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Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Mol KHJM, Liem VGB, van Lier F, Stolker RJ, Hoeks SE. Intraoperative hypotension in noncardiac surgery patients with chronic beta-blocker therapy: A matched cohort analysis. J Clin Anesth 2023; 89:111143. [PMID: 37216803 DOI: 10.1016/j.jclinane.2023.111143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 04/19/2023] [Accepted: 05/01/2023] [Indexed: 05/24/2023]
Abstract
STUDY OBJECTIVE To explore the incidence of intraoperative hypotension in patients with chronic beta-blocker therapy, expressed as time spent, area and time-weighted average under predefined mean arterial pressure thresholds. DESIGN Retrospective analysis of a prospective observational cohort registry. SETTING Patients ≥60 years undergoing intermediate- to high-risk noncardiac surgery with routine postoperative troponin measurements on the first three days after surgery. PATIENTS 1468 matched sets of patients (1:1 ratio with replacement) with and without chronic beta-blocker treatment. INTERVENTIONS None. MEASUREMENTS The primary outcome was the exposure to intraoperative hypotension in beta-blocker users vs. non-users. Time spent, area and time-weighted average under predefined mean arterial pressure thresholds (55-75 mmHg) were calculated to express the duration and severity of exposure. Secondary outcomes included incidence of postoperative myocardial injury and thirty-day mortality, myocardial infarction (MI) and stroke. Furthermore, analyses for patient subgroup and beta-blocker subtype were conducted. MAIN RESULTS In patients with chronic beta-blocker therapy, no increased exposure to intraoperative hypotension was observed for all characteristics and thresholds calculated (all P > .05). Beta-blocker users had lower heart rate before, during and after surgery (70 vs. 74, 61 vs. 65 and 68 vs. 74 bpm, all P < .001, respectively). Postoperative myocardial injury (13.6% vs. 11.6%, P = .269) and thirty-day mortality (2.5% vs. 1.4%, P = .055), MI (1.4% vs. 1.5%, P = .944) and stroke (1.0% vs 0.7%, P = .474) rates were comparable. The results were consistent in subtype and subgroup analyses. CONCLUSIONS In this matched cohort analysis, chronic beta-blocker therapy was not associated with increased exposure to intraoperative hypotension in patients undergoing intermediate- to high-risk noncardiac surgery. Furthermore, differences in patient subgroups and postoperative adverse cardiovascular events as a function of treatment regimen could not be demonstrated.
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Affiliation(s)
- Kristin H J M Mol
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Victor G B Liem
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Felix van Lier
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Robert Jan Stolker
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Sanne E Hoeks
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Gao L, Chen L, Wang B, He J, Liu C, Wang R, Cheng R. Management of Postoperative Myocardial Injury After Non-cardiac Surgery in Patients Aged ≥ 80 Years: Our 10 Years' Experience. Front Cardiovasc Med 2022; 9:869243. [PMID: 35497998 PMCID: PMC9043516 DOI: 10.3389/fcvm.2022.869243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostoperative myocardial injury (PMI) is associated with short- and long-term mortality. The incidence of PMI in very old patients is currently unknown. There is currently neither known effective prophylaxis nor a uniform strategy for the elderly with PMI.ObjectiveTo share our 10 years of experience in the comprehensive management of PMI after non-cardiac surgery in patients aged ≥ 80 years.MethodsIn this case series, we retrospectively collected and assessed the 2,984 cases aged ≥ 80 years who accepted non-cardiac surgery from 2011 to 2021 at the second Medical Center, Chinese PLA General Hospital. The incidence, risk factors, management strategy, and prognosis of surgical patients with PMI were analyzed.ResultsA total of 2,984 patients met our inclusion criteria. The overall incidence of PMI was 14%. In multivariable analysis, coronary artery disease, chronic heart failure, and hypotension were independently associated with the development of PMI. The patients with PMI were at a higher risk of death (OR, 2.69; 95% CI, 1.78–3.65). They were more likely to have received low molecular heparin, anti-plantlet therapy, beta-blocker, early coronary angiography, and statin than patients without PMI. The 30-day (0.96% vs. 0.35%; OR 3.46; 95% CI, 1.49–7.98; P < 0.001) and 1-year mortality (5.37% vs. 2.60%; OR 2.35; 95% CI, 1.12–6.53; P < 0.001) was significantly higher in patients with PMI compared with those without PMI.ConclusionsThe incidence of PMI in very old patients was high. The PMI is associated with an increased risk of 30 days and 1-year mortality. These patients can benefit from intensification of assessment and individualized care of multi-morbidities during the perioperative period. Especially cardiovascular medical treatments, such as antiplatelet, anticoagulation, β-blockers, and statins are very important for patients with PMI.
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Affiliation(s)
- Linggen Gao
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Lei Chen
- Department of Thoracic Surgery, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Bin Wang
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Jing He
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Chaoyang Liu
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Rong Wang
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
- *Correspondence: Rong Wang
| | - Rui Cheng
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
- Rui Cheng
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Perioperative Care of Patients at High Risk for Stroke During or After Non-cardiac, Non-neurological Surgery: 2020 Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 32:210-226. [PMID: 32433102 DOI: 10.1097/ana.0000000000000686] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Perioperative stroke is associated with considerable morbidity and mortality. Stroke recognition and diagnosis are challenging perioperatively, and surgical patients receive therapeutic interventions less frequently compared with stroke patients in the outpatient setting. These updated guidelines from the Society for Neuroscience in Anesthesiology and Critical Care provide evidence-based recommendations regarding perioperative care of patients at high risk for stroke. Recommended areas for future investigation are also proposed.
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Santangelo G, Faggiano A, Toriello F, Carugo S, Natalini G, Bursi F, Faggiano P. Risk of cardiovascular complications during non-cardiac surgery and preoperative cardiac evaluation. Trends Cardiovasc Med 2021; 32:271-284. [PMID: 34233205 DOI: 10.1016/j.tcm.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/21/2021] [Accepted: 06/30/2021] [Indexed: 12/21/2022]
Abstract
The preoperative evaluation of candidates to non-cardiac surgery requires a knowledge of factors related both to the type of surgery and to the risk of each patient, in order to predict the potential cardiovascular complications. Over the past several decades, the field of preoperative cardiac evaluation before non-cardiac surgery has evolved substantially on the basis of the current guidelines of international medical societies. The aim of this paper is to summarize available evidence on the risk of non-cardiac surgery, focusing on appropriate cardiovascular assessment prior to surgery.
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Affiliation(s)
- Gloria Santangelo
- San Paolo Hospital, Division of Cardiology, Department of Health Sciences, University of Milan, Italy
| | - Andrea Faggiano
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Internal Medicine, Cardiology Unit, University of Milan, Milan, Italy
| | - Filippo Toriello
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Internal Medicine, Cardiology Unit, University of Milan, Milan, Italy
| | - Stefano Carugo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Internal Medicine, Cardiology Unit, University of Milan, Milan, Italy
| | | | - Francesca Bursi
- San Paolo Hospital, Division of Cardiology, Department of Health Sciences, University of Milan, Italy
| | - Pompilio Faggiano
- Fondazione Poliambulanza, Cardiovascular Department, Brescia, Italy.
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Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade. Eur J Trauma Emerg Surg 2021; 48:799-810. [PMID: 33847766 PMCID: PMC9001541 DOI: 10.1007/s00068-021-01647-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/11/2021] [Indexed: 12/14/2022]
Abstract
As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.
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Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, Mijalski C, Nelson MT, Power M, Welch BG. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association. Circulation 2021; 143:e923-e946. [PMID: 33827230 DOI: 10.1161/cir.0000000000000968] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.
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Bhatia K, Narasimhan B, Aggarwal G, Hajra A, Itagi S, Kumar S, Chakraborty S, Patel N, Jain V, Bandyopadhyay D, Amgai B, Aronow WS. Perioperative pharmacotherapy to prevent cardiac complications in patients undergoing noncardiac surgery. Expert Opin Pharmacother 2020; 22:755-767. [PMID: 33350868 DOI: 10.1080/14656566.2020.1856368] [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: 12/22/2022]
Abstract
Introduction: Despite advances in surgical and anesthetic techniques, perioperative cardiovascular complications are a major cause of 30-day perioperative mortality. Major cardiovascular complications after noncardiac surgery include myocardial ischemia, congestive heart failure, arrhythmias, and cardiac arrest. Along with surgical risk assessment, perioperative medical optimization can reduce the rates and clinical impact of these complications.Areas Covered: In this review, the authors discuss the pharmacological basis, existing evidence, and professional society recommendations for drug management in preventing cardiovascular complications in patients undergoing noncardiac surgery.Expert opinion: Perioperative management of cardiovascular disease is an increasingly important and growing area of clinical practice. Societal guidelines regarding the use of most routine cardiovascular medications are based on a number of large clinical studies and provide a basic foundation to guide management. However, the heterogeneous nature of patients, as well as surgeries, makes it practically impossible to devise a 'one size fits all' recommendation in this setting. Thus, the importance of a more individualized approach to perioperative risk stratification and management is being increasingly recognized. The underlying comorbidities and cardiac profile as well as the risk of cardiac complications associated with the planned surgery must be factored in to understand the nuance of the management strategies.
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Affiliation(s)
- Kirtipal Bhatia
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | - Bharat Narasimhan
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | | | - Adrija Hajra
- Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Soumya Itagi
- PSG Institute of Medical Sciences and Research, Coimbatore, India
| | - Shathish Kumar
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | | | | | - Dhrubajyoti Bandyopadhyay
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | | | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Robert D. Sanders, B.Sc., M.B.B.S., Ph.D., F.R.C.A., Recipient of the 2020 James E. Cottrell, M.D., Presidential Scholar Award. Anesthesiology 2020; 133:720-723. [DOI: 10.1097/aln.0000000000003512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nan Y, Jia F, Du X, Mei Z. Beta-blocker exposure for short-term outcomes following non-cardiac surgery: A meta-analysis of observational studies. Int J Surg 2020; 76:153-162. [PMID: 32169568 DOI: 10.1016/j.ijsu.2020.02.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 01/07/2023]
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Contemporary personalized β-blocker management in the perioperative setting. J Anesth 2019; 34:115-133. [PMID: 31637510 DOI: 10.1007/s00540-019-02691-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
Abstract
Beta-adrenergic blockers (β-blockers) are clearly indicated for the long-term treatment of patients with systolic heart failure and post-acute myocardial infarction. Early small-scale studies reported their potential benefits for perioperative use; subsequent randomized controlled trials, however, failed to reproduce earlier findings. Furthermore, their role in reducing major postoperative cardiac events following noncardiac and cardiac surgery remains controversial. This case-based review presents an overview of contemporary literature on perioperative β-blocker use with a focus on data available since 2008 when the PreOperative ISchemic Evaluation (POISE) trial was published. Our review suggests that studies should determine the effects of situational-based guidelines on perioperative β-blocker use on the risk of cardiac adverse events and mortality in the perioperative period.
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Perioperative kardiovaskuläre Morbidität und Letalität bei nichtherzchirurgischen Eingriffen. Anaesthesist 2019; 68:653-664. [DOI: 10.1007/s00101-019-0616-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Venkatesan S, Jørgensen ME, Manning HJ, Andersson C, Mozid AM, Coburn M, Moonesinghe SR, Foex P, Mythen M, Grocott MPW, Hardman JG, Myles PR, Sanders RD. Preoperative chronic beta-blocker prescription in elderly patients as a risk factor for postoperative mortality stratified by preoperative blood pressure: a cohort study. Br J Anaesth 2019; 123:118-125. [PMID: 31101323 DOI: 10.1016/j.bja.2019.03.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 03/01/2019] [Accepted: 03/21/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Recent data suggest that beta blockers are associated with increased perioperative risk in hypertensive patients. We investigated whether beta blockers were associated with an increased risk in elderly patients with raised preoperative arterial blood pressure. METHODS We conducted a propensity-score-matched cohort study of primary care data from the UK Clinical Practice Research Datalink (2004-13), including 84 633 patients aged 65 yr or over. Conditional logistic regression models, including factors that were significantly associated with the outcome, were constructed for 30-day mortality after elective noncardiac surgery. The effects of beta blockers (primary outcome), renin-angiotensin system (RAS) inhibitors, calcium-channel blockers, thiazides, loop diuretics, and statins were investigated at systolic and diastolic arterial pressure thresholds. RESULTS Beta blockers were associated with increased odds of postoperative 30-day mortality in patients with systolic hypertension (defined as systolic BP >140 mm Hg; adjusted odds ratio [aOR]: 1.92; 95% confidence interval [CI]: 1.05-3.51). After excluding patients for whom prior data suggest benefit from perioperative beta blockade (patients with prior myocardial infarction or heart failure), rather than adjusting for them, the point estimate shifted slightly (aOR: 2.06; 95% CI: 1.09-3.89). Compared with no use, statins (aOR: 0.35; 95% CI: 0.17-0.75) and thiazides (aOR: 0.28; 95% CI: 0.10-0.78) were associated with lower mortality in patients with systolic hypertension. CONCLUSIONS These data suggest that the safety of perioperative beta blockers may be influenced by preoperative blood pressure thresholds. A randomised controlled trial of beta-blocker withdrawal, in select populations, is required to identify a causal relationship.
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Affiliation(s)
- Sudhir Venkatesan
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Mads Emil Jørgensen
- Department of Internal Medicine, Division of Cardiology, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Helen J Manning
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| | - Charlotte Andersson
- The Cardiovascular Research Center, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Abdul M Mozid
- Department of Cardiology, Bristol Heart Institute, Bristol, UK
| | - Mark Coburn
- Department of Anaesthesia, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - S Ramani Moonesinghe
- University College London Hospitals & National Institute of Health Biomedical Research Centre, London, UK
| | - Pierre Foex
- Nuffield Division of Anaesthetics, Oxford University Hospital, Oxford, UK
| | - Monty Mythen
- University College London Hospitals & National Institute of Health Biomedical Research Centre, London, UK
| | - Michael P W Grocott
- Integrative Physiology and Critical Illness, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | | | - Puja R Myles
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Robert D Sanders
- Anesthesiology & Critical Care Trials & Interdisciplinary Outcomes Network, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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What we can learn from Big Data about factors influencing perioperative outcome. Curr Opin Anaesthesiol 2019; 31:723-731. [PMID: 30169341 DOI: 10.1097/aco.0000000000000659] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW This narrative review will discuss what value Big Data has to offer anesthesiology and aims to highlight recently published articles of large databases exploring factors influencing perioperative outcome. Additionally, the future perspectives of Big Data and its major pitfalls will be discussed. RECENT FINDINGS The potential of Big Data has given an incentive to create nationwide and anesthesia-initiated registries like the MPOG and NACOR. These large databases have contributed in elucidating some of the rare perioperative complications, such as declined cognition after exposure to general anesthesia and epidural hematomas in parturients. Additionally, they are useful in finding patterns such as similar outcome in subtypes of beta-blockers and lower incidence of pneumonia in preoperative influenza vaccinations in the elderly. SUMMARY Big Data is becoming increasingly popular with the collaborative collection of registries offering anesthesia a way to explore rare perioperative complications and outcome to encourage further hypotheses testing. Although Big Data has its flaws in security, lack of expertise and methodological concerns, the future potential of analytics combined with genomics, machine learning and real-time decision support looks promising.
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Ruan Y, Wu R, Lam JCW, Zhang K, Lam PKS. Seasonal occurrence and fate of chiral pharmaceuticals in different sewage treatment systems in Hong Kong: Mass balance, enantiomeric profiling, and risk assessment. WATER RESEARCH 2019; 149:607-616. [PMID: 30522053 DOI: 10.1016/j.watres.2018.11.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/29/2018] [Accepted: 11/05/2018] [Indexed: 06/09/2023]
Abstract
Concern about the presence of chiral pharmaceuticals in the environment from wastewater discharge is mounting. In this work, the occurrence and fate of atenolol, metoprolol, venlafaxine, and chloramphenicol, including 10 different stereoisomers, were investigated in sewage and sludge from diverse treatment processes in 4 sewage treatment plants (STPs) in Hong Kong via 4 sampling campaigns over a period of 2 years. The average amounts of individual pharmaceuticals entering the STPs ranged from 4.91 g/d to 6290 g/d, with sludge carrying much lower amounts than the discharged effluent. Mass balance analysis revealed that: larger quantities of these pharmaceuticals were released during the dry seasons, biodegradation was the primary removal mechanism for atenolol and chloramphenicol, and the removal via primary sedimentation and disinfection processes was insignificant (<30%). Selectivity toward R-(+)-atenolol, S-(-)-metoprolol, and R-(-)-venlafaxine was mostly found across secondary-treated effluent samples. Sold as an enantiopure pharmaceutical in R,R-para-form, chloramphenicol was preferentially eliminated after biological process. This is the first study on the occurrence of chloramphenicol enantiomers in the aquatic environment. Ecotoxicological assessment indicated that atenolol and metoprolol could pose risks to marine fish in effluent-receiving waters (i.e., the western waters and Victoria Harbor) of Hong Kong, while R-(+)-atenolol could pose a risk to protozoans five times higher than the S-(-)-enantiomer.
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Affiliation(s)
- Yuefei Ruan
- State Key Laboratory of Marine Pollution (SKLMP), Research Centre for the Oceans and Human Health, Shenzhen Key Laboratory for the Sustainable Use of Marine Biodiversity, City University of Hong Kong, Hong Kong, China
| | - Rongben Wu
- State Key Laboratory of Marine Pollution (SKLMP), Research Centre for the Oceans and Human Health, Shenzhen Key Laboratory for the Sustainable Use of Marine Biodiversity, City University of Hong Kong, Hong Kong, China; Department of Chemistry, City University of Hong Kong, Hong Kong, China
| | - James C W Lam
- State Key Laboratory of Marine Pollution (SKLMP), Research Centre for the Oceans and Human Health, Shenzhen Key Laboratory for the Sustainable Use of Marine Biodiversity, City University of Hong Kong, Hong Kong, China; Department of Science and Environmental Studies, The Education University of Hong of Kong, Hong Kong, China.
| | - Kai Zhang
- State Key Laboratory of Marine Pollution (SKLMP), Research Centre for the Oceans and Human Health, Shenzhen Key Laboratory for the Sustainable Use of Marine Biodiversity, City University of Hong Kong, Hong Kong, China
| | - Paul K S Lam
- State Key Laboratory of Marine Pollution (SKLMP), Research Centre for the Oceans and Human Health, Shenzhen Key Laboratory for the Sustainable Use of Marine Biodiversity, City University of Hong Kong, Hong Kong, China; Department of Chemistry, City University of Hong Kong, Hong Kong, China.
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Jørgensen ME, Andersson C, Venkatesan S, Sanders RD. Beta-blockers in noncardiac surgery: Did observational studies put us back on safe ground? Br J Anaesth 2018; 121:16-25. [PMID: 29935568 DOI: 10.1016/j.bja.2018.02.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/10/2018] [Accepted: 02/07/2018] [Indexed: 01/10/2023] Open
Abstract
Based on landmark trials, international guidelines had for years promoted the use of beta-blockers in the setting of non-cardiac surgery. In 2011, concerns were raised regarding the integrity of some of the landmark trials, as the Dutch Erasmus Medical Center found some of them to be scientifically incorrect. Based on the remaining studies that were to be trusted, investigations showed that, in contrast to prior beliefs, the widespread use of perioperative beta-blockers might be harmful. A call for further investigations into the matter ushered in several observational studies evaluating the safety of perioperative beta-blocker therapy in specific patient subgroups. Within this review, we discuss important aspects for making these decisions, and compare the major observational studies and specific estimates of risk in subgroups of interest. We conclude that patients at high risk with heavy co-morbidities, such as heart failure, may benefit from beta-blocker therapy, whereas low-risk patients, such as patients with uncomplicated hypertension, may be at increased risk with beta-blocker therapy. We provide a critical review of current perioperative guidelines in view of the new observational data, suggesting that the recommended schematics, such as the Revised Cardiac Risk Index, for risk stratification of patients in this setting may be suboptimal. Further, we provide discussions of other aspects, including risk of sepsis, type of beta-blocker, and the potential of perioperative beta-blocker withdrawal, which may be important in guiding future studies. Summarising the current evidence, we argue that, after a precarious decade, we may just now, be back on safe ground.
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Affiliation(s)
- M E Jørgensen
- The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - C Andersson
- The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - S Venkatesan
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - R D Sanders
- Anesthesiology & Critical Care Trials & Interdisciplinary Outcome Network, Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
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18
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Affiliation(s)
- Karl Swedberg
- Department of Clinical and Molecular Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,National Heart and Lung Institute, Imperial College, London, UK
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19
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Lüscher TF. Perioperative care of cardiac patients: preventing myocardial injury, bleeding, and death. Eur Heart J 2017; 38:2379-2381. [PMID: 28821177 DOI: 10.1093/eurheartj/ehx459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Zurich Heart House, Careum Campus, Moussonstrasse 4, 8091 Zurich, Switzerland
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