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Lamperti M, Romero CS, Guarracino F, Cammarota G, Vetrugno L, Tufegdzic B, Lozsan F, Macias Frias JJ, Duma A, Bock M, Ruetzler K, Mulero S, Reuter DA, La Via L, Rauch S, Sorbello M, Afshari A. Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2025; 42:1-35. [PMID: 39492705 DOI: 10.1097/eja.0000000000002069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2024]
Abstract
BACKGROUND When considering whether a patient is fit for surgery, a comprehensive patient assessment represents the first step for an anaesthetist to evaluate the risks associated with the procedure and the patient's underlying diseases, and to optimise (whenever possible) the perioperative surgical journey. These guidelines from the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) update previous guidelines to provide new evidence on existing and emerging topics that consider the different aspects of the patient's surgical path. DESIGN A comprehensive literature review focused on organisation, clinical facets, optimisation and planning. The methodological quality of the studies included was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. A Delphi process agreed on the wording of recommendations, and clinical practice statements (CPS) supported by minimal evidence. A draft version of the guidelines was published on the ESAIC website for 4 weeks, and the link was distributed to all ESAIC members, both individual and national, encompassing most European national anaesthesia societies. Feedback was gathered and incorporated into the guidelines accordingly. Following the finalisation of the draft, the Guidelines Committee and ESAIC Board officially approved the guidelines. RESULTS In the first phase of the guidelines update, 17 668 titles were initially identified. After removing duplicates and restricting the search period from 1 January 2018 to 3 May 2023, the number of titles was reduced to 16 774, which were then screened, yielding 414 abstracts. Among these, 267 relevant abstracts were identified from which 204 appropriate titles were selected for a comprehensive GRADE analysis. Additionally, the study considered 4 reviews, 16 meta-analyses, 9 previously published guidelines, 58 prospective cohort studies and 83 retrospective studies. The guideline provides 55 evidence-based recommendations that were voted on by a Delphi process, reaching a solid consensus (>90% agreement). DISCUSSION This update of the previous guidelines has covered new organisational and clinical aspects of the preoperative anaesthesia assessment to provide a more objective evaluation of patients with a high risk of postoperative complications requiring intensive care. Telemedicine and more predictive preoperative scores and biomarkers should guide the anaesthetist in selecting the appropriate preoperative blood tests, x-rays, and so forth for each patient, allowing the anaesthetist to assess the risks and suggest the most appropriate anaesthetic plan. CONCLUSION Each patient should have a tailored assessment of their fitness to undergo procedures requiring the involvement of an anaesthetist. The anaesthetist's role is essential in this phase to obtain a broad vision of the patient's clinical conditions, to coordinate care and to help the patient reach an informed decision.
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Affiliation(s)
- Massimo Lamperti
- From the Anesthesiology Division, Integrated Hospital Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates (ML, BT, SM), Department of Anesthesia and Intensive Care, University General Hospital of Valencia (CSR). Department of Methodology, Universidad Europea de Valencia, Spain (CSR), Azienda Ospedaliero Universitaria Pisana, Cardiothoracic and vascular Anaesthesia and Intensive Care, Pisa (FG), Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara (GC), Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy (LV), Péterfy Sándor Hospital, Anesthesia and Intensive Care Unit. Budapest, Hungary (FL), Servei d'Anestesiologia i Medicina Periopeatòria, Hospital General de Granollers, Spain (JJMF), Department of Anaesthesia and Intensive Care, University Hospital Tulln, Austria (AD), Department of Anaesthesiology and Intensive Care Medicine, Hospital of Merano (SABES-ASDAA), Merano - Meran, Italy (MB), Teaching Hospital of Paracelsus Medical University and Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria (MB), the Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA (KR), Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Rostock University Medical Center, Rostock, Germany (DAR), Anesthesia and Intensive Care. Policlinico "G. Rodolico-San Marco", Catania, Italy (LLV), Department of Anaesthesiology and Intensive Care Medicine, Hospital of Merano (SABES-ASDAA), Merano - Meran (SR), Teaching Hospital of Paracelsus Medical University, Anesthesia and Intensive Care, School of Medicine, Kore University, Enna (SR), Anesthesia and Intensive Care, Giovanni Paolo II Hospital, Ragusa, Italy (SR), Rigshospitalet & Institute of Clinical Medicine, University of Copenhagen (MS) and Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Rigshospitalet, Denmark University of Copenhagen, Denmark (AA)
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Indja B, Chang J, Flynn CD, Vallely M. Preoperative Nonselective Chest Computed Tomography Prior to Primary Cardiac Surgery Results in Meaningful Change to Surgical Management: Systematic Review and Pooled Prevalence Meta-Analysis. Heart Lung Circ 2024; 33:1250-1258. [PMID: 38981829 DOI: 10.1016/j.hlc.2024.04.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 03/08/2024] [Accepted: 04/25/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Routine screening chest computed tomography (CT) prior to primary cardiac surgery is advocated by some surgeons due to the purported benefits of identifying significant aortic calcification that impacts ongoing management, such as performing anaortic off-pump surgery or adjusting cannulation strategy. Additionally, axial imaging can identify incidental findings that may require concomitant or staged procedures such as ascending aortic dilatation or pulmonary lesions. The objective of this study was to quantify the impact that nonselective chest CT prior to primary cardiac surgery had on subsequent management. METHOD A systematic review and pooled prevalence meta-analyses were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Included studies performed non-selective chest CT prior to primary cardiac surgery. RESULTS A total of eight studies, including 2,250 patients were included. The rate of mortality and stroke was low (1% and 2%, respectively). Calcification of the ascending aorta was identified in 15% of patients (95% confidence interval [CI] 5.0-26.0). A significant change to the surgical plan such as cannulation strategy, off-pump surgery, cancellation, or an additional procedure was required in 7% (95% CI 2.0-12.0). Clinically relevant incidental findings requiring in-patient management or follow-up were identified in 10% (95% CI 6.0-14.0). CONCLUSIONS Nonselective CT chest prior to primary cardiac surgery identifies clinically relevant findings that result in a modification of the surgical plan in a significant population of patients to address the risk of stroke associated with aortic calcification as well as the identification of important incidental findings such as pulmonary lesions.
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Affiliation(s)
- Ben Indja
- Department of Cardiothoracic Surgery, St George Hospital, Kogarah, NSW, Australia.
| | - Jaewon Chang
- Department of Cardiothoracic Surgery, St George Hospital, Kogarah, NSW, Australia
| | - Campbell D Flynn
- Department of Cardiothoracic Surgery, St George Hospital, Kogarah, NSW, Australia
| | - Michael Vallely
- Department of Cardiothoracic Surgery, St George Hospital, Kogarah, NSW, Australia; Department of Cardiothoracic Surgery, Macquarie University Hospital, Macquarie University, NSW, Australia
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Subramanian H, Knight J, Sultan I, Kaczorowski DJ, Subramaniam K. Pre-Habilitation of Cardiac Surgical Patients, Part 2: Frailty, Malnutrition, Respiratory disease, Alcohol/Smoking cessation and Depression. Semin Cardiothorac Vasc Anesth 2022; 26:295-303. [PMID: 36189933 DOI: 10.1177/10892532221130922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The concept of "pre-habilitation" comprises screening for and identification of pre-existing disorders followed by medical optimization. This is performed for many types of surgeries, but may have profound impacts on outcomes, particularly in cardiac surgery given the multiple comorbidities typically carried by these patients. Components of pre-habilitation include direct medical intervention by preoperative specialists as well as significant care coordination and shared decision-making. In this second part of a two-part review, the authors describe existing evidence to support the optimization of various preoperative problems and present a few institutional protocols utilized at out center for cardiac presurgical care. This second installment will focus on alcohol and smoking cessation and the management of frailty, malnutrition, respiratory disease, and depression.
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Affiliation(s)
- Harikesh Subramanian
- Department of Anesthesiology and Perioperative Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua Knight
- Department of Anesthesiology and Perioperative Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, 481457University of Pittsburgh Medical center, Pittsburgh, PA, USA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, 481457University of Pittsburgh Medical center, Pittsburgh, PA, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Rosati F, Baudo M, D'Ancona G, Tomasi C, Zanin F, Cuko B, DI Bacco L, Borghesi A, Zoppetti M, Muneretto C, Benussi S. Every cloud has a silver lining: COVID-19 chest-CT screening prevents unnecessary cardiac surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:606-613. [PMID: 35758087 DOI: 10.23736/s0021-9509.22.12278-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Unenhanced chest CT can identify incidental findings (IFs) leading to management strategy change. We report our institutional experience with routine chest-CT as preoperative screening tool during the COVID-19 pandemic, focusing on the impact of IFs. METHODS All patients scheduled for cardiac surgery from May 1st to December 31st 2020, underwent preoperative unenhanced chest-CT according to COVID-19 pandemic institutional protocol. We have analyzed IFs incidence, reported consequent operative changes, and identified IFs clinical determinants. RESULTS Out of 447, 278 patients were included. IFs rate was 7.2% (20/278): a solid mass (11/20, 55%), lymphoproliferative disease (1/20, 5%), SARS-CoV-2 pneumonia (2/20, 10%), pulmonary artery chronic thromboembolism (1/20, 5%), anomalous vessel anatomy (2/20, 10%), voluminous hiatal hernia (1/20, 5%), mitral annulus calcification (1/20, 5%), and porcelain aorta (1/20, 5%) were reported. Based on IFs, 4 patients (20%-4/278, 1.4%) were not operated, 8 (40%-8/278, 2.9%) underwent a procedure different from the one originally planned one, and 8 (40%-8/278, 2.9%) needed additional preoperative investigations before undergoing the planned surgery. At univariate regression, coronary artery disease, atrial fibrillation, and history of cancer were significantly more often present in patients presenting with significant IFs. History of malignancy was identified as the only independent determinant of significant IFs at chest-CT (OR=4.27 IQR: [1.14-14.58], P=0.0227). CONCLUSIONS Unenhanced chest-CT as a preoperative screening tool in cardiac surgery led to incidental detection of significant clinical findings, which justified even procedures cancellation. Malignancy history is a determinant for CT incidental findings and could support a tailored screening approach for high-risk patients.
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Affiliation(s)
- Fabrizio Rosati
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy -
| | - Massimo Baudo
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Giuseppe D'Ancona
- Department of Cardiovascular Research, Vivantes Klinikum Urban, Berlin, Germany
| | - Cesare Tomasi
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Francesca Zanin
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Besart Cuko
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Lorenzo DI Bacco
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Andrea Borghesi
- Operative Unit of 2nd Diagnostic Radiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Marco Zoppetti
- Operative Unit of 2nd Diagnostic Radiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Claudio Muneretto
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Stefano Benussi
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
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Morikawa K, Misumi S, Igarashi T, Fujimori A, Ogihara A, Akao R, Hasumi J, Watanabe T, Fujii Y, Ojiri H, Mori S. Clinical significance of chest CT for the exclusion of COVID-19 in pre-admission screening: Is it worthwhile using chest CT with reverse-transcription polymerase chain reaction test? Respir Investig 2022; 60:595-603. [PMID: 35581125 PMCID: PMC9080118 DOI: 10.1016/j.resinv.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/04/2022] [Accepted: 04/19/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND A single reverse-transcription polymerase chain reaction (RT-PCR) test is not sufficient to exclude COVID-19 in hospital pre-admission screening. However, repeated RT-PCR tests are time-consuming. This study investigates the utility of chest computed tomography (CT) for COVID-19 screening in asymptomatic patients. METHODS Between April 2020 and March 2021, RT-PCR testing and chest CT were performed to screen COVID-19 in 10 823 asymptomatic patients prior to admission. Chest CT findings were retrospectively evaluated using the reporting system of the Radiological Society of North America. Using RT-PCR results as a reference, we assessed the diagnostic efficacy of chest CT during both the low- and high-prevalence periods of the COVID-19 pandemic. RESULTS Following a positive RT-PCR test, 20 asymptomatic patients (0.18%) were diagnosed with COVID-19; in the low-prevalence period, 5 of 6556 patients (0.076%) were positive; and in the high-prevalence period, 15 of 4267 patients (0.35%) were positive. Of the 20 asymptomatic COVID-19 positive patients, chest CT results were positive for COVID-19 pneumonia in 8 patients. Chest CT results were false-positive in 185 patients (1.7% false-positive rate, and 60% false-negative rate). Pneumonia that was classified as a "typical appearance" of COVID-19 reported as false-positives in 36 of 39 patients (92.3%). Across the study period, the diagnostic efficacy of "typical appearance" on chest CT were characterized by a sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of 15%, 99.7%, 99.7%, 7.7%, and 99.8%; 20%, 99.6%, 99.6%, 4%, and 99.9%; and 13.3%, 99.7%, 99.7%, 14.3%, and 99.7%, in the entire study, low-, and high-prevalence periods, respectively. CONCLUSIONS Addition of chest CT to RT-PCR testing provides no benefit to the detection of COVID-19 in asymptomatic patients.
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Affiliation(s)
- Kazuhiko Morikawa
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Shigeki Misumi
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takao Igarashi
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ayako Fujimori
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Ogihara
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryo Akao
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Jun Hasumi
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Watanabe
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuriko Fujii
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroya Ojiri
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shohei Mori
- Division of Thoracic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Duman ZM, Timur B, Topel Ç, Aksu T. Clinical Use of Tailored Computed Tomography to Prevent Poststernotomy Dehiscence. Thorac Cardiovasc Surg 2021; 70:72-76. [PMID: 34972236 DOI: 10.1055/s-0041-1736243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Morphological and tissue density analysis of the sternum can be performed in the preoperative computed tomography (CT). The purpose of this study was to analyze morphology and tissue density of sternum in CT and effect for comparison sternal instability. METHODS Patients with sternal instability (n = 61) and sternal stability (n = 66) were enrolled in this study. All of the patients were studied using same thorax CT procedure. All the measurements were performed by one specific cardiovascular radiologist. The Hounsfield units (HUs) were measured in axial sections of the sternum trabecular bone. RESULTS Sternal instability group mean HU was 75.36 ± 13.19 and sternal stability group HU was 90.24 ± 12.16 (p < 0.000). HU is the statically significant predictor of sternal instability. CONCLUSION Our study showed a significant correlation between the mean HU value of sternum and sternal instability. We think that it is important to evaluate the existing thorax CT while performing preoperative risk analysis for sternal dehiscence.
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Affiliation(s)
- Zihni M Duman
- İstasyon Mahallesi Turgut Özal Bulvarı Numara: 11 Küçükçekmece, Istanbul, Turkey
| | - Barış Timur
- İstasyon Mahallesi Turgut Özal Bulvarı Numara: 11 Küçükçekmece, Istanbul, Turkey
| | - Çağdaş Topel
- İstasyon Mahallesi Turgut Özal Bulvarı Numara: 11 Küçükçekmece, Istanbul, Turkey
| | - Timuçin Aksu
- İstasyon Mahallesi Turgut Özal Bulvarı Numara: 11 Küçükçekmece, Istanbul, Turkey
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Porterie J, Kalavrouziotis D, Mohammadi S. Commentary: Preoperative Screening CT: Not Ready for Primetime in The COVID-19 Era. Semin Thorac Cardiovasc Surg 2020; 33:425-426. [PMID: 33171239 PMCID: PMC7834735 DOI: 10.1053/j.semtcvs.2020.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 10/27/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Jean Porterie
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouziotis
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siamak Mohammadi
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Kamel MK. Commentary: Do radiological findings play a role in the screening of COVID-19 in patients undergoing cardiac surgery? Semin Thorac Cardiovasc Surg 2020; 33:427-428. [PMID: 33171255 PMCID: PMC7833796 DOI: 10.1053/j.semtcvs.2020.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/30/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Mohamed K Kamel
- Department of Surgery, Central Michigan University College of Medicine, Michigan.
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