Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

“Successful Outcome” after Below-Knee Amputation: An Objective Definition and Influence of Clinical Variables

Functional success after below-knee amputation (BKA) has been poorly studied. The purpose of this study was to establish a consistent definition of “successful outcome” after BKA and to identify clinical variables influencing that definition. Three hundred nine consecutive patients undergoing BKA were evaluated postoperatively using the following definition for “successful outcome”: 1) wound healing of the BKA without need for revision to a higher level; 2) maintenance of ambulation with a prosthesis for at least 1 year or until death; and 3) survival for at least 6 months. Independent clinical predictors influencing outcome were determined using bivariate and multivariable logistic regression analyses. For the cohort, median survival and maintenance of ambulation were 44 months and 60 months, respectively. Although 86.4 per cent of patients healed without the need for revision to a higher level, 63.4 per cent maintained ambulation with a prosthesis for 1 year and 86.1 per cent survived for 6 months, successful outcome as defined by attaining all three components of the definitions occurred in only 51.1 per cent (n = 158) of patients. Of 19 clinical variables examined, six were identified in bivariate analysis as significantly associated with outcome. However, only three were found to be independent predictors of outcome using logistic regression modeling. The presence of coronary artery disease [odds ratio (OR), 0.465; 95% CI, 0.289–0.747], cerebrovascular disease (OR, 0.389; 95% CI, 0.154–0.980), and impaired ambulatory ability before BKA (OR, 0.310; 95% CI, 0.154–0.623) were each associated with a decreased odds for successful outcome. Patients who presented with impaired ambulatory ability in combination with another independent predictor had only a 20 per cent to 23 per cent probability of successful outcome and patients who presented with all three had a 10.4 per cent probability of success. In contrast, patients who had none of the independent predictors at presentation had a 67.5 per cent probability of successful outcome after BKA. A standardized definition of success after BKA capable of predicting outcomes is feasible and can be a useful tool to determine rehabilitation potential. When judged by our definition, patients without predictors of failure possess a high potential for rehabilitation, whereas patients with multiple predictors rarely rehabilitate, should probably receive palliative above-knee amputation, and forgo the expense of futile prosthetic training.

Predicting the need for intensive care following lung resection

On the basis of the evidence available, the authors would suggest a decision making algorithm to determine the need for ICU admission postoperatively similar to that shown in Fig. 1. First, patients should quit smoking at least 1 month and preferably 2 months before surgery. Those over the age of 70 years should receive elective ICU admission. Second, those at increased risk of general anesthesia, as judged by ASA and performance status scores and cardiovascular risk assessment, should be prebooked into the ICU in the postoperative period. A ppo FEV1 of less than 44% should warrant additional monitoring rather than mandate ICU admission. Pre-existing fibrotic lung disease mandates ICU admission. Third, perioperatively, protective (low tidal volume) ventilatory strategies should be applied during one lung ventilation. Patients undergoing one lung ventilation, and especially those undergoing extensive lymphatic dissection, should be monitored closely for signs of ALI in the first 5 days postoperatively. This, together with any indication of postoperative complications such as POP, BPF or empyema, should mandate immediate transfer to the ICU.

Utility of detailed preoperative cardiac testing and incidence of post-thoracotomy myocardial infarction

OBJECTIVE

Recent literature has questioned the efficacy of routine detailed preoperative cardiac ischemia testing and preoperative cardiac intervention before noncardiac surgical procedures.

METHODS

We performed a retrospective review of patients undergoing thoracotomy (n = 294) between January of 1999 and January of 2005.

RESULTS

The median age was 62 years. Detailed preoperative cardiac testing was performed on 184 patients (63%) and went beyond a thorough history, physical examination, and electrocardiogram to include at least one of the following: dobutamine stress echo (n = 116), nuclear stress test (n = 66), treadmill test (n = 8), and coronary angiogram (n = 40). Evidence for coronary disease was detected in 43% of tests (99/230) performed. Revascularization was performed in 10% of all patients (4/40) who underwent coronary angiography. Postoperative myocardial infarction occurred in 7 patients (2.4%) with 4 myocardial infarction-related mortalities. No significant difference was found in the incidence of myocardial infarction in patients with (n = 184) or without (n = 110) detailed preoperative cardiac testing (3.3% vs 0.9%, P = .29). Of the 4 patients (1.4%) who underwent revascularization to treat coronary lesions identified during prethoracotomy workup, 2 had a myocardial infarction, 1 of which was caused by thrombosis of a coronary stent. In the subset of patients who underwent lobectomy (n = 149), detailed cardiac testing was performed on 107 patients (72%). The incidence of myocardial infarction was similar in tested and untested patients (2.8% vs 2.4% respectively, P = 1.0).

CONCLUSION

Selective use of detailed preoperative cardiac testing refines risk stratification and identifies patients for corrective cardiac interventions; however, it did not prove fully protective against myocardial infarction after thoracotomy in our study.

The utility of B-type natriuretic peptide in predicting postoperative cardiac events and mortality in patients undergoing major emergency non-cardiac surgery

B-type natriuretic peptide (BNP) levels predict cardiovascular risk in several settings. We hypothesised that they would identify individuals at increased risk of complications and mortality following major emergency non-cardiac surgery. Forty patients were studied with a primary end-point of a new postoperative cardiac event, and/or development of significant ECG changes, and/or cardiac death. The main secondary outcome was all-cause mortality at 6 months. Pre-operative BNP levels were higher in 11 patients who suffered a new postoperative cardiac event (p = 0.001) and predicted this outcome with an area under the receiver operating characteristic curve of 0.85 (CI = 0.72-0.98, p = 0.001). A pre-operative BNP value > 170 pg x ml(-1) has a sensitivity of 82% and a specificity of 79% for the primary end-point. In this small study, pre-operative BNP levels identify patients undergoing major emergency non-cardiac surgery who are at increased risk of early postoperative cardiac events. Larger studies are required to confirm these data.

Stress echocardiography for risk stratification in patients with end-stage renal disease undergoing renal transplantation

BACKGROUND

The predictive accuracy of stress echocardiography (SE) for adverse cardiac events has been variable in the population with end-stage renal disease undergoing renal transplantation (RT).

METHODS

We performed a retrospective study of 149 patients who had pretransplant SE before RT between 1997 and 2003. Patients were followed up for a mean of 2.85 years for major adverse cardiovascular events (MACE).

RESULTS

Of 149 patients studied, 139 had a negative SE, 65% were African American; 12 underwent cardiac catheterization. Only 1 patient required pre-RT revascularization. Sixteen MACE occurred over the follow-up period. SE had 37.5% sensitivity, 95.3% specificity, 33.3% positive predictive value, and 96.1% negative predictive value for MACE in the first year post-RT. First-year posttransplant event rates were 4.0% versus 30% (P < .001) for patients with a negative SE and positive SE, respectively. Multivariate predictors of MACE were positive SE (hazard ratio [HR] 7.64), hemoglobin less than 11 g/dL post-RT (HR 4.44), and calcium channel blocker use posttransplant (HR 2.90).

CONCLUSIONS

A negative SE has low incidence of MACE in this intermediate- to high-risk patient subset. A positive SE predicts a sevenfold higher risk of cardiovascular events regardless of the need for revascularization before the transplant.

Critical Analysis of Clinical Success after Surgical Bypass for Lower-Extremity Ischemic Tissue Loss Using a Standardized Definition Combining Multiple Parameters: A New Paradigm of Outcomes Assessment

BACKGROUND

Success after surgical revascularization of the lower extremities, traditionally defined by graft patency or limb salvage, fails to consider other intuitive measures of importance. The purpose of the study was to construct a more comprehensive definition of clinical success and to identify clinical predictors of failure.

STUDY DESIGN

For the purpose of this study, clinical success was defined as achieving all of the following criteria: graft patency to the point of wound healing; limb salvage for 1 year; maintenance of ambulatory status for 1 year; and survival for 6 months. Between 1998 and 2004, 331 consecutive patients undergoing bypass for Rutherford III critical limb ischemia were measured for clinical success. Bivariate and logistic regression analyses were performed to determine demographic differences between success and failure.

RESULTS

Despite achieving acceptable graft patency (72.7% at 36 months) and limb salvage (73.3% at 36 months), clinical success combining all 4 defined parameters was only 44.4%. Independent predictors of failure included impaired ambulatory status at presentation (odds ratio [OR] = 6.44), presence of infrainguinal disease (OR = 3.93), end-stage renal disease (OR = 2.48), presence of gangrene (OR = 2.40), and hyperlipidemia (OR = 0.56). Probability of failure in patients possessing every predictor except hyperlipidemia at presentation was 97% (OR = 150.6).

CONCLUSIONS

Despite achieving acceptable graft patency and limb salvage, fewer than half of the patients achieved success when using a definition combining multiple parameters. A reappraisal of our current approach to critical limb ischemia in certain high-risk patients is warranted.

Ischemic heart disease

Because of changing demographics, increasing numbers of patients with IHD are presenting for noncardiac surgery, and the risks of perioperative morbidity and mortality are significant. The Lee Cardiac Risk Index is applicable in defining perioperative cardiac risk: however, ACC/AHA guidelines may not be applicable comprehensively. The role of biomarkers in risk stratification still needs to be defined. Structured management protocols that help assess, diagnose, and treat patients with IHD preoperatively are likely to help decrease postoperative morbidity and mortality, but clearly are not applicable to all patients. Augmented hemodynamic control with beta-blockers or alpha-2 agonists and modulating inflammation by statins can play an important role in improving outcomes in many patients with IHD; preoperative coronary revascularization may be of limited value. Intraoperative anesthetic management that minimizes hemodynamic perturbations is important; however, the choice of a particular technique typically is not critical. Of critical importance is the postoperative management of the patient. Postoperative myocardial injury should be identified, evaluated, and managed aggressively. Secondary stresses such as sepsis, extubation, and anemia, which can increase demand on the heart, should be treated or minimized. Clearly, optimal care of the patient with IHD entails closely coordinated assessment and management throughout the preoperative, intraoperative, and postoperative phases, if one is to optimize short- and long-term outcomes.

A comparison of percutaneous transluminal angioplasty versus amputation for critical limb ischemia in patients unsuitable for open surgery

BACKGROUND

Percutaneous transluminal angioplasty (PTA), although not the traditional therapy, seems to be a safe alternative for patients with critical limb ischemia who are believed to be unsuitable candidates for open surgery. However, the efficacy of PTA in this setting has not been analyzed. The purpose of this study was to compare the outcomes of PTA for limb salvage with outcomes of major limb amputation in physiologically impaired patients believed to be unsuitable for open surgery.

METHODS

From a prospective vascular registry, 314 patients (183 underwent amputation, and 131 underwent complex PTA for limb salvage) were identified as physiologically impaired or unsuitable for open surgery. This was defined as having at least one of the following: functional impairment (homebound ambulatory or transfer only), mental impairment (dementia), or medical impairment (two of the following: end-stage renal disease, coronary artery disease, and chronic obstructive pulmonary disease). Patients undergoing PTA were compared with patients undergoing amputation by examining the outcome parameters of survival, maintenance of ambulation, and maintenance of independent living status. Parameters were assessed by using Kaplan-Meier life-table curves (log-rank test and 95% confidence intervals [CIs]) and hazard ratios (HRs) from the Cox model.

RESULTS

PTA resulted in a 12-month limb salvage rate of 63%. Thirty-day mortality was 4.4% for the amputation group and 3.8% for the PTA group. After adjustment for age, race, diabetes, prior vascular procedure, dementia, and baseline functional status, PTA patients had significantly lower rates of ambulation failure (HR, 0.44; P = .0002) and loss of independence (HR, 0.53; P = .025) but had significantly higher mortality (HR, 1.62; P = .006) than amputees. However, when life tables were examined, the maintenance of ambulation advantage lasted only 12 months (PTA, 68.6%; 95% CI, 59.6%-77.7%; amputation, 48%; 95% CI, 40.4%-55.5%) and was not statistically significant at 2 years (62.2% [95% CI, 48.8%-71.5%] and 44% [95% CI, 35.8%-52.2%], respectively). Maintenance of independent living status advantage lasted only 3 months, with no statistically significant difference at 2 years (PTA, 60.5%; 95% CI, 45.4%-75.6%; amputation, 52.6%; 95% CI, 40.4%-64.9%). Although mortality was high in both cohorts, patients who underwent amputation had a survival advantage for all time intervals examined (at 2 years: PTA, 29%; 95% CI, 19.9%-38.1%; amputation, 48.1%; 95% CI, 39.2%-56.9%).

CONCLUSIONS

Patients who present with critical limb ischemia and physiologic impairments that preclude open surgery seem to have comorbidities that blunt any functional advantage achieved after PTA for limb salvage. PTA in this setting affords very little benefit compared with amputation alone.

Preoperative Risk Stratification With Myocardial Perfusion Imaging in Intermediate and Low-Risk Non-Cardiac Surgery

BACKGROUND

Perioperative cardiac risk in high risk surgery is often stratified with myocardial perfusion single-photon emission computed tomography (SPECT). However, little and no data are available about intermediate and low-risk surgery, respectively.

METHODS AND RESULTS

A total of 1,220 consecutive patients underwent electrocardiography-gated dipyridamole stress SPECT to evaluate myocardial perfusion and cardiac function before intermediate or low risk non-cardiac surgery. Variables predictive of perioperative cardiac events were determined and the usefulness of combining pretest information and the incremental prognostic value of SPECT was estimated. The frequency of all cardiac events depended on clinical risk factors and type of surgical procedures. After sorting the patients with clinical risk factors and surgical risk, assessment of myocardial perfusion or cardiac function yielded significant risk stratification in intermediate, but not in low-risk surgery. Adding functional data to perfusion variables offered an incremental prognostic value for patients with an intermediate clinical risk and scheduled intermediate risk surgery.

CONCLUSIONS

Integrating information about clinical risk factors, type of surgery, myocardial perfusion and cardiac function allows detailed preoperative risk stratification. Preoperative SPECT provides an incremental prognostic value in intermediate, but not in low-risk surgery.

Perioperative cardiac risk: pathophysiology, assessment and management

Cardiac complications are the leading cause of perioperative morbidity and mortality following noncardiac surgery. The annual cost of perioperative cardiovascular events exceeds 20 billion US dollars. A strategic preoperative evaluation holds the potential to reduce perioperative cardiac events and healthcare costs; however, our current understanding of the pathophysiological basis of postoperative acute coronary syndromes is limited. Although significant advances continue to facilitate early and reliable noninvasive detection of high-risk coronary anatomy, the most appropriate interventions remain unclear. Pharmacotherapy, revascularization, safer anesthesia and early detection of perioperative heart failure may all reduce perioperative morbidity and mortality, although the evidence base is incomplete and controversial. A close working relationship between the primary care physician, cardiologist, surgeon and anesthesiologist will facilitate rational, tailored and optimized management decisions that constitute our best opportunity to reduce perioperative cardiovascular risk.

Angioplasty and noncardiac surgery: risks of myocardial infarction

Prophylactic percutaneous transluminal coronary angioplasty is one revascularization strategy employed to reduce risks of cardiac complications after noncardiac surgery in certain patients. Reduced adverse cardiac event rates are at least partially offset by costs and complications of angioplasty. Patients who undergo noncardiac surgery within 90 days of coronary angioplasty may be at increased risk for postoperative cardiac complications.

Determinants of functional outcome after revascularization for critical limb ischemia: An analysis of 1000 consecutive vascular interventions

BACKGROUND

When reporting standards for successful lower extremity revascularization were established, it was assumed that arterial reconstruction, patency, and limb salvage would correlate with the ultimate goal of therapy: improved functional performance. In reality, factors determining improvement of ambulation and maintenance of independent living status after revascularization have been poorly studied. The purpose of this study was to assess the important determinants of functional outcome for patients after intervention for critical limb ischemia.

METHODS

The results of 1000 revascularized limbs from 841 patients were studied. Indications were rest pain, 41.1%; ischemic ulceration, 35.6%; gangrene, 23.3%; infrainguinal, 70.9%; aortoiliac, 24.2%; and both, 4.9%. Treatment was by endovascular intervention, 35.5%; open surgery, 61.7%; and both, 2.8%. Patient were mean age of 68 +/- 12 years, and 56.6% were men, 74.7% were white, 54.2% had diabetes mellitus, 67% were smokers, 13.4% had end-stage renal disease and were on dialysis, and 36% had prior vascular surgery. Patients were treated with conventional therapy by fellowship-trained vascular specialists at a single center and were analyzed according to the type of intervention, the arterial level treated, age, race, gender, presentation, the presence of diabetes, smoking history, end-stage renal disease, coronary disease, hypertension, hyperlipidemia, obesity, chronic obstructive pulmonary disease, previous stroke, dementia, prior vascular surgery, preoperative ambulatory status, limb loss <or=1 year of treatment, and independent living status. The technical outcomes of reconstruction patency and limb salvage as well as the functional outcomes of survival, maintenance of ambulation, and independent living status were measured for each variable using Kaplan-Meier life-table analysis, and differences were assessed using the log-rank test. A Cox proportional hazards model was used to assess independent predictors of outcome and obtain adjusted hazard ratios and 95% confidence intervals.

RESULTS

At 5 years, 72.4% of the entire cohort had a patent reconstruction and 72.1% had an intact limb. Overall 5-year functional outcomes were 41.9% for survival, 70.6% for maintenance of ambulation, and 81.3% for independent living status. Outcome was not significantly affected by the type of treatment (endovascular or open surgery) or by the level of disease treated (aortoiliac, infrainguinal, or both). The most important independent, statistically significant predictors of particularly poor functional outcome were impaired ambulatory ability at the time of presentation (70% 5-year mortality, hazard ratio, 3.34; 39.5% failure to eventually ambulate, hazard ratio, 2.83; 30% loss of independent living status, hazard ratio, 7.97), and the presence of dementia (73% late mortality, hazard ratio, 1.57; 41.2% failure to eventually ambulate, hazard ratio, 2.20; 46.4% loss of independent living status, hazard ratio, 5.44). These factors were even more predictive than limb amputation alone.

CONCLUSION

Functional outcome for patients undergoing intervention for critical limb ischemia is not solely determined by the traditional measures of reconstruction patency and limb salvage, but also by certain intrinsic patient comorbidities at the time of presentation. These findings question the benefit of our current approach to critical limb ischemia in functionally impaired, chronically ill patients--patients who undoubtedly will be more prevalent as our population ages.

[Cost per episode of care in the surgical treatment of skin cancer]

BACKGROUND

Skin cancer is the most common form of malignancy in humans. It can be treated with various techniques and by different specialists. The procedure with the lowest failure rates is surgical excision.

OBJECTIVES

To calculate the cost per episode of care in the surgical treatment of non-melanoma skin cancer (NMSC) when performed by dermatologists.

MATERIAL AND METHOD

An episode of NMSC surgical care was defined as the series of healthcare services required for a dermatologist to treat skin cancer. The cost per episode was calculated using the economic data made available by the public health institution in which the analysis was performed.

RESULTS

The cost per episode of care varied between 273.71 and 1,129.84 euro, depending on the surgical procedure performed and the related health services required.

CONCLUSIONS

Skin cancer is one of the cutaneous diseases with clinical manifestations that are easily recognized by dermatologists, who frequently do not even need histological confirmation to make the diagnosis and choose the therapeutic approach. Consequently, dermatological surgeons are highly efficient, since the episode of care is performed with a minimum of healthcare services and only in appropriately selected individuals. The cost of treatment varies substantially, depending on the complexity of the surgical procedures and the site where they are performed.

Cardiorespiratory Fitness and Short-term Complications After Bariatric Surgery

BACKGROUND

Morbid obesity is associated with reduced functional capacity, multiple comorbidities, and higher overall mortality. The relationship between complications after bariatric surgery and preoperative cardiorespiratory fitness has not been previously studied.

METHODS

We evaluated cardiorespiratory fitness in 109 patients with morbid obesity prior to laparoscopic Roux-en-Y gastric bypass surgery. Charts were abstracted using a case report form by reviewers blinded to the cardiorespiratory evaluation results.

RESULTS

The mean age (+/- SD) was 46.0 +/- 10.4 years, and 82 patients (75.2%) were female. The mean body mass index (BMI) was 48.7 +/- 7.2 (range, 36.0 to 90.0 kg/m(2)). The composite complication rate, defined as death, unstable angina, myocardial infarction, venous thromboembolism, renal failure, or stroke, occurred in 6 of 37 patients (16.6%) and 2 of 72 patients (2.8%) with peak oxygen consumption (Vo(2)) levels < 15.8 mL/kg/min or > 15.8 mL/kg/min (lowest tertile), respectively (p = 0.02). Hospital lengths of stay and 30-day readmission rates were highest in the lowest tertile of peak Vo(2) (p = 0.005). There were no complications in those with BMI < 45 kg/m(2) or peak Vo(2) > or= 15.8 mL/kg/min. Multivariate analysis adjusting for age and gender found peak Vo(2) was a significant predictor of complications: odds ratio, 1.61 (per unit decrease); 95% confidence interval, 1.19 to 2.18 (p = 0.002).

CONCLUSIONS

Reduced cardiorespiratory fitness levels were associated with increased, short-term complications after bariatric surgery. Cardiorespiratory fitness should be optimized prior to bariatric surgery to potentially reduce postoperative complications.

Clinician agreement with perioperative cardiovascular evaluation guidelines and clinical outcomes

The American College of Cardiology/American Heart Association (ACC/AHA) published guidelines for preoperative cardiac risk stratification in 1996. Although clinician practice may differ from the guidelines, it remains unclear whether deviation from these guidelines affects clinical outcomes. This study sought to determine if discordance between clinician practice and the ACC/AHA guidelines affects perioperative cardiac outcomes. Eight hundred twenty-three patients who underwent 864 consecutive preoperative evaluations performed from 1995 to 1997 at a tertiary care academic medical center were prospectively followed. Clinician recommendations for preoperative cardiac testing were compared with ACC/AHA guideline recommendations. Frequencies of perioperative cardiac complications were compared between concordant and discordant testing recommendations. There were 33 perioperative cardiac complications (3.8%). Overall, there was no difference in the frequency of complications when there was discordance with the ACC/AHA guidelines compared with concordance (4.1% vs 3.7%, p = 0.81). The ACC/AHA guidelines recommended cardiac testing for 236 patients (27.3%). Clinicians ordered testing in half of those cases (n = 112). There was a lower frequency of cardiac complications when clinicians did not perform testing as recommended by the ACC/AHA guidelines (3.2% vs 10.7%, p = 0.02). Conversely, clinicians ordered cardiac testing in 45 patients (7%) when not recommended by the guidelines. Patients in this group had a trend toward more cardiac complications (6.7% vs 2.4%, p = 0.09). In conclusion, the failure of clinicians to follow the ACC/AHA guidelines when perioperative testing was recommended did not result in a higher frequency of cardiac complications.

Anesthetic management of pial synangiosis and intracranial hemorrhage with a Fontan circulation

We report the case of a 11-year-old girl with Moyamoya syndrome, who had undergone staged-repair of tricuspid atresia to a Fontan circulation, scheduled to undergo bilateral pial synangiosis. Surgery for the first hemisphere was complicated by intracranial hemorrhage requiring an emergency craniotomy. The case highlights the importance of understanding Fontan physiology and its interrelationship with the cerebral circulation in the setting of cerebrovascular insufficiency and raised intracranial pressure.

Epidural Post-Operative Analgesia in Major Urologic Surgery: Our Experiences

Pulmonary, cardiovascular, gastrointestinal and urinary dysfunctions are among the physiologic outcomes of surgical lesions and stress, as well as metabolic, muscular and neuroendocrine disorders.

Our purpose is to prevent such complications in order to optimize the healing process and improve the patient's satisfaction through the application of a post-operative codified analgesia protocol allowing the combined use of local anaesthetics and morphine by both epidural bolus injection and elastomeric pump.

All the patients enrolled underwent the same anaesthetic program: the data processing emphasizes the satisfactory analgesic results of the treatment. More than 80% of the patients did not feel pain at awakening, up to 98.5% during the following hours; one patient only was still complaining 96 hours after surgery.

This excellent analgesic function results in an extremely low rate of severe post-operative complications, despite the fact that patients underwent radical and often prolonged surgery (31% was affected by severe systemic pathology).

We encountered a negligible and easy-to-treat complication rate secondary to the analgesic technique or to the infused drugs; the epidural analgesia proved effective in the healing process, with high satisfaction of clinicians and patients.

This represents for sure a fundamental alternative to the various methods described in literature.

Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients

BACKGROUND

Despite being a major determinant of functional independence, ambulation after major limb amputation has not been well studied. The purpose, therefore, of this study was to investigate the relationship between a variety of preoperative clinical characteristics and postoperative functional outcomes in order to formulate treatment recommendations for patients requiring major lower limb amputation.

METHODS

From January 1998 through December 2003, 627 major limb amputations (37.6% below knee amputations, 4.3% through knee amputations, 34.5% above knee amputations, and 23.6% bilateral amputations) were performed on 553 patients. Their mean age was 63.7 years; 55% were men, 70.2% had diabetes mellitus, and 91.5% had peripheral vascular disease. A retrospective review was performed correlating various preoperative presenting factors such as age at presentation, race, medical comorbidities, preoperative ambulatory status, and preoperative independent living status, with postoperative functional endpoints of prosthetic usage, survival, maintenance of ambulation, and maintenance of independent living status. Kaplan-Meier survival curves were constructed and compared by using the log-rank test. Odds ratios (OR) and hazard ratios (HR) with 95% confidence intervals were constructed by using multiple logistic regressions and Cox proportional hazards models.

RESULTS

Statistically significant preoperative factors independently associated with not wearing a prosthesis in order of greatest to least risk were nonambulatory before amputation (OR, 9.5), above knee amputation (OR, 4.4), age > 60 years (OR, 2.7), homebound but ambulatory status (OR, 3.0), presence of dementia (OR, 2.4), end-stage renal disease (OR, 2.3), and coronary artery disease (OR, 2.0). Statistically significant preoperative factors independently associated with death in decreasing order of influence included age > or = 70 years (HR, 3.1), age 60 to 69 (HR, 2.5), and the presence of coronary artery disease (HR, 1.5). Statistically significant preoperative factors independently associated with failure of ambulation in decreasing order of influence included age > or = 70 years (HR, 2.3), age 60 to 69 (HR, 1.6), bilateral amputation (HR, 1.8), and end-stage renal disease (HR, 1.4). Statistically significant preoperative factors independently associated with failure to maintain independent living status in decreasing order of influence included age > or = 70 years (HR, 4.0), age 60 to 69 (HR, 2.7), level of amputation (HR, 1.8), homebound ambulatory status (HR, 1.6), and the presence of dementia (HR, 1.6).

CONCLUSIONS

Patients with limited preoperative ambulatory ability, age > or = 70, dementia, end-stage renal disease, and advanced coronary artery disease perform poorly and should probably be grouped with bedridden patients, who traditionally have been best served with a palliative above knee amputation. Conversely, younger healthy patients with below knee amputations achieved functional outcomes similar to what might be expected after successful lower extremity revascularization. Amputation in these instances should probably not be considered a failure of therapy but another treatment option capable of extending functionality and independent living.

Le bilan préopératoire du cancer bronchique

INTRODUCTION

The overall prognosis of non-small cell carcinoma of the bronchus (NSCLC) remains poor on account of frequently late diagnosis and associated co-morbidity preventing the optimal treatment of the tumour. Surgical resection remains the best curative treatment for limited stage disease.

STATE OF THE ART

The pre-operative assessment should determine whether the extent of the tumour permits complete resection and whether the physiological state of the patient would tolerate the curative resection required. The ultimate goal is to improve 5-year survival. In the case of initial inoperability the assessment should determine whether pre-operative oncological treatment might make an advanced tumour operable (e.g. stage IIIA), or whether targeted medical treatment might improve the patient sufficiently to tolerate an intervention initially judged too risky. The rapid development of the technical modalities available for the assessment requires a continuous review of the current practice guidelines. Positron emission tomography has considerably augmented the accuracy of classical radiological assessment. Nevertheless staging by imaging alone remains imprecise to the extent that invasive examinations are still necessary to provide histological proof of the clinical stage of NSCLC. The techniques for assessing mediastinal invasion are developing rapidly and becoming more accurate and less invasive. Mediastinoscopy enhanced by modern video technology, ultrasound guided endoscopic biopsies and thoracoscopy are complimentary rather than competing techniques. The functional assessment should estimate the operative risk of the proposed pulmonary resection, identify the targeted actions aimed at reducing this risk or, in the absence of such actions, suggest less invasive but less well validated surgical techniques or even palliative treatments. When the operative risk cannot be reduced its precise estimation at least allows the patient to decide whether the risk seems acceptable in relation to the chances of a cure.

VIEWPOINT AND CONCLUSIONS

In the future the pre-operative assessment of NSCLC should improve the detection of micro-metastases in order to optimise the choice of induction and adjuvant therapies. The increasing use of induction chemotherapy before surgical resection can only increase the importance of a detailed assessment for the selection of patients and the evaluation of results.

Postoperative Outcomes According to Preoperative Medical and Functional Status after Infrainguinal Revascularization for Critical Limb Ischemia in Patients 80 Years and Older

The purpose of this study was to provide outcomes after intervention for critical limb ischemia (CLI) in elderly patients (≥80 years) according to medical and functional status at presentation. From January 1998 to September 2003, 140 limbs/122 patients (age range 80–97 years) were treated (57 patients/66 limbs, infrainguinal bypass; 65 patients/74 limbs, infrainguinal angioplasty) for CLI. At presentation, 71 (58.2%) patients were functionally ambulatory, 41 (33.6%) were home-bound ambulators, and 10 (8.2%) were transfer-only ambulators. Overall end points after treatment as well as outcomes according to type of treatment and preoperative medical and functional status were determined. End points included reconstruction patency, limb salvage, survival, amputation-free survival, and maintenance of ambulatory and independent living status. Results for the 140 limbs/122 patients at 3 years (Kaplan-Meier curves) include primary patency, 55.3%; secondary patency, 73.2%; limb salvage, 78.3%; survival, 62.5%; amputation-free survival, 49.7%; maintenance of ambulation, 77.8%; and maintenance of independent living status, 82.9%. There was essentially no difference in outcomes based on type of treatment (endovascular vs open operation). When analyzing 2-year outcomes by functional status (ambulatory vs homebound vs transfer), there was deterioration in outcomes according to declining functional status at presentation for mortality (84.7% vs 66.4% vs 42%; P < 0.001), amputation-free survival (73.3% vs 48.2% vs 36.9%; P < 0.001), limb salvage (86% vs 66.5% vs 71.9%; P = 0.022), and secondary patency (84.3% vs 61.5% vs 69.2%; P = 0.005) regardless of treatment. Homebound ambulators were two times and transfer-only patients five times more likely to experience death (Cox hazard model); diabetics were four times more likely to lose a limb and experience a decline in ambulation and living status. Overall medical and functional status at presentation predicts postoperative functional outcomes. These data support a policy of aggressive vascular intervention in the functional elderly and clinical restraint in the functionally impaired patient with CLI.

Principles of anaesthesia in urological surgery

Anaesthesia for urological surgery poses particular challenges for the anaesthetist related to the patient population and procedure type. The aim of this article is to cover the general principles of anaesthesia, with dedicated sections relevant to practising urological surgeons. This represents vast amounts of knowledge that cannot be covered in one article. We will focus upon preoperative preparation for surgery and anaesthesia, perioperative management including monitoring and analgesia, and postoperative management including fluid balance, critical care and recovery. Significant proportions of urological surgical patients have some degree of renal failure and this may be related to the surgery required. Anaesthetic care of patients with chronic renal impairment and transplant surgery will be covered in a future review.

Transcanal Cochlear Implantation Under Monitored Anesthesia Care

OBJECTIVE

Given the associated risk of general anesthesia in elderly patients with cardiovascular disease, the authors set out to determine the feasibility of transcanal cochlear implantation under local anesthesia with monitored anesthesia care.

METHODS

A 70-year-old man with a history of coronary artery bypass grafting, diabetes mellitus, and an American Society of Anesthesiologists Class III cardiac status underwent cochlear implantation under local with monitored anesthesia care.

RESULT

With the described technique and regimen of intravenous remifentanil and dexmedetomidine, the patient tolerated the 60-minute procedure without tachycardia, hyper- or hypotension, or cardiac ischemia.

CONCLUSION

Cochlear implantation using the pericanal electrode technique performed under local anesthesia with monitored anesthesia care is possible in patients at risk for undergoing general anesthesia for cochlear implantation.

The value of screening preoperative chest x-rays: a systematic review

PURPOSE

Chest x-ray (CXR) is the most frequently ordered radiological test in Canada. Despite published guidelines, variable policies exist amongst different hospitals for ordering of preoperative CXRs. The purpose of this study was to systematically review the literature on the value of screening CXRs and establish evidence to support guidelines for the use of preoperative screening CXRs.

SOURCE

Medline and Embase were searched under set terms for all English language articles published during 1966-2004. All eligible studies were reviewed and data were extracted individually by two authors. Of the 513 articles identified, 14 studies met both inclusion and exclusion criteria.

PRINCIPAL FINDINGS

The quality of published evidence was modest as only six of the studies were rated as fair and eight as poor. Of the reported studies, diagnostic yield increased with age. However, most of the abnormalities consisted of chronic disorders such as cardiomegaly and chronic obstructive pulmonary disease (up to 65%). The rate of subsequent investigations was highly variable (4-47%). When further investigations were performed, the proportion of patients who had a change in management was low (10% of investigated patients). Postoperative pulmonary complications were also similar between patients who had preoperative CXRs (12.8%) and patients who did not (16%).

CONCLUSION

An association between preoperative screening CXRs and decrease in morbidity or mortality could not be established. As the prevalence of CXR abnormalities is low in patients under the age of 70, there is fair evidence that routine CXRs should not be performed for patients in this age group without risk factors. For patients over 70, there is insufficient evidence for or against performance of routine CXRs. The current recommendation from the Guidelines Association Committee that routine CXRs should not be performed for patients over 70 without risk factors is supported by this study.

The Preoperative Anesthesia Evaluation

Thorough and timely anesthesia preoperative evaluation is essential for good patient outcomes. Perioperative care is becoming more complex and comprehensive, while older and sicker patients are being considered for major thoracic surgery. In addition to pulmonary and wound care, prevention of cardiac complications with beta-blocker therapy, multimodal pain control, tighter glycemic control, nutritional support, and prevention of thromboembolism are important perioperative goals. Early identification of significant medical and nonmedical issues allows for complete evaluation and planning and decreases the likelihood of delays, cancellations, and complications. Good communication and preparation benefit everyone. The implementation of an anesthesia preoperative assessment program or clinic can help achieve these important goals.

Preoperative Cardiac Evaluation: Mechanisms, Assessment, and Reduction of Risk

The changing paradigm in cardiovascular disease in which atherosclerotic lesions exist in a spectrum of stable to unstable, the lack of a perfect prediction tool, and the paucity of randomized controlled data on appropriate intervention make protection of cardiac patients undergoing thoracic surgery challenging. Nociception-related sympathetic drive combines with inflammatory stimuli and the cardiodepressant effects of anesthesia to create a window of maximum risk in the early postoperative period (8-24 hours), and although multivariate models have shown that a combination of surgery-specific risk, patient-specific cardiovascular history, and estimated functional capacity best determine the need for further investigation, the optimal choice of investigation is unclear. Exercise or dobutamine stress echocardiography provide the best validated investigations, and in the case of poor images, dobutamine MR imaging is increasingly used. When disease is found, medical and interventional options are available. PCI is often used, but the risk of converting a stable flow-limiting lesion into a less stable non-flow-limiting lesion must be considered, along with a delay for anti-platelet therapy and endothelialization of the stent. Alternatively, medical protection with acute beta-blockade or alpha2-agonists reduces risk (although beta-blockade often is avoided in chronic lung disease, even nonselective agents are safe in patients with non-airways reactive COPD). In addition, it is likely that statin use reduces risk, probably by stabilizing plaques, but patients with cardiac risk are increasingly likely to be taking this medication already. The assessment and management of cardiac risk in the perioperative thoracic surgery patient is challenging. With focused, rational, and individually tailored management; tight monitoring of postoperative pain; and a close working relationship between the surgeon, anesthesiologist, and cardiologist, patient care can be optimized, and risk can be effectively controlled.

Thoraxchirurgie im Alter

In the near future, over 40% of patients with lung cancer will be over 70 years old at the time their disease is diagnosed. Age per se, however, should not lead to the denial of a potentially curative surgical intervention. It has been shown that older patients (over 70 years), as well as patients over 80 years of age, may tolerate a lobectomy or even a pneumonectomy quite well. Most patients with lung cancer are present or former smokers and have underlying pulmonary problems, especially chronic obstructive lung disease. They are at high risk of both morbidity and mortality from surgery due to significant cardiovascular disease. The indications for surgical intervention should be based on reliable preoperative tumor staging and pulmonary assessment by an experienced interdisciplinary panel of physicians, taking into consideration the individual cardiopulmonary status of the patient. This assessment, combined with the American Society of Anesthesiologists risk classification and the overall clinical assessment by the surgeon, will provide the best available evidence for carefully weighing the benefits and risks of an operation. The responsibility for this assessment must be viewed-in the case of early stage lung cancer-in relation to the relative lack of alternative treatments for surgical intervention with comparable 5-year survival rates (>50%).

Implementation of the ACC/AHA guidelines for preoperative cardiac risk assessment in a general medicine preoperative clinic: improving efficiency and preserving outcomes

BACKGROUND

The American College of Cardiology/American Heart Association (ACC/AHA) publishes recommendations for cardiac assessment of patients undergoing noncardiac surgery with the intent of promoting evidence-based, efficient preoperative screening and management. We sought to study the impact of guideline implementation for cardiac risk assessment in a general internal medicine preoperative clinic.

METHODS

The study was an observational cohort study of consecutive patients being evaluated in an outpatient preoperative evaluation clinic before and after implementation of the ACC/AHA guideline. Data was gathered by retrospective abstraction of hospital and clinic charts using standard definitions. 299 patients were reviewed prior to guideline implementation and their care compared to 339 consecutive patients after the guideline was implemented in the clinic.

RESULTS

Guideline implementation led to a reduction in exercise stress testing (30.8% before, 16.2% after; p<0.001) and hospital length of stay (6.5 days before, 5.6 days after; p=0.055). beta-Blocker therapy increased after the intervention (15.7% before; 34.5% after; p<0.001) and preoperative test appropriateness improved (86% before to 94.1% after; p<0.001).

CONCLUSIONS

Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in an internal medicine preoperative assessment clinic led to a more appropriate use of preoperative stress testing and beta-blocker therapy while preserving a low rate of cardiac complications.

Noncardiac surgery following percutaneous coronary intervention

Patient with coronary artery disease (CAD) undergoing major noncardiac surgery (NCS) are at increased risk of serious perioperative cardiac complications. At the same time, safety of percutaneous coronary intervention (PCI) before noncardiac surgery has been questioned. This paper reviews the available literature regarding the safety of PCI before NCS. At the same time, cardiac evaluation before NCS, perioperative medical management of patients undergoing NCS, and percutaneous coronary intervention and timing of NCS is also discussed.

Does a standardization tool to direct invasive therapy for symptomatic lower extremity peripheral arterial disease improve outcomes?

OBJECTIVES

While decision analysis and treatment algorithms have repeatedly been shown to improve quality of care in many areas of medicine, no such algorithm has emerged for the invasive management of lower extremity peripheral arterial disease. Using the best available evidence-based outcomes data, our group designed a standardization tool, the Lower Extremity Grading System (LEGS) score, which consistently directs limbs to a specific treatment on the basis of presentation. The purpose of this study was to examine whether use of such a tool improves outcomes by directing treatment of lower extremity peripheral arterial disease.

METHODS

Over 18 months (July 2001-December 2002) our group intervened in 673 limbs (angioplasty, open surgery, primary limb amputation) with lower extremity peripheral arterial disease. During this time we developed the LEGS score, and implemented its prospective use for the final 362 limbs. For the purpose of this study, all 673 limbs were retrospectively scored with the LEGS score to determine the LEGS recommended best treatment. Of the 673 limbs, 551 (81.9%) received the same treatment as recommended with LEGS and 122 (18.1%) received treatment contrary to LEGS. Limbs treated contrary to LEGS (cases) were then compared with matched control limbs (treated according to LEGS), with similar angiographic findings, clinical presentation, preoperative functional status, comorbid conditions and operative technical factors. Outcomes measured at 6 months included arterial reconstruction patency, limb salvage, survival, and maintenance of ambulatory status and independent living status. Kaplan-Meier curves were used to assess patency, limb salvage, and survival; associated survival curves were compared with the log-rank test. Functional outcomes were compared with the Fisher exact test.

RESULTS

After matching case limbs with control limbs, 9 limbs had no control match. Thus 113 limbs in 100 patients treated contrary to LEGS were compared with 113 limbs in 100 patients treated according to LEGS. Limbs treated contrary to LEGS resulted in significantly inferior outcomes at 6 months for measures of primary patency (57.5% vs 84.3%; P < .001), secondary patency (73.2% vs 96.2%; P < .001), limb salvage (89.7% vs 97.2%; P = .04), and maintenance of ambulatory status (78% vs 92%; P = .02). As an additional finding, 29.6% (92 of 311) of interventions performed before implementation of the algorithm were treated contrary to LEGS, and thus contrary to objectively determined best therapy, compared with 8.3% (30 of 362) after LEGS implementation (P < .001).

CONCLUSIONS

Limbs treated according to our standardization tool resulted in better outcomes compared with limbs treated contrary to the algorithm. These data suggest that routine use of an appropriately validated treatment standardization algorithm is capable of improving overall results for invasive treatment of lower extremity peripheral arterial disease.

Development of a perioperative medicine research agenda: a cross sectional survey

BACKGROUND

Post-operative complications are a significant source of morbidity and mortality for patients undergoing surgery. However, there is little research in the emerging field of perioperative medicine beyond cardiac risk stratification. We sought to determine the research priorities for perioperative medicine using a cross sectional survey of Canadian and American general internists.

METHODS

Surveys were electronically sent to 312 general internists from the Canadian Society of Internal Medicine and 130 internists from the perioperative medicine research interest group within the US based Society of General Internal Medicine. The questionnaire contained thirty research questions and respondents were asked to rate the priority of these questions for future study.

RESULTS

The research topics with the highest ratings included: the need for tight control of diabetes mellitus postoperatively and the value of starting aspirin on patients at increased risk for postoperative cardiac events. Research questions evaluating the efficacy and safety of perioperative interventions had higher ratings than questions relating to the prediction of postoperative risk. Questions relating to the yield of preoperative diagnostic tests had the lowest ratings (p < 0.001 for differences across these categories).

CONCLUSION

The results of this survey suggest that practicing general internists believe that interventions studies are a priority within perioperative medicine. These findings should help prioritize research in this emerging field.

Minimally invasive retroperitoneal approach for the treatment of infrarenal aortic disease

PURPOSE

In order to decrease complications and improve postoperative recovery, we have developed a minimally invasive retroperitoneal approach (MIRPA) for the treatment of infrarenal aortic disease. This study was carried out to define the limitations and applicability of this technique in the treatment of aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysms (AAAs).

METHODS

From November 2000 to February 2004, 150 patients with AAA (n = 130) or AIOD (n = 20) were prospectively included in the study. The procedure consisted in a standard aneurysmorrhaphy or bypass procedure performed through a video assisted left minilombotomy.The main outcomes measured were mortality, complications, operative time, aortic cross-clamp time, time to solid diet, and length of intensive care unit and hospital stay.

RESULTS

Operative mortality was 0.7 %. Nonfatal postoperative complications occurred in 12 patients (8%). Conversion to a standard procedure was necessary in 3 patients. Mean operative time was 207 +/- 57 minutes (AAA) and 224 +/- 55 minutes (AIOD). Mean aortic cross-clamp time was 76 +/- 26 minutes (AAA) and 48 +/- 21 minutes (AIOD). Median resumption of regular diet was 2 days. Median length of stay in the intensive care unit was 1 day and in the hospital 8 days.

CONCLUSION

Our results suggest that MIRPA is a safe and effective minimally invasive procedure in the treatment of infrarenal aortic disease.

Monitoring vital signs during outpatient Mohs and post-Mohs reconstructive surgery performed under local anesthesia

BACKGROUND

Although dermatologic surgery carries a low risk of serious adverse events, concern over the safety of outpatient surgical procedures in general has led some to question whether intraoperative patient monitoring should be performed during all procedures performed in the clinic setting.

OBJECTIVE

To characterize the intraoperative monitoring practices of Mohs surgeons and examine the relationship between changes in vital signs during skin surgery and the incidence of serious adverse events.

METHODS

We surveyed a group of Mohs surgeons and prospectively measured blood pressure, pulse, and pulse oximetry of 100 patients undergoing repair of Mohs surgery defects under local anesthesia in the outpatient clinic setting.

RESULTS

The majority of survey respondents utilize no intraoperative monitoring, and serious adverse events are rare (0.2 per 1000 procedures performed). Moderate fluctuations in our patients' vital signs occurred (<10% deviation from baseline); however, all measured variables returned to near baseline by procedure end and were not associated with any serious adverse events.

CONCLUSIONS

Surgical repair of Mohs defects performed under local anesthesia in the outpatient clinic setting continues to be very safe. Intraoperative vital sign measurements did not appear to be useful in detecting or avoiding potential adverse events in our patient population.

Anesthetic considerations in a patient with mitral valve disease for posterior fossa surgery

Mitral valve disease in patients undergoing posterior fossa surgery enhances the inherent risk of the procedure and can complicate the anesthetic management. A great challenge for the anesthesiologist is to choose the most appropriate perioperative technique that balances the specific anesthetic considerations of both the cardiac and the neurologic diseases. The authors describe the anesthetic management of a patient with a meningioma in the posterior fossa requiring craniectomy and tumor decompression. She was also diagnosed with severe mitral regurgitation and moderate mitral stenosis.

Noncardiac pulmonary, endocrine, and renal preoperative evaluation of the vascular surgical patient

Patients who have vascular disease who are to undergo an operation are at risk for developing perioperative and postoperative complications caused by coexisting diseases. A comprehensive preoperative evaluation is critical in identifying these coexisting diseases, and the anesthetic plan might require modification. This article focuses on important aspects of the pulmonary, endocrine (diabetes), and renal systems during the preoperative evaluation of the vascular surgical patient.

Intraoperative management of aortic aneurysm surgery

Managing the anesthesia of patients undergoing open aortic surgical repair is a great challenge. The anesthesiologist's role in myocardial,renal, and neurologic protection is crucial to the patient's overall outcome.Each case presents different challenges, and there is no one right way to manage the patient intraoperatively.