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Gurunathan U, Roe A, Milligan C, Hay K, Ravichandran G, Chawla G. Preoperative Renin-Angiotensin System Antagonists Intake and Blood Pressure Responses During Ambulatory Surgical Procedures: A Prospective Cohort Study. Anesth Analg 2024; 138:763-774. [PMID: 38236756 DOI: 10.1213/ane.0000000000006728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND There is limited evidence to inform the association between the intake of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) and intraoperative blood pressure (BP) changes in an ambulatory surgery population. METHODS Adult patients who underwent ambulatory surgery and were discharged on the same day or within 24 hours of their procedure were enrolled in this prospective cohort study. The primary outcome of the study was early intraoperative hypotension (first 15 minutes of induction). Secondary outcomes included any hypotension, BP variability, and recovery. Hypotension was defined as a decrease in systolic BP of >30% from baseline for ≥5 minutes or a mean BP of <55 mm Hg. Four exposure groups were compared (no antihypertensives, ACEI/ARB intake <10 hours before surgery, ACEI/ARB intake ≥10 hours before surgery, and other antihypertensives). RESULTS Of the 537 participants, early hypotension was observed in 25% (n = 134), and any hypotension in 41.5% (n = 223). Early hypotension occurred in 30% (29 of 98) and 41% (17 of 41) with the intake of ACEI/ARBs <10 and ≥10 hours before surgery, respectively, compared to 30% (9 of 30) with other antihypertensives and 21% (79 of 368) with no antihypertensives ( P = .02). Those on antihypertensives also experienced any hypotension more frequently than those who were not on antihypertensives ( P < .001). After adjusting for age and baseline BP in a regression analysis, antihypertensive exposure groups were observed to be associated only with any intraoperative hypotension ( P = .012). In the ACEI/ARB subset, there was no evidence of an association between time since the last ACEI/ARB dose, and hypotension or minimum mean or systolic BP. Compared to normal baseline BP, BP ≥ 140/90 mm Hg increased the odds of early and any hypotension (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.1-7.1 and OR, 7.7; 95% CI, 3.7-14.9, respectively; P < .001). Intraoperative variability in systolic and diastolic BP demonstrated significant differences with age, baseline BP, and antihypertensive exposure group ( P < .001). CONCLUSIONS Early and any hypotension occurred more frequently in those on antihypertensives than those not on antihypertensives. Unadjusted associations between antihypertensive exposure and intraoperative hypotension were largely explained by baseline hypertension rather than the timing of ACEI/ARBs or type of antihypertensive exposure. Patients with hypertension and on treatment experience more intraoperative BP variability and should be monitored appropriately.
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Affiliation(s)
- Usha Gurunathan
- From the Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Adrian Roe
- Department of Urology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Caitlin Milligan
- From the Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Karen Hay
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Gowri Ravichandran
- Department of Anaesthesia, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Gunjan Chawla
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia, Caboolture Hospital, Caboolture, Queensland, Australia
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Ma J, Zhang Y, Ge Q, Wu K. The effect of auricular acupuncture on preoperative blood pressure across age groups: a prospective randomized controlled trial. Clin Exp Hypertens 2023; 45:2169452. [PMID: 36681906 DOI: 10.1080/10641963.2023.2169452] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE To determine the effect of auricular acupuncture on preoperative blood pressure (BP) elevation in different age groups. MATERIALS AND METHODS Auricular acupuncture treats elevated BP among patients before surgery. This prospective, randomized clinical trial was performed at Li Huili Hospital of Ningbo Medical Center, China, from January to June 2021. We prospectively enrolled 120 patients with elevated BP aged 45 to 75 and observed them in the inpatient department. Patients were randomly assigned in a 1:1 ratio to undergo auricular acupuncture or sham control groups. In addition to usual care, the study group underwent auricular acupuncture bilaterally at HX6 7i-Ear apex, TF4-Shen men, TF1-Superior triangular fossa, and CO15-Heart. RESULTS A total of 120 patients completed the study, 60 in the study group and 60 in the control group. Of these, 76 (63.3%) were men, and the mean (standard deviation) was 64.55 (9.48) years. The differences in systolic BP comparisons after intervention were significant (7.88 mmHg; 95% confidence interval [CI], 2.94 to 12.81; P = .002). Diastolic BP also showed statistical significance (5.85 mmHg; 95% CI, 3.05 to 8.64; P < .01. Neither AA-related adverse events nor serious adverse events occurred. Stratified by age, the differences comparisons of systolic BP (-10.13 mmHg; 95% confidence interval [CI], -16.69 to -3.57; P < .01) and diastolic BP (-7.65 mmHg; 95% confidence interval [CI], -11.17 to -4.14; P < .01) were statistically significant for participants aged 60-75 years; The differences comparison of systolic BP (-2.37 mmHg; 95% confidence interval [CI], -8.04 to 3.31; P = .40) and diastolic BP (-1.46 mmHg; 95% confidence interval [CI], -5.68 to 2.76; P = .48) were not significant aged 45-59. CONCLUSION Auricular acupuncture can reduce BP before procedures. However, further research is needed on the antihypertensive effect on people aged 45-59. These findings provide clinicians with evidence of auricular acupuncture as a standard adjunctive therapy targeting this patient population.
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Affiliation(s)
- Jingjing Ma
- Department of Nursing, Ningbo Medical Center LiHuili Hospital, Ningbo, China
| | - Yiqing Zhang
- Department of Nursing, Ningbo Medical Center LiHuili Hospital, Ningbo, China
| | - Qingqing Ge
- Department of Nursing, Ningbo Medical Center LiHuili Hospital, Ningbo, China
| | - Keer Wu
- Department of Nursing, Ningbo Medical Center LiHuili Hospital, Ningbo, China
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Urbonas T, Lakha AS, King E, Pepes S, Ceresa C, Udupa V, Soonawalla Z, Silva MA, Gordon-Weeks A, Reddy S. The safety of telemedicine clinics as an alternative to in-person preoperative assessment for elective laparoscopic cholecystectomy in patients with benign gallbladder disease: a retrospective cohort study. Patient Saf Surg 2023; 17:23. [PMID: 37644474 PMCID: PMC10466851 DOI: 10.1186/s13037-023-00368-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/06/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The telemedicine clinic for follow up after minor surgical procedures in general surgery is now ubiquitously considered a standard of care. However, this method of consultation is not the mainstay for preoperative assessment and counselling of patients for common surgical procedures such as laparoscopic cholecystectomy. The aim of this study was to evaluate the safety of assessing and counselling patients in the telemedicine clinic without a physical encounter for laparoscopic cholecystectomy. METHODS We conducted a retrospective analysis of patients who were booked for laparoscopic cholecystectomy for benign gallbladder disease via general surgery telemedicine clinics from March 2020 to November 2021. The primary outcome was the cancellation rate on the day of surgery. The secondary outcomes were complication and readmission rates, with Clavein-Dindo grade III or greater deemed clinically significant. We performed a subgroup analysis on the cases cancelled on the day of surgery in an attempt to identify key reasons for cancellation following virtual clinic assessment. RESULTS We identified 206 cases booked for laparoscopic cholecystectomy from telemedicine clinics. 7% of patients had a cancellation on the day of surgery. Only one such cancellation was deemed avoidable as it may have been prevented by a face-to-face assessment. Severe postoperative adverse events (equal to or greater than Clavien-Dindo grade III) were observed in 1% of patients, and required re-intervention. 30-day readmission rate was 11%. CONCLUSIONS Our series showed that it is safe and feasible to assess and counsel patients for laparoscopic cholecystectomy remotely with a minimal cancellation rate on the day of operation. Further work is needed to understand the effect of remote consultations on patient satisfaction, its environmental impact, and possible benefits to healthcare economics to support its routine use in general surgery.
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Affiliation(s)
- Tomas Urbonas
- Department of hepatobiliary surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Adil Siraj Lakha
- Department of hepatobiliary surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Emily King
- Department of hepatobiliary surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Sophia Pepes
- Department of hepatobiliary surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Carlo Ceresa
- Department of hepatobiliary surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Venkatesha Udupa
- Department of hepatobiliary surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Zahir Soonawalla
- Department of hepatobiliary surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Michael A Silva
- Department of hepatobiliary surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Alex Gordon-Weeks
- Department of hepatobiliary surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Srikanth Reddy
- Department of hepatobiliary surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
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Adugna D, Worku T, Hiko A, Dheresa M, Letta S, Sertsu A, Kibret H. Cancellation of elective surgery and associated factors among patients scheduled for elective surgeries in public hospitals in Harari regional state, Eastern Ethiopia. Front Med (Lausanne) 2023; 10:1036393. [PMID: 37081837 PMCID: PMC10111426 DOI: 10.3389/fmed.2023.1036393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 03/20/2023] [Indexed: 04/07/2023] Open
Abstract
BackgroundCanceling elective surgeries is a significant problem in many hospitals leading to patient dissatisfaction, increased costs, and emotional trauma for patients and their families. Despite this, there is limited information about the cancellation of elective surgeries in Ethiopia, mainly in the study area.ObjectiveThis study aimed to assess the magnitude of cancellation and associated factors among patients scheduled for elective surgeries in public hospitals in the Harari Regional State, Eastern Ethiopia, from 1 August to 30 August 2021.MethodsA hospital-based cross-sectional study was conducted on 378 patients scheduled for elective surgeries. Data were gathered using a non-random sequential sampling approach. In addition, a structured face-to-face interviewer-administered questionnaire was employed. The gathered information was input into Epidata version 3.1 and then exported to Statistical Package for Social Software version 26. To find the variables associated with the cancellation of elective surgeries, binary and multi-variable logistic regression analyses were conducted. In the binary analysis, all variables with a p-value of less than 0.25 were included in the multivariable analysis. Finally, a 0.05 p-value with a 95% confidence interval and an adjusted odds ratio was used to declare a significant association.ResultsThis study included 378 patients scheduled for elective surgeries. Among those, 35.2% of the surgeries were canceled (95% confidence interval: 29.4–39.6). Being female (adjusted odds ratio: 2.46; 95% confidence interval: 1.44–4.203), lack of formal education (adjusted odds ratio: 2.03; 95% confidence interval: 1.15–3.58), place of residence (adjusted odds ratio: 1.70; 95% confidence interval: 1.03–2.81), increase in blood pressure (adjusted odds ratio: 5.09; 95% confidence interval:1.90–13.59), and ophthalmologic surgery (adjusted odds ratio: 3.76; 95% confidence interval: 1.41–10.0) were factors associated with the cancellation of elective surgeries.ConclusionIn this study, nearly one third of scheduled elective surgery was canceled. The primary contributing variables to the surgery cancellations were being female, lack of formal education, place of residence, ophthalmologic surgery, and increased blood pressure. Therefore, timely evidence-based reporting through the supervision team was advised to decrease cancellations.
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Cardiac assessment and management in older surgical patients. Int Anesthesiol Clin 2023; 61:1-7. [PMID: 36892982 DOI: 10.1097/aia.0000000000000393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Zhou T, Ma T, Gu Y, Zhang L, Che W, Wang Y. Percutaneous Transforaminal Endoscopic Surgery (PTES) for Treatment of Lumbar Degenerative Disease in Patients with Underlying Diseases: A Retrospective Cohort Study of 196 Cases. J Pain Res 2023; 16:1137-1147. [PMID: 37025953 PMCID: PMC10072145 DOI: 10.2147/jpr.s396993] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 03/07/2023] [Indexed: 04/03/2023] Open
Abstract
Objective To evaluate the postoperative outcomes, safety and feasibility of percutaneous transforaminal endoscopic surgery (PTES) for the treatment of lumbar degenerative disease (LDD) in the patients with underlying diseases. Methods From June 2017 to April 2019, PTES was performed to treat 226 patients of single-level LDD. According to clinical background, the patients were divided into two groups. A total of 102 patients with underlying diseases were included in group A. The other 124 LDD patients without underlying diseases were included in group B. The occurrence of postoperative complications was recorded. Leg pain was assessed before, immediately, 1 month, 2 months, 3 months, 6 months, 1 year, and 2 years after PTES using VAS, and ODI before PTES and 2 years after PTES were recorded. The therapeutic quality (Excellent, Good, Moderate or Poor) was defined according to MacNab grade at 2-year follow-up. Results No aggravation of underlying diseases or serious complications was observed in all patients within 6 months after the operation. Altogether, 196 patients were followed up for more than 2 years, 89 patients in group A and 107 patients in group B. The VAS score of leg pain and ODI dropped significantly after surgery (P<0.001) in both groups. One case of group B received PTES again due to recurrence 52 months after surgery. According to MacNab, the excellent and good rate was 97.75% (87/89) in group A and 96.26% (103/107) in group B. In operative duration, frequency of intraoperative fluoroscopy, blood loss, incision length, hospital stay, VAS, ODI, and the excellent and good rate, there was no statistical difference between the two groups. Conclusion PTES is safe, effective and feasible for the treatment of LDD with underlying diseases, which is comparable to PTES for LDD without underlying diseases. The entrance point of PTES (Gu's Point) is located at the corner of the flat back turning to the lateral side. PTES is not only a minimally invasive surgical technique but also includes a postoperative care system for preventing LDD recurrence.
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Affiliation(s)
- Tianyao Zhou
- Department of Orthopedic Surgery, Zhongshan Hospital Fudan University, Shanghai, 200032, People’s Republic of China
- Shanghai Southwest Spine Surgery Center, Shanghai, 200032, People’s Republic of China
| | - Tianle Ma
- Department of Orthopedic Surgery, Zhongshan Hospital Fudan University, Shanghai, 200032, People’s Republic of China
- Shanghai Southwest Spine Surgery Center, Shanghai, 200032, People’s Republic of China
| | - Yutong Gu
- Department of Orthopedic Surgery, Zhongshan Hospital Fudan University, Shanghai, 200032, People’s Republic of China
- Shanghai Southwest Spine Surgery Center, Shanghai, 200032, People’s Republic of China
- Correspondence: Yutong Gu, Email
| | - Liang Zhang
- Department of Orthopedic Surgery, Zhongshan Hospital Fudan University, Shanghai, 200032, People’s Republic of China
| | - Wu Che
- Department of Orthopedic Surgery, Zhongshan Hospital Fudan University, Shanghai, 200032, People’s Republic of China
| | - Yichao Wang
- Department of Orthopedic Surgery, Zhongshan Hospital Fudan University, Shanghai, 200032, People’s Republic of China
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Smith RL, Ward PA. Anaesthesia for ear surgery. ANAESTHESIA & INTENSIVE CARE MEDICINE 2023. [DOI: 10.1016/j.mpaic.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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Partridge JSL, Ryan J, Dhesi JK, Barker C, Bates L, Bell R, Bryden D, Carter S, Clegg A, Conroy S, Cowley A, Curtis A, Diedo B, Eardley W, Evley R, Hare S, Hopper A, Humphry N, Kanga K, Kilvington B, Lees NP, McDonald D, McGarrity L, McNally S, Meilak C, Mudford L, Nolan C, Pearce L, Price A, Proffitt A, Romano V, Rose S, Selwyn D, Shackles D, Syddall E, Taylor D, Tinsley S, Vardy E, Youde J. New guidelines for the perioperative care of people living with frailty undergoing elective and emergency surgery-a commentary. Age Ageing 2022; 51:6847803. [PMID: 36436009 DOI: 10.1093/ageing/afac237] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/02/2022] [Indexed: 11/28/2022] Open
Abstract
Frailty is common in the older population and is a predictor of adverse outcomes following emergency and elective surgery. Identification of frailty is key to enable targeted intervention throughout the perioperative pathway from contemplation of surgery to recovery. Despite evidence on how to identify and modify frailty, such interventions are not yet routine perioperative care. To address this implementation gap, a guideline was published in 2021 by the Centre for Perioperative Care and the British Geriatrics Society, working with patient representatives and all stakeholders involved in the perioperative care of patients with frailty undergoing surgery. The guideline covers all aspects of perioperative care relevant to adults living with frailty undergoing elective and emergency surgery. It is written for healthcare professionals, as well as for patients and their carers, managers and commissioners. Implementation of the guideline will require collaboration between all stakeholders, underpinned by an implementation strategy, workforce development with supporting education and training resources, and evaluation through national audit and research. The guideline is an important step in improving perioperative outcomes for people living with frailty and quality of healthcare services. This commentary provides a summary and discussion of the evidence informing the standards and recommendations in the published guideline.
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Affiliation(s)
- Judith S L Partridge
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Life Course and Population Sciences, King's College London London, UK
| | - Jack Ryan
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jugdeep K Dhesi
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Life Course and Population Sciences, King's College London London, UK
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Young S, Basavaraju A. General anaesthesia for ophthalmic surgery. ANAESTHESIA & INTENSIVE CARE MEDICINE 2022. [DOI: 10.1016/j.mpaic.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Núñez-Gil IJ, Travieso-González A, Riha H, Ramakrishna H. Device-Based Therapies for Resistant Hypertension: Implications for the Perioperative Clinician. J Cardiothorac Vasc Anesth 2022; 36:3250-3256. [PMID: 35031217 DOI: 10.1053/j.jvca.2021.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Iván J Núñez-Gil
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Hynek Riha
- Cardiothoracic Anesthesiology and Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Spiro C, Bennet S, Bhatia K. META‐ANALYSIS OF PATIENT RISK FACTORS ASSOCIATED WITH POST‐BARIATRIC SURGERY LEAK. Obes Sci Pract 2022; 9:112-126. [PMID: 37034561 PMCID: PMC10073826 DOI: 10.1002/osp4.628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/11/2022] Open
Abstract
Objective Modifiable risk factors such as diabetes, hyperlipidemia, hypertension, obstructive sleep apnea (OSA), chronic kidney disease (CKD), chronic steroid use and smoking, have been shown in observational studies to negatively affect surgical outcomes. The purpose of this study is to identify and determine the effect of modifiable risk factors on post-operative bariatric surgery leak, as pre-operative risk modification has been shown to reduce the impact on complications. Methods Electronic literature searches of MEDLINE, PUBMED, OVID and Cochrane Library databases were performed, including a manual reference check, over the period of 2010 and 2020. 620 articles were screened according to the PRISMA protocol. Results Twenty articles were included in the meta-analysis of risk factors. Significant risk factors and the associated effect sizes include: 1. Smoking with an overall OR of 1.31 [1.06, 1.61] and an OR of 1.72 [1.44, 2.05] in Sleeve gastrectomy (SG) patient cohorts; 2. Diabetes with an overall OR of 1.23 [1.08, 1.39] and an OR of 1.33 [1.02, 1.73] in Roux-en-Y patient cohorts; 3. Chronic kidney disease with an overall OR of 2.41 [1.62, 3.59] and 4. Steroid use with an overall OR of 1.57 [1.22, 2.02]. Non-significant risk factors include hypertension with an OR of 0.85, 1.83, OSA with an OR of 1.08 [0.83, 1.39] and hyperlipidemia with an OR of 0.80 [0.61, 1.04]. Combined SG and Roux-en-Y patient cohorts with hyperlipidemia have shown a protective effect of 0.78 [0.65, 0.94]. Conclusions Significant risk factors for leak post bariatric surgery are smoking in all patients and particularly SG patients, diabetes for all patients and particularly Roux-en-Y patients, and CKD and chronic steroid for all patients. Hyperlipidemia in two combined patient cohorts (SG and Roux-en-Y) appears to have a weak protective effect.
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Affiliation(s)
- Calista Spiro
- Austin Health Heidelberg VIC
- Calvary Bruce Private Hospital Bruce ACT
| | | | - Kiron Bhatia
- Austin Health Heidelberg VIC
- Heidelberg Weight Loss Surgery, Heidelberg Australia
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Sweitzer B. Preoperative Evaluation Can Delay Ophthalmologic Surgery Without Improving Outcomes. Ann Intern Med 2022; 175:747-748. [PMID: 35313111 DOI: 10.7326/m22-0709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- BobbieJean Sweitzer
- Inova Health, Falls Church, and Department of Medical Education, University of Virginia, Charlottesville, Virginia
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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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Balcı E, Demir ZA, Bahçecitapar M. Management of renin-angiotensin-aldosterone inhibitors and other antihypertensives and their clinical effects on pre-anesthesia blood pressure. Anesth Pain Med (Seoul) 2022; 17:112-119. [PMID: 34991190 PMCID: PMC8841255 DOI: 10.17085/apm.21050] [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: 05/22/2021] [Accepted: 10/23/2021] [Indexed: 11/28/2022] Open
Abstract
Background Blood pressure fluctuations appear more significant in patients with poorly controlled hypertension and are known to be associated with adverse perioperative morbidity. In the present study, we aimed to determine the effects of antihypertensive drug treatment strategies on preanesthetic operating room blood pressure measurements. Methods A total of 717 patients participated in our study; 383 patients who were normotensive based on baseline measurements and not under antihypertensive therapy were excluded from the analysis. The remaining 334 patients were divided into six groups according to the antihypertensive drug treatment. These six groups were examined in terms of preoperative baseline and pre-anesthesia blood pressure measurements. Results As a result of the study, it was observed that 24% of patients had high blood pressure precluding surgery, and patients using renin-angiotensin-aldosterone system inhibitors (RAASI) had higher pre-anesthesia systolic blood pressure than patients using other antihypertensive drugs. Patients who received beta-blockers were also observed to have the lowest pre-anesthesia systolic blood pressure, diastolic blood pressure, and mean blood pressure, compared to others. Conclusions Recently, whether RAASI should be continued preoperatively remains controversial. Our study shows that RAASI cannot provide optimal pre-anesthesia blood pressure and lead to an increase in the number of postponed surgeries, probably due to withdrawal of medication before the operation. Therefore, the preoperative discontinuation of RAASI should be reevaluated in future studies.
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Affiliation(s)
- Eda Balcı
- Department of Anesthesiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Zeliha Aslı Demir
- Department of Anesthesiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
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Rajan N, Rosero EB, Joshi GP. Patient Selection for Adult Ambulatory Surgery: A Narrative Review. Anesth Analg 2021; 133:1415-1430. [PMID: 34784328 DOI: 10.1213/ane.0000000000005605] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.
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Affiliation(s)
- Niraja Rajan
- From the Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Eric B Rosero
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
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Sweitzer B, Rajan N, Schell D, Gayer S, Eckert S, Joshi GP. Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement. Anesth Analg 2021; 133:1431-1436. [PMID: 34784329 DOI: 10.1213/ane.0000000000005652] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cataract surgeries are among the most common procedures requiring anesthesia care. Cataracts are a common cause of blindness. Surgery remains the only effective treatment of cataracts. Patients are often elderly with comorbidities. Most cataracts can be treated using topical or regional anesthesia with minimum or no sedation. There is minimal risk of adverse outcomes. There is general consensus that cataract surgery is extremely low risk, and the benefits of sight restoration and preservation are enormous. We present the Society for Ambulatory Anesthesia (SAMBA) position statement for preoperative care for cataract surgery.
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Affiliation(s)
- BobbieJean Sweitzer
- From the Departments of Anesthesiology and Surgical Services, Inova Health System, Falls Church, Virginia
| | - Niraja Rajan
- Hershey Outpatient Surgery Center, Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Dawn Schell
- Cole Eye and Anesthesiology Institutes, Cleveland Clinic, Cleveland, Ohio, Cleveland, Ohio
| | - Steven Gayer
- Department of Anesthesiology, University of Miami's Miller School of Medicine, Miami, Florida
| | - Stan Eckert
- Regional Medical Director Ambulatory Surgery Division, Hospital Corporation of America, Austin, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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17
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Tait A, Howell SJ. Preoperative hypertension: perioperative implications and management. BJA Educ 2021; 21:426-432. [PMID: 34707888 DOI: 10.1016/j.bjae.2021.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- A Tait
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S J Howell
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Medical Research at St James's, St James's University Hospital, Leeds, UK
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18
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Eley VA, Thuzar M, Navarro S, Dodd BR, Zundert AAV. Obesity, metabolic syndrome, and inflammation: an update for anaesthetists caring for patients with obesity. Anaesth Crit Care Pain Med 2021; 40:100947. [PMID: 34534700 DOI: 10.1016/j.accpm.2021.100947] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/11/2021] [Accepted: 03/20/2021] [Indexed: 11/25/2022]
Abstract
Our understanding of chronic inflammation in obesity is evolving. Suggested mechanisms include hypoxia of adipose tissue and a subsequent increase in circulating cytokines. It is now known that adipose tissue, far from being an inert tissue, produces and secretes multiple peptides that influence inflammation and metabolism, including substrates of the renin-angiotensin-aldosterone system (RAAS). RAAS blocking antihypertensive medication and cholesterol-lowering agents are now being evaluated for their metabolic and inflammation-modulating effects. Surgery also has pro-inflammatory effects, which may be exacerbated in patients with obesity. This narrative review will summarise the recent literature surrounding obesity, metabolic syndrome, inflammation, and interplay with the RAAS, with evidence-based recommendations for the optimisation of patients with obesity, prior to surgery and anaesthesia.
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Affiliation(s)
- Victoria A Eley
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, 4006 Queensland, Australia; Faculty of Medicine, The University of Queensland, St Lucia, 4067 Queensland, Australia.
| | - Moe Thuzar
- Faculty of Medicine, The University of Queensland, St Lucia, 4067 Queensland, Australia; Department of Endocrinology and Diabetes, Princess Alexandra Hospital, Ipswich Road Woolloongabba, 4102 Queensland, Australia; Endocrine Hypertension Research Centre, The University of Queensland Diamantina Institute, Ipswich Road Woolloongabba, 4102 Queensland, Australia
| | - Séverine Navarro
- Department of Immunology, QIMR Berghofer Medical Research Institute Herston Rd, Herston, 4006 Queensland, Australia; Woolworths Centre for Childhood Nutrition Research, Faculty of Health, School of Exercise and Nutrition Sciences, Queensland University of Technology, Kelvin Grove, 4059 Queensland, Australia
| | - Benjamin R Dodd
- Faculty of Medicine, The University of Queensland, St Lucia, 4067 Queensland, Australia; Department of Upper GI and Bariatric Surgery, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, 4006 Queensland, Australia
| | - André A Van Zundert
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, 4006 Queensland, Australia; Faculty of Medicine, The University of Queensland, St Lucia, 4067 Queensland, Australia
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Czajka S, Putowski Z, Krzych ŁJ. Intraoperative hypotension and its organ-related consequences in hypertensive subjects undergoing abdominal surgery: a cohort study. Blood Press 2021; 30:348-358. [PMID: 34323131 DOI: 10.1080/08037051.2021.1947777] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Purpose. Intraoperative hypotension is associated with organ hypoperfusion, which is deleterious to vital organs. Little is known about the prevalence and consequences of intraoperative hypotension in subjects with arterial hypertension (AH). The primary goal of this study was to investigate the prevalence and determinants of hypoperfusion-related clinical consequences of intraoperative hypotension, taking into account the role of AH, in a homogeneous cohort of patients undergoing abdominal surgery.Materials and methods. We enrolled 508 patients (219 males, median age 62 years). Intraoperative hypotension was defined as systolic blood pressure (SBP) <90 mmHg for at least 10 min or mean arterial pressure (MAP) <65 mmHg for at least 10 min or a need for noradrenaline infusion of at least 0.05 μg/kg/min for ≥10 min or intraoperative MAP drop of at least 30% from the baseline value for at least 10 min, regardless of the time of surgery. Acute kidney injury, stroke or transient ischaemic attack, delirium, and myocardial infarction were considered as the outcome.Results. AH concerned 234 (46%) individuals. The prevalence of intraoperative hypotension varied from 19.9 to 59.4%. Patients with AH were more likely to experience MAP drop of >30% than non-hypertensive patients (OR = 1.53; 95%CI 1.07-2.19; p = 0.02). The outcome was diagnosed in 38 (7.5%) patients. AH was a significant predictor of hypoperfusion-related events, regardless of the intraoperative hypotension definition applied (logOR 2.80 ÷ 3.22; p < 0.05 for all). Only intraoperative hypotension defined as 'MAP < 65mmHg' was found to be a determinant of negative outcome (logOR = 2.85; 95%CI 1.35-5.98; p < 0.01), with AUROC = 0.83 (95%CI 0.0-0.86); p < 0.01.Conclusion. AH is a significant predictor of hypoperfusion-related events, regardless of the intraoperative hypotension definition applied. In hypertensive patients, hypoperfusion-related clinical consequences are more frequent in high-risk and long-lasting procedures. MAP < 65 mmHg lasting for >10 min during surgery was identified as most associated with the negative outcome.
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Affiliation(s)
- Szymon Czajka
- Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Zbigniew Putowski
- Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Students' Scientific Society, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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Foëx P, Sear JW. Implications for perioperative practice of changes in guidelines on the management of hypertension: challenges and opportunities. Br J Anaesth 2021; 127:335-340. [PMID: 34127253 DOI: 10.1016/j.bja.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/20/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Pierre Foëx
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK.
| | - John W Sear
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
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21
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Lau ES, Scirica B, Schaefer IM, Miller AL, Loscalzo J. Hypertensive Heartbreak. N Engl J Med 2021; 384:2145-2152. [PMID: 34077647 DOI: 10.1056/nejmcps2018493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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22
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Clinical considerations in providing intravenous sedation with midazolam for obese patients in dentistry. Br Dent J 2021; 230:587-593. [PMID: 33990742 DOI: 10.1038/s41415-021-2944-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/07/2020] [Indexed: 11/08/2022]
Abstract
The widespread prevalence of obesity continues to rise. Obesity and dental disease share common risk factors and so the demand for dental care for obese patients is escalating. For some of these patients, there is a corresponding need to be able to provide intravenous sedation safely when it is necessary and appropriate to do so. However, obesity often presents with multiple comorbidities and airway complexities, leading to more challenging management and potentially increased risk. The risk assessment process as well as patient monitoring and management strategies will be explored in this article. By reviewing the literature from dentistry and other medical specialties, we also aim to establish the potential benefit in administering supplemental oxygen and the use of capnography in monitoring this cohort of patients.
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Huang Y, Chen J, Gao P, Gu C, Fan J, Hu Z, Cao X, Yin G, Zhou W. A comparison of the bilateral decompression via unilateral approach versus conventional approach transforaminal lumbar interbody fusion for the treatment of lumbar degenerative disc disease in the elderly. BMC Musculoskelet Disord 2021; 22:156. [PMID: 33557804 PMCID: PMC7871543 DOI: 10.1186/s12891-021-04026-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 01/27/2021] [Indexed: 11/17/2022] Open
Abstract
Background Bilateral decompression via unilateral approach (BDUA) is an effective surgical approach for treating lumbar degenerative diseases. However, no studies of prognosis, especially the recovery of the soft tissue, have reported using BDUA in an elderly population. The aims of these research were to investigate the early efficacy of the bilateral decompression via unilateral approach versus conventional approach transforaminal lumbar interbody fusion (TLIF) for the treatment of lumbar degenerative disc disease in the patients over 65 years of age, especially in the perioperative factors and the recovery of the soft tissue. Methods The clinical data from 61 aging patients with lumbar degenerative disease who received surgical treatment were retrospectively analyzed. 31 cases who received the lumbar interbody fusion surgery with bilateral decompression via unilateral approach (BDUA) were compared with 30 cases who received conventional approach transforaminal lumbar interbody fusion. The radiographic parameters were measured using X-ray including lumbar lordosis angle and fusion rate. Japanese Orthopedic Association (JOA), Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores were used to evaluate the clinical outcomes at different time points. Fatty degeneration ratio and area of muscle/vertebral body were used to detect recovery of soft tissue. Results The BDUA approach group was found to have significantly less intraoperative blood loss(p < 0.05) and postoperative drainage(p < 0.05) compared to conventional approach transforaminal lumbar interbody fusion group. Symptoms of spinal canal stenosis and nerve compression were significantly relieved postoperatively, as compared with the preoperative state. However, the opposite side had a lower rate of fatty degeneration (9.42 ± 3.17%) comparing to decompression side (11.68 ± 3.08%) (P < 0.05) six months after surgery in the BDUA group. While there were no significant differences (P > 0.05) in two sides of conventional transforaminal lumbar interbody fusion approach group six months after surgery. Conclusions Bilateral decompression via unilateral approach (BDUA) is able to reduce the intraoperative and postoperative body fluid loss in the elderly. The opposite side of decompression in BDUA shows less fatty degeneration in 6 months, which indicates better recovery of the soft tissue of the aging patients.
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Affiliation(s)
- Yifan Huang
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Jian Chen
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Peng Gao
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Changjiang Gu
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Jin Fan
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Zhiyi Hu
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Xiaojian Cao
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Guoyong Yin
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China.
| | - Wei Zhou
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China.
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Wilson RL, Shannon T, Calton E, Galvão DA, Taaffe DR, Hart NH, Lyons-Wall P, Newton RU. Efficacy of a weight loss program prior to robot assisted radical prostatectomy in overweight and obese men with prostate cancer. Surg Oncol 2020; 35:182-188. [DOI: 10.1016/j.suronc.2020.08.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/03/2020] [Accepted: 08/02/2020] [Indexed: 12/24/2022]
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Pfister CL, Govender S, Dyer RA, Rayner B, Flint M, Roodt F, Davids J, Nejthardt MB, Swanevelder JL, Chiu CJE, Cloete E, Koller V, Pretorius T, Fullerton Z, Roos J, Van Zyl R, Biccard BM. A Multicenter, Cross-Sectional Quality Improvement Project: The Perioperative Implementation of a Hypertension Protocol by Anesthesiologists. Anesth Analg 2020; 131:1401-1408. [PMID: 33079862 DOI: 10.1213/ane.0000000000004966] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hypertension is a common risk factor for cardiovascular morbidity and mortality, with a high prevalence in patients presenting for elective surgery. In limited resource environments, patients have poor access to primary care physicians, limiting the efficacy of lifestyle modification for the management of hypertension. In these circumstances, the perioperative period presents a unique opportunity for diagnosis and initiation and/or modification of pharmacotherapy of hypertension. Anesthesiologists are ideally placed to lead this aspect of perioperative medicine. The study objective was for anesthesiologists to identify patients at the preoperative visit with previously undiagnosed or poorly controlled chronic hypertension and follow a simple management algorithm. METHODS In collaboration with expert physicians, we designed and implemented an algorithm for the diagnosis and management of chronic hypertension. This was a multicenter, cross-sectional quality improvement project in 7 hospitals in the Western Cape, South Africa. On the day before scheduled elective surgery, adult in-patients had 2 sets of blood pressure (BP) readings taken, one by nurses and the other by anesthesiologists, using a noninvasive automated BP device. These were averaged on an electronic database, to diagnose hypertension. Patients with normal BP or well-controlled hypertension required no further management. Those with borderline BP received educational pamphlets. Patients with stage 1 or 2 hypertension were managed with medication according to the algorithm, starting 1 day postoperatively, and provided with educational pamphlets. Patients with stage 3 disease had their surgery postponed and were referred to a physician. The primary outcome was adherence by the anesthesiologist to the algorithm in the diagnosis and management of hypertension. An 80% adherence rate was considered successful implementation. The secondary outcome was the adherence to the algorithm at discharge. RESULTS Two hundred ninety-eight patients were screened for hypertension. One hundred six patients were eligible for the quality improvement project. Thirty-seven (34.9%) had borderline BP readings, 43 (40.6%) had stage 1, 22 (20.8%) stage 2, and 4 (3.8%) stage 3 hypertension, respectively. The adherence rate by the anesthesiologist in initiating treatment according to the algorithm was 89 of 106 (84.0%; 95% confidence interval [CI, 77.0-91.0). There was full adherence to the algorithm in 59 of 106 (55.5%; 95% CI, 46.2-65.1) at the time of discharge from hospital. CONCLUSIONS Anesthesiologists successfully implemented a quality improvement project for diagnosis and management of hypertension in the perioperative period. This has the potential to reduce the public health burden of hypertension in limited resource environments. Successful ongoing prescription and follow-up requires cooperation within a multidisciplinary team.
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Affiliation(s)
| | | | - Robert A Dyer
- From the Department of Anaesthesia and Perioperative Medicine
| | - Brian Rayner
- Division of Nephrology and Hypertension, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Margot Flint
- From the Department of Anaesthesia and Perioperative Medicine
| | - Francois Roodt
- Division of Anaesthesia, George Provincial Hospital, George, South Africa
| | - Jody Davids
- Division of Anaesthesia, George Provincial Hospital, George, South Africa
| | | | | | | | - Esther Cloete
- From the Department of Anaesthesia and Perioperative Medicine
| | - Veronica Koller
- Division of Anaesthesia, Paarl Hospital, Paarl, South Africa
| | - Tania Pretorius
- Division of Anaesthesia, Paarl Hospital, Paarl, South Africa
| | - Zahnne Fullerton
- Division of Anaesthesia, Victoria Hospital, Cape Town, South Africa
| | - John Roos
- Division of Anaesthesia, Mitchell's Plain Hospital, Cape Town, South Africa
| | - Riaan Van Zyl
- Division of Anaesthesia, Worcester Provincial Hospital, Worcester, South Africa
| | - Bruce M Biccard
- From the Department of Anaesthesia and Perioperative Medicine
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Foëx P, Sear JW. Hypertension: A Changing Role for Anesthesiologists. Anesth Analg 2020; 131:1397-1400. [DOI: 10.1213/ane.0000000000005181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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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Kim DK. Anesthetic management of hypertensive patients. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.9.519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
It is important for the clinicians to have a clear understanding of the anesthetic implications and increased risks due to hypertension to ensure safe surgical procedures in hypertensive patients. Preoperative hypertension is associated with greater intraoperative hemodynamic lability and an increased risk of perioperative cardiovascular complications. In addition to the patients’ baseline blood pressure (BP), the presence and severity of target organ damage and cardiovascular comorbidities should be evaluated preoperatively. Delaying surgery in hypertensive patients may be justified if there is an evidence of target organ damage that can be improved by such a delay. Further evaluation of suspected target organ damage before the surgery is also justified. Except withholding angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 10 to 24 hours before the surgery, the continuation of preoperative antihypertensive therapy is generally recommended. Though maintaining perioperative BP within the range of 80%–90% to 110%–120% of the baseline BP (permissible BP decrease/increase ≤10%–20%) is generally recommended, an individualized and pathophysiology-based approach to control BP might be the best option throughout the perioperative period. In other words, BP targets in the perioperative period should be determined based on the type of surgery, patients’ baseline BP, risks of hypotension-related organ ischemia, and hypertension-related bleeding.
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Soni S, Shah S, Chaggar R, Saini R, James E, Elliot J, Stephens J, McCormack T, Hartle A. Surgical cancellation rates due to peri‐operative hypertension: implementation of multidisciplinary guidelines across primary and secondary care. Anaesthesia 2020; 75:1314-1320. [DOI: 10.1111/anae.15084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2020] [Indexed: 11/29/2022]
Affiliation(s)
- S. Soni
- Division of Anaesthetics Pain Medicine and Intensive Care Imperial College London UK
- Imperial School of Anaesthesia London UK
| | - S. Shah
- Imperial School of Anaesthesia London UK
| | - R. Chaggar
- Northwick Park Hospital Harrow London UK
| | - R. Saini
- Great Ormond Street Hospital London UK
| | - E. James
- Imperial College Healthcare NHS Trust London UK
| | - J. Elliot
- Imperial College Healthcare NHS Trust London UK
| | | | - T. McCormack
- Primary Care Cardiovascular Medicine Hull York Medical School UK
| | - A. Hartle
- Imperial College Healthcare NHS Trust London UK
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Fitter, Better, Sooner: helping your patients in general practice recover more quickly from surgery. Br J Gen Pract 2020; 70:258-259. [PMID: 32354832 DOI: 10.3399/bjgp20x709841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/25/2019] [Indexed: 01/10/2023] Open
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Ceglowski P, Lehane K, Chow C, Pelecanos A, Tognolini A, Eley V. Arm Dimensions of Patients with Obesity and Their Experiences with Blood Pressure Measurement: An Observational Study. Obesity (Silver Spring) 2020; 28:718-723. [PMID: 32096341 DOI: 10.1002/oby.22746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/23/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In patients with obesity, it was determined what proportion had an arm slant angle (SA) < 83° and which measure best predicted arm conicity. Patient experience with noninvasive blood pressure measurement was evaluated. METHODS Arm SA was calculated from arm measurements. Linear regression determined whether BMI, weight, or right midarm circumference (MAC) best predicted conicity. Patient experiences were evaluated by survey and conventional content analysis of free-text comments. RESULTS One hundred participants had a median (interquartile range; range) BMI of 44.1 (39.1-53.1; 31.1-80.8). Thirty-three (33%) had a right arm SA < 83°. Seven (7%) had a right MAC outside the recommended range. BMI, weight, and the right MAC showed low correlation with and explained little of the variation (with age and sex adjustment) in right arm SA (r = -0.29, -0.27, -0.31; P = 0.003, 0.007, 0.002; R2 = 0.09, 0.08, 0.10). Forty-two (42%) reported noninvasive blood pressure measurement caused severe pain, and 30 (30%) reported skin damage. Themes identified in free-text responses were "problems with equipment," "feelings and experiences," and "concerns about accuracy." CONCLUSIONS Current equipment is inadequate for patients with obesity based on MAC and conicity. Pain and skin damage contributed to negative experiences of these patients.
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Affiliation(s)
- Peter Ceglowski
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Katie Lehane
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Christopher Chow
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Anita Pelecanos
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Angela Tognolini
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Victoria Eley
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Abstract
OBJECTIVE The present study aims to describe a widely held misconception in the literature concerning preoperative hypertension diagnosis. The blood pressure elevation occurring in the operative room is seen commonly even in subjects considered hitherto fully normotensive. As these patients have a condition which - similar to White Coat Hypertension (WCH) - indicates the presence of hypertension, and thus necessitates more frequent intraoperative checks. METHODS We have named a condition 'Diagnosed in Operating Room (DIOR) with Hypertension', following the preoperative stage at which it is detected. RESULT Our observational study evaluated 718 elective noncardiac surgery adult patients, finding 28% of them (n = 204) to be 'DIOR-tensive' and thus at risk for suboptimal intraoperative care. CONCLUSION In addition to recommending a modification to the domain's best practices, we provide a preliminary description of DIOR hypertension patient identifying characteristics (older, higher body weight and BMI, and higher rates of chronic obstructive pulmonary disease, hypothyroidism and obesity), so that DIOR hypertension patients may be more readily identified, and that future research may build on the findings, and that the operating team may remain generally aware that this problem can occur and be dealt with regardless of the patient's medical history.
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Canceling dental procedures due to elevated blood pressure: Is it appropriate? J Am Dent Assoc 2020; 151:239-244. [PMID: 32067694 DOI: 10.1016/j.adaj.2019.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 11/22/2019] [Accepted: 12/16/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND In 1974, the American Dental Association first considered recommending that dental offices measure blood pressure (BP) routinely, and it has been further encouraged since 2006. Investigators in several dental publications have recommended cancellation of dental procedures based solely on BP greater than 180/110 millimeters of mercury for urgent oral health care and greater than 160/100 mm Hg for elective oral health care, in the absence of prior medical consultation. METHODS The authors reviewed the evidence for cancellation of any dental or surgical procedures by using an Ovid MEDLINE search for the terms dental, elevated blood pressure, and hypertension. In addition, the authors searched resources at ebd.ada.org using the same criteria. The authors collaborated to develop recommendations in view of 2017 guidelines on this subject. RESULTS To the authors' knowledge, there are no professionally accepted criteria or study evidence indicating a specific BP elevation at which to prohibit oral health care. Researchers of a 2015 review on management of comorbidities in ambulatory anesthesia failed to find increased morbidity from hypertension in the outpatient setting. CONCLUSIONS To the authors' knowledge, there are no prospective study investigators that have addressed whether or when to cancel dental procedures due to office-measured elevated BP. The authors recommend using current anesthesiology guidelines based on functional status and past BP measurements to prevent unnecessary cancellations. PRACTICAL IMPLICATIONS It is seldom necessary to cancel dental procedures on the basis of BP measured before a planned procedure for patients under a physician's care.
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Koutsaki M, Patoulias D, Tsinivizov P, Doumas M, Kallistratos M, Thomopoulos C, Poulimenos L, Agnelli G, Mancia G, Manolis A. Evaluation, risk stratification and management of hypertensive patients in the perioperative period. Eur J Intern Med 2019; 69:1-7. [PMID: 31606306 DOI: 10.1016/j.ejim.2019.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/18/2019] [Accepted: 09/15/2019] [Indexed: 12/19/2022]
Abstract
Uncontrolled hypertension represents an important cause for postponing a non-cardiac surgery. Perioperative management of hypertensive patients should focus on cardiovascular risk stratification, evaluation of blood pressure levels and hypertension control, registration of the ongoing antihypertensive regimen and counseling about clinical decisions related to the expected perioperative blood pressure fluctuations. To date, there is a lack of evidence on how hypertensive patients should be perioperatively treated, while an empirical clinical approach is usually pursued in the usual practice. The present review appraises the gaps in the evidence and illustrates the current empirical approach of perioperative management of hypertension in non-cardiac surgery.
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Affiliation(s)
- Maria Koutsaki
- Department of Cardiology, Asklepeion General Hospital, Athens, Greece
| | - Dimitrios Patoulias
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pavlos Tsinivizov
- Department of Cardiology, Asklepeion General Hospital, Athens, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Malima ZA, Torborg A, Cronjé L, Biccard BM. Predictors of post-spinal hypotension in elderly patients; a prospective observational study in the Durban Metropole. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2019. [DOI: 10.36303/sajaa.2019.25.5.a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims and objective: To evaluate the pre-spinal risk factors for hypotension associated with spinal anaesthesia in elderly surgical patients.
Summary of background data: Hypotension is associated with morbidity and mortality following noncardiac surgery. Reducing the incidence of hypotension associated with spinal anaesthesia may be associated with improved postoperative outcomes.
Methods: This was a prospective, observational study, using convenience sampling. All patients over 55 years of age scheduled to receive spinal anaesthesia for lower limb surgery were eligible. Exclusion criteria included the need for resuscitation and/or the need for vasopressors prior to anaesthesia and surgery, and patients who declined spinal anaesthesia. The dosage of spinal anaesthesia and the use of intraoperative sedation were left to the attending anaesthesiologist. The primary outcome was hypotension, which was defined as a decrease in the systolic blood pressure by 25% from the baseline, or a systolic blood pressure below 100 mmHg.
The following pre-spinal risk factors were assessed in a multivariable logistic regression for their association with spinal hypotension: age, American Society of Anaesthesiologists-Physical September 2019 Status, sex, dose of local anaesthetic, isobaric bupivacaine or bupivacaine with dextrose, baseline blood pressure, baseline heart rate and fluid preloading prior to spinal anaesthesia.
Results: Three hundred and eighty-nine patients were recruited. The primary outcome of spinal hypotension was independently associated with female sex (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.19–3.28), increasing dosage of bupivacaine (OR 1.14, CI 1.01–1.29), and the use of isobaric bupivacaine (OR 1.50, CI 0.95–2.36).
Conclusion: Spinal hypotension was associated with female sex, increasing dosage of bupivacaine, and the use of isobaric bupivacaine.
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Abstract
In the past, best practices for perioperative management have been based as much on dogma as science. The creation of optimized perioperative pathways, known as enhanced recovery after surgery, has been shown to simultaneously improve patient outcomes and reduce cost. In this article, we critically review interventions (and omission of interventions) that should be considered by every surgical team to optimize preanesthesia care. This includes patient education, properly managing existing medical comorbidities, optimizing nutrition, and the use of medications before incision that have been shown to reduce surgical stress, opioid requirements, and postoperative complications. Anesthetic techniques, the use of adjunct medications administered after incision, and postoperative management are beyond the scope of this review. When possible, we have relied on randomized trials, meta-analyses, and systematic reviews to support our recommendations. In some instances, we have drawn from the general and colorectal surgery literature if evidence in gynecologic surgery is limited or of poor quality. In particular, hospital systems should aim to adhere to antibiotic and thromboembolic prophylaxis for 100% of patients, the mantra, "nil by mouth after midnight" should be abandoned in favor of adopting a preoperative diet that maintains euvolemia and energy stores to optimize healing, and bowel preparation should be abandoned for patients undergoing gynecologic surgery for benign indications and minimally invasive gynecologic surgery.
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Abstract
Older patients undergoing surgery have reduced physiologic reserve caused by the combined impact of physiologic age-related changes and the increased burden of comorbid conditions. The preoperative assessment of older patients is directed at evaluating the patient's functional reserve and identifying opportunities to minimize any potential for complications. In addition to a standard preoperative evaluation that includes cardiac risk and a systematic review of systems, the evaluation should be supplemented with a review of geriatric syndromes. Age-based laboratory testing protocols can lead to unnecessary testing, and all testing should be requested if indicated by underlying disease and surgical risk.
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Affiliation(s)
- Sheila Ryan Barnett
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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38
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Leader R, Thayer T, Maher B, Bell C. Hypertension − an update for the dental (sedation) team. ACTA ACUST UNITED AC 2019. [DOI: 10.12968/denu.2019.46.6.508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hypertension is the commonest risk factor contributing to the global burden of disease. Public Health England estimates that, in England, 24% of the population are hypertensive, with 40% possibly undiagnosed. With this in mind, dentists, in particular those undertaking sedation, are in a perfect position to screen for high blood pressure and refer on for further detailed assessment. This paper outlines when a referral to the General Medical Practitioner (GP) should be considered, when sedation should be deferred and how hypertension is diagnosed and managed in primary care based on the National Institute for Health and Care Excellence (NICE)/British Hypertension Society (BHS) guidelines.CPD/Clinical Relevance: The purpose of this article is to update General Dental Practitioners (GDPs), including those who practise IV Midazolam sedation, on how patients who present with suspected hypertension are managed by their GP. Consideration is given to what blood pressures are deemed safe to sedate and what blood pressures should be referred for further assessment, even if considered safe to sedate.
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Affiliation(s)
- Ross Leader
- Foundation Doctor and Staff Grade in Oral & Maxillofacial Surgery, University Hospital Aintree, Lower Lane, Liverpool, L9 7AL
| | - Tom Thayer
- Consultant and Honorary Senior Lecturer in Oral Surgery, University of Liverpool Dental School, Pembroke Place, Liverpool L3 5PS
| | - Bridget Maher
- Consultant in Clinical Pharmacology and General Internal Medicine, Hypertension Lead, University Hospital Aintree, Lower Lane, Liverpool, L9 7AL
| | - Chris Bell
- Academic Foundation Doctor, Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, LL13 7TD, UK
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39
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Howell SJ. Consensus statements and expert guidance: interpret with care. Br J Anaesth 2019; 122:719-722. [DOI: 10.1016/j.bja.2019.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 01/13/2023] Open
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Bailey CR, Ahuja M, Bartholomew K, Bew S, Forbes L, Lipp A, Montgomery J, Russon K, Potparic O, Stocker M. Guidelines for day-case surgery 2019: Guidelines from the Association of Anaesthetists and the British Association of Day Surgery. Anaesthesia 2019; 74:778-792. [PMID: 30963557 DOI: 10.1111/anae.14639] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2019] [Indexed: 12/18/2022]
Abstract
Guidelines are presented for the organisational and clinical management of anaesthesia for day-case surgery in adults and children. The advice presented is based on previously published recommendations, clinical studies and expert opinion.
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Affiliation(s)
- C R Bailey
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Chair of Working Party, Association of Anaesthetists, London, UK
| | - M Ahuja
- Department of Anaesthesia, Royal Wolverhampton Hospitals NHS Trust, Elected Member, British Association of Day Surgery, Wolverhampton, UK
| | - K Bartholomew
- Department of Anaesthesia, Calderdale and Huddersfield NHS Foundation Trust, Elected Member, Association of Paediatric Anaesthetists of Great Britain and Ireland, Huddersfield, UK
| | - S Bew
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Elected Member, Association of Paediatric Anaesthetists of Great Britain and Ireland, Leeds, UK
| | - L Forbes
- Department of Anaesthesia, Ninewells Hospital, Elected Member Trainee Committee, Association of Anaesthetists, Dundee, Scotland
| | - A Lipp
- Department of Anaesthesia, Norfolk and Norwich University Hospital, Elected Member, British Association of Day Surgery, Norwich, UK
| | - J Montgomery
- Department of Anaesthesia, Torbay and South Devon NHS Foundation Trust, Elected Member, British Association of Day Surgery, Torbay, UK
| | - K Russon
- Department of Anaesthesia, Rotherham NHS Foundation Trust, Elected Member, British Association of Day Surgery, Rotherham, UK
| | - O Potparic
- Department of Anaesthesia, Chelsea and Westminster NHS Foundation Trust, SAS Committee, Association of Anaesthetists, London, UK
| | - M Stocker
- Department of Anaesthesia, Torbay and South Devon, NHS Foundation Trust, President, British Association of Day Surgery, Torbay, UK
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41
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Perioperative Quality Initiative consensus statement on preoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth 2019; 122:552-562. [DOI: 10.1016/j.bja.2019.01.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 12/18/2018] [Accepted: 01/01/2019] [Indexed: 11/17/2022] Open
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42
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Okocha O, Gerlach RM, Sweitzer B. Preoperative Evaluation for Ambulatory Anesthesia: What, When, and How? Anesthesiol Clin 2019; 37:195-213. [PMID: 31047124 DOI: 10.1016/j.anclin.2019.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Most surgery in the United States occurs in offices, free-standing surgicenters, and hospital-based outpatient facilities. Patients are frequently elderly with comorbidities, and procedures are increasingly complex. Traditionally, patients have been evaluated on the day of surgery by anesthesia providers. Obtaining information on patients' health histories, establishing criteria for appropriateness, and communicating medication instructions streamline throughput, lower cancellations and delays, and improve provider and patient satisfaction. Routine testing does not lower risk or improve outcomes. Evaluating and optimizing patients with significant diseases, especially those with suboptimal management, has positive impact on ambulatory surgery and anesthesia.
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Affiliation(s)
- Obianuju Okocha
- Department of Anesthesiology, Northwestern University, NMH/Feinberg 5-704, 251 East Huron Street, Chicago, IL 60611, USA
| | - Rebecca M Gerlach
- Department of Anesthesia & Critical Care, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA
| | - BobbieJean Sweitzer
- Department of Anesthesiology, Northwestern University, NMH/Feinberg 5-704, 251 East Huron Street, Chicago, IL 60611, USA.
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Albrecht E, Wiles MD. Peri‐operative management of diabetes: the need for a lead. Anaesthesia 2019; 74:845-849. [DOI: 10.1111/anae.14604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2019] [Indexed: 12/25/2022]
Affiliation(s)
- E. Albrecht
- Department of Anaesthesia Lausanne University Hospital LausanneSwitzerland
| | - M. D. Wiles
- Department of Anaesthetics Sheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
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44
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Lee LKK, Tsai PNW, Ip KY, Irwin MG. Pre-operative cardiac optimisation: a directed review. Anaesthesia 2019; 74 Suppl 1:67-79. [PMID: 30604417 DOI: 10.1111/anae.14511] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 12/30/2022]
Affiliation(s)
- L. K. K. Lee
- Department of Anaesthesia; Pamela Youde Nethersole Eastern Hospital; Hong Kong Special Administrative Region; Hong Kong China
| | - P. N. W. Tsai
- Department of Adult Intensive Care Unit; Queen Mary Hospital; Hong Kong Special Administrative Region; Hong Kong China
| | - K. Y. Ip
- Department of Anaesthesiology; Queen Mary Hospital; Hong Kong Special Administrative Region; Hong Kong China
| | - M. G. Irwin
- Department of Anaesthesiology; The University of Hong Kong; Hong Kong Special Administrative Region; Hong Kong China
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45
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Venkatesan S, Myles PR, Manning HJ, Mozid AM, Andersson C, Jørgensen ME, Hardman JG, Moonesinghe SR, Foex P, Mythen M, Grocott MPW, Sanders RD. Cohort study of preoperative blood pressure and risk of 30-day mortality after elective non-cardiac surgery. Br J Anaesth 2018. [PMID: 28633374 DOI: 10.1093/bja/aex056] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Preoperative blood pressure (BP) thresholds associated with increased postoperative mortality remain unclear. We investigated the relationship between preoperative BP and 30-day mortality after elective non-cardiac surgery. Methods We performed a cohort study of primary care data from the UK Clinical Practice Research Datalink (2004-13). Parsimonious and fully adjusted multivariable logistic regression models, including restricted cubic splines for numerical systolic and diastolic BP, for 30-day mortality were constructed. The full model included 29 perioperative risk factors, including age, sex, comorbidities, medications, and surgical risk scale. Sensitivity analyses were conducted for age (>65 vs <65 years old) and the timing of BP measurement. Results A total of 251 567 adults were included, with 589 (0.23%) deaths within 30 days of surgery. After adjustment for all risk factors, preoperative low BP was consistently associated with statistically significant increases in the odds ratio (OR) of postoperative mortality. Statistically significant risk thresholds started at a preoperative systolic pressure of 119 mm Hg (adjusted OR 1.02 [95% confidence interval (CI) 1.01-1.02]) compared with the reference (120 mm Hg) and diastolic pressure of 63 mm Hg [OR 1.24 (95% CI 1.03-1.49)] compared with the reference (80 mm Hg). As BP decreased, the OR of mortality risk increased. Subgroup analysis demonstrated that the risk associated with low BP was confined to the elderly. Adjusted analyses identified that diastolic hypertension was associated with increased postoperative mortality in the whole cohort. Conclusions In this large observational study we identified a significant dose-dependent association between low preoperative BP values and increased postoperative mortality in the elderly. In the whole population, elevated diastolic, not systolic, BP was associated with increased mortality.
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Affiliation(s)
- S Venkatesan
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - P R Myles
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - H J Manning
- Department of Obstetrics and Gynaecology, University of Wisconsin, Madison, WI, USA
| | - A M Mozid
- Department of Cardiology, Bristol Heart Institute, Bristol, UK
| | - C Andersson
- Division of Cardiology, Department of Internal Medicine, Glostrup Hospital, University of Copenhagen, Denmark
| | - M E Jørgensen
- Cardiovascular Research Center, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - J G Hardman
- Department of Anaesthesia, University of Nottingham, Nottingham, UK
| | - S R Moonesinghe
- Department of Anaesthesia, Surgical Outcomes Research Centre, University College London Hospital, London, UK.,National Institute for Academic Anaesthesia's Health Services Research Centre, London, UK
| | - P Foex
- Nuffield Division of Anaesthetics, Oxford University Hospital, Oxford, UK
| | - M Mythen
- Department of Anaesthesia, Surgical Outcomes Research Centre, University College London Hospital, London, UK.,National Institute for Academic Anaesthesia's Health Services Research Centre, London, UK
| | - M P W Grocott
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Obstetrics and Gynaecology, University of Wisconsin, Madison, WI, USA.,Integrative Physiology and Critical Illness, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R D Sanders
- Anesthesiology and Critical Care Trials and Interdisciplinary Outcomes Network (ACTION), Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI 53792-3272, USA
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Crowther M, Roodt F, Biccard BM. Pre‐operative hypertension and intra‐operative hypotension: a reply. Anaesthesia 2018; 73:1438-1439. [DOI: 10.1111/anae.14432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M. Crowther
- Groote Schuur Hospital Cape Town South Africa
| | - F. Roodt
- George Provincial Hospital George South Africa
| | - B. M. Biccard
- Groote Schuur Hospital and University of Cape Town Cape Town South Africa
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A prospective observational study of the impact of an electronic questionnaire (ePAQ-PO) on the duration of nurse-led pre-operative assessment and patient satisfaction. PLoS One 2018; 13:e0205439. [PMID: 30339687 PMCID: PMC6195264 DOI: 10.1371/journal.pone.0205439] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/25/2018] [Indexed: 11/19/2022] Open
Abstract
Objective Standard pre-operative assessment at our institution involves a comprehensive history and examination by a nurse practitioner. An electronic pre-operative assessment questionnaire, ePAQ-PO® (ePAQ, Sheffield, UK) has previously been developed and validated. This study aimed to determine the impact of ePAQ-PO on nurse consultation times and patient satisfaction in low-risk patients. Methods The duration of pre-operative assessment consultation was recorded for American Society of Anesthesiology physical classification 1 and 2 patients undergoing pre-operative assessment by an electronic questionnaire (ePAQ-PO group) and standard face-to-face assessment by a nurse practitioner (standard group). Patients were also asked to complete an eight-item satisfaction questionnaire. Eighty-six patients were included (43 in each group). Results After adjusting for the duration of physical examination, median (IQR [min-max]) consultation time was longer in the standard compared to the ePAQ-PO group (25 (18–33 [10–49]) min vs. 12 (8–17 [4–45]) min, respectively; p <0.001). Response rate for the satisfaction questionnaire was 93%. There was no significant difference in patient satisfaction scores (38/39 in standard group vs. 39/41 in ePAQ-PO group were fully satisfied with their pre-operative assessment; p = 0.494). Conclusion Pre-operative assessment using ePAQ-PO is associated with a significant reduction of over 50% in the duration of the assessment without impacting on patient satisfaction.
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Ahmad I, El-Boghdadly K. From evidence based on practice to evidence-based practice: time for a difficult airway management research strategy. Anaesthesia 2018; 74:135-139. [DOI: 10.1111/anae.14452] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- I. Ahmad
- Guy's and St Thomas’ NHS Foundation Trust and Honorary Senior Lecturers; King's College London; London UK
| | - K. El-Boghdadly
- Guy's and St Thomas’ NHS Foundation Trust and Honorary Senior Lecturers; King's College London; London UK
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Association between peri-operative angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers and acute kidney injury in major elective non-cardiac surgery: a multicentre, prospective cohort study. Anaesthesia 2018; 73:1214-1222. [PMID: 29984818 DOI: 10.1111/anae.14349] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 02/11/2024]
Abstract
The peri-operative use of angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers is thought to be associated with an increased risk of postoperative acute kidney injury. To reduce this risk, these agents are commonly withheld during the peri-operative period. This study aimed to investigate if withholding angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers peri-operatively reduces the risk of acute kidney injury following major non-cardiac surgery. Patients undergoing elective major surgery on the gastrointestinal tract and/or the liver were eligible for inclusion in this prospective study. The primary outcome was the development of acute kidney injury within seven days of operation. Adjusted multi-level models were used to account for centre-level effects and propensity score matching was used to reduce the effects of selection bias between treatment groups. A total of 949 patients were included from 160 centres across the UK and Republic of Ireland. From this population, 573 (60.4%) patients had their angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers withheld during the peri-operative period. One hundred and seventy-five (18.4%) patients developed acute kidney injury; there was no difference in the incidence of acute kidney injury between patients who had their angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers continued or withheld (107 (18.7%) vs. 68 (18.1%), respectively; p = 0.914). Following propensity matching, withholding angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers did not demonstrate a protective effect against the development of postoperative acute kidney injury (OR (95%CI) 0.89 (0.58-1.34); p = 0.567).
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Yimer H, Yaregal D, Getinet H, Hailekirose A. Evidence based guideline on perioperative optimization of hypertensive patients booked for elective surgery at a low-income country. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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