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Dong L, Sun T, Yang J, Zhou Y, Liu X, Liu Z, Lv H, Ma Z, Chen Y. Remimazolam has similar anesthetic effect and superior safety compared to propofol in elderly patients: A meta-analysis of randomized controlled trials. World J Surg 2024. [PMID: 38955808 DOI: 10.1002/wjs.12273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/16/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND The superiority between remimazolam and propofol for anesthesia is controversial in elderly patients (≥60 years). This meta-analysis aimed to systematically compare anesthetic effect and safety profile between remimazolam and propofol in elderly patients under any surgery. METHODS Cochrane Library, Web of Science, and PubMed were searched until December 25, 2023 for relevant randomized controlled trials. RESULTS Ten studies with 806 patients receiving remimazolam (experimental group) and 813 patients receiving propofol (control group) were included. Time to loss of consciousness [standard mean difference (SMD) (95% confidence interval (CI): 1.347 (-0.362, 3.055), p = 0.122] and recovery time [SMD (95% CI): -0.022 (-0.300, 0.257), p = 0.879] were similar between experimental and control groups. Mean arterial pressure at baseline minus 1 min after induction [SMD (95% CI): -1.800 (-3.250, -0.349), p = 0.015], heart rate at baseline minus 1 min after induction [SMD (95% CI): -1.041 (-1.537, -0.545), p < 0.001], incidences of hypoxemia [relative risk (RR) (95% CI): 0.247 (0.138, 0.444), p < 0.001], respiratory depression [RR (95% CI): 0.458 (0.300, 0.700), p < 0.001], bradycardia [RR (95% CI): 0.409 (0.176, 0.954), p = 0.043], hypotension [RR (95% CI): 0.415 (0.241, 0.714), p = 0.007], and injection pain [RR (95% CI): 0.172 (0.113, 0.263), p < 0.001] were lower in the experimental group compared to the control group. Postoperative nausea and vomiting was not different between groups [RR (95% CI): 1.194 (0.829, 1.718), p = 0.341]. Moreover, this meta-analysis displayed a low risk of bias, minimal publication bias, and good robustness. CONCLUSION Remimazolam shows comparative anesthetic effect and better safety profile than propofol in elderly patients under any surgery.
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Affiliation(s)
- Liyun Dong
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Tianze Sun
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Jiecheng Yang
- Child Care, Merice Cody Public School, Toronto, Ontario, Canada
| | - Yue Zhou
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Xinyan Liu
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Zhijie Liu
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Hangyu Lv
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Zhen Ma
- Department of Anaesthesia, Handan Central Hospital, Handan, China
| | - Yongxue Chen
- Department of Anaesthesia, Handan Central Hospital, Handan, China
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An SM, Lee HJ, Woo JH, Chae JS, Shin SJ. Predictive Value of Ultrasound-Measured Quadriceps Depth and Frailty Status for Hypotension in Older Patients Undergoing Reverse Total Shoulder Arthroplasty in the Beach Chair Position under General Anesthesia. J Pers Med 2024; 14:642. [PMID: 38929863 PMCID: PMC11204871 DOI: 10.3390/jpm14060642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
The beach chair position (BCP) is widely used in shoulder surgery; however, it frequently leads to hypotension. Hypotension in BCP is prevalent among older patients who are at risk of secondary complications such as ischemic injuries. Therefore, this prospective study aimed to investigate the association and predictive value of frailty, as assessed by ultrasound-measured quadriceps depth and questionnaire, in patients aged ≥65 years undergoing elective shoulder surgery under general anesthesia. A multivariable logistic regression analysis was performed to identify independent risk factors for hypotension in BCP under general anesthesia. Receiver operating characteristic curves were constructed to assess the predictive values of various parameters. The results indicated that a quadriceps depth < 2.3 cm and BCP for an extended period significantly increased the risk of hypotension. The combined consideration of quadriceps depth < 2.3 cm and frailty demonstrated markedly superior predictive power compared with each factor individually. In conclusion, the study findings facilitate the screening and identification of risk factors for older patients undergoing surgery in BCP, thereby enhancing perioperative management.
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Affiliation(s)
- Sang-Mee An
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea
| | - Hyun Jung Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea
| | - Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea
| | - Ji Seon Chae
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea
| | - Sang-jin Shin
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea
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Koterazawa S, Takahashi T, Somiya S, Ito K, Haitani T, Kanno T, Higashi Y, Yamada H, Imamura M. Ureteroscopy for urolithiasis in bedridden patients: it is feasible and acceptable. World J Urol 2024; 42:272. [PMID: 38683217 DOI: 10.1007/s00345-024-04895-5] [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: 08/29/2023] [Accepted: 02/21/2024] [Indexed: 05/01/2024] Open
Abstract
PURPOSE To investigate the safety of transurethral ureteroscopy (URS) for urolithiasis in bedridden patients and to identify bedridden patient-specific risk factors for postoperative complications. METHODS The patients who underwent URS for urolithiasis were divided into bedridden patients and good performance status (PS) patients, and the groups were compared regarding their clinical characteristics and postoperative complications. A multivariable logistic regression analysis was performed to evaluate independent predictors of postoperative febrile urinary tract infection (fUTI). RESULTS A total of 1626 patients were included, 276 in the bedridden patient group, and 1350 in the good PS patient group. The bedridden patient group had a significantly higher age and higher proportion of females and had multiple comorbidities. In 77 patients (27.9%), 88 postoperative complications developed for the bedridden patient group. Clavien-Dindo grade III or IV complications were observed in only 8 patients. No grade V complications were observed. The most common complication was fUTI. The frequency of fUTI with grade III or IV for the bedridden patient group (2.2%) was higher compared with the good PS patient group (0.5%), but the difference was not statistically significant (p = 0.13). Bedridden patient-specific risk factors for fUTI included female sex, diabetes mellitus, cerebrovascular comorbidities, lower extremity contracture, and prolonged operative time. CONCLUSION URS for urolithiasis is a feasible and acceptable procedure in bedridden patients, despite the moderate rate of postoperative complications. The identified risk factors provide a framework for risk stratification and individualized care in this unique patient population.
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Affiliation(s)
- Shigeki Koterazawa
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Toshifumi Takahashi
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Shinya Somiya
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Katsuhiro Ito
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Takao Haitani
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Toru Kanno
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Yoshihito Higashi
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Hitoshi Yamada
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Masaaki Imamura
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan.
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Zhang H, Qiu S, Chen F, Wang X. Combined Serum Albumin and Left Ventricular Ejection Fraction Predict All-Cause Death in Patients with Stable Coronary Artery Disease. Cardiol Res Pract 2024; 2024:9969628. [PMID: 38584962 PMCID: PMC10999290 DOI: 10.1155/2024/9969628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/06/2023] [Accepted: 03/20/2024] [Indexed: 04/09/2024] Open
Abstract
Objective To explore the feasibility of serum albumin (Alb) and left ventricular ejection fraction (LVEF) in predicting all-cause death (ACD) in patients with stable coronary artery disease (SCAD). Methods Patients with SCAD were divided into 4 groups according to their Alb and LVEF levels: Group A: Alb ≤4 g/dL and LVEF > 50%; Group B: Alb ≤4 g/dL and LVEF ≤50%; Group C: Alb >4 g/dL and LVEF ≤50%; Group D: Alb >4 g/dL and LVEF >50%. The K-M curve and log-rank test were used to compare ACD among the four groups over three years. Receiver operating characteristic (ROC) curves were used to compare the efficacy of predicting ACD among the combination of Alb and LVEF and either Alb or LVEF alone. Cox regression analysis identified the influencing factors of ACD in patients with SCAD and detected the correlation between Alb and LVEF. Results ACD occurred in 18 (8.9%) of 203 patients with SCAD, with an average follow-up of 26.53 ± 14.34 months. In the Kaplan‒Meier analysis, the risk of ACD in the four groups ranged from high to low: Group B (17.6%) > Group A (26.7%) > Group D (0.9%) > Group C (0%, P < 0.001). The ROC curve showed that the combination of Alb and LVEF (AUC = 0.888) had better predictive value for ACD than either Alb (AUC = 0.879) or LVEF alone (AUC = 0.651), P < 0.001. Multivariate Cox regression analysis showed that Alb ≤4 g/dL predicted ACD events after adjusting for baseline (HR: 12.16, 95% CI: 1.57 to 94.41; P=0.017) and treatment (HR: 19.36, 95% CI: 2.53-147.78, P=0.004). Alb was positively correlated with LVEF (r = 0.22, P=0.002). Conclusions Alb combined with LVEF is more effective than a single index in predicting ACD in SCAD and could be used as a new model to judge the prognosis of SCAD.
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Affiliation(s)
- Hua Zhang
- Department of Medical Ultrasound, The Second Affiliated Hospital of Guangzhou Medical University, No. 250, Changgang East Road, Haizhu District, Guangzhou, Guangdong, China
| | - Shaodong Qiu
- Department of Medical Ultrasound, The Second Affiliated Hospital of Guangzhou Medical University, No. 250, Changgang East Road, Haizhu District, Guangzhou, Guangdong, China
| | - Fei Chen
- Department of Medical Ultrasound, The Second Affiliated Hospital of Guangzhou Medical University, No. 250, Changgang East Road, Haizhu District, Guangzhou, Guangdong, China
| | - Xiaojun Wang
- Department of Medical Ultrasound, The Second Affiliated Hospital of Guangzhou Medical University, No. 250, Changgang East Road, Haizhu District, Guangzhou, Guangdong, China
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Ranjeva S, Nagebretsky A, Odozynski G, Fernandez-Bustamante A, Frendl G, Gupta RA, Sprung J, Subramaniam B, Ruiz RM, Bartels K, Giquel J, Lee JW, Houle T, Melo MFV. Effects of Intra-operative Cardiopulmonary Variability On Post-operative Pulmonary Complications in Major Non-cardiac Surgery: A Retrospective Cohort Study. J Med Syst 2024; 48:31. [PMID: 38488884 DOI: 10.1007/s10916-024-02050-6] [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: 10/06/2023] [Accepted: 02/27/2024] [Indexed: 03/17/2024]
Abstract
Intraoperative cardiopulmonary variables are well-known predictors of postoperative pulmonary complications (PPC), traditionally quantified by median values over the duration of surgery. However, it is unknown whether cardiopulmonary instability, or wider intra-operative variability of the same metrics, is distinctly associated with PPC risk and severity. We leveraged a retrospective cohort of adults (n = 1202) undergoing major non-cardiothoracic surgery. We used multivariable logistic regression to evaluate the association of two outcomes (1)moderate-or-severe PPC and (2)any PPC with two sets of exposure variables- (a)variability of cardiopulmonary metrics (inter-quartile range, IQR) and (b)median intraoperative cardiopulmonary metrics. We compared predictive ability (receiver operating curve analysis, ROC) and parsimony (information criteria) of three models evaluating different aspects of the intra-operative cardiopulmonary metrics: Median-based: Median cardiopulmonary metrics alone, Variability-based: IQR of cardiopulmonary metrics alone, and Combined: Medians and IQR. Models controlled for peri-operative/surgical factors, demographics, and comorbidities. PPC occurred in 400(33%) of patients, and 91(8%) experienced moderate-or-severe PPC. Variability in multiple intra-operative cardiopulmonary metrics was independently associated with risk of moderate-or-severe, but not any, PPC. For moderate-or-severe PPC, the best-fit predictive model was the Variability-based model by both information criteria and ROC analysis (area under the curve, AUCVariability-based = 0.74 vs AUCMedian-based = 0.65, p = 0.0015; AUCVariability-based = 0.74 vs AUCCombined = 0.68, p = 0.012). For any PPC, the Median-based model yielded the best fit by information criteria. Predictive accuracy was marginally but not significantly higher for the Combined model (AUCCombined = 0.661) than for the Median-based (AUCMedian-based = 0.657, p = 0.60) or Variability-based (AUCVariability-based = 0.649, p = 0.29) models. Variability of cardiopulmonary metrics, distinct from median intra-operative values, is an important predictor of moderate-or-severe PPC.
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Affiliation(s)
- Sylvia Ranjeva
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA.
| | - Alexander Nagebretsky
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | | | | | - Gyorgy Frendl
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - R Alok Gupta
- Department of Anesthesiology, Northwestern Medicine, Chicago, USA
| | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic, Rochester, USA
| | - Bala Subramaniam
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, USA
| | | | - Karsten Bartels
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, USA
| | - Jadelis Giquel
- Department of Anesthesiology, University of Miami Hospital and Clinics, Miami, USA
| | - Jae-Woo Lee
- Department of Anesthesiology, University of California San Francisco, San Francisco, USA
| | - Timothy Houle
- Department of Anesthesiology, Anesthesia Research Center, Massachusetts General Hospital, Boston, USA
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Hirai S, Ida M, Kinugasa Y, Kawaguchi M. Association between preoperative frailty and surgical Apgar score in abdominal cancer surgery: a secondary analysis of a prospective observational study. JA Clin Rep 2024; 10:2. [PMID: 38217669 PMCID: PMC10787715 DOI: 10.1186/s40981-024-00687-3] [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: 12/20/2023] [Revised: 01/03/2024] [Accepted: 01/06/2024] [Indexed: 01/15/2024] Open
Abstract
INTRODUCTION The surgical Apgar score is useful for predicting postoperative morbidity and mortality. However, its applicability in frail patients with minimal hemodynamic variation remains unknown. This study aimed to investigate the association between frailty and surgical Apgar score. METHODS This secondary analysis included 210 patients ≥ 65 years of age undergoing elective major abdominal surgery for cancer. Frailty was assessed using the Fried Frailty Phenotype Questionnaire and defined as a total score of ≥ 3. The surgical Apgar score (range, 0-10; including mean blood pressure, heart rate, and blood loss volume) was compared between patients with or without frailty using the Mann-Whitney U test. Postoperative severe complications and length of postoperative stay were compared between patients with surgical Apgar scores ≤ 7 and > 7. RESULTS Among the included patients, 45 were classified as frail. The median [1st quartile, 3rd quartile] surgical Apgar scores in patients with and without frailty were 7.0 [7.0, 8.0] and 8.0 [7.0, 8.0], respectively (P = 0.03). Patients with surgical Apgar score ≤7 had a higher incidence of serious postoperative complications (P = 0.03) and longer hospital stays (P < 0.001) compared with patients with surgical Apgar score >7. CONCLUSION Frail patients have lower SAS, and patients with lower SAS have higher postoperative complication rates and longer hospital stays in patients who underwent cancer surgery.
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Affiliation(s)
- Sayaka Hirai
- Department of Anaesthesiology, Nara Medical University, Kashihara, Japan
| | - Mitsuru Ida
- Department of Anaesthesiology, Nara Medical University, Kashihara, Japan.
| | - Yuki Kinugasa
- Department of Medical Technical Center, Nara Medical University Hospital, Kashihara, Japan
| | - Masahiko Kawaguchi
- Department of Anaesthesiology, Nara Medical University, Kashihara, Japan
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Lai YH, Latmore M, Joo SS, Hong J. Regional anesthesia for the geriatric patient: a narrative review and update on hip fracture repair. Int Anesthesiol Clin 2024; 62:79-85. [PMID: 37955145 DOI: 10.1097/aia.0000000000000422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Affiliation(s)
- Yan H Lai
- Department of Anesthesiology, Pain, and Perioperative Medicine, Mount Sinai West and Morningside Hospitals, Icahn School of Medicine, New York, NY
| | - Malikah Latmore
- Department of Anesthesiology, Pain, and Perioperative Medicine, Mount Sinai West and Morningside Hospitals, Icahn School of Medicine, New York, NY
| | - Sarah S Joo
- Department of Anesthesiology, Pain, and Perioperative Medicine, Mount Sinai West and Morningside Hospitals, Icahn School of Medicine, New York, NY
| | - Janet Hong
- Department of Anesthesiology, Pain, and Perioperative Medicine, Mount Sinai West and Morningside Hospitals, Icahn School of Medicine, New York, NY
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She KY, Huang L, Zhang HT, Gao Y, Yao KR, Luo Q, Tang X, Li L, Zhao L, Wang ZH, Yang XJ, Yin XH. Effect of prehabilitation on postoperative outcomes in the frail older people: A systematic review and meta-analysis. Geriatr Nurs 2024; 55:79-88. [PMID: 37976559 DOI: 10.1016/j.gerinurse.2023.10.027] [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: 08/25/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE The study investigates the impact of preoperative rehabilitation on the surgical prognosis of frail older patients. METHOD The effect sizes of all studies retrieved and included by the nine databases were analyzed and expressed as RR and WMD. RESULTS 8 studies with 902 participants met the criteria for inclusion. A significant reduction in total complications (RR = 0.84, 95 % CI = 0.73 to 0.97, P = 0.021) and the 6MWT after surgery (WMD = 74.76, 95 % CI = 44.75 to 104.77, P = 0.000) was observed in the prehabilitation group. But it had no differences in mortality(RR = 1.89, 95 % CI = 0.75 to 4.72, P = 0.176), readmission rates(RR = 1.04, 95 % CI = 0.56 to 1.91, P = 0.906) and LOS(WMD = -0.24, 95 % CI = -1.00 to 0.52, P = 0.540). CONCLUSIONS Prehabilitation had positive effect on postoperative complications and functional recovery in frail older patients.
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Affiliation(s)
- Ke-Yi She
- School of Nursing, University of South China, Hengyang, Hunan, China
| | - Li Huang
- The Second Hospital, University of South China, Hengyang, Hunan, China
| | - Hong-Tao Zhang
- School of Nursing, University of South China, Hengyang, Hunan, China
| | - Yue Gao
- School of Nursing, University of South China, Hengyang, Hunan, China
| | - Ke-Ru Yao
- School of Nursing, University of South China, Hengyang, Hunan, China
| | - Qin Luo
- School of Nursing, University of South China, Hengyang, Hunan, China
| | - Xi Tang
- School of Nursing, University of South China, Hengyang, Hunan, China
| | - Lu Li
- School of Nursing, University of South China, Hengyang, Hunan, China
| | - Lu Zhao
- School of Nursing, University of South China, Hengyang, Hunan, China
| | - Zhi-Han Wang
- School of Nursing, University of South China, Hengyang, Hunan, China
| | - Xin-Jun Yang
- School of Nursing, University of South China, Hengyang, Hunan, China
| | - Xin-Hong Yin
- School of Nursing, University of South China, Hengyang, Hunan, China.
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Dammavalam V, Murphy J, Johnkutty M, Elias M, Corn R, Bergese S. Perioperative cognition in association with malnutrition and frailty: a narrative review. Front Neurosci 2023; 17:1275201. [PMID: 38027517 PMCID: PMC10651720 DOI: 10.3389/fnins.2023.1275201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Postoperative delirium (POD) is a prevalent clinical entity characterized by reversible fluctuating altered mental status and cognitive impairment with acute and rapid onset a few days after major surgery. Postoperative cognitive decline (POCD) is a more permanent extension of POD characterized by prolonged global cognitive impairment for several months to years after surgery and anesthesia. Both syndromes have been shown to increase morbidity and mortality in postoperative patients making their multiple risk factors targets for optimization. In particular, nutrition imparts a significant and potentially reversible risk factor. Malnutrition and frailty have been linked as risk factors and predictive indicators for POD and less so for POCD. This review aims to outline the association between nutrition and perioperative cognitive outcomes as well as potential interventions such as prehabilitation.
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Affiliation(s)
- Vikalpa Dammavalam
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY, United States
| | - Jasper Murphy
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Meenu Johnkutty
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Murad Elias
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY, United States
| | - Ryan Corn
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY, United States
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY, United States
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Ajoku U, Johnson MG, McIntosh G, Thomas K, Bailey CS, Hall H, Fisher CG, Manson N, Rampersaud YR, Dea N, Christie S, Abraham E, Weber MH, Charest-Morin R, Attabib N, le Roux A, Phan P, Paquet J, Lewkonia P, Goytan M. Temporal analysis of complication rates of cervical spine surgery for degenerative spine disease between younger and older cohorts using the CSORN registry: Is age just a number? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3583-3590. [PMID: 37596474 DOI: 10.1007/s00586-023-07882-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/14/2023] [Accepted: 07/31/2023] [Indexed: 08/20/2023]
Abstract
STUDY DESIGN An ambispective review of consecutive cervical spine surgery patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) between January 2015 and September 2019. PURPOSE To compare complication rates of degenerative cervical spine surgery over time between older (> 65) and younger age groups (< 65). More elderly people are having spinal surgery. Few studies have examined the temporal nature of complications of cervical spine surgery by patient age groups. METHODS Adverse events were collected prospectively using adverse event forms. Binary logistic regression analysis was utilized to assess associations between risk modifiers and adverse events at the intra-, peri-operative and 3 months post-surgery. RESULTS Of the 761 patients studied (age < 65, n = 581 (76.3%) and 65 + n = 180 (23.7%), the intra-op adverse events were not significantly different; < 65 = 19 (3.3%) vs 65 + = 11 (6.1%), p < 0.087. Peri-operatively, the < 65 group had significantly lower percentage of adverse events (65yrs (11.2%) vs. 65 + = (26.1%), p < 0.001). There were no differences in rates of adverse events at 3 months post-surgery (< 65 = 39 (6.7%) vs. 65 + = 12 (6.7%), p < 0.983). Less blood loss (OR = 0.99, p < 0.010) and shorter length of hospital stay (OR = 0.97, p < 0.025) were associated with not having intra-op adverse events. Peri-operatively, > 1 operated level (OR = 1.77, p < 0.041), shorter length of hospital stay (OR = 0.86, p < 0.001) and being younger than 65 years (OR = 2.11, p < 0.006) were associated with not having adverse events. CONCLUSION Following degenerative cervical spine surgery, the older and younger age groups had significantly different complication rates at peri-operative time points, and the intra-operative and 3-month post-operative complication rates were similar in the groups.
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Affiliation(s)
- Uchenna Ajoku
- Winnipeg Spine Program, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Michael G Johnson
- Winnipeg Spine Program, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Greg McIntosh
- Canadian Spine Outcome Research Network, 10 Armstrong Crescent, PO Box 1053, Markdale, ON, N0C 1H0, Canada.
| | - Ken Thomas
- University of Calgary, Calgary, AB, Canada
| | - Christopher S Bailey
- London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, London, ON, Canada
| | - Hamilton Hall
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Charles G Fisher
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Neil Manson
- Canada East Spine Centre, Saint John Orthopedics, Dalhousie Medicine New Brunswick, Saint John Campus, Saint John, NB, Canada
| | - Y Raja Rampersaud
- Divisions of Orthopaedic and Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Nicolas Dea
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Sean Christie
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Edward Abraham
- Canada East Spine Centre, Saint John Orthopedics, Dalhousie Medicine New Brunswick, Saint John Campus, Saint John, NB, Canada
| | | | - Raphaele Charest-Morin
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Najmedden Attabib
- Canada East Spine Centre, Division of Neurosurgery, Zone 2, Horizon Health Network, Saint John, NB, Canada
| | - André le Roux
- Canada East Spine Centre, Division of Neurosurgery, Zone 2, Horizon Health Network, Saint John, NB, Canada
| | | | - Jerome Paquet
- Centre de Recherche CHU de Quebec, CHU de Quebec-Universite Laval, Quebec City, QC, Canada
| | | | - Michael Goytan
- Winnipeg Spine Program, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
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11
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Jin Z, Rismany J, Gidicsin C, Bergese SD. Frailty: the perioperative and anesthesia challenges of an emerging pandemic. J Anesth 2023; 37:624-640. [PMID: 37311899 PMCID: PMC10263381 DOI: 10.1007/s00540-023-03206-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 05/22/2023] [Indexed: 06/15/2023]
Abstract
Frailty is a complex and multisystem biological process characterized by reductions in physiological reserve. It is an increasingly common phenomena in the surgical population, and significantly impacts postoperative recovery. In this review, we will discuss the pathophysiology of frailty, as well as preoperative, intraoperative, and postoperative considerations for frailty care. We will also discuss the different models of postoperative care, including enhanced recovery pathways, as well as elective critical care admission. With discoveries of new effective interventions, and advances in healthcare information technology, optimized pathways could be developed to provide the best care possible that meets the challenges of perioperative frailty.
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Affiliation(s)
- Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA
| | - Joshua Rismany
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA
| | - Christopher Gidicsin
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA.
- Department of Neurosurgery, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA.
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12
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Chao CT, Hung KY. Vascular frailty, a proposal for new frailty type: A narrative review. Kaohsiung J Med Sci 2023; 39:318-325. [PMID: 36866657 DOI: 10.1002/kjm2.12664] [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: 01/31/2023] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 03/04/2023] Open
Abstract
Frailty is the incremental accumulation of minute defects that progressively impair health and performance. Frailty is commonly observed in older adults; however, secondary frailty may also occur in patients with metabolic disorders or major organ failure. In addition to physical frailty, several distinct types of frailty have been identified, including oral, cognitive, and social frailty, each of which is of practical importance. This nomenclature suggests that detailed descriptions of frailty can potentially advance relevant researches. In this narrative review, we first summarize the clinical value and plausible biological origin of frailty, as well as how to appropriately assess it using physical frailty phenotypes and frailty indexes. In the second part, we discuss the issue of vascular tissue as a relatively underappreciated organ whose pathologies contribute to the development of physical frailty. Moreover, when vascular tissue undergoes degeneration, it exhibits vulnerability to subtle injuries and manifests a unique phenotype amenable to clinical assessment prior to or accompanying physical frailty development. Finally, we propose that vascular frailty, based on an extensive set of experimental and clinical evidence, can be considered a new frailty type that requires our attention. We also outline potential methods for the operationalization of vascular frailty. Further studies are required to validate our claim and sharpen the spectrum of this degenerative phenotype.
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Affiliation(s)
- Chia-Ter Chao
- Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital BeiHu Branch, Taipei, Taiwan.,Nephrology Division, Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuan-Yu Hung
- Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Nephrology Division, Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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13
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Gu Y, Wan Y, Ren JH, Zhao Y, Wang Y, Shen JH. Analysis of systolic and diastolic blood pressure variability in frail, pre-frail, and non-frail elderly patients: The relationship between frailty syndrome and blood pressure variability in the elderly. Medicine (Baltimore) 2023; 102:e32874. [PMID: 36827031 DOI: 10.1097/md.0000000000032874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Frailty can change the prognosis and treatment approach of chronic diseases. We, therefore, conducted this study to explore the relationship between frailty syndrome and blood pressure variability in the elderly. The clinical data of 150 elderly patients with debilitating syndrome admitted to the neurology department of our hospital from May 2021 to May 2022 were selected, and they were grouped according to Fried debilitation scale and divided into 50 cases each in the debilitation group, pre-debilitation group, and no-debilitation group. The general data, co-morbidities, medications, and biochemical indexes were collected. The 24-hour ambulatory blood pressure monitoring was performed in each group, and the mean systolic blood pressure, diastolic blood pressure, nocturnal systolic load value, and diastolic load value were analyzed to determine the relationship between blood pressure variability and senile frailty. Serum albumin (ALB) and high-density lipoprotein were significantly lower in the debilitated and pre-debilitated groups than in the non-debilitated group (P < .05). Multivariate logistic regression analysis revealed that age (odds ratio [OR]: 3.910, 95% confidence intervals [CI]: 2.021-5.402) was a risk factor for frailty in the elderly, and serum ALB (OR: 0.656, 95% CI: 0.110-0.960) and HDL (OR: 0.581, 95% CI: 0.237-0.944) were protective factors for frailty in the elderly. Age, type of medication taken, co-morbidities, serum ALB, and HDL are influencing factors of debilitating syndrome. Serum ALB and HDL are protective factors against debilitating syndrome in the elderly. Age is an independent risk factor of debilitation in the elderly and increased fluctuation of blood pressure in the elderly can increase their risk of developing debilitating syndrome.
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Affiliation(s)
- Yan Gu
- Department of Geriatrics, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, China
| | - Ying Wan
- Department of Geriatrics, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, China
| | - Jue-Hui Ren
- Department of Geriatrics, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, China
| | - Yi Zhao
- Department of Geriatrics, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, China
| | - Yan Wang
- Department of Geriatrics, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, China
| | - Jun-Hua Shen
- Department of Emergency, The Affiliated Hospital 2 of Nantong University,, Nantong, Jiangsu, China
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14
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Batista AFR, Petty D, Fairhurst C, Davies S. Psoas muscle mass index as a predictor of long-term mortality and severity of complications after major intra-abdominal colorectal surgery – A retrospective analysis. J Clin Anesth 2023; 84:110995. [PMID: 36371943 DOI: 10.1016/j.jclinane.2022.110995] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/09/2022] [Accepted: 10/31/2022] [Indexed: 11/12/2022]
Abstract
STUDY OBJECTIVE Determine if psoas muscle area measured in routine preoperative computed tomography scans (CT) can be used to identify patients at increased risk of adverse postoperative outcomes after major elective abdominal surgery. DESIGN Retrospective analysis of data from a single-centre cohort study conducted in York Hospital between the 1st August of 2015 and the 31st of august of 2020. SETTING Preoperative clinic. PATIENTS 639 patients who attended the preoperative assessment clinic prior to major elective colorectal surgery and had an abdominal CT scan done up to 120 days before surgery. INTERVENTIONS None. MEASUREMENTS Psoas muscle area at the L3 level was measured in preoperative CT scans and normalised to patient height (psoas muscle index). The lowest sex-stratified tertile of psoas muscle index (PMI) was classed as sarcopenic. The primary outcome was 2-year mortality. Secondary outcomes included postoperative complications assessed using Clavien-Dindo graded major and minor complications, comprehensive complication index (CCI), and length of stay. MAIN RESULTS Multivariable regression analysis showed that sarcopenia was associated with 2-year mortality (aOR 1.79, 95% CI 1.03-3.10; p = 0.037) and survival at 2-years was significantly reduced in sarcopenic patients (log-rank test, p = 0.012). Sarcopenia was the only statistically significant predictor of major complications in multivariable logistic regression analysis (aOR 1.69, 95% CI 1.04-2.74, p = 0.034) and associated with an estimated increase of 16.6% in the comprehensive complication index (CCI) score of patients that had complications in multivariable linear regression analysis. Sarcopenia was not associated with length of stay. CONCLUSIONS Sarcopenia defined by psoas muscle mass is an independent predictor of 2-year mortality, major complications and severity of complications after major colorectal surgery and may be used for preoperative risk assessment.
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15
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Aykut A, Salman N. Poor nutritional status and frailty associated with acute kidney injury after cardiac surgery: A retrospective observational study. J Card Surg 2022; 37:4755-4761. [PMID: 36352787 DOI: 10.1111/jocs.17134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/07/2022] [Accepted: 10/21/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a major determinant of short- and long-term morbidity and mortality following cardiac surgery. The present study examines the effect of preoperative nutritional status and frailty on this significant adverse event. METHODS The data of 455 patients who underwent on-pump coronary artery bypass grafting (CABG) were analyzed retrospectively. Demographic data were recorded, and intraoperative and postoperative parameters, frailty score, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI) were calculated. Risk factors for AKI within 7 postoperative days were investigated in accordance with the kidney disease improving global outcomes classification. RESULTS Preoperative urea and creatinine values were significantly higher (p = .006 vs. p = .006), while hemoglobin, hematocrit, and estimated glomerular filtration rate values were significantly lower (p = .011, p = .008 vs. p = .006) in the AKI group than no AKI group. In the intraoperative period, the cardiopulmonary bypass time was longer in the AKI group (p = .031), and the need for dopamine, steradine, and red blood cells transfusion was greater (p = .026, p = .038 vs. p = .015) than no AKI group. The number of patients with a frailty score of 1-3 was significantly higher in the AKI group (p = .042). Similarly, the GNRI and PNI values, indicating nutritional status, were higher in the AKI group (p = .047 vs. p = .024). The independent risk factors for AKI were a GNRI of <91, the intraoperative need for dobutamine, preoperative serum creatinine of >1.3, and hemoglobin of <10 (p < .05). CONCLUSIONS Malnutrition and frailty are strongly associated with AKI after CABG. Clinicians can effectively predict the risk of AKI through an evaluation of frailty and nutritional scores, which can be easily calculated in the preoperative period.
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Affiliation(s)
- Aslıhan Aykut
- Department of Anesthesiology and Reanimation, Health Sciences University Ankara City Hospital, Ankara, Turkey
| | - Nevriye Salman
- Department of Anesthesiology and Reanimation, Health Sciences University Ankara City Hospital, Ankara, Turkey
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16
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Afonso AM, Sastow D, Cadwell JB, Downey RJ, Fischer GW, Shahrokni A. Intraoperative haemodynamics and postoperative intensive care unit admission in older patients with cancer. J Perioper Pract 2022; 32:301-309. [PMID: 34134558 PMCID: PMC11251495 DOI: 10.1177/17504589211012351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Research on the impact of various intraoperative haemodynamic variables on the incidence of postoperative ICU admission among older patients with cancer is limited. In this study, the relationship between intraoperative haemodynamic status and postoperative intensive care unit admission among older patients with cancer is explored. METHODS Patients aged ≥75 who underwent elective oncologic surgery lasting ≥120min were analysed. Chi-squared and t-tests were used to assess the associations between intraoperative variables with postoperative intensive care unit admission. Multivariable regressions were used to analyse potential predict risk factors for postoperative intensive care unit admission. RESULTS Out of 994 patients, 48 (4.8%) were admitted to the intensive care unit within 30 days following surgery. Intensive care unit admission was associated with the presence of ≥4 comorbid conditions, intraoperative blood loss ≥100mL, and intraoperative tachycardia and hypertensive urgency. On multivariable analysis, operation time ≥240min (Odds Ratio [OR] = 2.29, p = 0.01), and each minute spent with intraoperative hypertensive urgency (OR = 1.06, p = 0.01) or tachycardia (OR = 1.01, p = 0.002) were associated with postoperative intensive care unit admission. CONCLUSION Intraoperative hypertensive urgency and tachycardia were associated with postoperative intensive care unit admission in older patients undergoing cancer surgery.
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Affiliation(s)
- Anoushka M. Afonso
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dahniel Sastow
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joshua B. Cadwell
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J. Downey
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gregory W. Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Armin Shahrokni
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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17
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Messina A, La Via L, Milani A, Savi M, Calabrò L, Sanfilippo F, Negri K, Castellani G, Cammarota G, Robba C, Morenghi E, Astuto M, Cecconi M. Spinal anesthesia and hypotensive events in hip fracture surgical repair in elderly patients: a meta-analysis. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:19. [PMID: 37386657 DOI: 10.1186/s44158-022-00047-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/20/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND Spinal anesthesia (SA) is widely used for anesthetic management of patients undergoing hip surgery, and hypotension is the most common cardiovascular side effect of SA. This paper aims to assess the lowest effective dose of SA that reduces the occurrence of intraoperative hypotension in elderly patients scheduled for major lower limb orthopedic surgery. METHODS We conducted a systematic review of randomized controlled trials (RCTs) performed in elderly patients scheduled for surgical hip repair and a meta-analysis with meta-regression on the occurrence of hypotensive episodes at different effective doses of anesthetics. We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials registered. RESULTS Our search retrieved 2085 titles, and after screening, 6 were finally included in both the qualitative and quantitative analysis, including 344 patients [15% (10-28) males], with a median (25th to 75th interquartile) age of 82 (80-85). The risk of bias assessment reported "low risk" for 5 (83.3%) and "some concerns" for 1 (16.7%) of the included RCTs. The low dose of SA of [mean 6.5 mg (1.9)] anesthetic was associated with a lower incidence of hypotension [OR = 0.09 (95%CI 0.04-0.21); p = 0.04; I2 = 56.9%], as compared to the high-dose of anesthetic [mean 10.5 mg (2.4)]. CONCLUSIONS In the included studies of this meta-analysis, a mean dose of 6.5 mg of SA was effective in producing intraoperative comfort and motor block and associated with a lower incidence of hypotension as compared to a mean dose of 10.5 mg. TRIAL REGISTRATION CRD42020193627.
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Affiliation(s)
- Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Luigi La Via
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy.
| | - Angelo Milani
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
| | - Marzia Savi
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
| | - Lorenzo Calabrò
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Katerina Negri
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
| | | | - Gianmaria Cammarota
- Department of Anesthesia and Intensive Care Medicine, Maggiore della Carità University Hospital, Novara, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Emanuela Morenghi
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Marinella Astuto
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
- School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico", University of Catania, Catania, Italy
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
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18
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Putowski Z, Czok M, Krzych ŁJ. The impact of intraoperative blood pressure variability on the risk of postoperative adverse outcomes in non-cardiac surgery: a systematic review. J Anesth 2022; 36:316-322. [PMID: 35028755 PMCID: PMC8967760 DOI: 10.1007/s00540-022-03035-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/31/2021] [Indexed: 10/26/2022]
Abstract
Hemodynamic stability during surgery seems to account for positive postoperative outcomes in patients. However, little is known about the impact of intraoperative blood pressure variability (IBPV) on the postoperative complications. The aim was to investigate whether IBPV is associated with the development of postoperative complications and what is the nature of this association. We conducted a systematic search in PubMed, Medical Subject Headings, Embase, Web of Science, SCOPUS, clinicaltrials.gov, and Cochrane Library on the 8th of April, 2021. We included studies that only focused on adults who underwent primarily elective, non-cardiac surgery in which intraoperative blood pressure variation was measured and analyzed in regard to postoperative, non-surgical complications. We identified 11 papers. The studies varied in terms of applied definitions of blood pressure variation, of which standard deviation and average real variability were the most commonly applied definitions. Among the studies, the most consistent analyzed outcome was a 30-day mortality. The studies presented highly heterogeneous results, even after taking into account only the studies of best quality. Both higher and lower IBPV were reported to be associated for postoperative complications. Based on a limited number of studies, IBPV does not seem to be a reliable indicator in predicting postoperative complications. Existing premises suggest that either higher or lower IBPV could contribute to postoperative complications. Taking into account the heterogeneity and quality of the studies, the conclusions may not be definitive.
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Affiliation(s)
- Zbigniew Putowski
- Students' Scientific Society, Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 14 Street, 40752, Katowice, Poland.
| | - Marcelina Czok
- Students' Scientific Society, Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 14 Street, 40752, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
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19
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Pai SL, Jacob AK, Wang RD. Preoperative optimization of geriatric and frail patients. Int Anesthesiol Clin 2022; 60:33-42. [PMID: 34456275 DOI: 10.1097/aia.0000000000000340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Adam K Jacob
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - R Doris Wang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
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20
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Low Psoas Lumbar Vertebral Index Is Associated with Mortality after Hip Fracture Surgery in Elderly Patients: A Retrospective Analysis. J Pers Med 2021; 11:jpm11070673. [PMID: 34357140 PMCID: PMC8305556 DOI: 10.3390/jpm11070673] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 11/17/2022] Open
Abstract
The psoas-to-lumbar index (PLVI) has been reported as a simple and easy way to measure central sarcopenia. However, only few studies have evaluated the association between PLVI and survival in surgical patients. This study evaluated the association between preoperative PLVI and mortality in elderly patients who underwent hip fracture surgery. We retrospectively analyzed 615 patients who underwent hip fracture surgery between January 2014 and December 2018. The median value of each PLVI was calculated according to sex, and the patients were categorized into two groups on the basis of the median value (low PLVI group vs. high PLVI group). Cox regression analysis was performed to evaluate the risk factors for 1 year and overall mortalities. The median values of PLVI were 0.62 and 0.50 in men and women, respectively. In the Cox regression analysis, low PLVI was significantly associated with higher 1 year (hazard ratio (HR): 1.87, 95% confidence interval (CI): 1.18–2.96, p = 0.008) and overall mortalities (HR: 1.51, 95% CI: 1.12–2.03, p = 0.006). Low PLVI was significantly associated with a higher mortality. Therefore, PLVI might be an independent predictor of mortality in elderly patients undergoing hip fracture surgery.
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21
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Pedemonte JC, Sun H, Franco-Garcia E, Zhou C, Heng M, Quraishi SA, Westover B, Akeju O. Postoperative delirium mediates 180-day mortality in orthopaedic trauma patients. Br J Anaesth 2021; 127:102-109. [PMID: 34074525 PMCID: PMC8258970 DOI: 10.1016/j.bja.2021.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 03/06/2021] [Accepted: 03/18/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Frailty has been associated with increased incidence of postoperative delirium and mortality. We hypothesised that postoperative delirium mediates a clinically significant (≥1%) percentage of the effect of frailty on mortality in older orthopaedic trauma patients. METHODS This was a single-centre, retrospective observational study including 558 adults 65 yr and older, who presented with an extremity fracture requiring hospitalisation without initial ICU admission. We used causal statistical inference methods to estimate the relationships between frailty, postoperative delirium, and mortality. RESULTS In the cohort, 180-day mortality rate was 6.5% (36/558). Frail and prefrail patients comprised 23% and 39%, respectively, of the study cohort. Frailty was associated with increased 180 day mortality from 1.4% to 12.2% (11% difference; 95% confidence interval [CI], 8.4-13.6), which translated statistically into an 88.7% (79.9-94.3%) direct effect and an 11.3% (5.7-20.1%) postoperative delirium mediated effect. Prefrailty was also associated with increased 180 day mortality from 1.4% to 4.4% (2.9% difference; 2.4-3.4), which was translated into a 92.5% (83.8-99.9%) direct effect and a 7.5% (0.1-16.2%) postoperative delirium mediated effect. CONCLUSIONS Frailty is associated with increased postoperative mortality, and delirium might mediate a clinically significant, but small percentage of this effect. Studies should assess whether, in patients with frailty, attempts to mitigate delirium might decrease postoperative mortality.
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Affiliation(s)
- Juan C Pedemonte
- Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USA; División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Carmen Zhou
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Boston, MA, USA
| | - Sadeq A Quraishi
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Henry and Allison McCance Center for Brain Health, Boston, MA, USA; Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USA; Henry and Allison McCance Center for Brain Health, Boston, MA, USA
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22
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Bhatti S, Rashed H, Abell T. Autonomic Nervous System Profiling In Response to Liver Transplantation: Prognostic Evaluation and Preliminary Study. Transplant Proc 2021; 53:1711-1718. [PMID: 33994186 DOI: 10.1016/j.transproceed.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 03/12/2021] [Accepted: 04/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Liver cirrhosis leads to autonomic dysfunction (AD). We present a pilot study and review of published literature to investigate the long-term changes in the Autonomic Nervous System (ANS) of patients who underwent liver transplant. We propose Autonomic Function Tests (AFT) can be used as a predictor of liver transplant outcome. METHODS Twenty-eight patients (19 men and 9 women; mean age 45 years) with cirrhosis due to different etiologies underwent a noninvasive ANS evaluation test, pre- and post-liver transplant at 3 to 6 months, 8 to 12 months, and 14 to 24 months. Data were compared with 45 age-matched controls (14 men and 31 women). We investigated changes in the following 3 adrenergic measures: percentage of cutaneous vasoconstriction in the hand and foot in response to cold stress test and cutaneous blood flow adjustment ratio; and 3 cardiovagal measures: change in heart rate in relation to deep respiration, forced respiration represented as Valsalva Ratio, and head-up tilting (30/15 ratio). RESULTS A total of 23 of 28 patients (82%) had impairment in AFT before transplant, 16 of 28 (57%) in the sympathetic adrenergic measures, and 15 of 28 (54%) in the parasympathetic cardiovagal measures. There was a gradual improvement in ANS function posttransplant, with a significant improvement in the cardiovagal measure of Valsalva Ratio (P < .05 from baseline). These data suggest some temporary decline in ANS functions within the first 6 months posttransplant. CONCLUSIONS To optimize outcomes in liver transplant patients with autonomic dysfunction, autonomic testing perhaps combined with frailty testing can be used as objective measures of mortality in the pre-liver transplant stage.
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Affiliation(s)
- Sundus Bhatti
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Hani Rashed
- University of Louisville, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Louisville, Kentucky
| | - Thomas Abell
- University of Louisville, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Louisville, Kentucky.
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Complications as a Mediator of the Perioperative Frailty-Mortality Association. Anesthesiology 2021; 134:577-587. [PMID: 33529334 DOI: 10.1097/aln.0000000000003699] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Preoperative frailty is strongly associated with postoperative complications and mortality. However, the pathways between frailty, postoperative complications, and mortality are poorly described. The authors hypothesized that the occurrence of postoperative complications would mediate a substantial proportion of the total effect of frailty on mortality after elective noncardiac surgery. METHODS Following protocol registration, the authors conducted a retrospective cohort study of intermediate- to high-risk elective noncardiac surgery patients (2016) using National Surgical Quality Improvement Program data. The authors conducted Bayesian mediation analysis of the relationship between preoperative frailty (exposure, using the Risk Analysis Index), serious complications (mediator), and 30-day mortality (outcome), comprehensively adjusting for confounders. The authors estimated the total effect of frailty on mortality (composed of the indirect effect mediated by complications and the remaining direct effect of frailty) and estimated the proportion of the frailty-mortality association mediated by complications. RESULTS The authors identified 205,051 patients; 1,474 (0.7%) died. Complications occurred in 20,211 (9.9%). A 2 SD increase in frailty score resulted in a total association with mortality equal to an odds ratio of 3.79 (95% credible interval, 2.48 to 5.64), resulting from a direct association (odds ratio, 1.76; 95% credible interval, 1.34 to 2.30) and an indirect association mediated by complications (odds ratio, 2.15; 95% credible interval, 1.58 to 2.96). Complications mediated 57.3% (95% credible interval, 40.8 to 73.8) of the frailty-mortality association. Cardiopulmonary complications were the strongest mediators among complication subtypes. CONCLUSIONS Complications mediate more than half of the association between frailty and postoperative mortality in elective noncardiac surgery. EDITOR’S PERSPECTIVE
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Shanker A, Upadhyay P, Rangasamy V, Muralidhar K, Subramaniam B. Impact of frailty in cardiac surgical patients-Assessment, burden, and recommendations. Ann Card Anaesth 2021; 24:133-139. [PMID: 33884967 PMCID: PMC8253036 DOI: 10.4103/aca.aca_90_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Elderly patients undergoing cardiac surgery are at an increased risk of adverse postoperative outcomes. Frailty, a state of decreased physiological reserve, is highly prevalent among elderly patients. Despite being associated with adverse surgical outcomes, no universally accepted definition or measurement tool for frailty exists. Moreover, regardless of all the recommendations, a routine perioperative frailty assessment is often ignored. In addition to complications, frailty increases the burden to the healthcare system, which is of particular concern in Southeast Asia due to its socioeconomically disadvantaged and resource limited settings. This narrative review focuses to develop clinical practice plans for perioperative frailty assessment in the context of a cardiac surgical setting.
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Affiliation(s)
- Akshay Shanker
- Department of Anesthesia, Critical Care, and Pain Medicine, Lewis Katz School of Medicine at Temple University, 3500 North Broad St., Philadelphia, Pennsylvania; Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Preeti Upadhyay
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Valluvan Rangasamy
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Kanchi Muralidhar
- Department of Anesthesia, Narayana Institute of Cardiac Sciences, Narayana Hrudayalaya Health City, Bengaluru, Karnataka, India
| | - Balachundhar Subramaniam
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
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Hannah TC, Neifert SN, Caridi JM, Martini ML, Lamb C, Rothrock RJ, Yuk FJ, Gilligan J, Genadry L, Gal JS. Utility of the Hospital Frailty Risk Score for Predicting Adverse Outcomes in Degenerative Spine Surgery Cohorts. Neurosurgery 2020; 87:1223-1230. [PMID: 32542353 DOI: 10.1093/neuros/nyaa248] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/15/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND As spine surgery becomes increasingly common in the elderly, frailty has been used to risk stratify these patients. The Hospital Frailty Risk Score (HFRS) is a novel method of assessing frailty using International Classification of Diseases, Tenth Revision (ICD-10) codes. However, HFRS utility has not been evaluated in spinal surgery. OBJECTIVE To assess the accuracy of HFRS in predicting adverse outcomes of surgical spine patients. METHODS Patients undergoing elective spine surgery at a single institution from 2008 to 2016 were reviewed, and those undergoing surgery for tumors, traumas, and infections were excluded. The HFRS was calculated for each patient, and rates of adverse events were calculated for low, medium, and high frailty cohorts. Predictive ability of the HFRS in a model containing other relevant variables for various outcomes was also calculated. RESULTS Intensive care unit (ICU) stays were more prevalent in high HFRS patients (66%) than medium (31%) or low (7%) HFRS patients. Similar results were found for nonhome discharges and 30-d readmission rates. Logistic regressions showed HFRS improved the accuracy of predicting ICU stays (area under the curve [AUC] = 0.87), nonhome discharges (AUC = 0.84), and total complications (AUC = 0.84). HFRS was less effective at improving predictions of 30-d readmission rates (AUC = 0.65) and emergency department visits (AUC = 0.60). CONCLUSION HFRS is a better predictor of length of stay (LOS), ICU stays, and nonhome discharges than readmission and may improve on modified frailty index in predicting LOS. Since ICU stays and nonhome discharges are the main drivers of cost variability in spine surgery, HFRS may be a valuable tool for cost prediction in this specialty.
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Affiliation(s)
- Theodore C Hannah
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Colin Lamb
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert J Rothrock
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeffrey Gilligan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lisa Genadry
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Padkins M, Breen T, Anavekar N, Barsness G, Kashani K, Jentzer JC. Association Between Albumin Level and Mortality Among Cardiac Intensive Care Unit Patients. J Intensive Care Med 2020; 36:1475-1482. [PMID: 33016174 DOI: 10.1177/0885066620963875] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To study the effect of hypoalbuminemia on short- and long-term mortality in Cardiac Intensive Care Unit (CICU) patients. METHODS We reviewed 12,418 unique CICU patients from 2007 to 2018. Hypoalbuminemia was defined as an admission albumin level <3.5 g/dL. Predictors of hospital mortality were identified using multivariable logistic regression. RESULTS We included 2,680 patients (22%) with a measured admission albumin level. The median age was 68 (39% females). Admission diagnoses included acute coronary syndrome, heart failure, cardiac arrest, and cardiogenic shock. The median albumin level was 3.4 g/dL and 55% of patients had hypoalbuminemia. Hospital mortality occurred in 16%, and patients with hypoalbuminemia had higher hospital mortality (21% vs. 9%, adjusted OR 2.64, 95% CI 2.09-3.34, p < 0.001). Albumin level was inversely associated with hospital mortality (adjusted OR 0.60 per 1 g/dL higher albumin level, 95% CI 0.47-0.75, p <0.001), with a stepwise increase in the hospital mortality at lower albumin levels. Post-discharge mortality was higher in hospital survivors with hypoalbuminemia, and increased as a function of lower albumin levels. CONCLUSION Hypoalbuminemia is common in CICU patients and associated with higher short- and long-term mortality. Progressively lower serum albumin was incrementally associated with higher hospital and post-discharge mortality.
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Affiliation(s)
- Mitchell Padkins
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic, Rochester, MN, USA
| | - Thomas Breen
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic, Rochester, MN, USA
| | - Nandan Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Gregory Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Recommendations for Preoperative Assessment and Shared Decision-Making in Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:185-195. [PMID: 32431570 DOI: 10.1007/s40140-020-00377-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of review Recommendations about shared decision-making and guidelines on preoperative evaluation of patients undergoing non-cardiac surgery are abundant, but respective recommendations for cardiac surgery are sparse. We provide an overview of available evidence. Recent findings While there currently is no consensus statement on the preoperative anesthetic evaluation and shared decision-making for the adult patient undergoing cardiac surgery, evidence pertaining to specific organ systems is available. Summary We provide a comprehensive review of available evidence pertaining to preoperative assessment and shared decision-making for patients undergoing cardiac surgery and recommend a thorough preoperative workup in this vulnerable population.
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Ke JXC, MacDonald DB, McIsaac DI. Perioperative Acute Care of Older Patients Living with Frailty. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00355-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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30
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[67-year-old female before extended gastrectomy for antral cancer : Preparation for the medical specialist examination: part 36]. Anaesthesist 2019; 68:247-250. [PMID: 31624880 DOI: 10.1007/s00101-019-00666-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Rangasamy V, Henriques TS, Xu X, Subramaniam B. Preoperative Blood Pressure Complexity Indices as a Marker for Frailty in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 34:616-621. [PMID: 31668744 DOI: 10.1053/j.jvca.2019.09.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/25/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Frailty, a state of decreased physiological reserve, increases the risk of adverse outcomes. There is no standard tool for frailty during perioperative period. Autonomic dysfunction, an underlying process in frailty, could result in hemodynamic fluctuations. Complexity, the physiological adaptability of a system can quantify these fluctuations. The authors hypothesized that complexity could be a marker for frailty and explored their relationship in cardiac surgical patients. DESIGN Prospective, observational study. SETTING Single-center teaching hospital. PARTICIPANTS Three hundred and sixty-four adult patients undergoing cardiac surgery. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Preoperative beat-to-beat systolic arterial pressure (SAP) and mean arterial pressure (MAP) time series were obtained. Complexity indices were calculated using multiscale entropy (MSE) analysis. Frailty was assessed from: age >70 years, body mass index <18.5, hematocrit <35%, albumin <3.4 g/dL, and creatinine >2.0 mg/dL. The association between complexity indices and frailty was explored by logistic regression and predictive ability by C-statistics. In total, 190 (52%) patients had frailty. The complexity index (MSEΣ) median (quartile 1, quartile 3) of SAP and MAP time series decreased significantly in frail patients (SAP: 8.32 [7.27, 9.24] v 9.13 [8.00, 9.72], p < 0.001 and MAP: 8.56 [7.56; 9.27] v 9.18 [8.26; 9.83], p < 0.001). MSE Σ demonstrated a fair predictive ability of frailty (C-statistic: SAP 0.62 and MAP 0.64). CONCLUSION Preoperative BP complexity indices correlate and predict frailty. Impaired autonomic control is the underlying mechanism to explain this finding. A simple automated measure of preoperative BP complexity in the surgeon's office has the potential to reliably assess frailty.
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Affiliation(s)
- Valluvan Rangasamy
- Center for Anesthesia Research and Excellence (CARE), Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Teresa S Henriques
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto University, Porto, Portugal
| | - Xinling Xu
- Center for Anesthesia Research and Excellence (CARE), Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Balachundhar Subramaniam
- Center for Anesthesia Research and Excellence (CARE), Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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