of perioperative bleeding should be fully considered before using antiplatelet and anticoagulant drugs. This review is intended to describe the epidemiology, diagnosis, pathophysiology, risk factors, prognosis and treatment of postoperative myocardial infarction /injury.
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Affiliation(s)
- Linggen Gao
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Lei Chen
- Department of Thoracic Surgery, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Jing He
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Bin Wang
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Chaoyang Liu
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Rong Wang
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Li Fan
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
- *Correspondence: Li Fan
| | - Rui Cheng
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
- Rui Cheng
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Lizano-Díez I, Poteet S, Burniol-Garcia A, Cerezales M. The burden of perioperative hypertension/hypotension: A systematic review. PLoS One 2022; 17:e0263737. [PMID: 35139104 PMCID: PMC8827488 DOI: 10.1371/journal.pone.0263737] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/25/2022] [Indexed: 11/30/2022] Open
Abstract
Study objective Our goal is to review the outcomes of acute hypertensive/hypotensive episodes from articles published in the past 10 years that assessed the short- and long-term impact of acute hypertensive/hypotensive episodes in the perioperative setting. Methods We conducted a systematic peer review based upon PROSPERO and Cochrane Handbook protocols. The following study characteristics were collected: study type, author, year, population, sample size, their definition of acute hypertension, hypotension or other measures, and outcomes (probabilities, odds ratio, hazard ratio, and relative risk) and the p-values; and they were classified according to the type of surgery (cardiac and non-cardiac). Results A total of 3,680 articles were identified, and 66 articles fulfilled the criteria for data extraction. For the perioperative setting, the number of articles varies by outcome: 20 mortality, 16 renal outcomes, 6 stroke, 7 delirium and 34 other outcomes. Hypotension was reported to be associated with mortality (OR 1.02–20.826) as well as changes from the patient’s baseline blood pressure (BP) (OR 1.02–1.36); hypotension also had a role in the development of acute kidney injury (AKI) (OR 1.03–14.11). Postsurgical delirium was found in relation with BP lability (OR 1.018–1.038) and intra- and postsurgical hypotension (OR 1.05–1.22), and hypertension (OR 1.44–2.34). Increased OR (37.67) of intracranial hemorrhage was associated to postsurgical systolic BP >130 mmHg. There was a wide range of additional diverse outcomes related to hypo-, hypertension and BP lability. Conclusions The perioperative management of BP influences short- and long-term effects of surgical procedures in cardiac and non-cardiac interventions; these findings support the burden of BP fluctuations in this setting.
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OUP accepted manuscript. J Am Med Inform Assoc 2022; 29:1416-1424. [PMID: 35575780 PMCID: PMC9277651 DOI: 10.1093/jamia/ocac035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 01/23/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We developed a comprehensive, medication-related clinical decision support (CDS) software prototype for use in the operating room. The purpose of this study was to compare the usability of the CDS software to the current standard electronic health record (EHR) medication administration and documentation workflow. MATERIALS AND METHODS The primary outcome was the time taken to complete all simulation tasks. Secondary outcomes were the total number of mouse clicks and the total distance traveled on the screen in pixels. Forty participants were randomized and assigned to complete 7 simulation tasks in 1 of 2 groups: (1) the CDS group (n = 20), who completed tasks using the CDS and (2) the Control group (n = 20), who completed tasks using the standard medication workflow with retrospective manual documentation in our anesthesia information management system. Blinding was not possible. We video- and audio-recorded the participants to capture quantitative data (time on task, mouse clicks, and pixels traveled on the screen) and qualitative data (think-aloud verbalization). RESULTS The CDS group mean total task time (402.2 ± 85.9 s) was less than the Control group (509.8 ± 103.6 s), with a mean difference of 107.6 s (95% confidence interval [CI], 60.5-179.5 s, P < .001). The CDS group used fewer mouse clicks (26.4 ± 4.5 clicks) than the Control group (56.0 ± 15.0 clicks) with a mean difference of 29.6 clicks (95% CI, 23.2-37.6, P < .001). The CDS group had fewer pixels traveled on the computer monitor (59.5 ± 20.0 thousand pixels) than the Control group (109.3 ± 40.8 thousand pixels) with a mean difference of 49.8 thousand pixels (95% CI, 33.0-73.7, P < .001). CONCLUSIONS The perioperative medication-related CDS software prototype substantially outperformed standard EHR workflow by decreasing task time and improving efficiency and quality of care in a simulation setting.
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Chandra M, Rose N, Nishanth C, Srinivasan R. Preoperative ultrasonographic evaluation of subclavian vein and inferior vena cava for predicting hypotension associated with induction of general anesthesia. Anesth Essays Res 2022; 16:54-59. [PMID: 36249155 PMCID: PMC9558654 DOI: 10.4103/aer.aer_9_22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 01/31/2022] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction: Induction of general anesthesia is often associated with hypotension and is a common scenario faced by anesthesiologists. Intraoperative hypotension can have detrimental effects and cause various adverse effects leading to an extended hospital stay. Patients' preinduction volume status can have an effect on postinduction blood pressure. Ultrasonography is a useful tool for measuring intravascular volume status. We studied the ability of ultrasonographic measurement of subclavian vein (SCV) and inferior vena cava (IVC) diameter, collapsibility index (CI) to predict hypotension after induction of general anesthesia. Materials and Methods: We included 120 patients in our study. SCV measurements during spontaneous and deep inspiration and IVC measurements were taken before induction and postinduction blood pressure was monitored. Patients with mean arterial blood pressure <60 mmHg or with a 30% decrease from baseline were considered to be having hypotension. Results: The CI of IVC with a cutoff 37% showed sensitivity of 94% and specificity of 84% which was statistically significant. The CI of 36% of SCV during deep breathing was found to have high sensitivity and specificity of 90% and 87%. Conclusion: Our study in spontaneously breathing preoperative patients shows that SCV CI in deep breathing and IVC CI is very sensitive and reliable in predicting postinduction hypotension. Bedside ultrasound measurements can be easily done to obtain valuable information to recognize patients who could be at risk from postinduction hypotension.
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Nanji KC, Shaikh SD, Jaffari A, Franz C, Bates DW. A Monte Carlo Simulation to Estimate the Additional Cost Associated With Adverse Medication Events Leading to Intraoperative Hypotension and/or Hypertension in the United States. J Patient Saf 2021; 17:e758-e764. [PMID: 34852412 PMCID: PMC8647903 DOI: 10.1097/pts.0000000000000926] [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] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Intraoperative hypertension and hypotension are common and often related to adverse medication events (AMEs). The study objective is to estimate the annual additional fully allocated costs to the U.S. healthcare system related to AMEs associated with clinically significant intraoperative hypertension and hypotension. METHODS Using anesthesia-trained observers in randomly selected operating rooms, we estimated the rates of clinically significant intraoperative hypotension and hypertension. We conducted systematic literature reviews to estimate incidence and additional costs of acute kidney injury (AKI), acute myocardial injury, and stroke after intraoperative hypotension and hypertension. We used Monte Carlo simulation to estimate annual costs to the U.S. healthcare system. RESULTS Intraoperative hypotension (mean arterial pressure <55 mm Hg for >6 minutes) occurred in 11 of 277 operations (3.97%), hypotension (>30% drop from baseline mean arterial pressure in patients with coronary artery disease) in 9 operations (3.25%) and hypertension in 14 operations (5.05%). After hypotension, incremental incidence of AKI was 1.46% (additional cost $17,289/case), acute myocardial injury was 0.75% ($21,340/case), and stroke was 0.05% ($19,903/case). After hypertension, incremental stroke incidence was 4.76% ($28,320/case). Annually in the United States, we estimated 11,513 cases of AKI, 5914 of acute myocardial injury, 345 of stroke after intraoperative hypotension, and 47,774 cases of stroke after intraoperative hypertension, costing the U.S. $1.7 billion (90% confidence interval, $1.4-$2.0 billion), of which $923 million (90% confidence interval, $763-$1101 million) is preventable. CONCLUSIONS Adverse medication events related to blood pressure are frequent, costly, and can cause considerable patient harm. Cost estimates for these events may provide a means of prioritizing safety improvements to reduce cost of care and improve patient outcomes.
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Affiliation(s)
- Karen C. Nanji
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA, USA
- Partners Healthcare Systems, Inc., Wellesley, MA, USA
| | - Sofia D. Shaikh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Alireza Jaffari
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - David W. Bates
- Harvard Medical School, Boston, MA, USA
- Partners Healthcare Systems, Inc., Wellesley, MA, USA
- Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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Temesgen N, Fenta E, Eshetie C, Gelaw M. Early intraoperative hypotension and its associated factors among surgical patients undergoing surgery under general anesthesia: An observational study. Ann Med Surg (Lond) 2021; 71:102835. [PMID: 34691441 PMCID: PMC8517152 DOI: 10.1016/j.amsu.2021.102835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 02/06/2023] Open
Abstract
Background Early intraoperative hypotension (eIOH) is a common complication of general anesthesia and is significantly associated with postoperative morbidity and mortality. The incidence of eIOH was high, especially in resource-limited settings. Identifying the factors associated with the occurrence of eIOH might allow avoidance and planning of a timely treatment of it. Objective To assess the incidence of early intraoperative hypotension and its associated factors among surgical patients undergoing Surgical procedures under general anesthesia at XX Comprehensive Specialized Hospital, North-central Ethiopia, 2021. Methods A total of 424 surgical patients under general anesthesia were included in this prospective observational study. The data were collected by a structured questionnaire. Variables with p-values of less than 0.2 in the bivariable logistic regression were fitted to multivariable logistic regression. Data was presented in odds ratios with a 95% confidence interval. Descriptive statistics were used to summarize data. Results The incidence of early intra-operative hypotension (eIOH) was 21.2%. In this study older age (age≥ 60 years) (AOR: 2.063 (95% CI;1.194, 3.563)), ASA physical status (AOR: (II2.259 (95% CI;1.229, 4.153)), III(AOR: 2.810 (95% CI;1.319, 5.986)), a BMI of 25–29.9 kg/m2 (AOR: 2.098 (1.128, 3.901), a BMI of ≥30 kg/m2 (AOR: 3.090 (95% CI;1.324, 7.210)), emergency surgical procedures (AOR: 2.215 (95% CI;1.287, 3.810)), the estimated blood loss greater than 500 ml (AOR: 2.510 (95% CI;1.478, 4.261)) were found to be independent factors of eIOH. Conclusion This study revealed that the incidence of eIOH was high (21.2%). Older age, ASA II and III, BMI ≥25, emergency surgical procedures, and a significant amount of blood loss (EBL ≥500 ml) were the main predictors of an increased occurrence of eIOH. Early intraoperative hypotension is associated with postoperative morbidity and mortality. Emergency surgical procedures, and a significant amount of blood loss are the main predictors of an increased occurrence of eIOH. Thyroidectomy has a relatively short duration and less amount of estimated blood loss when compared to major surgical procedures. The occurrence of eIOH after general anesthesia for general surgery is a common problem. Arterial hypotension in patients undergoing surgery under general anesthesia usually described by the very general term intraoperative hypotension.
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22
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Heterogeneous impact of hypotension on organ perfusion and outcomes: a narrative review. Br J Anaesth 2021; 127:845-861. [PMID: 34392972 DOI: 10.1016/j.bja.2021.06.048] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/08/2021] [Accepted: 06/25/2021] [Indexed: 12/20/2022] Open
Abstract
Arterial blood pressure is the driving force for organ perfusion. Although hypotension is common in acute care, there is a lack of accepted criteria for its definition. Most practitioners regard hypotension as undesirable even in situations that pose no immediate threat to life, but hypotension does not always lead to unfavourable outcomes based on experience and evidence. Thus efforts are needed to better understand the causes, consequences, and treatments of hypotension. This narrative review focuses on the heterogeneous underlying pathophysiological bases of hypotension and their impact on organ perfusion and patient outcomes. We propose the iso-pressure curve with hypotension and hypertension zones as a way to visualize changes in blood pressure. We also propose a haemodynamic pyramid and a pressure-output-resistance triangle to facilitate understanding of why hypotension can have different pathophysiological mechanisms and end-organ effects. We emphasise that hypotension does not always lead to organ hypoperfusion; to the contrary, hypotension may preserve or even increase organ perfusion depending on the relative changes in perfusion pressure and regional vascular resistance and the status of blood pressure autoregulation. Evidence from RCTs does not support the notion that a higher arterial blood pressure target always leads to improved outcomes. Management of blood pressure is not about maintaining a prespecified value, but rather involves ensuring organ perfusion without undue stress on the cardiovascular system.
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23
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Gregory A, Stapelfeldt WH, Khanna AK, Smischney NJ, Boero IJ, Chen Q, Stevens M, Shaw AD. Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery. Anesth Analg 2021; 132:1654-1665. [PMID: 33177322 PMCID: PMC8115733 DOI: 10.1213/ane.0000000000005250] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Intraoperative hypotension (IOH) occurs frequently during surgery and may be associated with organ ischemia; however, few multicenter studies report data regarding its associations with adverse postoperative outcomes across varying hemodynamic thresholds. Additionally, no study has evaluated the association between IOH exposure and adverse outcomes among patients by various age groups.
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Affiliation(s)
- Anne Gregory
- From the Department of Critical Care Medicine, University of Alberta
| | - Wolf H Stapelfeldt
- Department of Anesthesiology & Critical Care Medicine, Saint Louis University
| | - Ashish K Khanna
- Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | | | | | | | | | - Andrew D Shaw
- From the Department of Critical Care Medicine, University of Alberta.,Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta
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24
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Hallqvist L, Granath F, Fored M, Bell M. Intraoperative Hypotension and Myocardial Infarction Development Among High-Risk Patients Undergoing Noncardiac Surgery: A Nested Case-Control Study. Anesth Analg 2021; 133:6-15. [PMID: 33555690 DOI: 10.1213/ane.0000000000005391] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hemodynamic instability during anesthesia and surgery is common and associated with cardiac morbidity and mortality. Information is needed regarding optimal blood pressure (BP) threshold in the perioperative period. Therefore, the effect of intraoperative hypotension (IOH) on risk of perioperative myocardial infarction (MI) was explored. METHODS A nested case-control study with patients developing MI <30 days postsurgery matched with non-MI patients, sampled from a large surgery cohort. Study participants were adults undergoing noncardiac surgery at 3 university hospitals in Sweden, 2007-2014. Matching criteria were age, sex, American Society of Anesthesiologists (ASA) physical status, cardiovascular disease, hospital, year-, type-, and extent of surgery. Medical records were reviewed to validate MI diagnoses and retrieve information on comorbid history, baseline BP, laboratory and intraoperative data. Main exposure was IOH, defined as a decrease in systolic blood pressure (SBP), in mm Hg, from preoperative individual resting baseline lasting at least 5 minutes. Outcomes were acute MI, fulfilling the universal criteria, subclassified as type 1 and 2, occurring within 30 days and mortality beyond 30 days among case and control patients. Conditional logistic regression assessed the association between IOH, decrease in SBP from individual baseline, and perioperative MI. Mortality rates were estimated using Cox proportional hazards. Relative risk estimates are reported as are the corresponding absolute risks derived from the well-characterized source population. RESULTS A total of 326 cases met the inclusion criteria and were successfully matched with 326 controls. The distribution of MI type was 59 (18%) type 1 and 267 (82%) type 2. Median time to MI diagnosis was 2 days; 75% were detected within a week of surgery. Multivariable analysis acknowledged IOH as an independent risk factor of perioperative MI. IOH, with reduction of 41-50 mm Hg, from individual baseline SBP, was associated with a more than tripled increased odds, odds ratio (OR) = 3.42 (95% confidence interval [CI], 1.13-10.3), and a hypotensive event >50 mm Hg with considerably increased odds in respect to MI risk, OR = 22.6, (95% CI, 7.69-66.2). In patients with a very high-risk burden, the absolute risk of an MI diagnosis increased from 3.6 to 68 per 1000 surgeries. CONCLUSIONS In patients undergoing noncardiac surgery, IOH is a possible contributor to clinically significant perioperative MI. The high absolute MI risk associated with IOH, among a growing population of patients with a high-risk burden, suggests that increased vigilance of BP control in these patients may be beneficial.
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Affiliation(s)
- Linn Hallqvist
- From the Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden.,Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Granath
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Michael Fored
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Max Bell
- From the Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden.,Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
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25
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Foëx P, Higham H. Hypotension Is Associated With Perioperative Myocardial Infarction: Individualized Blood Pressure Is Important. Anesth Analg 2021; 133:2-5. [PMID: 34127584 DOI: 10.1213/ane.0000000000005543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Pierre Foëx
- From the Nuffield Division of Anaesthetics, University of Oxford, Oxford, United Kingdom
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26
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Sapra R, Hallqvist L, Schlegel TT, Ugander M, Bell M, Maanja M. Predicting peri-operative troponin elevation by advanced electrocardiography. J Electrocardiol 2021; 68:1-5. [PMID: 34246860 DOI: 10.1016/j.jelectrocard.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Peri-operative mortality remains a global problem and an improved pre-operative risk assessment identifying those at highest risk for peri-operative myocardial injury might improve postsurgical outcomes. AIMS To determine whether pre-operative measures of advanced electrocardiography (A-ECG) could predict elevated serum troponin T (TnT) in patients undergoing elective, major non-cardiac surgery. MATERIAL AND METHODS This observational cohort study included 257 surgical patients who underwent elective major non-cardiac surgery between the years 2012-2013 and 2015-2016 at Karolinska University Hospital. All selected patients were ≥ 18 years of age [median age 70 (63-75) years], had a pre-operative digital 12‑lead ECG < 6 months prior to the procedure and a postoperative high-sensitivity cardiac TnT (hs-cTnT) sample. A-ECG confounders including atrial fibrillation or flutter, abundant premature atrial or ventricular contractions, bundle branch blocks, QRS duration >110 ms, heart rate > 100 beats/min and paced rhythms were excluded. Previously validated A-ECG diagnostic scores that detect cardiovascular pathologies were calculated and compared in patients with and without peri-operative myocardial injury, defined as hs-cTnT >14 ng l-1. RESULTS Pre-operative left ventricular systolic dysfunction by A-ECG was more probable in patients with than without peri-operative myocardial injury (p = 0.03). CONCLUSIONS While a pre-operative A-ECG score for LVSD was able to differentiate between patients with versus without elevated peri-operative TnT levels, it did not add any further utility to standard clinical parameters for predicting troponin-related events in the studied population.
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Affiliation(s)
- Richa Sapra
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Linn Hallqvist
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Todd T Schlegel
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden; Nicollier-Schlegel SARL, Trélex, Switzerland
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden; The Kolling Institute, Royal North Shore Hospital, Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Max Bell
- Department of Anaesthesia and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Maren Maanja
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden.
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27
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Epidural Anesthesia-Analgesia and Recurrence-free Survival after Lung Cancer Surgery: A Randomized Trial. Anesthesiology 2021; 135:419-432. [PMID: 34192298 DOI: 10.1097/aln.0000000000003873] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Regional anesthesia and analgesia reduce the stress response to surgery and decrease the need for volatile anesthesia and opioids, thereby preserving cancer-specific immune defenses. This study therefore tested the primary hypothesis that combining epidural anesthesia-analgesia with general anesthesia improves recurrence-free survival after lung cancer surgery. METHODS Adults scheduled for video-assisted thoracoscopic lung cancer resections were randomized 1:1 to general anesthesia and intravenous opioid analgesia or combined epidural-general anesthesia and epidural analgesia. The primary outcome was recurrence-free survival (time from surgery to the earliest date of recurrence/metastasis or all-cause death). Secondary outcomes included overall survival (time from surgery to all-cause death) and cancer-specific survival (time from surgery to cancer-specific death). Long-term outcome assessors were blinded to treatment. RESULTS Between May 2015 and November 2017, 400 patients were enrolled and randomized to general anesthesia alone (n = 200) or combined epidural-general anesthesia (n = 200). All were included in the analysis. The median follow-up duration was 32 months (interquartile range, 24 to 48). Recurrence-free survival was similar in each group, with 54 events (27%) with general anesthesia alone versus 48 events (24%) with combined epidural-general anesthesia (adjusted hazard ratio, 0.90; 95% CI, 0.60 to 1.35; P = 0.608). Overall survival was also similar with 25 events (13%) versus 31 (16%; adjusted hazard ratio, 1.12; 95% CI, 0.64 to 1.96; P = 0.697). There was also no significant difference in cancer-specific survival with 24 events (12%) versus 29 (15%; adjusted hazard ratio, 1.08; 95% CI, 0.61 to 1.91; P = 0.802). Patients assigned to combined epidural-general had more intraoperative hypotension: 94 patients (47%) versus 121 (61%; relative risk, 1.29; 95% CI, 1.07 to 1.55; P = 0.007). CONCLUSIONS Epidural anesthesia-analgesia for major lung cancer surgery did not improve recurrence-free, overall, or cancer-specific survival compared with general anesthesia alone, although the CI included both substantial benefit and harm. EDITOR’S PERSPECTIVE
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28
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Remimazolam Anesthesia for MitraClip Implantation in a Patient with Advanced Heart Failure. Case Rep Anesthesiol 2021; 2021:5536442. [PMID: 34035965 PMCID: PMC8116154 DOI: 10.1155/2021/5536442] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/30/2021] [Indexed: 12/30/2022] Open
Abstract
Remimazolam, a novel and ultrashort-acting benzodiazepine, has been available for general anesthesia in Japan. The administration of remimazolam does not induce injection pain, has been reported to have less cardiovascular depressant effects during general anesthesia, and flumazenil can antagonize the effects of remimazolam. However, in clinical trials, no patient who is complicated with severe heart failure or undergoes cardiac surgery was included. We present anesthetic management with remimazolam for MitraClip® implantation in a patient with severe mitral regurgitation and advanced heart failure. Remimazolam was administered both in anesthetic induction and maintenance with less cardiovascular depressant effects. After surgical procedures were completed, the patient smoothly recovered from anesthesia and the tracheal was extubated just after administration of flumazenil. Remimazolam may be able to achieve appropriate anesthetic management in patients complicated with severe cardiovascular diseases.
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29
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Machado MN, Rodrigues FB, Nakazone MA, Martin DF, Sabbag ATR, Grigolo IH, Silva-Júnior OL, Maia LN, Jaffe AS. Prediction of Death After Noncardiac Surgery: Potential Advantage of Using High-Sensitivity Troponin T as a Continuous Variable. J Am Heart Assoc 2021; 10:e018008. [PMID: 33660524 PMCID: PMC8174224 DOI: 10.1161/jaha.120.018008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Increased high‐sensitivity cardiac troponin T (hs‐cTnT) above the upper reference limit (URL) after noncardiac surgery identifies patients at risk for mortality. Prior studies have not analyzed hs‐cTnT as a continuous variable or probed age‐ and sex‐specific URLs. This study compared the prediction of 30‐day mortality using continuous postoperative hs‐cTnT levels to the use of the overall URL and age‐ and sex‐specific URLs. Methods and Results Patients (876) >40 years of age who underwent noncardiac surgery were included. Hs‐cTnT was measured on postoperative day 1. Cox proportional hazards models were used to compare associations between 30‐day mortality and using hs‐cTnT as a continuous variable, or above the overall or age‐ and sex‐specific URLs. Comparisons were performed by the area under the receiver operating characteristic curve analysis. Mortality was 4.2%. For each 1 ng/L increase in postoperative hs‐cTnT, there was a 0.3% increase in mortality (P<0.001). Patients with postoperative hs‐cTnT >14 ng/L were 37% of the cohort, while those above age‐ and sex‐specific URLs were 25.3%. Both manifested higher mortality (hazard ratio [HR], 3.19; 95% CI, 1.20–8.49; P=0.020) and (HR, 2.76; P=0.009) than those with normal levels. The area under receiver operating characteristic curve was 0.89 using hs‐cTnT as a continuous variable, 0.87 for age‐ and sex‐specific URLs, and 0.86 for the overall URL. Conclusions Hs‐cTnT as a continuous variable was independently associated with 30‐day mortality and had the highest accuracy. Hs‐cTnT elevations using overall and/or age‐ and sex‐specific URLs were also associated with higher mortality.
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Affiliation(s)
- Mauricio N Machado
- Division of Cardiology Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Fernando B Rodrigues
- Division of Emergency and Chest Pain Center Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Marcelo A Nakazone
- Division of Cardiology Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil.,Integrated Research Center Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Danilo F Martin
- Division of Cardiology Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Amália T R Sabbag
- Division of Anesthesiology Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Ingrid H Grigolo
- Integrated Research Center Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Osvaldo L Silva-Júnior
- Integrated Research Center Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Lilia N Maia
- Division of Cardiology Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil.,Integrated Research Center Hospital de Base Faculdade de Medicina de São José do Rio Preto São Paulo Brazil
| | - Allan S Jaffe
- Cardiovascular Department and Department of Laboratory Medicine and Pathology Mayo Clinic MN
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30
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Wijnberge M, Schenk J, Bulle E, Vlaar AP, Maheshwari K, Hollmann MW, Binnekade JM, Geerts BF, Veelo DP. Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis. BJS Open 2021; 5:6073395. [PMID: 33609377 PMCID: PMC7893468 DOI: 10.1093/bjsopen/zraa018] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 09/07/2020] [Indexed: 12/21/2022] Open
Abstract
Background Intraoperative hypotension, with varying definitions in literature, may be associated with postoperative complications. The aim of this meta-analysis was to assess the association of intraoperative hypotension with postoperative morbidity and mortality. Methods MEDLINE, Embase and Cochrane databases were searched for studies published between January 1990 and August 2018. The primary endpoints were postoperative overall morbidity and mortality. Secondary endpoints were postoperative cardiac outcomes, acute kidney injury, stroke, delirium, surgical outcomes and combined outcomes. Subgroup analyses, sensitivity analyses and a meta-regression were performed to test the robustness of the results and to explore heterogeneity. Results The search identified 2931 studies, of which 29 were included in the meta-analysis, consisting of 130 862 patients. Intraoperative hypotension was associated with an increased risk of morbidity (odds ratio (OR) 2.08, 95 per cent confidence interval 1.56 to 2.77) and mortality (OR 1.94, 1.32 to 2.84). In the secondary analyses, intraoperative hypotension was associated with cardiac complications (OR 2.44, 1.52 to 3.93) and acute kidney injury (OR 2.69, 1.31 to 5.55). Overall heterogeneity was high, with an I2 value of 88 per cent. When hypotension severity, outcome severity and study population variables were added to the meta-regression, heterogeneity was reduced to 50 per cent. Conclusion Intraoperative hypotension during non-cardiac surgery is associated with postoperative cardiac and renal morbidity, and mortality. A universally accepted standard definition of hypotension would facilitate further research into this topic.
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Affiliation(s)
- M Wijnberge
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - J Schenk
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - E Bulle
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - A P Vlaar
- Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - K Maheshwari
- Department of General Anaesthesiology, Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - M W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - J M Binnekade
- Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - B F Geerts
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - D P Veelo
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
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Christensen AL, Jacobs E, Maheshwari K, Xing F, Zhao X, Simon SE, Domino KB, Posner KL, Stewart AF, Sanford JA, Sessler DI. Development and Evaluation of a Risk-Adjusted Measure of Intraoperative Hypotension in Patients Having Nonemergent, Noncardiac Surgery. Anesth Analg 2020; 133:445-454. [PMID: 33264120 PMCID: PMC8257473 DOI: 10.1213/ane.0000000000005287] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intraoperative hypotension is common and associated with organ injury and death, although randomized data showing a causal relationship remain sparse. A risk-adjusted measure of intraoperative hypotension may therefore contribute to quality improvement efforts.
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Affiliation(s)
| | | | - Kamal Maheshwari
- Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Fei Xing
- From the Mathematica, Washington, DC
| | | | | | - Karen B Domino
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Karen L Posner
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Alvin F Stewart
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Joseph A Sanford
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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32
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Dony P, Seidel L, Pirson M, Haller G. Common clinical thresholds of intraoperative hypotension and 30-day mortality following surgery: A retrospective cohort study. Acta Anaesthesiol Scand 2020; 64:1388-1396. [PMID: 32659863 DOI: 10.1111/aas.13670] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 06/18/2020] [Accepted: 06/28/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND A wide range of thresholds define intraoperative hypotension and can be used to guide intraoperative blood pressure management. Many clinicians use the systolic blood pressure (SBP) <80 mmHg, the mean arterial pressure (MAP) <60 mmHg and the SBP percent drop from baseline (ΔSBP) >20% as alarming limits that should not be exceeded. Whether these common thresholds are valid limits that can inform clinicians on a possible increased risk of post-operative complications, particularly 30-day mortality, is currently unclear. METHODS We performed a retrospective registry-based cohort study between January 2015 and July 2016 using departmental hospital databases and the National Death Registry. Uni- and multivariate analyses were performed to assess the association between each of these three thresholds and 30-day post-operative mortality. Six specific markers of hypotension were used. RESULTS Of 11 304 patients, 86 (0.76%) died within 30 days following surgery. All intraoperative hypotension markers for SBP < 80 mmHg and MAP < 60 mmHg were significantly associated with 30-day mortality (P < .005). Markers of ΔSBP > 20% were not significant. After adjustment for age, gender, American Society of Anesthesiologists (ASA) score, emergency status and risk related to the type of surgery, both SBP < 80 mmHg and MAP < 60 mmHg (the per cent area under the threshold marker) showed the strongest associations with 30-day mortality, with odds ratios (ORs) of 3.02 (95% confidence interval (CI) 1.81-5.07) and 3.77 (95% CI 2.25-6.31) respectively. CONCLUSIONS Commonly accepted thresholds of intraoperative hypotension, such as an SBP of 80 mmHg and an MAP of 60 mmHg, are valid alarming limits that are significantly and independently associated with 30-day mortality.
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Affiliation(s)
- Philippe Dony
- Health Services and Economics Research Unit: School of Public Health Free University of Brussels Brussels Belgium
| | - Laurence Seidel
- Department of Medico‐economic Information and Biostatistics University Hospital of Liège Liège Belgium
| | - Magali Pirson
- Health Services and Economics Research Unit: School of Public Health Free University of Brussels Brussels Belgium
| | - Guy Haller
- Department of Anesthesia Intensive Care & Pharmacology Geneva University Hospital Genève Switzerland
- Department of Epidemiology & Preventive Medicine Monash University Clayton Vic. Australia
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33
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Naylor AJ, Sessler DI, Maheshwari K, Khanna AK, Yang D, Mascha EJ, Suleiman I, Reville EM, Cote D, Hutcherson MT, Nguyen BM, Elsharkawy H, Kurz A. Arterial Catheters for Early Detection and Treatment of Hypotension During Major Noncardiac Surgery: A Randomized Trial. Anesth Analg 2020; 131:1540-1550. [PMID: 33079877 DOI: 10.1213/ane.0000000000004370] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Continuous blood pressure monitoring may facilitate early detection and prompt treatment of hypotension. We tested the hypothesis that area under the curve (AUC) mean arterial pressure (MAP) <65 mm Hg is reduced by continuous invasive arterial pressure monitoring. METHODS Adults having noncardiac surgery were randomly assigned to continuous invasive arterial pressure or intermittent oscillometric blood pressure monitoring. Arterial catheter pressures were recorded at 1-minute intervals; oscillometric pressures were typically recorded at 5-minute intervals. We estimated the arterial catheter effect on AUC-MAP <65 mm Hg using a multivariable proportional odds model adjusting for imbalanced baseline variables and duration of surgery. Pressures <65 mm Hg were categorized as 0, 1-17, 18-91, and >91 mm Hg × minutes of AUC-MAP <65 mm Hg (ie, no hypotension and 3 equally sized groups of increasing hypotension). RESULTS One hundred fifty-two patients were randomly assigned to arterial catheter use and 154 to oscillometric monitoring. For various clinical reasons, 143 patients received an arterial catheter, while 163 were monitored oscillometrically. There were a median [Q1, Q3] of 246 [187, 308] pressure measurements in patients with arterial catheters versus 55 (46, 75) measurements in patients monitored oscillometrically. In the primary intent-to-treat analysis, catheter-based monitoring increased detection of AUC-MAP <65 mm Hg, with an estimated proportional odds ratio (ie, odds of being in a worse hypotension category) of 1.78 (95% confidence interval [CI], 1.18-2.70; P = .006). The result was robust over an as-treated analysis and for sensitivity analyses with thresholds of 60 and 70 mm Hg. CONCLUSIONS Intraoperative blood pressure monitoring with arterial catheters detected nearly twice as much hypotension as oscillometric measurements.
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Affiliation(s)
| | | | | | - Ashish K Khanna
- From the Departments of Outcomes Research
- General Anesthesiology
| | - Dongsheng Yang
- From the Departments of Outcomes Research
- Quantitative Health Sciences, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward J Mascha
- From the Departments of Outcomes Research
- Quantitative Health Sciences, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Devan Cote
- From the Departments of Outcomes Research
| | | | | | | | - Andrea Kurz
- From the Departments of Outcomes Research
- General Anesthesiology
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Blood pressure management and perioperative myocardial injury. Int Anesthesiol Clin 2020; 59:36-44. [PMID: 33060430 DOI: 10.1097/aia.0000000000000301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hallqvist L, Granath F, Bell M. Myocardial infarction after noncardiac surgery in Sweden: a national, retrospective observational cohort study. Br J Anaesth 2020; 125:47-54. [DOI: 10.1016/j.bja.2020.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 10/24/2022] Open
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Li N, Kong H, Li SL, Zhu SN, Zhang Z, Wang DX. Intraoperative hypotension is associated with increased postoperative complications in patients undergoing surgery for pheochromocytoma-paraganglioma: a retrospective cohort study. BMC Anesthesiol 2020; 20:147. [PMID: 32532209 PMCID: PMC7291712 DOI: 10.1186/s12871-020-01066-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/08/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Dramatic hemodynamic fluctuation occurs frequently during surgery for pheochromocytoma or paraganglioma. However, the criteria of intraoperative hemodynamic instability vary widely, and most of them were defined arbitrarily but not according to patients' prognosis. The objective was to analyze the relationship between different thresholds and durations of intraoperative hyper-/hypotension and the risk of postoperative complications in patients undergoing surgery for pheochromocytoma or paraganglioma. METHODS This was a retrospective single-center cohort study performed in a tertiary care hospital from January 1, 2005 to December 31, 2017. Three hundred twenty-seven patients who underwent surgery for pheochromocytoma or paraganglioma, of which the diagnoses were confirmed by postoperative pathologic examination, were enrolled. Those who were less than 18 years, underwent surgery involving non-tumor organs, or had incomplete data were excluded. The primary endpoint was a composite of the occurrence of AKI or other complications during hospital stay after surgery. Multivariate Logistic regression models were used to analyze the association between different thresholds and durations of intraoperative hyper-/hypotension and the development of postoperative complications. RESULTS Forty three (13.1%) patients developed complications during hospital stay after surgery. After adjusting for confounding factors, intraoperative hypotension, defined as systolic blood pressure (SBP) of ≤95 mmHg for ≥20 min (OR 3.211; 99% CI 1.081-9.536; P = 0.006), SBP of ≤90 mmHg for ≥20 min (OR 3.680; 98.8% CI 1.107-12.240; P = 0.006), SBP of ≤85 mmHg for ≥10 min (OR 3.975; 98.3% CI 1.321-11.961; P = 0.003), and SBP of ≤80 mmHg for ≥1 min (OR 3.465; 95% CI 1.484-8.093; P = 0.004), were associated with an increased risk of postoperative complications. On the other hand, intraoperative hypertension was not significantly associated with the development of postoperative complications. CONCLUSIONS For patients undergoing surgery for pheochromocytoma or paraganglioma, intraoperative hypotension is associated with increased postoperative complications; and the harmful effects are level- and duration-dependent. The effects of intraoperative hypertension need to be studied further.
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Affiliation(s)
- Nan Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku street, Beijing, 100034, China
| | - Hao Kong
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku street, Beijing, 100034, China
| | - Shuang-Ling Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku street, Beijing, 100034, China
| | - Sai-Nan Zhu
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Zheng Zhang
- Department of Urology, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku street, Beijing, 100034, China.
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Uchoa RB, Caramelli B. Troponin I as a mortality marker after lung resection surgery - a prospective cohort study. BMC Anesthesiol 2020; 20:118. [PMID: 32429842 PMCID: PMC7236915 DOI: 10.1186/s12871-020-01037-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular complications associated with thoracic surgery increase morbidity, mortality, and treatment costs. Elevated cardiac troponin level represents a predictor of complications after non-cardiac surgeries, but its role after thoracic surgeries remains undetermined. The objective of this study was to analyze the relationship between troponin I elevation and morbidity and mortality after one year in patients undergoing lung resection surgery. METHODS This prospective cohort study evaluated 151 consecutive patients subjected to elective lung resection procedures using conventional and video-assisted thoracoscopic techniques at a University Hospital in Brazil, from July 2012 to November 2015. Preoperative risk stratification was performed using the scores obtained by the American College of Physicians (ACP) and the Society of Cardiology of the state of São Paulo (EMAPO) scoring systems. Troponin I levels were measured in the immediate postoperative period (POi) and on the first and second postoperative days. RESULTS Most patients had a low risk for complications according to the ACP (96.7%) and EMAPO (82.8%) scores. Approximately 49% of the patients exhibited increased troponin I (≥0.16 ng/ml), at least once, and 22 (14.6%) died in one year. Multivariate analysis showed that the elevation of troponin I, on the first postoperative day, correlated with a 12-fold increase in mortality risk within one year (HR 12.02, 95% CI: 1.82-79.5; p = 0.01). CONCLUSIONS In patients undergoing lung resection surgery, with a low risk of complications according to the preoperative evaluation scores, an increase in troponin I levels above 0.16 ng/ml in the first postoperative period correlated with an increase in mortality within one year.
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Affiliation(s)
- Ricardo B Uchoa
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Rua Maestro Elias Lobo 596, São Paulo, SP, CEP 01433-000, Brazil
| | - Bruno Caramelli
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Rua Maestro Elias Lobo 596, São Paulo, SP, CEP 01433-000, Brazil.
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de Keijzer IN, Vos JJ, Scheeren TWL. Hypotension Prediction Index: from proof-of-concept to proof-of-feasibility. J Clin Monit Comput 2020; 34:1135-1138. [DOI: 10.1007/s10877-020-00465-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 01/30/2023]
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Truchetti G, Otis C, Brisville AC, Beauchamp G, Pang D, Troncy E. Management of veterinary anaesthesia in small animals: A survey of current practice in Quebec. PLoS One 2020; 15:e0227204. [PMID: 31945076 PMCID: PMC6964820 DOI: 10.1371/journal.pone.0227204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/14/2019] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To describe how small animal anaesthesia is performed in French-speaking Eastern Canada, and the variations between practices, in particular based on practice type, veterinarian gender and experience. DESIGN Observational study, survey. SAMPLE 156 respondents. PROCEDURE A questionnaire was designed to assess current small animal anaesthesia practices in French-speaking Eastern Canada, mainly in the province of Quebec. The questionnaire was available through SurveyMonkey, and consisted of four parts: demographic information about the veterinarians surveyed, evaluation and management of anaesthetic risk, anaesthesia procedure, monitoring and safety. Gender, year of graduation, and type of practice were tested as potential risk factors. Chi-square exact test was used to study relations between each risk factor, and the effect of the selected risk factor on each response of the survey. For ordinal data, the Cochran-Mantel-Haenszel test was used to maximize power. RESULTS Response rate over a period of 3 months was 20.85% (156 respondents). Overall, the way anaesthesia is performed by most respondents does not meet international guidelines, such as patient preparation and evaluation prior to anaesthesia, not using individualised protocols (for 41%), not obtaining intravenous access (12.4% use it for all their anaesthesia in cats, and 30.6% in dogs), lack of patient monitoring at certain intervals for 55% of the responses, and client prompted optional analgesia (for 29% of respondents). Some practices are more compliant than others. Among them, referral centres generally offer better care than general practices. CONCLUSIONS AND CLINICAL RELEVANCE The level of care in anaesthesia and analgesia in practices in French-speaking Eastern Canada is concerning, highlighting the need for more sustained continuing education.
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Affiliation(s)
| | - Colombe Otis
- Groupe de Recherche en Pharmacologie Animale du Québec (GREPAQ), Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, Quebec, Canada
| | | | - Guy Beauchamp
- Groupe de Recherche en Pharmacologie Animale du Québec (GREPAQ), Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, Quebec, Canada
| | - Daniel Pang
- Groupe de Recherche en Pharmacologie Animale du Québec (GREPAQ), Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, Quebec, Canada
| | - Eric Troncy
- Groupe de Recherche en Pharmacologie Animale du Québec (GREPAQ), Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, Quebec, Canada
- * E-mail:
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Perioperative multidisciplinary implementation enhancing recovery after hip arthroplasty in geriatrics with preoperative chronic hypoxaemia. Sci Rep 2019; 9:19145. [PMID: 31844090 PMCID: PMC6914796 DOI: 10.1038/s41598-019-55607-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/29/2019] [Indexed: 11/19/2022] Open
Abstract
We investigated risk factors for postoperative serious adverse events (SAEs) in elderly patients with preoperative chronic hypoxaemia undergone total hip arthroplasty (THA) or hemiarthroplasty and performed an implementation to modify and improve clinical outcome. A retrospective medical record review was performed to identify geriatric patients who receiving THA or hemiarthroplasty at a single university teaching hospital, Kunming, Yunnan, China between January 2009 and August 2017. Total of 450 elderly patients were included in the study. Data were collected on baseline characteristics, detailed treatments, and adverse events. Univariate and multivariate logistic regression analysis were used to identify risk factors for SAEs. In multivariate regression analysis, a higher occurrence of general anaesthesia and multiple episodes of hypotension were associated with higher risk of SAEs (general anesthesia: odds ratio [OR] 5.09, 95% confidence interval [CI] 1.96–13.24, P = 0.001; hypotension time: OR 4.29, 95% CI 1.66–11.10, P = 0.003). After the multidisciplinary implementation, the postoperative length of stay was decreased from 15 days to 10 days (P < 0.0001); incidence of SAEs was decreased from 21.1% to 7.0% (P = 0.002), and the all-cause mortality rate within 30 days decreased from 4.6% to 1.0% (P = 0.040). Our observational study demonstrated that an increasing application of general anaesthesia and longer time of hypotension were associated with an increased risk of postoperative SAEs in patients after THA or hemiarthroplasty. Additionally, optimizing stable haemodynamics under higher application of combined-spinal epidural anaesthesia was associated with improved outcome up to 30 days after THA or hemiarthroplasty.
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Schneck E, Schulte D, Habig L, Ruhrmann S, Edinger F, Markmann M, Habicher M, Rickert M, Koch C, Sander M. Hypotension Prediction Index based protocolized haemodynamic management reduces the incidence and duration of intraoperative hypotension in primary total hip arthroplasty: a single centre feasibility randomised blinded prospective interventional trial. J Clin Monit Comput 2019; 34:1149-1158. [DOI: 10.1007/s10877-019-00433-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 11/26/2019] [Indexed: 12/18/2022]
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Vos JJ, Scheeren TWL. Intraoperative hypotension and its prediction. Indian J Anaesth 2019; 63:877-885. [PMID: 31772395 PMCID: PMC6868662 DOI: 10.4103/ija.ija_624_19] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 09/17/2019] [Accepted: 10/06/2019] [Indexed: 12/11/2022] Open
Abstract
Intraoperative hypotension (IOH) very commonly accompanies general anaesthesia in patients undergoing major surgical procedures. The development of IOH is unwanted, since it is associated with adverse outcomes such as acute kidney injury and myocardial injury, stroke and mortality. Although the definition of IOH is variable, harm starts to occur below a mean arterial pressure (MAP) threshold of 65 mmHg. The odds of adverse outcome increase for increasing duration and/or magnitude of IOH below this threshold, and even short periods of IOH seem to be associated with adverse outcomes. Therefore, reducing the hypotensive burden by predicting and preventing IOH through proactive appropriate treatment may potentially improve patient outcome. In this review article, we summarise the current state of the prediction of IOH by the use of so-called machine-learning algorithms. Machine-learning algorithms that use high-fidelity data from the arterial pressure waveform, may be used to reveal 'traits' that are unseen by the human eye and are associated with the later development of IOH. These algorithms can use large datasets for 'training', and can subsequently be used by clinicians for haemodynamic monitoring and guiding therapy. A first clinically available application, the hypotension prediction index (HPI), is aimed to predict an impending hypotensive event, and additionally, to guide appropriate treatment by calculated secondary variables to asses preload (dynamic preload variables), contractility (dP/dtmax), and afterload (dynamic arterial elastance, Eadyn). In this narrative review, we summarise the current state of the prediction of hypotension using such novel, automated algorithms and we will highlight HPI and the secondary variables provided to identify the probable origin of the (impending) hypotensive event.
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Affiliation(s)
- Jaap J Vos
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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An R, Pang QY, Liu HL. Association of intra-operative hypotension with acute kidney injury, myocardial injury and mortality in non-cardiac surgery: A meta-analysis. Int J Clin Pract 2019; 73:e13394. [PMID: 31332896 DOI: 10.1111/ijcp.13394] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 07/01/2019] [Accepted: 07/17/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Intra-operative hypotension might induce poor postoperative outcomes in non-cardiac surgery, and the relationship between the level or duration of Intra-operative hypotension (IOH) and postoperative adverse events is still unclear. In this study, we performed a meta-analysis to determine how IOH could affect acute kidney injury (AKI), myocardial injury and mortality in non-cardiac surgery. METHODS We searched PubMed (Medline), Embase, Springer, The Cochrane Library, Ovid and Google Scholar, and retrieved the related clinical trials on intra-operative hypotension and prognosis in non-cardiac surgery. RESULTS Fifteen observational studies were included. The meta-analysis showed that in non-cardiac surgery, intra-operative hypotension (mean arterial pressure [MAP]) <60 mm Hg for more than 1 minute was associated with an increased risk of postoperative acute kidney injury(AKI) [1-5 minutes: odds ratio (OR) = 1.13, 95% CI (1.04, 1.23), I2 = 0, P = .003; 5-10 minutes: OR = 1.18, 95% CI (1.07, 1.31), I2 = 0, P = .001; >10 minutes: OR = 1.35, 95% CI (1.1, 1.67), I2 = 52.6%, P = .004] and myocardial injury [1-5 minutes: OR = 1.16, 95% CI (1.01, 1.33), I2 = 30.6%, P = .04; 5-10 minutes: OR = 1.34, 95% CI (1.01, 1.77), I2 = 70.4%, P = .046; >10 minutes: OR = 1.43, 95% CI (1.18, 1.72), I2 = 39.4%, P < .0001]. Intra-operative hypotension (MAP < 60 mm Hg) for 1-5 minutes was not associated with postoperative 30-day mortality [OR = 1.15, 95% CI (0.95, 1.4), I2 = 0, P = .154], but intra-operative hypotension (MAP < 60 mm Hg) for more than 5 min was associated with an increased risk of postoperative 30-day mortality [OR = 1.11, 95% CI (1.06, 1.17), I2 = 51.9%, P < .0001]. CONCLUSION Intra-operative hypotension was associated with an increased risk of postoperative AKI, myocardial injury and 30-day mortality in non-cardiac surgery. Intra-operative MAP < 60 mm Hg more than 1 minute should be avoided.
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Affiliation(s)
- Ran An
- Department of Anesthesiology, Chongqing University Cancer Hospital/Chongqing Cancer Institute/Chongqing Cancer Center, Chongqing City, 400030, China
| | - Qian-Yun Pang
- Department of Anesthesiology, Chongqing University Cancer Hospital/Chongqing Cancer Institute/Chongqing Cancer Center, Chongqing City, 400030, China
| | - Hong-Liang Liu
- Department of Anesthesiology, Chongqing University Cancer Hospital/Chongqing Cancer Institute/Chongqing Cancer Center, Chongqing City, 400030, China
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Schäfer P, Fahlenkamp A, Rossaint R, Coburn M, Kowark A. Better haemodynamic stability under xenon anaesthesia than under isoflurane anaesthesia during partial nephrectomy - a secondary analysis of a randomised controlled trial. BMC Anesthesiol 2019; 19:125. [PMID: 31288740 PMCID: PMC6617591 DOI: 10.1186/s12871-019-0799-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 07/03/2019] [Indexed: 11/12/2022] Open
Abstract
Background Renal dysfunction following intraoperative arterial hypotension is mainly caused by an insufficient renal blood flow. It is associated with higher mortality and morbidity rates. We hypothesised that the intraoperative haemodynamics are more stable during xenon anaesthesia than during isoflurane anaesthesia in patients undergoing partial nephrectomy. Methods We performed a secondary analysis of the haemodynamic variables collected during the randomised, single-blinded, single-centre PaNeX study, which analysed the postoperative renal function in 46 patients who underwent partial nephrectomy. The patients received either xenon or isoflurane anaesthesia with 1:1 allocation ratio. We analysed the duration of the intraoperative systolic blood pressure decrease by > 40% from baseline values and the cumulative duration of a mean arterial blood pressure (MAP) of < 65 mmHg as primary outcomes. The secondary outcomes were related to other blood pressure thresholds, the amount of administered norepinephrine, and the analysis of confounding factors on the haemodynamic stability. Results The periods of an MAP of < 65 mmHg were significantly shorter in the xenon group than in the isoflurane group. The medians [interquartile range] were 0 [0–10.0] and 25.0 [10.0–47.5] minutes, for the xenon and isoflurane group, respectively (P = 0.002). However, the cumulative duration of a systolic blood pressure decrease by > 40% did not significantly differ between the groups (P = 0.51). The periods with a systolic blood pressure decrease by 20% from baseline, MAP decrease to values < 60 mmHg, and the need for norepinephrine, as well as the cumulative dose of norepinephrine were significantly shorter and lower, respectively, in the xenon group. The confounding factors, such as demographic data, surgical technique, or anaesthesia data, were similar in the two groups. Conclusion The patients undergoing xenon anaesthesia showed a better haemodynamic stability, which might be attributed to the xenon properties. The indirect effect of xenon anaesthesia might be of importance for the preservation of renal function during renal surgery and needs further elaboration. Trial registration ClinicalTrials.gov: NCT01839084. Registered 24 April 2013. Electronic supplementary material The online version of this article (10.1186/s12871-019-0799-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Patrick Schäfer
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Astrid Fahlenkamp
- Department of Anaesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Mark Coburn
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Ana Kowark
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
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Joosten A, Alexander B, Duranteau J, Taccone FS, Creteur J, Vincent JL, Cannesson M, Rinehart J. Feasibility of closed-loop titration of norepinephrine infusion in patients undergoing moderate- and high-risk surgery. Br J Anaesth 2019; 123:430-438. [PMID: 31255290 DOI: 10.1016/j.bja.2019.04.064] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/09/2019] [Accepted: 05/08/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Vasopressor agents are used to prevent intraoperative hypotension and ensure adequate perfusion. Vasopressors are usually administered as intermittent boluses or manually adjusted infusions, but this practice requires considerable time and attention. We have developed a closed-loop vasopressor (CLV) controller to correct hypotension more efficiently. Here, we conducted a proof-of-concept study to assess the feasibility and performance of CLV control in surgical patients. METHODS Twenty patients scheduled for elective surgical procedures were included in this study. The goal of the CLV system was to maintain MAP within 5 mm Hg of the target MAP by automatically adjusting the rate of a norepinephrine infusion using MAP values recorded continuously from an arterial catheter. The primary outcome was the percentage of time that patients were hypotensive, as defined by a MAP of 5 mm Hg below the chosen target. Secondary outcomes included the total dose of norepinephrine, percentage of time with hypertension (MAP>5 mm Hg of the chosen target), raw percentage "time in target" and Varvel performance criteria. RESULTS The 20 subjects (median age: 64 years [52-71]; male (35%)) underwent elective surgery lasting 154 min [124-233]. CLV control maintained MAP within ±5 mm Hg of the target for 91.6% (85.6-93.3) of the intraoperative period. Subjects were hypotensive for 2.6% of the intraoperative period (range, 0-8.4%). Additional performance criteria for the controller included mean absolute performance error of 2.9 (0.8) and mean predictive error of 0.5 (1.0). No subjects experienced major complications. CONCLUSIONS In this proof of concept study, CLV control minimised perioperative hypotension in subjects undergoing moderate- or high-risk surgery. Further studies to demonstrate efficacy are warranted. TRIAL REGISTRY NUMBER NCT03515161 (ClinicalTrials.gov).
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology and Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France.
| | - Brenton Alexander
- Department of Anesthesiology, University of California-San Diego, San Diego, CA, USA
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California-Irvine, Irvine, CA, USA
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Abstract
Older people are the fastest growing segment of the population and over-represented among people requiring emergency general surgery. Independent of comorbid and procedural factors, perioperative risk increases with increasing age. This effect is amplified with frailty or sarcopenia. Multidisciplinary perioperative care aligned with goals of care is most likely to achieve optimal patient and health system outcomes; however, substantial knowledge gaps exist in emergency general surgery for older people. Anesthesiologists are uniquely positioned to address these knowledge gaps, including optimizing goal-directed intraoperative care, appropriate provision of acute postoperative monitoring, and integration of principles of geriatric medicine in perioperative care.
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Continuous Noninvasive Arterial Pressure Monitoring in Obese Patients During Bariatric Surgery. Anesth Analg 2019; 128:477-483. [DOI: 10.1213/ane.0000000000003943] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mukai A, Suehiro K, Kimura A, Funai Y, Matsuura T, Tanaka K, Yamada T, Mori T, Nishikawa K. Comparison of the venous–arterial CO2 to arterial–venous O2 content difference ratio with the venous–arterial CO2 gradient for the predictability of adverse outcomes after cardiac surgery. J Clin Monit Comput 2019; 34:41-53. [DOI: 10.1007/s10877-019-00286-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/13/2019] [Indexed: 01/24/2023]
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Verbree-Willemsen L, Grobben RB, van Waes JAR, Peelen LM, Nathoe HM, van Klei WA, Grobbee DE. Causes and prevention of postoperative myocardial injury. Eur J Prev Cardiol 2019; 26:59-67. [PMID: 30207484 PMCID: PMC6287250 DOI: 10.1177/2047487318798925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/14/2018] [Indexed: 01/10/2023]
Abstract
Over the past few years non-cardiac surgery has been recognised as a serious circulatory stress test which may trigger cardiovascular events such as myocardial infarction, in particular in patients at high risk. Detection of these postoperative cardiovascular events is difficult as clinical symptoms often go unnoticed. To improve detection, guidelines advise to perform routine postoperative assessment of cardiac troponin. Troponin elevation - or postoperative myocardial injury - can be caused by myocardial infarction. However, also non-coronary causes, such as cardiac arrhythmias, sepsis and pulmonary embolism, may play a role in a considerable number of patients with postoperative myocardial injury. It is crucial to acquire more knowledge about the underlying mechanisms of postoperative myocardial injury because effective prevention and treatment options are lacking. Preoperative administration of beta-blockers, aspirin, statins, clonidine, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and preoperative revascularisation have all been investigated as preventive options. Of these, only statins should be considered as the initiation or reload of statins may reduce the risk of postoperative myocardial injury. There is also not enough evidence for intraoperative measures such blood pressure optimisation or intensified medical therapy once patients have developed postoperative myocardial injury. Given the impact, better preoperative identification of patients at risk of postoperative myocardial injury, for example using preoperatively measured biomarkers, would be helpful to improve cardiac optimisation.
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Affiliation(s)
- Laura Verbree-Willemsen
- Department of Epidemiology, Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht,
Utrecht University, The Netherlands
| | - Remco B Grobben
- Department of Cardiology, University
Medical Center Utrecht, Utrecht University, The Netherlands
| | - Judith AR van Waes
- Department of Anaesthesiology,
University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Linda M Peelen
- Department of Epidemiology, Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht,
Utrecht University, The Netherlands
- Department of Anaesthesiology,
University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Hendrik M Nathoe
- Department of Cardiology, University
Medical Center Utrecht, Utrecht University, The Netherlands
| | - Wilton A van Klei
- Department of Anaesthesiology,
University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Diederick E Grobbee
- Department of Epidemiology, Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht,
Utrecht University, The Netherlands
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50
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Meng L, Yu W, Wang T, Zhang L, Heerdt PM, Gelb AW. Blood Pressure Targets in Perioperative Care. Hypertension 2018; 72:806-817. [DOI: 10.1161/hypertensionaha.118.11688] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Lingzhong Meng
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, CT (L.M., P.M.H.)
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, China (W.Y.)
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (T.W.)
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan Province, China (L.Z.)
| | - Paul M. Heerdt
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, CT (L.M., P.M.H.)
| | - Adrian W. Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (A.W.G.)
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