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Narendren A, Whitehead N, Burrell LM, Yudi MB, Yeoh J, Jones N, Weinberg L, Miles LF, Lim HS, Clark DJ, Al-Fiadh A, Farouque O, Koshy AN. Management of Acute Coronary Syndromes in Older People: Comprehensive Review and Multidisciplinary Practice-Based Recommendations. J Clin Med 2024; 13:4416. [PMID: 39124683 PMCID: PMC11312870 DOI: 10.3390/jcm13154416] [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: 06/10/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Managing health care for older adults aged 75 years and older can pose unique challenges stemming from age-related physiological differences and comorbidities, along with elevated risk of delirium, frailty, disability, and polypharmacy. This review is aimed at providing a comprehensive analysis of the management of acute coronary syndromes (ACS) in older patients, a demographic substantially underrepresented in major clinical trials. Because older patients often exhibit atypical ACS symptoms, a nuanced diagnostic and risk stratification approach is necessary. We aim to address diagnostic challenges for older populations and highlight the diminished sensitivity of traditional symptoms with age, and the importance of biomarkers and imaging techniques tailored for older patients. Additionally, we review the efficacy and safety of pharmacological agents for ACS management in older people, emphasizing the need for a personalized and shared decision-making approach to treatment. This review also explores revascularization strategies, considering the implications of invasive procedures in older people, and weighing the potential benefits against the heightened procedural risks, particularly with surgical revascularization techniques. We explore the perioperative management of older patients experiencing myocardial infarction in the setting of noncardiac surgeries, including preoperative risk stratification and postoperative care considerations. Furthermore, we highlight the critical role of a multidisciplinary approach involving cardiologists, geriatricians, general and internal medicine physicians, primary care physicians, and allied health, to ensure a holistic care pathway in this patient cohort.
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Affiliation(s)
- Ahthavan Narendren
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Cardiology, Northern Health, Epping, VIC 3076, Australia
| | - Natalie Whitehead
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Louise M. Burrell
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Matias B. Yudi
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Nicholas Jones
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Laurence Weinberg
- Department of Critical Care, The University of Melbourne, Melbourne, VIC 3010, Australia; (L.W.); (L.F.M.)
- Department of Anaesthesia, Austin Health, Heidelberg, VIC 3084, Australia
| | - Lachlan F. Miles
- Department of Critical Care, The University of Melbourne, Melbourne, VIC 3010, Australia; (L.W.); (L.F.M.)
- Department of Anaesthesia, Austin Health, Heidelberg, VIC 3084, Australia
| | - Han S. Lim
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Cardiology, Northern Health, Epping, VIC 3076, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - David J. Clark
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Ali Al-Fiadh
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Anoop N. Koshy
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Parkville, VIC 3052, Australia
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Mohamed B, Yarlagadda K, Self Z, Simon A, Rigueiro F, Sohooli M, Eisenschenk S, Doré S. Obstructive Sleep Apnea and Stroke: Determining the Mechanisms Behind their Association and Treatment Options. Transl Stroke Res 2024; 15:239-332. [PMID: 36922470 DOI: 10.1007/s12975-023-01123-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/02/2023] [Accepted: 01/02/2023] [Indexed: 03/18/2023]
Abstract
Sleep-disordered breathing (SDB) can be a sequela of stroke caused by vascular injury to vital respiratory centers, cerebral edema, and increased intracranial pressure of space-occupying lesions. Likewise, obstructive sleep apnea (OSA) contributes to increased stroke risk through local mechanisms such as impaired ischemic cerebrovascular response and systemic effects such as promoting atherosclerosis, hypercoagulability, cardiac arrhythmias, vascular-endothelial dysfunction, and metabolic syndrome. The impact of OSA on stroke outcomes has been established, yet it receives less attention in national guidelines on stroke management than hyperglycemia and blood pressure dysregulation. Furthermore, whether untreated OSA worsens stroke outcomes is not well-described in the literature. This scoping review provides an updated investigation of the correlation between OSA and stroke, including inter-relational pathophysiology. This review also highlights the importance of OSA treatment and its role in stroke outcomes. Knowledge of pathophysiology, the inter-relationship between these common disorders, and the impact of OSA therapy on outcomes affect the clinical management of patients with acute ischemic stroke. In addition, understanding the relationship between stroke outcomes and pre-existing OSA will allow clinicians to predict outcomes while treating acute stroke.
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Affiliation(s)
- Basma Mohamed
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Keerthi Yarlagadda
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Zachary Self
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Alexandra Simon
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Frank Rigueiro
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Maryam Sohooli
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Stephan Eisenschenk
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Sylvain Doré
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
- Departments of Neurology, Psychiatry, Pharmaceutics, and Neuroscience, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
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3
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van Rijbroek LS, Noordergraaf GJ, de Man-van Ginkel JM, van Boekel RLM. The association of hemodynamic parameters and clinical demographic variables with acute postoperative pain in female oncological breast surgery patients: A retrospective cohort study. Scand J Pain 2024; 24:sjpain-2023-0066. [PMID: 38460147 DOI: 10.1515/sjpain-2023-0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/03/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVES Appropriate administration of intraoperative analgesia is an essential factor in care and reasonable recovery times. Inappropriate intraoperative analgesia puts the patient at risk of acute postoperative pain (APOP). The absence of an objective standard for intraoperative nociceptive monitoring complicates pain care. Heart rate (HR) and mean arterial blood pressure (MABP) have been suggested as useful parameters during general anesthesia for nociceptive monitoring. However, studies focusing on whether intraoperative heart rate variability (HRv) and mean arterial blood pressure variability (MABPv) during general anesthesia can accurately monitor nociception in patients have remained inconclusive. The current study aimed to (1) identify the association of intraoperative heart rate and blood pressure variability in patients undergoing low-risk surgery with the incidence of APOP in the immediate postoperative setting and (2) evaluate the associations of clinical demographic factors with the incidence of APOP. METHODS A retrospective observational cohort study was conducted. The outcome was moderate-to-severe APOP, defined as a numeric rating scale score of ≥ 4. HRv, MABPv, and potential confounders, such as age, body mass index, duration of surgery, smoking, depression, preoperative use of analgesics, and type of surgery, were used as independent variables. RESULTS Data from 764 female oncological breast surgery patients were analyzed. No statistically significant association of HRv and MABPv with APOP was found. Lower age was associated with higher odds of APOP (odds ratio [OR] 0.978, p = 0.001). Increased length of surgery (OR 1.013, p = 0.022) and a history of depression were associated with increased odds of APOP (OR 2.327, p = 0.010). The subtype of surgery was statistically significantly associated with APOP (p = 0.006). CONCLUSIONS Our results suggest that heart rate and blood pressure variability intraoperatively, in female patients undergoing low-risk surgery, are not associated with, and thus not predictive of, APOP in the immediate postoperative setting.
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Affiliation(s)
- Lieselotte S van Rijbroek
- Department of Anesthesiology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Gerrit J Noordergraaf
- Department of Anesthesiology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Janneke M de Man-van Ginkel
- Nursing Science, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
- Nursing Science, Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Regina L M van Boekel
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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4
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Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, Bezzina CR, Biagini E, Blom NA, de Boer RA, De Winter T, Elliott PM, Flather M, Garcia-Pavia P, Haugaa KH, Ingles J, Jurcut RO, Klaassen S, Limongelli G, Loeys B, Mogensen J, Olivotto I, Pantazis A, Sharma S, Van Tintelen JP, Ware JS, Kaski JP. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44:3503-3626. [PMID: 37622657 DOI: 10.1093/eurheartj/ehad194] [Citation(s) in RCA: 349] [Impact Index Per Article: 349.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Talle A, Hashemzadeh M, Movahed MR. Very Low Risk for In-hospital Adverse Outcome Such as ST-elevation or Non-ST-elevation Myocardial Infarction in Patients Undergoing Knee Surgery. Crit Pathw Cardiol 2022; 21:84-86. [PMID: 35234177 DOI: 10.1097/hpc.0000000000000282] [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: 10/19/2022]
Abstract
BACKGROUND Knee surgery is a very common surgery. The risk of cardiac events is thought to be low. The goal of this study was to evaluate inpatients adverse outcomes such as ST-elevation myocardial infarction (STEMI) or Non-ST-elevation myocardial infarction in patients undergoing knee surgery. METHOD Using the nation inpatient sample database, we evaluated the occurrence of STEMI and Non-STEMI in a very large population. RESULTS Using 2 random samples from 2005 to 2014, 10 years apart involving 7444 knee surgeries, the occurrence of STEMI and Non-STEMI were very low. In 2005, only 1 STEMI (0.0%) and 4 non-STEMI (0.1%) events occurred in inpatient knee-surgery patients. In the 2014 group, 0 STEMI (0.0%) and 5 non-STEMI (0.16%) events occurred in inpatient knee-surgery patients. Overall, STEMI or non-STEMI events occurred in 0.13% of inpatient knee-surgery procedures. CONCLUSIONS Inpatients' adverse outcome of patients undergoing knee surgery is very low suggesting that extensive cardiac workup for knee surgery may not be warranted.
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Affiliation(s)
- Armin Talle
- From the Sarver Heart Center, University of Arizona, Phoenix, Phoenix, AZ
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6
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Kotani T, Inoue S, Kawaguchi M. Perioperative Dental Injury Associated With Intubated General Anesthesia. Anesth Prog 2022; 69:3-9. [PMID: 35377930 PMCID: PMC8985457 DOI: 10.2344/anpr-68-03-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 04/28/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Factors related to perioperative dental injury have likely changed as a variety of airway devices and preventive measures have been introduced. This retrospective chart review used data from an institutional registry to evaluate the incidence, timing, and contributing factors of patient self-reported dental injury and to assess the impact of dental injury on patient satisfaction. METHODS Multivariate logistic analysis was performed on the records of 14,820 patients using the incidence of dental injury as the dependent variable and covariates in the anesthesia registry and a postoperative questionnaire as independent variables to investigate factors significantly associated perioperative dental injury. In addition, satisfaction with the anesthesia service was compared between patients with and without injury using a matched-pair population. RESULTS A total of 101 dental injuries were identified. Of those, 25% were associated with intubation and extubation in the operating room, while most other injuries occurred postoperatively. Duration of anesthesia (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.03) and emergency surgery (OR, 1.92; 95% CI, 1.11-3.30) were independently associated with perioperative dental injury. Dental injury did not significantly decrease a patient's satisfaction with the anesthesia service (P = .441). CONCLUSION Most perioperative dental injuries are unrelated to anesthesia procedures. However, the duration of anesthesia and emergency surgery were significantly associated with perioperative dental injury, while decreased patient satisfaction was not.
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Affiliation(s)
- Taichi Kotani
- Department of Anesthesiology and Division of Intensive Care, Nara Medical University, Nara, Japan
| | - Satoki Inoue
- Department of Anesthesiology and Division of Intensive Care, Nara Medical University, Nara, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology and Division of Intensive Care, Nara Medical University, Nara, Japan
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7
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Grillo VTRDS, Jaldin RG, Sertório ND, Bertanha M, Sobreira ML, Yoshida RDA, Yoshida WB. True isolated deep femoral artery aneurysm associated with peripheral artery disease: case report. J Vasc Bras 2021; 20:e20200220. [PMID: 34211539 PMCID: PMC8218824 DOI: 10.1590/1677-5449.200220] [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] [Indexed: 11/22/2022] Open
Abstract
True deep femoral artery aneurysms are extremely rare, accounting for about 0.5% of all peripheral aneurysms. In this report, we describe a 79-year-old male patient with a history of prior abdominal aortic aneurysm surgery via a conventional approach who was admitted to the vascular surgery service at the Hospital das Clínicas with intermittent claudication of the lower limbs. Arterial color-Doppler ultrasonography of the right lower limb was performed, revealing peripheral arterial disease of the femoral--popliteal and infrapatellar segments. Computed tomography angiography identified aortoiliac and bifurcated graft occlusion from the infrarenal segment of the aorta, in addition to a deep femoral artery aneurysm with diameters of 3.7 cm x 3.5 cm and length of 7 cm. Resection of the aneurysm was followed by revascularization of the deep femoral artery by interposition of a Dacron® graft and reimplantation of the superficial femoral artery into the graft. In cases of deep femoral artery aneurysms with concomitant peripheral arterial disease, it is important to ensure revascularization and adequate perfusion of the lower limb.
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Affiliation(s)
- Vinicius Tadeu Ramos da Silva Grillo
- Universidade Estadual Paulista "Júlio de Mesquita Filho" - UNESP, Hospital das Clínicas da Faculdade de Medicina de Botucatu - HC-FMB, Serviço de Cirurgia Vascular e Endovascular, Botucatu, SP, Brasil
| | - Rodrigo Gibin Jaldin
- Universidade Estadual Paulista "Júlio de Mesquita Filho" - UNESP, Hospital das Clínicas da Faculdade de Medicina de Botucatu - HC-FMB, Serviço de Cirurgia Vascular e Endovascular, Botucatu, SP, Brasil
| | - Nathália Dias Sertório
- Universidade Estadual Paulista "Júlio de Mesquita Filho" - UNESP, Hospital das Clínicas da Faculdade de Medicina de Botucatu - HC-FMB, Serviço de Cirurgia Vascular e Endovascular, Botucatu, SP, Brasil
| | - Matheus Bertanha
- Universidade Estadual Paulista "Júlio de Mesquita Filho" - UNESP, Hospital das Clínicas da Faculdade de Medicina de Botucatu - HC-FMB, Serviço de Cirurgia Vascular e Endovascular, Botucatu, SP, Brasil
| | - Marcone Lima Sobreira
- Universidade Estadual Paulista "Júlio de Mesquita Filho" - UNESP, Hospital das Clínicas da Faculdade de Medicina de Botucatu - HC-FMB, Serviço de Cirurgia Vascular e Endovascular, Botucatu, SP, Brasil
| | - Ricardo de Alvarenga Yoshida
- Universidade Estadual Paulista "Júlio de Mesquita Filho" - UNESP, Hospital das Clínicas da Faculdade de Medicina de Botucatu - HC-FMB, Serviço de Cirurgia Vascular e Endovascular, Botucatu, SP, Brasil
| | - Winston Bonetti Yoshida
- Universidade Estadual Paulista "Júlio de Mesquita Filho" - UNESP, Hospital das Clínicas da Faculdade de Medicina de Botucatu - HC-FMB, Serviço de Cirurgia Vascular e Endovascular, Botucatu, SP, Brasil
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Ohya H, Watanabe J, Suwa Y, Nakagawa K, Suwa H, Ozawa M, Ishibe A, Kunisaki C, Endo I. Comparison of the continuation and discontinuation of perioperative antiplatelet therapy in laparoscopic surgery for colorectal cancer: A retrospective, multicenter, observational study (YCOG 1603). Ann Gastroenterol Surg 2021; 5:67-74. [PMID: 33532682 PMCID: PMC7832956 DOI: 10.1002/ags3.12387] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/08/2020] [Accepted: 07/20/2020] [Indexed: 11/07/2022] Open
Abstract
AIM The present study aimed to examine the effect of continuing antiplatelet therapy in the perioperative period for patients undergoing laparoscopic resection for colorectal cancer who had received preoperative antiplatelet therapy. METHODS This retrospective, multicenter, observational study included patients who underwent laparoscopic surgery for colorectal cancer between January 2011 and May 2020. The study population was limited to patients who used antiplatelet therapy preoperatively. RESULTS A total of 214 colorectal cancer patients who received antiplatelet therapy preoperatively were included in the present study. Eighty-nine patients underwent surgery under the continuation of antiplatelet therapy, and 125 patients underwent surgery under the discontinuation of antiplatelet therapy before surgery. There were no significant differences between the two groups with regard to intraoperative blood loss (P = .889), intraoperative blood transfusion (P = 1.000), and conversion to laparotomy (P = 1.000). There were no significant differences between the two groups in the incidence of postoperative hemorrhagic complications (Clavien-Dindo Grade ≥II, P = .453; Grade ≥III, P = .572) or three-point major adverse cardiovascular events (P = .268). However, there were two cases of postoperative non-fatal stroke in the discontinued antiplatelet therapy group. CONCLUSIONS The present study revealed that there were no significant differences in the surgical outcomes and postoperative complications between colorectal cancer patients who underwent laparoscopic resection with the continuation of antiplatelet therapy in the perioperative period and those in whom antiplatelet therapy was discontinued during the perioperative period. From the viewpoint of cardiovascular and cerebrovascular risk, it may be better for patients undergoing laparoscopic surgery for colorectal cancer to continue antiplatelet therapy. This study was registered with the Japanese Clinical Trials Registry as UMIN000038707 (http://www.umin.ac.jp/ctr/index.htm).
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Affiliation(s)
- Hiroki Ohya
- Department of SurgeryGastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Jun Watanabe
- Department of SurgeryGastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Yusuke Suwa
- Department of SurgeryGastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Kazuya Nakagawa
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
| | - Hirokazu Suwa
- Department of SurgeryYokosuka Kyosai HospitalYokosukaJapan
| | - Mayumi Ozawa
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
| | - Atsushi Ishibe
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
| | - Chikara Kunisaki
- Department of SurgeryGastroenterological CenterYokohama City University Medical CenterYokohamaJapan
| | - Itaru Endo
- Department of Gastroenterological SurgeryYokohama City University Graduate School of MedicineYokohamaJapan
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9
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Naji A, Stolin GB, Ahmed A, Gatling J. Preoperative Assessment of Geriatric Patients Undergoing Elective Intracranial Surgery. Cureus 2020; 12:e12284. [PMID: 33510988 PMCID: PMC7829029 DOI: 10.7759/cureus.12284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A comprehensive preoperative assessment of elderly patients undergoing intracranial surgeries can reduce perioperative morbidity and mortality. Elderly patients often present with a wide array of comorbid medical conditions and extensive medication lists, which may influence the preoperative evaluation, anesthetic plan, and perioperative care. This article provides a basic overview of the preoperative assessment of elderly patients undergoing intracranial surgeries.
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Affiliation(s)
- Abdullah Naji
- Anesthesiology, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, USA
| | - Gabriel B Stolin
- Anesthesiology, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, USA
| | | | - Jason Gatling
- Anesthesiology, Loma Linda University Medical Center, Loma Linda, USA
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10
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Cornell LF, Mclaughlin SA, Pruthi S, Mussallem DM. Special considerations of breast cancer management in the elderly. BREAST CANCER MANAGEMENT 2020. [DOI: 10.2217/bmt-2020-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
There are increasing numbers of elderly patients diagnosed with breast cancer. These patients are under-represented in available clinical trials, and as such, there are limited evidence-based guidelines for treatment in this population. Elderly patients have unique needs and management strategies should be tailored accordingly. This article reviews available literature regarding breast cancer management and special considerations in elderly patients.
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Affiliation(s)
- Lauren F Cornell
- Jacoby Center for Breast Health, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Sarah A Mclaughlin
- Jacoby Center for Breast Health, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Sandhya Pruthi
- Breast Diagnostic Clinic, Mayo Clinic, Rochester, MN 55905, USA
| | - Dawn M Mussallem
- Jacoby Center for Breast Health, Mayo Clinic, Jacksonville, FL 32224, USA
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11
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Preoperative Screening for Obstructive Sleep Apnea to Improve Long-term Outcomes. Anesthesiology 2020; 133:702-704. [PMID: 32796203 DOI: 10.1097/aln.0000000000003492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Wajima Z. Anesthesia Management of Special Patient Populations Undergoing Electroconvulsive Therapy: A Review. J NIPPON MED SCH 2019; 86:70-80. [PMID: 31130568 DOI: 10.1272/jnms.jnms.2019_86-202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Electroconvulsive therapy (ECT) is the safe application of electricity to the scalp of a patient, using brief-pulse stimulation techniques under general anesthesia and muscle paralysis, inducing a series of generalized epileptic seizures. Principal indications for ECT are major depression (unipolar or bipolar) with a lack of response to medications, intolerance to medications due to side effects or coexisting conditions, the need for a rapid response because of other conditions such as catatonia, psychosis, suicidality, or clinically significant dehydration or malnutrition, mania, and schizophreniform disorder or schizoaffective disorder, and, medical disorders such as Parkinson's disease, neuroleptic malignant syndrome, and chronic pain. Anesthesia management of special patient populations undergoing ECT has been described in textbooks and guidelines, but some descriptions may be antiquated. Therefore, this review describes recent knowledge on anesthesia management of patients who require ECT, such as those with neurologic disorders, cardiovascular disorders, pregnancy, and other concurrent medical illness. Based on the findings of a recent paper, ECT may be safer than is widely reported. According to the American Psychiatric Association, ECT has no absolute contraindications; however, some conditions pose a relatively high risk, and there are many other kinds of complications associated with ECT that can lead to death. Understanding such complications and their management strategies can avoid unnecessary discontinuation of treatment due to manageable complications of ECT and, furthermore, ECT clinicians must also consider the risk-benefit ratio when treating high-risk patients.
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Affiliation(s)
- Zen'ichiro Wajima
- Department of Anesthesiology, Tokyo Medical University Hachioji Medical Center
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Luo Y, Jiang C, Krittanawong C, Arevalo Molina AB, Murray S, Huang F, Zhang J, Salgado M, Xu J. Systemic sclerosis and the risk of perioperative major adverse cardiovascular events for inpatient non-cardiac surgery. Int J Rheum Dis 2019; 22:1023-1028. [PMID: 30834657 DOI: 10.1111/1756-185x.13537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 12/31/2018] [Accepted: 02/10/2019] [Indexed: 01/03/2023]
Abstract
AIM We investigated the association between systemic sclerosis (SSc) and perioperative cardiovascular risk for inpatient non-cardiac surgical procedures. METHODS We used data from the National Inpatient Sample (NIS) for the year 2014 to identify patients undergoing inpatient non-cardiac surgery. SSc and major adverse cardiovascular events (MACE) were defined by International Classification of Diseases 9th Revision diagnosis codes. Univariate and multivariate analyses were performed. We adjusted for demographic information, socioeconomic status, cardiac comorbidities, cardiovascular risk factors and procedural category. Two models were used with different categorization strategies for surgical procedures. RESULTS A total of 8 156 379 hospitalizations for non-cardiac surgeries were included, 4385 of which had a diagnosis of SSc. Patients with SSc were older, more likely to be female and Caucasian and with higher cardiac and systemic comorbidity burden. In univariate analysis, SSc was associated with higher risk of perioperative MACE (odds ratio [OR] = 2.9; P < 0.001) and all-cause death (P = 3.07; P < 0.001). Multivariate analysis yielded conflicting results regarding the association between SSc and perioperative MACE (Model 1: OR = 1.42; P = 0.146; Model 2: OR = 1.59; P = 0.048). Subsequent analysis showed that only perioperative myocardial infarction (Model 1 OR = 1.85; P = 0.048; Model 2 OR = 1.94; P = 0.031) was independently associated with SSc. CONCLUSION We did not find consistent association between SSc and perioperative MACE in non-cardiac surgical procedures. SSc may be associated with perioperative myocardial infarction.
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Affiliation(s)
- Yiming Luo
- Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Changchuan Jiang
- Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chayakrit Krittanawong
- Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ana Belen Arevalo Molina
- Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shane Murray
- Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Feng Huang
- Department of Rheumatology and Immunology, China PLA General Hospital, Beijing, China
| | - Jianglin Zhang
- Department of Rheumatology and Immunology, China PLA General Hospital, Beijing, China
| | - Maria Salgado
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Jiehui Xu
- Mailman School of Public Health, Columbia University Medical Center, New York, New York
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14
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Individualizing Local-Regional Therapy of Breast Cancer in the Elderly. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0272-0] [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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15
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General Remarks. Plast Reconstr Surg 2018. [DOI: 10.1007/978-981-10-3400-8_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Ethun CG, Bilen MA, Jani AB, Maithel SK, Ogan K, Master VA. Frailty and cancer: Implications for oncology surgery, medical oncology, and radiation oncology. CA Cancer J Clin 2017; 67:362-377. [PMID: 28731537 DOI: 10.3322/caac.21406] [Citation(s) in RCA: 343] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Answer questions and earn CME/CNE The concept of frailty has become increasingly recognized as one of the most important issues in health care and health outcomes and is of particular importance in patients with cancer who are receiving treatment with surgery, chemotherapy, and radiotherapy. Because both cancer itself, as well as the therapies offered, can be significant additional stressors that challenge a patient's physiologic reserve, the incidence of frailty in older patients with cancer is especially high-it is estimated that over one-half of older patients with cancer have frailty or prefrailty. Defining frailty can be challenging, however. Put simply, frailty is a state of extreme vulnerability to stressors that leads to adverse health outcomes. In reality, frailty is a complex, multidimensional, and cyclical state of diminished physiologic reserve that results in decreased resiliency and adaptive capacity and increased vulnerability to stressors. In addition, over 70 different measures of frailty have been proposed. Still, it has been demonstrated that frail patients are at increased risk of postoperative complications, chemotherapy intolerance, disease progression, and death. Although international standardization of frailty cutoff points are needed, continued efforts by oncology physicians and surgeons to identify frailty and promote multidisciplinary decision making will help to develop more individualized management strategies and optimize care for patients with cancer. CA Cancer J Clin 2017;67:362-377. © 2017 American Cancer Society.
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Affiliation(s)
- Cecilia G Ethun
- General Surgery Resident, Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Mehmet A Bilen
- Assistant Professor, Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Ashesh B Jani
- Professor, Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K Maithel
- Associate Professor, Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Kenneth Ogan
- Professor of Urology, Department of Urology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Viraj A Master
- Professor, Department of Urology, Winship Cancer Institute, Emory University, Atlanta, GA
- Director of Clinical Research, Department of Urology, Winship Cancer Institute, Emory University, Atlanta, GA
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Han F, Wang Y, Wang Y, Dong J, Nie C, Chen M, Hou L. Intraoperative cardiac arrest: A 10-year study of patients undergoing tumorous surgery in a tertiary referral cancer center in China. Medicine (Baltimore) 2017; 96:e6794. [PMID: 28445319 PMCID: PMC5413284 DOI: 10.1097/md.0000000000006794] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Intraoperative cardiac arrest (IOCA) is a lethal complication of noncardiac surgery. According to several reports, immediate survival after IOCA is approximately 50%. In this study, a retrospective case analysis was performed to determine the incidence of IOCA, the potential causes of cardiac arrest, and the risk factors of no resuscitation in patients undergoing tumorous surgery.The medical records of surgery patients who experienced cardiac arrest during the intraoperative period between 2005 and 2014 were reviewed. The general conditions of the patients with IOCA were compared between the successfully resuscitated group and the unresuscitated group.Fifteen patients with IOCA among 142,853 patients undergoing tumorous surgery were reviewed during the study period. Immediate survival after IOCA was 60%. Hospital survival was 46.7%. The incidence of IOCA decreased during 2010 to 2014 when compared with the rate during 2005 to 2009 (P < .05). The risk factors affecting the success of resuscitation after IOCA included American Society of Anesthesiologists Physical Status (ASA PS) classification ≥ III (P < .05) and preoperative tachycardia (heart rate ≥100/min, P < .05). The methods of anesthesia had no effects on the results of resuscitation.The incidence of IOCA in patients undergoing tumorous surgery was 1.05 per 10,000 anesthesia. The overall mortality of IOCA was 0.56/10,000. The frequency of IOCA decreased within 10 years. There was no cardiac arrest primarily attributable to anesthesia over this study period. The risk factors leading to unsuccessful resuscitation after IOCA were ASA PS classification ≥ III and preoperative tachycardia.
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Perioperative β-Blockade in Noncardiac Surgery: A Cautionary Tale of Over-reliance on Small Randomized Prospective Trials. Clin Ther 2016; 38:2302-2316. [PMID: 27666127 DOI: 10.1016/j.clinthera.2016.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/26/2016] [Accepted: 08/25/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Our aim was to analyze the current scientific literature relevant to the use of β-adrenergic receptor antagonists for the prevention of cardiovascular morbidity and mortality in patients undergoing noncardiac surgery. METHODS A PubMed search was conducted for the following concepts: pre- or perioperative, β-adrenergic receptor antagonist, treatment outcome, and cardiovascular complication. Randomized clinical trials measuring the effect of β-adrenergic blocking agents against that of placebo on cardiovascular outcomes after noncardiac surgery were included in the review. FINDINGS Two small randomized controlled trials published in 1996 and 1999 reported associations between perioperative β-blockade and significant reductions in long-term and 30-day cardiac mortality, respectively. These 2 studies prompted guideline changes in 2002 encouraging perioperative β-blockade in subsets of noncardiac surgery patients. However, subsequent trials failed to validate these results. In 2008, the first large randomized controlled trial on the topic was published and found an association between perioperative β-blockade and an increase in perioperative mortality. Furthermore, in 2011, the lead author of the 1999 study was dismissed from his academic position for scientific misconduct, casting doubt on the validity of guidelines based on his work. Existing studies are highly heterogeneous, making comparisons difficult. Current literature does not support initiating perioperative β-blockade in noncardiac surgery patients not already receiving these medications. IMPLICATIONS Future research on the topic should account for the influence individual genetic variation can have on outcomes and β-blocker metabolism. Additionally, the relationship between outcomes and the β-1 selectivity of different β-blockers should be explored.
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Levitan EB, Graham LA, Valle JA, Richman JS, Hollis R, Holcomb CN, Maddox TM, Hawn MT. Pre-operative echocardiography among patients with coronary artery disease in the United States Veterans Affairs healthcare system: A retrospective cohort study. BMC Cardiovasc Disord 2016; 16:173. [PMID: 27596717 PMCID: PMC5011899 DOI: 10.1186/s12872-016-0357-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/26/2016] [Indexed: 11/10/2022] Open
Abstract
Background Echocardiography is not recommended for routine pre-surgical evaluation but may have value for patients at high risk of major adverse cardiovascular events (MACE). The objective of this study was to evaluate whether pre-operative echocardiography is associated with lower risk of post-operative MACE among patients with coronary artery disease. Methods Using administrative and registry data, we examined associations of echocardiography within 3 months prior to surgery with postoperative MACE (myocardial infarction, revascularization, or death within 30 days) among patients with coronary artery disease undergoing elective, non-cardiac surgeries in the United States Veterans Affairs healthcare system in 2000–2012. Results Echocardiography preceded 4,378 (16.4 %) of 26,641 surgeries. MACE occurred within 30 days following 944 (3.5 %) surgeries. A 10 % higher case-mix adjusted rate of pre-operative echocardiography assessed at the hospital level was associated with a hospital-level risk of MACE that was 1.0 % (95 % confidence interval [CI] 0.1 %, 2.0 %) higher overall and 1.7 % (95 % CI 0.2 %, 3.2 %) higher among patients with recent myocardial infarction, valvular heart disease, or heart failure. At the patient level, pre-operative echocardiography was associated with an odds ratio for MACE of 1.9 (95 % CI 1.7, 2.2) overall and 1.8 (95 % CI 1.5, 2.2) among patients with recent myocardial infarction, valvular heart disease, or heart failure adjusting for MACE risk factors. Conclusions Pre-operative echocardiography was not associated with lower risk of post-operative MACE, even in a high risk population. Future guidelines should encourage pre-operative echocardiography only in specific patients with cardiovascular disease among whom findings can be translated into effective changes in care. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0357-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, 35294-0022, Birmingham, AL, USA. .,Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
| | - Laura A Graham
- Department of Epidemiology, University of Alabama at Birmingham, 35294-0022, Birmingham, AL, USA.,Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Javier A Valle
- Division of Cardiology, University of Colorado, Denver, CO, USA
| | - Joshua S Richman
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.,Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert Hollis
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.,Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Carla N Holcomb
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.,Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Thomas M Maddox
- Division of Cardiology, University of Colorado, Denver, CO, USA.,Veterans Affairs Eastern Colorado Health Care System, Denver, CO, USA
| | - Mary T Hawn
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.,Department of Surgery, Stanford University, Stanford, CA, USA
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Guerrier G, Rondet S, Hallal D, Levy J, Bourdon H, Brezin AP, Samama CM. Risk factors for intraoperative hypertension in patients undergoing cataract surgery under topical anaesthesia. Anaesth Crit Care Pain Med 2016; 35:343-346. [PMID: 27320050 DOI: 10.1016/j.accpm.2016.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/10/2015] [Accepted: 01/20/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE Hypertension is the most common operative medical complication in patients undergoing cataract surgery under topical anaesthesia. Our objective was to identify risk factors for high blood pressure requiring anaesthetic interventions. METHODS All patients undergoing elective cataract operations were included in an observational prospective study preceded by a medical history description and physical examination. Intraoperative adverse medical events and type of management were recorded. RESULTS We studied 514 elective cataract operations. The overall rate of hypertension during surgery was 10.4% (n=54). Independent risk factors for developing intraoperative hypertension were female sex (OR=3.8 [1.4-10.3]; P=0.01), age>80years (OR=4.5 [1.5-13.8]; P=0.01) and anxiety (OR=10.5 [4.1-27.0]; P<0.001). The incidence of hypertension was not significantly reduced by premedication (OR=0.5 [0.04-6.0]; P=0.6). There was no significant difference between patients with or without hypertension history in the rates of hypertensive events (OR=3.2 [0.6-15.5]; P=0.15). Management of hypertension or anxiety was similar in patients regardless of their past medical history or ASA risk class. CONCLUSIONS A specific at-risk population may benefit from targeted preoperative interventions for reducing intraoperative anxiety and hypertension.
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Affiliation(s)
- Gilles Guerrier
- Département d'anesthésie-réanimation, hôpital Cochin, université Paris-Descartes, 75014 Paris, France.
| | - Sylvie Rondet
- Département d'anesthésie-réanimation, hôpital Cochin, université Paris-Descartes, 75014 Paris, France
| | - Dalila Hallal
- Département d'anesthésie-réanimation, hôpital Cochin, université Paris-Descartes, 75014 Paris, France
| | - Jacques Levy
- Département d'anesthésie-réanimation, hôpital Cochin, université Paris-Descartes, 75014 Paris, France
| | - Hugo Bourdon
- Service d'ophtalmologie, hôpital Cochin, université Paris-Descartes, 75014 Paris, France
| | - Antoine P Brezin
- Service d'ophtalmologie, hôpital Cochin, université Paris-Descartes, 75014 Paris, France
| | - Charles Marc Samama
- Département d'anesthésie-réanimation, hôpital Cochin, université Paris-Descartes, 75014 Paris, France
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Thomas KN, Cotter JD, Williams MJA, van Rij AM. Diagnosis, Incidence, and Clinical Implications of Perioperative Myocardial Injury in Vascular Surgery. Vasc Endovascular Surg 2016; 50:247-55. [DOI: 10.1177/1538574416637441] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Introduction: Routine measurement of cardiac biomarkers such as troponin T (TnT) is recommended perioperatively, especially in high-risk vascular surgery. Long-term prognosis is worse even in those with nonspecific perioperative myocardial injury. However, a clear understanding of these biomarker profiles and how they should affect patient management is lacking. Methods: We examined the perioperative profile of high-sensitivity TnT (hsTnT) release in 85 patients undergoing elective major vascular surgery. Plasma hsTnT was measured preoperatively, at 6, 12, and 24 hours postoperatively, and then every 24 hours for a maximum of 5 days. Significant elevations in hsTnT with/without clinical indicators of ischemia were used to diagnose myocardial infarction or injury. Results: A high incidence of myocardial injury was evident (46% had elevated hsTnT); only 5% were associated with myocardial infarction, and 41% were due to myocardial injury. Conclusions: This study emphasizes the high incidence of perioperative myocardial injury and stress in vascular surgery as revealed by the use of the robust and very sensitive biomarker of myocardial damage, hsTnT. The high availability and swift development of increasingly sensitive assays allow detection of abnormal elevated hsTnT levels in a higher proportion of the population. Consequent challenges are the reduced specificity to separate acute events as well as to deduce the prognostic value of elevations due to confusing criteria; this is especially the case in a patient group with multiple comorbidities that affect hsTnT levels chronically.
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Affiliation(s)
- Kate N. Thomas
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- School of Physical Education, Sport and Exercise Sciences, University of Otago, Dunedin, New Zealand
| | - James D. Cotter
- School of Physical Education, Sport and Exercise Sciences, University of Otago, Dunedin, New Zealand
| | - Michael J. A. Williams
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - André M. van Rij
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Ellington DR, Erekson EA, Richter HE. Outcomes of Surgery for Stress Urinary Incontinence in the Older Woman. Clin Geriatr Med 2015; 31:487-505. [PMID: 26476111 PMCID: PMC4609316 DOI: 10.1016/j.cger.2015.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
As population demographics continue to evolve, specifics on age-related outcomes of stress urinary incontinence interventions will be critical to patient counseling and management planning. Understanding medical factors unique to older women and their lower urinary tract conditions will allow caregivers to optimize surgical outcomes, both physical and functional, and minimize complications within this population.
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Affiliation(s)
- David R. Ellington
- University of Alabama at Birmingham, Division of Urogynecology and Pelvic Reconstructive Surgery, 176 F Suite 10382, 619 19 Street South, Birmingham, Alabama 35249-7333, Phone: (205)-934-1704, Fax: (205)-975-8893,
| | - Elisabeth A. Erekson
- The Geisel School of Medicine at Dartmouth, Division of Female Pelvic Medicine and Reconstructive Surgery, 1 Medical Center Dr., Lebanon, NH 03756, Phone: (603) 653-9312, Fax: (603) 650-0906,
| | - Holly E. Richter
- University of Alabama at Birmingham, Division of Urogynecology and Pelvic Reconstructive Surgery, 176 F Suite 10382, 619 19 Street South, Birmingham, Alabama 35249-7333
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O'Shaughnessy MA, Adams JE. Perioperative Management of Hypertension in Hand Surgery Patients. J Hand Surg Am 2015; 40:1684-7. [PMID: 25957044 DOI: 10.1016/j.jhsa.2015.03.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/13/2015] [Accepted: 03/19/2015] [Indexed: 02/02/2023]
Affiliation(s)
| | - Julie E Adams
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
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Bogaev RC, Meyers DE. Medical Treatment of Heart Failure and Coronary Heart Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_20] [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: 12/01/2022]
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Levin AI, Coetzee AR. Statins and perioperative myocardial infarction. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2007.10872486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Wijeysundera DN, Duncan D, Nkonde-Price C, Virani SS, Washam JB, Fleischmann KE, Fleisher LA. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2246-64. [PMID: 25085964 DOI: 10.1161/cir.0000000000000104] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates. METHODS PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions. RESULTS We identified 17 studies, of which 16 were RCTs (12 043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI: 1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR: 0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded. CONCLUSIONS Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.
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Marsico F, Giugliano G, Ruggiero D, Parente A, Paolillo S, Guercio LD, Esposito G, Trimarco B, Filardi PP. Prevalence and severity of asymptomatic coronary and carotid artery disease in patients with abdominal aortic aneurysm. Angiology 2014; 66:360-4. [PMID: 24965380 DOI: 10.1177/0003319714540319] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We evaluated the prevalence and severity of occult coronary artery disease (CAD) and cerebrovascular disease (CeVD) in patients with abdominal aortic aneurysm (AAA). We studied 100 consecutive patients with no history of CAD, normal electrocardiogram, normal systolic function, and no angina or dyspnea. All patients underwent carotid Doppler study and invasive coronary angiography. Significant CAD was observed in 61% of patients. In all, 51% of patients with significant CAD showed either left main (n = 7), 3-vessel (n = 17), or proximal left anterior descending (n = 7) CAD, corresponding to 31% of the total cohort. Cerebrovascular disease was detected in 53% of patients, and in 38% of them was significant (peak systolic flow velocity ≥125 <230 cm/s). In 36% of patients with CeVD either left main (n = 5), 3-vessel (n = 11), or proximal left anterior descending (n = 3) CAD was observed. Severe asymptomatic CAD is prevalent in AAA, and 31% of patients fulfill indications for coronary revascularization.
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Affiliation(s)
- Fabio Marsico
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giuseppe Giugliano
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Donatella Ruggiero
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Antonio Parente
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Luca Del Guercio
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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Lidsky ME, Speicher PJ, Turley RS, Barbas AS, Clary BM. Does the presence of coronary artery disease impact perioperative outcomes following partial hepatectomy? J Gastrointest Surg 2014; 18:709-18. [PMID: 24435455 DOI: 10.1007/s11605-014-2451-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 01/02/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Coronary artery disease (CAD) is often considered a contraindication to hepatectomy despite a lack of data to support this practice. The purpose of this study is to evaluate the impact of CAD on postoperative outcomes in patients undergoing hepatectomy. MATERIAL AND METHODS A total of 1,206 consecutive patients undergoing hepatectomy from August 1995 to June 2009 were included. Propensity matching was performed to identify differences in morbidity and mortality between patients with and without CAD. Subgroup analyses were performed to stratify patients based on the severity of CAD and the interval between coronary intervention and hepatectomy. RESULTS Of all patients, 138 (11.4%) had a diagnosis of CAD and were more likely to have a malignant diagnosis and other comorbid conditions including renal insufficiency, COPD, and diabetes. Matched patients with CAD had no significant differences in complication rates, with 2.2 and 5.8% of CAD patients experiencing a postoperative myocardial infarction or arrhythmia, respectively. Propensity matching failed to identify differences in mortality or morbidity. Subgroup analysis revealed similar rates of mortality and complications regardless of the severity of CAD or the time interval between coronary intervention and hepatectomy. CONCLUSION Despite the increased prevalence of major medical comorbidities, selected patients with CAD can safely undergo hepatectomy with acceptable rates of postoperative morbidity and mortality.
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Affiliation(s)
- Michael E Lidsky
- Department of Surgery, Duke University Medical Center, DUMC 3247, Durham, NC, 27710, USA,
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Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing vascular surgery. Ann Surg 2013; 261:e143-4. [PMID: 24368637 DOI: 10.1097/sla.0000000000000355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tyng CJ, Maciel MJS, Moreira BL, Matushita Jr. JPK, Bitencourt AGV, Poli MRB. Preparation and management of complications in prostate biopsies. Radiol Bras 2013. [DOI: 10.1590/s0100-39842013000600009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Saigusa T, Izawa A, Miura T, Ebisawa S, Shiba Y, Miyashita Y, Tomita T, Koyama J, Fukui D, Takano T, Amano J, Ikeda U. Low Levels of High-Density Lipoprotein Cholesterol Predict the Presence of Coronary Artery Disease in Patients With Aortic Aneurysms. Angiology 2013; 65:710-5. [DOI: 10.1177/0003319713502391] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
To identify predictors of the presence of coronary artery disease (CAD) in patients with planned surgery for aortic aneurysms, we reviewed clinical profiles and angiography records of 191 patients with aortic aneurysms (34 thoracic, 137 abdominal, and 20 thoracoabdominal; 162 men; mean age, 75.2 ± 7.7 years). The incidence of CAD was 38.7% among all the patients. Patients with CAD had significantly low levels of high-density lipoprotein cholesterol (HDL-C) as compared with patients without CAD (45 ± 9 vs 51 ± 13 mg/dL; P = .009). Multivariate analysis showed that only low HDL-C levels were associated with the presence of CAD (adjusted odds ratio, 0.946; 95% confidence interval, 0.911-0.983; P = .004). The optimal cutoff level of HDL-C to predict CAD was 47.50 mg/dL. The CAD is common in patients with aortic aneurysms, and low levels of HDL-C are independently associated with the presence of CAD.
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Affiliation(s)
- Tatsuya Saigusa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Atsushi Izawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takashi Miura
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Soichiro Ebisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuji Shiba
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yusuke Miyashita
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takeshi Tomita
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Jun Koyama
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Daisuke Fukui
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tamaki Takano
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Jun Amano
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Uichi Ikeda
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
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Yazdanyar A, Wasko MC, Scalzi LV, Kraemer KL, Ward MM. Short-term perioperative all-cause mortality and cardiovascular events in women with systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2013; 65:986-91. [PMID: 23213026 DOI: 10.1002/acr.21915] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 11/07/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Persons with systemic lupus erythematosus (SLE) are at an increased risk of cardiovascular disease (CVD) events, but this excess CVD burden in the perioperative setting is yet to be determined. We aimed to determine the risk of perioperative short-term all-cause mortality and CVD events among women with SLE compared to those without SLE. METHODS We conducted a cross-sectional analysis of pooled hospital discharge data of the Nationwide Inpatient Sample from 1998-2002. We abstracted diseases and procedures using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The principal procedure was categorized into either a low, intermediate, or high risk level. Survey logistic regression adjusting for potential confounders provided estimates for stratum-specific odds of adverse events in women with SLE relative to those without SLE for each procedure risk level. RESULTS All-cause mortality was significantly greater among women with SLE having a low- (odds ratio [OR] 1.54, 95% confidence interval [95% CI] 1.00-2.37) or a high-risk principal procedure (OR 2.52, 95% CI 1.34-4.75) relative to women without SLE, but did not differ significantly among persons with intermediate-risk procedures. Women with SLE with a low-risk procedure were also more likely to experience a composite CVD event relative to women without SLE (OR 1.40, 95% CI 1.04-1.87). CONCLUSION Women with SLE are at an increased risk for short-term perioperative adverse events. These results highlight a need for greater scrutiny during perioperative evaluation and management of women with SLE.
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Affiliation(s)
- Ali Yazdanyar
- Section of Hospital Medicine, Department of Medicine, The Reading Hospital and Medical Center, West Reading, PA 19611, USA.
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Procedure guidelines for radionuclide myocardial perfusion imaging with single-photon emission computed tomography. Nucl Med Commun 2013; 34:813-26. [PMID: 23719150 DOI: 10.1097/mnm.0b013e32836171eb] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery. Chest 2013; 143:e166S-e190S. [DOI: 10.1378/chest.12-2395] [Citation(s) in RCA: 542] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Abdominal Aortic Calcification and Surgical Outcomes in Patients With No Known Cardiovascular Risk Factors. Ann Surg 2013; 257:774-81. [DOI: 10.1097/sla.0b013e31826ddd5f] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Older P. Anaerobic threshold, is it a magic number to determine fitness for surgery? Perioper Med (Lond) 2013; 2:2. [PMID: 24472514 PMCID: PMC3964343 DOI: 10.1186/2047-0525-2-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 01/24/2013] [Indexed: 10/28/2022] Open
Abstract
The use of cardiopulmonary exercise testing (CPET) to evaluate cardiac and respiratory function was pioneered as part of preoperative assessment in the mid 1990s. Surgical procedures have changed since then. The patient population may have aged; however, the physiology has remained the same. The use of an accurate physiological evaluation remains as germane today as it was then. Certainly no 'magic' is involved. The author recognizes that not everyone accepts the classical theories of the anaerobic threshold (AT) and that there is some discussion around lactate and exercise. The article looks at aerobic capacity as an important predictor of perioperative mortality and also looks at some aspects of CPET relative to surgical risk evaluation.
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Affiliation(s)
- Paul Older
- Department of Anaesthetics, Western Hospital, Melbourne, Australia.
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Lurati Buse GAL, Schumacher P, Seeberger E, Studer W, Schuman RM, Fassl J, Kasper J, Filipovic M, Bolliger D, Seeberger MD. Randomized comparison of sevoflurane versus propofol to reduce perioperative myocardial ischemia in patients undergoing noncardiac surgery. Circulation 2012; 126:2696-704. [PMID: 23136158 DOI: 10.1161/circulationaha.112.126144] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Volatile anesthetics provide myocardial preconditioning in coronary surgery patients. We hypothesized that sevoflurane compared with propofol reduces the incidence of myocardial ischemia in patients undergoing major noncardiac surgery. METHODS AND RESULTS We enrolled 385 patients at cardiovascular risk in 3 centers. Patients were randomized to maintenance of anesthesia with sevoflurane or propofol. We recorded continuous ECG for 48 hours perioperatively, measured troponin T and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) on postoperative days 1 and 2, and evaluated postoperative delirium by the Confusion Assessment Method. At 6 and 12 months, we contacted patients by telephone to assess major adverse cardiac events. The primary end point was a composite of myocardial ischemia detected by continuous ECG and/or troponin elevation. Additional end points were postoperative NT-proBNP concentrations, major adverse cardiac events, and delirium. Patients and outcome assessors were blinded. We tested dichotomous end points by χ(2) test and NT-proBNP by Mann-Whitney test on an intention-to-treat basis. Myocardial ischemia occurred in 75 patients (40.8%) in the sevoflurane and 81 (40.3%) in the propofol group (relative risk, 1.01; 95% confidence interval, 0.78-1.30). NT-proBNP release did not differ across allocation on postoperative day 1 or 2. Within 12 months, 14 patients (7.6%) suffered a major adverse cardiac event after sevoflurane and 17 (8.5%) after propofol (relative risk, 0.90; 95% confidence interval, 0.44-1.83). The incidence of delirium did not differ (11.4% versus 14.4%; P=0.379). CONCLUSIONS Compared with propofol, sevoflurane did not reduce the incidence of myocardial ischemia in high-risk patients undergoing major noncardiac surgery. The sevoflurane and propofol groups did not differ in postoperative NT-proBNP release, major adverse cardiac events at 1 year, or delirium.
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Affiliation(s)
- Giovanna A L Lurati Buse
- Department of Anesthesia and Intensive Care Medicine, University Hospital Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland.
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Vazirani S, Lankarani-Fard A, Liang LJ, Stelzner M, Asch SM. Perioperative processes and outcomes after implementation of a hospitalist-run preoperative clinic. J Hosp Med 2012; 7:697-701. [PMID: 22961756 DOI: 10.1002/jhm.1968] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 07/07/2012] [Accepted: 07/09/2012] [Indexed: 11/05/2022]
Abstract
BACKGROUND A structured, medical preoperative evaluation may positively impact the perioperative course of medically complex patients. Hospitalists are in a unique position to assist in preoperative evaluations, given their expertise with inpatient medicine and postoperative surgical consultation. OBJECTIVE To evaluate specific outcomes after addition of a Hospitalist-run, medical Preoperative clinic to the standard Anesthesia preoperative evaluation. DESIGN, SETTING, PATIENTS A pre/post retrospective, comparative review of outcomes of 5223 noncardiac surgical patients at a tertiary care Veterans Administration (VA) medical center. RESULTS Length of stay was reduced for inpatients with an American Society of Anesthesia (ASA) score of 3 or higher (P < 0.0001). There was a trend towards a reduction in same-day, medically avoidable surgical cancellations (8.5% vs 4.9%, P = 0.065). More perioperative beta blockers were used (P < 0.0001) and more stress tests were ordered (P = 0.012). Inpatient mortality rates were reduced (1.27% vs 0.36%, P = 0.0158). CONCLUSION A structured medical preoperative evaluation may benefit medically complex patients and improve perioperative processes and outcomes.
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Affiliation(s)
- Sondra Vazirani
- Department of Medicine, Hospitalist Division, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA 90073, USA.
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Englesbe MJ, Lee JS, He K, Fan L, Schaubel DE, Sheetz KH, Harbaugh CM, Holcombe SA, Campbell DA, Sonnenday CJ, Wang SC. Analytic morphomics, core muscle size, and surgical outcomes. Ann Surg 2012; 256:255-61. [PMID: 22791101 DOI: 10.1097/sla.0b013e31826028b1] [Citation(s) in RCA: 175] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Assess the relationship between lean core muscle size, measured on preoperative cross-sectional images, and surgical outcomes. BACKGROUND Novel measures of preoperative risk are needed. Analytic morphomic analysis of cross-sectional diagnostic images may elucidate vast amounts of patient-specific data, which are never assessed by clinicians. METHODS The study population included all patients within the Michigan Surgical Quality Collaborative database with a computerized tomography(CT) scan before major, elective general or vascular surgery (N = 1453). The lean core muscle size was calculated using analytic morphomic techniques. The primary outcome measure was survival, whereas secondary outcomes included surgical complications and costs. Covariate adjusted outcomes were assessed using Kaplan-Meier analysis, multivariate cox regression, multivariate logistic regression, and generalized estimating equation methods. RESULTS The mean follow-up was 2.3 years and 214 patients died during the observation period. The covariate-adjusted hazard ratio for lean core muscle area was 1.45 (P = 0.028), indicating that mortality increased by 45% per 1000 mm(2) decrease in lean core muscle area. When stratified into tertiles of core muscle size, the 1-year survival was 87% versus 95% for the smallest versus largest tertile, whereas the 3-year survival was 75% versus 91%, respectively (P < 0.003 for both comparisons). The estimated average risk of complications significantly differed and was 20.9%, 15.0%, and 12.3% in the lower, middle, and upper tertiles of lean core muscle area, respectively. Covariate-adjusted cost increased significantly by an estimated $10,110 per 1000 mm(2) decrease in core muscle size (P = 0.003). CONCLUSIONS Core muscle size is an independent and potentially important preoperative risk factor. The techniques used to assess preoperative CT scans, namely analytic morphomics, may represent a novel approach to better understanding patient risk.
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Affiliation(s)
- Michael J Englesbe
- Analytic Morphomics Group, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI 48109-5331, USA.
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WYLIE SJ, WONG GTC, CHAN YC, IRWIN MG. Endovascular aneurysm repair: a perioperative perspective. Acta Anaesthesiol Scand 2012; 56:941-9. [PMID: 22621365 DOI: 10.1111/j.1399-6576.2012.02681.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2012] [Indexed: 11/28/2022]
Abstract
Endovascular aneurysm repair (EVAR), has surpassed open repair as the technique of choice in many centres in response to several large studies which showed significantly improved 30-day mortality. While several multicentre EVAR trials looked at surgical outcomes, very few have specifically investigated the effect of anaesthetic techniques or perioperative care of these patients. The purpose of this review to is to present some of the current evidence for the different aspects of perioperative management of patients undergoing EVAR. This includes surgical considerations, pre-operative assessment, and choice of anaesthetic technique as well as pharmacological protective strategies.
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Affiliation(s)
- S. J. WYLIE
- Barts and the Royal London NHS Trust; London
| | - G. T. C. WONG
- Department of Anaesthesiology; University of Hong Kong; Hong Kong
| | - Y. C. CHAN
- Department of Surgery; University of Hong Kong; Hong Kong
| | - M. G. IRWIN
- Department of Anaesthesiology; University of Hong Kong; Hong Kong
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Yazdanyar A, Wasko MC, Kraemer KL, Ward MM. Perioperative all-cause mortality and cardiovascular events in patients with rheumatoid arthritis: comparison with unaffected controls and persons with diabetes mellitus. ARTHRITIS AND RHEUMATISM 2012; 64:2429-37. [PMID: 22354534 PMCID: PMC3442932 DOI: 10.1002/art.34428] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is associated with an increased cardiovascular (CV) burden similar to that of diabetes mellitus (DM). This risk may warrant preoperative CV assessment as is performed for patients with DM. We aimed to determine whether the risks of perioperative death and CV events among patients with RA differed from those among unaffected controls and patients with DM. METHODS We used 1998-2002 data from the Nationwide Inpatient Sample (NIS) database of the Healthcare Cost Utilization Project (HCUP) to identify hospitalizations of patients undergoing elective noncardiac surgery. Using established guidelines, surgical procedures were categorized as either low risk, intermediate risk, or high risk of having CV events. Logistic models provided the adjusted odds of study end points in patients with RA, DM, or both relative to patients with neither condition. RESULTS Among 7,756,570 patients undergoing a low-risk, intermediate-risk, or high-risk noncardiac procedure, 2.34%, 0.51%, and 2.12%, respectively, had a composite CV event, and death occurred in 1.47%, 0.50%, and 2.59%, respectively. Among those undergoing an intermediate-risk procedure, death was less likely in RA patients than in DM patients (0.30% versus 0.65%; P < 0.001), but the difference in mortality rates among those undergoing low-risk versus high-risk procedures was not significant. Patients with RA were less likely to have a CV event than were patients with DM for procedures of low risk (3.38% versus 5.30%; P < 0.001) and intermediate risk (0.34% versus 1.07%; P < 0.001). In adjusted models, RA was not independently associated with an increased risk of perioperative death or a CV event. CONCLUSION RA was not associated with adverse perioperative CV risk or mortality risk, which suggests that current perioperative clinical care does not need to be changed in this regard.
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Affiliation(s)
- Ali Yazdanyar
- Section of Hospital Medicine, Department of Medicine, Reading Hospital and Medical Center, Sixth Avenue and Spruce Street, West Reading, PA 19612, USA.
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Experience With Noncardiac Surgery in Destination Therapy Left Ventricular Assist Devices Patients. ASAIO J 2012; 58:396-401. [DOI: 10.1097/mat.0b013e31825b8d36] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Duvall WL, Sealove B, Pungoti C, Katz D, Moreno P, Kim M. Angiographic investigation of the pathophysiology of perioperative myocardial infarction. Catheter Cardiovasc Interv 2012; 80:768-76. [DOI: 10.1002/ccd.23446] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 10/04/2011] [Accepted: 10/25/2011] [Indexed: 11/11/2022]
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Evaluation of the perioperative risk factors in patients with the abdominal aorta aneurysm--literature review. POLISH JOURNAL OF SURGERY 2011; 83:571-8. [PMID: 22189286 DOI: 10.2478/v10035-011-0091-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
INTRODUCTION Antiplatelet agents such as aspirin and clopidogrel are increasingly encountered in clinical practice. Otorhinolaryngological surgeons are involved in the peri-operative decision of whether to continue treatment and risk haemorrhage or to discontinue treatment and risk thrombosis. METHODS Literature relating to the risk of spontaneous or operative haemorrhage was reviewed. The morbidity and mortality associated with cessation of agents was evaluated. Published guidelines were also evaluated. A protocol for the management of antiplatelet agents in the peri-operative period, with particular reference to ENT operations, is presented. CONCLUSION SIGNIFICANT morbidity and mortality is associated with the premature cessation of antiplatelet agents. Data from cardiac surgery suggest that operative blood loss only marginally increases in patients on aspirin and clopidogrel. However, the management of antiplatelet agents in the peri-operative period should be made after multidisciplinary consultation.
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Mercantini P, Di Somma S, Magrini L, Kazemi Nava A, Scarinci A, La Torre M, Ferri M, Ferri E, Petrucciani N, Ziparo V. Preoperative Brain Natriuretic Peptide (BNP) Is a Better Predictor of Adverse Cardiac Events Compared to Preoperative Scoring System in Patients Who Underwent Abdominal Surgery. World J Surg 2011; 36:24-30. [DOI: 10.1007/s00268-011-1354-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW Preoperative anesthesia consultation before major surgery presents opportunities to better document comorbid illness, optimize medical conditions, facilitate referrals to specialists, order specialized investigations, initiate interventions to decrease risk, discuss aspects of perioperative care, and arrange appropriate postoperative care. The goal of this review is to discuss the implications of recent studies that have evaluated the processes-of-care and outcomes related to preoperative anesthesia consultation. RECENT FINDINGS An increasing proportion of surgical patients undergo outpatient preoperative anesthesia consultation. These consultations effectively communicate information to anesthesia providers in operating rooms, reduce the time required to complete preoperative assessments, improve patients' education about perioperative care, and increase patient acceptance of regional anesthesia. Recent population-based data also demonstrate that consultations are associated with reductions in hospital length-of-stay, but not postoperative mortality. In addition, rates of specialized preoperative cardiac testing are increased following anesthesia consultation but the value of these tests remains debatable. SUMMARY Preoperative anesthesia consultations have become increasingly common and have shown some clear beneficial effects on perioperative care and outcomes. Further research remains needed to identify efficacious interventions for reducing perioperative risk, measure the prognostic value of specialized preoperative tests, and compare the safety of different models for performing preoperative consultations.
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Preoperative beta-blocker usage: is it really worthy of being a quality indicator? Ann Thorac Surg 2011; 92:788-95; discussion 795-6. [PMID: 21704300 DOI: 10.1016/j.athoracsur.2011.03.088] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 03/07/2011] [Accepted: 03/09/2011] [Indexed: 01/17/2023]
Abstract
BACKGROUND Since 2007, the use of preoperative β-blockers has been used as a quality standard for patients undergoing coronary artery bypass graft surgery. Recent studies have called into question of the benefit of empiric preoperative β-blocker use. METHODS Data were extracted from our Society of Thoracic Surgeons certified database for patients undergoing isolated coronary artery bypass graft surgery from 2000 to 2008. We compared the outcomes for patients who received preoperative β-blockers with those of patients who did not. RESULTS The study group had 12,855 patients, of whom 7,967 (62.0%) were treated preoperatively with β-blockers. Using propensity matching, we selected two matched groups of 4,474 patients with preoperative β-blocker use and 4,474 not using preoperative β-blockers. In the unmatched cohort, only deep sternal infection (0.3% versus 0.5% without β-blockers; p=0.032), pneumonia (1.9% versus 2.4% without β-blockers; p=0.039), and intraoperative blood usage (37.2% versus 34.1% without β-blockers; p<0.001) reached statistically significant difference. In the matched groups, there was no difference between adverse event rates in patients treated with β-blockers and those who were not. The number of patients requiring intraoperative blood product use was significantly higher among β-blocker-treated patients (p=0.004). Calculating the adjusted odds ratios showed that in the matched groups, the preoperative use of β-blockers was not an independent predictor of mortality. CONCLUSIONS A rational for preoperative β-blockade exists. However, as with any medical intervention, its application should be tailored to specific clinical scenarios. With no differences in mortality or morbidity, our findings do not support preoperative β-blockade as a useful quality indicator for coronary artery bypass graft surgery.
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