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Juri T, Suehiro K, Takai M, Nakada D, Takahashi K, Fujimoto Y, Mori T. Agreement between non-invasive and invasive arterial blood pressure during surgery in the prone position: an error grid analysis. J Anesth 2024:10.1007/s00540-024-03385-7. [PMID: 39138698 DOI: 10.1007/s00540-024-03385-7] [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: 06/12/2024] [Accepted: 07/30/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE Prone position has recently gained renewed importance as a treatment for acute respiratory distress syndrome and spine and brain surgeries. Our study aimed to perform an error grid analysis to examine the clinical discrepancies between arterial blood pressure (ABP) and non-invasive blood pressure (NIBP) in the prone position and to investigate the risk factors influencing these differences. METHODS Error grid analysis was performed retrospectively on 1389 pairs of 100 consecutive prone positioning cases. This analysis classifies the difference between the two methods into five clinically relevant zones, from "no risk" to "dangerous risk". Additionally, multivariable ordinal logistic regression analysis was conducted to evaluate the relationship between the risk zones of mean blood pressure (MBP), as classified by error grid analysis and the covariate of interest. RESULTS Error grid analysis showed that the proportions of measurement pairs in risk zones A-E for systolic blood pressure were 96.8%, 3.2%, 0.1%, 0%, and 0%, respectively. In contrast, the MBP proportions were 74.0%, 25.1%, 0.9%, 0.1%, and 0%. Multivariable ordinal logistic regression analysis revealed that the position of arms (next to the head) was a significant factor (adjusted odds ratio: 4.35, 95% CI: 2.38-8.33, P < 0.001). CONCLUSION Error grid analysis revealed a clinically unacceptable discrepancy between ABP and NIBP for MBP during prone positioning surgery. The position of the arms next to the head was associated with increased clinical discrepancy between the two MBP measurement methods.
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Affiliation(s)
- Takashi Juri
- Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, 1-5-7 Asahimachi, Abenoku, Osaka, Osaka, 545-8586, Japan
| | - Koichi Suehiro
- Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, 1-5-7 Asahimachi, Abenoku, Osaka, Osaka, 545-8586, Japan.
| | - Masayo Takai
- Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, 1-5-7 Asahimachi, Abenoku, Osaka, Osaka, 545-8586, Japan
| | - Daisuke Nakada
- Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, 1-5-7 Asahimachi, Abenoku, Osaka, Osaka, 545-8586, Japan
| | - Kanae Takahashi
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yohei Fujimoto
- Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, 1-5-7 Asahimachi, Abenoku, Osaka, Osaka, 545-8586, Japan
| | - Takashi Mori
- Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, 1-5-7 Asahimachi, Abenoku, Osaka, Osaka, 545-8586, Japan
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Saugel B, Fletcher N, Gan TJ, Grocott MPW, Myles PS, Sessler DI. PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management. Br J Anaesth 2024; 133:264-276. [PMID: 38839472 PMCID: PMC11282474 DOI: 10.1016/j.bja.2024.04.046] [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: 12/19/2023] [Revised: 03/09/2024] [Accepted: 04/05/2024] [Indexed: 06/07/2024] Open
Abstract
Arterial pressure monitoring and management are mainstays of haemodynamic therapy in patients having surgery. This article presents updated consensus statements and recommendations on perioperative arterial pressure management developed during the 11th POQI PeriOperative Quality Initiative (POQI) consensus conference held in London, UK, on June 4-6, 2023, which included a diverse group of international experts. Based on a modified Delphi approach, we recommend keeping intraoperative mean arterial pressure ≥60 mm Hg in at-risk patients. We further recommend increasing mean arterial pressure targets when venous or compartment pressures are elevated and treating hypotension based on presumed underlying causes. When intraoperative hypertension is treated, we recommend doing so carefully to avoid hypotension. Clinicians should consider continuous intraoperative arterial pressure monitoring as it can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring. Postoperative hypotension is often unrecognised and might be more important than intraoperative hypotension because it is often prolonged and untreated. Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension including choice of vasopressors. Research is also needed to guide monitoring and management strategies for recognising, preventing, and treating postoperative hypotension.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, UK
| | - Tong J Gan
- Division of Anesthesiology and Perioperative Medicine, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
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Thomsen KK, Sessler DI, Krause L, Hoppe P, Opitz B, Kessler T, Chindris V, Bergholz A, Flick M, Kouz K, Zöllner C, Schulte-Uentrop L, Saugel B. Processed electroencephalography-guided general anesthesia and norepinephrine requirements: A randomized trial in patients having vascular surgery. J Clin Anesth 2024; 95:111459. [PMID: 38599161 DOI: 10.1016/j.jclinane.2024.111459] [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: 12/21/2023] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024]
Abstract
STUDY OBJECTIVE Processed electroencephalography (pEEG) may help clinicians optimize depth of general anesthesia. Avoiding excessive depth of anesthesia may reduce intraoperative hypotension and the need for vasopressors. We tested the hypothesis that pEEG-guided - compared to non-pEEG-guided - general anesthesia reduces the amount of norepinephrine needed to keep intraoperative mean arterial pressure above 65 mmHg in patients having vascular surgery. DESIGN Randomized controlled clinical trial. SETTING University Medical Center Hamburg-Eppendorf, Hamburg, Germany. PATIENTS 110 patients having vascular surgery. INTERVENTIONS pEEG-guided general anesthesia. MEASUREMENTS Our primary endpoint was the average norepinephrine infusion rate from the beginning of induction of anesthesia until the end of surgery. MAIN RESULT 96 patients were analyzed. The mean ± standard deviation average norepinephrine infusion rate was 0.08 ± 0.04 μg kg-1 min-1 in patients assigned to pEEG-guided and 0.12 ± 0.09 μg kg-1 min-1 in patients assigned to non-pEEG-guided general anesthesia (mean difference 0.04 μg kg-1 min-1, 95% confidence interval 0.01 to 0.07 μg kg-1 min-1, p = 0.004). Patients assigned to pEEG-guided versus non-pEEG-guided general anesthesia, had a median time-weighted minimum alveolar concentration of 0.7 (0.6, 0.8) versus 0.8 (0.7, 0.8) (p = 0.006) and a median percentage of time Patient State Index was <25 of 12 (1, 41) % versus 23 (3, 49) % (p = 0.279). CONCLUSION pEEG-guided - compared to non-pEEG-guided - general anesthesia reduced the amount of norepinephrine needed to keep mean arterial pressure above 65 mmHg by about a third in patients having vascular surgery. Whether reduced intraoperative norepinephrine requirements resulting from pEEG-guided general anesthesia translate into improved patient-centered outcomes remains to be determined in larger trials.
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Affiliation(s)
- Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Daniel I Sessler
- OutcomesResearch Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Opitz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till Kessler
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Viorel Chindris
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; OutcomesResearch Consortium, Cleveland, OH, USA
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leonie Schulte-Uentrop
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; OutcomesResearch Consortium, Cleveland, OH, USA
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Hewson DW, Tedore TR, Hardman JG. Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence. Br J Anaesth 2024; 133:380-399. [PMID: 38811298 PMCID: PMC11282476 DOI: 10.1016/j.bja.2024.04.044] [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: 02/20/2024] [Revised: 04/23/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.
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Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Tiffany R Tedore
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Jonathan G Hardman
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK
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Chapalain X, Morvan T, Gentric JC, Subileau A, Jacob C, Cadic A, Caillard A, Huet O. Continuous non-invasive vs. invasive arterial blood pressure monitoring during neuroradiological procedure: a comparative, prospective, monocentric, observational study. Perioper Med (Lond) 2024; 13:77. [PMID: 39034414 PMCID: PMC11265173 DOI: 10.1186/s13741-024-00442-3] [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: 01/17/2024] [Accepted: 07/16/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND In the perioperative setting, the most accurate way to continuously measure arterial blood pressure (ABP) is using an arterial catheter. Surrogate methods such as finger cuff have been developed to allow non-invasive measurements and are increasingly used, but need further evaluation. The aim of this study is to evaluate the accuracy and clinical concordance between two devices for the measurement of ABP during neuroradiological procedure. METHODS This is a prospective, monocentric, observational study. All consecutive patients undergoing a neuroradiological procedure were eligible. Patients who needed arterial catheter for blood pressure measurement were included. During neuroradiological procedure, ABP (systolic, mean and diatolic blood pressure) was measured with two different technologies: radial artery catheter and Nexfin. Bland-Altman and error grid analyses were performed to evaluate the accuracy and clinical concordance between devices. RESULTS From March 2022 to November 2022, we included 50 patients, mostly ASA 3 (60%) and required a cerebral embolization (94%) under general anaesthesia (96%). Error grid analysis showed that 99% of non-invasive ABP measures obtained with the Nexfin were located in the risk zone A or B. However, 65.7% of hypertension events and 41% of hypotensive events were respectively not detected by Nexfin. Compared to the artery catheter, a significant relationship was found for SAP (r2 = 0.78) and MAP (r2 = 0.80) with the Nexfin (p < 0.001). Bias and limits of agreement (LOA) were respectively 9.6 mmHg (- 15.6 to 34.8 mmHg) and - 0.8 mmHg (- 17.2 to 15.6 mmHg), for SAP and MAP. CONCLUSIONS Nexfin is not strictly interchangeable with artery catheter for ABP measuring. Further studies are needed to define its clinical use during neuroradiological procedure. TRIAL REGISTRATION Clinicaltrials.gov, registration number: NCT05283824.
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Affiliation(s)
- Xavier Chapalain
- Department of Anesthesiology and Surgical Intensive Care, University and Regional Hospital Centre Brest, Boulevard Tanguy Prigent, Brest, Cedex, 29609, France
- Laboratoire ORPHY, Université de Bretagne Occidentale, Brest, France
| | - Thomas Morvan
- Department of Anesthesiology and Surgical Intensive Care, University and Regional Hospital Centre Brest, Boulevard Tanguy Prigent, Brest, Cedex, 29609, France
| | - Jean-Christophe Gentric
- Department of Neuroradiology, University and Regional Hospital Centre Brest, Brest, France
- Laboratoire GETBO, UMR 1304, Université de Bretagne Occidentale, Brest, France
| | - Aurélie Subileau
- Department of Anesthesiology and Surgical Intensive Care, University and Regional Hospital Centre Brest, Boulevard Tanguy Prigent, Brest, Cedex, 29609, France
| | - Christophe Jacob
- Department of Anesthesiology and Surgical Intensive Care, University and Regional Hospital Centre Brest, Boulevard Tanguy Prigent, Brest, Cedex, 29609, France
| | - Anna Cadic
- Department of Anesthesiology and Surgical Intensive Care, University and Regional Hospital Centre Brest, Boulevard Tanguy Prigent, Brest, Cedex, 29609, France
| | - Anaïs Caillard
- Department of Anesthesiology and Surgical Intensive Care, University and Regional Hospital Centre Brest, Boulevard Tanguy Prigent, Brest, Cedex, 29609, France
| | - Olivier Huet
- Department of Anesthesiology and Surgical Intensive Care, University and Regional Hospital Centre Brest, Boulevard Tanguy Prigent, Brest, Cedex, 29609, France.
- Laboratoire ORPHY, Université de Bretagne Occidentale, Brest, France.
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Bækgaard ES, Madsen BK, Crone V, El-Hallak H, Møller MH, Vester-Andersen M, Krag M. Perioperative hypotension and use of vasoactive agents in non-cardiac surgery: A scoping review. Acta Anaesthesiol Scand 2024. [PMID: 38965670 DOI: 10.1111/aas.14485] [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: 04/26/2024] [Revised: 06/03/2024] [Accepted: 06/13/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Perioperative hypotension is common and associated with adverse patient outcomes. Vasoactive agents are often used to manage hypotension, but the ideal drug, dose and duration of treatment has not been established. With this scoping review, we aim to provide an overview of the current body of evidence regarding the vasoactive agents used to treat perioperative hypotension in non-cardiac surgery. METHODS We included all studies describing the use of vasoactive agents for the treatment of perioperative hypotension in non-cardiac surgery. We excluded literature reviews, case studies, and studies on animals and healthy subjects. We posed the following research questions: (1) in which surgical populations have vasoactive agents been studied? (2) which agents have been studied? (3) what doses have been assessed? (4) what is the duration of treatment? and (5) which desirable and undesirable outcomes have been assessed? RESULTS We included 124 studies representing 10 surgical specialties. Eighteen different agents were evaluated, predominantly phenylephrine, ephedrine, and noradrenaline. The agents were administered through six different routes, and numerous comparisons between agents, dosages and routes were included. Then, 88 distinct outcome measures were assessed, of which 54 were judged to be non-patient-centred. CONCLUSIONS We found that studies concerning vasoactive agents for the treatment of perioperative hypotension varied considerably in all aspects. Populations were heterogeneous, interventions and exposures included multiple agents compared against themselves, each other, fluids or placebo, and studies reported primarily non-patient-centred outcomes.
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Affiliation(s)
| | - Bennedikte Kollerup Madsen
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Vera Crone
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
| | - Hayan El-Hallak
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital-Gentofte, Hellerup, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital-Herlev-Gentofte, Herlev, Denmark
| | - Mette Krag
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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7
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Lydon K, Shah S, Mongan KL, Mongan PD, Cantrell MC, Awad Z. Intraoperative fluid management is not predictive of AKI in major pancreatic surgery: a retrospective cohort study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:39. [PMID: 38956707 PMCID: PMC11218130 DOI: 10.1186/s44158-024-00176-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Pancreatic surgery is associated with a significant risk for acute kidney injury (AKI) and clinically relevant postoperative pancreatic fistula (CR-POPF). This investigation evaluated the impact of intraoperative volume administration, vasopressor therapy, and blood pressure management on the primary outcome of AKI and the secondary outcome of a CR-POPF after pancreatic surgery. METHODS This retrospective single-center cohort investigated 200 consecutive pancreatic surgeries (January 2018-December 2021). Patients were categorized for the presence/absence of AKI (Kidney Disease Improving Global Outcomes) and CR-POPF. After univariate analysis, multivariable models were constructed to control for the univariate cofactor differences in the primary and secondary outcomes. RESULTS AKI was identified in 20 patients (10%) with significant univariate differences in demographics (body mass index and gender), comorbidities, indices of chronic renal insufficiency, and an increased AKI Risk score. Surgical characteristics, intraoperative fluid, vasopressor, and blood pressure management were similar in patients with and without AKI. Patients with AKI had increased blood loss, lower urine output, and packed red blood cell administration. After multivariate analysis, male gender (OR = 7.9, 95% C.I. 1.8-35.1) and the AKI Risk score (OR = 6.3, 95% C.I. 2.4-16.4) were associated with the development of AKI (p < 0.001). Intraoperative and postoperative volume, vasopressor administration, and intraoperative hypotension had no significant impact in the multivariate analysis. CR-POPF occurred in 23 patients (11.9%) with no significant contributing factors in the multivariate analysis. Patients who developed AKI or a CR-POPF had an increase in surgical complications, length of stay, discharge to a skilled nursing facility, and mortality. CONCLUSION In this analysis, intraoperative volume administration, vasopressor therapy, and a blood pressure < 55 mmHg for more than 10 min were not associated with an increased risk of AKI. After multivariate analysis, male gender and an elevated AKI Risk score were associated with an increased likelihood of AKI.
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Affiliation(s)
- Kerri Lydon
- Department of Anesthesiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Saurin Shah
- Department of Anesthesiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Kai L Mongan
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Paul D Mongan
- Department of Anesthesiology, University of Florida College of Medicine, Jacksonville, FL, USA.
| | | | - Ziad Awad
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA
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Chen NP, Li YW, Cao SJ, Zhang Y, Li CJ, Zhou WJ, Li M, Du YT, Zhang YX, Xing MW, Ma JH, Mu DL, Wang DX. Intraoperative hypotension is associated with decreased long-term survival in older patients after major noncardiac surgery: Secondary analysis of three randomized trials. J Clin Anesth 2024; 97:111520. [PMID: 38954871 DOI: 10.1016/j.jclinane.2024.111520] [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: 10/03/2023] [Revised: 04/03/2024] [Accepted: 06/05/2024] [Indexed: 07/04/2024]
Abstract
STUDY OBJECTIVE To assess the association of intraoperative hypotension with long-term survivals in older patients after major noncardiac surgery mainly for cancer. DESIGN A secondary analysis of databases from three randomized trials with long-term follow-up. SETTING The underlying trials were conducted in 17 tertiary hospitals in China. PATIENTS Patients aged 60 to 90 years who underwent major noncardiac thoracic or abdominal surgeries (≥ 2 h) in a single center were included in this analysis. EXPOSURES Restricted cubic spline models were employed to determine the lowest mean arterial pressure (MAP) threshold that was potentially harmful for long-term survivals. Patients were arbitrarily divided into three groups according to the cumulative duration or area under the MAP threshold. The association between intraoperative hypotension exposure and long-term survivals were analyzed with the Cox proportional hazard regression models. MEASUREMENTS Our primary endpoint was overall survival. Secondary endpoints included recurrence-free and event-free survivals. MAIN RESULTS A total of 2664 patients (mean age 69.0 years, 34.9% female sex, 92.5% cancer surgery) were included in the final analysis. MAP < 60 mmHg was adopted as the threshold of intraoperative hypotension. Patients were divided into three groups according to duration under MAP < 60 mmHg (<1 min, 1-10 min, and > 10 min) or area under MAP <60 mmHg (< 1 mmHg⋅min, 1-30 mmHg⋅min, and > 30 mmHg⋅min). After adjusting confounders, duration under MAP < 60 mmHg for > 10 min was associated with a shortened overall survival when compared with the < 1 min patients (adjusted hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.09 to 1.57, P = 0.004); area under MAP < 60 mmHg for > 30 mmHg⋅min was associated with a shortened overall survival when compared with the < 1 mmHg⋅min patients (adjusted HR 1.40, 95% CI 1.16 to 1.68, P < 0.001). Similar associations exist between duration under MAP < 60 mmHg for > 10 min or area under MAP < 60 mmHg for > 30 mmHg⋅min and recurrence-free or event-free survivals. CONCLUSIONS In older patients who underwent major noncardiac surgery mainly for cancer, intraoperative hypotension was associated with worse overall, recurrence-free, and event-free survivals.
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Affiliation(s)
- Na-Ping Chen
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China.
| | - Ya-Wei Li
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China.
| | - Shuang-Jie Cao
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China; School of Anesthesiology, Shandong Second Medical University, Weifang, Shandong, China.
| | - Yue Zhang
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China; Clinical Research Institute, Shenzhen Peking University-The Hong Kong University of Science & Technology Medical Center, Shenzhen, Guangdong, China.
| | - Chun-Jing Li
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China.
| | - Wei-Jie Zhou
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China.
| | - Mo Li
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China.
| | - Ya-Ting Du
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China; The Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| | - Yu-Xiu Zhang
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China.
| | - Mao-Wei Xing
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China; The Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| | - Jia-Hui Ma
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China.
| | - Dong-Liang Mu
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China.
| | - Dong-Xin Wang
- The Department of Anesthesiology, Peking University First Hospital, Beijing, China; Outcomes Research Consortium, Cleveland, Ohio, USA.
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Maleczek M, Laxar D, Kapral L, Kuhrn M, Abulesz YT, Dibiasi C, Kimberger O. A Comparison of Five Algorithmic Methods and Machine Learning Pattern Recognition for Artifact Detection in Electronic Records of Five Different Vital Signs: A Retrospective Analysis. Anesthesiology 2024; 141:32-43. [PMID: 38466210 DOI: 10.1097/aln.0000000000004971] [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: 03/12/2024]
Abstract
BACKGROUND Research on electronic health record physiologic data is common, invariably including artifacts. Traditionally, these artifacts have been handled using simple filter techniques. The authors hypothesized that different artifact detection algorithms, including machine learning, may be necessary to provide optimal performance for various vital signs and clinical contexts. METHODS In a retrospective single-center study, intraoperative operating room and intensive care unit (ICU) electronic health record datasets including heart rate, oxygen saturation, blood pressure, temperature, and capnometry were included. All records were screened for artifacts by at least two human experts. Classical artifact detection methods (cutoff, multiples of SD [z-value], interquartile range, and local outlier factor) and a supervised learning model implementing long short-term memory neural networks were tested for each vital sign against the human expert reference dataset. For each artifact detection algorithm, sensitivity and specificity were calculated. RESULTS A total of 106 (53 operating room and 53 ICU) patients were randomly selected, resulting in 392,808 data points. Human experts annotated 5,167 (1.3%) data points as artifacts. The artifact detection algorithms demonstrated large variations in performance. The specificity was above 90% for all detection methods and all vital signs. The neural network showed significantly higher sensitivities than the classic methods for heart rate (ICU, 33.6%; 95% CI, 33.1 to 44.6), systolic invasive blood pressure (in both the operating room [62.2%; 95% CI, 57.5 to 71.9] and the ICU [60.7%; 95% CI, 57.3 to 71.8]), and temperature in the operating room (76.1%; 95% CI, 63.6 to 89.7). The CI for specificity overlapped for all methods. Generally, sensitivity was low, with only the z-value for oxygen saturation in the operating room reaching 88.9%. All other sensitivities were less than 80%. CONCLUSIONS No single artifact detection method consistently performed well across different vital signs and clinical settings. Neural networks may be a promising artifact detection method for specific vital signs. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Mathias Maleczek
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, and Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Daniel Laxar
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, and Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Lorenz Kapral
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Melanie Kuhrn
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Yannic-Tomas Abulesz
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Christoph Dibiasi
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, and Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Oliver Kimberger
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, and Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
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Cairns BB, McNeil MV, Milne AD. An audit of postoperative haemodynamic stability after intraoperative labetalol administration in non-cardiac surgery patients. J Perioper Pract 2024; 34:241-247. [PMID: 38343016 PMCID: PMC11282684 DOI: 10.1177/17504589231223011] [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] [Indexed: 07/27/2024]
Abstract
Anaesthesiologists commonly use intravenous labetalol to adjust patient haemodynamics during surgical procedures. Cases of profound hypotension after continuous labetalol infusions have been reported; however, there is limited evidence regarding the safety of intraoperative labetalol boluses. This audit examined the frequency of postoperative hypotension and bradycardia in 292 adult non-cardiac surgery patients treated with intraoperative labetalol boluses. Blood pressure and heart rate data were collected from the post-anaesthesia care unit and on the floor units for 24 hours after surgery. The median total intraoperative labetalol dose was 10mg. A total of 30/292 patients had all-cause postoperative hypotension within 24 hours of surgery, 26 of which had other medical or surgical precipitants. Fifteen patients developed bradycardia. There were no deaths or intensive care unit admissions attributed to labetalol. This audit demonstrates a low risk of all-cause postoperative hypotension (10%) and bradycardia (5%) after the use of small IV doses of intraoperative labetalol.
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11
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Vale AGG, Govêia CS, Guimarães GMN, Terra LR, Ladeira LCA, Essado GA. Comparison of arterial hypotension incidence during general anesthesia induction - target-controlled infusion vs. bolus injection of propofol: a randomized clinical trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844503. [PMID: 38641324 PMCID: PMC11079452 DOI: 10.1016/j.bjane.2024.844503] [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: 09/18/2023] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND The incidence of arterial hypotension during induction of general anesthesia is influenced by the method of propofol administration, but there is a dearth of randomized clinical trials comparing bolus injection and target-controlled infusion in relation to arterial hypotension. This study seeks to compare the incidence of arterial hypotension between these two methods of propofol administration. METHODS This prospective, randomized, single-center, non-blinded study included 60 patients (aged 35 to 55 years), classified as ASA physical status I or II, who were undergoing non-cardiac surgeries. They were randomly allocated using a computer to two groups based on the method of propofol administration during the induction of general anesthesia: the Target Group, receiving target-controlled infusion at 4 μg.mL-1, and the Bolus Group, receiving a bolus infusion of 2 mg.kg-1. Both groups also received midazolam 2 mg, fentanyl 3 μg.kg-1, and rocuronium 0.6 mg.kg-1. Over the first 10 minutes of anesthesia induction, Mean Arterial Pressure (MAP), Heart Rate (HR), level of Consciousness (qCON), and Suppression Rate (SR) were recorded every 2 minutes. RESULTS Twenty-seven patients remained in the TCI group, while 28 were in the Bolus group. Repeated measure analysis using mixed-effects models could not reject the null hypothesis for the effect of group-time interactions in MAP (p = 0.85), HR (p = 0.49), SR (p = 0.44), or qCON (p = 0.72). The difference in means for qCON (60.2 for TCI, 50.5 for bolus, p < 0.001), MAP (90.3 for TCI, 86.2 for bolus, p < 0.006), HR (76.2 for TCI, 76.9 for bolus, p = 0.93), and SR (0.01 for TCI, 5.5 for bolus, p < 0.001), irrespective of time (whole period means), revealed some significant differences. CONCLUSION Patients who received propofol bolus injection exhibited a lower mean arterial pressure, a greater variation in the level of consciousness, and a higher suppression rate compared to those who received it as a target-controlled infusion. However, the interaction effect between groups and time remains inconclusive.
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Affiliation(s)
- Ana G G Vale
- Hospital Universitário de Brasília, Brasília, DF, Brazil.
| | - Catia S Govêia
- Universidade de Brasília, Departamento de Anestesiologia, Brasília, DF, Brazil
| | | | - Laíze R Terra
- Hospital Universitário de Brasília, Brasília, DF, Brazil
| | - Luís C A Ladeira
- Universidade de Brasília, Departamento de Anestesiologia, Brasília, DF, Brazil
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12
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Barboi C, Stapelfeldt WH. Mortality following noncardiac surgery assessed by the Saint Louis University Score (SLUScore) for hypotension: a retrospective observational cohort study. Br J Anaesth 2024; 133:33-41. [PMID: 38702236 PMCID: PMC11213987 DOI: 10.1016/j.bja.2024.03.039] [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: 10/11/2023] [Revised: 03/07/2024] [Accepted: 03/13/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND The Saint Louis University Score (SLUScore) was developed to quantify intraoperative blood pressure trajectories and their associated risk for adverse outcomes. This study examines the prevalence and severity of intraoperative hypotension described by the SLUScore and its relationship with 30-day mortality in surgical subtypes. METHODS This retrospective analysis of perioperative data included surgical cases performed between January 1, 2010, and December 31, 2020. The SLUScore is calculated from cumulative time-periods for which the mean arterial pressure is below a range of hypotensive thresholds. After calculating the SLUScore for each surgical procedure, we quantified the prevalence and severity of intraoperative hypotension for each surgical procedure and the association between intraoperative hypotension and 30-day mortality. We used binary logistic regression to quantify the potential contribution of intraoperative hypotension to mortality. RESULTS We analysed 490 982 cases (57.7% female; mean age 57 yr); 33.2% of cases had a SLUScore>0, a median SLUScore of 13 (inter-quartile range [IQR] 7-21), with 1.19% average mortality. The SLUScore was associated with mortality in 12/14 surgical groups. The increases in the odds ratio for death within 30 days of surgery per SLUScore increment were: all surgery types 3.5% (95% confidence interval [95% CI] 3.2-3.9); abdominal/transplant surgery 6% (95% CI 1.5-10.7); thoracic surgery1.5% (95% CI 1-3.3); vascular surgery 3.01% (95% CI 1.9-4.05); spine/neurosurgery 1.1% (95% CI 0.1-2.1); orthopaedic surgery 1.4% (95% CI 0.7-2.2); gynaecological surgery 6.3% (95% CI 2.5-10.1); genitourinary surgery 4.84% (95% CI 3.5-6.15); gastrointestinal surgery 5.2% (95% CI 3.9-6.4); gastroendoscopy 5.5% (95% CI 4.4-6.7); general surgery 6.3% (95% CI 5.5-7.1); ear, nose, and throat surgery 1.6% (95% CI 0-3.27); and cardiac electrophysiology (including pacemaker procedures) 6.6% (95% CI 1.1-12.4). CONCLUSIONS The SLUScore was independently, but variably, associated with 30-day mortality after noncardiac surgery.
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Affiliation(s)
- Cristina Barboi
- Indiana University School of Medicine, Department of Anesthesiology, Indianapolis, IN, USA.
| | - Wolf H Stapelfeldt
- Indiana University School of Medicine, Department of Anesthesiology, Indianapolis, IN, USA; Richard L. Roudebush VA Medical Centre, Department of Anesthesiology, Indianapolis, IN, USA
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13
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Heybati K, Xie G, Ellythy L, Poudel K, Deng J, Zhou F, Chelf CJ, Ripoll JG, Ramakrishna H. Outcomes of Vasopressin-Receptor Agonists Versus Norepinephrine in Adults With Perioperative Hypotension: A Systematic Review. J Cardiothorac Vasc Anesth 2024; 38:1577-1586. [PMID: 38580478 DOI: 10.1053/j.jvca.2024.03.014] [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: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/07/2024]
Abstract
Consensus statements recommend the use of norepinephrine and/or vasopressin for hypotension in cardiac surgery. However, there is a paucity of data among other surgical subgroups and vasopressin analogs. Therefore, the authors conducted a systematic review of randomized controlled trials (RCTs) to compare vasopressin-receptor agonists with norepinephrine for hypotension among those undergoing surgery with general anesthesia. This review was registered prospectively (CRD42022316328). Literature searches were conducted by a medical librarian to November 28, 2023, across MEDLINE, EMBASE, CENTRAL, and Web of Science. The authors included RCTs enrolling adults (≥18 years of age) undergoing any surgery under general anesthesia who developed perioperative hypotension and comparing vasopressin receptor agonists with norepinephrine. The risk of bias was assessed by the Cochrane risk of bias tool for randomized trials (RoB-2). Thirteen (N = 719) RCTs were included, of which 8 (n = 585) enrolled patients undergoing cardiac surgery. Five trials compared norepinephrine with vasopressin, 4 trials with terlipressin, 1 trial with ornipressin, and the other 3 trials used vasopressin as adjuvant therapy. There was no significant difference in all-cause mortality. Among patients with vasoplegic shock after cardiac surgery, vasopressin was associated with significantly lower intensive care unit (N = 385; 2 trials; mean 100.8 v 175.2 hours, p < 0.005; median 120 [IQR 96-168] v 144 [96-216] hours, p = 0.007) and hospital lengths of stay, as well as fewer cases of acute kidney injury and atrial fibrillation compared with norepinephrine. One trial also found that terlipressin was associated with a significantly lower incidence of acute kidney injury versus norepinephrine overall. Vasopressin and norepinephrine restored mean arterial blood pressure with no significant differences; however, the use of vasopressin with norepinephrine was associated with significantly higher mean arterial blood pressure versus norepinephrine alone. Further high-quality trials are needed to determine pooled treatment effects, especially among noncardiac surgical patients and those treated with vasopressin analogs.
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Affiliation(s)
- Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN
| | - Guozhen Xie
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN
| | - Luqman Ellythy
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN
| | - Keshav Poudel
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN
| | - Jiawen Deng
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fangwen Zhou
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Beyls C, Lefebvre T, Mollet N, Boussault A, Meynier J, Abou-Arab O, Mahjoub Y. Norepinephrine weaning guided by the Hypotension Prediction Index in vasoplegic shock after cardiac surgery: protocol for a single-centre, open-label randomised controlled trial - the NORAHPI study. BMJ Open 2024; 14:e084499. [PMID: 38926148 PMCID: PMC11216048 DOI: 10.1136/bmjopen-2024-084499] [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: 01/20/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION Norepinephrine (NE) is the first-line recommended vasopressor for restoring mean arterial pressure (MAP) in vasoplegic syndrome (vs) following cardiac surgery with cardiopulmonary bypass. However, solely focusing on target MAP values can lead to acute hypotension episodes during NE weaning. The Hypotension Prediction Index (HPI) is a machine learning algorithm embedded in the Acumen IQ device, capable of detecting hypotensive episodes before their clinical manifestation. This study evaluates the clinical benefits of an NE weaning strategy guided by the HPI. MATERIAL AND ANALYSIS The Norahpi trial is a prospective, open-label, single-centre study that randomises 142 patients. Inclusion criteria encompass adult patients scheduled for on-pump cardiac surgery with postsurgical NE administration for vs patient randomisation occurs once they achieve haemodynamic stability (MAP>65 mm Hg) for at least 4 hours on NE. Patients will be allocated to the intervention group (n=71) or the control group (n=71). In the intervention group, the NE weaning protocol is based on MAP>65 mmHg and HPI<80 and solely on MAP>65 mm Hg in the control group. Successful NE weaning is defined as achieving NE weaning within 72 hours of inclusion. An intention-to-treat analysis will be performed. The primary endpoint will compare the duration of NE administration between the two groups. The secondary endpoints will include the prevalence, frequency and time of arterial hypotensive events monitored by the Acumen IQ device. Additionally, we will assess cumulative diuresis, the total dose of NE, and the number of protocol weaning failures. We also aim to evaluate the occurrence of postoperative complications, the length of stay and all-cause mortality at 30 days. ETHICS AND DISSEMINATION Ethical approval has been secured from the Institutional Review Board (IRB) at the University Hospital of Amiens (IRB-ID:2023-A01058-37). The findings will be shared through peer-reviewed publications and presentations at national and international conferences. TRIAL REGISTRATION NUMBER NCT05922982.
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Affiliation(s)
| | - Thomas Lefebvre
- Department of Anesthesiology and Critical Care, Amiens-Picardy University Hospital, Amiens, France
| | - Nicolas Mollet
- CHU Amiens-Picardie Pôle Coeur Thorax Vaisseaux, Amiens, France
| | | | | | - Osama Abou-Arab
- CHU Amiens-Picardie Pôle Coeur Thorax Vaisseaux, Amiens, France
| | - Yazine Mahjoub
- CHU Amiens-Picardie Pôle Coeur Thorax Vaisseaux, Amiens, France
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15
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Lee S, Islam N, Ladha KS, van Klei W, Wijeysundera DN. Intraoperative Hypotension in Patients Having Major Noncardiac Surgery Under General Anesthesia: A Systematic Review of Blood Pressure Optimization Strategies. Anesth Analg 2024:00000539-990000000-00845. [PMID: 38870081 DOI: 10.1213/ane.0000000000007074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Intraoperative hypotension is associated with increased risks of postoperative complications. Consequently, a variety of blood pressure optimization strategies have been tested to prevent or promptly treat intraoperative hypotension. We performed a systematic review to summarize randomized controlled trials that evaluated the efficacy of blood pressure optimization interventions in either mitigating exposure to intraoperative hypotension or reducing risks of postoperative complications. METHODS Medline, Embase, PubMed, and Cochrane Controlled Register of Trials were searched from database inception to August 2, 2023, for randomized controlled trials (without language restriction) that evaluated the impact of any blood pressure optimization intervention on intraoperative hypotension and/or postoperative outcomes. RESULTS The review included 48 studies (N = 46,377), which evaluated 10 classes of blood pressure optimization interventions. Commonly assessed interventions included hemodynamic protocols using arterial waveform analysis, preoperative withholding of antihypertensive medications, continuous blood pressure monitoring, and adjuvant agents (vasopressors, anticholinergics, anticonvulsants). These same interventions reduced intraoperative exposure to hypotension. Conversely, low blood pressure alarms had an inconsistent impact on exposure to hypotension. Aside from limited evidence that higher prespecified intraoperative blood pressure targets led to a reduced risk of complications, there were few data suggesting that these interventions prevented postoperative complications. Heterogeneity in interventions and outcomes precluded meta-analysis. CONCLUSIONS Several different blood pressure optimization interventions show promise in reducing exposure to intraoperative hypotension. Nonetheless, the impact of these interventions on clinical outcomes remains unclear. Future trials should assess promising interventions in samples sufficiently large to identify clinically plausible treatment effects on important outcomes. KEY POINTS
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Affiliation(s)
- Sandra Lee
- From the Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nehal Islam
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Karim S Ladha
- From the Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael's Hospital - Unity Health Toronto, Toronto, Ontario, Canada
| | - Wilton van Klei
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
- Division of Anaesthesiology, Intensive Care, and Emergency Medicine, University Medical Center Utrecht, Utrecht, Netherlands
| | - Duminda N Wijeysundera
- From the Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael's Hospital - Unity Health Toronto, Toronto, Ontario, Canada
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16
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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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17
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L'Écuyer S, Charbonney E, Carrier FM, Rose CF. Implication of Hypotension in the Pathogenesis of Cognitive Impairment and Brain Injury in Chronic Liver Disease. Neurochem Res 2024; 49:1437-1449. [PMID: 36635437 DOI: 10.1007/s11064-022-03854-z] [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: 07/25/2022] [Revised: 09/23/2022] [Accepted: 12/26/2022] [Indexed: 01/14/2023]
Abstract
The incidence of chronic liver disease is on the rise. One of the primary causes of hospital admissions for patients with cirrhosis is hepatic encephalopathy (HE), a debilitating neurological complication. HE is defined as a reversible syndrome, yet there is growing evidence stating that, under certain conditions, HE is associated with permanent neuronal injury and irreversibility. The pathophysiology of HE primarily implicates a strong role for hyperammonemia, but it is believed other pathogenic factors are involved. The fibrotic scarring of the liver during the progression of chronic liver disease (cirrhosis) consequently leads to increased hepatic resistance and circulatory anomalies characterized by portal hypertension, hyperdynamic circulatory state and systemic hypotension. The possible repercussions of these circulatory anomalies on brain perfusion, including impaired cerebral blood flow (CBF) autoregulation, could be implicated in the development of HE and/or permanent brain injury. Furthermore, hypotensive insults incurring during gastrointestinal bleed, infection, or liver transplantation may also trigger or exacerbate brain dysfunction and cell damage. This review will focus on the role of hypotension in the onset of HE as well as in the occurrence of neuronal cell loss in cirrhosis.
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Affiliation(s)
- Sydnée L'Écuyer
- Hepato-Neuro Laboratory, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis - Pavillon R, R08.422 Montréal (Québec), Québec, H2X 0A9, Canada
| | - Emmanuel Charbonney
- Department of Medicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - François Martin Carrier
- Department of Medicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Carrefour de l'innovation et santé des populations , Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, Canada
| | - Christopher F Rose
- Hepato-Neuro Laboratory, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis - Pavillon R, R08.422 Montréal (Québec), Québec, H2X 0A9, Canada.
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Miyazaki T, Taguchi S, Obata N, Mizobuchi S. Severe hypotension and postoperative cardiac arrest caused by 5-aminolevulinic acid: a case report. J Med Case Rep 2024; 18:264. [PMID: 38811941 PMCID: PMC11137901 DOI: 10.1186/s13256-024-04589-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: 03/22/2024] [Accepted: 05/15/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Although 5-aminolevulinic acid is useful for the photodynamic diagnosis of bladder tumors, it often causes severe intraoperative hypotension. We report a case of postoperative cardiac arrest in addition to severe intraoperative hypotension, probably owing to the use of 5-aminolevulinic acid. CASE PRESENTATION An 81-year-old Japanese man was scheduled to undergo transurethral resection of bladder tumor. The patient took 5-aminolevulinic acid orally 2 hours before entering the operating room. After the induction of anesthesia, his blood pressure decreased to 47/33 mmHg. The patient's hypotension did not improve even after noradrenaline was administered. After awakening from anesthesia, the patient's systolic blood pressure increased to approximately 100 mmHg, but approximately 5 hours after returning to the ward, cardiac arrest occurred for approximately 12 seconds. CONCLUSION We experienced a case of postoperative cardiac arrest in a patient, probably owing to the use of 5-aminolevulinic acid. Although the cause of cardiac arrest is unknown, perioperative hemodynamic management must be carefully performed in patients taking 5-aminolevulinic acid.
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Affiliation(s)
- Taishi Miyazaki
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-Cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Shinya Taguchi
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-Cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Norihiko Obata
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-Cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Satoshi Mizobuchi
- Department of Anesthesiology, Kobe University Hospital, 7-5-1 Kusunoki-Cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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Lee SW, Jang J, Seo WY, Lee D, Kim SH. Internal and External Validation of Machine Learning Models for Predicting Acute Kidney Injury Following Non-Cardiac Surgery Using Open Datasets. J Pers Med 2024; 14:587. [PMID: 38929808 PMCID: PMC11204685 DOI: 10.3390/jpm14060587] [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: 05/07/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
This study developed and validated a machine learning model to accurately predict acute kidney injury (AKI) after non-cardiac surgery, aiming to improve patient outcomes by assessing its clinical feasibility and generalizability. We conducted a retrospective cohort study using data from 76,032 adults who underwent non-cardiac surgery at a single tertiary medical center between March 2019 and February 2021, and used data from 5512 patients from the VitalDB open dataset for external model validation. The predictive variables for model training consisted of demographic, preoperative laboratory, and intraoperative data, including calculated statistical values such as the minimum, maximum, and mean intraoperative blood pressure. When predicting postoperative AKI, our gradient boosting machine model incorporating all the variables achieved the best results, with AUROC values of 0.868 and 0.757 for the internal and external validations using the VitalDB dataset, respectively. The model using intraoperative data performed best in internal validation, while the model with preoperative data excelled in external validation. In this study, we developed a predictive model for postoperative AKI in adult patients undergoing non-cardiac surgery using preoperative and intraoperative data, and external validation demonstrated the efficacy of open datasets for generalization in medical artificial modeling research.
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Affiliation(s)
- Sang-Wook Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; (S.-W.L.); (D.L.)
| | - Jaewon Jang
- Biomedical Engineering Research Center, Biosignal Analysis & Perioperative Outcome Research (BAPOR) Laboratory, Asan Institute for Lifesciences, Seoul 05505, Republic of Korea; (J.J.); (W.-Y.S.)
| | - Woo-Young Seo
- Biomedical Engineering Research Center, Biosignal Analysis & Perioperative Outcome Research (BAPOR) Laboratory, Asan Institute for Lifesciences, Seoul 05505, Republic of Korea; (J.J.); (W.-Y.S.)
| | - Donghee Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; (S.-W.L.); (D.L.)
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; (S.-W.L.); (D.L.)
- Department of Anesthesiology and Pain Medicine, Brain Korea 21 Project, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
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Alves MRD, Saturnino SF, Zen AB, de Albuquerque DGS, Diegoli H. Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis. CRITICAL CARE SCIENCE 2024; 36:e20240196en. [PMID: 38775544 PMCID: PMC11098079 DOI: 10.62675/2965-2774.20240196-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/08/2023] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To provide insights into the potential benefits of goal-directed therapy guided by FloTrac in reducing postoperative complications and improving outcomes. METHODS We performed a systematic review and meta-analysis of randomized controlled trials to evaluate goal-directed therapy guided by FloTrac in major surgery, comparing goal-directed therapy with usual care or invasive monitoring in cardiac and noncardiac surgery subgroups. The quality of the articles and evidence were evaluated with a risk of bias tool and GRADE. RESULTS We included 29 randomized controlled trials with 3,468 patients. Goal-directed therapy significantly reduced the duration of hospital stay (mean difference -1.43 days; 95%CI 2.07 to -0.79; I2 81%), intensive care unit stay (mean difference -0.77 days; 95%CI -1.18 to -0.36; I2 93%), and mechanical ventilation (mean difference -2.48 hours, 95%CI -4.10 to -0.86, I2 63%). There was no statistically significant difference in mortality, myocardial infarction, acute kidney injury or hypotension, but goal-directed therapy significantly reduced the risk of heart failure or pulmonary edema (RR 0.46; 95%CI 0.23 - 0.92; I2 0%). CONCLUSION Goal-directed therapy guided by the FloTrac sensor improved clinical outcomes and shortened the length of stay in the hospital and intensive care unit in patients undergoing major surgery. Further research can validate these results using specific protocols and better understand the potential benefits of FloTrac beyond these outcomes.
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Affiliation(s)
| | - Saulo Fernandes Saturnino
- Universidade Federal de Minas GeraisBelo HorizonteMGBrazilUniversidade Federal de Minas Gerais - Belo Horizonte (MG), Brazil.
| | - Ana Beatriz Zen
- Academia VBHC Educação e ConsultoriaSão PauloSPBrazilAcademia VBHC Educação e Consultoria - São Paulo (SP), Brazil.
| | | | - Henrique Diegoli
- Academia VBHC Educação e ConsultoriaSão PauloSPBrazilAcademia VBHC Educação e Consultoria - São Paulo (SP), Brazil.
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21
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Flick M, Lohr A, Weidemann F, Naebian A, Hoppe P, Thomsen KK, Krause L, Kouz K, Saugel B. Post-anesthesia care unit hypotension in low-risk patients recovering from non-cardiac surgery: a prospective observational study. J Clin Monit Comput 2024:10.1007/s10877-024-01176-9. [PMID: 38758404 DOI: 10.1007/s10877-024-01176-9] [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: 02/08/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024]
Abstract
Intraoperative hypotension is common and associated with organ injury. Hypotension can not only occur during surgery, but also thereafter. After surgery, most patients are treated in post-anesthesia care units (PACU). The incidence of PACU hypotension is largely unknown - presumably in part because arterial pressure is usually monitored intermittently in PACU patients. We therefore aimed to evaluate the incidence, duration, and severity of PACU hypotension in low-risk patients recovering from non-cardiac surgery. In this observational study, we performed blinded continuous non-invasive arterial pressure monitoring with finger-cuffs (ClearSight system; Edwards Lifesciences, Irvine, CA, USA) in 100 patients recovering from non-cardiac surgery in the PACU. We defined PACU hypotension as a mean arterial pressure (MAP) < 65 mmHg. Patients had continuous finger-cuff monitoring for a median (25th percentile, 75th percentile) of 64 (44 to 91) minutes. Only three patients (3%) had PACU hypotension for at least one consecutive minute. These three patients had 4, 4, and 2 cumulative minutes of PACU hypotension; areas under a MAP of 65 mmHg of 17, 9, and 9 mmHg x minute; and time-weighted averages MAP less than 65 mmHg of 0.5, 0.3, and 0.2 mmHg. The median volume of crystalloid fluid patients were given during PACU treatment was 200 (100 to 400) ml. None was given colloids or a vasopressor during PACU treatment. In low-risk patients recovering from non-cardiac surgery, the incidence of PACU hypotension was very low and the few episodes of PACU hypotension were short and of modest severity.
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Affiliation(s)
- Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anneke Lohr
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Weidemann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ashkan Naebian
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
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22
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Yuan R, Xu M, Hu C, Ma H, Meng F, Ren J, Wen J. Hemodynamic effects of withholding vs. continuing angiotensin II receptor blockers on the day of prone positioning spinal surgery in elderly patients. Front Med (Lausanne) 2024; 11:1352918. [PMID: 38765256 PMCID: PMC11100417 DOI: 10.3389/fmed.2024.1352918] [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: 12/09/2023] [Accepted: 02/26/2024] [Indexed: 05/21/2024] Open
Abstract
Introduction The hemodynamic effects of withholding vs. continuing angiotensin II receptor blockers (ARBs) before surgery in elderly patients undergoing spinal surgery in a prone position during anesthesia induction to skin incision are still unknown. Methods In this prospective study, 80 patients undergoing spinal surgery in a prone position with general anesthesia, aged 60-79 years, American Society of Anesthesiologists (ASA) II or III, were enrolled. Patients who had ARBs only in their preoperative medication list were randomly divided into two groups at a 1:1 ratio: In Group A, ARBs were continued on the morning of surgery, while in Group B, they were withhold. Norepinephrine was infused to maintain the blood pressure at the baseline level of ±20% during anesthesia induction in all patients. The primary outcome was the consumption of norepinephrine in each group from anesthesia induction to skin incision. The secondary outcomes include changes in invasive arterial blood pressure and heart rate, the fluid infusion volumes, the amounts of anesthetic drugs, and the total time from induction to skin incision. Results There were no significant differences in the demographics, the fluid infusion volumes, the amounts of anesthetic drugs, the total time from induction to skin incision, and hemodynamics at different time points (p > 0.05), while significant differences were found in norepinephrine consumption between the two groups (p < 0.001). Compared with Group B, the consumption of norepinephrine increased significantly in Group A (93.3 ± 29.8 vs. 124.1 ± 38.7 μg, p = 0.000). In addition, the same trend was illustrated in the pumping rate of norepinephrine between Group B (0.04 ± 0.01 μg·kg-1·min-1) and Group A (0.06 ± 0.02 μg·kg-1·min-1) (p = 0.004). Conclusion Our study conducted in elderly patients with hypotension undergoing prone spinal surgery demonstrated a greater pumping rate of norepinephrine during anesthesia induction in patients with ARBs continuing before surgery than those withholding, indicating that it was more difficult to maintain hemodynamic stability.Clinical Trial Registration: https://www.chictr.org.cn/showproj.html?proj=141081, ChiCTR2100053583.
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Affiliation(s)
- Ruimei Yuan
- Department of Anesthesiology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Min Xu
- Department of Endocrinology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Chunhai Hu
- Department of Urology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Huailing Ma
- Department of Anesthesiology, Shandong Provincial Third Hospital, Jinan, Shandong, China
| | - Fanjun Meng
- Department of Anesthesiology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jie Ren
- Department of Anesthesiology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jing Wen
- Department of Urology, Jinan Central Hospital, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Coeckelenbergh S, Boelefahr S, Alexander B, Perrin L, Rinehart J, Joosten A, Barvais L. Closed-loop anesthesia: foundations and applications in contemporary perioperative medicine. J Clin Monit Comput 2024; 38:487-504. [PMID: 38184504 DOI: 10.1007/s10877-023-01111-4] [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: 09/23/2023] [Accepted: 11/21/2023] [Indexed: 01/08/2024]
Abstract
A closed-loop automatically controls a variable using the principle of feedback. Automation within anesthesia typically aims to improve the stability of a controlled variable and reduce workload associated with simple repetitive tasks. This approach attempts to limit errors due to distractions or fatigue while simultaneously increasing compliance to evidence based perioperative protocols. The ultimate goal is to use these advantages over manual care to improve patient outcome. For more than twenty years, clinical studies in anesthesia have demonstrated the superiority of closed-loop systems compared to manual control for stabilizing a single variable, reducing practitioner workload, and safely administering therapies. This research has focused on various closed-loops that coupled inputs and outputs such as the processed electroencephalogram with propofol, blood pressure with vasopressors, and dynamic predictors of fluid responsiveness with fluid therapy. Recently, multiple simultaneous independent closed-loop systems have been tested in practice and one study has demonstrated a clinical benefit on postoperative cognitive dysfunction. Despite their advantages, these tools still require that a well-trained practitioner maintains situation awareness, understands how closed-loop systems react to each variable, and is ready to retake control if the closed-loop systems fail. In the future, multiple input multiple output closed-loop systems will control anesthetic, fluid and vasopressor titration and may perhaps integrate other key systems, such as the anesthesia machine. Human supervision will nonetheless always be indispensable as situation awareness, communication, and prediction of events remain irreplaceable human factors.
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Affiliation(s)
- Sean Coeckelenbergh
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Assistance Publique Hôpitaux de Paris, Villejuif, France.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Sebastian Boelefahr
- Department of Anesthesiology and Intensive Care, Klinikum Aschaffenburg-Alzenau, Frankfurt University and Wuerzburg University Affiliated Academic Training Hospital, Aschaffenburg, Germany
| | - Brenton Alexander
- Department of Anesthesiology & Perioperative Care, University of California San Diego, San Diego, CA, USA
| | - Laurent Perrin
- Department of Anaesthesia and Resuscitation, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Joseph Rinehart
- Outcomes Research Consortium, Cleveland, OH, USA
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - Alexandre Joosten
- Department of Anesthesiology & Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Luc Barvais
- Department of Anaesthesia and Resuscitation, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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24
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Scott MJ. Perioperative Patients With Hemodynamic Instability: Consensus Recommendations of the Anesthesia Patient Safety Foundation. Anesth Analg 2024; 138:713-724. [PMID: 38153876 PMCID: PMC10916753 DOI: 10.1213/ane.0000000000006789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 12/30/2023]
Abstract
In November of 2022, the Anesthesia Patient Safety Foundation held a Consensus Conference on Hemodynamic Instability with invited experts. The objective was to review the science and use expert consensus to produce best practice recommendations to address the issue of perioperative hemodynamic instability. After expert presentations, a modified Delphi process using discussions, voting, and feedback resulted in 17 recommendations regarding advancing the perioperative care of the patient at risk of, or with, hemodynamic instability. There were 17 high-level recommendations. These recommendations related to the following 7 domains: Current Knowledge (5 statements); Preventing Hemodynamic Instability-Related Harm During All Phases of Care (4 statements); Data-Driven Quality Improvement (3 statements); Informing Patients (2 statements); The Importance of Technology (1 statement); Launch a National Campaign (1 statement); and Advancing the Science (1 statement). A summary of the recommendations is presented in Table 1 .
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Affiliation(s)
- Michael J. Scott
- From the Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Anesthesia Critical Care and Pain Medicine, University College London, London, United Kingdom
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25
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Zewdu M, Mersha AT, Ashagre HE, Arefayne NR, Tegegne BA. Incidence of intraoperative hypotension and its factors among adult traumatic head injury patients in comprehensive specialized hospitals, Northwest Ethiopia: a multicenter observational study. BMC Anesthesiol 2024; 24:125. [PMID: 38561657 PMCID: PMC10983668 DOI: 10.1186/s12871-024-02511-y] [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: 01/10/2024] [Accepted: 03/26/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Traumatic head injury (THI) poses a significant global public health burden, often contributing to mortality and disability. Intraoperative hypotension (IH) during emergency neurosurgery for THI can adversely affect perioperative outcomes, and understanding associated risk factors is essential for prevention. METHOD A multi-center observational study was conducted from February 10 to June 30, 2022. A simple random sampling technique was used to select the study participants. Patient data were analyzed using bivariate and multivariate logistic regression to identify significant factors associated with intraoperative hypotension (IH). Odds ratios with 95% confidence intervals were used to show the strength of association, and P value < 0.05 was considered as statistically significant. RESULT The incidence of intra-operative hypotension was 46.41% with 95%CI (39.2,53.6). The factors were duration of anesthesia ≥ 135 min with AOR: 4.25, 95% CI (1.004,17.98), severe GCS score with AOR: 7.23, 95% CI (1.098,47.67), intracranial hematoma size ≥ 15 mm with AOR: 7.69, 95% CI (1.18,50.05), and no pupillary abnormality with AOR: 0.061, 95% CI (0.005,0.732). CONCLUSION AND RECOMMENDATION: The incidence of intraoperative hypotension was considerably high. The duration of anesthesia, GCS score, hematoma size, and pupillary abnormalities were associated. The high incidence of IH underscores the need for careful preoperative neurological assessment, utilizing CT findings, vigilance for IH in patients at risk, and proactive management of IH during surgery. Further research should investigate specific mitigation strategies.
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Affiliation(s)
- Melaku Zewdu
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Abraham Tarekegn Mersha
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Henos Enyew Ashagre
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Nurhusen Riskey Arefayne
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Biresaw Ayen Tegegne
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
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26
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de Keijzer IN, Vos JJ, Yates D, Reynolds C, Moore S, Lawton RJ, Scheeren TWL, Davies SJ. Impact of clinicians' behavior, an educational intervention with mandated blood pressure and the hypotension prediction index software on intraoperative hypotension: a mixed methods study. J Clin Monit Comput 2024; 38:325-335. [PMID: 38112879 PMCID: PMC10995090 DOI: 10.1007/s10877-023-01097-z] [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: 08/18/2023] [Accepted: 10/21/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE Intraoperative hypotension (IOH) is associated with adverse outcomes. We therefore explored beliefs regarding IOH and barriers to its treatment. Secondarily, we assessed if an educational intervention and mandated mean arterial pressure (MAP), or the implementation of the Hypotension Prediction Index-software (HPI) were associated with a reduction in IOH. METHODS Structured interviews (n = 27) and questionnaires (n = 84) were conducted to explore clinicians' beliefs and barriers to IOH treatment, in addition to usefulness of HPI questionnaires (n = 14). 150 elective major surgical patients who required invasive blood pressure monitoring were included in three cohorts to assess incidence and time-weighted average (TWA) of hypotension (MAP < 65 mmHg). Cohort one received standard care (baseline), the clinicians of cohort two had a training on hypotension and a mandated MAP > 65 mmHg, and patients of the third cohort received protocolized care using the HPI. RESULTS Clinicians felt challenged to manage IOH in some patients, yet they reported sufficient knowledge and skills. HPI-software was considered useful and beneficial. No difference was found in incidence of IOH between cohorts. TWA was comparable between baseline and education cohort (0.15 mmHg [0.05-0.41] vs. 0.11 mmHg [0.02-0.37]), but was significantly lower in the HPI cohort (0.04 mmHg [0.00 to 0.11], p < 0.05 compared to both). CONCLUSIONS Clinicians believed they had sufficient knowledge and skills, which could explain why no difference was found after the educational intervention. In the HPI cohort, IOH was significantly reduced compared to baseline, therefore HPI-software may help prevent IOH. TRIAL REGISTRATION ISRCTN 17,085,700 on May 9th, 2019.
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Affiliation(s)
- Ilonka N de Keijzer
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands.
| | - Jaap Jan Vos
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands
| | - David Yates
- Department of Anesthesia, Critical Care and Perioperative Medicine York Teaching Hospitals NHS Foundation Trust, Centre for Health and Population Sciences, Hull York Medical School, York, UK
| | - Caroline Reynolds
- Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Sally Moore
- Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | | | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands
| | - Simon J Davies
- Department of Anesthesia, Critical Care and Perioperative Medicine York Teaching Hospitals NHS Foundation Trust, Centre for Health and Population Sciences, Hull York Medical School, York, UK
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Lynch D, Mongan PD, Hoefnagel AL. The impact of an anesthesia residency teaching service on anesthesia-controlled time and postsurgical patient outcomes: a retrospective observational study on 15,084 surgical cases. Patient Saf Surg 2024; 18:12. [PMID: 38561787 PMCID: PMC10985884 DOI: 10.1186/s13037-024-00394-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Limited data exists regarding the impact of anesthesia residents on operating room efficiency and patient safety outcomes. This investigation hypothesized that supervised anesthesiology residents do not increase anesthesia-controlled or prolonged extubation times compared to supervised certified registered nurse anesthetists (CRNA)/certified anesthesiologist assistants (CAA) or anesthesiologists working independently. Secondary objectives included differences in critical outcomes such as intraoperative hypotension, cardiac and pulmonary complications, acute kidney injury, and mortality. METHODS This retrospective single-center 24-month (January 1, 2020- December 31, 2021) cohort focused on primary outcomes of anesthesia-controlled times and prolonged extubation (>15 min) with additional assessment of secondary patient outcomes in adult patients having general anesthesia with an endotracheal tube or laryngeal mask airway for elective non-cardiac surgery. The study excluded sedation, obstetric, endoscopic, ophthalmology, and non-operating room procedures. Procedures were divided into three groups: anesthesiologists working solo, anesthesiologists supervising residents, or anesthesiologists supervising CRNA/CAAs. After univariate analysis, multivariable models were constructed to control for the univariate cofactor differences in the primary and secondary outcomes. RESULTS A total of 15,084 surgical cases met the inclusion criteria for this study for the three different care models: solo anesthesiologists (1,204 cases), anesthesiologist/resident pairing (3,146 cases), and anesthesiologist/CRNA/CAA (14,040 cases). Before multivariate analysis, the resident group exhibited longer anesthesia-controlled times (median, [interquartile range], 26.1 [21.7-32.0], p < 0.001), compared to CRNA/CAA (23.9 [19.7-29.5]), and attending-only surgical cases (21.0 [17.9-25.4]). After adjusting for covariates in a general linear regression model (age, BMI, ASA classification, comorbidities, arterial line insertion, surgical service, and surgical location), there were no significant differences in the anesthesia-controlled times between the provider groups. Prolonged extubation times (>15 min) were significantly less common in the anesthesiologist-only group compared to the other groups (p < 0.001). Despite these time differences, there were no clinically significant differences among the groups in postoperative pulmonary or cardiac complications, renal impairment, or the 30-day mortality rate of patients. CONCLUSION Anesthesia residents do not increase anesthesia-controlled operating room times or adversely affect clinically relevant patient outcomes compared to anesthesiologists working independently or supervising certified registered nurse anesthetists or certified anesthesiologist assistants.
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Affiliation(s)
- Davene Lynch
- University of Florida College of Medicine, Jacksonville, USA
| | - Paul D Mongan
- University of Florida College of Medicine, Jacksonville, USA.
- University of Florida College of Medicine- Jacksonville, 655 West 8th Street, 32209, Jacksonville, FL, Box C-72, USA.
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28
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Bao X, Kumar SS, Shah NJ, Penning D, Weinstein M, Malhotra G, Rose S, Drover D, Pennington MW, Domino K, Meng L, Treggiari M, Clavijo C, Wagener G, Chitilian H, Maheshwari K. AcumenTM hypotension prediction index guidance for prevention and treatment of hypotension in noncardiac surgery: a prospective, single-arm, multicenter trial. Perioper Med (Lond) 2024; 13:13. [PMID: 38439069 PMCID: PMC10913612 DOI: 10.1186/s13741-024-00369-9] [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: 08/06/2023] [Accepted: 02/25/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Intraoperative hypotension is common during noncardiac surgery and is associated with postoperative myocardial infarction, acute kidney injury, stroke, and severe infection. The Hypotension Prediction Index software is an algorithm based on arterial waveform analysis that alerts clinicians of the patient's likelihood of experiencing a future hypotensive event, defined as mean arterial pressure < 65 mmHg for at least 1 min. METHODS Two analyses included (1) a prospective, single-arm trial, with continuous blood pressure measurements from study monitors, compared to a historical comparison cohort. (2) A post hoc analysis of a subset of trial participants versus a propensity score-weighted contemporaneous comparison group, using external data from the Multicenter Perioperative Outcomes Group (MPOG). The trial included 485 subjects in 11 sites; 406 were in the final effectiveness analysis. The post hoc analysis included 457 trial participants and 15,796 comparison patients. Patients were eligible if aged 18 years or older, American Society of Anesthesiologists (ASA) physical status 3 or 4, and scheduled for moderate- to high-risk noncardiac surgery expected to last at least 3 h. MEASUREMENTS minutes of mean arterial pressure (MAP) below 65 mmHg and area under MAP < 65 mmHg. RESULTS Analysis 1: Trial subjects (n = 406) experienced a mean of 9 ± 13 min of MAP below 65 mmHg, compared with the MPOG historical control mean of 25 ± 41 min, a 65% reduction (p < 0.001). Subjects with at least one episode of hypotension (n = 293) had a mean of 12 ± 14 min of MAP below 65 mmHg compared with the MPOG historical control mean of 28 ± 43 min, a 58% reduction (p< 0.001). Analysis 2: In the post hoc inverse probability treatment weighting model, patients in the trial demonstrated a 35% reduction in minutes of hypotension compared to a contemporaneous comparison group [exponentiated coefficient: - 0.35 (95%CI - 0.43, - 0.27); p < 0.001]. CONCLUSIONS The use of prediction software for blood pressure management was associated with a clinically meaningful reduction in the duration of intraoperative hypotension. Further studies must investigate whether predictive algorithms to prevent hypotension can reduce adverse outcomes. TRIAL REGISTRATION Clinical trial number: NCT03805217. Registry URL: https://clinicaltrials.gov/ct2/show/NCT03805217 . Principal investigator: Xiaodong Bao, MD, PhD. Date of registration: January 15, 2019.
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Affiliation(s)
- Xiaodong Bao
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Sathish S Kumar
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nirav J Shah
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Donald Penning
- Department of Anesthesiology, Henry Ford Health System, Detroit, MI, USA
| | - Mitchell Weinstein
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gaurav Malhotra
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sydney Rose
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - David Drover
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Matthew W Pennington
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Karen Domino
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Lingzhong Meng
- Department of Anesthesiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mariam Treggiari
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Claudia Clavijo
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gebhard Wagener
- Department of Anesthesiology, College of Physicians & Surgeons of Columbia University, New York, NY, USA
| | - Hovig Chitilian
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kamal Maheshwari
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
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Willie-Permor D, Rahgozar S, Zarrintan S, Alsaigh T, Gaffey AC, Malas MB. Patients with Prior Exposure to a Combination of Statins & Angiotensin-Converting Enzyme Inhibitors (ACE-Is)/Angiotensin Receptor Blockers (ARBs) Have Better Outcomes after Carotid Revascularization than Patients with Prior Exposure to Statins Alone: A MultiCenter Analysis. Ann Vasc Surg 2024; 100:165-171. [PMID: 37852362 DOI: 10.1016/j.avsg.2023.08.036] [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: 04/01/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Statin use has been studied and confirmed to have a beneficial impact on perioperative carotid endarterectomy (CEA) and carotid artery stenting (CAS) outcomes. The benefits of Angiotensin-converting enzyme inhibitors (ACE-I) in hypertension, ischemic heart disease, heart failure, diabetes mellitus, and renal disease are well-known; however, the impact of continuing or withholding ACE-Is/angiotensin receptor blockers (ARBs) on CEA and CAS outcomes is not addressed well in the literature. This study aimed to evaluate the impact of preoperative statin use combined with ACE-Is/ARBs in patients undergoing CEA or CAS on mortality and morbidity using a multi-institutional database. METHODS Using the data of all patients who underwent carotid artery revascularization, including CEA, transcarotid artery revascularization, and transfemoral carotid artery stenting from 2016 to 2021 in the Vascular Quality Initiative data, we determined as our primary outcome 30-day mortality/stroke after carotid revascularization based on periop exposure to statins alone, or the combination of statins and ACE-Is/ARBs. Secondary outcomes were postop myocardial infarction and postop congestive heart failure. Poisson regression with robust variance was used to determine postop outcomes comparing the combination of statin and ACE-Is/ARBs group with statins alone group. RESULTS A total of 131,285 patients were included in the study, with 59,860 (46%) patients receiving statin only, and 71,425 (54%) receiving both statin and ACE-Is/ARBs preoperatively. Both patient groups differed significantly in preop clinical and demographic characteristics. After adjusting for potential confounders, the statins plus ACE-I/ARB group had a 12% lower risk of postop mortality/stroke (Incident Rate Ratio comparing Statin/ACE group to Statins Only group [IRR] 0.88, 95% confidence interval 0.81-0.95, P = 0.001), 18% lower risk of postop congestive heart failure (IRR 0.82, 95% CI 0.68-0.98, P = 0.029), and similar risk of postop myocardial infarction (IRR 1.05 95% confidence interval 0.91-1.20, P = 0.54) compared to the statin-only group. CONCLUSION Statins combined with ACE-Is/ARBs perioperatively offer better protection compared to statins alone in patients undergoing carotid revascularization surgery. We recommend the continuation of ACE-Is/ARBs use in patients undergoing carotid revascularization, especially if they have concurrent hypertension. Further prospective studies are needed to evaluate the benefit of adding ACE-Is/ARBs.
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Affiliation(s)
- Daniel Willie-Permor
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA
| | - Shima Rahgozar
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA
| | - Sina Zarrintan
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA
| | - Tom Alsaigh
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA
| | - Ann C Gaffey
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA
| | - Mahmoud B Malas
- Department of Surgery, Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), University of California San Diego (UCSD), La Jolla, CA.
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Philteos J, McCluskey SA, Emerson S, Djaiani G, Goldstein D, Soussi S. Impact of goal-directed hemodynamic therapy on perioperative outcomes in head and neck free flap surgery: A before-and-after pilot study. Health Sci Rep 2024; 7:e1943. [PMID: 38524770 PMCID: PMC10959725 DOI: 10.1002/hsr2.1943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/29/2023] [Accepted: 02/07/2024] [Indexed: 03/26/2024] Open
Abstract
Background Free flap reconstruction for head and neck cancer is associated with a high risk of perioperative complications. One of the modifiable risk factors associated with perioperative morbidity is intraoperative hypotension (IOH). The main aim of this pilot study is to determine if the intraoperative use of goal-directed hemodynamic therapy (GDHT) is associated with a reduction in the number of IOH events in this population. Methods A before-and-after study design. The patients who had intraoperative GDHT were compared to patients from a previous period before the implementation of GDHT. The primary outcome was the number of IOH episodes defined as five or more successive minutes with a mean arterial pressure <65 mmHg. The secondary outcomes included major postoperative morbidity and 30-day mortality. Results A total of 414 patients were included. These were divided into two groups. The control group (n = 346; January 1, 2018, to December 31, 2019), and the monitored group (n = 68; January 1, 2020, to May 1, 2021). The median intraoperative administered fluid volume was similar between the control and monitored groups (2250 interquartile range [IQR] [1607-3050] vs. 2210 IQR [1700-2807] mL). The monitored group was found to have an increased use of norepinephrine and dobutamine (respectively, 1.2% vs. 5.9% and 2.4% vs. 30.9%; p < 0.05). When adjusting for confounders (comorbidities, estimated blood loss, and duration of anesthesia) the incidence rate ratio (95% confidence interval) of number of IOH events was 0.94 (0.86-1.03), p = 0.24. The rate of postoperative flap and medical complications did not differ between the two groups. Conclusions Even though the use of vasopressors/inotropes was higher in the monitored group, the number of IOH episodes and postoperative morbidity and mortality were similar between the two groups. Further change in hemodynamic management will require the use of specific blood pressure targets in the GDHT fluid algorithm.
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Affiliation(s)
- Justine Philteos
- Department of Otolaryngology—Head and Neck SurgeryUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Stuart A. McCluskey
- Department of Anesthesiology and Pain MedicineUniversity of TorontoTorontoOntarioCanada
- Department of Anesthesia and Pain ManagementToronto General Hospital, University Health NetworkTorontoOntarioCanada
| | - Sophia Emerson
- Department of Anesthesiology and Pain MedicineUniversity of TorontoTorontoOntarioCanada
- Department of Anesthesia and Pain ManagementToronto General Hospital, University Health NetworkTorontoOntarioCanada
| | - George Djaiani
- Department of Anesthesiology and Pain MedicineUniversity of TorontoTorontoOntarioCanada
- Department of Anesthesia and Pain ManagementToronto General Hospital, University Health NetworkTorontoOntarioCanada
| | - David Goldstein
- Department of Otolaryngology—Head and Neck SurgeryUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Sabri Soussi
- Department of Anesthesiology and Pain MedicineUniversity of TorontoTorontoOntarioCanada
- Department of Anesthesia and Pain ManagementToronto Western Hospital, University Health NetworkTorontoOntarioCanada
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Nakanishi T, Tsuji T, Sento Y, Hashimoto H, Fujiwara K, Sobue K. Association between postinduction hypotension and postoperative mortality: a single-centre retrospective cohort study. Can J Anaesth 2024; 71:343-352. [PMID: 37989941 PMCID: PMC10923972 DOI: 10.1007/s12630-023-02653-6] [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: 04/14/2023] [Revised: 08/12/2023] [Accepted: 08/16/2023] [Indexed: 11/23/2023] Open
Abstract
PURPOSE We aimed to elucidate whether postinduction hypotension (PIH), defined as hypotension between anesthesia induction and skin incision, and intraoperative hypotension (IOH) are associated with postoperative mortality. METHODS We conducted a retrospective cohort study of adult patients with an ASA Physical Status I-IV who underwent noncardiac and nonobstetric surgery under general anesthesia between 2015 and 2021 at Nagoya City University Hospital. The primary and secondary outcomes were 30-day and 90-day postoperative mortality, respectively. We calculated four hypotensive indices (with time proportion of the area under the threshold being the primary exposure variable) to evaluate the association between hypotension (defined as a mean blood pressure < 65 mm Hg) and mortality using multivariable logistic regression models. We used propensity score matching and RUSBoost (random under-sampling and boosting), a machine-learning model for imbalanced data, for sensitivity analyses. RESULTS Postinduction hypotension and IOH were observed in 82% and 84% of patients, respectively. The 30-day and 90-day postoperative mortality rates were 0.4% (52/14,210) and 1.0% (138/13,334), respectively. Postinduction hypotension was not associated with 30-day mortality (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.93 to 1.13; P = 0.60) and 90-day mortality (aOR, 1.01; 95% CI, 0.94 to 1.07; P = 0.82). Conversely, IOH was associated with 30-day mortality (aOR, 1.19; 95% CI, 1.12 to 1.27; P < 0.001) and 90-day mortality (aOR, 1.12; 95% CI, 1.06 to 1.19; P < 0.001). Sensitivity analyses supported the association of IOH but not PIH with postoperative mortality. CONCLUSION Despite limitations, including power and residual confounding, postoperative mortality was associated with IOH but not with PIH.
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Affiliation(s)
- Toshiyuki Nakanishi
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Japan.
- Department of Materials Process Engineering, Nagoya University, Nagoya, Japan.
| | - Tatsuya Tsuji
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoshiki Sento
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroya Hashimoto
- Clinical Research Management Center, Nagoya City University Hospital, Nagoya, Japan
| | - Koichi Fujiwara
- Department of Materials Process Engineering, Nagoya University, Nagoya, Japan
| | - Kazuya Sobue
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Saugel B, Annecke T, Bein B, Flick M, Goepfert M, Gruenewald M, Habicher M, Jungwirth B, Koch T, Kouz K, Meidert AS, Pestel G, Renner J, Sakka SG, Sander M, Treskatsch S, Zitzmann A, Reuter DA. Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies. J Clin Monit Comput 2024:10.1007/s10877-024-01132-7. [PMID: 38381359 DOI: 10.1007/s10877-024-01132-7] [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: 01/18/2024] [Accepted: 01/25/2024] [Indexed: 02/22/2024]
Abstract
Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Thorsten Annecke
- Department of Anesthesiology and Intensive Care Medicine, Cologne Merheim Medical Center, Hospital of the University of Witten/Herdecke, Cologne, Germany
| | - Berthold Bein
- Department for Anaesthesiology, Asklepios Hospital Hamburg St. Georg, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Goepfert
- Department of Anaesthesiology and Intensive Care Medicine, Alexianer St. Hedwigkliniken Berlin, Berlin, Germany
| | - Matthias Gruenewald
- Department of Anaesthesiology and Intensive Care Medicine, Evangelisches Amalie Sieveking Krankenhaus, Hamburg, Germany
| | - Marit Habicher
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Bettina Jungwirth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Tilo Koch
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Agnes S Meidert
- Department of Anaesthesiology, University Hospital LMU Munich, Munich, Germany
| | - Gunther Pestel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jochen Renner
- Department of Anesthesiology and Intensive Care Medicine, Municipal Hospital Kiel, Kiel, Germany
| | - Samir G Sakka
- Department of Intensive Care Medicine, Gemeinschaftsklinikum Mittelrhein gGmbH, Academic Teaching Hospital of the Johannes Gutenberg University Mainz, Koblenz, Germany
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Amelie Zitzmann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
| | - Daniel A Reuter
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
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Cylwik J, Celińska-Spodar M, Dudzic M. Individualized Perioperative Hemodynamic Management Using Hypotension Prediction Index Software and the Dynamics of Troponin and NTproBNP Concentration Changes in Patients Undergoing Oncological Abdominal Surgery. J Pers Med 2024; 14:211. [PMID: 38392644 PMCID: PMC10890224 DOI: 10.3390/jpm14020211] [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: 01/15/2024] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION Abdominal oncologic surgeries pose significant risks due to the complexity of the surgery and patients' often weakened health, multiple comorbidities, and increased perioperative hazards. Hypotension is a major risk factor for perioperative cardiovascular complications, necessitating individualized management in modern anesthesiology. AIM This study aimed to determine the dynamics of changes in troponin and NTproBNP levels during the first two postoperative days in patients undergoing major cancer abdominal surgery with advanced hemodynamic monitoring including The AcumenTM Hypotension Prediction Index software (HPI) (Edwards Lifesciences, Irvine, CA, USA) and their association with the occurrence of postoperative cardiovascular complications. METHODS A prospective study was conducted, including 50 patients scheduled for abdominal cancer surgery who, due to the overall risk of perioperative complications (ASA class 3 or 4), were monitored using the HPI software. Hypotension was qualified as at least one ≥ 1 min episode of a MAP < 65 mm Hg. Preoperatively and 24 and 48 h after the procedure, the levels of NTproBNP and troponin were measured, and an ECG was performed. RESULTS We analyzed data from 46 patients and found that 82% experienced at least one episode of low blood pressure (MAP < 65 mmHg). However, the quality indices of hypotension were low, with a median time-weighted average MAP < 65 mmHg of 0.085 (0.03-0.19) mmHg and a median of 2 (2-1.17) minutes spent below MAP < 65 mmHg. Although the incidence of perioperative myocardial injury was 10%, there was no evidence to suggest a relationship with hypotension. Acute kidney injury was seen in 23.9% of patients, and it was significantly associated with a number of episodes of MAP < 50 mmHg. Levels of NTproBNP were significantly higher on the first postoperative day compared to preoperative values (285.8 [IQR: 679.8] vs. 183.9 [IQR: 428.1] pg/mL, p < 0.001). However, they decreased on the second day (276.65 [IQR: 609.4] pg/mL, p = 0.154). The dynamics of NTproBNP were similar for patients with and without heart failure, although those with heart failure had significantly higher preoperative concentrations (435.9 [IQR: 711.15] vs. 87 [IQR: 232.2] pg/mL, p < 0.001). Patients undergoing laparoscopic surgery showed a statistically significant increase in NTproBNP. CONCLUSIONS This study suggests that advanced HPI monitoring in abdominal cancer surgery effectively minimizes intraoperative hypotension with no significant NTproBNP or troponin perioperative dynamics, irrespective of preoperative heart failure.
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Affiliation(s)
- Jolanta Cylwik
- Anesthesiology and Intensive Care Unit, Mazovia Regional Hospital, 08-110 Siedlce, Poland
| | - Małgorzata Celińska-Spodar
- Anesthesiology and Intensive Care Unit, Mazovia Regional Hospital, 08-110 Siedlce, Poland
- Anesthesiology and Intensive Care Unit, The National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Mariusz Dudzic
- Critical Care, Edwards Lifesciences, 00-807 Warsaw, Poland
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Spataru A, Eiben P, Pluddemann A. Performance of closed-loop systems for intravenous drug administration: a systematic review and meta-analysis of randomised controlled trials. J Clin Monit Comput 2024; 38:5-18. [PMID: 37695449 DOI: 10.1007/s10877-023-01069-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/13/2023] [Indexed: 09/12/2023]
Abstract
Closed-loop drug delivery systems are autonomous computers able to administer medication in response to changes in physiological parameters (controlled variables). While limited evidence suggested that closed-loop systems can perform better than manual drug administration in certain settings, this technology remains a research tool with an uncertain risk/benefit profile. Our aim was comparing the performance of closed-loop systems with manual intravenous drug administration in adults. We searched MEDLINE, CENTRAL, and Embase from inception until November 2022, without restriction to language. We assessed for inclusion randomised controlled trials comparing closed-loop and manual administration of intravenous drugs in adults, intraoperatively or in the Intensive Care Unit. We identified 32 studies on closed-loop administration of propofol, noradrenaline, phenylephrine, insulin, neuromuscular blockers, and vasodilators. Most studies were at moderate or high risk of bias. The results showed that closed-loop systems reduced the duration of blood pressure outside prespecified targets during noradrenaline (MD 14.9%, 95% CI 9.6-20.2%, I2 = 66.6%) and vasodilators administration (MD 7.4%, 95% CI 5.2-9.7%, I2 = 62.3%). Closed-loop systems also decreased the duration of recovery after propofol (MD 1.3 min, 95% CI 0.4-2.1 min, I2 = 58.6%) and neuromuscular blockers (MD 9.0 min, 95% CI 7.9-10.0 min, I2 = 0%). The certainty of the evidence was low or very low for most outcomes. Automatic technology may be used to improve the hemodynamic profile during noradrenaline and vasodilators administration and reduce the duration of postanaesthetic recovery.Registration: This systematic review was registered with PROSPERO (CRD42022336950) on the 7th of June 2022.
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Affiliation(s)
- Ana Spataru
- Department of Neurocritical Care, Southampton General Hospital, Hampshire, SO164YO, UK.
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK.
| | - Paola Eiben
- Department of Anaesthesia, St. Bartholomew's Hospital, Barts Health NHS Trust, London, EC1A7BE, UK
| | - Annette Pluddemann
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
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Huang S, Liao Z, Chen A, Wang J, Xu X, Zhang L. Effect of carotid corrected flow time combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients: a prospective cohort study. Int J Surg 2024; 110:799-809. [PMID: 37983823 PMCID: PMC10871564 DOI: 10.1097/js9.0000000000000863] [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: 08/10/2023] [Accepted: 10/22/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Hypotension often occurs following the induction of general anesthesia in elderly patients undergoing surgery and can lead to severe complications. This study assessed the effect of carotid corrected flow time (FTc) combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients. MATERIALS AND METHODS The prospective cohort study was divided into two parts. The first part (Part I) consisted of 112 elderly patients. Carotid FTc was measured using Color Doppler Ultrasound 5 min before anesthesia induction. Hypotension was defined as a decrease of greater than 30% in systolic blood pressure (SBP) or a decrease of greater than 20% in mean arterial pressure (MAP) from baseline, or an absolute SBP below 90 mmHg and MAP below 60 mmHg within 3 min after induction of general anesthesia. The predictive value of carotid FTc was determined using receiver operating characteristic (ROC) curve. The second part (Part II) consisted of 65 elderly patients. Based on the results in Part I, elderly patients with carotid FTc below the optimal cut-off value received perioperative fluid therapy at a volume of 8 ml/kg of balanced crystalloids (lactated Ringer's solution) in 30 min before induction. The effect of carotid FTc combined with perioperative fluid therapy was assessed by comparing observed incidence of hypotension after induction. RESULTS The area under the ROC for carotid FTc to predict hypotension after induction was 0.876 [95% confidence interval (CI) 0.800-0.952, P <0.001]. The optimal cut-off value was 334.95 ms (sensitivity of 87.20%; specificity of 82.20%). The logistic regression analysis revealed that carotid FTc is an independent predictor for post-induction hypotension in elderly patients. The incidence of post-induction hypotension was significantly lower ( P <0.001) in patients with carotid FTc less than 334.95 ms who received perioperative fluid therapy (35.71%) compared to those who did not (92.31%). CONCLUSIONS Carotid FTc combined with the perioperative fluid therapy could significantly reduce the incidence of hypotension after the induction of general anesthesia in elderly patients.
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Affiliation(s)
- Shishi Huang
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou
| | - Zhenqi Liao
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou
| | - Andi Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, People’s Republic of China
| | - Jiali Wang
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou
| | - Xiaodong Xu
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou
| | - Liangcheng Zhang
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou
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Johnson KL, Meyers JS, Mortensen GN, Steege JR, Mara KC, Brinkman NJ. Remimazolam: A Retrospective Study of Initial Safety and Recovery Data in Diverse Procedural Sedation. Clin Ther 2024; 46:90-95. [PMID: 38071132 DOI: 10.1016/j.clinthera.2023.11.004] [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: 07/29/2023] [Revised: 11/02/2023] [Accepted: 11/10/2023] [Indexed: 02/27/2024]
Abstract
PURPOSE The new ultra-short-acting benzodiazepine, remimazolam, offers a pharmacokinetic and pharmacodynamic advantage over commonly used procedural sedation medication. This retrospective study explored the real-world utilization of remimazolam during procedural sedation to support the development of a nurse sedation protocol. The primary outcome was to identify associations between recovery time, adverse reactions, and dose-response in expanded patient populations. METHODS This study reviewed charts of 292 adult patients from 3 hospitals within one institution who received remimazolam during procedural sedation between June 1, 2021 and December 31, 2021. Data were analyzed using logistic and linear regression. FINDINGS The median time to alert in patients receiving remimazolam alone was 12 minutes (interquartile range 10, 17) and increased when additional sedation medications were utilized. Receiving additional sedative medication significantly increased the odds of hypoxia (OR 2.77, 95% CI 1.30-5.91, P = 0.008) after adjusting for body mass index (BMI), American Society of Anesthesiologists physical status (ASA-PS), and total remimazolam dose. There was a 25% increase in odds of experiencing hypoxia for every 5 kg/m2 increase in BMI (95% CI 1.01-1.54, P = 0.037). IMPLICATIONS Remimazolam presents as a promising option for nurse procedural sedation, offering minimal impact on hemodynamics and respirations, quick recovery, and no residual sedative effects.
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Zhang K, Wang L, Qi F, Meng T. Hypotensive Levels on Endoscopic Sinus Surgery Visibility: A Randomized Non-Inferiority Trial. Laryngoscope 2024; 134:569-576. [PMID: 37449719 DOI: 10.1002/lary.30867] [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: 04/12/2023] [Revised: 06/02/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Optimization of endoscopic sinus surgery (ESS) conditions is a common focus of interest for otolaryngologists and anesthesiologists. Relying on hypotension alone to achieve a bloodless field may not without risks. We sought to determine whether ESS is feasible in the context of moderate hypotension. METHODS This randomized non-inferiority trial enrolled 96 adult patients who were to undergo ESS. The patients were divided into two groups: Controlled hypotension group (n = 48, MAP reduction to 55-65 mmHg, minimum of 60% of baseline blood pressure) or Individualized hypotension group (n = 48, MAP reduction to 75-80% of baseline blood pressure). All participants were placed in 10° reverse Trendelenburg position during ESS, and cottonoid patties dammed with epinephrine was recommended to clear the operative field of bleeding. The two groups were compared according to Boezaart grading scale (BS) score, estimated blood loss, blood loss rate, arterial lactate level and postoperative recovery. RESULTS Both levels of intraoperative hypotension (62.2 ± 2.3 mmHg vs. 74.0 ± 2.8 mmHg) provided acceptable surgical conditions with no difference in mean BS scores [2.00 (1.88-2.33) vs. 2.00 (1.85-2.45), p = 0.926]. The 95% CI for median value differences in mean BS scores is lower than the preset non-inferiority margin. There were no differences in blood loss rate and estimated blood loss between two groups (p > 0.05) Postoperative arterial lactate and Ramsay sedation scores were significantly different between the two groups (p < 0.05). CONCLUSIONS In ESS, both levels of intraoperative hypotension, combined with position adjustment and low-concentration adrenaline to constrict nasal mucosal blood vessels, provided acceptable surgical conditions. LEVEL OF EVIDENCE 2 Laryngoscope, 134:569-576, 2024.
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Affiliation(s)
- Kangda Zhang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Lichun Wang
- Department of Pain Management, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Feng Qi
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Tao Meng
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
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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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Dong Z, Chen X, Ritter J, Bai L, Huang J. American society of anesthesiologists physical status classification significantly affects the performances of machine learning models in intraoperative hypotension inference. J Clin Anesth 2024; 92:111309. [PMID: 37922642 PMCID: PMC10873053 DOI: 10.1016/j.jclinane.2023.111309] [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: 07/02/2023] [Revised: 09/24/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
STUDY OBJECTIVE To explore how American Society of Anesthesiologists (ASA) physical status classification affects different machine learning models in hypotension prediction and whether the prediction uncertainty could be quantified. DESIGN Observational Studies SETTING: UofL health hospital PATIENTS: This study involved 562 hysterectomy surgeries performed on patients (≥ 18 years) between June 2020 and July 2021. INTERVENTIONS None MEASUREMENTS: Preoperative and intraoperative data is collected. Three parametric machine learning models, including Bayesian generalized linear model (BGLM), Bayesian neural network (BNN), a newly proposed BNN with multivariate mixed responses (BNNMR), and one nonparametric model, Gaussian Process (GP), were explored to predict patients' diastolic and systolic blood pressures (continuous responses) and patients' hypotensive event (binary response) for the next five minutes. Data was separated into American Society of Anesthesiologists (ASA) physical status class 1- 4 before being read in by four machine learning models. Statistical analysis and models' constructions are performed in Python. Sensitivity, specificity, and the confidence/credible intervals were used to evaluate the prediction performance of each model for each ASA physical status class. MAIN RESULTS ASA physical status classes require distinct models to accurately predict intraoperative blood pressures and hypotensive events. Overall, high sensitivity (above 0.85) and low uncertainty can be achieved by all models for ASA class 4 patients. In contrast, models trained without controlling ASA classes yielded lower sensitivity (below 0.5) and larger uncertainty. Particularly, in terms of predicting binary hypotensive event, for ASA physical status class 1, BNNMR yields the highest sensitivity of 1. For classes 2 and 3, BNN has the highest sensitivity of 0.429 and 0.415, respectively. For class 4, BNNMR and GP are tied with the highest sensitivity of 0.857. On the other hand, the sensitivity is just 0.031, 0.429, 0.165 and 0.305 for BNNMR, BNN, GBLM and GP models respectively, when training data is not divided by ASA physical status classes. In terms of predicting systolic blood pressure, the GP regression yields the lowest root mean squared errors (RMSE) of 2.072, 7.539, 9.214 and 0.295 for ASA physical status classes 1, 2, 3 and 4, respectively, but a RMSE of 126.894 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. RMSEs are 2.175, 13.861, 17.560 and 22.426 for classes 1, 2, 3 and 4 respectively for the BGLM. In terms of predicting diastolic blood pressure, the GP regression yields the lowest RMSEs of 2.152, 6.573, 5.371 and 0.831 for ASA physical status classes 1, 2, 3 and 4, respectively; RMSE of 8.084 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. Finally, in terms of the width of the 95% confidence interval of the mean prediction for systolic and diastolic blood pressures, GP regression gives narrower confidence interval with much smaller margin of error across all four ASA physical status classes. CONCLUSIONS Different ASA physical status classes present different data distributions, and thus calls for distinct machine learning models to improve prediction accuracy and reduce predictive uncertainty. Uncertainty quantification enabled by Bayesian inference provides valuable information for clinicians as an additional metric to evaluate performance of machine learning models for medical decision making.
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Affiliation(s)
- Zehua Dong
- Department of Industrial and Systems Engineering, University at Buffalo, United States of America.
| | - Xiaoyu Chen
- Department of Industrial and Systems Engineering, University at Buffalo, United States of America.
| | - Jodie Ritter
- Department of Industrial Engineering, University of Louisville, United States of America.
| | - Lihui Bai
- Department of Industrial Engineering, University of Louisville, United States of America.
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, United States of America.
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Gore P, Liu H, Bohringer C. Can Currently Available Non-invasive Continuous Blood Pressure Monitors Replace Invasive Measurement With an Arterial Catheter? Cureus 2024; 16:e54707. [PMID: 38529464 PMCID: PMC10961923 DOI: 10.7759/cureus.54707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/27/2024] Open
Abstract
Deviations from normal blood pressure (BP) during general anesthesia have been clearly linked to several adverse outcomes. Measuring BP accurately is therefore critically important for producing excellent outcomes in health care. Normal BP does not necessarily guarantee adequate organ perfusion however and adverse events have occurred even when BP seemed adequate. Invasive blood pressure monitoring has recently evolved beyond merely measuring BP. Arterial line-derived pulse contour analysis is used now to assess both cardiac output and stroke volume variation as indices of adequate intravascular volume. Confirmation of acceptable cardiac output with data derived from invasive intra-arterial catheters has become very important when managing high-risk patients. Newer devices that measure BP continuously and non-invasively in the digital arteries via a finger cuff have also become available. Many clinicians contemplate now if these new devices are ready to replace invasive monitoring with an arterial catheter. Unlike non-invasive devices, intra-arterial catheters allow frequent blood sampling. This makes it possible to assess vital parameters like pH, hemoglobin concentration, ionized calcium, potassium, glucose, and arterial partial pressure of oxygen and carbon dioxide frequently. Non-invasive continuous BP measurement has been found to be unreliable in critically ill patients, the elderly, and patients with calcified arteries. Pulse contour-derived estimates of cardiac output and stroke volume variation have been validated better with data derived from arterial lines than that from the newer finger cuff monitors. Significant advances have been recently made with non-invasive continuous BP monitors. Invasive monitoring with an arterial line however remains the gold standard for measuring BP and assessing pulse contour analysis-derived hemodynamic variables in critically ill patients. In the future, non-invasive continuous BP monitors will likely replace intermittent oscillometers in the operating room and the postoperative period. They will however not eliminate the need for arterial catheterization in critically ill patients.
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Affiliation(s)
- Payton Gore
- Anesthesiology, University of California Davis Medical Center, Sacramento, USA
| | - Hong Liu
- Anesthesiology, University of California Davis Medical Center, Sacramento, USA
| | - Christian Bohringer
- Anesthesiology, University of California Davis Medical Center, Sacramento, USA
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Coeckelenbergh S, Joosten A, Cannesson M, Rinehart J. Closing the loop: automation in anesthesiology is coming. J Clin Monit Comput 2024; 38:1-4. [PMID: 37707703 DOI: 10.1007/s10877-023-01077-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Abstract
Anesthesiology and intensive care medicine provide fertile ground for innovation in automation, but to date we have only achieved preliminary studies in closed-loop intravenous drug administration. Anesthesiologists have yet to implement these tools on a large scale despite clear evidence that they outperform manual titration. Closed-loops continuously assess a predefined variable as input into a controller and then attempt to establish equilibrium by administering a treatment as output. The aim is to decrease the error between the closed-loop controller's input and output. In this editorial we consider the available intravenous anesthesia closed-loop systems, try to clarify why they have not yet been implemented on a large scale, see what they offer, and propose the future steps towards automation in anesthesia.
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Affiliation(s)
- Sean Coeckelenbergh
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Assistance Publique - Hôpitaux de Paris, 12 avenue Paul Vaillant-Couturier, Villejuif, 94800, France.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Assistance Publique - Hôpitaux de Paris, 12 avenue Paul Vaillant-Couturier, Villejuif, 94800, France
- Department of Anesthesiology & Perioperative Medicine, University of California, Los Angeles, CA, USA
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, University of California, Los Angeles, CA, USA
| | - Joseph Rinehart
- Outcomes Research Consortium, Cleveland, OH, USA
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA
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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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Okamoto S, Ogata H, Ooba S, Saeki A, Sato F, Miyamoto K, Kobata M, Okutani H, Ueki R, Kariya N, Hirose M. The Impact of Nociception Monitor-Guided Multimodal General Anesthesia on Postoperative Outcomes in Patients Undergoing Laparoscopic Bowel Surgery: A Randomized Controlled Trial. J Clin Med 2024; 13:618. [PMID: 38276124 PMCID: PMC10816099 DOI: 10.3390/jcm13020618] [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: 12/27/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Excess surgical stress responses, caused by heightened nociception, can lead to elevated levels of postoperative inflammation, resulting in an increased incidence of complications after surgery. We hypothesized that utilizing nociception monitor-guided multimodal general anesthesia would exert effects on postoperative outcomes (e.g., serum concentrations of C-reactive protein (CRP) after surgery, postoperative complications). METHODS This single-center, double-blinded, randomized trial enrolled ASA class I/II adult patients with normal preoperative CRP levels, scheduled for laparoscopic bowel surgery. Patients were randomized to receive either standard care (control group) or nociception monitor-guided multimodal general anesthesia using the nociceptive response (NR) index (NR group), where NR index was kept below 0.85 as possible. The co-primary endpoint was serum concentrations of CRP after surgery or rates of 30-day postoperative complications (defined as Clavien-Dindo grades ≥ II). MAIN RESULTS One hundred and four patients (control group, n = 52; NR group, n = 52) were enrolled for analysis. The serum CRP level on postoperative day (POD) 1 was significantly lower in the NR group (2.70 mg·dL-1 [95% confidence interval (CI), 2.19-3.20]) than in the control group (3.66 mg·dL-1 [95% CI, 2.98-4.34], p = 0.024). The postoperative complication rate was also significantly lower in the NR group (11.5% [95% CI, 5.4-23.0]) than in the control group (38.5% [95% CI, 26.5-52.0], p = 0.002). CONCLUSIONS Nociception monitor-guided multimodal general anesthesia, which suppressed intraoperative nociception, mitigated serum concentrations of CRP level, and decreased postoperative complications after laparoscopic bowel surgery.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Munetaka Hirose
- Department of Anesthesiology and Pain Medicine, Hyogo Medical University Faculty of Medicine, Nishinomiya, Hyogo 663-8501, Japan
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Frassanito L, Di Bidino R, Vassalli F, Michnacs K, Giuri PP, Zanfini BA, Catarci S, Filetici N, Sonnino C, Cicchetti A, Arcuri G, Draisci G. Personalized Predictive Hemodynamic Management for Gynecologic Oncologic Surgery: Feasibility of Cost-Benefit Derivatives of Digital Medical Devices. J Pers Med 2023; 14:58. [PMID: 38248759 PMCID: PMC10820080 DOI: 10.3390/jpm14010058] [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: 11/22/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Intraoperative hypotension is associated with increased perioperative complications, hospital length of stay (LOS) and healthcare expenditure in gynecologic surgery. We tested the hypothesis that the adoption of a machine learning-based warning algorithm (hypotension prediction index-HPI) might yield an economic advantage, with a reduction in adverse outcomes that outweighs the costs for its implementation as a medical device. METHODS A retrospective-matched cohort cost-benefit Italian study in gynecologic surgery was conducted. Sixty-six female patients treated with standard goal-directed therapy (GDT) were matched in a 2:1 ratio with thirty-three patients treated with HPI based on ASA status, diagnosis, procedure, surgical duration and age. RESULTS The most relevant contributor to medical costs was operating room occupation (46%), followed by hospital stay (30%) and medical devices (15%). Patients in the HPI group had EURO 300 greater outlay for medical devices without major differences in total costs (GDT 5425 (3505, 8127), HPI 5227 (4201, 7023) p = 0.697). A pre-specified subgroup analysis of 50% of patients undergoing laparotomic surgery showed similar medical device costs and total costs, with a non-significant saving of EUR 1000 in the HPI group (GDT 8005 (5961, 9679), HPI 7023 (5227, 11,438), p = 0.945). The hospital LOS and intensive care unit stay were similar in the cohorts and subgroups. CONCLUSIONS Implementation of HPI is associated with a scenario of cost neutrality, with possible economic advantage in high-risk settings.
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Affiliation(s)
- Luciano Frassanito
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy; (P.P.G.); (B.A.Z.); (S.C.); (N.F.); (C.S.); (G.D.)
| | - Rossella Di Bidino
- Department of Health Technology, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy; (R.D.B.); (G.A.)
| | - Francesco Vassalli
- Department of Critical Care and Perinatal Medicine, IRCCS Istituto G. Gaslini, 16147 Genoa, Italy;
| | | | - Pietro Paolo Giuri
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy; (P.P.G.); (B.A.Z.); (S.C.); (N.F.); (C.S.); (G.D.)
| | - Bruno Antonio Zanfini
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy; (P.P.G.); (B.A.Z.); (S.C.); (N.F.); (C.S.); (G.D.)
| | - Stefano Catarci
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy; (P.P.G.); (B.A.Z.); (S.C.); (N.F.); (C.S.); (G.D.)
| | - Nicoletta Filetici
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy; (P.P.G.); (B.A.Z.); (S.C.); (N.F.); (C.S.); (G.D.)
| | - Chiara Sonnino
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy; (P.P.G.); (B.A.Z.); (S.C.); (N.F.); (C.S.); (G.D.)
| | - Americo Cicchetti
- Department of Management Studies, Faculty of Economics, Catholic University of Sacred Heart, 00168 Rome, Italy;
| | - Giovanni Arcuri
- Department of Health Technology, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy; (R.D.B.); (G.A.)
| | - Gaetano Draisci
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy; (P.P.G.); (B.A.Z.); (S.C.); (N.F.); (C.S.); (G.D.)
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Hong L, Feng T, Qiu R, Lin S, Xue Y, Huang K, Chen C, Wang J, Xie R, Song S, Zhang C, Zou J. A novel interpretative tool for early prediction of low cardiac output syndrome after valve surgery: online machine learning models. Ann Med 2023; 55:2293244. [PMID: 38128272 PMCID: PMC10763875 DOI: 10.1080/07853890.2023.2293244] [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: 06/06/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE Low cardiac output syndrome (LCOS) is a severe complication after valve surgery, with no uniform standard for early identification. We developed interpretative machine learning (ML) models for predicting LCOS risk preoperatively and 0.5 h postoperatively for intervention in advance. METHODS A total of 2218 patients undergoing valve surgery from June 2019 to Dec 2021 were finally enrolled to construct preoperative and postoperative models. Logistic regression, support vector machine (SVM), random forest classifier, extreme gradient boosting, and deep neural network were executed for model construction, and the performance of models was evaluated by area under the curve (AUC) of the receiver operating characteristic and calibration curves. Our models were interpreted through SHapley Additive exPlanations, and presented as an online tool to improve clinical operability. RESULTS The SVM algorithm was chosen for modeling due to better AUC and calibration capability. The AUCs of the preoperative and postoperative models were 0.786 (95% CI 0.729-0.843) and 0.863 (95% CI 0.824-0.902), and the Brier scores were 0.123 and 0.107. Our models have higher timeliness and interpretability, and wider coverage than the vasoactive-inotropic score, and the AUC of the postoperative model was significantly higher. Our preoperative and postoperative models are available online at http://njfh-yxb.com.cn:2022/lcos. CONCLUSIONS The first interpretable ML tool with two prediction periods for online early prediction of LCOS risk after valve surgery was successfully built in this study, in which the SVM model has the best performance, reserving enough time for early precise intervention in critical care.
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Affiliation(s)
- Liang Hong
- Cardiovascular Intensive Care Unit, Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Tianling Feng
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Runze Qiu
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - Shiteng Lin
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yinying Xue
- Cardiovascular Intensive Care Unit, Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Kaizong Huang
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - Chen Chen
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - Jiawen Wang
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China
| | - Rongrong Xie
- Cardiovascular Intensive Care Unit, Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Sanbing Song
- Cardiovascular Intensive Care Unit, Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Cui Zhang
- Cardiovascular Intensive Care Unit, Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jianjun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
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Qian MP, Dong MR, Han MM, Li J, Kang F. ABO blood types may affect transient neurological events after surgical revascularization in patients with moyamoya disease: a retrospective single center study. BMC Anesthesiol 2023; 23:419. [PMID: 38114904 PMCID: PMC10729420 DOI: 10.1186/s12871-023-02385-6] [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: 09/15/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Moyamoya disease (MMD) is a cerebrovascular disease with unknown cause. Patients with MMD disease usually experience transient neurological events (TNEs) after revascularization surgery. This retrospective single-center study was aimed to explore the risk factors of postoperative TNEs after surgical revascularization in patients with MMD. METHODS We selected 324 patients who underwent surgical revascularization between January 2017 and September 2022 in our center. The perioperative characteristics of the patients were recorded and the outcome was TNEs after surgery. An analysis of risk factors contributing to postoperative TNEs by using logistic regression model. RESULTS Three hundred twelve patients were enrolled, and the incidence of postoperative TNEs was 34% in our study. Males were more likely to suffer from postoperative TNEs (OR = 2.344, p = 0.002). Preoperative ischemic presentation (OR = 1.849, p = 0.048) and intraoperative hypotension (OR = 2.332, p = 0.002) were associated with postoperative TNEs. Compared to patients with blood type O, patients with blood type A (OR = 2.325, p = 0.028), B (OR = 2.239, p = 0.027) and AB (OR = 2.938, p = 0.019) had a significantly higher incidence of postoperative TNEs. A risk prediction model for postoperative TNEs was established, and the established risk prediction area under the receiver operating characteristic curve (ROC) of the model was 0.741. CONCLUSIONS Males, preoperative ischemic presentation and intraoperative hypotension were associated with postoperative TNEs. We also found a possible link between postoperative TNEs and ABO blood types after surgical revascularization for moyamoya patients.
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Affiliation(s)
- Mei-Ping Qian
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Mei-Rong Dong
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Ming-Ming Han
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Juan Li
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Fang Kang
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China.
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Valencia Morales DJ, Garbajs NZ, Tawfic SS, Jose T, Laporta ML, Schroeder DR, Weingarten TN, Sprung J. Intraoperative Blood Pressure Variability and Early Postoperative Stroke: A Case-Control Study. Am Surg 2023; 89:5191-5200. [PMID: 36426383 DOI: 10.1177/00031348221136578] [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] [Indexed: 12/22/2023]
Abstract
BACKGROUND This study aims to assess the association of postoperative stroke with intraoperative hemodynamic variability and transfusion management. METHODS In this case-control study, adult patients (≥ 18 years) who had a stroke within 72 hours of a surgical procedure were matched to 2 control patients according to age, sex, and procedure type. Primary risk factors assessed were intraoperative fluid administration, blood product transfusion, vasopressor use, and measures of variability in systolic and diastolic blood pressure and heart rate: maximum, minimum, range, SD, and average real variability. The variables were analyzed with conditional logistic regression, which accounted for the 1:2 matched case-control study design. RESULTS Among 687 581 procedures, we identified 64 postoperative strokes (incidence, 9.3 [95% CI, 7.2-11.9] strokes per 100 000 procedures). These cases were matched with 128 controls. Stroke cases had higher Charlson cmorbidity index scores than did controls (P = .046). Blood pressure and heart rate variability measures were not associated with stroke. The risk of stroke was increased with red blood cell (RBC) transfusion (odds ratio [OR], 14.82; 95% CI, 3.40-64.66; P < .001), vasopressor use (OR, 3.91; 95% CI, 1.59-9.60; P = .003), and longer procedure duration (OR, 1.23/h; 95% CI, 1.01-1.51; P = .04). Multivariable analysis of procedure duration, RBC transfusion, and vasopressor use showed that only RBC transfusion was independently associated with an increased risk of stroke (OR, 10.10; 95% CI, 2.14-47.72; P = .004). CONCLUSIONS Blood pressure variability was not associated with an increased risk of postoperative stroke; however, RBC transfusion was an independent risk factor.
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Affiliation(s)
| | - Nika Zorko Garbajs
- Department of Vascular Neurology and Intensive Therapy, University Medical Centre, Ljubljana, Slovenia
| | - Sarah S Tawfic
- Department of Internal Medicine, Mayo Clinic Rochester, Minnesota
| | - Thulasee Jose
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darrell R Schroeder
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Fujii T, Takakura M, Taniguchi T, Tamura T, Nishiwaki K. Intraoperative hypotension affects postoperative acute kidney injury depending on the invasiveness of abdominal surgery: A retrospective cohort study. Medicine (Baltimore) 2023; 102:e36465. [PMID: 38050260 PMCID: PMC10695494 DOI: 10.1097/md.0000000000036465] [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: 10/09/2023] [Accepted: 11/13/2023] [Indexed: 12/06/2023] Open
Abstract
Intraoperative hypotension (IOH) or highly invasive surgery adversely affects postoperative clinical outcomes. It is, however, unclear whether IOH affects postoperative acute kidney injury (AKI) depending on the invasiveness of abdominal surgery. We speculated that IOH in highly invasive abdominal surgery is a significant risk factor for postoperative AKI. We retrospectively reviewed the data of 448 patients who underwent abdominal surgery. Patients were divided into 3 groups: highly (such as pancreaticoduodenectomy and hepatectomy), moderately (open abdominal surgery), and minimally (laparoscopic surgery) invasive surgeries. The association between the time-weighted average (TWA) of mean arterial pressure (MAP) values (≤60 and ≤ 55 mm Hg) and AKI occurrences in each group was assessed. Postoperative AKI occurred after highly, moderately, and minimally invasive surgeries in 33 of 222 (14.9%), 14 of 110 (12.7%), and 12 of 116 (10.3%) cases, respectively (P = .526). The median [interquartile range] of TWA-MAP ≤ 60 mm Hg, as an IOH parameter, was 0.94 [0.33-2.08] mm Hg in highly, 0.54 [0.16-1.46] mm Hg in moderately, and 0.14 [0.03-0.57] mm Hg in minimally invasive surgeries (P < 0001). In addition, there was a significant association between TWA-MAP and AKI in highly invasive surgery, unlike in moderately and minimally invasive surgery, with adjusted odds ratios (95% confidence interval) for TWA-MAP ≤ 60 and ≤ 55 mm Hg associated with AKI of 1.23 [1.00-1.52] (P = .049) and 1.55 [1.02-2.36] (P = .041), respectively. Intraoperative MAP ≤ 60 mm Hg in highly invasive abdominal surgery is associated with postoperative AKI, compared to moderately and minimally invasive surgeries. Additionally, low MAP thresholds in highly invasive surgery increase postoperative AKI risk.
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Affiliation(s)
- Tasuku Fujii
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Masashi Takakura
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Tomoya Taniguchi
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Takahiro Tamura
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Lu W, Liu C, He J, Wang R, Gao D, Cheng R. Surgical and medical co-management optimizes surgical outcomes in older patients with chronic diseases undergoing robot-assisted laparoscopic radical prostatectomy. Aging Male 2023; 26:2159368. [PMID: 36974926 DOI: 10.1080/13685538.2022.2159368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION While robotic-assisted laparoscopic radical prostatectomy (RRP) is a standard mode for localized prostate cancer (PC), the risk of complications in older patients with chronic diseases and complex medical conditions can be a deterrent to surgery. Surgical and medical co-management (SMC) is a new strategy to improve patients' healthcare outcomes in surgical settings. METHODS We reviewed the clinical data of older patients with chronic diseases who were cared for with SMC undergoing RRP in our hospital in the past 3 years and compared them with the clinical data from the general urology ward. Preoperative conditions and related indicators of recovery, and incidence of postoperative complications with the Clavien Grade System were compared between these two groups. RESULTS The indicators of recovery were significantly better, and the incidence rates of complications were significantly reduced in the SMC group at grades I-IV (p < 0.05), as compared to the general urology ward group. CONCLUSIONS The provision of care by SMC for older patients focused on early identification, comorbidity management, preoperative optimization, and collaborative management would significantly improve surgical outcomes. The SMC strategy is worthy of further clinical promotion in RRP treatment in older men with chronic diseases and complex medical conditions.
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Affiliation(s)
- Wenning Lu
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Chaoyang Liu
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Jing He
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Rong Wang
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Dewei Gao
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Rui Cheng
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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Buchholz V, Hazard R, Yin Z, Tran N, Yip SWS, Le P, Kioussis B, Hinton J, Liu DS, Lee DK, Weinberg L. The impact of intraoperative and postoperative fluid balance on complications for transthoracic esophagectomy: a retrospective analysis. BMC Res Notes 2023; 16:315. [PMID: 37932807 PMCID: PMC10629189 DOI: 10.1186/s13104-023-06574-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: 06/03/2023] [Accepted: 10/13/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVE Transthoracic esophagectomy is associated with significant morbidity and mortality. Therefore, it is imperative to optimize perioperative management and minimize complications. In this retrospective analysis, we evaluated the association between fluid balance and esophagectomy complications at a tertiary hospital in Melbourne, Australia, with a particular focus on respiratory morbidity and anastomotic leaks. Cumulative fluid balance was calculated intraoperatively, postoperatively in recovery postoperative day (POD) 0, and on POD 1 and 2. High and low fluid balance was defined as greater than or less than the median fluid balance, respectively, and postoperative surgical complications were graded using the Clavien-Dindo classification. RESULTS In total, 109 patients, with an average age of 64 years, were included in this study. High fluid balance on POD 0, POD1 and POD 2 was associated with a higher incidence of anastomotic leak (OR 8.59; 95%CI: 2.64-39.0). High fluid balance on POD 2 was associated with more severe complications (of any type) (OR 3.33; 95%CI: 1.4-8.26) and severe pulmonary complications (OR 3.04; 95%CI: 1.27-7.67). For every 1 L extra cumulative fluid balance in POD 1, the odds of a major complication increase by 15%, while controlling for body mass index (BMI) and American Society of Anaesthesiologists (ASA) class. The results show that higher cumulative fluid balance is associated with worsening postoperative outcomes in patients undergoing transthoracic esophagectomy. Restricted fluid balance, especially postoperatively, may mitigate the risk of postoperative complications - however prospective trials are required to establish this definitively.
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Affiliation(s)
- Vered Buchholz
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Australia
| | - Riley Hazard
- Department of Anesthesia, Austin Health, Melbourne, Australia
| | - Zoe Yin
- Department of Anesthesia, Austin Health, Melbourne, Australia
| | - Nghiep Tran
- Department of Anesthesia, Austin Health, Melbourne, Australia
| | | | - Peter Le
- Department of Anesthesia, Austin Health, Melbourne, Australia
| | | | - Jake Hinton
- Department of Anesthesia, Austin Health, Melbourne, Australia
| | - David S Liu
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Australia
- General and Gastrointestinal Surgery Research Group, The University of Melbourne, Austin Precinct, Melbourne, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Laurence Weinberg
- Department of Anesthesia, Austin Health, Melbourne, Australia.
- Department of Critical Care, University of Melbourne, Melbourne, Australia.
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