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Gutierrez Del Arroyo A, Patel A, Abbott TEF, Begum S, Dias P, Somanath S, Middleditch A, Cleland S, Brealey D, Pearse RM, Ackland GL. Preoperative N-terminal pro-B-type natriuretic peptide and myocardial injury after stopping or continuing renin-angiotensin system inhibitors in noncardiac surgery: a prespecified analysis of a phase 2 randomised controlled multicentre trial. Br J Anaesth 2024; 132:857-866. [PMID: 38341283 DOI: 10.1016/j.bja.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Patients with elevated preoperative plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP >100 pg ml-1) experience more complications after noncardiac surgery. Individuals prescribed renin-angiotensin system (RAS) inhibitors for cardiometabolic disease are at particular risk of perioperative myocardial injury and complications. We hypothesised that stopping RAS inhibitors before surgery increases the risk of perioperative myocardial injury, depending on preoperative risk stratified by plasma NT-proBNP concentrations. METHODS In a preplanned analysis of a phase 2a trial in six UK centres, patients ≥60 yr old undergoing elective noncardiac surgery were randomly assigned either to stop or continue RAS inhibitors before surgery. The pharmacokinetic profile of individual RAS inhibitors determined for how long they were stopped before surgery. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury (plasma high-sensitivity troponin-T ≥15 ng L-1 or a ≥5 ng L-1 increase, when preoperative high-sensitivity troponin-T ≥15 ng L-1) within 48 h after surgery. The co-exposures of interest were preoperative plasma NT-proBNP (< or >100 pg ml -1) and stopping or continuing RAS inhibitors. RESULTS Of 241 participants, 101 (41.9%; mean age 71 [7] yr; 48% females) had preoperative NT-proBNP >100 pg ml -1 (median 339 [160-833] pg ml-1), of whom 9/101 (8.9%) had a formal diagnosis of cardiac failure. Myocardial injury occurred in 63/101 (62.4%) subjects with NT-proBNP >100 pg ml-1, compared with 45/140 (32.1%) subjects with NT-proBNP <100 pg ml -1 {odds ratio (OR) 3.50 (95% confidence interval [CI] 2.05-5.99); P<0.0001}. For subjects with preoperative NT-proBNP <100 pg ml-1, 30/75 (40%) who stopped RAS inhibitors had myocardial injury, compared with 15/65 (23.1%) who continued RAS inhibitors (OR for stopping 2.22 [95% CI 1.06-4.65]; P=0.03). For preoperative NT-proBNP >100 pg ml-1, myocardial injury rates were similar regardless of stopping (62.2%) or continuing (62.5%) RAS inhibitors (OR for stopping 0.98 [95% CI 0.44-2.22]). CONCLUSIONS Stopping renin-angiotensin system inhibitors in lower-risk patients (preoperative NT-proBNP <100 pg ml -1) increased the likelihood of myocardial injury before noncardiac surgery.
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Affiliation(s)
- Ana Gutierrez Del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Akshaykumar Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Salma Begum
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Sameer Somanath
- County Durham and Darlington NHS Foundation Trust, Durham, UK
| | | | | | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK; UCL Hospitals NHS Foundation Trust, London, UK
| | - Rupert M Pearse
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
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Janssen H, Jhanji S, Oliver NS, Ackland GL. Ward monitoring 4.0: real-time metabolic insights from continuous glucose monitoring into perioperative organ dysfunction. Br J Anaesth 2024; 132:843-848. [PMID: 38448275 DOI: 10.1016/j.bja.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/08/2024] [Accepted: 01/27/2024] [Indexed: 03/08/2024] Open
Abstract
The now-routine clinical deployment of continuous glucose monitoring has demonstrated benefit in real-world settings. We make the case that continuous glucose monitoring can help re-examine, at scale, the role that (stress) hyperglycaemia plays in fuelling organ dysfunction after tissue trauma. Provided robust perioperative data do emerge, well-established continuous glucose monitoring technology could soon help transform the perioperative landscape.
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Affiliation(s)
- Henrike Janssen
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Shaman Jhanji
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK
| | - Nick S Oliver
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
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Roth S, M'Pembele R, Nienhaus J, Mauermann E, Ionescu D, Szczeklik W, De Hert S, Filipovic M, Beck-Schimmer B, Spadaro S, Matute P, Bolliger D, Turhan SC, van Waes J, Lagarto F, Theodoraki K, Gupta A, Gillmann HJ, Guzzetti L, Kotfis K, Wulf H, Larmann J, Corneci D, Chammartin F, Howell SJ, Lurati Buse G. Association between self-reported functional capacity and general postoperative complications: analysis of predefined outcomes of the MET-REPAIR international cohort study. Br J Anaesth 2024; 132:811-814. [PMID: 38326210 DOI: 10.1016/j.bja.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/04/2024] [Accepted: 01/04/2024] [Indexed: 02/09/2024] Open
Affiliation(s)
- Sebastian Roth
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; CARID (Cardiovascular Research Institute Düsseldorf), University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - René M'Pembele
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; CARID (Cardiovascular Research Institute Düsseldorf), University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
| | - Johannes Nienhaus
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; CARID (Cardiovascular Research Institute Düsseldorf), University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Eckhard Mauermann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Daniela Ionescu
- Department of Anaesthesia and Intensive Care I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Stefan De Hert
- Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Miodrag Filipovic
- Division of Anesthesiology, Intensive Care, Rescue and Pain Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Beatrice Beck-Schimmer
- Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Purificación Matute
- Department of Anaesthesia, Hospital Clinic of Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Daniel Bolliger
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sanem C Turhan
- Department of Anesthesiology and ICU, Ankara University Medical School, Ankara, Turkey
| | - Judith van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Filipa Lagarto
- Department of Anesthesiology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Kassiani Theodoraki
- Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anil Gupta
- Department of Perioperative Medicine and Intensive Care, Karolinska Hospital and Institution for Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Hans-Jörg Gillmann
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Luca Guzzetti
- Anesthesia and Intensive Care Department, University Hospital, Varese, Italy
| | - Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Hinnerk Wulf
- Department of Anesthesiology and Critical Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Jan Larmann
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dan Corneci
- Carol Davila University of Medicine and Pharmacy Bucharest Head of Anesthesia and Intensive Care Department I, Central Military Emergency University Hospital "Dr. Carol Davila", Bucharest, Romania
| | - Frédérique Chammartin
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Simon J Howell
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Giovanna Lurati Buse
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; CARID (Cardiovascular Research Institute Düsseldorf), University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Martinez-Perez S, van Waes JAR, Vernooij LM, Cuthbertson BH, Beattie WS, Wijeysundera DN, van Klei WA. Postoperative troponin surveillance to detect myocardial infarction: an observational cohort modelling study. Br J Anaesth 2024; 132:667-674. [PMID: 38233301 DOI: 10.1016/j.bja.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/29/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Clinical presentation of postoperative myocardial infarction (POMI) is often silent. Several international guidelines recommend routine troponin surveillance in patients at risk. We compared how these different guidelines select patients for surveillance after noncardiac surgery with our established risk stratification model. METHODS We used outcome data from two prospective studies: Measurement of Exercise Tolerance before Surgery (METS) and Troponin Elevation After Major non-cardiac Surgery (TEAMS). We compared the major American, Canadian, and European guideline recommendations for troponin surveillance with our established risk stratification model. For each guideline and model, we quantified the number of patients requiring monitoring, % POMI detected, sensitivity, specificity, diagnostic odds ratio, and number needed to screen (NNS). RESULTS METS and TEAMS contributed 2350 patients, of whom 319 (14%) had myocardial injury, 61 (2.5%) developed POMI, and 14 (0.6%) died. Our risk stratification model selected fewer patients for troponin monitoring (20%), compared with the Canadian (78%) and European (79%) guidelines. The sensitivity to detect POMI was highest with the Canadian and European guidelines (0.85; 95% confidence interval [CI] 0.74-0.92). Specificity was highest using the American guidelines (0.91; 95% CI 0.90-0.92). Our risk stratification model had the best diagnostic odds ratio (2.5; 95% CI 1.4-4.2) and a lower NNS (21 vs 35) compared with the guidelines. CONCLUSIONS Most postoperative myocardial infarctions were detected by the Canadian and European guidelines but at the cost of low specificity and a higher number of patients undergoing screening. Patient selection based on our risk stratification model was optimal.
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Affiliation(s)
- Selene Martinez-Perez
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada
| | - Judith A R van Waes
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - W Scott Beattie
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology, St. Michael's Hospital, Toronto, ON, Canada
| | - Wilton A van Klei
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
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Zhuo XY, Lei SH, Sun L, Bai YW, Wu J, Zheng YJ, Liu KX, Liu WF, Zhao BC. Preoperative risk prediction models for acute kidney injury after noncardiac surgery: an independent external validation cohort study. Br J Anaesth 2024:S0007-0912(24)00097-7. [PMID: 38527923 DOI: 10.1016/j.bja.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Numerous models have been developed to predict acute kidney injury (AKI) after noncardiac surgery, yet there is a lack of independent validation and comparison among them. METHODS We conducted a systematic literature search to review published risk prediction models for AKI after noncardiac surgery. An independent external validation was performed using a retrospective surgical cohort at a large Chinese hospital from January 2019 to October 2022. The cohort included patients undergoing a wide range of noncardiac surgeries with perioperative creatinine measurements. Postoperative AKI was defined according to the Kidney Disease Improving Global Outcomes creatinine criteria. Model performance was assessed in terms of discrimination (area under the receiver operating characteristic curve, AUROC), calibration (calibration plot), and clinical utility (net benefit), before and after model recalibration through intercept and slope updates. A sensitivity analysis was conducted by including patients without postoperative creatinine measurements in the validation cohort and categorising them as non-AKI cases. RESULTS Nine prediction models were evaluated, each with varying clinical and methodological characteristics, including the types of surgical cohorts used for model development, AKI definitions, and predictors. In the validation cohort involving 13,186 patients, 650 (4.9%) developed AKI. Three models demonstrated fair discrimination (AUROC between 0.71 and 0.75); other models had poor or failed discrimination. All models exhibited some miscalibration; five of the nine models were well-calibrated after intercept and slope updates. Decision curve analysis indicated that the three models with fair discrimination consistently provided a positive net benefit after recalibration. The results were confirmed in the sensitivity analysis. CONCLUSIONS We identified three models with fair discrimination and potential clinical utility after recalibration for assessing the risk of acute kidney injury after noncardiac surgery.
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Affiliation(s)
- Xiao-Yu Zhuo
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, Guangzhou, China
| | - Shao-Hui Lei
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, Guangzhou, China; College of Anaesthesiology, Southern Medical University, Guangzhou, China
| | - Lan Sun
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Biostatistics, Lejiu Healthcare Technology Co., Ltd, Hangzhou, China
| | - Ya-Wen Bai
- College of Anaesthesiology, Southern Medical University, Guangzhou, China
| | - Jiao Wu
- College of Anaesthesiology, Southern Medical University, Guangzhou, China
| | - Yong-Jia Zheng
- College of Anaesthesiology, Southern Medical University, Guangzhou, China
| | - Ke-Xuan Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, Guangzhou, China; College of Anaesthesiology, Southern Medical University, Guangzhou, China; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Wei-Feng Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, Guangzhou, China; College of Anaesthesiology, Southern Medical University, Guangzhou, China.
| | - Bing-Cheng Zhao
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, Guangzhou, China; College of Anaesthesiology, Southern Medical University, Guangzhou, China; Outcomes Research Consortium, Cleveland, OH, USA.
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Li X, Wang C, Jin Y. Temporal trends and risk factors of perioperative cardiac events in patients over 80 years old with coronary artery disease undergoing noncardiac surgery: a high-volume single-center experience, 2014-2022. Postgrad Med J 2024; 100:252-261. [PMID: 38223919 DOI: 10.1093/postmj/qgad141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/11/2023] [Accepted: 12/09/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Temporal trends and risk factors of perioperative cardiac events (PCEs) in patients over 80 years old with coronary artery disease (CAD) undergoing noncardiac surgery are still unclear. METHODS We retrospectively reviewed 1478 patients over 80 years old, with known CAD undergoing selective noncardiac surgery in a single center (2014-2022). Patients were divided into three equal time groups based on the discharge date (2014-2016, 2017-2019, and 2020-2022), with 367, 473, and 638 patients in Groups 1-3, respectively. Perioperative clinical variables were extracted from the electronic medical records database. The primary outcome was the occurrence of PCEs intraoperatively or during hospitalization postoperatively, defined as any of the following events: myocardial infarction, heart failure, nonfatal cardiac arrest, and death. RESULTS PCEs occurred in 180 (12.2%) patients. Eight independent risk factors were associated with PCEs, including four clinical factors (body mass index < 22 kg/m2, history of myocardial infarction, history of heart failure, and general anesthesia) and four preoperative laboratory results (hemoglobin < 110 g/L, albumin < 40 g/L, creatinine > 120 μmol/L, and potassium <3.6 mmol/L). Significant rising trends were seen over the 9-year study period in the incidence of PCEs and independent risk factors including history of myocardial infarction, history of heart failure, general anesthesia, preoperative hemoglobin < 110 g/L, preoperative albumin < 40 g/L, and preoperative creatinine > 120 μmol/L (P for trend <0.05). CONCLUSION The incidence and independent risk factors of PCEs in patients over 80 years old with CAD undergoing noncardiac surgery showed significant rising trends over the last 9-year period.
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Affiliation(s)
- Xiaolin Li
- Department of Nutrition, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, N1 Shangcheng Road, Yiwu, 322000 Zhejiang, People's Republic of China
| | - Congying Wang
- Department of Cardiology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, N1 Shangcheng Road, Yiwu, 322000 Zhejiang, People's Republic of China
| | - Yunpeng Jin
- Department of Cardiology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, N1 Shangcheng Road, Yiwu, 322000 Zhejiang, People's Republic of China
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Alvarez Torres E, Bartoszko J, Martinez Perez S, Tait G, Santema M, Beattie WS, McCluskey SA, van Klei WA. Effect of a national guideline on postoperative troponin surveillance: a retrospective cohort study. Can J Anaesth 2024; 71:322-329. [PMID: 37973786 DOI: 10.1007/s12630-023-02647-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/19/2023] [Accepted: 08/08/2023] [Indexed: 11/19/2023] Open
Abstract
PURPOSE We aimed to evaluate the effect of the 2017 Canadian Cardiovascular Society (CCS) guidelines on troponin surveillance after noncardiac surgery. METHODS This was a single-centre, retrospective, observational study. Patients aged 40 yr or older undergoing intermediate- to high-risk elective noncardiac surgery between 2016 and 2021 were included. We compared the number and percentage of troponin tests ordered before and after the guidelines were published and compared patient characteristics, specifically cardiovascular comorbidity, using odds ratio's (OR) with 95% confidence intervals (CIs). Outcomes were myocardial injury, myocardial infarction (MI), and in-hospital mortality. RESULTS The cohort included 36,386 patients and the median age was 63 yr. Between 2016 and 2018, troponin surveillance was done in 2,461 (13%) of the 19,046 patients, compared with 2,398 (14%) of the 17,340 patients who had surgery between 2019 and 2021 (OR, 1.08; 95% CI, 1.02 to 1.15). Patients who had surgery in the second period had less cardiovascular comorbidity; the adjusted OR for troponin surveillance was 1.14 (95% CI, 1.07 to 1.21). In the two periods, troponin was elevated in 561 (2.9%) and 470 (2.7%) patients, an MI was documented in 54 (0.3%) and 36 (0.2%) patients, and 95 (0.5%) and 73 (0.4%) patients died, respectively. After adjustment for baseline differences in the two periods, the ORs for MI and mortality were 0.83 (95% CI, 0.54 to 1.27) and 0.88 (95% CI, 0.64 to 1.19), respectively. CONCLUSION Although the odds of troponin ordering were slightly but significantly higher after publication of the CCS guidelines, the odds for detecting an MI and for mortality did not change.
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Affiliation(s)
- Eva Alvarez Torres
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Selene Martinez Perez
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
| | - Gordon Tait
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
| | - Michael Santema
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
| | - W Scott Beattie
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Wilton A van Klei
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, 3EN-464, Toronto, ON, M5G 2C4, Canada.
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Tanabe K, Gilliland S. Perioperative Considerations for Modern Leadless Pacemakers. Semin Cardiothorac Vasc Anesth 2024; 28:38-46. [PMID: 38284295 DOI: 10.1177/10892532241230368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Since their initial approval by the Food and Drug Administration in 2016, leadless pacemakers have become increasingly prevalent. This growth has been driven by an improved adverse effect profile when compared to traditional pacemakers, including lower rates of infection, as well as eliminated risk of pocket hematoma and lead complications. More recently, technology enabling leadless synchronized atrioventricular pacing in patients with atrioventricular block has vastly expanded the indications for these devices. Anesthesiologists will increasingly be relied upon to safely care for patients with leadless pacemakers undergoing non-electrophysiology procedures and surgery. This article provides an overview of the technology, evidence base, current indications, and unique perioperative considerations for leadless pacemakers.
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Affiliation(s)
- Kenji Tanabe
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Samuel Gilliland
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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10
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Yoon HK, Kim HJ, Kim YJ, Lee H, Kim BR, Oh H, Park HP, Lee HC. Multicentre validation of a machine learning model for predicting respiratory failure after noncardiac surgery. Br J Anaesth 2024:S0007-0912(24)00050-3. [PMID: 38413342 DOI: 10.1016/j.bja.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/01/2024] [Accepted: 01/26/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Postoperative respiratory failure is a serious complication that could benefit from early accurate identification of high-risk patients. We developed and validated a machine learning model to predict postoperative respiratory failure, defined as prolonged (>48 h) mechanical ventilation or reintubation after surgery. METHODS Easily extractable electronic health record (EHR) variables that do not require subjective assessment by clinicians were used. From EHR data of 307,333 noncardiac surgical cases, the model, trained with a gradient boosting algorithm, utilised a derivation cohort of 99,025 cases from Seoul National University Hospital (2013-9). External validation was performed using three separate cohorts A-C from different hospitals comprising 208,308 cases. Model performance was assessed by area under the receiver operating characteristic (AUROC) curve and area under the precision-recall curve (AUPRC), a measure of sensitivity and precision at different thresholds. RESULTS The model included eight variables: serum albumin, age, duration of anaesthesia, serum glucose, prothrombin time, serum creatinine, white blood cell count, and body mass index. Internally, the model achieved an AUROC of 0.912 (95% confidence interval [CI], 0.908-0.915) and AUPRC of 0.113. In external validation cohorts A, B, and C, the model achieved AUROCs of 0.879 (95% CI, 0.876-0.882), 0.872 (95% CI, 0.870-0.874), and 0.931 (95% CI, 0.925-0.936), and AUPRCs of 0.029, 0.083, and 0.124, respectively. CONCLUSIONS Utilising just eight easily extractable variables, this machine learning model demonstrated excellent discrimination in both internal and external validation for predicting postoperative respiratory failure. The model enables personalised risk stratification and facilitates data-driven clinical decision-making.
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Affiliation(s)
- Hyun-Kyu Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hyun Joo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yi-Jun Kim
- Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - Hyeonhoon Lee
- Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Bo Rim Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hyongmin Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hee-Pyoung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea.
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11
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Alekberli T, Ohana BL, Zemmour H, Khader R, Shemer R, Dor Y, Landesberg G. The correlation between high-sensitivity troponin-T and cell-free cardiac DNA in the blood of patients undergoing noncardiac, predominantly vascular surgery. J Int Med Res 2024; 52:3000605241229638. [PMID: 38340803 PMCID: PMC10859063 DOI: 10.1177/03000605241229638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/13/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVE To present a novel method that uses an epigenetic fingerprint to measure changes in plasma concentrations of cardiac-specific cell-free DNA (CS-cfDNA) as a marker of myocardial cell death. METHODS This prospective, analytic, observational comparative study included patients with heart disease or multiple risk factors for heart disease undergoing major noncardiac, mostly vascular surgery, requiring an arterial-line, and at least 24 h hospitalization in the post anaesthesia care unit or critical care unit after surgery. Blood samples were collected at least four times per patient to measure troponin-T (via high-sensitivity troponin-T test) and CS-cfDNA pre- and postoperatively. RESULTS A total of 117 patients were included (group 1, 77 patients [66%] with low preoperative and postoperative troponin-T; group 2, 18 patients [15%] with low preoperative but increased postoperative troponin-T; group 3, 16 patients [14%] with high troponin-T both preoperatively and postoperatively; and group 4, six patients [5%] with elevated preoperative troponin-T that decreased postoperatively). The increase in CS-cfDNA after surgery was statistically significant only in group 2, which correlated with an increase in troponin-T in the same group. CONCLUSIONS CS-cfDNA increased early postoperatively, particularly in patients with silent postoperative troponin elevation, and was correlated with an increase in troponin-T. These results may suggest that, in the subgroup of patients with postoperative elevated troponin, cardiomyocyte death indeed occurred.
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Affiliation(s)
- Tural Alekberli
- Department of Anaesthesiology, Critical Care and Pain Medicine, Hadassah Medical School, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Anaesthesia, Edmundston Regional Hospital, Vitalite Health Network, University of Sherbrooke, Edmundston, NB, Canada
| | - Braha Lea Ohana
- Department of Developmental Biology and Cancer Research, The Institute for Medical Research Israel-Canada, Hadassah Medical School, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hai Zemmour
- Department of Developmental Biology and Cancer Research, The Institute for Medical Research Israel-Canada, Hadassah Medical School, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Rudy Khader
- Department of Anaesthesiology, Critical Care and Pain Medicine, Hadassah Medical School, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ruth Shemer
- Department of Developmental Biology and Cancer Research, The Institute for Medical Research Israel-Canada, Hadassah Medical School, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yuval Dor
- Department of Developmental Biology and Cancer Research, The Institute for Medical Research Israel-Canada, Hadassah Medical School, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Giora Landesberg
- Department of Anaesthesiology, Critical Care and Pain Medicine, Hadassah Medical School, Hebrew University of Jerusalem, Jerusalem, Israel
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12
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Kai T, Izumo M, Okuno T, Kobayashi Y, Sato Y, Kuwata S, Koga M, Tanabe Y, Sakamoto M, Akashi YJ. Prevalence and Clinical Outcomes of Noncardiac Surgery After Transcatheter Aortic Valve Replacement. Am J Cardiol 2024; 210:259-265. [PMID: 37875233 DOI: 10.1016/j.amjcard.2023.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/07/2023] [Accepted: 09/18/2023] [Indexed: 10/26/2023]
Abstract
Aortic stenosis is a prevalent valvular heart disease, especially in the older people. They often coexist with other co-morbidities, and noncardiac surgery carries a higher risk because of the underlying valve condition. Despite the growing concern about the safety and optimal management of noncardiac surgery post-transcatheter aortic valve replacement (TAVR), there is limited evidence on this matter. This study aims to assess the clinical outcomes of noncardiac surgeries after TAVR. This retrospective study included 718 patients who underwent TAVR. Of these, 36 patients underwent noncardiac surgery after TAVR. The primary end point was the incidence of cardiovascular adverse events post-TAVR and the secondary end point was the incidence of structural valve deterioration. Composite end points included disabling stroke, heart failure requiring hospitalization, and cardiac death as defined by Valve Academic Research Consortium 3. Most of these surgeries were orthopedic and classified as intermediate risk. All noncardiac surgeries were performed without perioperative adverse events. There was no observed structural valve deterioration, and the incidence of composite end points did not significantly differ between the surgical and nonsurgical groups during the follow-up period. Noncardiac surgery after TAVR can be performed safely and does not have a negative impact on prognosis. Further studies are warranted to determine the optimal strategy for noncardiac surgery after TAVR.
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Affiliation(s)
- Takahiko Kai
- Department ofCardiology, St. Marianna University School of Medicine, Kawasaki, Japan.
| | - Masaki Izumo
- Department ofCardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Taishi Okuno
- Department ofCardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshikuni Kobayashi
- Department ofCardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yukio Sato
- Department ofCardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shingo Kuwata
- Department ofCardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masashi Koga
- Department ofCardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yasuhiro Tanabe
- Department ofCardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Miki Sakamoto
- Department of Anesthesiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshihiro J Akashi
- Department ofCardiology, St. Marianna University School of Medicine, Kawasaki, Japan
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13
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van Lier F, Hoeks S, Pearse RM. Prediction, prognosis, and professionalism in perioperative medicine. Br J Anaesth 2024; 132:13-14. [PMID: 37977955 DOI: 10.1016/j.bja.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023] Open
Abstract
Guidelines provide a framework to take better care of our patients. They are published by different professional groups and are based on all the research done for us by hardworking colleagues. Compiling a guideline is an enormous amount of work and is generally done with the utmost care. However, recommendations often require a subjective interpretation of published research, where personal and academic interests can influence the outcome. We discuss two recently published guidelines on perioperative cardiovascular assessment that led to different conclusions on some important areas of patient care.
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Affiliation(s)
- Felix van Lier
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Sanne Hoeks
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rupert M Pearse
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
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14
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Vernooij LM, van Waes JAR, Grobben RB, van Lier F, Feng S, Machina M, McKenny M, Nathoe HM, Wijeysundera DN, van Klei WA, Beattie WS. Postoperative myocardial injury phenotypes and self-reported disability in patients undergoing noncardiac surgery: a multicentre observational study. Br J Anaesth 2024; 132:35-44. [PMID: 38057252 DOI: 10.1016/j.bja.2023.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Postoperative myocardial injury (PMI) comprises a spectrum of mechanisms resulting in troponin release. The impact of different PMI phenotypes on postoperative disability remains unknown. METHODS This was a multicentre prospective cohort study including patients aged ≥50 yr undergoing elective major noncardiac surgery. Patients were stratified in five groups based on the occurrence of PMI and clinical information on postoperative adverse events: PMI classified as myocardial infarction (MI; according to fourth definition), PMI plus adverse event other than MI, clinically silent PMI (PMI without adverse events), adverse events without PMI, and neither PMI nor an adverse event (reference). The primary endpoint was 6-month self-reported disability (assessed by WHO Disability Assessment Schedule 2.0 [WHODAS]). Disability-free survival was defined as WHODAS ≤16%. RESULTS We included 888 patients of mean age 69 (range 53-91) yr, of which 356 (40%) were women; 151 (17%) patients experienced PMI, and 625 (71%) experienced 6-month disability-free survival. Patients with PMI, regardless of its phenotype, had higher preoperative disability scores than patients without PMI (difference in WHODAS; β: 3.3, 95% confidence interval [CI]: 0.5-6.2), but scores remained stable after surgery (β: 1.2, 95% CI: -3.2-5.6). Before surgery, patients with MI (n=36, 4%) were more disabled compared with patients without PMI and no adverse events (β: 5.5, 95% CI: 0.3-10.8). At 6 months, patients with MI and patients without PMI but with adverse events worsened in disability score (β: 11.2, 95% CI: 2.3-20.2; β: 8.1, 95% CI: 3.0-13.2, respectively). Patients with clinically silent PMI did not change in disability score at 6 months (β: 1.39, 95% CI: -4.50-7.29, P=0.642). CONCLUSIONS Although patients with postoperative myocardial injury had higher preoperative self-reported disability, disability scores did not change at 6 months after surgery. However, patients experiencing myocardial infarction worsened in disability score after surgery.
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Affiliation(s)
- Lisette M Vernooij
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands; Department of Anesthesiology, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.
| | - Judith A R van Waes
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Remco B Grobben
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Felix van Lier
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Simon Feng
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Matthew Machina
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Michael McKenny
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Hendrik M Nathoe
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Duminda N Wijeysundera
- Department of Anesthesia, St. Michael's Hospital - Unity Health Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Wilton A van Klei
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands; Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - W Scott Beattie
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
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15
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Swerdlow B, Osborne-Smith L, Soelberg J. Design of a Workshop for Focused Transesophageal Echocardiography During Noncardiac Surgery in Nurse Anesthesia Education. J Med Educ Curric Dev 2024; 11:23821205241229001. [PMID: 38313304 PMCID: PMC10836131 DOI: 10.1177/23821205241229001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/09/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE The use of transesophageal echocardiography (TEE) by certified registered nurse anesthetists (CRNAs) during noncardiac surgery is relatively uncommon despite its unique potential to diagnose causes of hemodynamic instability. To address this problem, educational endeavors designed to provide practical TEE skills to CRNAs are needed. The aim of the current study was to evaluate the feasibility, acceptability, efficacy, and utility of a 2-day focused TEE workshop in nurse anesthesia education that employed a protocol involving a limited number of views and used goal-directed, qualitative assessments of critical physiologic parameters. METHODS This was a prospective, observational study involving 14 second-year nurse anesthesia students. The cohort was evaluated following completion of this workshop by simulator-based testing involving hypothetical clinical scenarios, and this test data was analyzed according to the percent successful acquisition and interpretation of TEE views to determine immediate objective teaching efficacy. The acceptability, perceived efficacy, and perceived utility of the workshop were assessed by online survey, and survey responses were qualitative and quantitative in nature. RESULTS Participants acquired appropriate TEE views associated with clinical scenarios 99% of the time and correctly interpreted the pathology in those views 93% of the time. Participants uniformly perceived significant educational value in this workshop and intend to incorporate TEE in their future clinical practice. CONCLUSIONS A 2-day workshop to teach focused TEE to nurse anesthesia trainees directed by a streamlined protocol is feasible, acceptable, and perceived as useful by participants, and provides practical experience and entry-level competency in this point-of-care ultrasound modality.
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Affiliation(s)
- Barry Swerdlow
- Nurse Anesthesia Program, Oregon Health & Science University, Portland, OR, USA
| | - Lisa Osborne-Smith
- Nurse Anesthesia Program, Oregon Health & Science University, Portland, OR, USA
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Julie Soelberg
- Nurse Anesthesia Program, Oregon Health & Science University, Portland, OR, USA
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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16
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Huang WK, Lian WY, Zhuo XY, Kang SY, Luo WC, Xie YS, Xi GY, Liu KX, Liu WF. Association between cumulative duration of deep anesthesia and postoperative acute kidney injury after noncardiac surgeries: a retrospective observational study. Ren Fail 2023; 45:2287130. [PMID: 38031451 PMCID: PMC11001356 DOI: 10.1080/0886022x.2023.2287130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 11/19/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Bispectral index (BIS) is a processed electroencephalography monitoring tool and is widely used in anesthetic depth monitoring. Deep anesthesia exposure may be associated with multiple adverse outcomes. However, the relationship between anesthetic depth and postoperative acute kidney injury (AKI) remains unclear. We sought to determine the effect of BIS-based deep anesthesia duration on postoperative AKI following noncardiac surgery. METHODS This retrospective study used data from the Vital Signs DataBase, including patients undergoing noncardiac surgeries with BIS monitoring. The BIS values were collected every second during anesthesia. Restricted cubic splines and logistic regression were used to assess the association between the cumulative duration of deep anesthesia and postoperative AKI. RESULTS 4774 patients were eligible, and 129 (2.7%) experienced postoperative AKI. Restricted cubic splines showed that a cumulative duration of BIS < 45 was nonlinearly associated with postoperative AKI (P-overall = 0.033 and P-non-linear = 0.023). Using the group with the duration of BIS < 45 less than 15 min as the reference, ORs of postoperative AKI were 2.59 (95% confidence interval [CI]:0.60 to 11.09, p = 0.200) in the 15-100 min group, and 4.04 (95%CI:0.92 to 17.76, p = 0.064) in the ≥ 100 min group after adjusting for preoperative and intraoperative covariates in multivariable logistic regression. CONCLUSIONS The cumulative duration of BIS < 45 was independently and nonlinearly associated with the risk of postoperative AKI in patients undergoing noncardiac surgery.
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Affiliation(s)
- Wen-Kao Huang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wan-Yi Lian
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiao-Yu Zhuo
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Song-Yun Kang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wen-Chi Luo
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yi-Shan Xie
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Gui-Yang Xi
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ke-Xuan Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei-Feng Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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17
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Brown ML, Cradeur M, Staffa SJ, Nasr VG, Hernandez MR, DiNardo JA. Anaesthesia for non-cardiac surgery in children and young adults with Fontan physiology. Cardiol Young 2023; 33:1896-1901. [PMID: 36330834 DOI: 10.1017/s104795112200333x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Patients with Fontan physiology require non-cardiac surgery. Our objectives were to characterise perioperative outcomes of patients with Fontan physiology undergoing non-cardiac surgery and to identify characteristics which predict discharge on the same day. MATERIALS AND METHOD Children and young adults with Fontan physiology who underwent a non-cardiac surgery or an imaging study under anaesthesia between 2013 and 2019 at a single-centre academic children's hospital were reviewed in a retrospective observational study. Continuous variables were compared using the Wilcoxon rank sum test, and categorical variables were analysed using the Chi-square test or Fisher's exact test. Multivariable logistic regression analysis results are presented by adjusted odds ratios with 95% confidence intervals and p values. RESULTS 182 patients underwent 344 non-cardiac procedures with anaesthesia. The median age was 11 years (IQR 5.2-18), 56.4% were male. General anaesthesia was administered in 289 (84%). 125 patients (36.3%) were discharged on the same day. On multivariable analysis, independent predictors that reduced the odds of same-day discharge included the chronic condition index (OR 0.91 per additional chronic condition, 95% CI 0.76-0.98, p = 0.022), undergoing a major surgical procedure (OR 0.17, 95% CI 0.05-0.64, p = 0.009), the use of intraoperative inotropes (OR 0.48, 95% CI 0.25-0.94, p = 0.031), and preoperative admission (OR = 0.24, 95% CI: 0.1-0.57, p = 0.001). DISCUSSION In a contemporary cohort of paediatric and young adults with Fontan physiology, 36.3% were able to be discharged on the same day of their non-cardiac procedure. Well selected patients with Fontan physiology can undergo anaesthesia without complications and be discharged same day.
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Affiliation(s)
- Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Michael Cradeur
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Michael R Hernandez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
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18
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Li M, Huang H. Anesthetic Management of Patients with Dilated Cardiomyopathy Undergoing Noncardiac Surgery. Medicina (Kaunas) 2023; 59:1567. [PMID: 37763685 PMCID: PMC10533037 DOI: 10.3390/medicina59091567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023]
Abstract
Dilated cardiomyopathy (DCM), a primary myocardial disease, is characterized by dilation of the left or both ventricles and systolic dysfunction with or without congestive heart failure. DCM per se is a well-recognized risk factor for sudden cardiac death and poor surgical outcomes following noncardiac surgery. Surgical trauma/stress represents unique challenges for DCM patient management. Unfortunately, there is a big knowledge gap in managing DCM patients undergoing non-cardiac surgery. Therefore, the aim of our review is to provide basic facts and current advances in DCM, as well as a practical guideline to perioperative care providers, for the management of surgical patients with DCM, who are quite rare compared with the general surgical population. This review summarizes recent advances in the medical management of DCM as well as perioperative assessment and management strategies for DCM patients undergoing noncardiac surgery. Optimal surgical outcomes depend on multiple-disciplinary care to minimize perioperative cardiovascular disturbances.
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Affiliation(s)
| | - Han Huang
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
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19
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Chen Z, Zhang Y, Zeng W, Ye L, Yu C, Shi F. Myocardial injury before noncardiac surgery. Front Cardiovasc Med 2023; 10:1207124. [PMID: 37692037 PMCID: PMC10492582 DOI: 10.3389/fcvm.2023.1207124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023] Open
Abstract
Non-cardiac surgical procedures present a significant circulatory stress and can potentially trigger cardiovascular events, such as myocardial infarction and heart failure. Myocardial injury before non-cardiac surgery is associated with an increased risk of mortality and major cardiovascular complications during perioperative period, as well as up to 5 years after non-cardiac surgery. While the definition of preoperative myocardial injury is not yet clear, it is generally understood as myocardial injury resulting from various causes of troponin elevation without acute coronary syndrome prior to surgery. Detecting preoperative myocardial injury through routine troponin monitoring is crucial for reducing perioperative risk, but it is also challenging. The aim of this review is to discuss the definition of preoperative myocardial injury, its pathophysiology, implications on clinical practice and decision-making for patients with elevated troponin levels before non-cardiac surgery.
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Affiliation(s)
- Zhibing Chen
- Department of General Surgery, Jiujiang First People’s Hospital, JiuJiang, China
| | - Yitao Zhang
- Cardiovascular Department, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Weijie Zeng
- Cardiovascular Department, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lin Ye
- Department of General Surgery, Jiujiang First People’s Hospital, JiuJiang, China
| | - Changda Yu
- Department of General Surgery, Jiujiang First People’s Hospital, JiuJiang, China
| | - Fan Shi
- Internal Medicine-Cardiovascular Department, Jiujiang First People’s Hospital, JiuJiang, China
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Popova E, Paniagua-Iglesias P, Álvarez-García J, Vives-Borrás M, González-Osuna A, García-Osuna Á, Rivas-Lasarte M, Hermenegildo-Chavez G, Diaz-Jover R, Azparren-Cabezon G, Barceló-Trias M, Moustafa AH, Aguilar-Lopez R, Ordonez-Llanos J, Alonso-Coello P. The Relevance of Implementing the Systematic Screening of Perioperative Myocardial Injury in Noncardiac Surgery Patients. J Clin Med 2023; 12:5371. [PMID: 37629413 PMCID: PMC10455326 DOI: 10.3390/jcm12165371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Perioperative myocardial injury (PMI) is a common cardiac complication. Recent guidelines recommend its systematic screening using high-sensitivity cardiac troponin (hs-cTn). However, there is limited evidence of local screening programs. We conducted a prospective, single-center study aimed at assessing the feasibility and outcomes of implementing systematic PMI screening. Hs-cTn concentrations were measured before and after surgery. PMI was defined as a postoperative hs-cTnT of ≥14 ng/L, exceeding the preoperative value by 50%. All patients were followed-up during the hospitalization, at one month and one year after surgery. The primary outcome was the incidence of death and major cardiovascular and cerebrovascular events (MACCE). The secondary outcomes focused on the individual components of MACCE. We included two-thirds of all eligible high-risk patients and achieved almost complete compliance with follow-ups. The prevalence of PMI was 15.7%, suggesting a higher presence of cardiovascular (CV) antecedents, increased perioperative CV complications, and higher preoperative hs-cTnT values. The all-cause death rate was 1.7% in the first month, increasing up to 11.2% at one year. The incidence of MACCE was 9.5% and 8.6% at the same time points. Given the observed elevated frequencies of PMI and MACCE, implementing systematic PMI screening is recommendable, particularly in patients with increased cardiovascular risk. However, it is important to acknowledge that achieving optimal screening implementation comes with various challenges and complexities.
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Affiliation(s)
- Ekaterine Popova
- Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain; (R.A.-L.); (P.A.-C.)
- Centro Cochrane Iberoamericano, 08025 Barcelona, Spain
| | - Pilar Paniagua-Iglesias
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (P.P.-I.); (G.H.-C.); (R.D.-J.); (G.A.-C.)
| | - Jesús Álvarez-García
- Department of Cardiology, Hospital Universitario Ramon y Cajal, 28034 Madrid, Spain
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (M.V.-B.); (M.R.-L.); (A.-H.M.)
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 29010 Madrid, Spain
| | - Miquel Vives-Borrás
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (M.V.-B.); (M.R.-L.); (A.-H.M.)
- Department of Cardiology, Fundació Institut d’Investigació Sanitària Illes Balears (IdISBa), 07120 Palma, Spain
| | - Aránzazu González-Osuna
- Department of Orthopedic Surgery and Traumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain;
| | - Álvaro García-Osuna
- Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (Á.G.-O.); (J.O.-L.)
| | - Mercedes Rivas-Lasarte
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (M.V.-B.); (M.R.-L.); (A.-H.M.)
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Majadahonda, Spain
| | - Gisela Hermenegildo-Chavez
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (P.P.-I.); (G.H.-C.); (R.D.-J.); (G.A.-C.)
| | - Ruben Diaz-Jover
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (P.P.-I.); (G.H.-C.); (R.D.-J.); (G.A.-C.)
| | - Gonzalo Azparren-Cabezon
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (P.P.-I.); (G.H.-C.); (R.D.-J.); (G.A.-C.)
| | - Montserrat Barceló-Trias
- Geriatric Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain;
| | - Abdel-Hakim Moustafa
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (M.V.-B.); (M.R.-L.); (A.-H.M.)
| | - Raul Aguilar-Lopez
- Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain; (R.A.-L.); (P.A.-C.)
- Cardiovascular Epidemiology Unit, Department of Cardiology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Jordi Ordonez-Llanos
- Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (Á.G.-O.); (J.O.-L.)
- Foundation for Clinical Biochemistry & Molecular Pathology, 08025 Barcelona, Spain
| | - Pablo Alonso-Coello
- Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain; (R.A.-L.); (P.A.-C.)
- Centro Cochrane Iberoamericano, 08025 Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), 28034 Madrid, Spain
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21
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Garg AX, Cuerden M, Cata J, Chan MTV, Devereaux PJ, Fleischmann E, Grande AM, Kabon B, Landoni G, Maziak DE, McLean S, Parikh C, Popova E, Reimer C, Trujillo Reyes JC, Roshanov P, Sessler DI, Srinathan S, Sontrop JM, Gonzalez Tallada A, Wang MK, Wells JR, Conen D. Effect of Colchicine on the Risk of Perioperative Acute Kidney Injury: Clinical Protocol of a Substudy of the Colchicine for the Prevention of Perioperative Atrial Fibrillation Randomized Clinical Trial. Can J Kidney Health Dis 2023; 10:20543581231185427. [PMID: 37457622 PMCID: PMC10338661 DOI: 10.1177/20543581231185427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023] Open
Abstract
Background Inflammation during and after surgery can lead to organ damage including acute kidney injury. Colchicine, an established inexpensive anti-inflammatory medication, may help to protect the organs from pro-inflammatory damage. This protocol describes a kidney substudy of the colchicine for the prevention of perioperative atrial fibrillation (COP-AF) study, which is testing the effect of colchicine versus placebo on the risk of atrial fibrillation and myocardial injury among patients undergoing thoracic surgery. Objective Our kidney substudy of COP-AF will determine whether colchicine reduces the risk of perioperative acute kidney injury compared with a placebo. We will also examine whether colchicine has a larger absolute benefit in patients with pre-existing chronic kidney disease, the most prominent risk factor for acute kidney injury. Design and Setting Randomized, superiority clinical trial conducted in 40 centers in 11 countries from 2018 to 2023. Patients Patients (~3200) aged 55 years and older having major thoracic surgery. Intervention Patients are randomized 1:1 to receive oral colchicine (0.5 mg tablet) or a matching placebo, given twice daily starting 2 to 4 hours before surgery for a total of 10 days. Patients, health care providers, data collectors, and outcome adjudicators will be blinded to the randomized treatment allocation. Methods Serum creatinine concentrations will be measured before surgery and on postoperative days 1, 2, and 3 (or until hospital discharge). The primary outcome of the substudy is perioperative acute kidney injury, defined as an increase (from the prerandomization value) in serum creatinine concentration of either ≥26.5 μmol/L (≥0.3 mg/dL) within 48 hours of surgery or ≥50% within 7 days of surgery. The primary analysis (intention-to-treat) will examine the relative risk of acute kidney injury in patients allocated to receive colchicine versus placebo. We will repeat the primary analysis using alternative definitions of acute kidney injury and examine effect modification by pre-existing chronic kidney disease, defined as a prerandomization estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m2. Limitations The substudy will be underpowered to detect small effects on more severe forms of acute kidney injury treated with dialysis. Results Substudy results will be reported in 2024. Conclusions This substudy will estimate the effect of colchicine on the risk of perioperative acute kidney injury in older adults undergoing major thoracic surgery. Clinical trial registration number NCT03310125.
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Affiliation(s)
| | | | - Juan Cata
- MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | | | | | | | | | - Sean McLean
- Vancouver Acute Department of Anesthesiology, Vancouver General Hospital, BC, Canada
| | - Chirag Parikh
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | | | | | - Pavel Roshanov
- London Health Sciences Centre, ON, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | | | - David Conen
- Population Health Research Institute, Hamilton, ON, Canada
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22
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Hong S, Song J, Ji SM, Lee W. What should be done when appropriate antiplatelet therapy fails to prevent stent thrombosis? Two case reports. Clin Case Rep 2023; 11:e7625. [PMID: 37384231 PMCID: PMC10293575 DOI: 10.1002/ccr3.7625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 05/04/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023] Open
Abstract
When performing noncardiac surgery in high-risk patients with PCI, anesthesiologists should be prepared for in-stent thrombosis, that do not respond to conventional treatments and cardiopulmonary resuscitation. VA-ECMO is an advantageous treatment method in those patients.
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Affiliation(s)
- Sungman Hong
- Department of Anesthesiology and Pain MedicineDankook University College of MedicineCheonanRepublic of Korea
| | - Jaegyok Song
- Department of Anesthesiology and Pain MedicineDankook University College of MedicineCheonanRepublic of Korea
| | - Sung mi Ji
- Department of Anesthesiology and Pain MedicineDankook University College of MedicineCheonanRepublic of Korea
| | - Wonkyu Lee
- Department of Anesthesiology and Pain MedicineDankook University College of MedicineCheonanRepublic of Korea
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23
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Legrand M, Kothari R, Fong N, Palaniappa N, Boldt D, Chen LL, Kurien P, Gabel E, Sturgess-DaPrato J, Harhay MO, Pirracchio R, Bokoch MP. Norepinephrine versus phenylephrine for treating hypotension during general anaesthesia in adult patients undergoing major noncardiac surgery: a multicentre, open-label, cluster-randomised, crossover, feasibility, and pilot trial. Br J Anaesth 2023; 130:519-527. [PMID: 36925330 DOI: 10.1016/j.bja.2023.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Intraoperative hypotension is associated with postoperative complications. The use of vasopressors is often required to correct hypotension but the best vasopressor is unknown. METHODS A multicentre, cluster-randomised, crossover, feasibility and pilot trial was conducted across five hospitals in California. Phenylephrine (PE) vs norepinephrine (NE) infusion as the first-line vasopressor in patients under general anaesthesia alternated monthly at each hospital for 6 months. The primary endpoint was first-line vasopressor administration compliance of 80% or higher. Secondary endpoints were acute kidney injury (AKI), 30-day mortality, myocardial injury after noncardiac surgery (MINS), hospital length of stay, and rehospitalisation within 30 days. RESULTS A total of 3626 patients were enrolled over 6 months; 1809 patients were randomised in the NE group, 1817 in the PE group. Overall, 88.2% received the assigned first-line vasopressor. No drug infiltrations requiring treatment were reported in either group. Patients were median 63 yr old, 50% female, and 58% white. Randomisation in the NE group vs PE group did not reduce readmission within 30 days (adjusted odds ratio=0.92; 95% confidence interval, 0.6-1.39), 30-day mortality (1.01; 0.48-2.09), AKI (1.1; 0.92-1.31), or MINS (1.63; 0.84-3.16). CONCLUSIONS A large and diverse population undergoing major surgery under general anaesthesia was successfully enrolled and randomised to receive NE or PE infusion. This pilot and feasibility trial was not powered for adverse postoperative outcomes and a follow-up multicentre effectiveness trial is planned. CLINICAL TRIAL REGISTRATION NCT04789330 (ClinicalTrials.gov).
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; INI-CRCT Network, Nancy, France.
| | - Rishi Kothari
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas Fong
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; School of Medicine, University of California, San Francisco, CA, USA
| | - Nandini Palaniappa
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - David Boldt
- Department of Anesthesia and Perioperative Care, University of California, Los Angeles, USA
| | - Lee-Lynn Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Philip Kurien
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Eilon Gabel
- Department of Anesthesia and Perioperative Care, University of California, Los Angeles, USA
| | - Jillene Sturgess-DaPrato
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Michael O Harhay
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Michael P Bokoch
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
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24
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Thangrom W, Roopsawang I, Aree-Ue S. Prevalence and Related Factors of Lower Urinary Tract Infection in Frail Older Adults Undergoing Major Noncardiac Surgery. Geriatrics (Basel) 2023; 8:geriatrics8020033. [PMID: 36960988 PMCID: PMC10037596 DOI: 10.3390/geriatrics8020033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Urinary tract infections are the most common complication after surgery in older adults, resulting in poor operative outcomes and reduced quality of life after discharge. However, there is limited research investigating the relationships between urinary tract infection and associated factors in frail older surgical patients, particularly in Thailand. This retrospective study included 220 frail older patients aged ≥ 60 years who had undergone major noncardiac surgery at a tertiary care hospital in Thailand from January 2015 to December 2019. The sample was recruited using the criteria indicated in the modified Frailty Index-11 and having the blood glucose level determined within 2 h before surgery. The prevalence of lower urinary tract infections was 15% post-surgery. Firth's logistic regression analysis revealed that the equation could predict the accuracy of lower urinary tract infections by 88.5%. Frailty, blood glucose levels, complication during admission, and personal factors together predicted the variability of lower urinary tract infections. Adjusting for other variables, being an older adult with severe frailty and complications during hospital admission significantly increased the risk of developing lower urinary tract infections (odds ratio = 3.46, p < 0.05; odds ratio = 9.53, p < 0.001, respectively).
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Affiliation(s)
- Warin Thangrom
- Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Inthira Roopsawang
- Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Suparb Aree-Ue
- Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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25
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Horvath K, Taschner A, Adamowitsch N, Falkner von Sonnenburg M, Fleischmann E, Kabon B, Fraunschiel M, Reiterer C, Graf A. Effect of Supplemental Oxygen on von Willebrand Factor Activity and Ristocetin Cofactor Activity in Patients at Risk for Cardiovascular Complications Undergoing Moderate-to High-Risk Major Noncardiac Surgery-A Secondary Analysis of a Randomized Trial. J Clin Med 2023; 12. [PMID: 36769870 DOI: 10.3390/jcm12031222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Increased von Willebrand Factor (vWF) activity mediates platelet adhesion and might be a contributor to the development of thrombotic complications after surgery. Although in vitro studies have shown that hyperoxia induces endovascular damage, the effect of perioperative supplemental oxygen as a possible trigger for increased vWF activity has not been investigated yet. We tested our primary hypothesis that the perioperative administration of 80% oxygen concentration increases postoperative vWF activity as compared to 30% oxygen concentration in patients at risk of cardiovascular complications undergoing major noncardiac surgery. A total of 260 patients were randomly assigned to receive 80% versus 30% oxygen throughout surgery and for two hours postoperatively. We assessed vWF activity and Ristocetin cofactor activity in all patients shortly before the induction of anesthesia, within two hours after surgery and on the first and third postoperative day. Patient characteristics were similar in both groups. We found no significant difference in vWF activity in the overall perioperative time course between both randomization groups. We observed significantly increased vWF activity in the overall study population throughout the postoperative time course. Perioperative supplemental oxygen showed no significant effect on postoperative vWF and Ristocetin cofactor activity in cardiac risk patients undergoing major noncardiac surgery. In conclusion, we found no significant influence of supplemental oxygen in patients undergoing major non-cardiac surgery on postoperative vWF activity and Ristocetin cofactor activity.
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26
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Zeng K, Long J, Li Y, Hu J. Preventing postoperative cognitive dysfunction using anesthetic drugs in elderly patients undergoing noncardiac surgery: a systematic review and meta-analysis. Int J Surg 2023; 109:21-31. [PMID: 36799783 PMCID: PMC10389238 DOI: 10.1097/js9.0000000000000001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/25/2022] [Indexed: 02/18/2023]
Abstract
Postoperative cognitive dysfunction (POCD) is a common neurological system disorder in surgical patients. The choice of anesthetic can potentially reduce POCD. The authors performed this network meta-analysis to compare different anesthetic drugs in reducing the incidence of POCD for elderly people undergoing noncardiac surgery. We searched MEDLINE, EMBASE, the Cochrane Library, and the Web of Science for randomized controlled trials comparing the different anesthetic drugs for noncardiac surgery in elderly from inception until July, 2022. The protocol was registered on the PROSPERO database (CRD#42020183014). A total of 34 trials involving 4314 patients undergoing noncardiac surgery in elderly were included. The incidence of POCD for each anesthetic drug was placebo (27.7%), dexmedetomidine (12.9%), ketamine (15.2%), propofol (16.8%), fentanyl (23.9%), midazolam (11.3%), sufentanil (6.3%), sevoflurane (24.0%), and desflurane (28.3%). Pairwise and network meta-analysis showed dexmedetomidine was significantly reducing the incidence of POCD when compared with placebo. Network meta-analysis also suggested dexmedetomidine was significantly reducing the incidence of POCD when compared with sevoflurane. Sufentanil and dexmedetomidine ranked the first and second in reducing the incidence of POCD with the surface under the cumulative ranking curve value of 87.4 and 81.5%. Sufentanil and dexmedetomidine had the greatest possibility to reduce the incidence of POCD for elderly people undergoing noncardiac surgery.
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Affiliation(s)
- Kuan Zeng
- Department of Psychiatry, Wuhan Mental Health Center
- Affiliated Wuhan Mental Health Center, Tongji Medical College of Huazhong University of Science and Technology
- Research Center for Psychological and Health Sciences, China University of Geosciences
| | - Jingyi Long
- Department of Psychiatry, Wuhan Mental Health Center
- Affiliated Wuhan Mental Health Center, Tongji Medical College of Huazhong University of Science and Technology
- Research Center for Psychological and Health Sciences, China University of Geosciences
| | - Yi Li
- Department of Psychiatry, Wuhan Mental Health Center
- Affiliated Wuhan Mental Health Center, Tongji Medical College of Huazhong University of Science and Technology
- Research Center for Psychological and Health Sciences, China University of Geosciences
| | - Jichang Hu
- Department of Pathophysiology, School of Basic Medicine, Key Laboratory of Education Ministry of China for Neurological Disorders, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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27
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Chew MS, Saugel B, Lurati-Buse G. Perioperative troponin surveillance in major noncardiac surgery: a narrative review. Br J Anaesth 2023; 130:21-8. [PMID: 36464518 DOI: 10.1016/j.bja.2022.08.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/08/2022] [Accepted: 08/31/2022] [Indexed: 12/03/2022] Open
Abstract
Myocardial injury is now an acknowledged complication in patients undergoing noncardiac surgery. Heterogeneity in the definitions of myocardial injury contributes to difficulty in evaluating the value of cardiac troponins (cTns) measurement in perioperative care. Pre-, post-, and peri-operatively increased cTns are encompassed by the umbrella term 'myocardial injury' and are likely to reflect different pathophysiological mechanisms. Increased cTns are independently associated with cardiovascular and non-cardiovascular complications, poor short-term and long-term cardiovascular outcomes, and increased mortality. Preoperative measurement of cTns aids preoperative risk stratification beyond the Revised Cardiac Risk Index. Systematic measurement detects acute perioperative increases and allows early identification of acute myocardial injury. Common definitions and standards for reporting are a prerequisite for designing impactful future trials and perioperative management strategies.
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28
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Franzini S, Brebion M, Crowe AM, Querciagrossa S, Ren M, Leva E, Orliaguet G. Use of combined cerebral and somatic renal near infrared spectroscopy during noncardiac surgery in children: a proposed algorithm. Paediatr Anaesth 2022; 32:1278-1284. [PMID: 36352522 DOI: 10.1111/pan.14552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 11/28/2022]
Abstract
Cerebral near infrared spectroscopy (NIRS) monitoring has been extensively applied in neonatology and in cardiac surgery, becoming a standard in many pediatric cardiac centers. However, compensatory physiological mechanisms favor cerebral perfusion to the detriment of peripheral tissue oxygenation. Therefore, simultaneous measurement of cerebral and somatic oxygen saturation has been advocated to ease the differential diagnosis between central and peripheral sources of hypoperfusion, which may go undetected by standard monitoring and not mirrored by cerebral NIRS alone. A clinical algorithm already exists in cardiac surgery, aimed to correct intraoperative cerebral oxygen desaturations. A similar algorithm still lacks in noncardiac pediatric surgery. The goal of this paper is to propose a clinical algorithm for the combined use of cerebral and somatic NIRS monitoring during anesthesia in the pediatric population undergoing noncardiac surgery. A panel of experienced pediatric anesthetists developed the algorithm that is based on the clinical experience and intraoperative observations. It aims to lessen the current variability in interpreting NIRS measurement. Multisite NIRS monitoring was achieved applying one pediatric sensor to the forehead for cerebral tissue perfusion reading and a second one to the decumbent lumbar region for recording somatic renal tissue perfusion. The algorithm describes a sequence of acts aimed to identify the putative cause of intraoperative organ tissue desaturation and suggests clinical interventions expected to restore adequate tissue perfusion. It is composed of two arms: the main arm includes patients with an observed decrease in cerebral perfusion (CrO2), the second one includes those with a stable CrSO2 with declining RrSO2. Described also are five clinical cases of infants and neonates in whom pathological alterations of organ perfusion were detected using intraoperative multisite NIRS monitoring, portrayed in the accompanying figures (Annex).
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Affiliation(s)
- Stefania Franzini
- Department of Pediatric Anesthesia and Intensive Care, Necker-Enfants Malades University Hospital, AP-HP Centre-Université Paris Cité, Paris, France
| | - Myriam Brebion
- Department of Pediatric Anesthesia and Intensive Care, Necker-Enfants Malades University Hospital, AP-HP Centre-Université Paris Cité, Paris, France
| | - Ann-Marie Crowe
- Department of Pediatric Anesthesia and Intensive Care, Necker-Enfants Malades University Hospital, AP-HP Centre-Université Paris Cité, Paris, France
| | - Stefania Querciagrossa
- Department of Pediatric Anesthesia and Intensive Care, Necker-Enfants Malades University Hospital, AP-HP Centre-Université Paris Cité, Paris, France
| | - Melissa Ren
- Department of Pediatric Anesthesia and Intensive Care, Necker-Enfants Malades University Hospital, AP-HP Centre-Université Paris Cité, Paris, France
| | - Ernesto Leva
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.,Department of Pediatric Surgery, University of Milan, School of Medicine and Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Gilles Orliaguet
- Department of Pediatric Anesthesia and Intensive Care, Necker-Enfants Malades University Hospital, AP-HP Centre-Université Paris Cité, Paris, France.,Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, Unité de recherche EA 7323, Hôpitaux Universitaires Paris Centre - Site Tarnier, Université Paris Cité, Paris, France
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29
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Hamilton ARL, Odegard KC, Yuki K. Exploring Noncardiac Surgical Needs From Infancy to Adulthood in Patients With Congenital Heart Disease. J Cardiothorac Vasc Anesth 2022; 36:4364-4369. [PMID: 36216687 DOI: 10.1053/j.jvca.2022.09.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES As life expectancy for patients born with congenital heart disease (CHD) continues to rise, these patients will present increasingly for noncardiac surgery during childhood and adolescence. This study aimed to map the lifespan of noncardiac surgical needs among patients with CHD and explore how these needs may change over time. DESIGN All patients with CHD presenting for noncardiac surgery between 2008 and 2014 were selected for review. SETTING The study was conducted at a single urban academic tertiary pediatric hospital. PARTICIPANTS All patients with CHD presenting for noncardiac surgery during the study period were included and grouped by cardiac diagnosis. INTERVENTIONS Descriptive analysis included patient demographics, CHD diagnosis, procedures performed, and clinical data, including baseline saturation and underlying cardiac function. MEASUREMENTS AND MAIN RESULTS A total of 3,011 noncardiac surgical procedures were performed on patients with CHD during the study period. The most common CHD diagnoses were patent ductus arteriosus (27.6%), ventricular septal defects (24.7%), and patent foramen ovale (24.3%). The median age was 4 years, 87% of all the patients were ≤10 years, and 41% had associated syndromes. Of the patients, 76% underwent a preoperative echocardiogram, and 10% had depressed cardiac function at the time of surgery. The most common procedures performed were ear, nose, and throat (20%), general surgery (14%), and radiology (11%). Intraoperative events were reported in 488 out of 3,010 encounters (16.2%), with the highest rates reported in patients with single-ventricle physiology (55/179; 30.7%). CONCLUSIONS These findings suggested a greater burden of noncardiac surgery in lower age groups, with ear, nose, and throat and general surgery most common in young children and orthopedic and dental procedures increasing in adolescence.
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Affiliation(s)
- A Rebecca L Hamilton
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA; Department of Cell and Molecular Biology, Karolinska Institute, Stockholm, Sweden.
| | - Kirsten C Odegard
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Koichi Yuki
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA
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Yap EN, Dusendang JR, Ng KP, Keny HV, Solomon MD, Cohn BR, Corley DA, Herrinton LJ. Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery. Popul Health Manag 2022; 25:712-720. [PMID: 36095257 DOI: 10.1089/pop.2022.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Limited sample size, incomplete measures, and inadequate risk adjustment adversely influence accurate health care quality measurements, surgical quality measurements, and accurate comparisons among hospitals. Since these measures are linked to resources for quality improvement and reimbursement, improving the accuracy of measurement has substantial implications for patients, clinicians, hospital administrators, insurers, and purchasers. The team examined risk-adjusted differences of postoperative cardiac events among 20 geographically dispersed, community-based medical centers within an integrated health care system and compared it with the National Surgical Quality Improvement Program (NSQIP) hospital-specific differences. The exposure included the hospital at which patients received noncardiac surgical care, with stratification of patients by the acuity of surgery (elective vs. urgent/emergent). Among 157,075 surgery patients, the unadjusted risk of cardiac event per 1000 ranged among hospitals from 2.1 to 6.9 for elective surgery and from 10.3 to 44.5 for urgent/emergent surgery. Across the 20 hospitals, hospital rankings estimated in the present analysis differed significantly from ranking reported by NSQIP (P for difference: elective, P = 0.0001; urgent/emergent, P < 0.0001) with significantly and substantially lower variation after risk adjustment. Current surgical quality measures may not adequately account for limitations of sample size, data capture, adequate risk adjustment, and surgical acuity in a given hospital, particularly for rare outcomes. These differences have implications for quality reporting and may introduce bias into hospital comparisons, particularly for hospitals with incomplete capture of their patients' baseline risk and acuity.
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Affiliation(s)
- Edward N Yap
- Department of Anesthesia, The Permanente Medical Group, Oakland, California, USA.,Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA
| | - Jennifer R Dusendang
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Kevin P Ng
- Department of Anesthesia, The Permanente Medical Group, Oakland, California, USA
| | - Hemant V Keny
- Department of Surgery, The Permanente Medical Group, Oakland, California, USA
| | - Matthew D Solomon
- Department of Cardiology, and The Permanente Medical Group, Oakland, California, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Bradley R Cohn
- Department of Anesthesia, The Permanente Medical Group, Oakland, California, USA
| | - Douglas A Corley
- Department of Gastroenterology, The Permanente Medical Group, Oakland, California, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Golbus JR, Joo H, Janda AM, Maile MD, Aaronson KD, Engoren MC, Cassidy RB, Kheterpal S, Mathis MR. Preoperative clinical diagnostic accuracy of heart failure among patients undergoing major noncardiac surgery: a single-centre prospective observational analysis. BJA Open 2022; 4:100113. [PMID: 36643721 PMCID: PMC9835767 DOI: 10.1016/j.bjao.2022.100113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/16/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Abstract
Background Reliable diagnosis of heart failure during preoperative evaluation is important for perioperative management and long-term care. We aimed to quantify preoperative heart failure diagnostic accuracy and explore characteristics of patients with heart failure misdiagnoses. Methods We performed an observational cohort study of adults undergoing major noncardiac surgery at an academic hospital between 2015 and 2019. A preoperative clinical diagnosis of heart failure was defined using keywords from the history and clinical examination or administrative documentation. Across stratified subsamples of cases with and without clinically diagnosed heart failure, health records were intensively reviewed by an expert panel to develop an adjudicated heart failure reference standard using diagnostic criteria congruent with consensus guidelines. We calculated agreement among experts, and analysed performance of clinically diagnosed heart failure compared with the adjudicated reference standard. Results Across 40 555 major noncardiac procedures, a stratified subsample of 511 patients was reviewed by the expert panel. The prevalence of heart failure was 9.1% based on clinically diagnosed compared with 13.3% (95% confidence interval [CI], 10.3-16.2%) estimated by the expert panel. Overall agreement and inter-rater reliability (kappa) among heart failure experts were 95% and 0.79, respectively. Based upon expert adjudication, heart failure was clinically diagnosed with an accuracy of 92.8% (90.6-95.1%), sensitivity 57.4% (53.1-61.7%), specificity 98.3% (97.1-99.4%), positive predictive value 83.5% (80.3-86.8%), and negative predictive value 93.8% (91.7-95.9%). Conclusions Limitations exist to the preoperative clinical diagnosis of heart failure, with nearly half of cases undiagnosed preoperatively. Considering the risks of undiagnosed heart failure, efforts to improve preoperative heart failure diagnoses are warranted.
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Affiliation(s)
- Jessica R. Golbus
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Hyeon Joo
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Allison M. Janda
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Michael D. Maile
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Keith D. Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Milo C. Engoren
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Ruth B. Cassidy
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Michael R. Mathis
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
- Department of Computational Bioinformatics, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
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Wesselink EM, Wagemakers SH, van Waes JAR, Wanderer JP, van Klei WA, Kappen TH. Associations between intraoperative hypotension, duration of surgery and postoperative myocardial injury after noncardiac surgery: a retrospective single-centre cohort study. Br J Anaesth 2022; 129:487-496. [PMID: 36064492 DOI: 10.1016/j.bja.2022.06.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/16/2022] [Accepted: 06/05/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Studies of intraoperative hypotension typically specify a blood pressure threshold associated with adverse outcomes. Such thresholds are likely to be study-biased, investigator-biased, or both. We hypothesised that a newly developed modelling method without a threshold, which is biologically more plausible than a threshold-based approach, would reveal a continuous association between exposure to intraoperative hypotension and adverse outcomes. METHODS Single-centre, retrospective cohort study of subjects ≥60 yr old undergoing noncardiac surgery. We modelled intraoperative hypotension using three different approaches: (1) unweighted, (2) weighted for degree of hypotension (depth), and (3) weighted for duration of hypotension. The primary outcome was myocardial injury, defined as elevated troponin I (>60 ng L-1) measured during the first 3 days after surgery. The associations between the three models, postoperative myocardial injury, and mortality (secondary outcome) were reported as penalised adjusted odds ratios (ORs) scaled between the 75th and 25th percentiles. RESULTS Myocardial injury occurred in 1812/15 452 (12%) procedures, with 554/15 452 (3.6%) procedures resulting in death before discharge from hospital. The unweighted lower blood pressure measure (OR: 0.26, 95% confidence interval [CI]: 0.12-0.53) and the depth-weighted measure (OR: 4.4, 95% CI: 2.6-7.4) were associated with myocardial injury. The duration-weighted measure was not associated with myocardial injury (OR: 0.89, 95% CI: 0.61-1.3). The unweighted measure (OR 0.08, 95% CI: 0.01-0.40) and the depth-weighted measure (OR: 12, 95% CI, 3.8-35) were associated with in-hospital mortality, but not the duration-weighted measure (OR: 1.3, 95% CI: 0.53-3.0). CONCLUSIONS Intraoperative hypotension appears to have a graded association with postoperative myocardial injury and mortality, with depth appearing to contribute more than duration.
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Affiliation(s)
- Esther M Wesselink
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sjors H Wagemakers
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jonathan P Wanderer
- Departments of Anesthesiology and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Teus H Kappen
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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Ofori SN, Marcucci M, Mbuagbaw L, Conen D, Borges FK, Chow CK, Sessler DI, Chan MTV, Hillis GS, Pettit S, Heels-Ansdell D, Devereaux PJ. Determinants of tobacco smoking abstinence 1 year after major noncardiac surgery: a secondary analysis of the VISION study. Br J Anaesth 2022; 129:497-505. [PMID: 35987704 DOI: 10.1016/j.bja.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tobacco smoking is a leading preventable cause of death and increases perioperative risk. Determinants of smoking abstinence after noncardiac surgery and the association between smoking and 1-yr vascular outcomes are not fully elucidated. METHODS We did a prospective cohort study of 40 004 patients, aged ≥45 yr, enrolled between August 2007 and November 2013, and followed for 1 yr after surgery. Patients were categorised as never smokers, ex-smokers (quit >4 weeks preoperatively), and current smokers (smoking ≤4 weeks preoperatively). Primary outcome was abstinence at 1 yr. Secondary outcome was a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke at 1 yr. RESULTS Of 4658 current smokers, 1838 (39.5%) were abstinent 1 yr after surgery. Median (inter-quartile range) time to resumption was 7 (3-23) days post-surgery. Perioperatively, 7.2% of current smokers obtained smoking cessation pharmacotherapy. Older age (adjusted risk ratio [aRR] 1.21; 95% confidence interval [CI]: 1.12-1.32); having recent coronary artery disease (aRR 1.41; 95% CI: 1.29-1.55); cancer (aRR 1.37; 95% CI: 1.18-1.59); and undergoing major vascular (aRR 1.20; 95% CI: 1.02-1.41), urgent/emergent (aRR 1.14; 95% CI: 1.05-1.23), or thoracic (aRR 1.41; 95% CI: 1.26-1.56) surgeries increased abstinence. One-year abstinence was less likely when patients stopped smoking 0-1 day (aRR 0.53; 95% CI: 0.43-0.66) and 2-14 days (aRR 0.76; 95% CI: 0.71-0.82) before surgery compared with >14 days before surgery. Current smokers (adjusted hazard ratio [aHR] 1.14; 95% CI: 1.01-1.29) and ex-smokers (aHR 1.11; 95% CI: 1.03-1.21) had higher risk of the 1-yr vascular outcome compared with never smokers. CONCLUSIONS Long-term tobacco abstinence is more likely after major surgery in those with serious medical comorbidities. Interventions to prevent smoking resumption after surgery remain a priority. Clinical trial registration NCT00512109.
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Affiliation(s)
- Sandra N Ofori
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada.
| | - Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Biostatistics Unit, St Joseph's Healthcare, Hamilton, ON, Canada
| | - David Conen
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Flavia K Borges
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Clara K Chow
- Westmead Applied Research Centre, University of Sydney, Sydney, Australia; Westmead Hospital, Sydney, Australia
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew T V Chan
- Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Graham S Hillis
- George Institute for Global Health, University of Sydney, Sydney, Australia; Royal Perth Hospital, Perth, Australia; University of Western Australia, Perth, Australia
| | - Shirley Pettit
- Population Health Research Institute, Hamilton, ON, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Philip J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Curtis AB, Korada SKC. Should Atrial Fibrillation Be Included in Preoperative Risk Assessment for Noncardiac Surgery? J Am Coll Cardiol 2022; 79:2486-8. [PMID: 35738708 DOI: 10.1016/j.jacc.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/20/2022] [Indexed: 11/24/2022]
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Prasada S, Desai MY, Saad M, Smilowitz NR, Faulx M, Menon V, Moudgil R, Chaudhury P, Hussein AA, Taigen T, Nakhla S, Mentias A. Preoperative Atrial Fibrillation and Cardiovascular Outcomes After Noncardiac Surgery. J Am Coll Cardiol 2022; 79:2471-85. [PMID: 35738707 DOI: 10.1016/j.jacc.2022.04.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND The impact of pre-existing atrial fibrillation (AF) on outcomes after noncardiac surgery is not clear. OBJECTIVES We aimed to study the impact of AF on the risk of adverse outcomes after noncardiac surgery in a nationwide cohort. METHODS We identified Medicare beneficiaries admitted for noncardiac surgery from 2015 to 2019 and divided the study cohort into 2 groups: with and without AF. Noncardiac surgery was classified into vascular, thoracic, general, genitourinary, gynecological, orthopedics and neurosurgery, breast, head and neck, and transplant. We used propensity score matching on exact age, sex, race, urgency and type of surgery, revised cardiac risk index (RCRI) and CHA2DS2-VASc score, and tight caliper on other comorbidities. The study outcomes were 30-day mortality, stroke, myocardial infarction, and heart failure. We examined the incremental utility of AF in addition to RCRI to predict adverse events after noncardiac surgery. RESULTS The study cohort included 8,635,758 patients who underwent noncardiac surgery (16.4% with AF). Patients with AF were older, more likely to be men, and had higher prevalence of comorbidities. After propensity score matching, AF was associated with higher risk of mortality (OR: 1.31; 95% CI: 1.30-1.32), heart failure (OR: 1.31; 95% CI: 1.30-1.33), and stroke (OR: 1.40; 95% CI: 1.37-1.43) and lower risk of myocardial infarction (OR: 0.81; 95% CI: 0.79-0.82). Results were consistent in subgroup analysis by sex, race, type of surgery, and all strata of RCRI and CHA2DS2-VASc score. AF improved the discriminative ability of RCRI (C-statistic 0.73 to 0.76). CONCLUSION Pre-existing AF is independently associated with postoperative adverse outcomes after NCS.
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Shaw AD, Khanna AK, Smischney NJ, Shenoy AV, Boero IJ, Bershad M, Hwang S, Chen Q, Stapelfeldt WH. Intraoperative hypotension is associated with persistent acute kidney disease after noncardiac surgery: a multicentre cohort study. Br J Anaesth 2022; 129:13-21. [PMID: 35595549 DOI: 10.1016/j.bja.2022.03.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Whilst intraoperative hypotension is associated with postoperative acute kidney injury (AKI), the link between intraoperative hypotension and acute kidney disease (AKD), defined as continuing renal dysfunction for up to 3 months after exposure, has not yet been studied. METHODS We conducted a retrospective multicentre cohort study using data from noncardiac, non-obstetric surgery extracted from a US electronic health records database. Primary outcome was the association between intraoperative hypotension, at three MAP thresholds (≤75, ≤65, and ≤55 mm Hg), and the following two AKD subtypes: (i) persistent (initial AKI incidence within 7 days of surgery, with continuation between 8 and 90 days post-surgery) and (ii) delayed (renal impairment without AKI within 7 days, with AKI occurring between 8 and 90 days post-surgery). Secondary outcomes included healthcare resource utilisation for patients with either AKD subtype or no AKD. RESULTS A total of 112 912 surgeries qualified for the study. We observed a rate of 2.2% for delayed AKD and 0.6% for persistent AKD. Intraoperative hypotension was significantly associated with persistent AKD at MAP ≤55 mm Hg (hazard ratio 1.1; 95% confidence interval: 1.38-1.22; P<0.004). However, IOH was not significantly associated with delayed AKD across any of the MAP thresholds. Patients with delayed or persistent AKD had higher healthcare resource utilisation across both hospital and intensive care admissions, compared with patients with no AKD. CONCLUSIONS Intraoperative hypotension is associated with persistent but not delayed acute kidney disease. Both types of acute kidney disease appear to be associated with increased healthcare utilisation. Correction of intraoperative hypotension is a potential opportunity to decrease postoperative kidney injury and associated costs.
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Affiliation(s)
- Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH, USA.
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Nathan J Smischney
- Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | - Qinyu Chen
- Boston Consulting Group, Boston, MA, USA
| | - Wolf H Stapelfeldt
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA; Anesthesiology Services, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
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Oh AR, Park J, Lee JH, Kim H, Yang K, Choi JH, Ahn J, Sung JD, Lee SH. Association Between Perioperative Adverse Cardiac Events and Mortality During One-Year Follow-Up After Noncardiac Surgery. J Am Heart Assoc 2022; 11:e024325. [PMID: 35411778 PMCID: PMC9238468 DOI: 10.1161/jaha.121.024325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiac complications are associated with perioperative mortality, but perioperative adverse cardiac events (PACEs) that are associated with long‐term mortality have not been clearly defined. We identified PACE as a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, or stroke during the 30‐day postoperative period and we compared mortality according to PACE occurrence. Methods and Results From January 2011 to June 2019, a total of 203 787 consecutive adult patients underwent noncardiac surgery at our institution. After excluding those with 30‐day mortality, mortality during a 1‐year follow‐up was compared. Machine learning with the extreme gradient boosting algorithm was also used to evaluate whether PACE was associated with 1‐year mortality. After excluding 1203 patients with 30‐day mortality, 202 584 patients were divided into 7994 (3.9%) patients with PACE and 194 590 (96.1%) without PACE. After an adjustment, the mortality was higher in the PACE group (2.1% versus 7.7%; hazard ratio [HR], 1.90; 95% CI, 1.74–2.09; P<0.001). Results were similar for 7839 pairs of propensity‐score‐matched patients (4.9% versus 7.9%; HR, 1.64; 95% CI, 1.44–1.87; P<0.001). PACE was significantly associated with mortality in the extreme gradient boostingmodel. Conclusions PACE as a composite outcome was associated with 1‐year mortality. Further studies are needed for PACE to be accepted as an end point in clinical studies of noncardiac surgery.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea.,Department of Anesthesiology and Pain Medicine Kangwon National University Hospital Chuncheon Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea.,Department of Biomedical Sciences Ajou University Graduate School of Medicine Suwon Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Hara Kim
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Kwangmo Yang
- Department of Biomedical Sciences Ajou University Graduate School of Medicine Suwon Korea.,Center for Health Promotion Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Jin-Ho Choi
- Department of Emergency Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Joonghyun Ahn
- Statistics and Data Center Research Institute for Future Medicine Samsung Medical Center Seoul Korea
| | - Ji Dong Sung
- Rehabilitation & Prevention Center Heart Vascular Stroke Institute Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Seung-Hwa Lee
- Rehabilitation & Prevention Center Heart Vascular Stroke Institute Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea.,Department of Biomedical Engineering Seoul National University College of Medicine Seoul Korea
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Loft FC, Rasmussen SM, Elvekjaer M, Haahr‐Raunkjaer C, Sørensen HBD, Aasvang EK, Meyhoff CS. Continuously monitored vital signs for detection of myocardial injury in high-risk patients - An observational study. Acta Anaesthesiol Scand 2022; 66:674-683. [PMID: 35247272 PMCID: PMC9314636 DOI: 10.1111/aas.14056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 12/21/2022]
Abstract
Background Patients are at risk of myocardial injury after major non‐cardiac surgery and during acute illness. Myocardial injury is associated with mortality, but often asymptomatic and currently detected through intermittent cardiac biomarker screening. This delays diagnosis, where vital signs deviations may serve as a proxy for early signs of myocardial injury. This study aimed to assess the association between continuous monitored vital sign deviations and subsequent myocardial injury following major abdominal cancer surgery and during acute exacerbation of chronic obstructive pulmonary disease. Methods Patients undergoing major abdominal cancer surgery or admitted with acute exacerbation of chronic obstructive pulmonary disease had daily troponin measurements. Continuous wireless monitoring of several vital signs was performed for up to 96 h after admission or surgery. The primary exposure was cumulative duration of peripheral oxygen saturation (SpO2) below 85% in the 24 h before the primary outcome of myocardial injury, defined as a new onset ischaemic troponin elevation assessed daily. If no myocardial injury occurred, the primary exposure was based on the first 24 h of measurement. Results A total of 662 patients were continuously monitored and 113 (17%) had a myocardial injury. Cumulative duration of SpO2 < 85% was significantly associated with myocardial injury (mean difference 14.2 min [95% confidence interval −4.7 to 33.1 min]; p = .005). Durations of hypoxaemia (SpO2 < 88% and SpO2 < 80%), tachycardia (HR > 110 bpm and HR > 130 bpm) and tachypnoea (RR > 24 min−1 and RR > 30 min−1) were also significantly associated with myocardial injury (p < .04, for all). Conclusion Duration of severely low SpO2 detected by continuous wireless monitoring is significantly associated with myocardial injury in high‐risk patients admitted to hospital wards. The effect of early detection and interventions should be assessed next.
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Affiliation(s)
- Frederik C. Loft
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Søren M. Rasmussen
- Digital Health Section Department of Health Technology Technical University of Denmark Kongens Lyngby Denmark
| | - Mikkel Elvekjaer
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Camilla Haahr‐Raunkjaer
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Helge B. D. Sørensen
- Digital Health Section Department of Health Technology Technical University of Denmark Kongens Lyngby Denmark
| | - Eske K. Aasvang
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Christian S. Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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Singh A, Broad J, Brenna CTA, Kaustov L, Choi S. The Effects of Dexmedetomidine on Perioperative Neurocognitive Outcomes After Noncardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Ann Surg Open 2022; 3:e130. [PMID: 37600088 PMCID: PMC10431438 DOI: 10.1097/as9.0000000000000130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 01/06/2022] [Indexed: 11/25/2022] Open
Abstract
Objective The purpose of this review is to examine the effect of dexmedetomidine on delayed neurocognitive recovery (dNCR; cognitive dysfunction ≥1 week postoperative) after major noncardiac surgery. Background Dexmedetomidine (DEX) effectively reduces delirium in the intensive care unit and reportedly attenuates cognitive decline following major noncardiac surgery. Ascertaining the true effect on postoperative cognition is difficult because studies are limited by suboptimal selection of cognitive assessment tools, timing of testing, and criteria for defining significant cognitive decline. Methods Prospective randomized trials comparing perioperative DEX to placebo for major noncardiac surgery assessing cognitive function ≥1 week postoperative were included. Pediatric, nonhuman, and non-English trials, and those where executive function was not assessed were excluded. Data were abstracted by 3 reviewers independently and in parallel according to PRISMA guidelines. The a priori binary primary outcome is dNCR defined as cognitive function declining by the minimal clinically important difference or accepted alternate measure (eg, Reliable Change Index ≥1.96). Bias was assessed with the Cochrane Collaboration tool. Data were pooled using a random effects model. Results Among 287 citations identified, 26 (9%) met criteria for full-text retrieval. Eleven randomized trials (1233 participants) were included for qualitative analysis, and 7 trials (616 participants) were included for meta-analysis of dNCR. Dexmedetomidine did not reduce the incidence of dNCR significantly (OR 0.57, 95% CI 0.30-1.10, P = 0.09) compared with placebo. There was no difference in the incidence of delirium (OR 0.94, 95% CI 0.55-1.63, P = 0.83) and a higher incidence of hemodynamic instability (OR 2.11, 95% CI 1.22-3.65, P = 0.008). Conclusions Dexmedetomidine does not reduce dNCR 1 week after major noncardiac surgery. This meta-analysis does not yet support the use of perioperative DEX to improve short term cognitive outcomes at this time; trials underway may yet change this conclusion while larger trials are needed to refine the point estimate of effect and examine long-term cognitive outcomes.
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Affiliation(s)
- Amara Singh
- From the Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Perioperative Brain Health Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Jeremy Broad
- From the Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Connor T. A. Brenna
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Perioperative Brain Health Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Lilia Kaustov
- From the Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Perioperative Brain Health Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Stephen Choi
- From the Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Perioperative Brain Health Centre, Sunnybrook Research Institute, Toronto, ON, Canada
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Garg AX, Cuerden M, Aguado H, Amir M, Belley-Cote EP, Bhatt K, Biccard BM, Borges FK, Chan M, Conen D, Duceppe E, Efremov S, Eikelboom J, Fleischmann E, Giovanni L, Gross P, Jayaram R, Kirov M, Kleinlugtenbelt Y, Kurz A, Lamy A, Leslie K, Likhvantsev V, Lomivorotov V, Marcucci M, Martínez-Zapata MJ, McGillion M, McIntyre W, Meyhoff C, Ofori S, Painter T, Paniagua P, Parikh C, Parlow J, Patel A, Polanczyk C, Richards T, Roshanov P, Schmartz D, Sessler D, Short T, Sontrop JM, Spence J, Srinathan S, Stillo D, Szczeklik W, Tandon V, Torres D, Van Helder T, Vincent J, Wang CY, Wang M, Whitlock R, Wittmann M, Xavier D, Devereaux PJ. Effect of a Perioperative Hypotension-Avoidance Strategy Versus a Hypertension-Avoidance Strategy on the Risk of Acute Kidney Injury: A Clinical Research Protocol for a Substudy of the POISE-3 Randomized Clinical Trial. Can J Kidney Health Dis 2022; 9:20543581211069225. [PMID: 35024154 PMCID: PMC8744204 DOI: 10.1177/20543581211069225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Most patients who take antihypertensive medications continue taking them on
the morning of surgery and during the perioperative period. However, growing
evidence suggests this practice may contribute to perioperative hypotension
and a higher risk of complications. This protocol describes an acute kidney
injury substudy of the Perioperative Ischemic Evaluation-3 (POISE-3) trial,
which is testing the effect of a perioperative hypotension-avoidance
strategy versus a hypertension-avoidance strategy in patients undergoing
noncardiac surgery. Objective: To conduct a substudy of POISE-3 to determine whether a perioperative
hypotension-avoidance strategy reduces the risk of acute kidney injury
compared with a hypertension-avoidance strategy. Design: Randomized clinical trial with 1:1 randomization to the intervention (a
perioperative hypotension-avoidance strategy) or control (a
hypertension-avoidance strategy). Intervention: If the presurgery systolic blood pressure (SBP) is <130 mmHg, all
antihypertensive medications are withheld on the morning of surgery. If the
SBP is ≥130 mmHg, some medications (but not angiotensin receptor blockers
[ACEIs], angiotensin receptor blockers [ARBs], or renin inhibitors) may be
continued in a stepwise manner. During surgery, the patients’ mean arterial
pressure (MAP) is maintained at ≥80 mmHg. During the first 48 hours after
surgery, some antihypertensive medications (but not ACEIs, ARBs, or renin
inhibitors) may be restarted in a stepwise manner if the SBP is ≥130
mmHg. Control: Patients receive their usual antihypertensive medications before and after
surgery. The patients’ MAP is maintained at ≥60 mmHg from anesthetic
induction until the end of surgery. Setting: Recruitment from 108 centers in 22 countries from 2018 to 2021. Patients: Patients (~6800) aged ≥45 years having noncardiac surgery who have or are at
risk of atherosclerotic disease and who routinely take antihypertensive
medications. Measurements: The primary outcome of the substudy is postoperative acute kidney injury,
defined as an increase in serum creatinine concentration of either ≥26.5
μmol/L (≥0.3 mg/dL) within 48 hours of randomization or ≥50% within 7 days
of randomization. Methods: The primary analysis (intention-to-treat) will examine the relative risk and
95% confidence interval of acute kidney injury in the intervention versus
control group. We will repeat the primary analysis using alternative
definitions of acute kidney injury and examine effect modification by
preexisting chronic kidney disease, defined as a prerandomization estimated
glomerular filtration rate <60 mL/min/1.73 m2. Results: Substudy results will be analyzed in 2022. Limitations: It is not possible to mask patients or providers to the intervention;
however, objective measures will be used to assess acute kidney injury. Conclusions: This substudy will provide generalizable estimates of the effect of a
perioperative hypotension-avoidance strategy on the risk of acute kidney
injury.
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Affiliation(s)
| | | | | | - Mohammed Amir
- Shifa International Hospital (STMU), Islamabad, Pakistan
| | | | - Keyur Bhatt
- SIDS Hospital & Research Centre, Guntur, India
| | | | | | - Matthew Chan
- The Chinese University of Hong Kong, Shatin, Hong Kong
| | - David Conen
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | | | | | - Mikhail Kirov
- Northern State Medical University of the Ministry of Healthcare of the Russian Federation, Arkhangelsk, Russia
| | | | | | - Andre Lamy
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | | | | | | | - Sandra Ofori
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | | | - Toby Richards
- The University of Western Australia, Perth, Australia
| | | | | | | | - Tim Short
- Auckland District Health Board, New Zealand
| | | | | | | | - David Stillo
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | - C Y Wang
- University of Malaya, Kuala Lumpur, Malaysia
| | | | | | | | - Denis Xavier
- St. John's National Academy of Health Sciences, Bangalore, India
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Stein ML, Staffa SJ, O'Brien Charles A, Callahan R, DiNardo JA, Nasr VG, Brown ML. Anesthesia in Children With Pulmonary Hypertension: Clinically Significant Serious Adverse Events Associated With Cardiac Catheterization and Noncardiac Procedures. J Cardiothorac Vasc Anesth 2022; 36:1606-1616. [PMID: 35181233 DOI: 10.1053/j.jvca.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/03/2022] [Accepted: 01/09/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine the incidence of clinically significant serious adverse events in a contemporary population of pediatric patients with pulmonary hypertension who require anesthesia and identify factors associated with adverse outcomes. DESIGN A retrospective, cross-sectional study. SETTING A single-center quaternary-care freestanding children's hospital in the northeastern United States. PARTICIPANTS Pediatric patients with pulmonary hypertension based on hemodynamic criteria on cardiac catheterization during a 3-year period from 2015 to 2018. INTERVENTIONS Anesthesia care for cardiac catheterization, noncardiac surgery, and diagnostic imaging. MEASUREMENTS AND MAIN RESULTS Two hundred forty-nine children underwent 862 procedures, 592 for cardiac catheterization and 278 for noncardiac surgery and diagnostic imaging. The median age was 1.6 years, and the weight was 9.5 lbs. On index catheterization, median pulmonary artery pressure was 36 mmHg, and the pulmonary vascular resistance was 5.1 indexed Wood units. Ten percent of anesthetics were performed with a natural airway, and 80% used volatile anesthetics. Serious adverse events occurred in 26% of procedures (confidence interval [CI], 22%-30%). The rate of periprocedural cardiac arrest was 8 per 1,000 anesthetic administrations. In multivariate analysis, younger age (adjusted odds ratio [aOR], 1.4 per year; CI, 1.1-1.9; p = 0.01), location in the catheterization laboratory (aOR, 5.1; CI, 1.7-16; p = 0.004), and longer procedure duration (aOR, 1.3 per 30 minutes; CI, 1.1-1.4; p = 0.001) were associated with serious adverse events. Patients with a tracheostomy in place were less likely to experience an adverse event (aOR, 0.1; CI, 0.04-0.5; p = 0.001). The primary anesthetic technique was not associated with adverse events. Interventional cardiac catheterization was associated with an increased incidence of adverse events compared with diagnostic catheterization (42% v 21%; OR, 2.23; CI, 1.5-3.3; p < 0.001). CONCLUSIONS Serious adverse events were common in this cohort. Careful planning to minimize anesthesia time in young children with pulmonary hypertension should be undertaken, and these factors considered in designing risk mitigation strategies.
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Affiliation(s)
- Mary Lyn Stein
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Amy O'Brien Charles
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Wang X, Tang B, Liu Y, Wang X, Wang S, An Z, Wang H. Clinical practice guidelines for management of dual antiplatelet therapy in patients with noncardiac surgery: A critical appraisal using the AGREE II instrument. J Clin Pharm Ther 2021; 47:652-661. [PMID: 34939677 DOI: 10.1111/jcpt.13593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 01/22/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Despite the availability of clinical practice guidelines (CPGs), there are considerable differences in their recommendations in the perioperative management of stented patients who need elective noncardiac surgery. Our aim was to systematically review the quality of CPGs for perioperative management of dual antiplatelet therapy (DAPT) and summarize the recommendations. METHODS A systematic search for perioperative DAPT guidelines was conducted on PubMed, Embase and websites of guideline organizations and professional societies until 4 February 2021. Independently, two assessors appraised the quality of CPGs using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument and extracted the data. Recommendations were summarized, and a comparative study was conducted to analyse the consistency among guidelines. RESULTS AND DISCUSSION A total of 10 guidelines fulfilled our inclusion criteria. The domain of scope and purpose and clarity of presentation obtained the highest median scores, while the domain of stakeholder involvement and rigour of development obtained the lowest median scores. Three guidelines (ACCP, ESC/ESA and ACC/AHA) with a score of at least 60% in most AGREE II domains were recommended. Recommendations across perioperative management of DAPT guidelines were inconsistent. WHAT IS NEW AND CONCLUSION The ACCP, ESC/ESA and ACC/AHA CPGs were recommended. There is a need for high-quality prospective studies assessing different management strategies on this issue. Given the lack of consensus, the results of this study will help to guide perioperative dual antiplatelet management strategies for patients with coronary stents who are undergoing noncardiac surgery.
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Affiliation(s)
- Xin Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Borui Tang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ying Liu
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinrui Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.,Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Shihui Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zhuoling An
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Huaguang Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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43
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Tao X, Xue FS, Tian T, Hu B. In reference to intraoperative dexmedetomidine for prevention of postoperative delirium in elderly patients with mild cognitive impairment. Int J Geriatr Psychiatry 2021; 36:1592-1593. [PMID: 34145633 DOI: 10.1002/gps.5589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Xing Tao
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Fu-Shan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Tian Tian
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Bin Hu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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44
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Guangyu Y, Jingfeng L, Xing L, Hong Y, Yao L. Cardio- and Cerebrovascular Outcomes of Postoperative Acute Kidney Injury in Noncardiac Surgical Patients With Hypertension. Front Pharmacol 2021; 12:696456. [PMID: 34512331 PMCID: PMC8430207 DOI: 10.3389/fphar.2021.696456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/05/2021] [Indexed: 11/26/2022] Open
Abstract
Background: The cardiovascular and cerebrovascular risk of postoperative acute kidney injury (AKI) in surgical patients is poorly described, especially in the hypertensive population. Methods: We conducted a retrospective cohort study among all hypertensive patients who underwent elective noncardiac surgery from January 1st, 2012 to August 1st, 2017 at the Third Xiangya Hospital. The primary outcomes were fatal stroke and fatal myocardial infarction (MI). The secondary outcomes were all-cause mortality. Results: The postoperative cumulative mortality within 3 months, 6 months, 1 year, 2 years, and 5 years were 1.27, 1.48, 2.15, 2.15, and 5.36%, for fatal stroke, and 2.05, 2.27, 2.70, 3.37, and 5.61% for fatal MI, respectively, in patients with postoperative AKI. Compared with non-AKI patients, those with postoperative AKI had a significantly higher risk of fatal stroke and fatal MI within 3 months [hazard ratio (HR): 5.49 (95% CI: 1.88−16.00) and 11.82 (95% CI: 4.56−30.62), respectively], 6 months [HR: 3.58 (95% CI: 1.43−8.97) and 9.23 (95% CI: 3.89−21.90), respectively], 1 year [HR: 3.64 (95% CI: 1.63−8.10) and 5.14 (95% CI: 2.50−10.57), respectively], 2 years [HR: 2.21 (95% CI: 1.03−4.72) and 3.06 (95% CI: 1.66−5.64), respectively], and 5 years [HR: 2.27 (95% CI: 1.30−3.98) and 1.98 (95% CI: 1.16−3.20), respectively]. In subgroup analysis of perioperative blood pressure (BP) lowering administration, postoperative AKI was significantly associated with 1-year and 5-year risk of fatal stroke [HR: 9.46 (95% CI: 2.85−31.40) and 3.88 (95% CI: 1.67−9.01), respectively] in patients with ACEI/ARB, and MI [HR: 6.62 (95% CI: 2.23−19.62) and 2.44 (95% CI: 1.22−4.90), respectively] in patients with CCB. Conclusion: Hypertensive patients with postoperative AKI have a significantly higher risk of fatal stroke and fatal MI, as well as all-cause mortality, within 5 years after elective noncardiac surgery. In patients with perioperative administration of ACEI/ARB and CCB, postoperative AKI was significantly associated with higher risk of fatal stroke and MI, respectively.
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Affiliation(s)
- Yan Guangyu
- Center of Clinical Research, The Third Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Lou Jingfeng
- Center of Clinical Research, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Liu Xing
- Department of Anesthesia, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yuan Hong
- Center of Clinical Research, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Lu Yao
- Center of Clinical Research, The Third Xiangya Hospital, Central South University, Changsha, China.,Department of Life Science and Medicine, King's College London, London, United Kingdom.,Key Laboratory of Medical Information Research(Central South University), College of Hunan Province, Changsha, China
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Kim J, Park J, Kwon JH, Kim S, Oh AR, Jang JN, Choi JH, Sung J, Yang K, Kim K, Ahn J, Lee SH. Association between Intraoperative Hyperlactatemia and Myocardial Injury after Noncardiac Surgery. Diagnostics (Basel) 2021; 11:diagnostics11091656. [PMID: 34573997 PMCID: PMC8465750 DOI: 10.3390/diagnostics11091656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Oxygen demand–supply mismatch is supposed to be one of the major causes of myocardial injuries after noncardiac surgery (MINS). Impaired tissue oxygenation during the surgery can lead to intraoperative hyperlactatemia. Therefore, we aimed to evaluate the relationship between intraoperative lactate level and MINS. Methods: A total of 1905 patients divided into groups according to intraoperative hyperlactatemia: 1444 patients (75.8%) into normal (≤2.2 mmol/L) and 461 patients (24.2%) into hyperlactatemia (>2.2 mmol/L) groups. The primary outcome was the incidence of MINS, and all-cause mortality within 30 days was compared. Results: In the crude population, the risks for MINS and 30-day mortality were higher for the hyperlactatemia group than the normal group (17.7% vs. 37.7%, odds ratio [OR]: 2.83, 95% confidence interval [CI]: 2.24–3.56, p < 0.001 and 0.8% vs. 4.8%, hazard ratio [HR]: 5.86, 95% CI: 2.9–12.84, p < 0.001, respectively). In 365 propensity score-matched pairs, intraoperative hyperlactatemia was consistently associated with MINS and 30-day mortality (21.6% vs. 31.8%, OR: 1.69, 95% CI: 1.21–1.36, p = 0.002 and 1.1% vs. 3.8%, HR: 3.55, 95% CI: 1.71–10.79, p < 0.03, respectively). Conclusion: Intraoperative lactate elevation was associated with a higher incidence of MINS and 30-day mortality.
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Affiliation(s)
- Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.K.); (J.P.); (J.-H.K.); (S.K.); (A.R.O.); (J.N.J.)
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.K.); (J.P.); (J.-H.K.); (S.K.); (A.R.O.); (J.N.J.)
| | - Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.K.); (J.P.); (J.-H.K.); (S.K.); (A.R.O.); (J.N.J.)
| | - Sojin Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.K.); (J.P.); (J.-H.K.); (S.K.); (A.R.O.); (J.N.J.)
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.K.); (J.P.); (J.-H.K.); (S.K.); (A.R.O.); (J.N.J.)
| | - Jae Ni Jang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.K.); (J.P.); (J.-H.K.); (S.K.); (A.R.O.); (J.N.J.)
| | - Jin-Ho Choi
- Department of Medicine, Division of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.-H.C.); (J.S.)
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Jidong Sung
- Department of Medicine, Division of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.-H.C.); (J.S.)
| | - Kwangmo Yang
- Centers for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea;
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul 06351, Korea; (K.K.); (J.A.)
| | - Joonghyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul 06351, Korea; (K.K.); (J.A.)
| | - Seung-Hwa Lee
- Department of Medicine, Division of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.-H.C.); (J.S.)
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul 06351, Korea
- Correspondence: ; Tel.: +82-2-3410-0360; Fax: +82-2-3410-5481
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Richter EW, Shehata IM, Elsayed-Awad HM, Klopman MA, Bhandary SP. Mitral Regurgitation in Patients Undergoing Noncardiac Surgery. Semin Cardiothorac Vasc Anesth 2021; 26:54-67. [PMID: 34467794 DOI: 10.1177/10892532211042827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Mitral regurgitation (MR) is one of the most frequently encountered types of valvular heart disease in the United States. Patients with significant MR (moderate-to-severe or severe) undergoing noncardiac surgery have an increased risk of perioperative cardiovascular complications. MR can arise from a diverse array of causes that fall into 2 broad categories: primary (diseases intrinsic to the valvular apparatus) and secondary (diseases that disrupt normal valve function via effects on the left ventricle or mitral annulus). This article highlights key guideline updates from the American College of Cardiologists (ACC) and the American Heart Association (AHA) that inform decision-making for the anesthesiologist caring for a patient with MR undergoing noncardiac surgery. The pathophysiology and natural history of acute and chronic MR, staging of chronic primary and secondary MR, and considerations for timing of valvular corrective surgery are reviewed. These topics are then applied to a discussion of anesthetic management, including preoperative risk evaluation, anesthetic selection, hemodynamic goals, and intraoperative monitoring of the noncardiac surgical patient with MR.
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47
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Park J, Oh AR, Kwon JH, Kim S, Kim J, Yang K, Choi JH, Kim K, Ahn J, Sung J, Lee SH. Association between cardiologist evaluation and mortality in myocardial injury after non-cardiac surgery. Heart 2021; 108:695-702. [PMID: 34400475 DOI: 10.1136/heartjnl-2021-319511] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/26/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Myocardial injury after non-cardiac surgery (MINS) is strongly associated with mortality, but few studies assessed treatment strategies. This study aimed to identify whether evaluation by cardiologists could reduce mortality in MINS patients. METHODS From a single-centre retrospective cohort, we enrolled a total of 5633 adult patients diagnosed with MINS between January 2010 and June 2019. The patients were divided into two groups based on evaluation by cardiologist, which was defined as a cardiology consultation or transfer to the cardiology department. For the outcome, 30-day mortality was compared in crude and propensity-score matched populations. RESULTS Of a total of 5633 patients, 2120 (37.6%) were evaluated by cardiologists and 3513 (62.4%) were not. Mortality during the first 30 days after surgery was significantly lower in MINS patients who were evaluated by cardiologists compared with those who were not (5.8% vs 8.3%; HR, 0.64; 95% CI 0.51 to 0.80; p<0.001 for all-cause mortality and 1.6% vs 2.0; HR 0.62; 95% CI 0.40 to 0.96; p=0.03 for cardiovascular mortality). The propensity score matched analysis showed similar results (5.6% vs 8.6%; HR 0.64; 95% CI 0.50 to 0.81; p<0.001 for all-cause mortality and 1.3% vs 2.2%; HR 0.58; 95% CI 0.35 to 0.95; p=0.03 for cardiovascular mortality). CONCLUSIONS Cardiologist evaluation was associated with lower mortality in patients diagnosed with MINS. Further studies are needed to identify effective treatment strategies for MINS. TRIAL REGISTRATION NUMBER KCT0004244.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sojin Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kwangmo Yang
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Ho Choi
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea.,Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Joonghyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Jidong Sung
- Rehabilitation & Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hwa Lee
- Rehabilitation & Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea .,Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, South Korea
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48
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Weersink CSA, van Waes JAR, Grobben RB, Nathoe HM, van Klei WA. Patient Selection for Routine Troponin Monitoring After Noncardiac Surgery. J Am Heart Assoc 2021; 10:e019912. [PMID: 34219462 PMCID: PMC8483467 DOI: 10.1161/jaha.120.019912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Myocardial infarction is an important complication after noncardiac surgery. Therefore, perioperative troponin surveillance is recommended for patients at risk. The aim of this study was to identify patients at high risk of perioperative myocardial infarction (POMI), in order to aid appropriate selection and to omit redundant laboratory measurements in patients at low risk. Methods and Results This observational cohort study included patients ≥60 years of age who underwent intermediate to high risk noncardiac surgery. Routine postoperative troponin I monitoring was performed. The primary outcome was POMI. Classification and regression tree analysis was used to identify patient groups with varying risks of POMI. In each subgroup, the number needed to screen to identify 1 patient with POMI was calculated. POMI occurred in 216 (4%) patients and other myocardial injury in 842 (15%) of the 5590 included patients. Classification and regression tree analysis divided patients into 14 subgroups in which the risk of POMI ranged from 1.7% to 42%. Using a risk of POMI ≥2% to select patients for routine troponin I monitoring, this monitoring would be advocated in patients ≥60 years of age undergoing emergency surgery, or those undergoing elective surgery with a Revised Cardiac Risk Index class >2 (ie >1 risk factor). The number needed to screen to detect a patient with POMI would be 14 (95% CI 14–14) and 26% of patients with POMI would be missed. Conclusions To improve selection of high‐risk patients ≥60 years of age, routine postoperative troponin I monitoring could be considered in patients undergoing emergency surgery, or in patients undergoing elective surgery classified as having a revised cardiac risk index class >2.
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Affiliation(s)
- Corien S A Weersink
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
| | - Remco B Grobben
- Department of Cardiology University Medical Center Utrecht Utrecht The Netherlands
| | - Hendrik M Nathoe
- Department of Cardiology University Medical Center Utrecht Utrecht The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
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49
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McNamara JR, McMahon A, Griffin M. Perioperative Management of the Fontan Patient for Cardiac and Noncardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:275-285. [PMID: 34023201 DOI: 10.1053/j.jvca.2021.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 11/11/2022]
Abstract
The Fontan circulation is the single-ventricle approach to surgical palliation of complex congenital heart disease wherein biventricular separation and function cannot be safely achieved. Incremental improvements in this surgical technique, along with improvements in the long-term medical management of these patients, have led to greater survival of these patients and a remarkably steady increase in the number of adults living with this unusual circulation and physiology. This has implications for healthcare providers who now have a greater chance of encountering Fontan patients during the course of their practice. This has particularly important implications for anesthesiologists because the effects of their interventions on the finely balanced Fontan circulation may be profound. The American Heart Association and American College of Cardiology recommend that, when possible, elective surgery should be performed in an adult congenital heart disease center, although this may not be feasible in the provision of true emergency care. This review article summarizes the pathophysiology pertinent to the provision of anesthesia in this complex patient group and describes important modifications to anesthetic technique and perioperative management.
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Affiliation(s)
- John Richard McNamara
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Aisling McMahon
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Griffin
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
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50
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Park J, Oh AR, Lee S, Lee J, Min JJ, Kwon J, Kim J, Yang K, Choi J, Lee S, Gwon H, Kim K, Ahn J, Lee SM. Associations Between Preoperative Glucose and Hemoglobin A1c Level and Myocardial Injury After Noncardiac Surgery. J Am Heart Assoc 2021; 10:e019216. [PMID: 33728934 PMCID: PMC8174354 DOI: 10.1161/jaha.120.019216] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/09/2021] [Indexed: 12/17/2022]
Abstract
Background Perioperative blood glucose level has shown an association with postoperative outcomes. We compared the incidences of myocardial injury after noncardiac surgery (MINS) and 30-day mortality, according to preoperative blood glucose and hemoglobin A1c (HbA1c) levels. Methods and Results The patients were divided according to blood glucose level within 1 day before surgery. The hyperglycemia group was defined with fasting glucose >140 mg/dL or random glucose >180 mg/dL. In addition, we compared the outcomes according to HbA1c >6.5% among patients with available HbA1c within 3 months before surgery. The primary outcome was MINS, and 30-day mortality was also compared. A total of 12 304 patients were enrolled and divided into 2 groups: 8324 (67.7%) in the normal group and 3980 (32.3%) in the hyperglycemia group. After adjustment with inverse probability of weighting, the hyperglycemia group exhibited significantly higher incidences of MINS and 30-day mortality (18.7% versus 27.6%; odds ratio, 1.29; 95% CI, 1.18-1.42; P<0.001; and 2.0% versus 5.1%; hazard ratio, 2.00; 95% CI, 1.61-2.49; P<0.001, respectively). In contrast to blood glucose, HbA1c was not associated with MINS or 30-day mortality. Conclusions Preoperative hyperglycemia was associated with MINS and 30-day mortality, whereas HbA1c was not. Immediate glucose control may be more crucial than long-term glucose control in patients undergoing noncardiac surgery. Registration URL: https://www.cris.nih.go.kr; Unique identifier: KCT0004244.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Seung‐Hwa Lee
- Division of CardiologyDepartment of MedicineHeart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Jong‐Hwan Lee
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Jeong Jin Min
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Ji‐Hye Kwon
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Jihoon Kim
- Division of CardiologyDepartment of MedicineHeart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Kwangmo Yang
- Center for Health PromotionSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Jin‐Ho Choi
- Division of CardiologyDepartment of MedicineHeart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
- Department of Emergency MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Sang‐Chol Lee
- Division of CardiologyDepartment of MedicineHeart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Hyeon‐Cheol Gwon
- Division of CardiologyDepartment of MedicineHeart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Kyunga Kim
- Statistics and Data CenterResearch Institute for Future MedicineSamsung Medical CenterSeoulKorea
- Department of Digital HealthSamsung Advanced Institute for Health Sciences & TechnologySungkyunkwan UniversitySeoulKorea
| | - Joonghyun Ahn
- Statistics and Data CenterResearch Institute for Future MedicineSamsung Medical CenterSeoulKorea
| | - Sangmin Maria Lee
- Department of Anesthesiology and Pain MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
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