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Kornvig S, Kehlet H, Jørgensen CC, Fink-Jensen A, Videbech P, Lindberg-Larsen M, Gromov K, Rasmussen MB, Bieder MJ, Varnum C. Psychopharmacological treatment in patients planned for hip or knee replacement. Basic Clin Pharmacol Toxicol 2024; 135:52-59. [PMID: 38726877 DOI: 10.1111/bcpt.14017] [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: 02/05/2024] [Revised: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 06/11/2024]
Abstract
Psychopharmacological treatment may be an independent risk factor for increased length of stay and readmission after hip and knee replacement. Thus, temporary perioperative discontinuation may be beneficial. However, little is known regarding the treatments, and not all are feasible to discontinue. Therefore, the aim of this study was to describe the treatments in terms of type, dose, duration, indication and initiating physician to assess the feasibility of temporary perioperative discontinuation. We included 482 patients planned for hip or knee replacement in psychopharmacological treatment for psychiatric disorders from 2021 to 2023 at five orthopaedic departments in Denmark. Most patients were treated with antidepressants (89%); most frequently, either selective serotonin reuptake inhibitors (SSRIs; 48%) or serotonin-norepinephrine reuptake inhibitors (SNRIs; 21%). The majority received monotherapy (70%); most frequently, an SSRI (36%) or an SNRI (12%). Most antidepressants were initiated by general practitioners (71%), and the treatments had lasted for more than a year (87%). The doses of SSRIs/SNRIs were moderate, and the most frequent indication for antidepressants was depression (77%). These results imply that temporary perioperative SSRI/SNRI discontinuation may be feasible in hip and knee replacement patients and support a future randomized controlled trial investigating the potential benefits of temporary discontinuation.
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Affiliation(s)
- Simon Kornvig
- Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
| | - Christoffer Calov Jørgensen
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Hospital of Northern Zealand, Hillerød, Denmark
| | - Anders Fink-Jensen
- Mental Health Center Frederiksberg and Clinical Institute, University of Copenhagen, Copenhagen, Denmark
| | - Poul Videbech
- Mental Health Center Glostrup and Clinical Institute, University of Copenhagen, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital - Svendborg, Svendborg, Denmark
| | - Kirill Gromov
- Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Mathias Bæk Rasmussen
- Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Aalborg University Hospital - Farsø, Aalborg, Denmark
| | - Manuel Josef Bieder
- Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Næstved Hospital, Næstved, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
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Kulikov A, Gruenbaum SE, Quinones-Hinojosa A, Pugnaloni PP, Lubnin A, Bilotta F. Preoperative Risk Assessment Before Elective Craniotomy: Are Aspirin, Arrhythmias, Deep Venous Thromboses, and Hyperglycemia Contraindications to Surgery? World Neurosurg 2024; 186:68-77. [PMID: 38479642 DOI: 10.1016/j.wneu.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/18/2024]
Abstract
OBJECTIVE Perioperative risk assessment and stratification before craniotomy is necessary to identify and optimize modifiable risk factors. Due to the high costs of diagnostic testing and concerns for delaying surgery, some have questioned whether and when surgery delays are warranted and supported by the current body of literature. The objective of this scoping review was to evaluate the available evidence on the prognostic value of preoperative risk assessment before anesthesia for elective craniotomy. METHODS In this scoping review, we reviewed 156 papers that assess preoperative risk assessment before elective craniotomy, of which 27 papers were included in the final analysis. RESULTS There is little high-quality evidence to suggest significant risk reduction when 4 common preexisting abnormalities are present: preoperative chronic aspirin therapy, cardiac arrhythmias, deep vein thrombosis, or hyperglycemia. CONCLUSIONS The risk of delaying craniotomy should ultimately be weighed against the perceived risks associated the patient's comorbid conditions and should be considered on an individualized basis.
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Affiliation(s)
- Alexander Kulikov
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Shaun E Gruenbaum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, Florida.
| | | | - Pier Paolo Pugnaloni
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrey Lubnin
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy
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Kulikov A, Krovko Y, Zagidullin T, Bilotta F. Implementation of perioperative blood glucose monitoring and insulin infusion protocol can decrease postoperative infection rate in diabetic patients undergoing elective craniotomy: An observational study. J Clin Neurosci 2024; 124:137-141. [PMID: 38705025 DOI: 10.1016/j.jocn.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Severe perioperative hyperglycemia (SH) is a proven risk factor for postoperative complications after craniotomy. To reduce this risk, it has been proposed to implement the standardized clinical protocol for scheduled perioperative blood glucose concentration (BGC) monitoring. This would be followed by intravenous (IV) insulin infusion to keep BGC below 180 mg/dl in the perioperative period. The aim of this prospective observational study was to assess the impact of this type of protocol on the postoperative infection rate in patients undergoing elective craniotomy. METHODS A total of 42 patients were prospectively enrolled in the study. Protocol included scheduled BGC monitoring in the perioperative period and rapid-acting insulin IV infusion when intraoperative SH was detected. The diagnosis of infection (wound, pulmonary, blood stream, urinary tract infection or central nervous system infection) was established according to CDC criteria within the first postoperative week. A previously enrolled group of patients with sporadic BGC monitoring and subcutaneous insulin injections for SH management was used as a control group. RESULTS An infectious complication (i.e., pneumonia) was diagnosed only in one patient (2 %) in the prospective group. In comparison with the control group, a decrease in the risk of postoperative infection was statistically significant with OR = 0.08 [0.009 - 0.72] (p = 0.02). Implementation of the perioperative BGC monitoring and the correction protocol prevented both severe hyperglycemia and hypoglycemia with BGC < 70 mg/dl. CONCLUSION Scheduled BGC monitoring and the use of low-dose insulin infusion protocol can decrease the postoperative infection rate in patients undergoing elective craniotomy. Future studies are needed to prove the causality of the implementation of such a protocol with an improved outcome.
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Affiliation(s)
- Alexander Kulikov
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia.
| | - Yulia Krovko
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Timur Zagidullin
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Italy
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Merola R, Vargas M. Economic Indicators, Quantity and Quality of Health Care Resources Affecting Post-surgical Mortality. J Epidemiol Glob Health 2024:10.1007/s44197-024-00249-x. [PMID: 38801492 DOI: 10.1007/s44197-024-00249-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE to identify correlations between quality and quantity of health care resources, national economic indicators, and postoperative in-hospital mortality as reported in the EUSOS study. METHODS Different variables were identified from a series of publicly available database. Postoperative in-hospital mortality was identified as reported by EUSOS study. Spearman non-parametric and Coefficients of non-linear regression were calculated. RESULTS Quality of health care resources was strongly and negatively correlated to postoperative in-hospital mortality. Quantity of health care resources were negatively and moderately correlated to postoperative in-hospital mortality. National economic indicators were moderately and negatively correlated to postoperative in-hospital mortality. General mortality, as reported by WHO, was positively but very moderately correlated with postoperative in-hospital mortality. CONCLUSIONS Postoperative in-hospital mortality is strongly determined by quality of health care instead of quantity of health resources and health expenditures. We suggest that improving the quality of health care system might reduce postoperative in-hospital mortality.
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Affiliation(s)
- Raffaele Merola
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy.
| | - Maria Vargas
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
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Pang Q, Feng Y, Yang Y, Liu H. Preoperative fasting glucose value can predict acute kidney injury in non-cardiac surgical patients without diabetes but not in patients with diabetes. Perioper Med (Lond) 2024; 13:39. [PMID: 38735977 PMCID: PMC11089748 DOI: 10.1186/s13741-024-00398-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/07/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) is a common and costly complication after non-cardiac surgery. Patients with or without diabetes could develop hyperglycemia before surgery, and preoperative hyperglycemia was closely associated with postoperative poor outcomes, but the association between preoperative fasting blood glucose level and postoperative AKI is still unclear. METHODS Data from patients undergoing non-cardiac surgery in Chongqing University Cancer Hospital from January 1, 2017, to May 31, 2023, were collected, preoperative glucose value and perioperative variables were extracted, the primary exposure of interest was preoperative glucose value, and the outcome was postoperative AKI. RESULTS Data from 39,986 patients were included in the final analysis, 741(1.9%) patients developed AKI, 134(5.6%) in the cohort with DM, and 607(1.6%) in the cohort without DM(OR 1.312, 95% CI 1.028-1.675, P = 0.029). A significant non-linear association between preoperative glucose and AKI exists in the cohort without DM after covariable adjustment (P = 0.000), and every 1 mmol/L increment of preoperative glucose level increased OR by 15% (adjusted OR 1.150, 95% CI 1.078-1.227, P = 0.000), the optimal cut-point of preoperative fasting glucose level to predict AKI was 5.39 mmol/L (adjusted OR 1.802, 95%CI 1.513-2.146, P = 0.000). However, in the cohort with DM, the relation between preoperative glucose and postoperative AKI was not significant after adjusting by covariables (P = 0.437). No significance exists between both cohorts in the risk of AKI over the range of preoperative glucose values. CONCLUSION A preoperative fasting glucose value of 5.39 mmol/L can predict postoperative acute kidney injury after non-cardiac surgery in patients without diagnosed diabetes, but it is not related to AKI in patients with the diagnosis.
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Affiliation(s)
- Qianyun Pang
- Department of Anesthesiology, Chongqing University Cancer Hospital, Hanyu Road 181, Shapingba District, Chongqing, 400030, People's Republic of China
| | - Yumei Feng
- Department of Anesthesiology, Chongqing University Cancer Hospital, Hanyu Road 181, Shapingba District, Chongqing, 400030, People's Republic of China
| | - Yajun Yang
- Department of Anesthesiology, Chongqing University Cancer Hospital, Hanyu Road 181, Shapingba District, Chongqing, 400030, People's Republic of China
| | - Hongliang Liu
- Department of Anesthesiology, Chongqing University Cancer Hospital, Hanyu Road 181, Shapingba District, Chongqing, 400030, People's Republic of China.
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Zöllner C. [Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. DIE ANAESTHESIOLOGIE 2024; 73:294-323. [PMID: 38700730 PMCID: PMC11076399 DOI: 10.1007/s00101-024-01408-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.
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Affiliation(s)
- Christian Zöllner
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Martinistr. 52, 20246, Hamburg, Deutschland.
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7
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Krohn JN, Habboub B, Gosch M. [Fragility Fractures: Preoperative assessment and optimisation]. Z Gerontol Geriatr 2024; 57:235-243. [PMID: 38668778 DOI: 10.1007/s00391-024-02299-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/13/2024] [Indexed: 05/09/2024]
Abstract
Fragility fractures are associated with high morbidity and mortality. An interdisciplinary collaboration and an individualized, patient-centered approach are essential to ensure an optimized preoperative period and to improve perioperative safety. Preoperative responsibilities of trauma surgery include in the first step the identification of fragility fractures and the necessity for geriatric involvement. Orthogeriatric co-management (OCM) focuses on the identification of the medical, functional and social needs of the patient. In the preoperative period attention is focussed on acute diseases in need of treatment that have a negative impact on the course of further treatment and the prevention of delirium.
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Affiliation(s)
- Jan-Niklas Krohn
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Prof. Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland.
| | - Basel Habboub
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Prof. Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland
| | - Markus Gosch
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Prof. Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland
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8
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Bello CM, Harnik MA, Luedi MM, Heidegger T. Alternatives to the in-person anaesthetist-led preoperative assessment in adults undergoing low-risk or intermediate-risk surgery. A scoping review: putting an end to 'semper idem'. Eur J Anaesthesiol 2024; 41:391-392. [PMID: 38567680 PMCID: PMC10990006 DOI: 10.1097/eja.0000000000001887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Corina M Bello
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern (CMB, MAH, MML) and Department of Anesthesiology, Spitalregion Rheintal, Werdenberg, Sarganserland, Grabs, Switzerland (TH)
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Kinugasa Y, Ida M, Kawaguchi M. Fried Frailty Phenotype Questionnaire scores and postoperative patient-reported outcomes of patients undergoing major abdominal cancer surgery: A secondary analysis. Geriatr Gerontol Int 2024; 24:464-469. [PMID: 38597119 DOI: 10.1111/ggi.14872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 02/22/2024] [Accepted: 03/29/2024] [Indexed: 04/11/2024]
Abstract
AIM This study aimed to evaluate the effects of Fried Frailty Phenotype Questionnaire (FFPQ) scores on patient-reported postoperative outcomes. METHODS This secondary analysis of a prospective observational study included 230 inpatients aged ≥65 years undergoing elective abdominal cancer surgery. The primary outcome was the Quality of Recovery-15 score on postoperative days 2, 4 and 7. The secondary outcomes included disability-free survival, defined as a 12-item World Health Organization Disability Assessment Schedule 2.0 score of <16% at 3 months. The associations of the FFPQ scores, ranging from 0 (robust) to 5 (frailty), with the primary and secondary outcomes were assessed using multiple analysis. RESULTS After confirming the linearity of the FFPQ score for the outcomes, multiple regression analysis adjusted for prominent factors showed that the FFPQ score was a significant factor influencing the decrease in the Quality of Recovery-15 score on postoperative day 2 (β = -2.67, 95% confidence interval -5.20, -0.15), 4 (β = -3.54, 95% confidence interval -5.77, -1.30) and 7 (β = -3.70, 95% confidence interval -5.75, -1.65). The adjusted odds ratio of the FFPQ score for disability-free survival postoperatively was 0.66 (95% confidence interval 0.49-0.90). CONCLUSIONS Patients with higher FFPQ scores before elective major abdominal cancer surgery were likely to have lower postoperative Quality of Recovery-15 scores and poor disability-free survival. Geriatr Gerontol Int 2024; 24: 464-469.
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Affiliation(s)
- Yuki Kinugasa
- Department of Anesthesiology, Nara Medical University, Kashihara, Japan
| | - Mitsuru Ida
- Department of Anesthesiology, Nara Medical University, Kashihara, Japan
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Büyükkasap AE, Yazıcı G. Knowledge levels of doctors and nurses working in surgical clinics about nutrients and food supplements, a multicentre descriptive study. BMC Nurs 2024; 23:277. [PMID: 38664695 PMCID: PMC11044485 DOI: 10.1186/s12912-024-01968-z] [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: 02/19/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024] Open
Abstract
PURPOSE The use of nutrients and food supplements is increasing worldwide. Nutrients and food supplements frequently used in the surgical period may cause complications and side effects. This study was conducted to determine the level of knowledge about sixty-one nutrients and food supplements among doctors and nurses working in surgical clinics. DESIGN A multicentre descriptive, quantitative, cross-sectional study. METHODS The study was conducted between 15 February and 31 May 2022 with a total of 410 participants, including 143 doctors and 267 nurses, working in the surgical clinics of 8 hospitals, including public, university and private hospitals, within the borders of one province in Turkey. Data were collected face-to-face using a questionnaire developed by the researchers, which included descriptive characteristics of the doctors and nurses and questions about sixty-one nutrients and food supplements. RESULTS The median overall success score of the doctors and nurses participating in the study regarding the use of nutrients and food supplements was 3.20 out of 100 points, the median success score of complications and side effects of nutrients and food supplements in the surgical period was 7.06 out of 33 points, the median success score for discontinuation of nutrients and food supplements prior to surgery was 0.21 out of 16 points, and the median success score for drug interactions of nutrients and food supplements was 1.70 out of 51 points. In addition, it was found that the overall success scores of doctors and nurses regarding nutrients and food supplements increased statistically significantly with increasing age and working years. The total success score of doctors and nurses who received training in nutrients and food supplements was statistically significantly higher than that of doctors and nurses who did not receive training. CONCLUSION In conclusion, it was found that the level of knowledge of nutrients and food supplements among doctors and nurses working in surgical clinics was less than half or even close to zero. Therefore, it is recommended that training on nutrients and food supplements should be included in the undergraduate and postgraduate education of doctors and nurses in order to prevent complications, side effects, drug interactions and patient safety related to the use of nutrients and food supplements in the surgical period.
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Affiliation(s)
| | - Gülay Yazıcı
- Faculty of Health Sciences, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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11
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Cammarota G, De Robertis E, Simonte R. Unexpected intensive care unit admission after surgery: impact on clinical outcome. Curr Opin Anaesthesiol 2024; 37:192-198. [PMID: 38390879 DOI: 10.1097/aco.0000000000001342] [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: 02/24/2024]
Abstract
PURPOSE OF REVIEW This review is focused on providing insights into unplanned admission to the intensive care unit (ICU) after surgery, including its causes, effects on clinical outcome, and potential strategies to mitigate the strain on healthcare systems. RECENT FINDINGS Postoperative unplanned ICU admission results from a combination of several factors including patient's clinical status, the type of surgical procedure, the level of supportive care and clinical monitoring outside the ICU, and the unexpected occurrence of major perioperative and postoperative complications. The actual impact of unplanned admission to ICU after surgery on clinical outcome remains uncertain, given the conflicting results from several observational studies and recent randomized clinical trials. Nonetheless, unplanned ICU admission after surgery results a significant strain on hospital resources. Consequently, this issue should be addressed in hospital policy with the aim of implementing preoperative risk assessment and patient evaluation, effective communication, vigilant supervision, and the promotion of cooperative healthcare. SUMMARY Unplanned ICU admission after surgery is a multifactorial phenomenon that imposes a significant burden on healthcare systems without a clear impact on clinical outcome. Thus, the early identification of patient necessitating ICU interventions is imperative.
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Affiliation(s)
- Gianmaria Cammarota
- Department of Translational Medicine, Università del Piemonte Orientale, Novara
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Rachele Simonte
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
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12
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Rao Y, Wang J, Yang F, Ni X. Safety of Continuing Aspirin Use in Patients With Coronary Heart Disease Who Undergo Thyroid Surgery During the Perioperative Period. EAR, NOSE & THROAT JOURNAL 2024:1455613241230844. [PMID: 38491759 DOI: 10.1177/01455613241230844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024] Open
Abstract
Objective: To investigate the safety of continuing aspirin use in patients with coronary heart disease undergoing thyroid surgery during the perioperative period. Methods: Forty-four patients with coronary heart disease who underwent thyroid surgery in our department from July 2019 to June 2023 were selected as the observation group, and the observation group continued to use aspirin during the perioperative period. Forty-four patients who underwent the same surgery during the same period without coronary heart disease and without anticoagulant or antiplatelet therapy were selected as control group 1. Another 44 patients with coronary heart disease who underwent the same surgery from August 2015 to June 2019 and used low molecular weight heparin bridging during the perioperative period were selected as control group 2. Clinical data from the 3 groups of patients were collected for retrospective analysis. Results: The age and proportion of male patients in the observation group and control group 2 were higher than those in control group 1, and the total hospital stay in control group 2 was longer than in the observation group and control group 1, with statistically significant differences (all P < .05). There were no statistically significant differences in surgical time, intraoperative blood loss, postoperative drainage volume, duration of drainage tube retention, postoperative hospital stay, and perioperative hemoglobin, platelet, and international normalized ratio between the 3 groups of patients (all P > .05). All patients in the 3 groups successfully completed surgery without serious complications or death during the perioperative period. Conclusion: Continuing to use aspirin in patients with coronary heart disease who undergo thyroid surgery during the perioperative period can safely complete surgery without increasing the risk of intraoperative and postoperative bleeding.
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Affiliation(s)
- Yuansheng Rao
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Department of Otolaryngology, Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jianhong Wang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fan Yang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Ni
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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13
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Pires MR, Rodrigues DS, Segura-Grau E. Anaesthetic peripheral nerve blocks for a total knee replacement revision due to infection in a patient with symptomatic chronic coronary syndrome: A case report. J Perioper Pract 2024; 34:75-77. [PMID: 36946239 DOI: 10.1177/17504589231159196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
This report aims to describe the perioperative management of a high-risk cardiovascular patient proposed for urgent total knee replacement revision. We discuss the use of peripheral nerve blocks and its impact on haemodynamic stability and clinical outcomes, including major cardiovascular adverse events and myocardial injury after non-cardiac surgery.
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Affiliation(s)
- Marta R Pires
- Instituto Português de Oncologia de Lisboa Francisco Gentil, EPE, Lisboa, Portugal
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Ntalouka MP, Brotis A, Karagianni MD, Arvaniti C, Mermiri M, Solou M, Stamoulis K, Bareka M, Fountas KN, Arnaoutoglou EM. Perioperative management of antithrombotics in elective intracranial procedures: systematic review, critical appraisal. Acta Neurochir (Wien) 2024; 166:97. [PMID: 38383680 DOI: 10.1007/s00701-024-05990-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 02/23/2024]
Abstract
PURPOSE Perioperative management of patients medicated with antithrombotics requiring elective intracranial procedures is challenging. We ought to (1) identify the clinical practice guidelines (CPGs) and recommendations (CPRs) on perioperative management of antithrombotic agents in elective intracranial surgery and (2) assess their methodological quality and reporting clarity. METHODS The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered (PROSPERO, CRD42023415710). An electronic search was conducted using PubMed, Scopus, and Google Scholar. The search terms used were "adults," "antiplatelets," "anticoagulants," "guidelines," "recommendations," "english language," "cranial surgery," "brain surgery," "risk of bleeding," "risk of coagulation," and "perioperative management" in all possible combinations. The search period extended from 1964 to April 2023 and was limited to literature published in the English language. The eligible studies were evaluated by three blinded raters, by employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. RESULTS A total of 14 sets of guidelines were evaluated. Two guidelines from the European Society of Anaesthesiology and one from the American College of Chest Physicians found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. The interrater agreement was good with a mean Cohens Kappa of 0.70 (range, 46.5-94.4%) in the current analysis. CONCLUSION The perioperative management of antithrombotics in intracranial procedures may be challenging, complex, and demanding. Due to the lack of high quality data, uncertainty remains regarding the optimal practices to balance the risk of thromboembolism against that of bleeding.
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Affiliation(s)
- Maria P Ntalouka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece.
| | - Alexandros Brotis
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria D Karagianni
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Christina Arvaniti
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria Mermiri
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria Solou
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Konstantinos Stamoulis
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Metaxia Bareka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Konstantinos N Fountas
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Eleni M Arnaoutoglou
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
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15
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Rosenbaum HK, Van den Eynde V, Gillman PK. Expert Opinion on Anesthetic Considerations For Patients Receiving a Classic Monoamine Oxidase Inhibitor. Anesth Analg 2024:00000539-990000000-00752. [PMID: 38373141 DOI: 10.1213/ane.0000000000006858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Affiliation(s)
- Harvey K Rosenbaum
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Vincent Van den Eynde
- PsychoTropical Research, Bucasia, Queensland, Australia
- Department of Psychiatry, RadboudUMC, Nijmegen, the Netherlands
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16
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Koning NJ, Lokin JLC, Roovers L, Kallewaard JW, van Harten WH, Kalkman CJ, Preckel B. Introduction of a Post-Anaesthesia Care Unit in a Teaching Hospital Is Associated with a Reduced Length of Hospital Stay in Noncardiac Surgery: A Single-Centre Interrupted Time Series Analysis. J Clin Med 2024; 13:534. [PMID: 38256668 PMCID: PMC10816897 DOI: 10.3390/jcm13020534] [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: 12/18/2023] [Revised: 01/10/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND A post-anaesthesia care unit (PACU) may improve postoperative care compared with intermediate care units (IMCU) due to its dedication to operative care and an individualized duration of postoperative stay. The effects of transition from IMCU to PACU for postoperative care following intermediate to high-risk noncardiac surgery on length of hospital stay, intensive care unit (ICU) utilization, and postoperative complications were investigated. METHODS This single-centre interrupted time series analysis included patients undergoing eleven different noncardiac surgical procedures associated with frequent postoperative admissions to an IMCU or PACU between January 2018 and March 2019 (IMCU episode) and between October 2019 and December 2020 (PACU episode). Primary outcome was hospital length of stay, secondary outcomes included postoperative complications and ICU admissions. RESULTS In total, 3300 patients were included. The hospital length of stay was lower following PACU admission compared to IMCU admission (IMCU 7.2 days [4.2-12.0] vs. PACU 6.0 days [3.6-9.1]; p < 0.001). Segmented regression analysis demonstrated that the introduction of the PACU was associated with a decrease in hospital length of stay (GMR 0.77 [95% CI 0.66-0.91]; p = 0.002). No differences between episodes were detected in the number of postoperative complications or postoperative ICU admissions. CONCLUSIONS The introduction of a PACU for postoperative care of patients undergoing intermediate to high-risk noncardiac surgery was associated with a reduction in the length of stay at the hospital, without increasing postoperative complications.
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Affiliation(s)
- Nick J. Koning
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - Joost L. C. Lokin
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
- Department of Anesthesiology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | - Lian Roovers
- Clinical Research Center, Rijnstate Hospital, 6815 AD Arnhem, The Netherlands (W.H.v.H.)
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centre, 1105 AZ Amsterdam, The Netherlands
| | - Wim H. van Harten
- Clinical Research Center, Rijnstate Hospital, 6815 AD Arnhem, The Netherlands (W.H.v.H.)
- Health Services & Technology Research, University of Twente, 7522 NB Enschede, The Netherlands
| | - Cor J. Kalkman
- Department of Anesthesiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Benedikt Preckel
- Department of Anesthesiology, Amsterdam University Medical Centre, 1105 AZ Amsterdam, The Netherlands
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17
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Richez J, Rothschild PR, Baillard C, Guerrier G. Investigating pupillometry to detect preoperative anxiety: a pilot study. Front Psychol 2024; 14:1296387. [PMID: 38239470 PMCID: PMC10795181 DOI: 10.3389/fpsyg.2023.1296387] [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: 09/19/2023] [Accepted: 12/04/2023] [Indexed: 01/22/2024] Open
Abstract
Guidelines from the European Society of Anesthesia (ESA) insist on the importance of preoperative anxiety management. However, its assessment currently relies on questionnaires that are long to submit and sometimes difficult to interpret. Exploring the balance between sympathetic and parasympathetic neural systems through the use of pupillometry is a promising path to identify anxiety and thus provides an objective and reproducible assessment tool. A single-center prospective observational study was conducted in a population of ambulatory ophthalmological surgery patients. Preoperative anxiety was assessed using the Surgical Fear Questionnaire (SFQ). Measurements were taken using an Algiscan® (IDMed) type pupillometer before, during, and after insertion of the peripheral IV catheter. A statistical correlation test was carried out between the different evaluations of anxiety and the coefficient of variation of the pupillary diameter (VCPD). A total of 71 patients were included in the study between July 2020 and February 2021, with a median SFQ score of 23 [IQR 11-34]. No significant statistical correlation was found between the baseline pupillary diameter, or VCPD, and preoperative anxiety levels. Similarly, the pupillometric variables did not differ significantly when adjusting for the level of anxiety during and after painful stimulation due to canulation. More studies are necessary to explore the potential correlation between preoperative anxiety and pupillometry.
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Affiliation(s)
- Jason Richez
- Department of Anaesthesia and Intensive Care, Hopital Cochin, Assistance Publique-Hopitaux de Paris, Paris, France
| | | | - Christophe Baillard
- Department of Anaesthesia and Intensive Care, Hopital Cochin, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Gilles Guerrier
- Department of Anaesthesia and Intensive Care, Hopital Cochin, Assistance Publique-Hopitaux de Paris, Paris, France
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18
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Kuiper BI, Janssen LMJ, Versteeg KS, Ten Tusscher BL, van der Spoel JI, Lubbers WD, Kazemier G, Loer SA, Schober P, van Halm VP. Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery? BMC Anesthesiol 2024; 24:9. [PMID: 38166642 PMCID: PMC10759340 DOI: 10.1186/s12871-023-02394-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/20/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes. METHODS This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records. MAIN RESULTS A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year. CONCLUSIONS This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.
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Affiliation(s)
- B I Kuiper
- Department of Surgery, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - L M J Janssen
- Department of Anesthesiology, Amsterdam UMC location VUmc, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands.
| | - K S Versteeg
- Department of Internal medicine, section geriatrics, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - B L Ten Tusscher
- Department of Intensive Care Medicine, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - J I van der Spoel
- Department of Intensive Care Medicine, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - W D Lubbers
- Department of Anesthesiology, Amsterdam UMC location VUmc, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
| | - G Kazemier
- Department of Surgery, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S A Loer
- Department of Anesthesiology, Amsterdam UMC location VUmc, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
| | - P Schober
- Department of Anesthesiology, Amsterdam UMC location VUmc, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
| | - V P van Halm
- Department of Cardiology, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
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19
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Guerrier G, Moubarak C, Bernabei F, Baillard C, Rothschild PR. Relationship between heart rate variability and preoperative anxiety assessed by Verbal Analogue Scale and Surgical Fear Questionnaire before cataract surgery. Br J Anaesth 2024; 132:188-189. [PMID: 37879998 DOI: 10.1016/j.bja.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 09/27/2023] [Accepted: 10/01/2023] [Indexed: 10/27/2023] Open
Affiliation(s)
- Gilles Guerrier
- Anaesthetic and Intensive Care Department, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, Centre de Recherche des Cordeliers, INSERM, Paris, France.
| | - Claire Moubarak
- Anaesthetic and Intensive Care Department, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Federico Bernabei
- Department of Ophthalmology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christophe Baillard
- Anaesthetic and Intensive Care Department, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre-Raphaël Rothschild
- Université de Paris, Centre de Recherche des Cordeliers, INSERM, Paris, France; Department of Ophthalmology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
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20
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M'Pembele R, Roth S, Lurati Buse G. [The role of cardiac biomarkers in perioperative risk evaluation of noncardiac surgery patients-A summary of the ESAIC guidelines 2023]. DIE ANAESTHESIOLOGIE 2024; 73:44-50. [PMID: 38063866 PMCID: PMC10791894 DOI: 10.1007/s00101-023-01363-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND The recently published ESAIC guidelines highlight the clinical value of cardiac troponins (cTn) and B‑type natriuretic peptides (BNP) for risk assessment in patients undergoing noncardiac surgery. OBJECTIVE Summary of the ESAIC guideline recommendations. MATERIAL AND METHODS The evidence for the recommendations was extracted from studies that investigated the perioperative role of cTn and BNP as prognostic factors, for risk prediction and for therapeutic guidance. To collate this evidence 12 relevant endpoints as well as risk benefit analyses of systematic screening were considered to issue the strength of the recommendations. RESULTS The body of evidence for these guidelines was based on 115 studies. The evidence varied significantly across the 12 predefined endpoints. Additionally, there was a gradient in evidence for the use of cTn and BNP as prognostic factors, for risk prediction and for therapeutic guidance. The guidelines issue a weak recommendation for the use of preoperative, postoperative and combined measurement of cTn as well as for preoperative BNP measurement to assess the prognosis. For risk prediction a weak recommendation was formulated for combined and postoperative cTn and preoperative BNP measurements. No recommendation could be given for the evidence on biomarkers as data were very limited. CONCLUSION Both cTn and BNP can be used as prognostic factors or to predict the risk for selected endpoints. Therapeutic interventions should not be guided by cardiac biomarker levels.
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Affiliation(s)
- René M'Pembele
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
- CARID (Cardiovascular Research Institute Düsseldorf), Universitätsklinikum Düsseldorf, Heinrich Heine Universität, Düsseldorf, Deutschland.
| | - Sebastian Roth
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland
- CARID (Cardiovascular Research Institute Düsseldorf), Universitätsklinikum Düsseldorf, Heinrich Heine Universität, Düsseldorf, Deutschland
| | - Giovanna Lurati Buse
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland
- CARID (Cardiovascular Research Institute Düsseldorf), Universitätsklinikum Düsseldorf, Heinrich Heine Universität, Düsseldorf, Deutschland
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21
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Schenk A, Kowark A, Berger M, Rossaint R, Schmid M, Coburn M. Pre-Interventional Risk Assessment in The Elderly (PIRATE): Development of a scoring system to predict 30-day mortality using data of the Peri-Interventional Outcome Study in the Elderly. PLoS One 2023; 18:e0294431. [PMID: 38127877 PMCID: PMC10734910 DOI: 10.1371/journal.pone.0294431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 11/01/2023] [Indexed: 12/23/2023] Open
Abstract
Risk assessment before interventions in elderly patients becomes more and more vital due to an increasing number of elderly patients requiring surgery. Existing risk scores are often not tailored to marginalized groups such as patients aged 80 years or older. We aimed to develop an easy-to-use and readily applicable risk assessment tool that implements pre-interventional predictors of 30-day mortality in elderly patients (≥80 years) undergoing interventions under anesthesia. Using Cox regression analysis, we compared different sets of predictors by taking into account their ease of availability and by evaluating predictive accuracy. Coefficient estimates were utilized to set up a scoring system that was internally validated. Model building and evaluation were based on data from the Peri-Interventional Outcome Study in the Elderly (POSE), which was conducted as a European multicenter, observational prospective cohort study. Our risk assessment tool, named PIRATE, contains three predictors assessable at admission (urgency, severity and living conditions). Discriminatory power, as measured by the concordance index, was 0.75. The estimated prediction error, as measured by the Brier score, was 0.036 (covariate-free reference model: 0.043). PIRATE is an easy-to-use risk assessment tool that helps stratifying elderly patients undergoing interventions with anesthesia at increased risk of mortality. PIRATE is readily available and applies to a wide variety of settings. In particular, it covers patients needing elective or emergency surgery and undergoing in-hospital or day-case surgery. Also, it applies to all types of interventions, from minor to major. It may serve as a basis for multidisciplinary and informed shared decision-making.
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Affiliation(s)
- Alina Schenk
- Department of Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, Bonn, Germany
| | - Ana Kowark
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
- Department of Anaesthesiology, Medical Faculty University Hospital RWTH Aachen, Aachen, Germany
| | - Moritz Berger
- Department of Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, Bonn, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, Medical Faculty University Hospital RWTH Aachen, Aachen, Germany
| | - Matthias Schmid
- Department of Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, Bonn, Germany
| | - Mark Coburn
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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22
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Lurati Buse G, Bollen Pinto B, Abelha F, Abbott TEF, Ackland G, Afshari A, De Hert S, Fellahi JL, Giossi L, Kavsak P, Longrois D, M'Pembele R, Nucaro A, Popova E, Puelacher C, Richards T, Roth S, Sheka M, Szczeklik W, van Waes J, Walder B, Chew MS. ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation. Eur J Anaesthesiol 2023; 40:888-927. [PMID: 37265332 DOI: 10.1097/eja.0000000000001865] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. AIMS The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. METHODS The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. RESULTS In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. CONCLUSION The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.
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Affiliation(s)
- Giovanna Lurati Buse
- From the Department of Anaesthesiology, University Hospital Dusseldorf, Dusseldorf, Germany (GLB, RMP, AN, SR), Division of Anaesthesiology, Geneva University Hospitals (HUG), Geneva, Switzerland (BBP, MS, BW), Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, Portugal (FA), Cardiovascular Research and Development Center (UnIC@RISE), Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal (FA), William Harvey Research Institute, Queen Mary University of London, London, UK (TEA, GA), Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK (GA), Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH), Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, 59 boulevard Pinel, 69500 Lyon, France (J-LF), "Patients as Partners" program, Geneva University Hospitals (HUG), Geneva, Switzerland (LG), Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada (PK), Department of Anesthesiology and Intensive Care, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France (DL), Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain (EP), Centro Cochrane Iberoamericano, Barcelona, Spain (EP), Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel-Stadt, Switzerland (CP), Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland (CP), Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia (TR), Institute of Clinical Trials and Methodology and Division of Surgery, University College London, UK (TR), Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (WS), Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (JvW), Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University Hospital, Sweden (MSC)
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23
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Chew MS, Longrois D. Cost-effectiveness of detection of peri-operative myocardial injury: Beat to the punch or jumping the gun? Eur J Anaesthesiol 2023; 40:886-887. [PMID: 37909156 DOI: 10.1097/eja.0000000000001852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Affiliation(s)
- Michelle S Chew
- From the Department of Anaesthesia and Intensive Care, Linköping University Hospital, Linköping, Sweden (MSC); and Department of Anesthesiology and Intensive Care, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France (DL)
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24
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Atar D, Rosseland LA, Jammer I, Aakre KM, Wiseth R, Molund M, Gualandro DM, Omland T. Implementing screening for myocardial injury in non-cardiac surgery: perspectives of an ad-hoc interdisciplinary expert group. SCAND CARDIOVASC J 2023; 57:31-39. [PMID: 37141087 DOI: 10.1080/14017431.2022.2112071] [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: 05/05/2023]
Abstract
Objectives. Perioperative myocardial injury (PMI) is increasingly recognised as an important complication of non-cardiac surgery, with often clinically silent presentation, but detrimental prognosis. Active screening for PMI, involving the detection of dynamic and elevated levels of cardiac troponin, has recently been advocated by an increasing number of guidelines; however, active PMI screening has not been reflected in clinical practice. Design. As consensus on a common screening and management pathway is lacking, we synthesise the current evidence to provide suggestions on the selection of patients for screening, organisation of a screening program, and a potential management pathway, building upon a recently published perioperative screening algorithm. Results. Screening should be performed using high-sensitivity assays both preoperatively and postoperatively (postoperative Days 1 and 2) in patients at high-risk of experiencing perioperative complications. Conclusion. This expert opinion piece by an interdisciplinary group of predominantly Norwegian clinicians aims to assist healthcare professionals planning to implement guideline-recommended PMI screening at a local level in order to improve patient outcomes following non-cardiac surgery.
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Affiliation(s)
- Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Leiv Arne Rosseland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Ib Jammer
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kristin Moberg Aakre
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Rune Wiseth
- Clinic of Cardiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marius Molund
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | - Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Torbjørn Omland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
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Olotu C, Lebherz L, Ascone L, Scherwath A, Kühn S, Härter M, Kiefmann R. Cognitive Deficits in Executive and Language Functions Predict Postoperative Delirium. J Cardiothorac Vasc Anesth 2023; 37:2552-2560. [PMID: 37778949 DOI: 10.1053/j.jvca.2023.08.154] [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: 06/29/2023] [Revised: 08/18/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES Postoperative delirium (POD) remains the most common complication in older adults, with cognitive impairment being the main risk factor. Patients with mild cognitive impairment, in particular, have much to lose from delirium; despite this, their cognitive impairment might be clinically overlooked. Understanding which cognitive domains are particularly predictive in this regard may improve the sensitivity of preoperative testing and allow for a more targeted application of resource-intensive measures to prevent delirium in the perioperative period. The authors conducted this study with the aim of identifying the most indicative cognitive domains. DESIGN A secondary analysis of a randomized controlled trial. SETTING At a single center, the University Medical Centre Hamburg in Hamburg, Germany. PARTICIPANTS Patients ≥60 years without major neurocognitive disorders (dementia, Mini-Mental State Examination score ≤23) scheduled for cardiovascular surgery. MEASUREMENTS AND MAIN RESULTS Preoperative neuropsychologic testing and delirium screening were performed twice daily until postoperative day 5. A multiple logistic regression model was applied to determine the predictive ability of test performances for the development of delirium. RESULTS A total of 541 patients were included in the analysis; the delirium rate was 15.6%. After controlling for confounders, only low performance within the Trail Making Test B/A (odds ratio [OR] = 1.32; 95% CI: 1.05-1.66) and letter fluency (OR = 0.66; 95% CI: 0.45-0.96) predicted a particularly high risk for delirium development. The discriminative ability of the final multiple logistic regression model to predict POD had an area under the curve of 0.786. CONCLUSIONS Impairment in the cognitive domains of executive function and language skills associated with memory, inhibition, and access speed seem to be particularly associated with the development of delirium after surgery in adults ≥65 years of age without apparent preoperative neurocognitive impairment.
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Affiliation(s)
- Cynthia Olotu
- Department of Anaesthesiology, University Medical Center Hamburg, Hamburg, Germany.
| | - Lisa Lebherz
- Institute of Medical Psychology, University Medical Center Hamburg, Hamburg, Germany
| | - Leonie Ascone
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg, Hamburg, Germany
| | - Angela Scherwath
- Institute of Medical Psychology, University Medical Center Hamburg, Hamburg, Germany; Department of Stem Cell Transplantation, University Medical Center Hamburg, Hamburg, Germany
| | - Simone Kühn
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg, Hamburg, Germany
| | - Martin Härter
- Institute of Medical Psychology, University Medical Center Hamburg, Hamburg, Germany
| | - Rainer Kiefmann
- Department of Anaesthesiology, University Medical Center Hamburg, Hamburg, Germany; Anesthesia Department, Rotkreuzklinikum Munich, Munich, Germany
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Lu W, Liu C, He J, Wang R, Gao D, Cheng R. Surgical and medical co-management optimizes surgical outcomes in older patients with chronic diseases undergoing robot-assisted laparoscopic radical prostatectomy. Aging Male 2023; 26:2159368. [PMID: 36974926 DOI: 10.1080/13685538.2022.2159368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION While robotic-assisted laparoscopic radical prostatectomy (RRP) is a standard mode for localized prostate cancer (PC), the risk of complications in older patients with chronic diseases and complex medical conditions can be a deterrent to surgery. Surgical and medical co-management (SMC) is a new strategy to improve patients' healthcare outcomes in surgical settings. METHODS We reviewed the clinical data of older patients with chronic diseases who were cared for with SMC undergoing RRP in our hospital in the past 3 years and compared them with the clinical data from the general urology ward. Preoperative conditions and related indicators of recovery, and incidence of postoperative complications with the Clavien Grade System were compared between these two groups. RESULTS The indicators of recovery were significantly better, and the incidence rates of complications were significantly reduced in the SMC group at grades I-IV (p < 0.05), as compared to the general urology ward group. CONCLUSIONS The provision of care by SMC for older patients focused on early identification, comorbidity management, preoperative optimization, and collaborative management would significantly improve surgical outcomes. The SMC strategy is worthy of further clinical promotion in RRP treatment in older men with chronic diseases and complex medical conditions.
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Affiliation(s)
- Wenning Lu
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Chaoyang Liu
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Jing He
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Rong Wang
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Dewei Gao
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Rui Cheng
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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Foex P, Afshari A, Kranke P, Romero CS. A new era for troponins in clinical practice guidelines. Eur J Anaesthesiol 2023; 40:879-883. [PMID: 37909154 DOI: 10.1097/eja.0000000000001909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Affiliation(s)
- Pierre Foex
- From the Nuffield Division of Anaesthetics, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, UK (PF), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AA), Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine. University Hospital Würzburg, Würzburg, Germany (PK), Department of Anaesthesia, Intensive Care and Pain Medicine. General University Hospital. Universidad Europea de Valencia, Valencia, Spain (CSR)
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Hardt K, Wappler F. Anesthesia for Morbidly Obese Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:779-785. [PMID: 37874129 PMCID: PMC10762842 DOI: 10.3238/arztebl.m2023.0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 09/27/2023] [Accepted: 09/27/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND The prevalence of morbid obesity (BMI >35 kg/m2) has risen steadily in recent decades. With the corresponding rise in the number of bariatric operations, anesthesiologists deal with this patient group more commonly than before, particularly in specialized centers. METHODS This review is based on publications retrieved by a selective search in PubMed, including current guidelines and recommendations issued by specialist societies, as well as expert opinion. RESULTS In the anesthesiological care of morbidly obese patients, a preoperative assessment and risk stratification are just as important as the thoughtful selection of the anesthesia technique, the drugs used and their dosage, and perioperative management. A thorough understanding of the pathophysiological changes and comorbidities of morbid obesity and the associated risks is essential. The risk of pulmonary complications such as respiratory failure, hypoxia, and apnea is markedly higher in morbidly obese patients, especially those with obstructive sleep apnea. Short-acting, less lipophilic anesthetic drugs are particularly useful, as is multimodal pain therapy for the avoidance of high opiate doses. The indication for intensified postoperative monitoring depends on the patient's preexisting illnesses, the type of anesthesia, and the type of surgical procedure. Regional anesthetic techniques should be used if possible. CONCLUSION The perioperative care of morbidly obese patients presents special challenges. The anesthesiologist must be aware of potential comorbidities, specific risks, and pathophysiological changes in order to provide adequate care to this patient group.
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Affiliation(s)
- Katharina Hardt
- University Hospital of the Witten/Herdecke University – Cologne, Department of Anesthesiology and Operative Intensive Care Medicine, Cologne-Merheim Hospital
| | - Frank Wappler
- University Hospital of the Witten/Herdecke University – Cologne, Department of Anesthesiology and Operative Intensive Care Medicine, Cologne-Merheim Hospital
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29
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Yang L, Shi S, Li J, Fang Z, Guo J, Kang W, Shi J, Yuan S, Yan F, Zhou C. Postoperative elevated cardiac troponin levels predict all-cause mortality and major adverse cardiovascular events following noncardiac surgery: A dose-response meta-analysis of prospective studies. J Clin Anesth 2023; 90:111229. [PMID: 37573706 DOI: 10.1016/j.jclinane.2023.111229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
STUDY OBJECTIVE To perform a dose-response meta-analysis for the association between postoperative myocardial injury (PMI) in noncardiac surgery and the risk of all-cause mortality or major adverse cardiovascular event (MACE). DESIGN Dose-response meta-analysis of prospective studies with weighted (WL) or generalized (GL) linear and restricted cubic spline (RCS) regression. SETTING Teaching hospitals. PATIENTS Adult patients undergoing noncardiac surgery. INTERVENTIONS No. MEASUREMENTS The primary outcome was all-cause mortality. The secondary outcome was MACE. MAIN RESULTS 29 studies (53,518 patients) were included. The overall incidence of PMI was 26.0% (95% CI 21.0% to 32.0%). Compared to those without PMI, patients with PMI had an increased risk of all-cause mortality at short- (<12 months) (cardiac troponin[cTn]I: unadj OR 1.71,95%CI 1.22 to 2.41, P < 0.001; cTnT: unadj OR 2.33,95%CI 2.07 to 2.63, P < 0.001), and long-term (≥ 12 months) (cTnI: unadj OR 1.80, 95%CI 1.63 to 1.99; cTnT: unadj OR 1.47,95%CI 1.33 to 1.62) (All P < 0.001) follow-up. For MACE, the group with elevated values was associated with an increased risk (cTnI: unadj OR 1.98, 95% CI 1.13 to 3.47, P = 0.018; cTnT: unadj OR 2.29, 95% CI 1.88 to 2.79, P < 0.001). Dose-response analysis showed positive associations between PMI (per 1× upper reference limit[URL] increment) and all-cause mortality both at short- (unadj OR) (WL, OR 1.09, 95% CI 1.09 to 1.10; GL, OR 1.06, 95% CI 1.06 to 1.07; RCS in the range of 1-2× URL, OR = 2.43, 95%CI 2.25 to 2.62) and long-term follow-up (unadj HR) (WL, OR 1.16, 95% CI 1.14 to 1.17; GL, OR 1.15, 95% CI 1.13 to 1.16; RCS in the range of 1-2.75× URL, OR = 1.23, 95%CI 1.13 to 1.33), and MACE at longest follow-up (unadj OR) (WL: OR 1.53, 95% CI 1.49 to 1.57; GL: OR 1.46, 95% CI 1.42 to 1.50; RCS in the range of 1-2 x URL, OR = 3.10, 95%CI 2.51 to 3.81) (All P < 0.001). For mild cTn increase below URL, the risk of mortality increased with every increment of 0.25xURL (WL, OR 1.03, 95% CI 1.02 to 1.03; GL, OR 1.05, 95% CI 1.03 to 1.07; RCS in the range of 0-0.5 URL, OR = 9.41, 95% CI 7.41 to 11.95) (All P < 0.001). CONCLUSIONS This study shows positive WL or GL and RCS dose-response relationships between PMI and all-cause mortality at short (< 12 mons)- and long-term (≥ 12 mons) follow-up, and MACE at longest follow-up. For mild cTn increase below URL, the risk of mortality also increases even with every increment of 0.25× URL.
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Affiliation(s)
- Lijing Yang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Sheng Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jun Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Zhongrong Fang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jingfei Guo
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Wenying Kang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jia Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Chenghui Zhou
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China; Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.
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30
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Vernooij JEM, Boerlage RM, Doggen CJM, Preckel B, Dirksen CD, van Leeuwen BL, Spruit RJ, Festen S, van der Wal-Huisman H, van Basten JP, Kalkman CJ, Koning NJ. Is a preoperative multidisciplinary team meeting (cost)effective to improve outcome for high-risk adult patients undergoing noncardiac surgery: the PREPARATION study-a multicenter stepped-wedge cluster randomized trial. Trials 2023; 24:660. [PMID: 37821994 PMCID: PMC10568883 DOI: 10.1186/s13063-023-07685-3] [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: 08/14/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND As a result of increased life expectancy and improved care for patients suffering from chronic disease, the number of patients with multimorbidity requiring surgical intervention is increasing. For complex surgical patients, it is essential to balance the potential benefits of surgical treatment against the risk of permanent loss of functional capacity and quality of life due to complications. European and US guidelines on perioperative care recommend preoperative multidisciplinary team (MDT) discussions for high-risk noncardiac surgical patients. However, the evidence underlying benefits from preoperative MDT meetings with all relevant perioperative specialties present is limited. The current study aims to investigate the effect of implementation of preoperative MDT discussions for high-risk patients undergoing noncardiac surgery on serious adverse events. METHODS/DESIGN PREPARATION is a stepped-wedge cluster randomized trial in 14 Dutch hospitals without currently established preoperative MDT meeting. The intervention, preoperative MDT meetings, will be implemented sequentially with seven blocks of 2 hospitals switching from control (preoperative screening as usual) to the intervention every 3 months. Each hospital will be randomized to one of seven blocks. We aim to include 1200 patients. The primary outcome is the incidence of serious adverse events at 6 months. Secondary outcomes include (cost)effectiveness, functional outcome, and quality of life for up to 12 months. DISCUSSION PREPARATION is the first study to assess the effectiveness of a preoperative MDT meeting for high-risk noncardiac surgical patients in the presence of an anesthesiologist. If the results suggest that preoperative MDT discussions for high-risk patients are (cost)-effective, the current study facilitates implementation of preoperative MDT meetings in clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT05703230. Registered on 11/09/2022.
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Affiliation(s)
- Jacqueline E M Vernooij
- Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands.
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Romijn M Boerlage
- Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschedé, The Netherlands
- Clinical Research Center, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam Public Health, Quality of Care, Amsterdam Cardiovascular Science, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Carine J M Doggen
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschedé, The Netherlands
- Clinical Research Center, Rijnstate Hospital, Arnhem, The Netherlands
| | - Benedikt Preckel
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam Public Health, Quality of Care, Amsterdam Cardiovascular Science, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Carmen D Dirksen
- Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rutger J Spruit
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Suzanne Festen
- University Center for Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Hanneke van der Wal-Huisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jean P van Basten
- Department of Urology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Cor J Kalkman
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Nick J Koning
- Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands
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31
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Dankert A, Neumann-Schirmbeck B, Dohrmann T, Greiwe G, Plümer L, Löser B, Sehner S, Zöllner C, Petzoldt M. Preoperative Spirometry in Patients With Known or Suspected Chronic Obstructive Pulmonary Disease Undergoing Major Surgery: The Prospective Observational PREDICT Study. Anesth Analg 2023; 137:806-818. [PMID: 36730893 DOI: 10.1213/ane.0000000000006235] [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: 02/04/2023]
Abstract
BACKGROUND Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative pulmonary risk assessment, but the scientific literature is conflicting. The Preoperative Diagnostic Tests for Pulmonary Risk Assessment in Chronic Obstructive Pulmonary Disease (PREDICT) study aimed to determine whether preoperative PFTs improve the prediction of postoperative pulmonary complications (PPCs) in patients with known or suspected chronic obstructive pulmonary disease (COPD) undergoing major surgery. A secondary aim was to determine whether the Global Initiative for Chronic Obstructive Lung Diseases (GOLD) classification of airflow limitation severity (grades I-IV) is associated with PPC. METHODS In this prospective, single-center study, patients with GOLD key indicators for COPD scheduled for major surgery received PFTs. Patients with confirmed COPD (forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] ≤0.7) were included in the COPD cohort and compared with a reference cohort without COPD. We developed 3 multivariable risk prediction models and compared their ability to predict PPC: the "standard model" (medical preconditions, and sociodemographic and surgical data), the "COPD assessment model" (additional GOLD key indicators, pack-years, and poor exercise capacity), and the "PFT model" (additional PFT parameters selected by adaptive least absolute shrinkage and selection operator [LASSO] regression). Multiple LASSO regressions were used for cross-validation. RESULTS A total of 31,714 patients were assessed for eligibility; 1271 individuals received PFTs. Three hundred twenty patients (240 with confirmed COPD: 78 GOLD I, 125 GOLD II, 28 GOLD III, 9 GOLD IV, and 80 without COPD) completed follow-up. The diagnostic performance was similar among the standard model (cross-validated area under the curve [cvAUC], 0.723; bias-corrected bootstrapped [bc-b] 95% confidence interval [CI], 0.663-0.775), COPD assessment model (cvAUC, 0.724; bc-b 95% CI, 0.662-0.777), and PFT model (cvAUC, 0.729; bc-b 95% CI, 0.668-0.782). Previously known COPD was an independent predictor in the standard and COPD assessment model. %FEV1 PRED was the only PFT parameter selected by LASSO regression and was an independent predictor in the PFT model (adjusted odds ratios [OR], 0.98; 95% CI, 0.967-.0.998; P = .030). The risk for PPC significantly increased with GOLD grades ( P < .001). COPD was newly diagnosed in 53.8% of the patients with confirmed COPD; however, these individuals were not at increased risk for PPC ( P = .338). CONCLUSIONS COPD is underdiagnosed in surgical patients. Patients with newly diagnosed COPD commonly presented with low GOLD severity grades and were not at higher risk for PPC. Neither a structured COPD-specific assessment nor preoperative PFTs added incremental diagnostic value to the standard clinical preassessment in patients with known or suspected COPD. Unnecessary postponement of surgery and undue health care costs can be avoided.
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Affiliation(s)
- André Dankert
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt Neumann-Schirmbeck
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Dohrmann
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gillis Greiwe
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lili Plümer
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Löser
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - Susanne Sehner
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Marsman M, Meulenbeld TG, Kappen TH, van Klei WA. The patient perspective on informed consent for anaesthesia when scheduled for cardiac surgery: An observational study. Eur J Anaesthesiol 2023; 40:793-796. [PMID: 37678203 DOI: 10.1097/eja.0000000000001874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Marije Marsman
- From the Department of Anesthesiology and Intensive Care Medicine (MM, TGM, THK, WAvK), Department of Information Technology, University Medical Center Utrecht, Utrecht, The Netherlands (THK), Department of Anaesthesia and Pain Management, Toronto General Hospital, University Health Network (WavK), Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto (WavK) and Toronto General Hospital Research Institute, Toronto, ON, Canada (WavK)
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Wienhold J, Kemper I, Czaplik M, Follmann A, Rossaint R, Derwall M. [Teleconsultation for preoperative evaluation and informed consent-Are we ready for a paradigm shift?]. DIE ANAESTHESIOLOGIE 2023; 72:697-702. [PMID: 37563314 DOI: 10.1007/s00101-023-01319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 08/12/2023]
Abstract
In Germany, approximately 17 million anaesthesiological procedures and, consequently, roughly the same number of preoperative consultations are conducted each year. So far, these have predominantly taken place in person. However, recent developments in technology, medical-legal aspects, and politics, combined with the catalyzing effect of the pandemic situation, have led to a significant boost in telemedicine. In the field of anaesthesia, there are new approaches to implementing telemedicine in the pre- and postoperative setting. This article focuses on the preoperative setting and presents general requirements for a teleconsultation as preoperative evaluation, the current state of technology, and medical-legal aspects.
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Affiliation(s)
- Jan Wienhold
- Klinik für Anästhesiologie, Medizinische Fakultät der RWTH Aachen, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - Ilka Kemper
- Geschäftsbereich Recht, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Michael Czaplik
- Klinik für Anästhesiologie, Medizinische Fakultät der RWTH Aachen, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Andreas Follmann
- Klinik für Anästhesiologie, Medizinische Fakultät der RWTH Aachen, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Rolf Rossaint
- Klinik für Anästhesiologie, Medizinische Fakultät der RWTH Aachen, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Matthias Derwall
- St. Johannes Hospital Dortmund, Johannesstraße 9-17, 44137, Dortmund, Deutschland
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van Klei WA, van Waes JAR, Beattie WS. Routine post-operative troponin surveillance after non-cardiac surgery: are we ready? Eur Heart J 2023; 44:3440-3442. [PMID: 37525944 DOI: 10.1093/eurheartj/ehad487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/30/2023] [Accepted: 07/18/2023] [Indexed: 08/02/2023] Open
Affiliation(s)
- Wilton A van Klei
- Department of Anesthesiology, University Health Network Toronto, Toronto General Hospital, 200 Elizabeth Street, 3EN-464, Toronto, ON M5G 2C4, Canada
- Department of Anesthesiology, University of Toronto, Toronto, M5G 1E2 ON, Canada
- Department of Anesthesiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - W Scott Beattie
- Department of Anesthesiology, University Health Network Toronto, Toronto General Hospital, 200 Elizabeth Street, 3EN-464, Toronto, ON M5G 2C4, Canada
- Department of Anesthesiology, University of Toronto, Toronto, M5G 1E2 ON, Canada
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35
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Klaschik S, Coburn M. [Special features of the perioperative course in patients with frailty syndrome]. DIE ANAESTHESIOLOGIE 2023; 72:685-694. [PMID: 37594509 DOI: 10.1007/s00101-023-01321-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 08/19/2023]
Abstract
The demographic change with an increase in the number of geriatric patients presents major challenges for perioperative medicine. Frailty is a multimorbidity complex that incorporates a combination of various factors, such as physical weakness, slower walking speed and unwanted weight loss. It is of great importance that these patients receive an individually adapted perioperative care. This includes, among others, a preoperative examination for frailty, a structured prehabilitation according to the concept of better in, better out, the compliance with the guidelines on prevention and timely treatment of postoperative delirium as well as the continuous maintenance of the body's homeostasis. By means of these measures the risk of complications in this patient group can be reduced and the best possible postoperative results can be achieved.
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Affiliation(s)
- Sven Klaschik
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Mark Coburn
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
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Zhang Y, Jia L, Tian Y, He J, He M, Chen L, Hao P, Li T, Peng L, Chong W, Hai Y, You C, Fang F. Association of Postoperative Drift in Hemoglobin With Mortality After Brain Tumor Craniotomy. Neurosurgery 2023; 93:168-175. [PMID: 36752640 DOI: 10.1227/neu.0000000000002396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/07/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Postoperative downward drift in hemoglobin (Hb) concentration may be associated with complications and death, even if nadir Hb remains more than the red blood cell transfusion threshold of 7 g/dL. OBJECTIVE To assess whether postoperative Hb drift in patients undergoing brain tumor craniotomy influences mortality in the immediate perioperative period. METHODS This retrospective cohort study included patients undergoing craniotomy for brain tumors. We defined no postoperative Hb decrease, mild decrease, moderate decrease, and severe decrease as postoperative Hb drift of ≤25%, 26% to 50%, 51% to 75%, and >75%, respectively. The primary outcome was 30-day mortality after craniotomy. RESULTS This study included 8159 patients who underwent a craniotomy for brain tumors. Compared with patients with no postoperative Hb drift, the odds of postoperative mortality at 30 days increased in patients with mild postoperative Hb drift (adjusted odds ratio [OR] 2.47, 95% CI 1.72-3.56), moderate drift (adjusted OR 6.56, 95% CI 3.42-12.59), and severe drift (adjusted OR 12.33, 95% CI 3.48-43.62). When postoperative Hb drift was analyzed as a continuous variable, for each 10% increase in Hb drift, the adjusted OR of postoperative mortality at 30 days was 1.46 (95% CI 1.31-1.63). CONCLUSION In patients undergoing brain tumor craniotomy, a small postoperative Hb drift was associated with increased odds of postoperative mortality at 30 days, even if the nadir Hb level remained greater than the red blood cell transfusion threshold of 7 g/dL. Future randomized clinical trials of perioperative transfusion practices may examine the effect of both nadir Hb and Hb drift.
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Affiliation(s)
- Yu Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Jia
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Yixin Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jialing He
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Miao He
- Department of Anesthesia, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Lvlin Chen
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Pengfei Hao
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Tiangui Li
- Department of Neurosurgery, Longquan Hospital, Chengdu, Sichuan, China
| | - Liyuan Peng
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yang Hai
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fang Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Zhu Y, Bi Y, Yu Q, Liu B. Assessment of the prognostic value of preoperative high-sensitive troponin T for myocardial injury and long-term mortality for groups at high risk for cardiovascular events following noncardiac surgery: a retrospective cohort study. Front Med (Lausanne) 2023; 10:1135786. [PMID: 37425305 PMCID: PMC10325788 DOI: 10.3389/fmed.2023.1135786] [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: 01/01/2023] [Accepted: 06/02/2023] [Indexed: 07/11/2023] Open
Abstract
Background Few studies explored the association between high-sensitive cardiac troponin T (hs-cTnT) and long-term mortality for patients after surgery. This study was conducted to assess the association of hs-cTnT with long-term mortality and to investigate the extent to which this association is mediated via myocardial injury after noncardiac surgery (MINS). Methods This retrospective cohort study included all patients with hs-cTnT measurements who underwent non-cardiac surgery at Sichuan University West China Hospital. Data were collected from February 2018 and November 2020, with follow-up through February 2022. The primary outcome was all-cause mortality within 1 year. As secondary outcomes, MINS, length of hospital stay (LOS), and ICU admission were analyzed. Results The cohort included 7,156 patients (4,299 [60.1%] men; 61.0 [49.0-71.0] years). Among 7,156 patients, there were 2,151 (30.05%) with elevated hs-cTnT(>14 ng/L). After more than 1 year of follow-up, more than 91.8% of mortality information was available. During one-year follow-up after surgery, there were 308 deaths (14.8%) with a preoperative hs-cTnT >14 ng/L, compared with 192 deaths (3.9%) with a preoperative hs-cTnT <=14 ng/L(adjusted hazard ratio [aHR] 1.93, 95% CI 1.58-2.36; p < 0.001). Elevated preoperative hs-cTnT was also associated with several other adverse outcomes (MINS: adjusted odds ratio [aOR] 3.01; 95% CI, 2.46-3.69; p < 0.001; LOS: aOR 1.48, 95%CI 1.34-1.641; p < 0.001; ICU admission: aOR 1.52, 95%CI 1.31-1.76; p < 0.001). MINS explained approximately 33.6% of the variance in mortality due to preoperative hs-cTnT levels. Conclusion Preoperative elevated hs-cTnT concentrations have a significant association with long-term mortality after noncardiac surgery, one-third of which may by accounted for by MINS.
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Affiliation(s)
- Yingchao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yaodan Bi
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qian Yu
- Department of Anesthesiology, Public Health Clinical Center of Chengdu, Chengdu, Sichuan, China
| | - Bin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Lin S, Huang X, Zhang Y, Zhang X, Cheng E, Liu J. Intraoperative Variables Enhance the Predictive Performance of Myocardial Injury in Patients with High Cardiovascular Risk After Thoracic Surgery When Added to Baseline Prediction Model. Ther Clin Risk Manag 2023; 19:435-445. [PMID: 37252064 PMCID: PMC10225131 DOI: 10.2147/tcrm.s408135] [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: 02/27/2023] [Accepted: 05/08/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Myocardial injury after non-cardiac surgery is closely related to major adverse cardiac and cerebrovascular event and is difficult to identify. This study aims to investigate how to predict the myocardial injury of thoracic surgery and whether intraoperative variables contribute to the prediction of myocardial injury. Methods The prospective study included adult patients with high cardiovascular risk who underwent elective thoracic surgery from May 2022 to October 2022. Multivariate logistic regression was used to establish a model with baseline variables and a model with baseline and intraoperative variables. We compare the predictive performance of two models for postoperative myocardial injury. Results In general, 31.5% (94 of 298) occurred myocardial injury. Age ≥65 years old, obesity, smoking, preoperative hsTnT, and one-lung ventilation time were independent predictors of myocardial injury. Compared with baseline model, the intraoperative variables improved model fit, modestly improved the reclassification (continuous net reclassification improvement 0.409, 95% CI, 0.169 to 0.648, P<0.001, improved integrated discrimination 0.036, 95% CI, 0.011 to 0.062, P<0.01) of myocardial injury cases, and achieved higher net benefit in decision curve analysis. Conclusion The risk stratification and anesthesia management of high-risk patients are essential. The addition of intraoperative variables to the baseline predictive model improved the performance of the overall model of myocardial injury and helped anesthesiologists screen out the patients at the greatest risk for myocardial injury and adjust anesthesia strategies.
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Affiliation(s)
- Shuchi Lin
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Xiaofan Huang
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Ying Zhang
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Xiaohan Zhang
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Erhong Cheng
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Jindong Liu
- Department of Anesthesiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
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Graeßner M, Jungwirth B, Frank E, Schaller SJ, Kochs E, Ulm K, Blobner M, Ulm B, Podtschaske AH, Kagerbauer SM. Enabling personalized perioperative risk prediction by using a machine-learning model based on preoperative data. Sci Rep 2023; 13:7128. [PMID: 37130884 PMCID: PMC10153050 DOI: 10.1038/s41598-023-33981-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/21/2023] [Indexed: 05/04/2023] Open
Abstract
Preoperative risk assessment is essential for shared decision-making and adequate perioperative care. Common scores provide limited predictive quality and lack personalized information. The aim of this study was to create an interpretable machine-learning-based model to assess the patient's individual risk of postoperative mortality based on preoperative data to allow analysis of personal risk factors. After ethical approval, a model for prediction of postoperative in-hospital mortality based on preoperative data of 66,846 patients undergoing elective non-cardiac surgery between June 2014 and March 2020 was created with extreme gradient boosting. Model performance and the most relevant parameters were shown using receiver operating characteristic (ROC-) and precision-recall (PR-) curves and importance plots. Individual risks of index patients were presented in waterfall diagrams. The model included 201 features and showed good predictive abilities with an area under receiver operating characteristic (AUROC) curve of 0.95 and an area under precision-recall curve (AUPRC) of 0.109. The feature with the highest information gain was the preoperative order for red packed cell concentrates followed by age and c-reactive protein. Individual risk factors could be identified on patient level. We created a highly accurate and interpretable machine learning model to preoperatively predict the risk of postoperative in-hospital mortality. The algorithm can be used to identify factors susceptible to preoperative optimization measures and to identify risk factors influencing individual patient risk.
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Affiliation(s)
- Martin Graeßner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Bettina Jungwirth
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Elke Frank
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
- Commercial department, Klinikum rechts der isar, Technical University of Munich, Munich, Germany
| | - Stefan Josef Schaller
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anaesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eberhard Kochs
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kurt Ulm
- Department of Medical Statistics and Epidemiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Bernhard Ulm
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Armin Horst Podtschaske
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Simone Maria Kagerbauer
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany.
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
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Bang TJ, Chung JH, Walker CM, Brixey AG, Christensen JD, Faiz SA, Hanak M, Hobbs SB, Kandathil A, Little BP, Madan R, Moore WH, Richman IB, Setters B, Todd MJ, Yang SC, Donnelly EF. ACR Appropriateness Criteria® Routine Chest Imaging. J Am Coll Radiol 2023; 20:S224-S233. [PMID: 37236745 DOI: 10.1016/j.jacr.2023.02.006] [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: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Routine chest imaging has been used to identify unknown or subclinical cardiothoracic abnormalities in the absence of symptoms. Various imaging modalities have been suggested for routine chest imaging. We review the evidence for or against the use of routine chest imaging in different clinical scenarios. This document aims to determine guidelines for the use of routine chest imaging as initial imaging for hospital admission, initial imaging prior to noncardiothoracic surgery, and surveillance imaging for chronic cardiopulmonary disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | | | | | - Anupama G Brixey
- Portland VA Healthcare System and Oregon Health & Science University, Portland, Oregon
| | | | - Saadia A Faiz
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Chest Physicians
| | - Michael Hanak
- Rush University Medical Center, Chicago, Illinois; American Academy of Family Physicians
| | | | - Asha Kandathil
- UT Southwestern Medical Center, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Rachna Madan
- Brigham & Women's Hospital, Boston, Massachusetts
| | - William H Moore
- New York University Langone Medical Center, New York, New York
| | - Ilana B Richman
- Yale School of Medicine, New Haven, Connecticut; Society of General Internal Medicine
| | - Belinda Setters
- Robley Rex VA Medical Center, Louisville, Kentucky; American Geriatrics Society
| | - Michael J Todd
- University of Michigan Medical Center, Ann Arbor, Michigan; Committee on Emergency Radiology-GSER
| | - Stephen C Yang
- Johns Hopkins University School of Medicine, Baltimore, Maryland; The Society of Thoracic Surgeons
| | - Edwin F Donnelly
- Specialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio
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Byvaltsev VA, Goloborodko VY, Kalinin AA, Shepelev VV, Pestryakov YY, Riew KD. A standardized anesthetic/analgetic regimen compared to standard anesthetic/analgetic regimen for patients with high-risk factors undergoing open lumbar spine surgery: a prospective comparative single-center study. Neurosurg Rev 2023; 46:95. [PMID: 37093302 DOI: 10.1007/s10143-023-02005-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/10/2023] [Accepted: 04/16/2023] [Indexed: 04/25/2023]
Abstract
The objective of the study is to improve the results of patients undergoing lumbar spine surgery who are at high risk for anesthesia and/or surgical complications. Two independent groups were compared: the study group (SG, n = 40) (standardized neuroanesthetic protocol with multimodal analgesia) and the control group (CG, n = 40) (intravenous anesthesia based on propofol and fentanyl). The data were collected using prospective observation of early and long-term results of lumbar fusion. After 24 months, the level of functional state and quality of life were studied. Patients in the SG did not have statistically significant changes in intraoperative hemodynamics; the best indicators of cognitive functions were noted. The effectiveness of the SG compared with the CG was confirmed by a statistically significantly lower amount of perioperative opioid drugs required (p = 0.01) and a minimal level of incisional pain (p < 0.05). An intergroup comparison of the adverse effects of anesthesia revealed a significantly lower number in the SG (n = 4) compared to the CG (n = 16) (p = 0.004). The number of postoperative surgical complications was comparable (p = 0.72). Intergroup comparison showed improved ODI, SF-36, and the Macnab scale at 24 months after surgery in the SG compared to the CG (p < 0.05). Long-term clinical results correlated with the level of incisional pain in the first three postoperative days. Our standardized neuroanesthetic protocol ensured effective treatment of postoperative incisional pain, significantly decreased the perioperative use of opioids, reduced adverse anesthesia events, and improved long-term clinical results in patients with high risk factors for anesthetic complications who undergoing open lumbar spine surgery.
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Affiliation(s)
- Vadim A Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, 1 Krassnogo Vosstaniya Street, off 201, 664003, Irkutsk, Irkutskaya Oblast, Russia.
- Department of Neurosurgery, Railway Clinical Hospital, Irkutsk, Russia.
- Department of Traumatology, Orthopedics and Neurosurgery, Irkutsk State Medical Academy of Postgraduate Education, Irkutsk, Russia.
| | - Victoria Yu Goloborodko
- Department of Neurosurgery, Irkutsk State Medical University, 1 Krassnogo Vosstaniya Street, off 201, 664003, Irkutsk, Irkutskaya Oblast, Russia
- Department of Neurosurgery, Railway Clinical Hospital, Irkutsk, Russia
| | - Andrei A Kalinin
- Department of Neurosurgery, Irkutsk State Medical University, 1 Krassnogo Vosstaniya Street, off 201, 664003, Irkutsk, Irkutskaya Oblast, Russia
- Department of Neurosurgery, Railway Clinical Hospital, Irkutsk, Russia
| | - Valerii V Shepelev
- Department of Neurosurgery, Irkutsk State Medical University, 1 Krassnogo Vosstaniya Street, off 201, 664003, Irkutsk, Irkutskaya Oblast, Russia
| | - Yurii Ya Pestryakov
- Department of Neurosurgery, Irkutsk State Medical University, 1 Krassnogo Vosstaniya Street, off 201, 664003, Irkutsk, Irkutskaya Oblast, Russia
| | - K Daniel Riew
- Department of Orthopedic Surgery, Columbia University, New York, USA
- Department of Neurological Surgery, Weill Cornell Medical College, New York, USA
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Network prediction of surgical complication clusters: a prospective multicenter cohort study. SCIENCE CHINA. LIFE SCIENCES 2023:10.1007/s11427-022-2200-1. [PMID: 36881319 DOI: 10.1007/s11427-022-2200-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 10/11/2022] [Indexed: 03/08/2023]
Abstract
Complicated relationships exist in both occurrence and progression of surgical complications, which are difficult to account for using a separate quantitative method such as prediction or grading. Data of 51,030 surgical inpatients were collected from four academic/teaching hospitals in a prospective cohort study in China. The relationship between preoperative factors, 22 common complications, and death was analyzed. With input from 54 senior clinicians and following a Bayesian network approach, a complication grading, cluster-visualization, and prediction (GCP) system was designed to model pathways between grades of complication and preoperative risk factor clusters. In the GCP system, there were 11 nodes representing six grades of complication and five preoperative risk factor clusters, and 32 arcs representing a direct association. Several critical targets were pinpointed on the pathway. Malnourished status was a fundamental cause widely associated (7/32 arcs) with other risk factor clusters and complications. American Society of Anesthesiologists (ASA) score ⩾3 was directly dependent on all other risk factor clusters and influenced all severe complications. Grade III complications (mainly pneumonia) were directly dependent on 4/5 risk factor clusters and affected all other grades of complication. Irrespective of grade, complication occurrence was more likely to increase the risk of other grades of complication than risk factor clusters.
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A systematic review of perioperative clinical practice guidelines for care of older adults living with frailty. Br J Anaesth 2023; 130:262-271. [PMID: 36707368 DOI: 10.1016/j.bja.2022.12.010] [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: 08/31/2022] [Revised: 11/21/2022] [Accepted: 12/11/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Perioperative frailty is prevalent and requires complex management, which could be guided by clinical practice guidelines (CPGs). The objective of this systematic review was to identify and synthesise CPGs that provide perioperative recommendations specific to older adults living with frailty. METHODS After protocol registration, we performed a systematic review of CPGs. MEDLINE, Embase, CINAHL, and 14 grey literature databases were searched (January 1, 2000 until December 22, 2021). We included all CPGs that contained at least one frailty-specific recommendation related to any phase of the perioperative period. We compiled all relevant recommendations, extracted underlying strength of evidence, and categorised them by perioperative phase of care. Within each phase, recommendations were synthesised inductively into themes. Quality of CPGs was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. RESULTS From 4707 citations, 13 guidelines were included; 8/13 were focused on the perioperative care of older surgical patients in general. Among 110 recommendations extracted, 37 themes were generated, with the majority pertaining to preoperative care. Four themes were supported by strong evidence: performing preoperative frailty assessments, using multidimensional frailty instruments, reducing urinary catheter use, and following multidisciplinary care and communication throughout the perioperative period. Per AGREE II, most guidelines (8/13; 62%) were recommended for use with modifications. CONCLUSIONS Despite increasing numbers of patients living with frailty, few guidelines exist that address frailty-specific perioperative care. Given the lack of strong evidence-based recommendations, particularly outside the preoperative period, high-quality primary research is required to underpin future guidelines and better inform the care of older surgical patients with frailty. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42022320149.
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Popova E, Alonso-Coello P, Álvarez-García J, Paniagua-Iglesias P, Rué-Monné M, Vives-Borrás M, Font-Gual A, Gich-Saladich I, Martínez-Bru C, Ordóñez-Llanos J, Carles-Lavila M. Cost-effectiveness of a high-sensitivity cardiac troponin T systematic screening strategy compared with usual care to identify patients with peri-operative myocardial injury after major noncardiac surgery. Eur J Anaesthesiol 2023; 40:179-189. [PMID: 36722187 DOI: 10.1097/eja.0000000000001793] [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: 02/02/2023]
Abstract
BACKGROUND About 300 million surgeries are performed worldwide annually and this figure is increasing constantly. Peri-operative myocardial injury (PMI), detected by cardiac troponin (cTn) elevation, is a common cardiac complication of noncardiac surgery, strongly associated with short- and long-term mortality. Without systematic peri-operative cTn screening, most cases of PMI may go undetected. However, little is known about cost effectiveness of a systematic PMI screening strategy with high-sensitivity cardiac troponin T (hs-cTnT) after noncardiac surgery. OBJECTIVE To assess, in patients with high cardiovascular risk, the cost-effectiveness of a systematic screening strategy using a hs-cTnT assay, to identify patients with PMI after major noncardiac surgery, compared with usual care. DESIGN Cost-effectiveness analysis; single centre prospective cohort study. SETTING Spanish University Hospital. PATIENTS From July 2016 to March 2019, we included 1477 consecutive surgical patients aged ≥65 or if <65, with documented history of cardiovascular disease or impaired renal function, who underwent major noncardiac surgery and required at least an overnight hospital stay. We excluded patients aged <65 years without cardiovascular disease, undergoing minor surgery, or with an expected <24 h hospital stays. INTERVENTIONS We conducted a decision-tree analysis, comparing a systematic screening strategy measuring hs-cTnT before surgery, and at the 2nd and 3rd days after surgery vs. a usual care strategy. We considered a third-party payer perspective and the outcomes of both strategies in the short-term (30 days follow-up). Information about costs was expressed in Euros-2021. We calculated the incremental cost-effectiveness ratio (ICER) of the systematic hs-cTnT strategy, defined as the expected cost per any additional PMI detected, and explored the robustness of the model using deterministic and probabilistic sensitivity analysis. MAIN OUTCOME MEASURES ICER of the systematic hs-cTnT screening strategy. RESULTS The ICER was €425 per any additionally detected PMI. The deterministic sensitivity analysis showed that a 15% variation in costs, and a 1% variation in the predictive values, had a minor impact over the ICER, except in case of the negative predictive value of the systematic hs-cTnT screening strategy. Monte Carlo simulations (probabilistic sensitivity analysis) showed that systematic hs-cTnT screening would be cost-effective in 100% of cases with a 'willingness to pay' of €780. CONCLUSIONS Our results suggest that systematic peri-operative PMI screening with hs-cTnT may be cost-effective in the short-term in patients undergoing major noncardiac surgery. Economic evaluations, with a long-term horizon, are still needed. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03438448.
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Affiliation(s)
- Ekaterine Popova
- From the IIB SANT PAU, Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain (EP, PA-C, IG-S), Centro Cochrane Iberoamericano, Barcelona, Spain (EP, PA-C), CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain (PA-C, IG-S), Hospital de la Santa Creu i Sant Pau, Department of Cardiology, Barcelona, Spain (JÁ-G, MV-B), Hospital Universitario Ramon y Cajal, Department of Cardiology, Madrid, Spain (JÁ-G), Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain (JÁ-G), Hospital de la Santa Creu i Sant Pau, Department of Anaesthesia and Pain Management, Barcelona, Spain (PP-I, AF-G), Institut de Recerca Biomèdica de Lleida (IRBLleida), Department of Basic Medical Sciences, Lleida, Spain (MR-M), Research Group in Statistical and Economic Analysis in Health (GRAEES), Lleida, Spain (MR-M), Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Department of Cardiology, Palma, Balearic Islands, Spain (MV-B), Hospital de la Santa Creu i Sant Pau, Department of Clinical Epidemiology and Public Health, Barcelona, Spain (IG-S), Hospital de la Santa Creu i Sant Pau, Department of Biochemistry, Barcelona, Spain (CM-B, JO-L), Fundación para la Bioquímica Clínica y Patología Molecular. Barcelona, Spain (JO-L), Universitat Rovira i Virgili, Economy Faculty, Reus, Spain (MC-L), Centro de Investigación en Economía y Sostenibilidad (ECO-SOS), Reus, Spain (MC-L)
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45
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Angel G, Trujillo C, Mallama M, Alonso-Coello P, Klimek M, Calvache JA. Methodological transparency of preoperative clinical practice guidelines for elective surgery. Systematic review. PLoS One 2023; 18:e0272756. [PMID: 36827452 PMCID: PMC9956602 DOI: 10.1371/journal.pone.0272756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 02/05/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Clinical practice guidelines (CPG) are statements that provide recommendations regarding the approach to different diseases and aim to increase quality while decreasing the risk of complications in health care. Numerous guidelines in the field of perioperative care have been published in the previous decade but their methodological quality and transparency are relatively unknown. OBJECTIVE To critically evaluate the transparency and methodological quality of published CPG in the preoperative assessment and management of adult patients undergoing elective surgery. DESIGN Systematic review and methodological appraisal study. DATA SOURCES We searched for eligible CPG published in English or Spanish between January 1, 2010, and June 30, 2022, in Pubmed MEDLINE, TRIP Database, Embase, the Cochrane Library, as well as in representatives' medical societies of Anaesthesiology and developers of CPG. ELIGIBILITY CRITERIA CPG dedicated on preoperative fasting, cardiac assessment for non-cardiac surgery, and the use of routine preoperative tests were included. Methodological quality and transparency of CPG were assessed by 3 evaluators using the 6 domains of the AGREE-II tool. RESULTS We included 20 CPG of which 14 were classified as recommended guidelines. The domain of "applicability" scored the lowest (44%), while the domains "scope and objective" and "editorial interdependence" received the highest median scores of 93% and 97% respectively. The remaining domains received scores ranging from 44% to 84%. The top mean scored CPG in preoperative fasting was ASA 2017 (93%); among cardiac evaluation, CPG for non-cardiac surgery were CCS 2017 (91%), ESC-ESA 2014 (90%), and AHA-ACC 2014 (89%); in preoperative testing ICSI 2020 (97%). CONCLUSIONS In the last ten years, most published CPG in the preoperative assessment or management of adult patients undergoing elective surgery focused on preoperative fasting, cardiac assessment for non-cardiac surgery, and use of routine preoperative tests, present moderate to high methodological quality and can be recommended for their use or adaptation. Applicability and stakeholder involvement domains must be improved in the development of future guidelines.
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Affiliation(s)
- Gustavo Angel
- Department of Anesthesiology, Universidad del Cauca, Cauca, Colombia
| | - Cristian Trujillo
- Department of Anesthesiology, Universidad del Cauca, Cauca, Colombia
| | - Mario Mallama
- Department of Anesthesiology, Universidad del Cauca, Cauca, Colombia
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Clinical Epidemiology and Public Health Department, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Markus Klimek
- Department of Anesthesiology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Jose A. Calvache
- Department of Anesthesiology, Universidad del Cauca, Cauca, Colombia
- Department of Anesthesiology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
- * E-mail:
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46
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Vernooij JEM, Koning NJ, Geurts JW, Holewijn S, Preckel B, Kalkman CJ, Vernooij LM. Performance and usability of pre-operative prediction models for 30-day peri-operative mortality risk: a systematic review. Anaesthesia 2023; 78:607-619. [PMID: 36823388 DOI: 10.1111/anae.15988] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 02/25/2023]
Abstract
Estimating pre-operative mortality risk may inform clinical decision-making for peri-operative care. However, pre-operative mortality risk prediction models are rarely implemented in routine clinical practice. High predictive accuracy and clinical usability are essential for acceptance and clinical implementation. In this systematic review, we identified and appraised prediction models for 30-day postoperative mortality in non-cardiac surgical cohorts. PubMed and Embase were searched up to December 2022 for studies investigating pre-operative prediction models for 30-day mortality. We assessed predictive performance in terms of discrimination and calibration. Risk of bias was evaluated using a tool to assess the risk of bias and applicability of prediction model studies. To further inform potential adoption, we also assessed clinical usability for selected models. In all, 15 studies evaluating 10 prediction models were included. Discrimination ranged from a c-statistic of 0.82 (MySurgeryRisk) to 0.96 (extreme gradient boosting machine learning model). Calibration was reported in only six studies. Model performance was highest for the surgical outcome risk tool (SORT) and its external validations. Clinical usability was highest for the surgical risk pre-operative assessment system. The SORT and risk quantification index also scored high on clinical usability. We found unclear or high risk of bias in the development of all models. The SORT showed the best combination of predictive performance and clinical usability and has been externally validated in several heterogeneous cohorts. To improve clinical uptake, full integration of reliable models with sufficient face validity within the electronic health record is imperative.
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Affiliation(s)
- J E M Vernooij
- Department of Anaesthesia, Rijnstate Hospital, the Netherlands
| | - N J Koning
- Department of Anaesthesia, Rijnstate Hospital, the Netherlands
| | - J W Geurts
- Department of Anaesthesia, Rijnstate Hospital, the Netherlands
| | - S Holewijn
- Department of Vascular Surgery, Rijnstate Hospital, the Netherlands
| | - B Preckel
- Department of Anaesthesia, Amsterdam UMC, Amsterdam, the Netherlands
| | - C J Kalkman
- University Medical Centre, Utrecht, the Netherlands
| | - L M Vernooij
- Department of Anaesthesia, University Medical Centre Utrecht, the Netherlands
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47
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Oh AR, Park J, Shin SJ, Choi B, Lee JH, Lee SH, Yang K. Prediction model for myocardial injury after non-cardiac surgery using machine learning. Sci Rep 2023; 13:1475. [PMID: 36702844 PMCID: PMC9879966 DOI: 10.1038/s41598-022-26617-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/16/2022] [Indexed: 01/27/2023] Open
Abstract
Myocardial injury after non-cardiac surgery (MINS) is strongly associated with postoperative outcomes. We developed a prediction model for MINS and have provided it online. Between January 2010 and June 2019, a total of 6811 patients underwent non-cardiac surgery with normal preoperative level of cardiac troponin (cTn). We used machine learning techniques with an extreme gradient boosting algorithm to evaluate the effects of variables on MINS development. We generated two prediction models based on the top 12 and 6 variables. MINS was observed in 1499 (22.0%) patients. The top 12 variables in descending order according to the effects on MINS are preoperative cTn level, intraoperative inotropic drug infusion, operation duration, emergency operation, operation type, age, high-risk surgery, body mass index, chronic kidney disease, coronary artery disease, intraoperative red blood cell transfusion, and current alcoholic use. The prediction models are available at https://sjshin.shinyapps.io/mins_occur_prediction/ . The estimated thresholds were 0.47 in 12-variable models and 0.53 in 6-variable models. The areas under the receiver operating characteristic curves are 0.78 (95% confidence interval [CI] 0.77-0.78) and 0.77 (95% CI 0.77-0.78), respectively, with an accuracy of 0.97 for both models. Using machine learning techniques, we demonstrated prediction models for MINS. These models require further verification in other populations.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seo Jeong Shin
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Byungjin Choi
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hwa Lee
- Heart Vascular Stroke Institute, Rehabilitation & Prevention Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea.
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Korea.
| | - Kwangmo Yang
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea.
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Korea.
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48
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Díez-García C, Gich Saladich I, Bolibar Ribas I. Effectiveness of Nurse-led Preoperative Assessment for Anesthesia: A Prospective Cohort Study. J Perianesth Nurs 2023:S1089-9472(22)00548-2. [PMID: 36635121 DOI: 10.1016/j.jopan.2022.10.007] [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: 06/26/2022] [Revised: 10/09/2022] [Accepted: 10/17/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE This study aimed to evaluate, in low-complexity surgical patients, the effectiveness of preoperative assessment carried out by nurses with formal postgraduate anaesthetic training compared to that carried out by anesthesiologists in terms of cancellations and inadequate surgical preparation. DESIGN This experimental research was conducted using a prospective cohort study. METHODS One hundred and eighty-three patients were recruited who had undergone low-complexity surgery between May and September 2020. Sixty-nine patients were preoperatively assessed by a nurse with specific 1-year postgraduate university training in anesthesia and 114 by an anesthesiologist. Data collection included a questionnaire to assess patient satisfaction and knowledge acquired from the preoperative assessment. FINDINGS Cancellations of surgery were the same in both cohorts (3.8%, 2.6%). The incidence of poor preparation attributable to the patient was also similar in both cohorts (17.0% vs 18.4%). Patients seen by nurses valued the satisfaction with the preoperative assessment more highly than patients seen by anesthesiologists (median 91.67 vs 84.62). In terms of Knowledge obtained from the preoperative assessment, both professionals did not show statistically significant differences in knowledge levels. CONCLUSIONS Preoperative patient assessment performed by a nurse, with formal anesthesia training, in low-complexity surgical patients can be as effective as that performed by an anesthesiologist, without having an impact on surgical cancellations or patient preparation. On the day of surgery, patients who had been assessed by a nurse were more satisfied with their care during the visit and acquired similar knowledge about preoperative preparation as patients assessed by anesthesiologists.
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Affiliation(s)
- Cecilia Díez-García
- Nursing Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Ignasi Gich Saladich
- Department of Clinical Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP). Spain; Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Ignasi Bolibar Ribas
- Department of Clinical Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP). Spain; Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
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49
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Perioperative troponin surveillance in major noncardiac surgery: a narrative review. Br J Anaesth 2023; 130:21-28. [PMID: 36464518 DOI: 10.1016/j.bja.2022.08.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/08/2022] [Accepted: 08/31/2022] [Indexed: 12/03/2022] Open
Abstract
Myocardial injury is now an acknowledged complication in patients undergoing noncardiac surgery. Heterogeneity in the definitions of myocardial injury contributes to difficulty in evaluating the value of cardiac troponins (cTns) measurement in perioperative care. Pre-, post-, and peri-operatively increased cTns are encompassed by the umbrella term 'myocardial injury' and are likely to reflect different pathophysiological mechanisms. Increased cTns are independently associated with cardiovascular and non-cardiovascular complications, poor short-term and long-term cardiovascular outcomes, and increased mortality. Preoperative measurement of cTns aids preoperative risk stratification beyond the Revised Cardiac Risk Index. Systematic measurement detects acute perioperative increases and allows early identification of acute myocardial injury. Common definitions and standards for reporting are a prerequisite for designing impactful future trials and perioperative management strategies.
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50
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Kietaibl AT, Huber J, Clodi M, Abrahamian H, Ludvik B, Fasching P. [Position statement: surgery and diabetes mellitus (Update 2023)]. Wien Klin Wochenschr 2023; 135:256-271. [PMID: 37101047 PMCID: PMC10133078 DOI: 10.1007/s00508-022-02121-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 04/28/2023]
Abstract
This position statement reflects the perspective of the Austrian Diabetes Association concerning the perioperative management of people with diabetes mellitus based on the available scientific evidence. The paper covers necessary preoperative examinations from an internal/diabetological point of view as well as the perioperative metabolic control by means of oral antihyperglycemic and/or insulin therapy.
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Affiliation(s)
- Antonia-Therese Kietaibl
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Klinik Ottakring, Wien, Österreich
| | - Joakim Huber
- Interne Abteilung mit Akutgeriatrie und Palliativmedizin, Franziskus Spital, Standort Landstraße, Wien, Österreich
| | - Martin Clodi
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich.
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich.
| | | | - Bernhard Ludvik
- 1. Medizinische Abteilung für Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
| | - Peter Fasching
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Klinik Ottakring, Wien, Österreich
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