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White MJ, Zaccaria I, Ennahdi-Elidrissi F, Putzu A, Dimassi S, Luise S, Diaper J, Mulin S, Baudat AD, Gil-Wey B, Elia N, Walder B, Bollen Pinto B. Personalised perioperative dosing of ivabradine in noncardiac surgery: a single-centre, randomised, placebo-controlled, double-blind feasibility pilot trial. Br J Anaesth 2024:S0007-0912(24)00316-7. [PMID: 38960832 DOI: 10.1016/j.bja.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Perioperative myocardial injury after noncardiac surgery is associated with postoperative mortality. Heart rate (HR) is an independent risk factor for perioperative myocardial injury. In this pilot trial we tested the feasibility of a randomised, placebo-controlled trial of personalised HR-targeted perioperative ivabradine. METHODS This was a single-centre, randomised, placebo-controlled, double-blind, parallel group, feasibility pilot trial conducted at Geneva University Hospitals. We included patients ≥75 yr old or ≥45 yr old with cardiovascular risk factors planned for intermediate- or high-risk surgery. Patients were randomised to receive ivabradine (2.5, 5.0, or 7.5 mg) or placebo according to their HR, twice daily, from the morning of surgery until postoperative day 2. Primary outcomes were appropriate dosage and blinding success rates. RESULTS Between October 2020 and January 2022, we randomised 78 patients (recruitment rate of 1.3 patients week-1). Some 439 of 444 study drug administrations were adequate (99% appropriate dosage rate). The blinding success rate was 100%. There were 137 (31%) administrations of Pill A (placebo in both groups for HR ≤70 beats min-1). Nine (11.5%) patients had a high-sensitive cardiac troponin T elevation ≥14 ng L-1 between any two measurements. The number of bradycardia episodes was eight in the placebo group and nine in the ivabradine group. CONCLUSIONS This pilot study demonstrates the feasibility of, and provides guidance for, a future trial testing the efficacy of personalised perioperative ivabradine. Future studies should include patients at higher risk of cardiac complications. CLINICAL TRIAL REGISTRATION NCT04436016.
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Affiliation(s)
- Marion J White
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Isabelle Zaccaria
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Florence Ennahdi-Elidrissi
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Putzu
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Saoussen Dimassi
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphane Luise
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - John Diaper
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphanie Mulin
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Aurélie D Baudat
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Béatrice Gil-Wey
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nadia Elia
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernhard Walder
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernardo Bollen Pinto
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Zhao X, Zhang Y, Kou M, Wang Z, He Q, Wen Z, Chen J, Song Y, Wu S, Huang C, Huang W. The exploration of perioperative hypotension subtypes: a prospective, single cohort, observational pilot study. Front Med (Lausanne) 2024; 11:1358067. [PMID: 38952866 PMCID: PMC11215119 DOI: 10.3389/fmed.2024.1358067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 06/05/2024] [Indexed: 07/03/2024] Open
Abstract
Background Hypotension is a risk factor for postoperative complications, but evidence from randomized trials does not support that a higher blood pressure target always leads to optimized outcomes. The heterogeneity of underlying hemodynamics during hypotension may contribute to these contradictory results. Exploring the subtypes of hypotension can enable optimal management of intraoperative hypotension. Methods This is a prospective, observational pilot study. Patients who were ≥ 45 years old and scheduled to undergo moderate-to-high-risk noncardiac surgery were enrolled in this study. The primary objective of this pilot study was to investigate the frequency and distribution of perioperative hypotension and its subtypes (hypotension with or without cardiac output reduction). The exposure of hypotension and its subtypes in patients with and without myocardial or acute kidney injury were also explored. Results Sixty patients were included in the analysis. 83% (50/60) of the patients experienced perioperative hypotension. The median duration of hypotension for each patient was 8.0 [interquartile range, 3.1-23.3] minutes. Reduced cardiac output was present during 77% of the hypotension duration. Patients suffering from postoperative myocardial or acute kidney injury displayed longer duration and more extensive exposure in all hypotension subtypes. However, the percentage of different hypotension subtypes did not differ in patients with or without postoperative myocardial or acute kidney injury. Conclusion Perioperative hypotension was frequently accompanied by cardiac output reduction in moderate-to-high-risk noncardiac surgical patients. However, due to the pilot nature of this study, the relationship between hypotension subtypes and postoperative myocardial or acute kidney injury still needs further exploration. Clinical trial registration https://www.chictr.org.cn/showprojEN.html?proj=134260, CTR2200055929.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Shihui Wu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chanyan Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenqi Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Kim J, Lee S, Choi J, Ryu DK, Woo S, Park M. Effect of continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers on the day of surgery on myocardial injury after non-cardiac surgery: A retrospective cohort study. J Clin Anesth 2024; 94:111401. [PMID: 38330844 DOI: 10.1016/j.jclinane.2024.111401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/17/2024] [Accepted: 01/23/2024] [Indexed: 02/10/2024]
Abstract
STUDY OBJECTIVE To evaluate the effect of continuing of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) prescriptions 24 h before surgery on postoperative myocardial injury and blood pressure in patients undergoing non-cardiac surgery. DESIGN A single-center, retrospective study. SETTING Operating room and perioperative care area. PATIENTS 42,432 patients who had been taking chronic ACEI/ARB underwent non-cardiac surgery from January 2012 to June 2022. INTERVENTIONS Patients who discontinued ACEI/ARB 24 h before surgery (withheld group, n=31,055) and those who continued ACEI/ARB 24 h before surgery (continued group, n=11,377). MEASUREMENTS Primary outcome was myocardial injury after non-cardiac surgery (MINS) within 7 days postoperatively. MINS was defined as an elevated postoperative cardiac troponin measurement above the 99th percentile of the upper reference limit with a rise/fall pattern. Perioperative blood pressure and clinical outcomes were secondary outcomes. MAIN RESULTS Among 42,432 patients, MINS occurred in 2848 patients (6.7%) and was the all-cause of death within 30 days in 122 patients (0.3%). Incidence of MINS was significantly higher in the continued group than the withheld group (847/11,377 [7.4%] vs. 2001/31,055 [6.4%]; OR [95% CI] 1.17 [1.07-1.27]; P<0.001). After 1:1 propensity score matching, 11,373 patients were included in each group. There was still a significant difference for the occurrence of MINS between two groups in matched cohort (7.4% vs. 6.6%, OR [95% CI] 1.14 [1.03-1.26]; P=0.015). Time-average weight of mean arterial pressure <65 mmHg during surgery was significantly higher in the continued group (mean 0.11 vs. 0.09 [95% CI of mean difference] [0.01-0.03]; P<0.001). However, there was no significant difference in other clinical outcomes and mortality. CONCLUSIONS Withholding ACEI/ARB before surgery was associated with a reduced risk of intraoperative hypotension and postoperative myocardial injury, but it did not affect overall clinical outcomes in patients undergoing non-cardiac surgery.
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Affiliation(s)
- Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seungwon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jisun Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae Kyun Ryu
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seunghyeon Woo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - MiHye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Kouz K, Thiele R, Michard F, Saugel B. Haemodynamic monitoring during noncardiac surgery: past, present, and future. J Clin Monit Comput 2024; 38:565-580. [PMID: 38687416 PMCID: PMC11164815 DOI: 10.1007/s10877-024-01161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/02/2024] [Indexed: 05/02/2024]
Abstract
During surgery, various haemodynamic variables are monitored and optimised to maintain organ perfusion pressure and oxygen delivery - and to eventually improve outcomes. Important haemodynamic variables that provide an understanding of most pathophysiologic haemodynamic conditions during surgery include heart rate, arterial pressure, central venous pressure, pulse pressure variation/stroke volume variation, stroke volume, and cardiac output. A basic physiologic and pathophysiologic understanding of these haemodynamic variables and the corresponding monitoring methods is essential. We therefore revisit the pathophysiologic rationale for intraoperative monitoring of haemodynamic variables, describe the history, current use, and future technological developments of monitoring methods, and finally briefly summarise the evidence that haemodynamic management can improve patient-centred outcomes.
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Robert Thiele
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | | | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
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Gutierrez Del Arroyo A, Patel A, Abbott TEF, Begum S, Dias P, Somanath S, Middleditch A, Cleland S, Brealey D, Pearse RM, Ackland GL. Preoperative N-terminal pro-B-type natriuretic peptide and myocardial injury after stopping or continuing renin-angiotensin system inhibitors in noncardiac surgery: a prespecified analysis of a phase 2 randomised controlled multicentre trial. Br J Anaesth 2024; 132:857-866. [PMID: 38341283 PMCID: PMC11103084 DOI: 10.1016/j.bja.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Patients with elevated preoperative plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP >100 pg ml-1) experience more complications after noncardiac surgery. Individuals prescribed renin-angiotensin system (RAS) inhibitors for cardiometabolic disease are at particular risk of perioperative myocardial injury and complications. We hypothesised that stopping RAS inhibitors before surgery increases the risk of perioperative myocardial injury, depending on preoperative risk stratified by plasma NT-proBNP concentrations. METHODS In a preplanned analysis of a phase 2a trial in six UK centres, patients ≥60 yr old undergoing elective noncardiac surgery were randomly assigned either to stop or continue RAS inhibitors before surgery. The pharmacokinetic profile of individual RAS inhibitors determined for how long they were stopped before surgery. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury (plasma high-sensitivity troponin-T ≥15 ng L-1 or a ≥5 ng L-1 increase, when preoperative high-sensitivity troponin-T ≥15 ng L-1) within 48 h after surgery. The co-exposures of interest were preoperative plasma NT-proBNP (< or >100 pg ml -1) and stopping or continuing RAS inhibitors. RESULTS Of 241 participants, 101 (41.9%; mean age 71 [7] yr; 48% females) had preoperative NT-proBNP >100 pg ml -1 (median 339 [160-833] pg ml-1), of whom 9/101 (8.9%) had a formal diagnosis of cardiac failure. Myocardial injury occurred in 63/101 (62.4%) subjects with NT-proBNP >100 pg ml-1, compared with 45/140 (32.1%) subjects with NT-proBNP <100 pg ml -1 {odds ratio (OR) 3.50 (95% confidence interval [CI] 2.05-5.99); P<0.0001}. For subjects with preoperative NT-proBNP <100 pg ml-1, 30/75 (40%) who stopped RAS inhibitors had myocardial injury, compared with 15/65 (23.1%) who continued RAS inhibitors (OR for stopping 2.22 [95% CI 1.06-4.65]; P=0.03). For preoperative NT-proBNP >100 pg ml-1, myocardial injury rates were similar regardless of stopping (62.2%) or continuing (62.5%) RAS inhibitors (OR for stopping 0.98 [95% CI 0.44-2.22]). CONCLUSIONS Stopping renin-angiotensin system inhibitors in lower-risk patients (preoperative NT-proBNP <100 pg ml -1) increased the likelihood of myocardial injury before noncardiac surgery.
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Affiliation(s)
- Ana Gutierrez Del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Akshaykumar Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Salma Begum
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Sameer Somanath
- County Durham and Darlington NHS Foundation Trust, Durham, UK
| | | | | | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK; UCL Hospitals NHS Foundation Trust, London, UK
| | - Rupert M Pearse
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
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Bui D, Hayward G, Chen TH, Apruzzese P, Asher S, Maslow M, Gorgone M, Hunter C, Flaherty D, Kendall M, Maslow A. Hemodynamic Monitoring In The Cardiac Surgical Patient: Comparison of Three Arterial Catheters. J Cardiothorac Vasc Anesth 2024; 38:1115-1126. [PMID: 38461034 DOI: 10.1053/j.jvca.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE Systemic systolic (SAP) and mean (MAP) arterial pressure monitoring is the cornerstone in hemodynamic management of the cardiac surgical patient, and the radial artery is the most common site of catheter placement. The present study compared 3 different arterial line procedures. It is hypothesized that a 20-G 12.7- cm catheter inserted into the radial artery will be equal to a 20-G 12.7- cm angiocath placed in the brachial artery, and superior to a 20-G 5.00 cm angiocath placed in the radial artery. DESIGN A prospective randomized control study was performed. SETTING Single academic university hospital. PARTICIPANTS Adult patients ≥18 years old undergoing nonemergent cardiac surgery using cardiopulmonary bypass (CPB). INTERVENTIONS After approval by the Rhode Island Hospital institutional review board, a randomized prospective control study to evaluate 3 different peripheral intraarterial catheter systems was performed: (1) Radial Short (RS): 20-G 5- cm catheter; (2) Radial Long (RL): 20-G 12- cm catheter; and (3) Brachial Long (BL): 20-G 12- cm catheter. MEASUREMENTS AND RESULTS Gradients between central aortic and peripheral catheters (CA-P) were compared and analyzed before CPB and 2 and 10 minutes after separation from CPB. The placement of femoral arterial lines and administration of vasoactive medications were recorded. After exclusions, 67 BL, 61 RL, and 66 RS patients were compared. Before CPB, CA-P SAP and MAP gradients were not significant among the 3 groups. Two minutes after CPB, the CA-P SAP gradient was significant for the RS group (p = 0.005) and insignificant for BL (p = 0.47) and RL (p = 0.39). Two-group analysis revealed that CA-P SAP gradients are similar between BL and RL (p = 0.84), both of which were superior to RS (p = 0.02 and p = 0.04, respectively). At 10 minutes after CPB, the CA-P SAP gradient for RS remained significant (p = 0.004) and similar to the gradient at 2 minutes. The CA-P SAP gradients increased from 2 to 10 minutes for BL (p = 0.13) and RL (p = 0.06). Two minutes after CPB, the CA-P MAP gradients were significant for the BL (p = 0.003), RL (p < 0.0001), and RS (p < 0.0001) groups. Two-group analysis revealed that the CA-P MAP gradients were lower for the BL group compared with the RL (p = 0.054) and RS (p< 0.05) groups. Ten minutes after CPB, the CA-P MAP gradients in the RL and RS groups remained significant (p < 0.0001) and both greater than the BL group (p = 0.002). A femoral arterial line was placed more frequently in the RS group (8/66 = 12.1%) than in the RL group (3/61 = 4.9%) and the BL group (2/67 = 3.0%). Vasopressin was administered significantly more frequently in the RS group. CONCLUSION Regarding CA-P SAP gradients, the RL group performed equally to the BL group, both being superior to RS. Regarding CA-P MAP gradients, BL was superior to RL and RS. Clinically, femoral line placement and vasopressin administration were fewer for the BL and RL groups when compared with the RS group. This study demonstrated the benefits of a long (12.7 cm) 20- G angiocath placed in the radial artery.
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Affiliation(s)
- Danny Bui
- Departments of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Geoffrey Hayward
- Departments of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Tzong Huei Chen
- Departments of Anesthesiology, Rhode Island Hospital, Providence, RI
| | | | - Shyamal Asher
- Departments of Anesthesiology, Rhode Island Hospital, Providence, RI
| | | | - Michelle Gorgone
- Departments of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Caroline Hunter
- Departments of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Devon Flaherty
- Departments of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Mark Kendall
- Departments of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Andrew Maslow
- Departments of Anesthesiology, Rhode Island Hospital, Providence, RI.
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Wang Y, Ren L, Li Y, Zhou Y, Yang J. The effect of glycopyrrolate vs. atropine in combination with neostigmine on cardiovascular system for reversal of residual neuromuscular blockade in the elderly: a randomized controlled trial. BMC Anesthesiol 2024; 24:123. [PMID: 38561654 PMCID: PMC10983731 DOI: 10.1186/s12871-024-02512-x] [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: 11/29/2023] [Accepted: 03/26/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Glycopyrrolate-neostigmine (G/N) for reversing neuromuscular blockade (NMB) causes fewer changes in heart rate (HR) than atropine-neostigmine (A/N). This advantage may be especially beneficial for elderly patients. Therefore, this study aimed to compare the cardiovascular effects of G/N and A/N for the reversal of NMB in elderly patients. METHODS Elderly patients aged 65-80 years who were scheduled for elective non-cardiac surgery under general anesthesia were randomly assigned to the glycopyrrolate group (group G) or the atropine group (group A). Following the last administration of muscle relaxants for more than 30 min, group G received 4 ug/kg glycopyrrolate and 20 ug/kg neostigmine, while group A received 10 ug/kg atropine and 20 ug/kg neostigmine. HR, mean arterial pressure (MAP), and ST segment in lead II (ST-II) were measured 1 min before administration and 1-15 min after administration. RESULTS HR was significantly lower in group G compared to group A at 2-8 min after administration (P < 0.05). MAP was significantly lower in group G compared to group A at 1-4 min after administration (P < 0.05). ST-II was significantly depressed in group A compared to group G at 2, 3, 4, 5, 6, 7, 8, 9, 11, 13, 14, and 15 min after administration (P < 0.05). CONCLUSIONS In comparison to A/N, G/N for reversing residual NMB in the elderly has a more stable HR, MAP, and ST-II within 15 min after administration.
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Affiliation(s)
- Yanping Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China.
| | - Liyuan Ren
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
| | - Yanshuang Li
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
| | - Yinhui Zhou
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
| | - Jianjun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
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Bollen Pinto B, Ackland GL. Pathophysiological mechanisms underlying increased circulating cardiac troponin in noncardiac surgery: a narrative review. Br J Anaesth 2024; 132:653-666. [PMID: 38262855 DOI: 10.1016/j.bja.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/23/2023] [Accepted: 12/15/2023] [Indexed: 01/25/2024] Open
Abstract
Assay-specific increases in circulating cardiac troponin are observed in 20-40% of patients after noncardiac surgery, depending on patient age, type of surgery, and comorbidities. Increased cardiac troponin is consistently associated with excess morbidity and mortality after noncardiac surgery. Despite these findings, the underlying mechanisms are unclear. The majority of interventional trials have been designed on the premise that ischaemic cardiac disease drives elevated perioperative cardiac troponin concentrations. We consider data showing that elevated circulating cardiac troponin after surgery could be a nonspecific marker of cardiomyocyte stress. Elevated concentrations of circulating cardiac troponin could reflect coordinated pathological processes underpinning organ injury that are not necessarily caused by ischaemia. Laboratory studies suggest that matching of coronary artery autoregulation and myocardial perfusion-contraction coupling limit the impact of systemic haemodynamic changes in the myocardium, and that type 2 ischaemia might not be the likeliest explanation for cardiac troponin elevation in noncardiac surgery. The perioperative period triggers multiple pathological mechanisms that might cause cardiac troponin to cross the sarcolemma. A two-hit model involving two or more triggers including systemic inflammation, haemodynamic strain, adrenergic stress, and autonomic dysfunction might exacerbate or initiate acute myocardial injury directly in the absence of cell death. Consideration of these diverse mechanisms is pivotal for the design and interpretation of interventional perioperative trials.
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Affiliation(s)
- Bernardo Bollen Pinto
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
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Ackland GL, Patel A, Abbott TEF, Begum S, Dias P, Crane DR, Somanath S, Middleditch A, Cleland S, Gutierrez del Arroyo A, Brealey D, Pearse RM. Discontinuation vs. continuation of renin-angiotensin system inhibition before non-cardiac surgery: the SPACE trial. Eur Heart J 2024; 45:1146-1155. [PMID: 37935833 PMCID: PMC10984566 DOI: 10.1093/eurheartj/ehad716] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/07/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND AND AIMS Haemodynamic instability is associated with peri-operative myocardial injury, particularly in patients receiving renin-angiotensin system (RAS) inhibitors (angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers). Whether stopping RAS inhibitors to minimise hypotension, or continuing RAS inhibitors to avoid hypertension, reduces peri-operative myocardial injury remains unclear. METHODS From 31 July 2017 to 1 October 2021, patients aged ≥60 years undergoing elective non-cardiac surgery were randomly assigned to either discontinue or continue RAS inhibitors prescribed for existing medical conditions in six UK centres. Renin-angiotensin system inhibitors were withheld for different durations (2-3 days) before surgery, according to their pharmacokinetic profile. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury [plasma high-sensitivity troponin-T (hs-TnT) ≥ 15 ng/L within 48 h after surgery, or ≥5 ng/L increase when pre-operative hs-TnT ≥15 ng/L]. Pre-specified adverse haemodynamic events occurring within 48 h of surgery included acute hypertension (>180 mmHg) and hypotension requiring vasoactive therapy. RESULTS Two hundred and sixty-two participants were randomized to continue (n = 132) or stop (n = 130) RAS inhibitors. Myocardial injury occurred in 58 (48.3%) patients randomized to discontinue, compared with 50 (41.3%) patients who continued, RAS inhibitors [odds ratio (for continuing): 0.77; 95% confidence interval (CI) 0.45-1.31]. Hypertensive adverse events were more frequent when RAS inhibitors were stopped [16 (12.4%)], compared with 7 (5.3%) who continued RAS inhibitors [odds ratio (for continuing): 0.4; 95% CI 0.16-1.00]. Hypotension rates were similar when RAS inhibitors were stopped [12 (9.3%)] or continued [11 (8.4%)]. CONCLUSIONS Discontinuing RAS inhibitors before non-cardiac surgery did not reduce myocardial injury, and could increase the risk of clinically significant acute hypertension. These findings require confirmation in future studies.
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Affiliation(s)
- Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Akshaykumar Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Salma Begum
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - David R Crane
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Sameer Somanath
- County Durham and Darlington NHS Foundation Trust, Darlington, UK
| | | | | | - Ana Gutierrez del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
- UCL Hospitals NHS Foundation Trust, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Rupert M Pearse
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
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10
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Noto A, Chalkias A, Madotto F, Ball L, Bignami EG, Cecconi M, Guarracino F, Messina A, Morelli A, Princi P, Sanfilippo F, Scolletta S, Tritapepe L, Cortegiani A. Continuous vs intermittent Non-Invasive blood pressure MONitoring in preventing postoperative organ failure (niMON): study protocol for an open-label, multicenter randomized trial. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:7. [PMID: 38321507 PMCID: PMC10845743 DOI: 10.1186/s44158-024-00142-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/18/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Blood pressure has become one of the most important vital signs to monitor in the perioperative setting. Recently, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) recommended, with low level of evidence, continuous monitoring of blood pressure during the intraoperative period. Continuous monitoring allows for early detection of hypotension, which may potentially lead to a timely treatment. Whether the ability to detect more hypotension events by continuous noninvasive blood pressure (C-NiBP) monitoring can improve patient outcomes is still unclear. Here, we report the rationale, study design, and statistical analysis plan of the niMON trial, which aims to evaluate the effect of intraoperative C-NiBP compared with intermittent (I-NiBP) monitoring on postoperative myocardial and renal injury. METHODS The niMon trial is an investigator-initiated, multicenter, international, open-label, parallel-group, randomized clinical trial. Eligible patients will be randomized in a 1:1 ratio to receive C-NiBP or I-NiBP as an intraoperative monitoring strategy. The proportion of patients who develop myocardial injury in the first postoperative week is the primary outcome; the secondary outcomes are the proportions of patients who develop postoperative AKI, in-hospital mortality rate, and 30 and 90 postoperative days events. A sample size of 1265 patients will provide a power of 80% to detect a 4% absolute reduction in the rate of the primary outcome. CONCLUSIONS The niMON data will provide evidence to guide the choice of the most appropriate intraoperative blood pressure monitoring strategy. CLINICAL TRIAL REGISTRATION Clinical Trial Registration: NCT05496322, registered on the 5th of August 2023.
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Affiliation(s)
- Alberto Noto
- Division of Anesthesia and Intensive Care, Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", Policlinico "G. Martino", University of Messina, Messina, Italy.
| | - Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104-5158, USA
- Outcomes Research Consortium, Cleveland, OH, 44195, USA
| | - Fabiana Madotto
- Dipartimento Area Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Elena Giovanna Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Moltancini 4, Pieve Emanuele, Milan, 20072, Italy
| | - Fabio Guarracino
- Cardiothoracic and Vascular Anesthesia and Intensive Care, Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Moltancini 4, Pieve Emanuele, Milan, 20072, Italy
| | - Andrea Morelli
- Department Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza," Policlinico Umberto Primo, Rome, Italy
| | - Pietro Princi
- Consiglio Nazionale Delle Ricerche, CNR-IPCF, Messina, Italy
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
| | - Sabino Scolletta
- Department of Medicine, Surgery and Neuroscience, Anesthesia and Intensive Care Unit, University of Siena, Siena, Italy
| | - Luigi Tritapepe
- Unit of Anesthesia and Intensive Care, San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Cortegiani
- Department of Surgical Oncological and Oral Science, University of Palermo, Palermo, Italy
- Department of Anesthesia Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
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11
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Wang J, Lin F, Zeng M, Liu M, Zheng M, Ren Y, Li S, Yang X, Chen Y, Chen X, Sessler DI, Peng Y. Intraoperative blood pressure and cardiac complications after aneurysmal subarachnoid hemorrhage: a retrospective cohort study. Int J Surg 2024; 110:965-973. [PMID: 38016131 PMCID: PMC10871595 DOI: 10.1097/js9.0000000000000928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 11/08/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Previous studies report that intraoperative hypotension worsens outcomes after aneurysmal subarachnoid hemorrhage (aSAH). However, the hypotensive harm threshold for major adverse cardiovascular events (MACE) remains unclear. METHODS The authors included aSAH patients who had general anesthesia for aneurysmal clipping/coiling. MACE were defined by a composite of acute myocardial injury, acute myocardial infarction, and other cardiovascular complications identified by electrocardiogram and echocardiography. The authors initially used logistic regression and change-point analysis based on the second derivative to identify mean arterial pressure (MAP) of 75 mmHg as the harm threshold. Thereafter, our major exposure was MAP below 75 mmHg characterized by area, duration, and time-weighted average. The area below 75 mmHg represents the severity and duration of exposure and was defined as the sum of all areas below a specified threshold using the trapezoid rule. Time-weighted average MAP was derived by dividing area below the threshold by the duration of anesthesia. All analyses were adjusted for baseline risk factors including age greater than 70 years, female sex, severity of intracerebral hemorrhage, history of cardiovascular disease, and preoperative elevated myocardial enzymes. RESULTS Among 1029 patients enrolled, 254 (25%) developed postoperative MACE. Patients who experienced MACE were slightly older (59±11 vs. 54±11 years), were slightly more often women (69 vs. 58%), and had a higher prevalence of cardiovascular history (65 vs. 47%). Adjusted cardiovascular risk increased nearly linearly over the entire range of observed MAP. However, there was a slight inflexion at MAP of 75 mmHg. MACE was significantly associated with area [adjusted odds ratios (aOR) 1.004 per 10 mmHg.min, 95% CI: 1.001-1.007, P =0.002), duration (aOR 1.031 per 10 min, 95% CI: 1.009-1.054, P =0.006), and time-weighted average (aOR 3.516 per 10 mmHg, 95% CI: 1.818-6.801, P <0.001) of MAP less than 75 mmHg. CONCLUSIONS Lower blood pressures were associated with cardiovascular complications over the entire observed range, but worsened when MAP was less than 75 mmHg. Pending trial data to establish causality, it may be prudent to keep MAP above 75 mmHg in patients having surgical aSAH repairs to reduce the risk of MACE.
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Affiliation(s)
- Juan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Maoyao Zheng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yue Ren
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xiaodong Yang
- Institute of Computing Technology, Chinese Academy of Sciences, Beijing, People’s Republic of China
| | - Yiqiang Chen
- Institute of Computing Technology, Chinese Academy of Sciences, Beijing, People’s Republic of China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Daniel I. Sessler
- Department of Outcome Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Outcome Research Consortium, Cleveland, Ohio, USA
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12
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Bos EME, Tol JTM, de Boer FC, Schenk J, Hermanns H, Eberl S, Veelo DP. Differences in the Incidence of Hypotension and Hypertension between Sexes during Non-Cardiac Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:666. [PMID: 38337360 PMCID: PMC10856734 DOI: 10.3390/jcm13030666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/12/2024] [Accepted: 01/20/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Major determinants of blood pressure (BP) include sex and age. In youth, females have lower BP than males, yet in advanced age, more pronounced BP increases result in higher average BPs in females over 65. This hypothesis-generating study explored whether age-related BP divergence impacts the incidence of sex-specific intraoperative hypotension (IOH) or hypertension. Methods: We systematically searched PubMed and Embase databases for studies reporting intraoperative BP in males and females in non-cardiac surgery. We analyzed between-sex differences in the incidence of IOH and intraoperative hypertension (primary endpoint). Results: Among 793 identified studies, 14 were included in this meta-analysis, comprising 1,110,636 patients (56% female). While sex was not associated with IOH overall (females: OR 1.10, 95%CI [0.98-1.23], I2 = 99%), a subset of studies with an average age ≥65 years showed increased exposure to IOH in females (OR 1.17, 95%CI [1.01-1.35], I2 = 94%). One study reported sex-specific differences in intraoperative hypertension, with a higher incidence in females (31% vs. 28%). Conclusions: While sex-specific reporting on intraoperative BP was limited, IOH did not differ between sexes. However, an exploratory subgroup analysis offers the hypothesis that females of advanced age may face an increased risk of IOH, warranting further investigation.
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Affiliation(s)
- Elke M. E. Bos
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
| | - Johan T. M. Tol
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
| | - Fabienne C. de Boer
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
| | - Jimmy Schenk
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Henning Hermanns
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
| | - Susanne Eberl
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
| | - Denise P. Veelo
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (E.M.E.B.)
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13
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Fitzgerald GD, Newton JM, Atasi L, Buniak CM, Burgos-Luna JM, Burnett BA, Carver AR, Cheng C, Conyers S, Davitt C, Deshmukh U, Donovan BM, Easter SR, Einerson BD, Fox KA, Habib AS, Harrison R, Hecht JL, Licon E, Nino JM, Munoz JL, Nieto-Calvache AJ, Polic A, Ramsey PS, Salmanian B, Shamshirsaz AA, Shamshirsaz AA, Shrivastava VK, Woolworth MB, Yurashevich M, Zuckerwise L, Shainker SA. Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care. Am J Obstet Gynecol MFM 2024; 6:101229. [PMID: 37984691 DOI: 10.1016/j.ajogmf.2023.101229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.
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Affiliation(s)
- Garrett D Fitzgerald
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Dr Fitzgerald).
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Newton)
| | - Lamia Atasi
- Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO (Dr Atasi)
| | - Christina M Buniak
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Dr Buniak)
| | | | - Brian A Burnett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Burnett)
| | - Alissa R Carver
- Department of Obstetrics and Gynecology, Wilmington Maternal-Fetal Medicine, Wilmington, NC (Dr Carver)
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Health Science Center at San Antonio, University of Texas, San Antonio, TX (Dr Cheng)
| | - Steffany Conyers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Caroline Davitt
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Uma Deshmukh
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Bridget M Donovan
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
| | - Sara Rae Easter
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Easter)
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Einerson)
| | - Karin A Fox
- Baylor College of Medicine, Houston, TX (Dr Fox)
| | - Ashraf S Habib
- Duke University School of Medicine, Durham, NC (Dr Habib)
| | - Rachel Harrison
- Department of Obstetrics and Gynecology, Advocate Aurora Health, Chicago, IL (Dr Harrison)
| | - Jonathan L Hecht
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Ernesto Licon
- Miller Women's & Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Licon)
| | - Julio Mateus Nino
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest School of Medicine, Winston-Salem, NC (Dr Nino)
| | - Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX (Dr Munoz)
| | | | | | - Patrick S Ramsey
- University of Texas Health/University Health San Antonio, San Antonio, TX (Dr Ramsey)
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, University of Colorado Health Anschutz Medical Campus, Boulder, CO (Dr Salmanian)
| | | | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Vineet K Shrivastava
- Miller Women's and Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Shrivastava)
| | | | - Mary Yurashevich
- Department of Anesthesiology, Duke Health, Durham, NC (Dr Yurashevich)
| | - Lisa Zuckerwise
- and Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Zuckerwise)
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
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14
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Liu C, Zhang T, Cao L, Lin W. Comparison of esketamine versus dexmedetomidine for attenuation of cardiovascular stress response to double-lumen tracheal tube intubation: a randomized controlled trial. Front Cardiovasc Med 2023; 10:1289841. [PMID: 38188254 PMCID: PMC10768184 DOI: 10.3389/fcvm.2023.1289841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/29/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction The insertion of a double-lumen tracheal tube may cause a transient but more intense sympathetic response. We examined the effects of esketamine vs. dexmedetomidine as an adjuvant to anesthesia induction to blunt double lumen tracheal (DLT) intubation induced cardiovascular stress response. Methods In a randomized, double-blind trial, 78 adult patients scheduled for elective thoracotomy under general anesthesia requiring DLT intubation were enrolled. The patients were randomly divided into three groups: each group received one of the following drugs prior to induction of anesthesia: dexmedetomidine 0.8 µg/kg (Group A), esketamine 0.5 mg/kg (Group B), or normal saline (group C). The primary outcome was the incidence of a DLT intubation-related cardiovascular stress response, defined as an increase in mean arterial pressure or heart rate of >30% above the baseline values. The secondary outcomes were changes in hemodynamic and cardiac function. Results The incidence of the response to cardiovascular stress was 23.1%, 30.8%, and 65.4% in groups A, B, and C, respectively. There was a significant decrease in intubation response in groups A and B in comparison with group C (P < 0.01); however, there was no significant difference between group A and group B (P > 0.05). Following the drug infusion and the induction of anesthesia, there was a significant decrease in HR and cardiac output in group A compared with group B. In contrast, no significant differences were observed in the left ventricular ejection fraction or in stroke volume between the three groups during induction of anesthesia. Discussion Esketamine 0.5 mg/kg and dexmedetomidine 0.8 µg/kg attenuate cardiovascular stress responses related to DLT intubation. As adjuvants to etomidate induction, they do not impair cardiac function (ChiCTR1900028030).
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Affiliation(s)
- Chunyu Liu
- Department of Anesthesiology, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Tianhua Zhang
- Department of Anesthesiology, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Longhui Cao
- Department of Anesthesiology, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Wenqian Lin
- Department of Anesthesiology, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Blood Transfusion, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, China
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15
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Yang L, Shi S, Li J, Fang Z, Guo J, Kang W, Shi J, Yuan S, Yan F, Zhou C. Postoperative elevated cardiac troponin levels predict all-cause mortality and major adverse cardiovascular events following noncardiac surgery: A dose-response meta-analysis of prospective studies. J Clin Anesth 2023; 90:111229. [PMID: 37573706 DOI: 10.1016/j.jclinane.2023.111229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
STUDY OBJECTIVE To perform a dose-response meta-analysis for the association between postoperative myocardial injury (PMI) in noncardiac surgery and the risk of all-cause mortality or major adverse cardiovascular event (MACE). DESIGN Dose-response meta-analysis of prospective studies with weighted (WL) or generalized (GL) linear and restricted cubic spline (RCS) regression. SETTING Teaching hospitals. PATIENTS Adult patients undergoing noncardiac surgery. INTERVENTIONS No. MEASUREMENTS The primary outcome was all-cause mortality. The secondary outcome was MACE. MAIN RESULTS 29 studies (53,518 patients) were included. The overall incidence of PMI was 26.0% (95% CI 21.0% to 32.0%). Compared to those without PMI, patients with PMI had an increased risk of all-cause mortality at short- (<12 months) (cardiac troponin[cTn]I: unadj OR 1.71,95%CI 1.22 to 2.41, P < 0.001; cTnT: unadj OR 2.33,95%CI 2.07 to 2.63, P < 0.001), and long-term (≥ 12 months) (cTnI: unadj OR 1.80, 95%CI 1.63 to 1.99; cTnT: unadj OR 1.47,95%CI 1.33 to 1.62) (All P < 0.001) follow-up. For MACE, the group with elevated values was associated with an increased risk (cTnI: unadj OR 1.98, 95% CI 1.13 to 3.47, P = 0.018; cTnT: unadj OR 2.29, 95% CI 1.88 to 2.79, P < 0.001). Dose-response analysis showed positive associations between PMI (per 1× upper reference limit[URL] increment) and all-cause mortality both at short- (unadj OR) (WL, OR 1.09, 95% CI 1.09 to 1.10; GL, OR 1.06, 95% CI 1.06 to 1.07; RCS in the range of 1-2× URL, OR = 2.43, 95%CI 2.25 to 2.62) and long-term follow-up (unadj HR) (WL, OR 1.16, 95% CI 1.14 to 1.17; GL, OR 1.15, 95% CI 1.13 to 1.16; RCS in the range of 1-2.75× URL, OR = 1.23, 95%CI 1.13 to 1.33), and MACE at longest follow-up (unadj OR) (WL: OR 1.53, 95% CI 1.49 to 1.57; GL: OR 1.46, 95% CI 1.42 to 1.50; RCS in the range of 1-2 x URL, OR = 3.10, 95%CI 2.51 to 3.81) (All P < 0.001). For mild cTn increase below URL, the risk of mortality increased with every increment of 0.25xURL (WL, OR 1.03, 95% CI 1.02 to 1.03; GL, OR 1.05, 95% CI 1.03 to 1.07; RCS in the range of 0-0.5 URL, OR = 9.41, 95% CI 7.41 to 11.95) (All P < 0.001). CONCLUSIONS This study shows positive WL or GL and RCS dose-response relationships between PMI and all-cause mortality at short (< 12 mons)- and long-term (≥ 12 mons) follow-up, and MACE at longest follow-up. For mild cTn increase below URL, the risk of mortality also increases even with every increment of 0.25× URL.
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Affiliation(s)
- Lijing Yang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Sheng Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jun Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Zhongrong Fang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jingfei Guo
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Wenying Kang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jia Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Chenghui Zhou
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China; Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.
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16
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Fu Y, Gao J, Zhang Z, Zhang N, Yu J, Chen C, Wen Z. Effects of preoperative mildly elevated pulmonary artery systolic pressure on the incidence of perioperative adverse events undergoing thoracoscopic lobectomy: an observational cohort study protocol. BMJ Open 2023; 13:e072084. [PMID: 37748854 PMCID: PMC10533698 DOI: 10.1136/bmjopen-2023-072084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 09/07/2023] [Indexed: 09/27/2023] Open
Abstract
INTRODUCTION Echocardiography provides a non-invasive estimation of pulmonary artery systolic pressure (PASP) and is the first diagnostic test for pulmonary hypertension. Recent studies have demonstrated that PASP of more than 30 mm Hg related to increased mortality and morbidity. However, perioperative risks and management for patients with mildly elevated PASP are not well established. This study aims to explore the association between mildly elevated PASP and perioperative adverse outcomes. METHODS AND ANALYSIS This will be a retrospective cohort study conducted at Shanghai Pulmonary Hospital in Shanghai, China. Eligible patients are adults (≥18 years) who performed preoperative echocardiography and followed thoracoscopic lobectomy. Our primary objective is to determine the effect of preoperative mildly elevated PASP on the incidence of hypotension during surgery. Whether mildly elevated PASP is related to other perioperative adverse events (including hypoxaemia, myocardial injury, new-onset atrial fibrillation, postoperative pulmonary complications, 30-day readmission and 30-day mortality) will be also analysed. An estimated 2300 patients will be included. ETHICS AND DISSEMINATION The study has been approved by the institutional review board of Shanghai Pulmonary Hospital (approval No: 2022LY1143). The research findings intend to be published in peer-reviewed scientific publications. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR2200066679).
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Affiliation(s)
- Yu Fu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, People's Republic of China
| | - Jiameng Gao
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, People's Republic of China
| | - Zhiyuan Zhang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, People's Republic of China
| | - Nan Zhang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, People's Republic of China
| | - Jing Yu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, People's Republic of China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, People's Republic of China
| | - Zongmei Wen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, People's Republic of China
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17
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Fowler AJ, Brayne AB, Pearse RM, Prowle JR. Long-term healthcare use after postoperative complications: an analysis of linked primary and secondary care routine data. BJA OPEN 2023; 7:100142. [PMID: 37638082 PMCID: PMC10457466 DOI: 10.1016/j.bjao.2023.100142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/24/2023] [Accepted: 04/21/2023] [Indexed: 08/29/2023]
Abstract
Background Postoperative complications are associated with reduced long-term survival. We characterise healthcare use changes after sentinel postoperative complications. Methods We linked primary and secondary care records of patients undergoing elective surgery at four East London hospitals (2012-7) with at least 90 days follow-up. Complication codes (wound infection, urinary tract infection, pneumonia, new stroke, and new myocardial infarction) recorded within 90 days of surgery were identified from primary or secondary care. Outcomes were change in healthcare contact days in the 2 yr before and after surgery, and 2 yr mortality. We report rate ratios (RaR) with 95% confidence intervals and adjusted for baseline healthcare use and confounders using negative binomial regression. Results We included 49 913 patients (median age 49 yr [inter-quartile range {IQR}: 34-64]), 27 958 (56.0%) were female. Amongst 3883 (7.8%) patients with complications (median age 58 [IQR: 43-72]), there were 18.4 days per year in contact with healthcare before surgery and 25.3 days after surgery (RaR: 1.38 [1.37-1.39]). Patients without complications (median age 48 [IQR: 33-63]) had 12.3 days per year in contact with healthcare before surgery and 14.0 days after surgery (RaR: 1.14 [1.14-1.15]). The adjusted incidence rate ratio of days in contact with healthcare associated with complications was 1.67 (1.49-1.87). More patients (391; 10.1%) with complications died within 2 yr than those without (1428; 3.1%). Conclusions Patients with postoperative complications are older with greater healthcare use before surgery. However, their absolute and relative increases in healthcare use after surgery are greater than patients without complications.
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Affiliation(s)
- Alexander J. Fowler
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
- Broomfield Hospital, Mid and South Essex NHS Foundation Trust, Chelmsford, Essex, UK
| | - Adam B. Brayne
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
- University Hospitals Plymouth, Derriford Road, Plymouth, Devon, UK
| | - Rupert M. Pearse
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - John R. Prowle
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
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Nolde JM, Schlaich MP, Sessler DI, Mian A, Corcoran TB, Chow CK, Chan MTV, Borges FK, McGillion MH, Myles PS, Mills NL, Devereaux PJ, Hillis GS. Machine learning to predict myocardial injury and death after non-cardiac surgery. Anaesthesia 2023; 78:853-860. [PMID: 37070957 DOI: 10.1111/anae.16024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 04/19/2023]
Abstract
Myocardial injury due to ischaemia within 30 days of non-cardiac surgery is prognostically relevant. We aimed to determine the discrimination, calibration, accuracy, sensitivity and specificity of single-layer and multiple-layer neural networks for myocardial injury and death within 30 postoperative days. We analysed data from 24,589 participants in the Vascular Events in Non-cardiac Surgery Patients Cohort Evaluation study. Validation was performed on a randomly selected subset of the study population. Discrimination for myocardial injury by single-layer vs. multiple-layer models generated areas (95%CI) under the receiver operating characteristic curve of: 0.70 (0.69-0.72) vs. 0.71 (0.70-0.73) with variables available before surgical referral, p < 0.001; 0.73 (0.72-0.75) vs. 0.75 (0.74-0.76) with additional variables available on admission, but before surgery, p < 0.001; and 0.76 (0.75-0.77) vs. 0.77 (0.76-0.78) with the addition of subsequent variables, p < 0.001. Discrimination for death by single-layer vs. multiple-layer models generated areas (95%CI) under the receiver operating characteristic curve of: 0.71 (0.66-0.76) vs. 0.74 (0.71-0.77) with variables available before surgical referral, p = 0.04; 0.78 (0.73-0.82) vs. 0.83 (0.79-0.86) with additional variables available on admission but before surgery, p = 0.01; and 0.87 (0.83-0.89) vs. 0.87 (0.85-0.90) with the addition of subsequent variables, p = 0.52. The accuracy of the multiple-layer model for myocardial injury and death with all variables was 70% and 89%, respectively.
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Affiliation(s)
- J M Nolde
- Dobney Hypertension Centre, Royal Perth Hospital Research Foundation, Perth, Australia
| | - M P Schlaich
- Dobney Hypertension Centre, Royal Perth Hospital Research Foundation, Perth, Australia
| | - D I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - A Mian
- School of Computer Science and Software Engineering, University of Western Australia, Perth, Australia
| | - T B Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital and Medical School, University of Western Australia and Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - C K Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, and Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - M T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - F K Borges
- McMaster University, Faculty of Health Sciences and Population Health Research Institute, Hamilton, ON, Canada
| | - M H McGillion
- McMaster University, Faculty of Health Sciences and Population Health Research Institute, Hamilton, ON, Canada
| | - P S Myles
- Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - N L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh and Usher Institute, Edinburgh, UK
| | - P J Devereaux
- McMaster University, Faculty of Health Sciences and Population Health Research Institute, Hamilton, ON, Canada
| | - G S Hillis
- Medical School, University of Western Australia and Department of Cardiology, Royal Perth Hospital, Perth, Australia
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19
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Zhu Y, Bi Y, Yu Q, Liu B. Assessment of the prognostic value of preoperative high-sensitive troponin T for myocardial injury and long-term mortality for groups at high risk for cardiovascular events following noncardiac surgery: a retrospective cohort study. Front Med (Lausanne) 2023; 10:1135786. [PMID: 37425305 PMCID: PMC10325788 DOI: 10.3389/fmed.2023.1135786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 06/02/2023] [Indexed: 07/11/2023] Open
Abstract
Background Few studies explored the association between high-sensitive cardiac troponin T (hs-cTnT) and long-term mortality for patients after surgery. This study was conducted to assess the association of hs-cTnT with long-term mortality and to investigate the extent to which this association is mediated via myocardial injury after noncardiac surgery (MINS). Methods This retrospective cohort study included all patients with hs-cTnT measurements who underwent non-cardiac surgery at Sichuan University West China Hospital. Data were collected from February 2018 and November 2020, with follow-up through February 2022. The primary outcome was all-cause mortality within 1 year. As secondary outcomes, MINS, length of hospital stay (LOS), and ICU admission were analyzed. Results The cohort included 7,156 patients (4,299 [60.1%] men; 61.0 [49.0-71.0] years). Among 7,156 patients, there were 2,151 (30.05%) with elevated hs-cTnT(>14 ng/L). After more than 1 year of follow-up, more than 91.8% of mortality information was available. During one-year follow-up after surgery, there were 308 deaths (14.8%) with a preoperative hs-cTnT >14 ng/L, compared with 192 deaths (3.9%) with a preoperative hs-cTnT <=14 ng/L(adjusted hazard ratio [aHR] 1.93, 95% CI 1.58-2.36; p < 0.001). Elevated preoperative hs-cTnT was also associated with several other adverse outcomes (MINS: adjusted odds ratio [aOR] 3.01; 95% CI, 2.46-3.69; p < 0.001; LOS: aOR 1.48, 95%CI 1.34-1.641; p < 0.001; ICU admission: aOR 1.52, 95%CI 1.31-1.76; p < 0.001). MINS explained approximately 33.6% of the variance in mortality due to preoperative hs-cTnT levels. Conclusion Preoperative elevated hs-cTnT concentrations have a significant association with long-term mortality after noncardiac surgery, one-third of which may by accounted for by MINS.
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Affiliation(s)
- Yingchao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yaodan Bi
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qian Yu
- Department of Anesthesiology, Public Health Clinical Center of Chengdu, Chengdu, Sichuan, China
| | - Bin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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20
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Chang Y, Zhou M, Huang J, Wang Y, Shao J. Incidence and risk factors of postoperative acute myocardial injury in noncardiac patients: A systematic review and meta-analysis. PLoS One 2023; 18:e0286431. [PMID: 37319136 PMCID: PMC10270363 DOI: 10.1371/journal.pone.0286431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/16/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Postoperative myocardial injury after noncardiac surgery is common and is associated with short- and long-term morbidity and mortality. However, the incidence and risk factors for postoperative acute myocardial injury (POAMI) are currently unknown due to inconsistent definitions. METHODS We systematically searched PubMed and Web of Science to identify studies that applied the change value of preoperative and postoperative cardiac troponins to define cardiac injury. We estimated the pooled incidence, risk factors, and 30-day and long-term mortality of POAMI in noncardiac patients. The study protocol was registered with PROSPERO, CRD42023401607. RESULTS Ten cohorts containing 11,494 patients were included for analysis. The pooled incidence of POAMI was 20% (95% CI: 16% to 23%). Preoperative hypertension (OR: 1.47; 95% CI: 1.30 to 1.66), cardiac failure (OR: 2.63; 95% CI: 2.01 to 3.44), renal impairment (OR: 1.66; 95% CI: 1.48 to 1.86), diabetes (OR: 1.43; 95% CI: 1.27 to 1.61), and preoperative beta-blocker intake (OR: 1.65; 95% CI: 1.10 to 2.49) were the risk factors for POAMI. Age (mean difference: 2.08 years; 95% CI: -0.47 to 4.62), sex (male, OR: 1.16; 95% CI: 0.77 to 1.76), body mass index (mean difference: 0.35; 95% CI: -0.86 to 1.57), preoperative coronary artery disease (OR: 2.10; 95% CI: 0.85 to 5.21), stroke (OR: 0.90; 95% CI: 0.50 to 1.59) and preoperative statins intake (OR: 0.65; 95% CI: 0.21 to 2.02) were not associated with POAMI. Patients with POAMI had higher preoperative hsTnT levels (mean difference: 5.92 ng/L; 95% CI: 4.17 to 7.67) and lower preoperative hemoglobin levels (mean difference: -1.29 g/dL; 95% CI: -1.43 to -1.15) than patients without. CONCLUSION Based on this meta-analysis, approximately 1 in 5 of noncardiac patients develop POAMI. However, the lack of a universally recognized definition for POAMI, which incorporates diverse cardiac biomarkers and patient groups, poses a challenge in accurately characterizing its incidence, risk factors, and clinical outcomes.
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Affiliation(s)
- Yuan Chang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Mengjiao Zhou
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jing Huang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yanqiong Wang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jianlin Shao
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
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Miyake K, Yoshida S, Seki T, Joo WJ, Takeuchi M, Kawakami K. Effectiveness of intraoperative nicorandil in patients with a history of ischemic heart disease undergoing high-risk noncardiac surgery: a retrospective cohort study. J Anesth 2023:10.1007/s00540-023-03204-5. [PMID: 37258777 DOI: 10.1007/s00540-023-03204-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 05/20/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Nicorandil is occasionally administered to prevent myocardial ischemia during the perioperative period in patients with ischemic heart disease (IHD); however, its effectiveness has not been clarified. In this study, we examined the effectiveness of intraoperative nicorandil administration in noncardiac surgery. METHODS We identified patients with a history of IHD who had undergone high-risk noncardiac surgery between April 2015 and March 2020 from a nationwide in-patient database in Japan. The patients were divided into those who received nicorandil (nicorandil group) and those who did not (control group). The primary outcome was the 30-day in-hospital mortality. The secondary outcome was major adverse cardiovascular events (MACE), defined as the composite outcome of the 30-day in-hospital mortality, acute myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting. One-to-one propensity score matching was performed. The outcomes were analyzed using a Cox proportional hazards model. RESULTS Of 8037 patients, 2886 received nicorandil during surgery. After propensity score matching, 2554 pairs were analyzed. There was no significant difference in the 30-day in-hospital mortality (26 [1.02%] vs. 36 [1.41%]; hazard ratio [HR] 1.36; 95% confidence interval [CI] 0.82-2.26; P = 0.229) or incidence of MACE (42 [1.64%] vs. 55 [2.15%]; HR 1.24; 95% CI 0.86-1.93; P = 0.216) between the control and nicorandil groups. CONCLUSION The findings of this study suggest that intraoperative nicorandil administration is not associated with the 30-day in-hospital mortality in high-risk noncardiac surgery.
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Affiliation(s)
- Kentaro Miyake
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Satomi Yoshida
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Woo Jin Joo
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
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22
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Lin S, Huang X, Zhang Y, Zhang X, Cheng E, Liu J. Intraoperative Variables Enhance the Predictive Performance of Myocardial Injury in Patients with High Cardiovascular Risk After Thoracic Surgery When Added to Baseline Prediction Model. Ther Clin Risk Manag 2023; 19:435-445. [PMID: 37252064 PMCID: PMC10225131 DOI: 10.2147/tcrm.s408135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/08/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Myocardial injury after non-cardiac surgery is closely related to major adverse cardiac and cerebrovascular event and is difficult to identify. This study aims to investigate how to predict the myocardial injury of thoracic surgery and whether intraoperative variables contribute to the prediction of myocardial injury. Methods The prospective study included adult patients with high cardiovascular risk who underwent elective thoracic surgery from May 2022 to October 2022. Multivariate logistic regression was used to establish a model with baseline variables and a model with baseline and intraoperative variables. We compare the predictive performance of two models for postoperative myocardial injury. Results In general, 31.5% (94 of 298) occurred myocardial injury. Age ≥65 years old, obesity, smoking, preoperative hsTnT, and one-lung ventilation time were independent predictors of myocardial injury. Compared with baseline model, the intraoperative variables improved model fit, modestly improved the reclassification (continuous net reclassification improvement 0.409, 95% CI, 0.169 to 0.648, P<0.001, improved integrated discrimination 0.036, 95% CI, 0.011 to 0.062, P<0.01) of myocardial injury cases, and achieved higher net benefit in decision curve analysis. Conclusion The risk stratification and anesthesia management of high-risk patients are essential. The addition of intraoperative variables to the baseline predictive model improved the performance of the overall model of myocardial injury and helped anesthesiologists screen out the patients at the greatest risk for myocardial injury and adjust anesthesia strategies.
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Affiliation(s)
- Shuchi Lin
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Xiaofan Huang
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Ying Zhang
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Xiaohan Zhang
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Erhong Cheng
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Jindong Liu
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
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Turan A, Rivas E, Devereaux PJ, Pu X, Rodriguez-Patarroyo FA, Yalcin EK, Nault R, Maheshwari K, Ruetzler K, Sessler DI. Relative contributions of anaemia and hypotension to myocardial infarction and renal injury: Post hoc analysis of the POISE-2 trial. Eur J Anaesthesiol 2023; 40:365-371. [PMID: 36891761 DOI: 10.1097/eja.0000000000001816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
BACKGROUND Hypotension and postoperative anaemia are associated with myocardial and renal injury after noncardiac surgery, but the interaction between them remains unknown. OBJECTIVES To test the hypothesis that a double-hit of postoperative anaemia and hypotension synergistically worsens a 30-day composite of myocardial infarction (MI) and mortality and acute kidney injury (AKI). Characterising the interaction when hypotension and anaemia occur at same time on myocardial infarction and acute kidney injury. DESIGN Post hoc analysis of the POISE-2 trial. SETTING Patients were enrolled between July 2010 and December 2013 at 135 hospitals in 23 countries. PATIENTS Adults at least 45 years old with known or suspected cardiovascular disease. We excluded patients without available postoperative haemoglobin measurements or hypotension duration records. Exposures were the lowest haemoglobin concentration and the average daily duration of SBP less than 90 mmHg within the first four postoperative days. MAIN OUTCOME MEASURES The primary outcome was a collapsed composite of nonfatal MI and all-cause mortality during the initial 30 postoperative days; our secondary outcome was AKI. RESULTS We included 7940 patients. The mean ± SD lowest postoperative haemoglobin was 10 ± 2 g dl -1 , and 24% of the patients had SBP less than 90 mmHg with daily duration ranging from 0 to 15 h. Four hundred and nine (5.2%) patients had an infarction or died within 30 postoperative days, and 417 (6.4%) patients developed AKI. Lowest haemoglobin concentrations less than 11 g dl -1 , and duration of SBP less than 90 mmHg was associated with greater hazard of composite outcome of nonfatal MI and all-cause mortality, as well as with AKI. However, we did not find significant multiplicative interactions between haemoglobin splines and hypotension duration on the primary composite or on AKI. CONCLUSION Postoperative anaemia and hypotension were meaningfully associated with both our primary composite and AKI. However, lack of significant interaction suggests that the effects of hypotension and anaemia are additive rather than multiplicative. TRIAL REGISTRATION Clinicaltrials.gov: NCT01082874.
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Affiliation(s)
- Alparslan Turan
- From the Department of Outcomes Research (AT, ER, XP, FAR-P, EKY, KM, KR, DIS), Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA (AT, KM, KR), Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Spain (ER), Population Health Research Institute, Hamilton Health Sciences and McMaster University, and the Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Hamilton, Ontario, Canada (PJD), Department of Quantitative Health Sciences (XP) and Learner Medical School, Cleveland Clinic, Cleveland, Ohio, USA (RN)
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24
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Marcucci M, Painter TW, Conen D, Lomivorotov V, Sessler DI, Chan MTV, Borges FK, Leslie K, Duceppe E, Martínez-Zapata MJ, Wang CY, Xavier D, Ofori SN, Wang MK, Efremov S, Landoni G, Kleinlugtenbelt YV, Szczeklik W, Schmartz D, Garg AX, Short TG, Wittmann M, Meyhoff CS, Amir M, Torres D, Patel A, Ruetzler K, Parlow JL, Tandon V, Fleischmann E, Polanczyk CA, Lamy A, Jayaram R, Astrakov SV, Wu WKK, Cheong CC, Ayad S, Kirov M, de Nadal M, Likhvantsev VV, Paniagua P, Aguado HJ, Maheshwari K, Whitlock RP, McGillion MH, Vincent J, Copland I, Balasubramanian K, Biccard BM, Srinathan S, Ismoilov S, Pettit S, Stillo D, Kurz A, Belley-Côté EP, Spence J, McIntyre WF, Bangdiwala SI, Guyatt G, Yusuf S, Devereaux PJ. Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery : An International Randomized Controlled Trial. Ann Intern Med 2023; 176:605-614. [PMID: 37094336 DOI: 10.7326/m22-3157] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Among patients having noncardiac surgery, perioperative hemodynamic abnormalities are associated with vascular complications. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively. OBJECTIVE To compare the effects of a hypotension-avoidance and a hypertension-avoidance strategy on major vascular complications after noncardiac surgery. DESIGN Partial factorial randomized trial of 2 perioperative blood pressure management strategies (reported here) and tranexamic acid versus placebo. (ClinicalTrials.gov: NCT03505723). SETTING 110 hospitals in 22 countries. PATIENTS 7490 patients having noncardiac surgery who were at risk for vascular complications and were receiving 1 or more long-term antihypertensive medications. INTERVENTION In the hypotension-avoidance strategy group, the intraoperative mean arterial pressure target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld and the other long-term antihypertensive medications were administered only for systolic blood pressures 130 mm Hg or greater, following an algorithm. In the hypertension-avoidance strategy group, the intraoperative mean arterial pressure target was 60 mm Hg or greater; all antihypertensive medications were continued before and after surgery. MEASUREMENTS The primary outcome was a composite of vascular death and nonfatal myocardial injury after noncardiac surgery, stroke, and cardiac arrest at 30 days. Outcome adjudicators were masked to treatment assignment. RESULTS The primary outcome occurred in 520 of 3742 patients (13.9%) in the hypotension-avoidance group and in 524 of 3748 patients (14.0%) in the hypertension-avoidance group (hazard ratio, 0.99 [95% CI, 0.88 to 1.12]; P = 0.92). Results were consistent for patients who used 1 or more than 1 antihypertensive medication in the long term. LIMITATION Adherence to the assigned strategies was suboptimal; however, results were consistent across different adherence levels. CONCLUSION In patients having noncardiac surgery, our hypotension-avoidance and hypertension-avoidance strategies resulted in a similar incidence of major vascular complications. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research, National Health and Medical Research Council (Australia), and Research Grant Council of Hong Kong.
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Affiliation(s)
- Maura Marcucci
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Thomas W Painter
- Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia (T.W.P.)
| | - David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia (V.L., S.I.)
| | - Daniel I Sessler
- Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.V.C., W.K.K.W.)
| | - Flavia K Borges
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Kate Leslie
- Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia (K.L.)
| | - Emmanuelle Duceppe
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (E.D.)
| | - María José Martínez-Zapata
- Iberoamerican Cochrane Centre, Public Health and Clinical Epidemiology Service, IIB Sant Pau, CIBERESP, Barcelona, Spain (M.J.M.)
| | - Chew Yin Wang
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (C.Y.W., C.C.C.)
| | - Denis Xavier
- St. John's Medical College, Bangalore, India (D.X.)
| | - Sandra N Ofori
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Michael Ke Wang
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Sergey Efremov
- Saint Petersburg State University Hospital, Saint Petersburg, Russia (S.E.)
| | - Giovanni Landoni
- Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy (G.L.)
| | - Ydo V Kleinlugtenbelt
- Department of Orthopedic and Trauma Surgery, Deventer Ziekenhuis, Deventer, the Netherlands (Y.V.K.)
| | - Wojciech Szczeklik
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (W.S.)
| | - Denis Schmartz
- CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium (D.S.)
| | - Amit X Garg
- Department of Medicine, Western University, London, Ontario, Canada (A.X.G.)
| | - Timothy G Short
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand (T.G.S.)
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany (M.W.)
| | - Christian S Meyhoff
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark (C.S.M.)
| | - Mohammed Amir
- Department of Surgery, Shifa International Hospital and Shifa Tameer-e-Millat University, Islamabad, Pakistan (M.A.)
| | - David Torres
- Departamento de Epidemiología y Estudios en Salud, Universidad de Los Andes, Santiago, Chile (D.T.)
| | - Ameen Patel
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada (A.P., V.T.)
| | - Kurt Ruetzler
- Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
| | - Joel L Parlow
- Department of Anesthesiology and Perioperative Medicine, Queen's University, and Kingston Health Sciences Centre, Kingston, Ontario, Canada (J.L.P.)
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada (A.P., V.T.)
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria (E.F.)
| | - Carisi A Polanczyk
- UFRGS, Hospital de Clínicas de Porto Alegre, National Institute for Health Technology Assessment, IATS; Hospital Moinhos de Vento, Porto Alegre, Brazil (C.A.P.)
| | - Andre Lamy
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Raja Jayaram
- Department of Anaesthetics, Clinical Neurosciences, University of Oxford, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (R.J.)
| | - Sergey V Astrakov
- Department of Anesthesiology, Novosibirsk State University, Novosibirsk, Russia (S.V.A.)
| | - William Ka Kei Wu
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.V.C., W.K.K.W.)
| | - Chao Chia Cheong
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (C.Y.W., C.C.C.)
| | - Sabry Ayad
- Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
| | - Mikhail Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia (M.K.)
| | - Miriam de Nadal
- Department of Anesthesiology and Intensive Care, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M. de N.)
| | | | - Pilar Paniagua
- Anesthesiology Department, Santa Creu i Sant Pau University Hospital, Barcelona, Spain (P.P.)
| | - Hector J Aguado
- Trauma & Orthopaedic Surgery Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain (H.J.A.)
| | - Kamal Maheshwari
- Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
| | - Richard P Whitlock
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Michael H McGillion
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Jessica Vincent
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Ingrid Copland
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Kumar Balasubramanian
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Bruce M Biccard
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital, and University of Cape Town, Cape Town, South Africa (B.M.B.)
| | - Sadeesh Srinathan
- Section of Thoracic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada (S.S.)
| | - Samandar Ismoilov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Centre, Novosibirsk, Russia (V.L., S.I.)
| | - Shirley Pettit
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - David Stillo
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Andrea Kurz
- Anesthesiology Institute, Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., K.R., S.A., K.M., A.K.)
| | - Emilie P Belley-Côté
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Jessica Spence
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Shrikant I Bangdiwala
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (G.G.)
| | - Salim Yusuf
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
| | - P J Devereaux
- Population Health Research Institute, Hamilton, Ontario, Canada (M.M., D.C., F.K.B., S.N.O., M.K.W., A.L., R.P.W., M.H.M., J.V., I.C., K.B., S.P., D.S., E.P.B., J.S., W.F.M., S.I.B., S.Y., P.J.D.)
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25
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Czajka S, Putowski Z, Krzych ŁJ. Post-induction hypotension and intraoperative hypotension as potential separate risk factors for the adverse outcome: a cohort study. J Anesth 2023; 37:442-450. [PMID: 37083989 DOI: 10.1007/s00540-023-03191-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/31/2023] [Indexed: 04/22/2023]
Abstract
PURPOSE Intraoperative hypotension (IOH) is associated with organ hypoperfusion. There are different underlying causes of IOH depending on the phase of surgery. Post-induction hypotension (PIH) and early-intraoperative hypotension tend to be frequently differentiated. We aimed to explore further different phases of IOH and verify whether they are differently associated with postoperative complications. METHODS Patients undergoing abdominal surgery between October 2018 and July 2019 in a university hospital were screened. Post-induction hypotension was defined as MAP ≤ 65 mmHg between the induction of anaesthesia and the onset of surgery. Hypotension during surgery (IOH) was defined as MAP ≤ 65 mmHg occurring between the onset of surgery and its completion. Acute kidney injury, stroke or transient ischaemic attack, delirium, and myocardial infarction were considered as the outcome. RESULTS We enrolled 508 patients (219 males, median age 62 years). 158 subjects (31.1%) met PIH, 171 (33.7%) met IOH criteria, and 67 (13.2%) patients experienced both. PIH time accounted for 22.8% of the total hypotension time and 29.7% of the IOH time. The IOH time accounted for 5.17% of the total intraoperative time, while PIH for 8.91% of the pre-incision time. Female sex, lower height, body mass and lower pre-induction BP (SBP and MAP) were found to be associated with the incidence of PIH. The negative outcome was observed in 38 (7.5%) patients. Intraoperative MAP ≤ 65 mmHg, longer duration of the procedure (≥ 230 min), chronic arterial hypertension and age were associated with the presence of the outcome (p < 0.01 each). CONCLUSIONS The presence of IOH defined as MAP ≤ 65 mmHg is relevant to post-operative organ complications, the presence of PIH does not appear to be of such significance. Because cumulative duration of PIH and IOH differs significantly, especially in long-lasting procedures, direct comparison of the influence of PIH and IOH on outcome separately may be biased and should be taken into account in data interpretation. Further research is needed to deeply investigate this phenomenon.
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Affiliation(s)
- Szymon Czajka
- Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, 14 Medykow Street, 40-752, Katowice, Poland.
| | - Zbigniew Putowski
- Students' Scientific Society, Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, 14 Medykow Street, 40-752, Katowice, Poland
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26
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Nandate H, Takasaki Y, Nakata Y, Hamada T, Konishi A, Abe N, Kitamura S, Nishihara T, Yorozuya T. Incidence and characteristics of early elevation of cardiac troponin I after intrathoracic surgery: A single-center retrospective observational study. Medicine (Baltimore) 2023; 102:e33361. [PMID: 37000092 PMCID: PMC10063319 DOI: 10.1097/md.0000000000033361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 02/14/2023] [Accepted: 03/03/2023] [Indexed: 04/01/2023] Open
Abstract
The early elevation of cardiac troponins within 24 hours after noncardiac surgery is reportedly associated with increased postoperative morbidities. Several predisposing factors, including the frequent occurrence of hypoxia and increased pulmonary arterial pressure, may likely contribute to this elevation, especially after intrathoracic surgery. Therefore, this retrospective study aimed to elucidate the incidence and characteristics of the early elevation of cardiac troponin I after intrathoracic surgery. This study included 320 patients who underwent intrathoracic surgery between January 1, 2018, and June 30, 2021. Specific perioperative variables were retrospectively collected from their electrical clinical records. The serum concentration of high-sensitivity cardiac troponin I (hs cTnI) was measured twice immediately after the intensive care unit arrival and on the following day. We grouped these patients into two: the early elevation of hs cTnI (EECT) group (hs cTnI value > 26.2 ng/L by at least 1 measurement) and the non-early elevation (non-EECT) group. Patient characteristics were then compared between these groups. The hs cTnI level elevated within 24 hours postoperatively in 103 patients (32.2%). In univariate analysis, intraoperative variables, including the duration of unilateral ventilation (199.2 minutes, P = .0025) and surgery (210.6 minutes, P = .0012), estimated blood loss volume (406.7 mL, P = .0022), percentage of stored red blood cell (RBC) transfusion (10.7%, P = .0059), and percentage of lobectomy or combination of other lung resection types (88.3%, P = .00188), were significantly higher in the EECT group than in the non-EECT group. In the log-rank test, prolonged hospitalization was more prevalent in the EECT group (P = .0485). Furthermore, multivariate analysis revealed 3 independent risk factors for the early elevation of hs cTnI: coexisting chronic renal failure (odds ratio [OR], 3.25), lobectomy or combined resections (OR, 2.65), and stored RBC transfusion (OR, 3.41). The early elevation of hs cTnI commonly occurs after intrathoracic surgery, with an incidence of 32.2%. Its 3 independent risk factors are coexisting chronic renal failure, lung resection type, and stored RBC transfusion.
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Affiliation(s)
- Hideyuki Nandate
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
- Division of Intensive Care, Ehime University Hospital, Toon, Japan
| | - Yasushi Takasaki
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
- Division of Intensive Care, Ehime University Hospital, Toon, Japan
| | - Yukihiro Nakata
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
- Division of Intensive Care, Ehime University Hospital, Toon, Japan
| | - Taisuke Hamada
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Amane Konishi
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Naoki Abe
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Sakiko Kitamura
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Tasuku Nishihara
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Toshihiro Yorozuya
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
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27
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Bello C, Rössler J, Shehata P, Smilowitz NR, Ruetzler K. Perioperative strategies to reduce risk of myocardial injury after non-cardiac surgery (MINS): A narrative review. J Clin Anesth 2023; 87:111106. [PMID: 36931053 DOI: 10.1016/j.jclinane.2023.111106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/06/2023] [Accepted: 03/03/2023] [Indexed: 03/17/2023]
Abstract
Myocardial injury is a frequent complication of surgical patients after having non-cardiac surgery that is strongly associated with perioperative mortality. While intraoperative anesthesia-related deaths are exceedingly rare, about 1% of patients undergoing non-cardiac surgery die within the first 30 postoperative days. Given the number of surgeries performed annually, death following surgery is the second leading cause of death in the United States. Myocardial injury after non-cardiac surgery (MINS) is defined as an elevation in troponin concentrations within 30 days postoperatively. Although typically asymptomatic, patients with MINS suffer myocardial damage and have a 10% risk of death within 30 days after surgery and excess risks of mortality that persist during the first postoperative year. Many factors for the development of MINS are non-modifiable, such as preexistent coronary artery disease. Preventive measures, systematic approaches to surveillance and treatment standards are still lacking, however many factors are modifiable and should be considered in clinical practice: the importance of hemodynamic control, adequate oxygen supply, metabolic homeostasis, the use of perioperative medications such as statins, anti-thrombotic agents, beta-blockers, or anti-inflammatory agents, as well as some evidence regarding the choice of sedative and analgesic for anesthesia are discussed. Also, as age and complexity in comorbidities of the surgical patient population increase, there is an urgent need to identify patients at risk for MINS and develop prevention and treatment strategies. In this review, we provide an overview of current screening standards and promising preventive options in the perioperative setting and address knowledge gaps requiring further investigation.
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Affiliation(s)
- Corina Bello
- Department of Anaesthesiology and Pain Medicine, Inselspital Bern, University Hospital, University of Bern, Switzerland
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Peter Shehata
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, United States of America; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, New York, NY, United States of America
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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28
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Vernooij JEM, Koning NJ, Geurts JW, Holewijn S, Preckel B, Kalkman CJ, Vernooij LM. Performance and usability of pre-operative prediction models for 30-day peri-operative mortality risk: a systematic review. Anaesthesia 2023; 78:607-619. [PMID: 36823388 DOI: 10.1111/anae.15988] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 02/25/2023]
Abstract
Estimating pre-operative mortality risk may inform clinical decision-making for peri-operative care. However, pre-operative mortality risk prediction models are rarely implemented in routine clinical practice. High predictive accuracy and clinical usability are essential for acceptance and clinical implementation. In this systematic review, we identified and appraised prediction models for 30-day postoperative mortality in non-cardiac surgical cohorts. PubMed and Embase were searched up to December 2022 for studies investigating pre-operative prediction models for 30-day mortality. We assessed predictive performance in terms of discrimination and calibration. Risk of bias was evaluated using a tool to assess the risk of bias and applicability of prediction model studies. To further inform potential adoption, we also assessed clinical usability for selected models. In all, 15 studies evaluating 10 prediction models were included. Discrimination ranged from a c-statistic of 0.82 (MySurgeryRisk) to 0.96 (extreme gradient boosting machine learning model). Calibration was reported in only six studies. Model performance was highest for the surgical outcome risk tool (SORT) and its external validations. Clinical usability was highest for the surgical risk pre-operative assessment system. The SORT and risk quantification index also scored high on clinical usability. We found unclear or high risk of bias in the development of all models. The SORT showed the best combination of predictive performance and clinical usability and has been externally validated in several heterogeneous cohorts. To improve clinical uptake, full integration of reliable models with sufficient face validity within the electronic health record is imperative.
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Affiliation(s)
- J E M Vernooij
- Department of Anaesthesia, Rijnstate Hospital, the Netherlands
| | - N J Koning
- Department of Anaesthesia, Rijnstate Hospital, the Netherlands
| | - J W Geurts
- Department of Anaesthesia, Rijnstate Hospital, the Netherlands
| | - S Holewijn
- Department of Vascular Surgery, Rijnstate Hospital, the Netherlands
| | - B Preckel
- Department of Anaesthesia, Amsterdam UMC, Amsterdam, the Netherlands
| | - C J Kalkman
- University Medical Centre, Utrecht, the Netherlands
| | - L M Vernooij
- Department of Anaesthesia, University Medical Centre Utrecht, the Netherlands
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29
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Jin X, Laxminarayan S, Nagaraja S, Wallqvist A, Reifman J. Development and validation of a mathematical model to simulate human cardiovascular and respiratory responses to battlefield trauma. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2023; 39:e3662. [PMID: 36385572 DOI: 10.1002/cnm.3662] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 11/01/2022] [Accepted: 11/13/2022] [Indexed: 06/16/2023]
Abstract
Mathematical models of human cardiovascular and respiratory systems provide a viable alternative to generate synthetic data to train artificial intelligence (AI) clinical decision-support systems and assess closed-loop control technologies, for military medical applications. However, existing models are either complex, standalone systems that lack the interface to other applications or fail to capture the essential features of the physiological responses to the major causes of battlefield trauma (i.e., hemorrhage and airway compromise). To address these limitations, we developed the cardio-respiratory (CR) model by expanding and integrating two previously published models of the cardiovascular and respiratory systems. We compared the vital signs predicted by the CR model with those from three models, using experimental data from 27 subjects in five studies, involving hemorrhage, fluid resuscitation, and respiratory perturbations. Overall, the CR model yielded relatively small root mean square errors (RMSEs) for mean arterial pressure (MAP; 20.88 mm Hg), end-tidal CO2 (ETCO2 ; 3.50 mm Hg), O2 saturation (SpO2 ; 3.40%), and arterial O2 pressure (PaO2 ; 10.06 mm Hg), but a relatively large RMSE for heart rate (HR; 70.23 beats/min). In addition, the RMSEs for the CR model were 3% to 10% smaller than the three other models for HR, 11% to 15% for ETCO2 , 0% to 33% for SpO2 , and 10% to 64% for PaO2 , while they were similar for MAP. In conclusion, the CR model balances simplicity and accuracy, while qualitatively and quantitatively capturing human physiological responses to battlefield trauma, supporting its use to train and assess emerging AI and control systems.
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Affiliation(s)
- Xin Jin
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Srinivas Laxminarayan
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Sridevi Nagaraja
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Anders Wallqvist
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, Maryland, USA
| | - Jaques Reifman
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, Maryland, USA
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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Stroda A, Thelen S, M’Pembele R, Khademlou N, Jaekel C, Schiffner E, Bieler D, Bernhard M, Huhn R, Lurati Buse G, Roth S. Association between hypotension and myocardial injury in patients with severe trauma. Eur J Trauma Emerg Surg 2023; 49:217-225. [PMID: 35920849 PMCID: PMC9925499 DOI: 10.1007/s00068-022-02051-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE During resuscitation of patients with severe trauma, guidelines recommend permissive hypotension prior to surgical bleeding control. However, hypotension may be associated with reduced organ perfusion and multiple organ dysfunction, e.g. myocardial injury. The association between hypotension and myocardial injury in trauma patients is underexplored. We hypothesized that hypotension is associated with myocardial injury in this population. MATERIALS AND METHODS This retrospective study included patients ≥ 18 years suffering from severe trauma [defined as Injury Severity Score (ISS) ≥ 16] that were treated in the emergency department resuscitation room between 2016 and 2019. Primary endpoint was the incidence of myocardial injury defined as high-sensitive troponin T > 14 ng/l. Main exposure was the duration of arterial hypotension during resuscitation period defined as mean arterial pressure < 65 mmHg. RESULTS Out of 368 patients screened, 343 were analyzed (73% male, age: 55 ± 21, ISS: 28 ± 12). Myocardial injury was detected in 143 (42%) patients. Overall in-hospital mortality was 26%. Multivariate binary logistic regression with forced entry of nine predefined covariables revealed an odds ratio of 1.29 [95% confidence interval 1.16-1.44]; p = 0.012) for the association between the duration of hypotension and myocardial injury. CONCLUSION The duration of hypotension during resuscitation period is independently associated with the incidence of myocardial injury in patients with severe trauma.
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Affiliation(s)
- Alexandra Stroda
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Simon Thelen
- Department of Orthopedics and Trauma Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
| | - René M’Pembele
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Nick Khademlou
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Carina Jaekel
- Department of Orthopedics and Trauma Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Erik Schiffner
- Department of Orthopedics and Trauma Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Dan Bieler
- Department of Orthopedics and Trauma Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Michael Bernhard
- Emergency Department, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Ragnar Huhn
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany ,Department of Anesthesiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Giovanna Lurati Buse
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Sebastian Roth
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
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Perioperative troponin surveillance in major noncardiac surgery: a narrative review. Br J Anaesth 2023; 130:21-28. [PMID: 36464518 DOI: 10.1016/j.bja.2022.08.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/08/2022] [Accepted: 08/31/2022] [Indexed: 12/03/2022] Open
Abstract
Myocardial injury is now an acknowledged complication in patients undergoing noncardiac surgery. Heterogeneity in the definitions of myocardial injury contributes to difficulty in evaluating the value of cardiac troponins (cTns) measurement in perioperative care. Pre-, post-, and peri-operatively increased cTns are encompassed by the umbrella term 'myocardial injury' and are likely to reflect different pathophysiological mechanisms. Increased cTns are independently associated with cardiovascular and non-cardiovascular complications, poor short-term and long-term cardiovascular outcomes, and increased mortality. Preoperative measurement of cTns aids preoperative risk stratification beyond the Revised Cardiac Risk Index. Systematic measurement detects acute perioperative increases and allows early identification of acute myocardial injury. Common definitions and standards for reporting are a prerequisite for designing impactful future trials and perioperative management strategies.
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Harris DE. Perioperative Acute Myocardial Infarction and Ischemia After Noncardiac Surgery: Pathophysiology, Prevention, and Nursing Implications. AORN J 2022; 116:517-531. [DOI: 10.1002/aorn.13826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/10/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
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Kim SH, Chang B, Ahn HJ, Kim JA, Yang M, Kim H, Jeong BH. Safety of Rigid Bronchoscopy for Therapeutic Intervention at the Intensive Care Unit Bedside. Medicina (B Aires) 2022; 58:medicina58121762. [PMID: 36556963 PMCID: PMC9782846 DOI: 10.3390/medicina58121762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/27/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
Background and Objective: Although rigid bronchoscopy is generally performed in the operating room (OR), the intervention is sometimes emergently required at the intensive care unit (ICU) bedside. The aim of this study is to evaluate the safety of rigid bronchoscopy at the ICU bedside. Materials and Methods: We retrospectively analyzed medical records of patients who underwent rigid bronchoscopy while in the ICU from January 2014 to December 2020. According to the location of rigid bronchoscopic intervention, patients were classified into the ICU group (n = 171, cases emergently performed at the ICU bedside without anesthesiologists) and the OR group (n = 165, cases electively performed in the OR with anesthesiologists). The risk of intra- and post-procedural complications in the ICU group was analyzed using multivariable logistic regression, with the OR group as the reference category. Results: Of 336 patients, 175 (52.1%) were moribund and survival was not expected without intervention, and 170 (50.6%) received invasive respiratory support before the intervention. The most common reasons for intervention were post-intubation tracheal stenosis (39.3%) and malignant airway obstruction (34.5%). Although the overall rate of intra-procedural complications did not differ between the two groups (86.0% vs. 80.6%, p = 0.188), post-procedural complications were more frequent in the ICU group than in the OR group (24.0% vs. 12.1%, p = 0.005). Severe complications requiring unexpected invasive management occurred only post-procedurally and were more common in the ICU group (10.5% vs. 4.8%, p = 0.052). In the fully adjusted model, the ICU group had increased odds for severe post-procedural complications, but statistical significance was not observed (odds ratio, 2.54; 95% confidence interval, 0.73-8.88; p = 0.144). Conclusions: Although general anesthesia is generally considered the gold standard for rigid bronchoscopy, our findings indicate that rigid bronchoscopy may be safely performed at the ICU bedside in selective cases of emergency. Moreover, adequate patient selection and close post-procedural monitoring are required to prevent severe complications.
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Affiliation(s)
- Sang Hyuk Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea
| | - Boksoon Chang
- Department of Pulmonary, Allergy and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul 05278, Republic of Korea
| | - Hyun Joo Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Jie Ae Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Hojoong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Correspondence: ; Tel.: +82-2-3410-3429; Fax: +82-2-3410-3849
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Intraoperative Assessment of Surgical Stress Response Using Nociception Monitor under General Anesthesia and Postoperative Complications: A Narrative Review. J Clin Med 2022; 11:jcm11206080. [PMID: 36294399 PMCID: PMC9604770 DOI: 10.3390/jcm11206080] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/16/2022] Open
Abstract
We present a narrative review focusing on the new role of nociception monitor in intraoperative anesthetic management. Higher invasiveness of surgery elicits a higher degree of surgical stress responses including neuroendocrine-metabolic and inflammatory-immune responses, which are associated with the occurrence of major postoperative complications. Conversely, anesthetic management mitigates these responses. Furthermore, improper attenuation of nociceptive input and related autonomic effects may induce increased stress response that may adversely influence outcome even in minimally invasive surgeries. The original role of nociception monitor, which is to assess a balance between nociception caused by surgical trauma and anti-nociception due to anesthesia, may allow an assessment of surgical stress response. The goal of this review is to inform healthcare professionals providing anesthetic management that nociception monitors may provide intraoperative data associated with surgical stress responses, and to inspire new research into the effects of nociception monitor-guided anesthesia on postoperative complications.
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Wang GP, Guo Z. To Analyze the Mechanism of SalB Regulating SIRT1 to Inhibit NLRP3 and Its Ameliorative Effect on Tubulogastric Junction Tumor Lesions Complicated with Myocardial Injury. BIOMED RESEARCH INTERNATIONAL 2022; 2022:6560693. [PMID: 36277894 PMCID: PMC9586805 DOI: 10.1155/2022/6560693] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/15/2022] [Accepted: 09/17/2022] [Indexed: 11/18/2022]
Abstract
The objective of this research is to investigate the mediating impact of salvianolic acid B (SalB) on SIRT1 signaling pathway and the mechanism by which it inhibits Nod-like receptor protein 3 (NLRP3), as well as to examine how SalB affects myocardial injury brought on by tumor lesions at the junction of the tube and the stomach. Through the establishment of the integration of a stomach tube tumor lesion rats combined with the experimental rat model, this study establishes the normal group, model group, and different SalB dose groups. For each group of cells, cell activity and cell apoptosis were determined and compared using colorimetry and enzyme-linked immunosorbent method about lactate dehydrogenase (LDH). Interleukin-1 beta levels are measured. DCFH-DA fluorescent probe was applied to identify intracellular "reactive oxygen species" (ROS). "Western blot" was used to determine NLRP3, caspase-1, and apoptosis-related spotted protein (ASC) in each group of cells. And SIRT1 signaling pathway related to SIRT1, phosphorylated AMP protein-activated kinase α (P-AMPK α), AMP protein-activated kinase α (AMPKα), and "peroxisome-proliferator-activated receptor γ coactivator 1α (PGC-1α) protein expression" are used. According to the final findings, SalB mediated the SIRT1 signaling pathway and had a beneficial impact on the upregulation of SIRT1, P-AMPK/AMPK, and PGC-1 protein expressions. SalB positively affects the downregulation of NLRP3 inflammasome-related proteins. Caspase-1 and ASC protein expression suggesting that SalB may inhibit the activation of NLRP3 inflammasome induced by oxidative stress by activating SIRT1/AMPK/PGC-1α signaling pathway. This plays an antimyocardial injury effect.
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Affiliation(s)
- Guo-Ping Wang
- Changzhi People's Hospital of Shanxi Medical University, Changzhi, Shanxi 046000, China
| | - Zheng Guo
- Department of Anesthesiology, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi 03001, China
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Predicting personalised remifentanil effect site concentration for surgical incision using the nociception level index: A prospective calibration and validation study. Eur J Anaesthesiol 2022; 39:918-927. [PMID: 36125017 DOI: 10.1097/eja.0000000000001751] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inadequate antinociception can cause haemodynamic instability. The nociception level (NOL) index measures response to noxious stimuli, but its capacity to predict optimal antinociception is unknown. OBJECTIVE To determine if NOL index change to a tetanic stimulus in cardiac and noncardiac surgery patients could predict the required remifentanil concentration for haemodynamic stability at skin incision. DESIGN A prospective two-phase cohort study. SETTING University hospital. PATIENTS Patients undergoing remifentanil-propofol target controlled infusion (TCI) anaesthesia. INTERVENTIONS During the calibration phase, investigators evaluated the tetanic stimulus induced NOL index change under standardised TCI remifentanil-propofol anaesthesia during a no-touch period [bispectral index (BIS) between 40 and 60, NOL index under 15]. If the NOL index change was 20 or greater following tetanic stimulation, investigators repeated the tetanus at higher remifentanil concentrations until the response was blunted. Surgeons incised the skin at this remifentanil concentration. The investigators derived a prediction model and in the validation phase calculated, using the NOL response to a single tetanus, the required incision remifentanil concentration for the start of surgery. MAIN OUTCOME Haemodynamic stability at incision [i.e. maximum heart rate (HR) < 20% increase from baseline, minimum HR (40 bpm) and mean arterial pressure (MAP) ± <20% of baseline]. RESULTS During the calibration phase, no patient had hypertension. Two patients had a HR increase slightly greater than 20% (25.4 and 26.7%) within the first 2 min of surgery, but neither of these two patients had a HR above 76 bpm. Two patients were slightly hypotensive after incision (MAP 64 and 73 mmHg). During the validation phase, neither tachycardia nor hypotension occurred, but MAP increased to 21.5% above baseline for one patient. CONCLUSION During a no-touch period in patients under steady-state general anaesthesia [propofol effect site concentration (Ce) required for BIS between 40 and 60], the NOL index response to a tetanic stimulus under remifentanil antinociception can be used to personalise remifentanil Ce for the start of surgery and ensure stable haemodynamics. TRIAL REGISTRATION ClinicalTrials.gov: NCT03324269.
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Lan L, Shu Q, Yu C, Pei L, Zhang Y, Xu L, Huang Y. Incidence and risk factors for myocardial injury after laparoscopic adrenalectomy for pheochromocytoma: A retrospective cohort study. Front Oncol 2022; 12:979994. [PMID: 36172145 PMCID: PMC9511041 DOI: 10.3389/fonc.2022.979994] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPheochromocytoma is a rare catecholamine-secreting tumor. Tumor resection remains a high-risk procedure due to intraoperative hemodynamic instability nowadays, which may lead to myocardial injury. We aimed to determine the incidence and associated risk factors for myocardial injury after laparoscopic adrenalectomy for pheochromocytoma.MethodsAdult patients (n=350, American Society of Anesthesiology physical status 1–3) who underwent elective laparoscopic adrenalectomy for pheochromocytoma under general anesthesia between January 31, 2013 and January 31, 2020 were included in this observational, retrospective, single-center, cohort study. Blood troponin I levels were measured before and during the first 2 days after surgery. Myocardial injury was defined as an elevated troponin I level exceeding the 99th percentile upper reference limit due to cardiac ischemic causes.ResultsMyocardial injury occurred in 42/350 patients (12.0%, 95% confidence interval: 9.0%–15.9%). In multivariable analysis (adjusted odds ratios [95% confidence intervals]), previous ischemic heart disease or stroke (5.04 [1.40–18.08]; P=0.013), intraoperative heart rate >115 bpm (2.55 [1.06–6.12]; P=0.036), intraoperative systolic blood pressure >210 mmHg (2.38 [1.00–5.66]; P=0.049), and perioperative decrease in hemoglobin level(1.74 [1.15–2.64] per g/dL decrease; P=0.008) were associated with an increased risk of myocardial injury. For the cumulative duration of dichotomized intraoperative hemodynamics, multivariable analysis showed that intraoperative heart rate >115 bpm for >1 minute (2.67 [1.08–6.60]; P=0.034) and systolic blood pressure >210 mmHg for >1 minute (3.78 [1.47–9.73]; P=0.006) were associated with an increased risk of myocardial injury. The risk of myocardial injury progressively increased with a longer cumulative duration of intraoperative tachycardia and hypertension.ConclusionsThere is a high incidence of myocardial injury after laparoscopic adrenalectomy for pheochromocytoma. The identified risk factors may assist physicians in detecting high-risk patients and providing guidance for intraoperative hemodynamics and perioperative hemoglobin management.
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Affiliation(s)
- Ling Lan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qian Shu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Chunhua Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lijian Pei
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Li Xu, ; Yuguang Huang,
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Li Xu, ; Yuguang Huang,
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Ke JXC, McIsaac DI, George RB, Branco P, Cook EF, Beattie WS, Urquhart R, MacDonald DB. Postoperative mortality risk prediction that incorporates intraoperative vital signs: development and internal validation in a historical cohort. Can J Anaesth 2022; 69:1086-1098. [PMID: 35996071 DOI: 10.1007/s12630-022-02287-0] [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: 01/06/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Accurate risk reassessment after surgery is crucial for postoperative planning for monitoring and disposition. Existing postoperative mortality risk prediction models using preoperative features do not incorporate intraoperative hemodynamic derangements that may alter risk stratification. Intraoperative vital signs may provide an objective and readily available prognostic resource. Our primary objective was to derive and internally validate a logistic regression (LR) model by adding intraoperative features to established preoperative predictors to predict 30-day postoperative mortality. METHODS Following Research Ethics Board approval, we analyzed a historical cohort that included patients aged ≥ 45 undergoing noncardiac surgery with an overnight stay at two tertiary hospitals (2013 to 2017). Features included intraoperative vital signs (blood pressure, heart rate, end-tidal carbon dioxide partial pressure, oxygen saturation, and temperature) by threshold and duration of exposure, as well as patient, surgical, and anesthetic factors. The cohort was divided temporally 75:25 into derivation and validation sets. We constructed a multivariable LR model with 30-day all-cause mortality as the outcome and evaluated performance metrics. RESULTS There were 30,619 patients in the cohort (mean [standard deviation] age, 66 [11] yr; 50.2% female; 2.0% mortality). In the validation set, the primary LR model showed a c-statistic of 0.893 (99% confidence interval [CI], 0.853 to 0.927), a Nagelkerke R-squared of 0.269, a scaled Brier score of 0.082, and an area under precision-recall curve of 0.158 (baseline 0.017 for an uninformative model). The addition of intraoperative vital signs to preoperative factors minimally improved discrimination and calibration. CONCLUSION We derived and internally validated a model that incorporated vital signs to improve risk stratification after surgery. Preoperative factors were strongly predictive of mortality risk, and intraoperative predictors only minimally improved discrimination. External and prospective validations are needed. STUDY REGISTRATION www. CLINICALTRIALS gov (NCT04014010); registered on 10 July 2019.
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Affiliation(s)
- Janny Xue Chen Ke
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.
- T. H. Chan School of Public Health, Harvard University, Boston, MB, USA.
- Department of Anesthesia, St. Paul's Hospital, Providence Health Care, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada.
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ronald B George
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Paula Branco
- School of Electrical Engineering and Computer Science, University of Ottawa, Ottawa, ON, Canada
| | - E Francis Cook
- T. H. Chan School of Public Health, Harvard University, Boston, MB, USA
| | - W Scott Beattie
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - David B MacDonald
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
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Song Q, Li J, Jiang Z. Provisional Decision-Making for Perioperative Blood Pressure Management: A Narrative Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5916040. [PMID: 35860431 PMCID: PMC9293529 DOI: 10.1155/2022/5916040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
Blood pressure (BP) is a basic determinant for organ blood flow supply. Insufficient blood supply will cause tissue hypoxia, provoke cellular oxidative stress, and to some extent lead to organ injury. Perioperative BP is labile and dynamic, and intraoperative hypotension is common. It is unclear whether there is a causal relationship between intraoperative hypotension and organ injury. However, hypotension surely compromises perfusion and causes harm to some extent. Because the harm threshold remains unknown, various guidelines for intraoperative BP management have been proposed. With the pending definitions from robust randomized trials, it is reasonable to consider observational analyses suggesting that mean arterial pressures below 65 mmHg sustained for more than 15 minutes are associated with myocardial and renal injury. Advances in machine learning and artificial intelligence may facilitate the management of hemodynamics globally, including fluid administration, rather than BP alone. The previous mounting studies concentrated on associations between BP targets and adverse complications, whereas few studies were concerned about how to treat and multiple factors for decision-making. Hence, in this narrative review, we discussed the way of BP measurement and current knowledge about baseline BP extracting for surgical patients, highlighted the decision-making process for BP management with a view to providing pragmatic guidance for BP treatment in the clinical settings, and evaluated the merits of an automated blood control system in predicting hypotension.
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Affiliation(s)
- Qiliang Song
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Jipeng Li
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Zongming Jiang
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
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Gao L, Chen L, He J, Wang B, Liu C, Wang R, Fan L, Cheng R. Perioperative Myocardial Injury/Infarction After Non-cardiac Surgery in Elderly Patients. Front Cardiovasc Med 2022; 9:910879. [PMID: 35665266 PMCID: PMC9160386 DOI: 10.3389/fcvm.2022.910879] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/28/2022] [Indexed: 12/15/2022] Open
Abstract
At present, we have entered an aging society. Many diseases suffered by the elderly, such as malignant tumors, cardiovascular diseases, fractures, surgical emergencies and so on, need surgical intervention. With the improvement of Geriatrics, surgical minimally invasive technology and anesthesia level, more and more elderly patients can safely undergo surgery. Elderly surgical patients are often complicated with a variety of chronic diseases, and the risk of postoperative myocardial injury/infarction (PMI) is high. PMI is considered to be the increase of cardiac troponin caused by perioperative ischemia, which mostly occurs during operation or within 30 days after operation, which can increase the risk of short-term and long-term death. Therefore, it is suggested to screen troponin in elderly patients during perioperative period, timely identify patients with postoperative myocardial injury and give appropriate treatment, so as to improve the prognosis. The pathophysiological mechanism of PMI is mainly due to the increase of myocardial oxygen consumption and / the decrease of myocardial oxygen supply. Preoperative and postoperative risk factors of myocardial injury can be induced by mismatch of preoperative and postoperative oxygen supply. The treatment strategy should first control the risk factors and use the drugs recommended in the guidelines for treatment. Application of cardiovascular drugs, such as antiplatelet β- Receptor blockers, statins and angiotensin converting enzyme inhibitors can effectively improve postoperative myocardial ischemia. However, the risk of perioperative bleeding should be fully considered before using antiplatelet and anticoagulant drugs. This review is intended to describe the epidemiology, diagnosis, pathophysiology, risk factors, prognosis and treatment of postoperative myocardial infarction /injury.
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Affiliation(s)
- Linggen Gao
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Lei Chen
- Department of Thoracic Surgery, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Jing He
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Bin Wang
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Chaoyang Liu
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Rong Wang
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Li Fan
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
- *Correspondence: Li Fan
| | - Rui Cheng
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
- Rui Cheng
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Advances in Neuroimaging and Monitoring to Defend Cerebral Perfusion in Noncardiac Surgery. Anesthesiology 2022; 136:1015-1038. [PMID: 35482943 DOI: 10.1097/aln.0000000000004205] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Noncardiac surgery conveys a substantial risk of secondary organ dysfunction and injury. Neurocognitive dysfunction and covert stroke are emerging as major forms of perioperative organ dysfunction, but a better understanding of perioperative neurobiology is required to identify effective treatment strategies. The likelihood and severity of perioperative brain injury may be increased by intraoperative hemodynamic dysfunction, tissue hypoperfusion, and a failure to recognize complications early in their development. Advances in neuroimaging and monitoring techniques, including optical, sonographic, and magnetic resonance, have progressed beyond structural imaging and now enable noninvasive assessment of cerebral perfusion, vascular reserve, metabolism, and neurologic function at the bedside. Translation of these imaging methods into the perioperative setting has highlighted several potential avenues to optimize tissue perfusion and deliver neuroprotection. This review introduces the methods, metrics, and evidence underlying emerging optical and magnetic resonance neuroimaging methods and discusses their potential experimental and clinical utility in the setting of noncardiac surgery.
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Bekkenes M, Jørgensen MM, Flem Jacobsen A, Wang Fagerland M, Rakstad-Larsen H, Solberg OG, Aaberge L, Klingenberg O, Steinsvik T, Rosseland LA. A study protocol for the cardiac effects of a single dose of either oxytocin 2.5 IU or carbetocin 100 µg after caesarean delivery: a prospective randomized controlled multi-centre trial in Norway. F1000Res 2022; 10:973. [PMID: 34745566 PMCID: PMC8561611 DOI: 10.12688/f1000research.73112.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Both oxytocin and carbetocin are used to prevent uterine atony and post-partum haemorrhage after caesarean delivery in many countries, including Norway. Oxytocin causes dose-dependent ST-depression, troponin release, prolongation of QT-time and arrythmia, but little is known about myocardial effects of carbetocin. We have previously demonstrated comparable vasodilatory effects of oxytocin and carbetocin and are now undertaking a Phase 4 trial to investigate whether carbetocin causes similar changes to myocardial markers compared with oxytocin. Methods: Our randomized controlled trial will be conducted at three obstetrics units at Oslo University Hospital and Akershus University Hospital, Norway. Planned enrolment will be of 240 healthy, singleton pregnant women aged 18 to 50 years undergoing planned caesarean delivery. Based on pilot study data,
each participant will receive a one-minute intravenous injection of either oxytocin 2.5 IU or carbetocin 100 µg during caesarean delivery. The prespecified primary outcome is the change from baseline in high-sensitive troponin I plasma concentrations at 6–10 hours after study drug administration. Secondary outcomes include uterine tone grade at 2.5 and five minutes after study drug administration, adverse events for up to 48 hours after study drug administration, estimated blood loss within eight hours of delivery, need for rescue treatment and direct/indirect costs.
Enrolment and primary analysis are expected to be completed by the end of 2021. Discussion: Women undergoing caesarean delivery should be assessed for cardiovascular risk particularly as women with an obstetric history of pregnancy induced hypertension, gestational diabetes mellitus, preterm birth, placental abruption, and stillbirth are at increased risk of future cardiovascular disease. Any additional ischaemic myocardial risk from uterotonic agents will need to be balanced with the benefit of reducing the risk of postpartum haemorrhage. Any potential cardiotoxicity difference between oxytocin and carbetocin will help inform treatment decisions for pregnant women. Registration: Clinicaltrials.gov
NCT03899961 (02/04/2019).
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Affiliation(s)
- Maria Bekkenes
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Anne Flem Jacobsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Morten Wang Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | | | - Ole Geir Solberg
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Olav Klingenberg
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Trude Steinsvik
- Department of Laboratory Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Leiv Arne Rosseland
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Shimada T, Mascha EJ, Yang D, Bravo M, Rivas E, Ince I, Turan A, Sessler DI. Intra-operative hypertension and myocardial injury and/or mortality and acute kidney injury after noncardiac surgery: A retrospective cohort analysis. Eur J Anaesthesiol 2022; 39:315-323. [PMID: 35066561 DOI: 10.1097/eja.0000000000001656] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Whether intra-operative hypertension causes postoperative complications remains unclear. OBJECTIVE We sought to assess whether there is an absolute systolic hypertensive threshold associated with increased odds of a composite of postoperative myocardial injury and mortality, and acute kidney injury. DESIGN A retrospective cohort analysis using an electronic medical record registry. SETTING The Cleveland Clinic Main Campus, Cleveland, Ohio, USA, between January 2005 and December 2018. PATIENTS A total of 76 042 adults who had inpatient noncardiac surgery lasting at least an hour, creatinine recorded preoperatively and postoperatively, and had an available clinic blood pressure within 6 months before surgery. MAIN OUTCOME MEASURES Univariable smoothing and multivariable logistic regression were used to estimate the probability of each outcome as a function of the highest intra-operative pressure for a cumulative 5, 10, or 30 min. We further assessed whether the relationships between intra-operative hypertension and each outcome depended on baseline systolic blood pressure. RESULTS The composite of myocardial injury and mortality was observed in 1.9%, and acute kidney injury in 4.5% of patients. After adjustment for confounders, there was little or no relationship between systolic pressure and either outcome over the range from 120 to 200 mmHg. There were also no obvious change points or thresholds above which odds of each outcome increased. And finally, there was no interaction with preoperative clinic blood pressure. CONCLUSIONS There was no clinically meaningful relationship between intra-operative systolic pressure and the composite of myocardial injury and mortality, or acute kidney injury, over the range from 120 and 200 mmHg.
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Affiliation(s)
- Tetsuya Shimada
- From the Departments of Outcomes Research ( TS, EJM, DY, MB, ER, II, AT, DIS) , Quantitative Health Sciences (EJM, DY), General Anesthesiology (AT), Cleveland Clinic, Cleveland, Ohio, USA, Department of Anesthesiology, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan (TS), Department of Anesthesiology, National Defense Medical College, Tokorozawa, Saitama, Japan (TS), Department of Anesthesia Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain (ER), Altinbas University, Bahcelievler Medical Park Hospital, Istanbul, Turkey (II)
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Loft FC, Rasmussen SM, Elvekjaer M, Haahr‐Raunkjaer C, Sørensen HBD, Aasvang EK, Meyhoff CS. Continuously monitored vital signs for detection of myocardial injury in high-risk patients - An observational study. Acta Anaesthesiol Scand 2022; 66:674-683. [PMID: 35247272 PMCID: PMC9314636 DOI: 10.1111/aas.14056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 12/21/2022]
Abstract
Background Patients are at risk of myocardial injury after major non‐cardiac surgery and during acute illness. Myocardial injury is associated with mortality, but often asymptomatic and currently detected through intermittent cardiac biomarker screening. This delays diagnosis, where vital signs deviations may serve as a proxy for early signs of myocardial injury. This study aimed to assess the association between continuous monitored vital sign deviations and subsequent myocardial injury following major abdominal cancer surgery and during acute exacerbation of chronic obstructive pulmonary disease. Methods Patients undergoing major abdominal cancer surgery or admitted with acute exacerbation of chronic obstructive pulmonary disease had daily troponin measurements. Continuous wireless monitoring of several vital signs was performed for up to 96 h after admission or surgery. The primary exposure was cumulative duration of peripheral oxygen saturation (SpO2) below 85% in the 24 h before the primary outcome of myocardial injury, defined as a new onset ischaemic troponin elevation assessed daily. If no myocardial injury occurred, the primary exposure was based on the first 24 h of measurement. Results A total of 662 patients were continuously monitored and 113 (17%) had a myocardial injury. Cumulative duration of SpO2 < 85% was significantly associated with myocardial injury (mean difference 14.2 min [95% confidence interval −4.7 to 33.1 min]; p = .005). Durations of hypoxaemia (SpO2 < 88% and SpO2 < 80%), tachycardia (HR > 110 bpm and HR > 130 bpm) and tachypnoea (RR > 24 min−1 and RR > 30 min−1) were also significantly associated with myocardial injury (p < .04, for all). Conclusion Duration of severely low SpO2 detected by continuous wireless monitoring is significantly associated with myocardial injury in high‐risk patients admitted to hospital wards. The effect of early detection and interventions should be assessed next.
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Affiliation(s)
- Frederik C. Loft
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Søren M. Rasmussen
- Digital Health Section Department of Health Technology Technical University of Denmark Kongens Lyngby Denmark
| | - Mikkel Elvekjaer
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Camilla Haahr‐Raunkjaer
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Helge B. D. Sørensen
- Digital Health Section Department of Health Technology Technical University of Denmark Kongens Lyngby Denmark
| | - Eske K. Aasvang
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Christian S. Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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Voldby AW, Aaen AA, Loprete R, Eskandarani HA, Boolsen AW, Jønck S, Ekeloef S, Burcharth J, Thygesen LC, Møller AM, Brandstrup B. Perioperative fluid administration and complications in emergency gastrointestinal surgery-an observational study. Perioper Med (Lond) 2022; 11:9. [PMID: 35189974 PMCID: PMC8862386 DOI: 10.1186/s13741-021-00235-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/11/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The fluid balance associated with a better outcome following emergency surgery is unknown. The aim of this study was to explore the association of the perioperative fluid balance and postoperative complications during emergency gastrointestinal surgery. METHODS We retrospectively included patients undergoing emergency surgery for gastrointestinal obstruction or perforation. A perioperative fluid balance of 2.5 L divided the cohort in a conservative and liberal group. Outcome was Clavien-Dindo graded complications registered 90 days postoperatively. We used logistic regression adjusted for age, sex, American Society of Anesthesiologists' classification, use of epidural analgesia, use of vasopressor, type of surgery, intraabdominal pathology, and hospital. Predicted risk of complications was demonstrated on a continuous scale of the fluid balance. RESULTS We included 342 patients operated between July 2014 and July 2015 from three centers. The perioperative fluid balance was 1.6 L IQR [1.0 to 2.0] in the conservative vs. 3.6 L IQR [3.0 to 5.3] in the liberal group. Odds ratio of overall 2.6 (95% CI 1.5 to 4.4), p < 0.001, and cardiopulmonary complications 3.2 (95% CI 1.9 to 5.7), p < 0.001, were increased in the liberal group. A perioperative fluid balance of 0-2 L was associated with minimal risk of cardiopulmonary complications compared to 1.5-3.5 L for renal complications. CONCLUSION We found a perioperative fluid balance above 2.5 L to be associated with an increased risk of overall and cardiopulmonary complications following emergency surgery for gastrointestinal obstruction or perforation. A perioperative fluid balance of 0-2 L was associated with the lowest risk of cardiopulmonary complications and 1.5-3.5 L for renal complications.
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Affiliation(s)
- Anders W Voldby
- Department of Surgery, Holbæk Hospital, part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
| | - Anne A Aaen
- Department of Anesthesiology and Intensive Care Medicine, Holbæk Hospital, Holbæk, Denmark
| | | | - Hassan A Eskandarani
- Department of Anesthesiology and Intensive Care Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Anders W Boolsen
- Department of Surgery, Holbæk Hospital, part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
| | - Simon Jønck
- Department of Emergency Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Sarah Ekeloef
- Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Jakob Burcharth
- Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Lau C Thygesen
- Department of Population Health and Morbidity, University of Southern Denmark, Odense, Denmark
| | - Ann M Møller
- Department of Anesthesiology and Intensive Care Medicine, Herlev Hospital, Herlev, Denmark.,Institute for Clinical Medicins, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Brandstrup
- Department of Surgery, Holbæk Hospital, part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark. .,Institute for Clinical Medicins, University of Copenhagen, Copenhagen, Denmark.
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Guilherme E, Delignette MC, Pambet H, Lebreton T, Bonnet A, Pradat P, Boucheny C, Guichon C, Aubrun F, Gazon M. PCO 2 gap, its ratio to arteriovenous oxygen content, ScvO2 and lactate in high-risk abdominal surgery patients: An observational study. Anaesth Crit Care Pain Med 2022; 41:101033. [PMID: 35176527 DOI: 10.1016/j.accpm.2022.101033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/28/2021] [Accepted: 11/16/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The difference between arterial and central venous carbon dioxide partial pressure (PCO2 gap), a marker of oxygen delivery (DO2) and oxygen consumption (VO2) adequacy, has been evaluated as a promising prognostic tool in intensive care unit (ICU) patients. We therefore sought to study the association between intraoperative PCO2 gap and postoperative complications (POC) in the perioperative setting of elective major abdominal surgery. METHODS We conducted a single-centre prospective observational study. All adult patients who underwent major planned abdominal surgery were eligible. PCO2 gap was measured every 2 hours during surgery, at ICU admission and repeated 12 hours and 24 hours later. Severe POC within 28 days after surgery were defined as complications graded 3 or more according to Clavien-Dindo classification. Following a univariate analysis, a multivariable analysis using a logistic regression model was performed. RESULTS Ninety patients were included and divided into two groups according to the occurrence of POC. No significant difference was found between groups regarding baseline characteristics at inclusion. Thirty-nine (43%) patients developed postoperative complications. The median [IQR] intraoperative PCO2 gap was significantly higher in patients who had complications (6.5 [5.5-7.3] mmHg) compared to those who did not (5.0 [3.9-5.8] mmHg; p < 0.001). The area under the receiver operating characteristic curve for occurrence of POC was 0.78 for the PCO2 gap. After multivariable analysis, PCO2 gap was found independently associated with POC (OR: 14.9, 95% CI [4.68-60.1], p < 0.001) with a threshold value of 6.2 mmHg. The duration of surgery (OR: 1.01, 95% CI [1.00; 1.01], p = 0.04) and the need for vasoactive support during surgery (OR: 5.76, 95% CI [1.72; 24.1], p = 0.006) were also independently associated with POC. CONCLUSION Intraoperative PCO2 gap is a relevant predictive factor of severe postoperative complications in high-risk elective surgery patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT03914976.
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Affiliation(s)
- Enrique Guilherme
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France.
| | - Marie-Charlotte Delignette
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Hadrien Pambet
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Thibault Lebreton
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Aurélie Bonnet
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Pierre Pradat
- Clinical Research Center, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Camille Boucheny
- Clinical Research Center, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Céline Guichon
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Fréderic Aubrun
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; Research on Healthcare Performance (RESHAPE), U1290 - INSERM & Claude Bernard University Lyon 1, France
| | - Mathieu Gazon
- Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
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Lizano-Díez I, Poteet S, Burniol-Garcia A, Cerezales M. The burden of perioperative hypertension/hypotension: A systematic review. PLoS One 2022; 17:e0263737. [PMID: 35139104 PMCID: PMC8827488 DOI: 10.1371/journal.pone.0263737] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/25/2022] [Indexed: 11/30/2022] Open
Abstract
Study objective Our goal is to review the outcomes of acute hypertensive/hypotensive episodes from articles published in the past 10 years that assessed the short- and long-term impact of acute hypertensive/hypotensive episodes in the perioperative setting. Methods We conducted a systematic peer review based upon PROSPERO and Cochrane Handbook protocols. The following study characteristics were collected: study type, author, year, population, sample size, their definition of acute hypertension, hypotension or other measures, and outcomes (probabilities, odds ratio, hazard ratio, and relative risk) and the p-values; and they were classified according to the type of surgery (cardiac and non-cardiac). Results A total of 3,680 articles were identified, and 66 articles fulfilled the criteria for data extraction. For the perioperative setting, the number of articles varies by outcome: 20 mortality, 16 renal outcomes, 6 stroke, 7 delirium and 34 other outcomes. Hypotension was reported to be associated with mortality (OR 1.02–20.826) as well as changes from the patient’s baseline blood pressure (BP) (OR 1.02–1.36); hypotension also had a role in the development of acute kidney injury (AKI) (OR 1.03–14.11). Postsurgical delirium was found in relation with BP lability (OR 1.018–1.038) and intra- and postsurgical hypotension (OR 1.05–1.22), and hypertension (OR 1.44–2.34). Increased OR (37.67) of intracranial hemorrhage was associated to postsurgical systolic BP >130 mmHg. There was a wide range of additional diverse outcomes related to hypo-, hypertension and BP lability. Conclusions The perioperative management of BP influences short- and long-term effects of surgical procedures in cardiac and non-cardiac interventions; these findings support the burden of BP fluctuations in this setting.
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