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Perlas A, Arzola C, Portela N, Mitsakakis N, Hayawi L, Van de Putte P. Gastric Volume and Antral Area in the Fasting State: A Meta-analysis of Individual Patient Data. Anesthesiology 2024; 140:991-1001. [PMID: 38241328 DOI: 10.1097/aln.0000000000004914] [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: 01/21/2024]
Abstract
BACKGROUND Pulmonary aspiration of gastric content is a serious anesthetic complication. Gastric point-of-care ultrasound can determine the type and volume of gastric content when clinical information is equivocal. However, a cutoff value of either antral cross-sectional area or volume that may be considered as the upper limit of normal in fasting subjects is still controversial. The aim of this study is to characterize the distribution of baseline antral area and volume in fasting adult subjects and to identify an upper limit (95th percentile) of these distributions. METHODS The authors conducted a meta-analysis of individual participant data of primary studies from an academic research network of investigators collaborating in gastric ultrasound. Studies between January 2009 and December 2020 were included. RESULTS Twelve primary studies met inclusion criteria and were included in the analysis with a sample size of 1,203 subjects. The 95th percentile of area values (measured in the right lateral decubitus) was 9.9 cm2 (95% CI, 9.4 to 10.4), and of volume, 2.3 ml/kg (95% CI, 2.3 to 2.4). In addition, an antrum grade 0 or 1 indicates a 98% probability of an antral area below the 95th percentile. CONCLUSIONS An area of 10 cm2 measured in the right lateral decubitus could be a simple, data-driven upper limit of antral area that could serve as a surrogate of upper limit of normal gastric volume values in fasting adults. These results are limited by the highly selected sampling of the studies included. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Anahi Perlas
- Toronto Western Hospital, University Health Network, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Cristian Arzola
- Sinai Health System, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Natalia Portela
- Mount Sinai hospital, Sinai Health System, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Nicholas Mitsakakis
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Lamia Hayawi
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
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Chen L, Wang N, Xie G, Wang M, Yu Y, Wang H, Fang X. The safety of preoperative carbohydrate drinks in extremely elderly patients assessed by gastric ultrasonography: a randomized controlled trial. BMC Anesthesiol 2024; 24:78. [PMID: 38408918 PMCID: PMC10895784 DOI: 10.1186/s12871-024-02457-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/12/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Modern perioperative guidelines encourage drinking oral carbohydrates 2 h before management. Nevertheless, research on the safety of preoperative carbohydrate drinks, particularly in extremely elderly patients is lacking. We aimed to evaluate the safety of carbohydrate drinks 2 h before surgery in extremely elderly patients (≥ 80 years) using gastric ultrasonography. METHODS We conducted a randomized prospective comparative study of 70 patients aged over 80 years who were scheduled for total knee arthroplasty, hip fracture or humerus fracture surgery. These patients were randomly assigned to the carbohydrate group (n = 35), which fasted from midnight, except for drinking 355 mL of a carbohydrate-containing fluid 2 h before surgery, or the fasting group (n = 35), which fasted from midnight and drank no fluid before surgery. The primary outcome of the study was the cross-sectional area (CSA) of the gastric antrum in the right lateral decubitus position (RLDP) before surgery. The secondary outcomes included CSA in the supine position, intraoperative blood glucose levels and their variability coefficients, Perlas grade, and the visual analog scale of subjective feelings. RESULTS The CSA in the RLDP and supine positions revealed no differences between the carbohydrate and fasting groups at 0 h preoperatively (P > 0.05). In the qualitative assessment, preoperative 0-h Perlas grading did not differ significantly between the groups (P > 0.05). From 2 h before surgery to transfer out of the post-anesthesia care unit, the average blood glucose level of patients in the carbohydrate group was significantly higher than that in the fasting group (P < 0.001) but remained within the normal range. Moreover, the blood glucose variability coefficient was significantly lower in the carbohydrate group than in the fasting group (P = 0.009). Oral intake of 355 mL carbohydrates before surgery significantly relieved patients' feelings (P < 0.001). CONCLUSION Preoperative consumption of carbohydrate drinks 2 h before surgery is safe in "healthy" extremely elderly patients. In addition, preoperative drinking has potential value in maintaining ideal blood glucose levels and stable blood glucose fluctuations perioperatively and improving subjective perceptions of preoperative preparation. This finding warrants further investigation in clinical practice. TRIAL REGISTRATION Chinese Clinical Trial Registry (Registration Number ChiCTR1900024812), first registered on 29/07/2019.
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Affiliation(s)
- Lingyang Chen
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Nana Wang
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Guohao Xie
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Mingcang Wang
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Yulong Yu
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Huiqin Wang
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Xiangming Fang
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
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Yan Y, Jin Y, Cao Y, Chen C, Zhao X, Xia H, Yan L, Si Y, Zou J. Development and validation of a novel nomogram model to assess the risk of gastric contents in outpatients undergoing elective sedative gastrointestinal endoscopy procedures. Clin Res Hepatol Gastroenterol 2024; 48:102277. [PMID: 38159677 DOI: 10.1016/j.clinre.2023.102277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/24/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Gastric contents may contribute to patients' aspiration during anesthesia. Ultrasound can accurately assess the risk of gastric contents in patients undergoing sedative gastrointestinal endoscopy (GIE) procedures, but its efficiency is limited. Therefore, developing an accurate and efficient model to predict gastric contents in outpatients undergoing elective sedative GIE procedures is greatly desirable. METHODS This study retrospectively analyzed 1501 patients undergoing sedative GIE procedures. Gastric contents were observed under direct gastroscopic vision and suctioned through the endoscope. High-risk gastric contents were defined as having solid content or liquid volume > 25 ml and pH < 2.5; otherwise, they were considered low-risk gastric contents. Univariate analysis and multivariate analysis were used to select the independent risk factors to predict high-risk gastric contents. Based on the selected independent risk factors, we assigned values to each independent risk factor and established a novel nomogram. The performance of the nomogram was verified in the testing cohort by the metrics of discrimination, calibration, and clinical usefulness. In addition, an online accessible web calculator was constructed. RESULTS We found BMI, cerebral infarction, cirrhosis, male, age, diabetes, and gastroesophageal reflux disease were risk factors for gastric contents. The AUROCs were 0.911 and 0.864 in the development and testing cohort, respectively. Moreover, the nomogram showed good calibration ability. Decision curve analysis and Clinical impact curve demonstrated that the predictive nomogram was clinically useful. The website of the nomogram was https://medication.shinyapps.io/dynnomapp/. CONCLUSIONS This study demonstrates that clinical variables can be combined with algorithmic techniques to predict gastric contents in outpatients. Nomogram was constructed from routine variables, and the web calculator had excellent clinical applicability to assess the risk of gastric contents accurately and efficiently in outpatients, assist anesthesiologists in assessment and identify the most appropriate patients for ultrasound.
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Affiliation(s)
- Yuqing Yan
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yuzhan Jin
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yuanyuan Cao
- Department of Anesthesiology, Perioperative and Pain Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chen Chen
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiuxiu Zhao
- Department of Anesthesiology, Perioperative and Pain Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Huaming Xia
- Nanjing Xiaheng Network System Co., Ltd., Nanjing, China
| | - Libo Yan
- Jiangsu Kaiyuan Pharmaceutical Co., Ltd., Nanjing, China
| | - Yanna Si
- Department of Anesthesiology, Perioperative and Pain Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
| | - Jianjun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China; Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China.
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Javillier B, Grandjean F, Ounas K, Gautier N, Meunier P, Bonhomme V, Deflandre E. Effect of left paratracheal pressure on left carotid blood flow. Acta Anaesthesiol Scand 2024; 68:51-55. [PMID: 37795808 DOI: 10.1111/aas.14328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/30/2023] [Accepted: 09/03/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Gautier et al. demonstrated that a compression in the left paratracheal region (left paratracheal pressure, LPP) can be used to seal the oesophagus. However, at this level, the left common carotid artery is very close to the carotid that could be affected during the manipulation. This study aimed to assess the hemodynamic effects of LPP on the carotid blood flow. METHODS We prospectively included 47 healthy adult volunteers. We excluded pregnant women and people with anomalies of the carotid arteries. The common and internal carotid arteries were preliminarily studied with ultrasounds to exclude atheromatous plaques or vascular malformation. A planimetry of the common and internal carotid arteries was performed. Doppler echography served to measure the peak systolic (PSV) and end-diastolic velocities (EDV) in the common and internal carotid arteries. All measurements were repeated while applying LPP. RESULTS Forty-seven participants were enrolled (32 women; mean [SD] age: 42 [13] years). The mean PSV difference [95% CI] in the left common carotid artery before and after LPP at the group level was -15.30 [-31.09 to 0.48] cm s-1 (p = .14). The mean surface difference [95% CI] in the left common carotid artery before and after LPP was 24.52 [6.11-42.92] mm2 (p = .11). Similarly, the same surface at the level of the left internal carotid artery changed by -18.89 [-51.59 to 13.80] mm2 after LPP (p = .58). CONCLUSIONS Our results suggest that LPP does not have a significant effect on carotid blood flow in individuals without a carotid pathology. However, the safety of the manoeuvre should be evaluated in patients at risk of carotid anomalies.
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Affiliation(s)
- Benjamin Javillier
- Department of Anesthesia, Clinique Saint-Luc de Bouge, Namur, Belgium
- Liege University, Liege, Belgium
| | | | - Karim Ounas
- Department of Radiology, Liege University, Liege, Belgium
| | - Nicolas Gautier
- Department of Anesthesia, Clinique Sainte-Anne Saint-Remi, Brussels, Belgium
| | - Paul Meunier
- Department of Radiology, Liege University Hospital and Liege University, Liege, Belgium
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Anesthesia and Intensive Care Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Eric Deflandre
- Department of Anesthesia, Clinique Saint-Luc de Bouge, Namur, Belgium
- Department of Ambulatory Surgery, Clinique Saint-Luc de Bouge, Namur, Belgium
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Alfouzan RK, Arun Gopinathan P, Ui Haq I, Iyer K, Nawab AA, Alhumaidan A. Bibliometric Evaluation of the 100 Top-Cited Articles on Anesthesiology. Cureus 2023; 15:e50959. [PMID: 38249230 PMCID: PMC10800154 DOI: 10.7759/cureus.50959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 01/23/2024] Open
Abstract
This review is a bibliometric analysis based on anesthesiology, which is a medical specialty that deals with a patient's complete preoperative, intraoperative, and postoperative care. The objective of the review attempts to analyze the bibliometric characteristics of the 100 most top-cited articles on anesthesiology. The meta-data of the study were collected from the Core Collection of Web of Science database. A title search option was employed, and "Anesthesia" and "Anesthesiology" were typed in two different search boxes separated with the Boolean operator ''OR''. Further, the data were sorted by highest citation order; later, "article" was selected from the filter of document type, and all other types of documents were excluded. Finally, downloaded the bibliographic details of the 100 top-cited articles. VOSviewer Software (version 1.6.10 by van Eck and Waltman) was used for bibliometric network analysis for co-authors and keywords. Pearson chi-square test was used for statistical analysis. The 100 top-cited articles were published between the years of 1971 and 2018. These articles gained a maximum of 1006 to a minimum of 276 citations with an average of 384.57 cites/article. Open accessed articles gained a slightly higher ratio of citations, while more than half of the articles were published in the two leading journals of "Anesthesiology" and "Anesthesia and Analgesia". There was no statistically significant difference in both citation analysis among open and closed access journals and Anesthesia vs Non-Anesthesia journals. Thirty-six articles were published in journals not specifically related to Anesthesia. Most of the top-cited articles were contributed by the United States, whereas Surgery and General Anesthesia were the two most occurred keywords. We conclude that all the top-cited articles in anesthesiology were contributed by authors who belonged to the developed nations and the United States outclassed the rest of the world. This bibliometric analysis would be valuable to practitioners, academics, researchers, and students to understand the dynamics of progress in the field of anesthesiology.
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Affiliation(s)
- Rakan Khalid Alfouzan
- Department of Anesthesiology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Pillai Arun Gopinathan
- Department of Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, SAU
- Department of Maxillofacial Surgery and Diagnostic Sciences, King Abdullah International Medical Research Centre, Riyadh, SAU
| | - Ikram Ui Haq
- College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Kiran Iyer
- Department of Preventive Dental Sciences, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | | | - Abdullah Alhumaidan
- Department of Medicine and Surgery, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
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Azem K, Orbach-Zinger S, Heesen P, Finkelstein A, Eidelman LA, Shufaro Y, Arzola C. The effect of preoperative anxiety and ovarian stimulation on gastric antrum size: a prospective observational study. J Psychosom Obstet Gynaecol 2023; 44:2170226. [PMID: 36774546 DOI: 10.1080/0167482x.2023.2170226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
Pulmonary aspiration is a potentially lethal perioperative complication related to gastric size and contents. Several perioperative factors are believed to increase gastric size, while others are less studied. This prospective observational study aimed to investigate the effect of preoperative anxiety and hormone-induced ovarian stimulation on gastric size examined by gastric ultrasound. We recruited 49 female patients undergoing hormone-induced ovarian stimulation and oocyte retrieval for in vitro fertilization at Rabin Medical Centre, Petah Tikva, Israel. Preoperatively, women ranked their anxiety level using a verbal numeric anxiety score (VNS). In addition, we recorded the extent of ovarian stimulation and measured the antral cross-sectional area (CSA) using gastric ultrasound. There was no substantial correlation between preoperative VNS anxiety and antral CSA (p = .697). Moreover, the number of follicles, blood estradiol, and progesterone levels did not correlate with antral CSA (p = .590, p = .104, and p = .511, respectively). In conclusion, neither preoperative anxiety nor extensive ovarian stimulation affects gastric size in fasting healthy patients. However, further studies are warranted in this area to define these findings better. Trial registration: Clinicaltrials.gov, identifier: NCT04833530.
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Affiliation(s)
- Karam Azem
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Orbach-Zinger
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Philip Heesen
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Arthur Finkelstein
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leonid A Eidelman
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Shufaro
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Cristian Arzola
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
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Khanna AK, O'Connell NS, Ahuja S, Saha AK, Harris L, Cusson BD, Faris A, Huffman CS, Vallabhajosyula S, Clark CJ, Segal S, Wells BJ, Kirkendall ES, Sessler DI. Incidence, severity and detection of blood pressure and heart rate perturbations in postoperative ward patients after noncardiac surgery. J Clin Anesth 2023; 89:111159. [PMID: 37295123 DOI: 10.1016/j.jclinane.2023.111159] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/22/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023]
Abstract
STUDY OBJECTIVE We sought to determine changes in continuous mean and systolic blood pressure and heart rate in a cohort of non-cardiac surgical patients recovering on the postoperative ward. Furthermore, we estimated the proportion of vital signs changes that would remain undetected with intermittent vital signs checks. DESIGN Retrospective cohort. SETTING Post-operative general ward. PATIENTS 14,623 adults recovering from non-cardiac surgical procedures. INTERVENTIONS & MEASUREMENTS Using a wireless, noninvasive monitor, we recorded postoperative blood pressure and heart rate at 15-s intervals and encouraged nursing intervention as clinically indicated. MAIN RESULTS 7% of our cohort of 14,623 patients spent >15 sustained minutes with a MAP <65 mmHg, and 23% had MAP <75 mmHg for 15 sustained minutes. Hypertension was more common, with 67% of patients spending at least 60 sustained minutes with MAP >110 mmHg. Systolic pressures <90 mmHg were present for 15 sustained minutes in about a fifth of all patients, and 40% of patients had pressures >160 mmHg sustained for 30 min. 40% of patients were tachycardic with heart rates >100 beats/min for at least continuous 15 min and 15% of patients were bradycardic at a threshold of <50 beats/min for 5 sustained minutes. Conventional vital sign assessments at 4-h intervals would have missed 54% of mean pressure episodes <65 mmHg sustained >15 min, 20% of episodes of mean pressures >130 mmHg sustained >30 min, 36% of episodes of heart rate > 120 beats/min sustained <10 min, and 68% of episodes of heart rate sustained <40 beats per minute for >3 min. CONCLUSIONS Substantial hemodynamic disturbances persisted despite implementing continuous portable ward monitoring coupled with nursing alarms and interventions. A significant proportion of these changes would have gone undetected using traditional intermittent monitoring. Better understanding of effective responses to alarms and appropriate interventions on hospital wards remains necessary.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Sanchit Ahuja
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH and Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Amit K Saha
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Lynnette Harris
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Bruce D Cusson
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Ann Faris
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Center for Nursing Research, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA.
| | - Carolyn S Huffman
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Center for Nursing Research, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA.
| | - Saraschandra Vallabhajosyula
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Clancy J Clark
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Scott Segal
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Brian J Wells
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Center for Biomedical Informatics, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Eric S Kirkendall
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Center for Healthcare Innovation, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
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Rong H, Dai W, Qin Y, Meng Z, Zou X, Wang B, Wei Q, Xie Y. Ultrasonographic Assessment of Gastric Volume in Fasted Patients Undergoing Gastrointestinal Endoscopy Under Sedation. Ther Clin Risk Manag 2023; 19:685-698. [PMID: 37641782 PMCID: PMC10460589 DOI: 10.2147/tcrm.s424890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/13/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose In this prospective observational study, an ultrasonographic measurement of antral cross-sectional area (ACSA) was conducted to evaluate the gastric content and volume as well as to identify high-risk stomach in non-pregnant adult surgical patients adhering to preanesthetic fasting guidelines. Patients and Methods Fasted patients undergoing gastrointestinal endoscopy under sedation were included. Ultrasonographic measurements of ACSA were conducted in both semi-recumbent and right lateral decubitus positions before endoscopic procedures. Gastroscopy was employed to guide the measurement of suctioned gastric volume (GV). Ultrasonography was performed to assess gastric contents and identify patients with high-risk stomach. The relationship between ACSA and suctioned GV was also evaluated. Results ACSA was evaluated in 736 out of 782 patients. A significant positive correlation was discovered between ACSA in the right lateral decubitus position and suctioned GV, which was more reliable than in the semi-recumbent position. To analyze high-risk stomach with a GV > 100 mL, the cutoff value of ACSA in the right lateral decubitus was found to be 7.5 cm2, with the AUC, sensitivity and specificity of 0.80 (95% CI, 0.76-0.82; P<0.001), 82.4% and 67.3%, respectively. A novel mathematical model based on ACSA to estimate GV in non-pregnant fasted adults was presented. Conclusion Ultrasonographic measurement of ACSA can assist anesthesiologists in estimating the risk of pulmonary aspiration of gastric contents during general anesthesia and sedation.
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Affiliation(s)
- Heng Rong
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Weixin Dai
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yinying Qin
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Zhikeng Meng
- Department of Anesthesiology, The First People’s Hospital of Yulin, Yulin, People’s Republic of China
| | - Xia Zou
- Department of Anesthesiology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, People’s Republic of China
| | - Binbin Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Qiufeng Wei
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yubo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery After Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
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Chowdhury AR, Thakuria R, Maitra S, Nath S, Baidya DK, Subramanium R, Anand RK, Kayina CA. Carotid artery corrected flow time and respiratory variation of blood flow peak velocity for prediction of hypotension after induction of general anesthesia in adult patients undergoing emergency laparotomy for peritonitis: A prospective, observational study. J Anaesthesiol Clin Pharmacol 2023; 39:444-450. [PMID: 38025582 PMCID: PMC10661613 DOI: 10.4103/joacp.joacp_372_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 12/01/2023] Open
Abstract
Background and Aims Doppler waveform analysis of carotid artery has been found to predict fluid responsiveness in patients undergoing elective surgeries. We evaluated the role of carotid artery corrected flow time (FTc) and respiratory variation of blood flow peak velocity (ðVpeak) in predicting post induction hypotension in patients undergoing emergency laparotomy for peritonitis. Material and Methods Adult patients (n = 60) with perforation peritonitis undergoing emergency laparotomy under general anesthesia (GA) were recruited in this prospective, observational study. Carotid ultrasonography was performed pre-induction, to determine FTc and ðVpeak. Post-induction hemodynamic parameters were recorded for 5 minutes. Spearman's rank correlation coefficient was used to determine the relationship between hypotension and carotid artery measurements. Results Post-induction hypotension occurred in 48.3% of patients. The carotid artery FTc was significantly lower (P = 0.008) in patients who developed post-induction hypotension, but ðVpeak was statistically similar (P = 0.62) in both groups. Spearman's rank correlation coefficient revealed a statistically significant correlation between FTc and systolic blood pressure (SBP) change at one-minute post induction (r2 = -0.29, P = 0.03); however statistical significance were not achieved at 2 minutes and 3 minutes (P = 0.05 at both time points). Carotid artery FTc had an area under the receiver operating characteristic (AUROC) curve (95% CI) of 0.70 (0.57-0.84) to predict post-induction hypotension and best cutoff value of 344.8 ms with a sensitivity and specificity of 61% and 79%, respectively. Carotid artery ðVpeak had an AUROC curve (95% CI) of 0.54 (0.39-0.69) to predict post-induction hypotension and best cutoff value of 7.9% with a sensitivity and specificity of 62% and 55%, respectively. Conclusion Carotid artery FTc and ðVpeak are not reasonable predictors of hypotension in patients undergoing emergency laparotomy for perforation peritonitis.
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Affiliation(s)
- Apala R. Chowdhury
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
- Department of Anaesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ruma Thakuria
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
- Department of Anaesthesia and Critical Care, Max Hospital, Dehradun, Uttarakhand, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Sayan Nath
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Dalim K. Baidya
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeshwari Subramanium
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul K. Anand
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Choro A. Kayina
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Szabó M, Pleck AP, Soós SÁ, Keczer B, Varga B, Széll J. A preoperative ultrasound-based protocol for optimisation of fluid therapy to prevent early intraoperative hypotension: a randomised controlled study. Perioper Med (Lond) 2023; 12:30. [PMID: 37370150 DOI: 10.1186/s13741-023-00320-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Intraoperative hypotension is a risk factor for postoperative complications. Preoperative dehydration is a major contributor, although it is difficult to estimate its severity. Point-of-care ultrasound offers several potential methods, including measurements of the inferior vena cava. The addition of lung ultrasound may offer a safety limit. We aimed to evaluate whether the implication of an ultrasound-based preoperative fluid therapy protocol can decrease the incidence of early intraoperative hypotension. METHODS Randomised controlled study in a tertiary university department involves elective surgical patients of ASA 2-3 class, scheduled for elective major abdominal surgery under general anaesthesia with intubation. We randomised 40-40 patients; 38-38 were available for analysis. Conventional fluid therapy was ordered on routine preoperative visits. Ultrasound-based protocol evaluated the collapsibility index of inferior vena cava and lung ultrasound profiles. Scans were performed twice: 2 h and 30 min before surgery. A high collapsibility index (≥ 40%) indicated a standardised fluid bolus, while the anterior B-profile of the lung ultrasound contraindicated further fluid. The primary outcome was the incidence of postinduction and early intraoperative (0-10 min) hypotension (MAP < 65 mmHg and/or ≥ 30% of decrease from baseline). Secondary endpoints were postoperative lactate level, urine output and lung ultrasound score at 24 h. RESULTS The absolute criterion of postinduction hypotension was fulfilled in 12 patients in the conventional group (31.6%) and 3 in the ultrasound-based group (7.9%) (p = 0.0246). Based on composite criteria of absolute and/or relative hypotension, we observed 17 (44.7%) and 7 (18.4%) cases, respectively (p = 0.0136). The incidence of early intraoperative hypotension was also lower: HR for absolute hypotension was 2.10 (95% CI 1.00-4.42) in the conventional group (p = 0.0387). Secondary outcome measures were similar in the study groups. CONCLUSION We implemented a safe and effective point-of-care ultrasound-based preoperative fluid replacement protocol into perioperative care. TRIAL REGISTRATION The study was registered to ClinicalTrials.gov on 10/12/2021, registration number: NCT05171608 (registered prospectively on 10/12/2021).
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Affiliation(s)
- Marcell Szabó
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary.
| | | | - Sándor Árpád Soós
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Bánk Keczer
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Balázs Varga
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - János Széll
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
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11
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Liu Y, Wang Q, Zuo Q. Gastric Emptying Velocity After Labor Analgesia Assessed by Sonography: A Prospective Controlled Observational Study. Ther Clin Risk Manag 2023; 19:475-484. [PMID: 37346898 PMCID: PMC10281523 DOI: 10.2147/tcrm.s410984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/05/2023] [Indexed: 06/23/2023] Open
Abstract
Objective The effect of labor analgesia on gastric emptying rate will affect the management of fasting during the perinatal period. To evaluate gastric emptying after labor analgesia using the gastric antrum ultrasound examination. Methods From September 2022 to January 2023, a prospective controlled observational study was conducted. The Study group (epidural analgesia group) and Observation group (pharmacological and non-pharmacological interventions group) were successively enrolled and grouped using the random envelope method. However, labor analgesia was supplied according to maternal women's wishes, and intention-to-treat (ITT) and per-protocol (PP) analyses were performed to establish its effect on stomach emptying. The gastric emptying rate during the first stage of labor was considered to be the primary outcome. Results From September 2022 to January 2023, 120 persons were studied, 90 in the Study group and 30 in the Observation group. 33 people's analgesic selection was discordant with the grouped one. ITT analysis showed that the Study group's cross-sectional area (CSA) fell from baseline (624.19 ± 92.70 mm2) to 334.64 ± 46.32 mm2 after 1 hour and to 217.26 ± 29.90 mm2 after 2 hours. In the Observation group, the CSA similarly dropped from 620.10 ± 100.73 mm2 to 331.30 ± 51.19 mm2 and 214.70 ± 28.73 mm2, p<0.001. CSA was not significantly different between groups, p>0.05. The PP analysis also indicated no significant changes in the CSA between the two groups at 3 time-points, p>0.05. At the first hour, the Study and Observation group had stomach emptying speeds of 300.05 ± 103.74 mm2/h and 259.50 ± 125.25 mm2/h, respectively, which were greater than those at the second hour (115.75 ± 43.51 mm2/h vs 124.36 ± 58.98 mm2/h), p<0.001. Conclusion Epidural analgesia, pharmacological, and non-pharmacological labor analgesia had little effect on gastric emptying, and gastric antrum ultrasonography can be utilized to monitor maternal gastric volume changes.
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Affiliation(s)
- Yongfeng Liu
- Department of Anesthesiology, Medical Center Hospital of Qionglai, Qionglai City, Sichuan Province, People’s Republic of China
| | - Qian Wang
- Department of Anesthesiology, Medical Center Hospital of Qionglai, Qionglai City, Sichuan Province, People’s Republic of China
| | - Qinghai Zuo
- Department of Anesthesiology, People’s Hospital of Hechuan, Chongqing City, People’s Republic of China
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12
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Cavaliere F, Allegri M, Apan A, Brazzi L, Carassiti M, Cohen E, DI Marco P, Langeron O, Rossi M, Spieth P, Turnbull D, Weber F. A year in review in Minerva Anestesiologica 2022: anesthesia, analgesia, and perioperative medicine. Minerva Anestesiol 2023; 89:239-252. [PMID: 36880326 DOI: 10.23736/s0375-9393.23.17281-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Affiliation(s)
- Franco Cavaliere
- IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Massimo Allegri
- Unit of Pain Therapy of Column and Athlete, Policlinic of Monza, Monza, Italy
| | - Alparslan Apan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Giresun, Giresun, Türkiye
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio-Medico University, Rome, Italy
| | - Edmond Cohen
- Icahn School of Medicine at Mount Sinai, Department of Anesthesiology, New York, NY, USA
| | - Pierangelo DI Marco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiologic, and Geriatric Sciences, Faculty of Medicine, Sapienza University, Rome, Italy
| | - Olivier Langeron
- Department of Anesthesia and Intensive Care, Assistance Publique - Hôpitaux de Paris (APHP), Henri Mondor University Hospital, University Paris-Est Créteil (UPEC), Paris, France
| | - Marco Rossi
- IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Dresden, Dresden, Germany
| | - David Turnbull
- Department of Anesthetics and Neuro Critical Care, Royal Hallamshire Hospital, Sheffield, UK
| | - Frank Weber
- Department of Anesthesiology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
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13
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The Lateral Femoral Cutaneous and Over the Hip (LOH) Block for the Surgical Management of Hip Fractures: A Safe and Effective Anesthetic Strategy. J Orthop Trauma 2023; 37:135-141. [PMID: 36253914 DOI: 10.1097/bot.0000000000002508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip (LOH) block. DESIGN Retrospective. SETTING Orthopedic specialty hospital. PATIENTS/PARTICIPANTS 40 patients who presented between November 2021 and February 2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used. INTERVENTION Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve, and accessory obturator nerve. MAIN OUTCOME MEASUREMENTS Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates. RESULTS A total of 120 patients (40 each: general, spinal, and LOH block) were compared. The cohorts were similar in age, race, body mass index, sex, Charlson comorbidity index, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block cohort ( P < 0.05). Total OR time and anesthesia time were the shortest for the LOH block cohort ( P < 0.05). Patients in the LOH block cohort also had lower postoperative pain scores ( P < 0.05). Length of hospital stay was the shortest for patients in the LOH block cohort ( P < 0.05), and during discharge, patients in the LOH block cohort ambulated the furthest ( P < 0.05). No differences were found for anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates. CONCLUSIONS The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly patients requiring surgery. In addition, this block may decrease postoperative pain and length of hospital stay, and allow for greater ambulation in the early postoperative period for patients with hip fracture. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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14
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Jia H, He E, Gao S, Hao W, Li Y, Liu W, Chen X, Jia Y, Wang Y. Ultrasound assessment of gastric contents and volume in patients undergoing endoscopic endonasal transsphenoidal surgery: a prospective observational study. Sci Rep 2023; 13:2848. [PMID: 36801927 PMCID: PMC9938176 DOI: 10.1038/s41598-023-29893-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/13/2023] [Indexed: 02/19/2023] Open
Abstract
Intraoperative ingestion of blood, cerebrospinal fluid, and irrigation fluid can lead to an increase in gastric volume, resulting in the potential risk of aspiration in patients after endoscopic endonasal transsphenoidal surgery (EETS). In this prospective observational study, we aimed to assess the volume of gastric contents in patients undergoing this neurosurgical procedure using ultrasound, and to determine the factors associated with volume change. Eighty-two patients diagnosed with pituitary adenoma were recruited consecutively. Semi-quantitative (Perlas scores: 0, 1 and 2) and quantitative (cross-sectional area, CSA) ultrasound assessments of the gastric antrum were performed immediately before and after surgery in the semi-recumbent and semi-recumbent right-lateral positions. Seven (8.5%) patients had antrum scores from preoperative grade 0 to postoperative grade 2; nine (11%) patients had antrum scores from preoperative grade 0 to postoperative grade 1. The mean ± standard deviation (SD) of increased gastric volume was 71.0 ± 33.1 mL and 236.5 ± 32.4 mL in postoperative grade 1 and 2 groups, respectively. Subgroup analysis showed that 11 (13.4%) patients (4 in grade 1 and all in grade 2) had postoperative estimated gastric volume > 1.5 mL kg-1 (mean ± SD 3.08 ± 1.67, range 1.51-5.01 mL kg-1). Logistic regression analysis revealed that older age, diabetes mellitus, and long surgical duration were independent risk factors for significant volume change (all P < 0.05). Our results showed a significant increase in gastric volume in some patients who underwent EETS. Bedside ultrasound measurements of gastric volume can be used to assess the postoperative aspiration risk, particularly in older diabetic patients with a longer surgical duration.
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Affiliation(s)
- Haitao Jia
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Ertao He
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Shixiong Gao
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Wei Hao
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Yanli Li
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Wei Liu
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Xiaoxia Chen
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Yanfei Jia
- grid.411294.b0000 0004 1798 9345Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, 730030 Gansu China
| | - Yingbin Wang
- Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030, Gansu, China.
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Chaitra T, Palta S, Saroa R, Jindal S, Jain A. Assessment of residual gastric volume using point-of-care ultrasonography in adult patients who underwent elective surgery. Ultrasound J 2023; 15:7. [PMID: 36752856 PMCID: PMC9908785 DOI: 10.1186/s13089-023-00307-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/19/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Aspiration pneumonitis remains a dreaded complication that may lead to almost 9% of anaesthesia-related deaths. The presence of gastric contents has always been a contributing factor to an increased risk of aspiration. Preoperative gastric ultrasound has been suggested as a modality for determining residual volume in special populations and conditions. We conducted an observational study to determine the gastric residual volume in preoperative patients of elective surgery with gastric ultrasound and to study its correlation with patient factors. METHODS We enrolled 411 patients in the age group of 18-80 with ASA-PS I and II having BMI less than 35 kg/m2. Patients with prior gastrointestinal surgery and parturients were excluded from the present study. Gastric antrum in both supine and right lateral decubitus positions was measured using USG in the immediate preoperative period, and gastric residual volume was calculated, which was subsequently correlated with various patient factors. RESULTS On qualitative assessment, 97 and 118 patients were observed to have distended stomachs in the supine and right lateral decubitus positions, respectively. On quantitative assessment, 336 had safe GRV, 60 patients were classified as having a low risk of aspiration (GRV < 1.5 ml/kg) while 13 had a high risk of aspiration (> 1.5 ml/kg). Eight patients with a fasting duration of more than ten hours and five who fasted between 6 and 10 h had a gastric residual volume of more than 1.5 ml/h. Patients who were premedicated with histamine blockers had a statistically significant higher antral cross-sectional area (p-value - 0.022*) and GRV (p-value - 0.018*) in the right lateral decubitus position compared to patients who had taken proton pump inhibitors (PPIs). As BMI increased, there was a statistically significant (p-value < 0.001) increase in mean antral CSA in both supine and right lateral decubitus positions. There was a statistically significant association found between type 2 diabetes (p-value 0.045*) with antral grade. DISCUSSION Patients can have significant residual volume (> 1.5 ml/kg) despite adequate fasting, and preoperative gastric ultrasound can help in assessing the same and guiding perioperative airway management. PPIs are more effective in reducing gastric residual volume as compared to histamine blockers. Patients with a BMI of more than 30 and type 2 diabetes mellitus have significant correlation with increased gastric residual volume mandating preoperative gastric ultrasound assessment for effective management. CONCLUSIONS Patients with BMI over 30 and type 2 diabetes may benefit from POCGUS to guide perioperative airway management by stratifying GRV. Trial registration Name of registry-Clinical Trial Registry of India. Trial registration number-2020/03/024083. Date of registration-19.3.2020. URL- http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=39961&EncHid=&userName=.
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Affiliation(s)
- T.S. Chaitra
- grid.416286.f0000 0004 1793 9129Department of Anaesthesia, Sri Siddhartha Medical College Hospital and Research Centre, Tumkur, India
| | - Sanjeev Palta
- grid.413220.60000 0004 1767 2831Department of Anaesthesia, Government Medical College and Hospital, Chandigarh, India
| | - Richa Saroa
- grid.413220.60000 0004 1767 2831Department of Anaesthesia, Government Medical College and Hospital, Chandigarh, India
| | - Swati Jindal
- grid.413220.60000 0004 1767 2831Department of Anaesthesia, Government Medical College and Hospital, Chandigarh, India
| | - Aditi Jain
- Department of Anaesthesia, Government Medical College and Hospital, Chandigarh, India.
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Mertes PM, Tacquard C. Maîtriser le risque allergique en anesthésie réanimation. ANESTHÉSIE & RÉANIMATION 2023. [DOI: 10.1016/j.anrea.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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17
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Retained Food During Esophagogastroduodenoscopy Is a Risk Factor for Gastric-to-Pulmonary Aspiration. Dig Dis Sci 2023; 68:164-172. [PMID: 35596820 DOI: 10.1007/s10620-022-07536-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 04/21/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Residual food (RF) during esophagogastroduodenoscopy (EGD) is thought, but not proven, to be a risk factor for gastric-to-pulmonary aspiration. AIMS The aims of this study were to determine the prevalence of RF during EGD, to investigate whether RF was associated with an increased risk of aspiration, especially when monitored anesthesia care (MAC) or general anesthesia (GA) were administered, and to determine whether aspiration associated with RF led to a more severe clinical outcome. METHODS Patients undergoing EGD between October 2012 and September 2018 were identified. Patient age, sex, aspiration events, RF, sedation type, structural foregut abnormalities, and diagnoses associated with impaired esophageal or gastric motility were noted. The clinical course after an aspiration event was evaluated. RESULTS RF was identified during 4% of 81,367 EGDs. Aspiration events occurred during 41 (5/10,000) procedures. Aspiration was more likely to occur in patients with RF (odds ratio [OR] 15.1) or those receiving MAC or GA (OR 9.6 and 16.8 relative to conscious sedation, respectively). RF and MAC/GA were synergistically associated with increased odds of aspiration. In a multivariate nominal logistic regression model, older age (OR 2.6), MAC (OR 3.8), GA (OR 4.4), vagotomy (OR 5.2), achalasia (OR 3.8), and RF (OR 10.0) were risk factors for aspiration. Aspiration events in the presence or absence of RF led to similar clinical outcomes. CONCLUSIONS While aspiration events are rare in patients undergoing EGD, RF and the use of MAC or GA were associated with substantially increased odds of aspiration.
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Alcarraz P, Servente L, Kuster F, Duarte L, Garau M, Desirello M, Blanc L, Bracesco N, Perlas A. Preoperative fasting for the infusion of "yerba mate": a randomized clinical trial with ultrasound evaluation of gastric contents. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 72:757-761. [PMID: 35121062 PMCID: PMC9659983 DOI: 10.1016/j.bjane.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 12/22/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND The traditional infusion of "yerba mate" is widely consumed in South America and exported to countries around the world. Although generally considered a "clear fluid", there is no data to date on the gastric emptying time of yerba mate and safe preoperative fasting intervals. The objective of this study was to evaluate the gastric emptying time of a standardized infusion of yerba mate using bedside ultrasound and compare it with the time confirm of hot and cold tea. METHODS This was a prospective, randomized crossover experimental study. Thirty healthy volunteers were evaluated after 8 hours of fasting for both fluids and solids. Gastric antral area and gastric volume were evaluated at baseline and every 20 minutes after drinking 300 mL of randomly assigned infusion of "yerba mate", hot tea, or cold tea. RESULTS The mean gastric emptying time was: 69.7 ± 22.1 min, 63.1 ± 14.5 min, and 64.3 ± 23.5 min for the mate, hot tea, and cold tea respectively. No significant differences were found in emptying time among the infusion groups (p-value = 0.043). When same time measures were compared, the only significant difference detected was between hot teas and mate infusion at 20 minutes (p-value = 0.012) CONCLUSION: Yerba mate infusion has a similar gastric emptying time to that of tea. All subject's gastric volume returned to baseline values by 100 minutes. It is reasonable to recommend a similar fasting period of 2 hours for mate infusion prior to elective surgery.
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Affiliation(s)
- Paola Alcarraz
- Facultad de Medicina UDELAR, Hospital de Clínicas "Dr. Manuel Quintela", Departmento de Anestesiología, Montevideo, Uruguay.
| | - Liliana Servente
- Facultad de Medicina UDELAR, Hospital de Clínicas "Dr. Manuel Quintela", Departmento Clínico de Imagenología, Montevideo, Uruguay
| | - Federico Kuster
- Facultad de Medicina UDELAR, Hospital de Clínicas "Dr. Manuel Quintela", Departmento de Anestesiología, Montevideo, Uruguay
| | - Leticia Duarte
- Facultad de Medicina UDELAR, Hospital de Clínicas "Dr. Manuel Quintela", Departmento de Anestesiología, Montevideo, Uruguay
| | - Mariela Garau
- Facultad de Medicina UDELAR, Departmento de Métodos Cuantitativos, Montevideo, Uruguay
| | - María Desirello
- Facultad de Medicina UDELAR, Hospital de Clínicas "Dr. Manuel Quintela", Departmento Clínico de Imagenología, Montevideo, Uruguay
| | - Lourdes Blanc
- Facultad de Medicina UDELAR, Laboratorio de Radiobiología Departmento Biofísica, Montevideo, Uruguay
| | - Nelson Bracesco
- Facultad de Medicina UDELAR, Laboratorio de Radiobiología Departmento Biofísica, Montevideo, Uruguay
| | - Anahi Perlas
- University Health Network and University of Toronto, Toronto Western Hospital, Department of Anesthesia, Toronto, Canada
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Leibold C, Falbo R, Gupta A, Miller R, Pederson JM, Malpe M. A systematic review and meta-analysis of anesthesia type on hip fracture post-surgery outcomes. OTA Int 2022; 5:e204. [PMID: 36425088 PMCID: PMC9580260 DOI: 10.1097/oi9.0000000000000204] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
Objective To compare technical, clinical, and safety outcomes among hip fracture patients treated with procedures supplemented by general anesthesia (GA) or spinal/regional anesthesia (S/R). Data sources We searched for original studies on PubMed, Ovid MEDLINE, Ovid Embase, and Cochrane databases. Study selection Studies that reported clinical outcomes in patients that underwent hip fracture surgery, had available data on type of anesthesia administered, and clinical follow-up data were selected for data extraction. Data extraction The primary outcomes of interest were odds of mortality, including in-hospital, 30-day, 90-day, and 1-year mortality. Various adverse events (AEs) were also compared. Data synthesis Twenty-eight studies met our selection criteria, including 190,394 patients. A total of 107,314 (56.4%) patients were treated with procedures involving GA while 83,080 (43.6%) were treated with procedures involving S/R. There was no difference in 30-day or >1-year mortality rates between the GA and SR groups; however, compared to S/R group, the GA group had a significantly higher odds of in-hospital (P = .004) and 90-day mortality (P = .004). There was no difference in odds of adverse events between the GA and the S/R group. Conclusions Patients administered S/R for hip fracture procedures demonstrate lower risk of in-hospital mortality and 90-day mortality compared to patients administered GA. Level of evidence Therapeutic level III.
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Affiliation(s)
| | - Ryan Falbo
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center
| | | | - Richard Miller
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center
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Mogami M, Yamazaki Y, Nemoto C, Muto M, Tanaka Y, Inoue S. Critical aspiration pneumonia during induction of anesthesia in elective abdominal surgery: a case report. JA Clin Rep 2022; 8:58. [PMID: 35930204 PMCID: PMC9356121 DOI: 10.1186/s40981-022-00549-w] [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: 06/30/2022] [Revised: 07/17/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background We experienced the critical aspiration pneumonia during induction of anesthesia in elective abdominal surgery which standard fasting period was complied with. Case presentation A 64-year-old male was scheduled for gastrojejunostomy because of gastrointestinal obstruction. He fasted from the night before surgery. General anesthesia was induced, and cricoid pressure was applied during intubation. However, he vomited huge amount of gastric contents. The scheduled surgery was performed without surgical complications, and postoperatively respiratory management, including mechanical ventilation with prone positioning, was performed in high care unit. He was extubated on postoperative day 2. He was discharged from the hospital on POD 25. Conclusion The standard fasting period can prevent aspiration pneumonia in most cases. However, even in elective cases without abdominal symptoms, we consider that massive-volume gastric residual contents, especially in susceptible cases. We suggest that point-of-care gastric ultrasonography be performed in suspicious cases before induction of anesthesia.
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Hauber E, Alef M. [A multifactorial risk index for evaluation of anesthetic risk in dogs: the LeiV-Risk-Index]. TIERARZTLICHE PRAXIS. AUSGABE K, KLEINTIERE/HEIMTIERE 2022; 50:249-260. [PMID: 35700968 DOI: 10.1055/a-1839-5859] [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
OBJECTIVE The Leipzig Veterinary Risk-Index - "LeiV-Risk-Index" is a multifactorial risk index developed to enable an improved objective assessment of the anesthetic risk in dogs. The scoring system is based on 10 risk factors affecting perioperative mortality. The aim of this study was to evaluate the applicability of the LeiV-Risk-Index and its risk factors as well as to perform a direct comparison with the ASA-classification. MATERIAL AND METHODS An online survey was conducted among veterinarians working in small animal medicine throughout Germany. Participants received a questionnaire containing information on 15 selected patients. They were asked to classify the patients according to the LeiV-Risk-Index and ASA-classification and to answer several questions concerning their professional background. The results were statistically analyzed considering the consistency among veterinarians of rating the different patients by using Fleiss'-Kappa. The correlation of LeiV-Risk-Index and ASA-classification was calculated. RESULTS The consistency of all assigned LeiV-risk classes between participants was moderate (κ = 0.55) and higher than classification by ASA (κ = 0.33). On average, 3 different LeiV-risk classes and 4 different ASA-classes were assigned for one patient. There was a positive correlation between LeiV-risk class and increasing ASA-class. No effect of gender or clinical experience of the veterinarian could be demonstrated on ranking patients. There was also no effect of how confident veterinarians felt in applying the LeiV-Risk-Index. CONCLUSION UND CLINICAL RELEVANCE The LeiV-Risk-Index is the first index available in veterinary medicine for assessing anesthetic risk that is based on objective risk criteria and whose objectivity exceeds that of the ASA classification. Anesthetic patients can thus be evaluated more consistently in veterinary medicine as well. Utility and practicability were positively received by 95 % of the participants. Further revision of individual risk criteria needs to be reconsidered.
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Affiliation(s)
- Elke Hauber
- Klinik für Kleintiere, Abteilung für Anästhesiologie und Intensivmedizin, Veterinärmedizinische Fakultät der Universität Leipzig
| | - Michaele Alef
- Klinik für Kleintiere, Abteilung für Anästhesiologie und Intensivmedizin, Veterinärmedizinische Fakultät der Universität Leipzig
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González Cárdenas VH, Jáuregui Romero IM, Mena Méndez Y, Silva Enríquez PN, Soler Sandoval A. Factors associated with posoperative mortality in high perioperative risk patients. Cohort study. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.5554/22562087.e1045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Determining perioperative risk is part of the strategies implemented with the aim of reducing morbidity and mortality in the surgical population in the world. Although there is no established definition, high perioperative risk is associated with the group of patients with the highest disease burden.
Objective: To determine postoperative mortality and its associated factors in patients with high perioperative risk.
Methods: Analytical observational cohort study of high perioperative risk patients included in the database (n = 843) of the anesthesia program in a high complexity hospital in Colombia, between January 2011 and April 2018. Pre and postoperative variables were analyzed using uni and multivariate logistic regression per protocol. Overall and stratified mortality were estimated and factors associated with their occurrence were analyzed. Finally, survival was analyzed, the primary outcome being overall cohort mortality and stratified high cardiovascular risk mortality.
Results: Cumulative 7-day mortality was 3.68% (95% CI 2.40-4.95%) and 30-day mortality was 10.08% (95% CI 8.05-12.12%). Perioperative mortality in the high cardiovascular risk group in the first 7 days was 3.60% (95% CI 1.13-6.07%) and 14.86% (95% CI 10.15-19.58%) at 30 days. The following preoperative variables were associated with mortality: chronic obstructive pulmonary disease, chronic kidney disease, limited functional class and abdominal aortic aneurysm. A strong association was observed between postoperative complications and a significant increase in mortality rate; the most relevant complications were cerebrovascular events and cardiogenic shock.
Conclusions: In this group of high perioperative risk patients, and in the subgroup of high cardiovascular risk patients, overall mortality at 7 and at 30 days was estimated to be above values reported in various countries. Mortality was significantly increased by the presence of preoperative factors and postoperative complications.
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ROUSSET J, COPPERE Z, VALLEE A, MA S, CLARIOT S, BUREY J, ADJAVON S, DEVYS JM, QUESNEL C, FISCHLER M, BONNET F, LE GUEN M. Ultrasound assessment of the gastric content among diabetic and non-diabetic patients before elective surgery: a prospective multicenter study. Minerva Anestesiol 2022; 88:23-31. [DOI: 10.23736/s0375-9393.21.15603-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Balakrishna Achar P, D'Cunha D, Gurumurthy T, Acharya M. Gastric ultrasonography in assessment and quantification of gastric contents in fasting diabetic and nondiabetic patients. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2022. [DOI: 10.4103/mjdrdypu.mjdrdypu_75_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rock KC, Newman MF, Fleisher LA. Implications of Perioperative Morbidity for Long-Term Outcomes. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00001-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Koppenberg J, Stoevesandt D, Watzke S, Schwappach D, Bucher M. Analysis of 30 anaesthesia-related deaths in Germany between 2006 and 2015: An analysis of a closed claims database. Eur J Anaesthesiol 2022; 39:33-41. [PMID: 34397508 DOI: 10.1097/eja.0000000000001586] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anaesthesiology is one of the safest fields in medicine today in relation to mortality. Deaths directly because of anaesthesia have fortunately now become rare exceptions. Nevertheless, important findings can still be drawn from the rare deaths that still occur. OBJECTIVE The aim of this study was to identify and analyse the causes of deaths related to anaesthesia alone over a 10-year period. DESIGN Retrospective structured analysis of a database of medical liability claims. SETTING Hospitals at all levels of care in Germany. PATIENTS The database of a large insurance broker included data for 81 413 completed liability claims over the 10-year period from 2006 to 2015. Among 1914 cases associated with anaesthetic procedures, 56 deaths were identified. Of these, 30 clearly involved anaesthesia (Edwards category 1) and were included in the evaluation. INTERVENTIONS None (retrospective database analysis). MAIN OUTCOME MEASURES Causes of anaesthesia-related death identified from medical records, court records, expert opinions and autopsy reports. RESULTS The 30 deaths were analysed in detail at the case and document level. They included high proportions of 'potentially avoidable' deaths, at 86.6%, and what are termed 'never events', at 66.7%. Problems with the airway were the cause in 40% and problems with correct monitoring in 20%. In addition, communication problems were identified as a 'human factor' in 50% of the cases. CONCLUSION The majority of the anaesthesia-related deaths investigated could very probably have been avoided with simple anaesthesiological measures if routine guidelines had been followed and current standards observed. Actions to be taken are inferred from these results, and recommendations are made. In future, greater care must be taken to ensure that the level of safety already achieved in anaesthesiology can be maintained despite demographic developments and increasing economic pressures.
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Affiliation(s)
- Joachim Koppenberg
- Department of Anaesthesiology, Pain Therapy and Emergency Medicine, Lower Engadine Hospital and Health Centre, Scuol, Switzerland (JK), Dorothea Erxleben Lernzentrum Halle, Medical Faculty of Martin Luther University of Halle-Wittenberg, Halle, Germany (DS), Department of Psychiatry, Psychotherapy, and Psychosomatics, University Hospital of Halle (Saale), Germany (SW), Stiftung Patientensicherheit Schweiz, Zurich, Switzerland (DS), Institute for Social and Preventive Medicine (ISPM), University of Bern, Switzerland (DS) and Department of Anaesthesiology and Surgical Intensive Care Medicine, University Hospital of Halle (Saale), Germany (MB)
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Moake MM, Presley BC, Hill JG, Wolf BJ, Kane ID, Busch CE, Jackson BF. Point-of-Care Ultrasound to Assess Gastric Content in Pediatric Emergency Department Procedural Sedation Patients. Pediatr Emerg Care 2022; 38:e178-e186. [PMID: 32769837 PMCID: PMC7854775 DOI: 10.1097/pec.0000000000002198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES There is debate regarding the timing of procedural sedation and analgesia (PSA) in relation to fasting status. Point-of-care ultrasound (POCUS) provides the ability to measure gastric content and is being used as a surrogate for aspiration risk in anesthesia. We sought to evaluate the gastric content of pediatric emergency department (PED) patients undergoing PSA using POCUS. METHODS We performed a prospective observational study using a convenience sample of pediatric patients undergoing PSA between July 1, 2018, and June 30, 2019. Following a brief history, gastric content was measured using POCUS in both supine and right lateral decubitus positions at 2-hour intervals until the time of PSA. Qualitative content and calculated volume were classified based on the Perlas Model of anesthesia "Risk" assessment. RESULTS Ninety-three patients were enrolled with 61.3% male and mean age of 6.5 years. Gastric content was determined in 92 patients. There were 79.3% that had "high risk" content at the time of PSA, with a median fasting time of 6.25 hours and no serious adverse events. Fasting duration had a weak to moderate ability to predict "risk" category (area under the curve = 0.73), with no patient (n = 17) who underwent multiple evaluations awaiting PSA progressing from "high" to "low risk." CONCLUSIONS The majority of PED patients undergoing PSA at our institution had "high risk" gastric content with no clinically significant change occurring during serial evaluations. This calls into question the utility of delaying PSA based upon fasting status and lends support to a more comprehensive risk-benefit approach when planning pediatric PSA.
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Affiliation(s)
| | | | | | - Bethany J Wolf
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Ian D Kane
- From the Department of Pediatric Emergency Medicine
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Sessler DI. Anaesthesia's legacy: carpe diem. Br J Anaesth 2021; 128:413-415. [PMID: 34949440 DOI: 10.1016/j.bja.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Abstract
Intraoperative mortality is now rare. In contrast, 30-day postoperative mortality remains common, with most deaths occurring during the initial hospitalisation. The legacy of anaesthesiology will be determined by our success in dealing with postoperative mortality, which is currently the major problem in perioperative medicine. Carpe diem!
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Affiliation(s)
- Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
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Chen H, Lundberg SM, Erion G, Kim JH, Lee SI. Forecasting adverse surgical events using self-supervised transfer learning for physiological signals. NPJ Digit Med 2021; 4:167. [PMID: 34880410 PMCID: PMC8654960 DOI: 10.1038/s41746-021-00536-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 10/28/2021] [Indexed: 01/13/2023] Open
Abstract
Hundreds of millions of surgical procedures take place annually across the world, which generate a prevalent type of electronic health record (EHR) data comprising time series physiological signals. Here, we present a transferable embedding method (i.e., a method to transform time series signals into input features for predictive machine learning models) named PHASE (PHysiologicAl Signal Embeddings) that enables us to more accurately forecast adverse surgical outcomes based on physiological signals. We evaluate PHASE on minute-by-minute EHR data of more than 50,000 surgeries from two operating room (OR) datasets and patient stays in an intensive care unit (ICU) dataset. PHASE outperforms other state-of-the-art approaches, such as long-short term memory networks trained on raw data and gradient boosted trees trained on handcrafted features, in predicting six distinct outcomes: hypoxemia, hypocapnia, hypotension, hypertension, phenylephrine, and epinephrine. In a transfer learning setting where we train embedding models in one dataset then embed signals and predict adverse events in unseen data, PHASE achieves significantly higher prediction accuracy at lower computational cost compared to conventional approaches. Finally, given the importance of understanding models in clinical applications we demonstrate that PHASE is explainable and validate our predictive models using local feature attribution methods.
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Affiliation(s)
- Hugh Chen
- Paul G. Allen School of Computer Science and Engineering, University of Washington, 185 E Stevens Way NE, Seattle, WA, 98195, USA
| | | | - Gabriel Erion
- Paul G. Allen School of Computer Science and Engineering, University of Washington, 185 E Stevens Way NE, Seattle, WA, 98195, USA
- Medical Scientist Training Program, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Jerry H Kim
- Global Innovation Exchange, University of Washington, 12280 NE District Wy, Bellevue, WA, 98005, USA
| | - Su-In Lee
- Paul G. Allen School of Computer Science and Engineering, University of Washington, 185 E Stevens Way NE, Seattle, WA, 98195, USA.
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Sherwin M, Katz D. Using gastric ultrasound to assess gastric content in the pregnant patient. BJA Educ 2021; 21:404-407. [PMID: 34707884 DOI: 10.1016/j.bjae.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- M Sherwin
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - D Katz
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
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Prehabilitation Program in Elderly Patients: A Prospective Cohort Study of Patients Followed Up Postoperatively for Up to 6 Months. J Clin Med 2021; 10:jcm10194500. [PMID: 34640516 PMCID: PMC8509125 DOI: 10.3390/jcm10194500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/15/2021] [Accepted: 09/26/2021] [Indexed: 12/13/2022] Open
Abstract
The preoperative period may be an opportune period to optimize patients' physical condition with a multimodal preoperative program. The impact of a "prehabilitation" program on elderly patients is discussed. This mono-center observational cohort study included consecutively 139 patients planned for major abdominal and thoracic surgery, with 44 in the control group (age < 65) and 95 in the elderly group (age > 65). All patients followed a "prehabilitation" program including exercise training, nutritional optimization, psychological support, and behavioral change. Seventeen patients in the control group and 45 in the elderly group completed the study at six months. The 6-minute walk test (6 MWT) increased in both groups from the initial evaluation to the last (median value of 80 m (interquartile range 51) for those under 65 years; 59 m (34) for the elderly group; p = 0.114). The 6 MWT was also similar after one month of prehabilitation for both populations. The rate of postoperative complications was similar in the two groups. Prehabilitation showed equivalence in patients over 65 years of age compared to younger patients in terms of increase in functional capabilities and of postoperative evolution. This multimodal program represents a bundle of care that can benefit a frailer population.
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Litigation in Anesthesia and Intensive Care Units: An Italian Retrospective Study. Healthcare (Basel) 2021; 9:healthcare9081012. [PMID: 34442149 PMCID: PMC8392650 DOI: 10.3390/healthcare9081012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 12/04/2022] Open
Abstract
Anesthesiologists consider professional insurance and its medico-legal problems as a remarkable aspect of their job. “Associazione Anestesisti Rianimatori Ospedalieri Italiani—Emergenza ed Area Critica” (AAROI-EMAC) is the Italian professional association of anesthesiologists and intensivists that works to train its subscribers on safety measures. This is a retrospective observational study on an insurance complaints database for anesthetic accidents that result in injuries to patients. The analyzed period runs from 1 January 2014 to 31 December 2016. A total of 1309 complaints related to 873 insurance claims were analyzed. Criminal complaints comprised 805 (64.4%) of the total, and civil complaints were 445 (35.6%). The iatrogenic damage claimed included: death (58% of the cases); peripheral nerve damage (8%); spinal cord injuries (5%); unspecified injuries (7%); dental damage (4%); infections (3%); needing second surgical procedure (2%); and other injuries (13%). There is a statistical significance between the size of the hospital and the number of the claims: small hospital complaints comprised 40.1% of the cases, while complaints against medium-sized and large hospitals constituted 20.6% of the cases (χ2GL = 8 = 39.87, p = 0.00). In Italy, anesthesiologists and intensivists are often involved in litigation even when they are not directly responsible for iatrogenic injuries, and the most frequent claims in ICU are related post-operative complications.
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Zasso FB, Perelman VS, Ye XY, Melvin M, Wild E, Tavares W, You-Ten KE. Effects of prior exposure to a visual airway cognitive aid on decision-making in a simulated airway emergency: A randomised controlled study. Eur J Anaesthesiol 2021; 38:831-838. [PMID: 33883459 DOI: 10.1097/eja.0000000000001510] [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: 11/26/2022]
Abstract
BACKGROUND Decision-making deficits in airway emergencies have led to adverse patient outcomes. A cognitive aid would assist clinicians through critical decision-making steps, preventing key action omission. OBJECTIVE We aimed to investigate the effects of a visual airway cognitive aid on decision-making in a simulated airway emergency scenario. DESIGN Randomised controlled study. SETTING Single-institution, tertiary-level hospital in Toronto, Canada from September 2017 to March 2019. PARTICIPANTS Teams consisting of a participant anaesthesia resident, nurse and respiratory therapist were randomised to intervention (N = 20 teams) and control groups (N = 20 teams). INTERVENTION Participants in both groups received a 15-min didactic session on crisis resource management which included teamwork communication and the concepts of cognitive aids for the management of nonairway and airway critical events. Only participants in the intervention group were familiarised, oriented and instructed on a visual airway cognitive aid that was developed for this study. Within 1 to 4 weeks after the teaching session, teams were video-recorded managing a simulated 'cannot intubate-cannot oxygenate' scenario with the aid displayed in the simulation centre. MAIN OUTCOME MEASURES Decision-making time to perform a front-of-neck access (FONA), airway checklist actions, teamwork performances and a postscenario questionnaire. RESULTS Both groups performed similar key airway actions; however, the intervention group took a shorter decision-making time than the control group to perform a FONA after a last action [mean ± SD, 80.9 ± 54.5 vs. 122.2 ± 55.7 s; difference (95% CI) -41.2 (-76.5 to -6.0) s, P = 0.023]. Furthermore, the intervention group used the aid more than the control group (63.0 vs. 28.1%, P < 0.001). Total time of scenario completion, action checklist and teamwork performances scores were similar between groups. CONCLUSIONS Prior exposure and teaching of a visual airway cognitive aid improved decision-making time to perform a FONA during a simulated airway emergency.
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Affiliation(s)
- Fabricio B Zasso
- From the Departments of Anesthesia (FB-Z, M-M, E-W, KE-YT), Family Medicine-Emergency Medicine (VS-P), MiCcare Research Centre, Mount Sinai Hospital-Sinai Health System, University of Toronto, Toronto, Ontario, Canada (XY-Y), The Wilson Centre and Post-MD Education, Toronto, Ontario, Canada (W-T)
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Segura-Grau E, Segura-Grau A, Ara Jo R, Payeras G, Cabral J, Afreixo V. Reinforcing the valuable role of gastric ultrasound for volume and content assessment: an observational study. Braz J Anesthesiol 2021; 72:749-756. [PMID: 34324937 DOI: 10.1016/j.bjane.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/23/2021] [Accepted: 07/10/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pulmonary aspiration is one of the most important complications in anesthesiology. Assessment of gastric content by ultrasound is a good method to quantify gastric volume and to determine the risk of intraoperative pulmonary aspiration. The aim of this study is to determine the accuracy of the gastric ultrasonography in the qualitative analysis of gastric content, mainly in the analysis of small amounts of liquid content. METHODS Gastric ultrasound was performed to 36 patients before upper gastrointestinal endoscopy (UGI), making two longitudinal scans at the epigastric level, one in supine position and the other in right lateral decubitus position, measuring two diameters and the area of the gastric antrum and assessing the content characteristics determining whether it was an empty stomach or contained fluid or solid content. Subsequently, the ultrasound findings were compared with UGI findings. RESULTS Gastric areas were analyzed by the trace and the lengths of the craniocaudal and anteroposterior axes concluding that there are no significant differences between the two methods. No statistically significant difference was found between UGI and US assessment technics. No statistically significant difference was found between the estimated volume by UGI and US. CONCLUSIONS Though our study has some limitations, qualitative analysis of gastric content using ultrasound followed by endoscopy enabled the conclusion that there are no differences in the qualitative assessment regarding these two techniques, supporting the important role of point-of-care gastric ultrasound (POCGUS) in the assessment of pulmonary aspiration risk by the anesthesiologist in the perioperative period.
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Affiliation(s)
| | - Ana Segura-Grau
- San Francisco de As.ís Hospital, Ultrasonography Unit, Ecographic Diagnostic Center, Madrid, Spain
| | | | | | - Jorge Cabral
- University of Aveiro, Mathematics Department, Aveiro, Portugal
| | - Vera Afreixo
- University of Aveiro, Mathematics Department, Aveiro, Portugal
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Schenk J, Wijnberge M, Maaskant JM, Hollmann MW, Hol L, Immink RV, Vlaar AP, van der Ster BJP, Geerts BF, Veelo DP. Effect of Hypotension Prediction Index-guided intraoperative haemodynamic care on depth and duration of postoperative hypotension: a sub-study of the Hypotension Prediction trial. Br J Anaesth 2021; 127:681-688. [PMID: 34303491 DOI: 10.1016/j.bja.2021.05.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/29/2021] [Accepted: 05/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intraoperative and postoperative hypotension are associated with morbidity and mortality. The Hypotension Prediction (HYPE) trial showed that the Hypotension Prediction Index (HPI) reduced the depth and duration of intraoperative hypotension (IOH), without excess use of intravenous fluid, vasopressor, and/or inotropic therapies. Here, We hypothesised that intraoperative HPI-guided haemodynamic care would reduce the severity of postoperative hypotension in the PACU. METHODS This was a sub-study of the HYPE study, in which 60 adults undergoing elective noncardiac surgery were allocated randomly to intraoperative HPI-guided or standard haemodynamic care. Blood pressure was measured using a radial intra-arterial catheter, which was connected to a FloTracIQ sensor. Hypotension was defined as MAP <65 mm Hg, and a hypotensive event was defined as MAP <65 mm Hg for at least 1 min. The primary outcome was the time-weighted average (TWA) of postoperative hypotension. Secondary outcomes were absolute incidence, area under threshold for hypotension, and percentage of time spent with MAP <65 mm Hg. RESULTS Overall, 54/60 (90%) subjects (age 64 (8) yr; 44% female) completed the protocol, owing to failure of the FloTracIQ device in 6/60 (10%) patients. Intraoperative HPI-guided care was used in 28 subjects; 26 subjects were randomised to the control group. Postoperative hypotension occurred in 37/54 (68%) subjects. HPI-guided care did not reduce the median duration (TWA) of postoperative hypotension (adjusted median difference, vs standard of care: 0.118; 95% confidence interval [CI], 0-0.332; P=0.112). HPI-guidance reduced the percentage of time with MAP <65 mm Hg by 4.9% (adjusted median difference: -4.9; 95% CI, -11.7 to -0.01; P=0.046). CONCLUSIONS Intraoperative HPI-guided haemodynamic care did not reduce the TWA of postoperative hypotension.
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Affiliation(s)
- Jimmy Schenk
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Marije Wijnberge
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Jolanda M Maaskant
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, Location Academic Medical Centre and University of Amsterdam, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Liselotte Hol
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Rogier V Immink
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Alexander P Vlaar
- Department of Intensive Care, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands.
| | - Björn J P van der Ster
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Bart F Geerts
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Denise P Veelo
- Department of Anaesthesiology, Amsterdam UMC, Location Academic Medical Centre, Amsterdam, the Netherlands
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Naji A, Chappidi M, Ahmed A, Monga A, Sanders J. Perioperative Point-of-Care Ultrasound Use by Anesthesiologists. Cureus 2021; 13:e15217. [PMID: 34178536 PMCID: PMC8221658 DOI: 10.7759/cureus.15217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Point-of-Care ultrasound (POCUS) is the bedside utilization of ultrasound, in real-time, to aid in the diagnosis and treatment of patients. Image acquisition from POCUS utilization by anesthesiologists involves the assessment of multiple organs in different perioperative situations. POCUS can be utilized to enhance clinical decision-making in a variety of perioperative situations due to its ability to assess endotracheal tube placement, cardiac function, pulmonary function, aspiration risk, hemodynamics, vascular access, and nerve visualization for regional procedures. The mounting clinical evidence for the value of POCUS in perioperative settings, its growing affordability, and its low associated risks are responsible for the nationwide movement across many anesthesiology residency programs to increase the focus on perioperative ultrasound training. The purpose of this review is to present to current anesthesiologists and anesthesiology trainees, a broad discussion regarding the diverse utility and importance of POCUS in perioperative settings.
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Affiliation(s)
- Abdullah Naji
- Anesthesiology and Perioperative Medicine, Oregon Health Science University Hospital, Portland, USA
| | - Monica Chappidi
- Anesthesiology, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, USA
| | | | - Aaron Monga
- Anesthesiology, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, USA
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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Schmidt AR, Collins RT, Adusumelli Y, Ramamoorthy C, Weng Y, MacMillen KL, Navaratnam M. Impact of Modified Anesthesia Management for Pediatric Patients With Williams Syndrome. J Cardiothorac Vasc Anesth 2021; 35:3667-3674. [PMID: 34049787 DOI: 10.1053/j.jvca.2021.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study compared the percent change in systolic blood pressure and the incidence of adverse cardiac events (ACEs; defined as cardiac arrest, cardiopulmonary resuscitation, arrhythmias, or ST-segment changes) during anesthesia induction in patients with Williams syndrome (WS) before and after implementation of a perioperative management strategy. DESIGN Retrospective observational cohort study. SETTING Single quaternary academic referral center. PARTICIPANTS The authors reviewed the records of all children with WS at the authors' institution who underwent general anesthesia for cardiac catheterization, diagnostic imaging, or any type of surgery between November 2008 and August 2019. The authors identified 142 patients with WS, 48 of whom underwent 118 general anesthesia administrations. A historic group (HG) was compared with the intervention group (IG). INTERVENTIONS Change in perioperative management (three-stage risk stratification: preoperative intravenous hydration, intravenous anesthesia induction, and early use of vasoactives). MEASUREMENTS AND MAIN RESULTS The authors determined event rates within 60 minutes of anesthesia induction. Standardized mean difference (SMD) was calculated (SMD >0.2 suggests clinically meaningful difference). Sixty-seven general anesthesia encounters were recorded in the HG (mean age, 4.8 years; mean weight, 16.3 kg) and 51 in the IG (mean age, 6.0 years; mean weight, 18.2 kg). The change in systolic blood pressure was -17.5% (-30.0, -5.0) in the HG versus -9% (-18.0, 5.0) in the IG (p = 0.015; SMD = 0.419), and the incidence of ACEs was 6% in the HG and 2% in the IG (p = 0.542; SMD = 0.207). CONCLUSIONS Preoperative risk stratification, preoperative intravenous hydration, intravenous induction, and early use of continuous vasoactives resulted in greater hemodynamic stability, with a 2% incidence of ACEs.
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Affiliation(s)
- Alexander R Schmidt
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA.
| | - R Thomas Collins
- Divisions of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA
| | - Yamini Adusumelli
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA
| | - Chandra Ramamoorthy
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA
| | - Yingjie Weng
- Quantitative Sciences Unit, Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Palo Alto, CA
| | - Kirstie L MacMillen
- Divisions of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA
| | - Manchula Navaratnam
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital Stanford and Stanford University School of Medicine, Palo Alto, CA
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Delamarre L, Srairi M, Bouvet L, Conil JM, Fourcade O, Minville V. Anaesthesiologists' clinical judgment accuracy regarding preoperative full stomach: Diagnostic study in urgent surgical adult patients. Anaesth Crit Care Pain Med 2021; 40:100836. [PMID: 33753294 DOI: 10.1016/j.accpm.2021.100836] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND In urgent situations, preoperative full stomach assessment mostly relies on clinical judgment. Our primary objective was to assess the diagnostic performance of clinical judgment for the preoperative assessment of full stomach in urgent patients compared to gastric point-of-care ultrasound (PoCUS). Our secondary objective was to identify risk factors associated with PoCUS full stomach in urgent patients. METHODS We led a prospective observational study at our Hospital, between January and July 2016. Adult patients admitted for urgent surgery were eligible. Patients with altered gastric sonoanatomy, interventions reducing stomach content, impossible lateral decubitus were excluded. Clinical judgment and risk factors of full stomach were collected before gastric PoCUS measurements. Ultrasonographic full stomach was defined by solid contents or liquid volume ≥ 1.5 ml kg-1. Diagnostic performance was assessed through sensitivity, specificity, accuracy, positive and negative predictive value. RESULTS The prevalence of clinical and PoCUS full stomach in 196 included patients was 29% and 27%, respectively. Positive and negative predictive values were 42% (95% CI: 32.3-52.6%) and 79% (95% CI: 74.9-83.4%), respectively. Patients with PoCUS full stomach were clinically misdiagnosed in 55% of cases. PoCUS full stomach was associated with abdominal or gynaecological-obstetrical surgery (OR 3.6, 95% CI: 1.5-8.8, P < 0.01) but not with fasting durations. Positive solid intake after illness onset with respect to 6-h solid fasting rule was associated with PoCUS low-risk gastric content (OR 0.4, 95% CI: 0.2-0.9, P = 0.03). CONCLUSIONS Clinical judgment showed poor-to-moderate performance in urgent surgical patients for the diagnosis of full stomach. Gastric PoCUS should be used to assess risk of full stomach in this population.
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Affiliation(s)
- Louis Delamarre
- Department of Anaesthesiology and Intensive Care, Pierre Paul Riquet Hospital, University Hospital of Toulouse, University Toulouse-3 Paul Sabatier, 31059 Toulouse, France.
| | - Mohamed Srairi
- Department of Anaesthesiology and Intensive Care, Pierre Paul Riquet Hospital, University Hospital of Toulouse, University Toulouse-3 Paul Sabatier, 31059 Toulouse, France
| | - Lionel Bouvet
- Department of Anaesthesiology and Intensive Care, Hospices Civils de Lyon, Groupement Hospitalier Est - Hôpital Femme Mère Enfant, 69500 Bron, France
| | - Jean-Marie Conil
- Department of Anaesthesiology and Intensive Care, Pierre Paul Riquet Hospital, University Hospital of Toulouse, University Toulouse-3 Paul Sabatier, 31059 Toulouse, France
| | - Olivier Fourcade
- Department of Anaesthesiology and Intensive Care, Pierre Paul Riquet Hospital, University Hospital of Toulouse, University Toulouse-3 Paul Sabatier, 31059 Toulouse, France
| | - Vincent Minville
- Department of Anaesthesiology and Intensive Care, Pierre Paul Riquet Hospital, University Hospital of Toulouse, University Toulouse-3 Paul Sabatier, 31059 Toulouse, France
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Valverde A. Fluid Resuscitation for Refractory Hypotension. Front Vet Sci 2021; 8:621696. [PMID: 33778035 PMCID: PMC7987676 DOI: 10.3389/fvets.2021.621696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/01/2021] [Indexed: 12/22/2022] Open
Abstract
Hypotension is a common occurrence, especially in anesthetized patients and in critical patients suffering from hypovolemia due to shock and sepsis. Hypotension can also occur in normovolemic animals, anesthetized or conscious, under conditions of vasodilation or decreased cardiac function. The main consequence of hypotension is decreased organ perfusion and tissue injury/dysfunction. In the human literature there is no consensus on what is the threshold value for hypotension, and ranges from < 80 to < 100 mmHg for systolic blood pressure and from < 50 to < 70 mmHg for mean arterial blood pressure have been referenced for intraoperative hypotension. In veterinary medicine, similar values are referenced, despite marked differences in normal arterial blood pressure between species and with respect to humans. Therapeutic intervention involves fluid therapy to normalize volemia and use of sympathomimetics to enhance cardiac function and regulate peripheral vascular resistance. Despite these therapeutic measures, there is a subset of patients that are seemingly refractory and exhibit persistent hypotension. This review covers the physiological aspects that govern arterial blood pressure control and blood flow to tissues/organs, the pathophysiological mechanisms involved in hypotension and refractory hypotension, and therapeutic considerations and expectations that include proper interpretation of cardiovascular parameters, fluid recommendations and therapy rates, use of sympathomimetics and vasopressors, and newer approaches derived from the human literature.
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Affiliation(s)
- Alexander Valverde
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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Blaise Pascal FN, Malisawa A, Barratt-Due A, Namboya F, Pollach G. General anaesthesia related mortality in a limited resource settings region: a retrospective study in two teaching hospitals of Butembo. BMC Anesthesiol 2021; 21:60. [PMID: 33622245 PMCID: PMC7901086 DOI: 10.1186/s12871-021-01280-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/15/2021] [Indexed: 12/05/2022] Open
Abstract
Background General anaesthesia (GA) in developing countries is still a high-risk practice, especially in Africa, accompanied with high morbidity and mortality. No study has yet been conducted in Butembo in the Democratic Republic of the Congo to determine the mortality related to GA practice. The main objective of this study was to assess mortality related to GA in Butembo. Methods This was a retrospective descriptive and analytic study of patients who underwent surgery under GA in the 2 main teaching hospitals of Butembo from January 2011 to December 2015. Data were collected from patients files, anaesthesia registries and were analysed with SPSS 26. Results From a total of 921 patients, 539 (58.5%) were male and 382 (41.5%) female patients. A total of 83 (9.0%) patients died representing an overall perioperative mortality rate of 90 per 1000. Out of the 83 deaths, 38 occurred within 24 h representing GA related mortality of 41 per 1000. There was a global drop in mortality from 2011 to 2015. The risk factors of death were: being a neonate or a senior adult, emergency operation, ASA physical status > 2 and a single deranged vital sign preoperatively, presenting any complication during GA, anaesthesia duration > 120 minutes as well as visceral surgeries/laparotomies. Ketamine was the most employed anaesthetic. Conclusion GA related mortality is very high in Butembo. Improved GA services and outcomes can be obtained by training more anaesthesia providers, proper patients monitoring, improved infrastructure, better equipment and drugs procurement and considering regional anaesthesia whenever possible.
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Affiliation(s)
- Furaha Nzanzu Blaise Pascal
- Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi. .,Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo.
| | - Agnes Malisawa
- Matanda Hospital of Butembo, Butembo, Democratic Republic of the Congo
| | - Andreas Barratt-Due
- Division of Emergencies and Critical Care, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Felix Namboya
- Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gregor Pollach
- Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi
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Aiudi CM, Oliver JJ, Chowatia PA, Priya A, Mueller AL, Dalia AA. Perioperative Emergencies: Who, What, When, Where, Why? J Cardiothorac Vasc Anesth 2021; 35:3248-3254. [PMID: 33663977 DOI: 10.1053/j.jvca.2021.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/25/2021] [Accepted: 02/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE(S) Throughout the last several decades, the perioperative mortality rate from anesthesia care has declined, shifting focus to perioperative emergencies. Data on these emergencies, often referred to as "Anesthesia STAT" calls (STATs), are lacking at adult hospitals. The goal of this study was to determine the etiology of STATs at a major academic medical center and to determine surgical cases and patient comorbid conditions that increase the risk for STATs. DESIGN This was a retrospective observational study. SETTING This study took place at a large academic medical center. PARTICIPANTS Patients who underwent anesthesia care were included in this study. INTERVENTIONS No interventions were performed during this study. MEASUREMENTS AND MAIN RESULTS Data collected included the etiologies of STATs, patient demographic information, patient comorbid conditions, and surgeries during which STATs occurred. Between February 1, 2019, and January 31, 2020, 92 STATs occurred during 58,547 anesthetic cases, with an incidence rate of 0.16%. The most common etiology for a STAT was cardiac arrest, followed by respiratory compromise. Surgical services associated with a significant increase of STATs included general, thoracic, oral/maxillofacial, and vascular surgery. Comorbid conditions that significantly increased the risk of STATs included hypertension, coronary artery disease, congestive heart failure, obstructive sleep apnea, diabetes, and chronic kidney disease. CONCLUSIONS Cardiac arrest is the most common etiology of STATs. Specific surgical services and comorbid conditions are associated with an increased risk of STATs.
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Affiliation(s)
- Christopher M Aiudi
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Jevon J Oliver
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | | | - Anusha Priya
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ariel L Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Potvin J, Etchebarne I, Soubiron L, Biais M, Roullet S, Nouette-Gaulain K. Effects of capnometry monitoring during recovery in the post-anaesthesia care unit: a randomized controlled trial in adults (CAPNOSSPI). J Clin Monit Comput 2021; 36:379-385. [PMID: 33550546 DOI: 10.1007/s10877-021-00661-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/17/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE Continuous capnography should be used on patients admitted to post-anaesthesia care units (PACUs) with endotracheal tubes, but this monitoring is not always performed. Optimized ventilation in the PACU could be part of the global standards of practice to maintain the benefits of perioperative ventilation. The main objective was to study the rate of patients with alveolar hypoventilation before tracheal extubation or Laryngeal Mask Airway (LMA) removal upon the measurement of continuous capnography. METHODS In this prospective, parallel-group, randomized controlled study, we enrolled adult patients admitted to the PACU after general anaesthesia with an endotracheal tube or LMA in place. Patients were randomly assigned to two groups: in the Capno + group, nurses managed the patients with access to the capnometer and end-tidal carbon dioxide pressure (PETCO2) measurements; in the Capno- group, nurses monitored the patients without seeing PETCO2 measurements. The primary outcome was the percentage of patients with PETCO2 measurements above 45 mm Hg during the minute before extubation. Secondary endpoints included the delay in recovering spontaneous breathing, rate of hypoxemia, delay before extubation, and length of stay in the PACU. RESULTS Forty-eight patients were randomized into the two groups. The percentage of patients with PETCO2 > 45 mm Hg the minute before extubation was significantly decreased in the Capno + group (83.3% versus 54,1% in the Capno- and Capno + groups respectively, p = 0.029). There were no significant differences concerning secondary endpoints. CONCLUSIONS The use of PETCO2 monitoring improves patient safety by decreasing the incidence of CO2 retention during recovery from general anaesthesia. This study suggests that this monitoring should be integrated in the PACU. The risk of hypoxemia can also be prevented through the early recognition of apnoea.Clinical Trial registry: clinicaltrial.gov. identifier: NCT03370081.
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Affiliation(s)
- Julien Potvin
- CHU Bordeaux, Service d'Anesthésie-Réanimation, Hôpital Pellegrin, Place Amélie Raba-Léon, 33000, Bordeaux, France.
| | - Isabelle Etchebarne
- CHU Bordeaux, Service d'Anesthésie-Réanimation, Hôpital Pellegrin, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Laurent Soubiron
- CHU Bordeaux, Service d'Anesthésie-Réanimation, Hôpital Pellegrin, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Matthieu Biais
- CHU Bordeaux, Service d'Anesthésie-Réanimation, Hôpital Pellegrin, Place Amélie Raba-Léon, 33000, Bordeaux, France.,Biology of Cardiovascular Diseases, University Bordeaux, INSERM U1034, 33600, Pessac, France
| | - Stéphanie Roullet
- CHU Bordeaux, Service d'Anesthésie-Réanimation, Hôpital Pellegrin, Place Amélie Raba-Léon, 33000, Bordeaux, France.,Laboratoire de Maladies Rares: Génétique Et Métabolisme (MRGM), University Bordeaux, INSERM U12-11, 176 Rue Léo Saignat, F-33000, Bordeaux, France
| | - Karine Nouette-Gaulain
- CHU Bordeaux, Service d'Anesthésie-Réanimation, Hôpital Pellegrin, Place Amélie Raba-Léon, 33000, Bordeaux, France.,Laboratoire de Maladies Rares: Génétique Et Métabolisme (MRGM), University Bordeaux, INSERM U12-11, 176 Rue Léo Saignat, F-33000, Bordeaux, France
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Rozier R, Paul R, Madji Hounoum B, Villa E, Mhaidly R, Chiche J, Verhoeyen E, Marchetti S, Vandenberghe A, Raucoules M, Carles M, Ricci JE. Pharmacological preconditioning protects from ischemia/reperfusion-induced apoptosis by modulating Bcl-xL expression through a ROS-dependent mechanism. FEBS J 2021; 288:3547-3569. [PMID: 33340237 DOI: 10.1111/febs.15675] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 12/02/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022]
Abstract
Myocardial ischemia/reperfusion (I/R) injury is a frequent perioperative threat, with numerous strategies developed to limit and/or prevent it. One interesting axis of research is the anesthetic preconditioning (APc) agent's hypothesis (such as sevoflurane, SEV). However, APc's mode of action is still poorly understood and volatile anesthetics used as preconditioning agents are often not well suited in clinical practice. Here, in vitro using H9C2 cells lines (in myeloblast state or differentiated toward cardiomyocytes) and in vivo in mice, we identified that SEV-induced APc is mediated by a mild induction of reactive oxygen species (ROS) that activates Akt and induces the expression of the anti-apoptotic protein B-cell lymphoma-extra large (Bcl-xL), therefore protecting cardiomyocytes from I/R-induced death. Furthermore, we extended these results to human cardiomyocytes (derived from induced pluripotent stem - IPS - cells). Importantly, we demonstrated that this protective signaling pathway induced by SEV could be stimulated using the antidiabetic agent metformin (MET), suggesting the preconditioning properties of MET. Altogether, our study identified a signaling pathway allowing APc of cardiac injuries as well as a rational for the use of MET as a pharmacological preconditioning agent to prevent I/R injuries.
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Affiliation(s)
- Romain Rozier
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France
| | - Rachel Paul
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France
| | - Blandine Madji Hounoum
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France
| | - Elodie Villa
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France
| | - Rana Mhaidly
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France
| | - Johanna Chiche
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France
| | - Els Verhoeyen
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France
| | - Sandrine Marchetti
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France
| | - Ashaina Vandenberghe
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France
| | - Marc Raucoules
- Anesthésie Réanimation, Centre Hospitalier Universitaire, Nice, France
| | - Michel Carles
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France.,Anesthésie Réanimation, Centre Hospitalier Universitaire, Nice, France.,Réanimation, Faculté des Antilles, Centre Hospitalier Universitaire, Guadeloupe, France
| | - Jean-Ehrland Ricci
- INSERM, C3M, Université Côte d'Azur, Nice, France.,Equipe labellisée Ligue Contre le Cancer, Nice, France
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Lee SH, Park J, Lee JH, Min JJ, Hong KY, Cho H, Carriere K, Ahn J. Comparison of pre- and postoperative myocardial injuries on mortality after non-cardiac surgery: a retrospective analysis using an inverse probability weighting adjustment. Sci Rep 2020; 10:21050. [PMID: 33273559 PMCID: PMC7713127 DOI: 10.1038/s41598-020-78023-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 11/11/2020] [Indexed: 11/30/2022] Open
Abstract
Although both pre- and postoperative myocardial injuries are strongly associated with an increased postoperative mortality, no study has directly compared the effects of pre- and postoperative myocardial injuries on 30-day mortality after non-cardiac surgery. Therefore, we evaluated and compared the effects of pre- and postoperative myocardial injury on 30-day mortality after non-cardiac surgery. From January 2010 to December 2016, patients undergoing non-cardiac surgery were stratified into either the normal (n = 3182), preoperative myocardial injury (n = 694), or postoperative myocardial injury (n = 756) groups according to the peak cardiac troponin value. Myocardial injury was defined as a sole elevation of cardiac troponin value above the 99th percentile upper reference limit without ischemic symptom using the 4th universal definition of myocardial infarction. Patients in the preoperative myocardial injury group were further divided into the attenuated (n = 177) or persistent myocardial injury group (n = 517) according to the normalization of cardiac troponin level in postoperative period. As the primary outcome, postoperative 30-day mortalities were compared among the groups using the weighted Cox proportional-hazards regression models with the inverse probability weighting. Compared with the normal group, postoperative 30-day mortality was increased significantly both in the pre- and postoperative myocardial injury groups (1.4% vs. 10.7%; hazard ratio [HR] 3.12; 95% confidence interval [CI] 1.62-6.01; p = 0.001 and 1.4% vs. 7.4%; HR 4.49; 95% CI 2.34-8.60; p < 0.001, respectively), however, there was no difference between the pre- and postoperative myocardial injury groups (HR, 1.44; 95% CI 0.79-2.64; p = 0.45). In addition, the attenuated myocardial injury group showed a significantly lower postoperative 30-day mortality than the persistent myocardial injury group (5.6% vs. 12.4%; HR 2.23; 95% CI 1.17-4.44; p = 0.02). In patients undergoing non-cardiac surgery, preoperative myocardial injury also increased postoperative 30-day mortality to a similar degree of postoperative myocardial injury. Further studies on the importance of preoperative myocardial injury are needed.Clinical trial number and registry URL: KCT0004348 ( www.cris.nih.go.kr ).
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Affiliation(s)
- Seung-Hwa Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.
| | - Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Kwan Young Hong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Hyojin Cho
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Keumhee Carriere
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, Canada
- Statistics and Data Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joonghyun Ahn
- Statistics and Data Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Dony P, Seidel L, Pirson M, Haller G. Common clinical thresholds of intraoperative hypotension and 30-day mortality following surgery: A retrospective cohort study. Acta Anaesthesiol Scand 2020; 64:1388-1396. [PMID: 32659863 DOI: 10.1111/aas.13670] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 06/18/2020] [Accepted: 06/28/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND A wide range of thresholds define intraoperative hypotension and can be used to guide intraoperative blood pressure management. Many clinicians use the systolic blood pressure (SBP) <80 mmHg, the mean arterial pressure (MAP) <60 mmHg and the SBP percent drop from baseline (ΔSBP) >20% as alarming limits that should not be exceeded. Whether these common thresholds are valid limits that can inform clinicians on a possible increased risk of post-operative complications, particularly 30-day mortality, is currently unclear. METHODS We performed a retrospective registry-based cohort study between January 2015 and July 2016 using departmental hospital databases and the National Death Registry. Uni- and multivariate analyses were performed to assess the association between each of these three thresholds and 30-day post-operative mortality. Six specific markers of hypotension were used. RESULTS Of 11 304 patients, 86 (0.76%) died within 30 days following surgery. All intraoperative hypotension markers for SBP < 80 mmHg and MAP < 60 mmHg were significantly associated with 30-day mortality (P < .005). Markers of ΔSBP > 20% were not significant. After adjustment for age, gender, American Society of Anesthesiologists (ASA) score, emergency status and risk related to the type of surgery, both SBP < 80 mmHg and MAP < 60 mmHg (the per cent area under the threshold marker) showed the strongest associations with 30-day mortality, with odds ratios (ORs) of 3.02 (95% confidence interval (CI) 1.81-5.07) and 3.77 (95% CI 2.25-6.31) respectively. CONCLUSIONS Commonly accepted thresholds of intraoperative hypotension, such as an SBP of 80 mmHg and an MAP of 60 mmHg, are valid alarming limits that are significantly and independently associated with 30-day mortality.
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Affiliation(s)
- Philippe Dony
- Health Services and Economics Research Unit: School of Public Health Free University of Brussels Brussels Belgium
| | - Laurence Seidel
- Department of Medico‐economic Information and Biostatistics University Hospital of Liège Liège Belgium
| | - Magali Pirson
- Health Services and Economics Research Unit: School of Public Health Free University of Brussels Brussels Belgium
| | - Guy Haller
- Department of Anesthesia Intensive Care & Pharmacology Geneva University Hospital Genève Switzerland
- Department of Epidemiology & Preventive Medicine Monash University Clayton Vic. Australia
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Abstract
PURPOSE OF REVIEW The last decades, anesthesia has become safer, partly due to developments in monitoring. Advanced monitoring of children under anesthesia is challenging, due to lack of evidence, validity and size constraints. Most measured parameters are proxies for end organ function, in which an anesthesiologist is actually interested. Ideally, monitoring should be continuous, noninvasive and accurate. This present review summarizes the current literature on noninvasive monitoring in noncardiac pediatric anesthesia. RECENT FINDINGS For cardiac output (CO) monitoring, bolus thermodilution is still considered the gold standard. New noninvasive techniques based on bioimpedance and pulse contour analysis are promising, but require more refining in accuracy of CO values in children. Near-infrared spectroscopy is most commonly used in cardiac surgery despite there being no consensus on safety margins. Its place in noncardiac anesthesia has yet to be determined. Transcutaneous measurements of blood gases are used mainly in the neonatal intensive care unit, and is finding its way to the pediatric operation theatre. Especially CO2 measurements are accurate and useful. SUMMARY New techniques are available to assess a child's hemodynamic and respiratory status while under anesthesia. These new monitors can be used as complementary tools together with standard monitoring in children, to further improve perioperative safety.
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50
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Ruetzler K, Khanna AK, Sessler DI. Myocardial Injury After Noncardiac Surgery: Preoperative, Intraoperative, and Postoperative Aspects, Implications, and Directions. Anesth Analg 2020; 131:173-186. [PMID: 31880630 DOI: 10.1213/ane.0000000000004567] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Myocardial injury after noncardiac surgery (MINS) differs from myocardial infarction in being defined by troponin elevation apparently from cardiac ischemia with or without signs and symptoms. Such myocardial injury is common, silent, and strongly associated with mortality. MINS is usually asymptomatic and only detected by routine troponin monitoring. There is currently no known safe and effective prophylaxis for perioperative myocardial injury. However, appropriate preoperative screening may help guide proactive postoperative preventative actions. Intraoperative hypotension is associated with myocardial injury, acute kidney injury, and death. Hypotension is common and largely undetected in the postoperative general care floor setting, and independently associated with myocardial injury and mortality. Critical care patients are especially sensitive to hypotension, and the risk appears to be present at blood pressures previously regarded as normal. Tachycardia appears to be less important. Available information suggests that clinicians would be prudent to avoid perioperative hypotension.
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Affiliation(s)
- Kurt Ruetzler
- From the Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.,Outcomes Research Consortium, Cleveland, Ohio
| | - Ashish K Khanna
- Outcomes Research Consortium, Cleveland, Ohio.,Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, Ohio.,Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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