2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Positive Preoperative Stress Test is Associated with Increased Risk of Postoperative Myocardial Infarction in Patients Undergoing Aortoiliac Reconstruction for Chronic Limb-Threatening Ischemia

BACKGROUND

Aortofemoral or aortoiliac bypasses (AFBs/AIBs) are considered the gold standard treatment for patients with aortoiliac occlusive disease. Myocardial infarction (MI) is a postoperative risk in AFB/AIB surgeries and preoperative stress test (PST) is frequently utilized to inform operative planning and preoperative risk discussions. The aim of this study is to assess the utility of PST in determining outcomes following AFB/AIB in patients with chronic limb-threatening ischemia (CLTI).

METHODS

This is a retrospective study from Vascular Quality Initiative database. Patients undergoing AFB/AIB for chronic limb-threatening ischemia during 2009-2023 were stratified by PST result. Primary outcomes included postoperative MI and 30-day mortality. Secondary outcomes included in-hospital death, in-hospital death/MI, postoperative respiratory complications, postoperative congestive heart failure, intensive care unit stay > 3 days, and 1-year mortality. Logistic and Cox regressions were used for multivariate analyses.

RESULTS

The study included 2 cohorts of patients: negative (N = 1,809, 81.2%) and positive PST (N = 420, 18.8%). The patients with positive PST had increased rate of postoperative MI compared to the patients with negative PST (6.7% vs. 2.9%, P < 0.001). The rate of 30-day mortality was greater for patients with positive PST but the difference was not significant (3.8% vs. 2.9%, P = 0.315). After adjusting for potential confounders, positive PST was associated with increased risk of postoperative MI (adjusted odds ratio = 1.89 [95% confidence interval: 1.04-3.43], P = 0.038). However, positive PST was not associated with 30-day mortality. Pulmonary complications, congestive heart failure, and intensive care unit stay >3 days were also not associated with PST result. The overall survival rate at 1-year was 93.3% and 92.0% for patients with negative and positive PSTs (P = 0.343), respectively. After adjusting for potential confounders, postoperative MI was associated with increased hazards of death at 1 year (adjusted hazard ratio = 3.62 [95% confidence interval: 2.21-5.92], P < 0.001).

CONCLUSION

This study emphasizes the important of appropriate preoperative planning. A positive stress test before open aortic reconstruction for aortoiliac occlusive disease is associated with increased risk of postoperative MI. Although this was neither associated with increased risk of 30-day nor 1-year mortality, the negative impact of MI on patient functionality, quality of life, and 1-year death cannot be ignored.

Pre-operative subjective functional capacity and postoperative outcomes in adult non-cardiac surgery: a systematic review and meta-analysis

INTRODUCTION

Assessment of functional capacity is an essential part of peri-operative risk stratification. Subjective functional capacity is easier to examine than objective tests of patient fitness. However, the association between subjective functional capacity and postoperative outcomes has not been established.

METHODS

Four databases were searched for studies describing the associations between subjective functional capacity and postoperative outcomes in adults undergoing non-cardiac surgery. Meta-analysis was conducted among studies where functional capacity was expressed in metabolic equivalents. The primary outcome was postoperative major adverse cardiovascular events. Secondary outcomes were mortality and postoperative overall complications. We estimated the ORs of the outcomes in patients with poor functional capacity (< 4 metabolic equivalents) as compared with those with good functional capacity (≥ 4 metabolic equivalents). Random-effects models were used for the meta-analysis.

RESULTS

We identified 7835 abstracts. After screening and a full-text review, 23 studies were selected. Evaluation methods of functional capacity included: questionnaires (n = 7); specific questions (n = 6); and subjective assessment by anaesthetists (n = 5). The probability of major postoperative adverse cardiovascular events was significantly higher in patients with poor functional capacity (OR 1.84, 95%CI 1.62-2.08) than in those with good functional capacity. Patients with poor functional capacity also had higher odds of mortality (OR 2.48, 95%CI 1.45-4.25) and postoperative complications (OR 1.85, 95%CI 1.34-2.55).

DISCUSSION

Subjective functional capacity of < 4 metabolic equivalents was associated with postoperative complications including cardiovascular events and other serious outcomes. The results need to be interpreted with caution due to the diverse measures used to assess functional capacity.

Coronary Computed Angiography and Coronary Artery Calcium Score for Preoperative Cardiovascular Risk Stratification in Patients Undergoing Noncardiac Surgery

Perioperative and long-term postoperative major adverse cardiovascular events (MACE) are a leading cause of morbidity and mortality in patients undergoing noncardiac surgery. In selected high-risk patients, when information about cardiovascular status may influence surgical decisions, preoperative risk stratification is reasonable, with stress imaging being the preferred method. Coronary computed angiography (CCTA) and coronary artery calcium score (CACS) offer direct anatomical assessment of atherosclerotic coronary arteries and help gauge the extent and severity of coronary artery disease. Strong evidence supports that CCTA and CACS, either alone or in combination, are reliable methods for assessing the risk of both perioperative and long-term postoperative MACE, often demonstrating equal or superior prognostic performance compared to traditional imaging tools. Moreover, integrating CCTA or CACS into standard preoperative imaging protocols further enhances perioperative risk prediction and improves the ability to accurately stratify patients. Future research is needed to better define the role of CCTA and CACS in preoperative cardiovascular risk evaluation of patients undergoing noncardiac surgery.

Low functional capacity in peripheral artery disease is associated with increased platelet activity and cardiovascular events

BACKGROUND AND AIMS

Low functional capacity is an independent risk factor for cardiovascular (CV) events. Regular physical activity may reduce CV risk through suppression of inflammation and reduced platelet activity. We aimed to investigate the association of functional capacity quantified by the validated Duke Activity Status Index (DASI) with platelet activity and incident major adverse CV and limb events (MACLE) in individuals with peripheral artery disease (PAD) undergoing lower extremity revascularization (LER).

METHODS

Light transmission aggregometry and platelet RNAseq were performed on specimens isolated from men and women prior to LER. Functional capacity was assessed using DASI. Prospective follow-up occurred at 1, 6, 12, and every 6 months following the LER. Subjects were separated into tertiles of DASI scores and incidence rates for MACLE were calculated using log-rank tests. Mediation analysis using linear regression fit with least squares was performed to test whether DASI exerted its effect on MACLE via platelet aggregation.

RESULTS

281 patients completed the DASI questionnaire with scores ranging from 0.0 to 50.2 (bottom tertile: 0.0-9.95). Mean age was 74.4 ± 10.9 years and 32.4 % were female. During a median follow-up of 19 months, 163 (58.0 %) participants experienced a MACLE. After correction for demographics and CV risk factors, individuals in the lowest DASI tertile experienced significantly more MACLE than participants in other tertiles. The association between DASI and MACLE was consistent across multiple subgroups stratified by age, sex, body mass index, antiplatelet therapy, and clinical comorbidities. Mediation analyses suggested higher platelet aggregation to epinephrine in the bottom DASI tertile mediated 24.7 % [5.0 %, 103 %] of increased MACLE risk. Platelet mRNA demonstrated upregulation of inflammation pathways in the most sedentary individuals (lowest DASI tertile).

CONCLUSIONS

Patients with PAD and low functional capacity have increased platelet activity and high incidence of MACLE. Our data suggest that elevated platelet aggregation mediates one-quarter of the MACLE risk in persons with low functional capacity undergoing LER. Our findings support a potential platelet-mediated mechanism for improved CV outcomes associated with regular physical activity.

Patients Excluded from BEST-CLI were More Likely to Undergo a Major Amputation at a Single Urban Safety Net Hospital

INTRODUCTION

Best Endovascular Versus Best Surgical Therapy for Patients with Critical Limb Ischemia (BEST-CLI) is the largest randomized clinical trial (RCT) for chronic limb-threatening ischemia (CLTI). However, as with any RCT, generalizability is a concern. Our aims were to determine and quantify reasons for trial exclusion in all patients who underwent revascularization for CLTI at a single urban safety net hospital and to compare outcomes following revascularization of patients who were non-eligible for BEST-CLI with patients who were eligible.

METHODS

All patients who underwent revascularization for CLTI from 08/2014-10/2019 at a single center were identified. Trial and site-specific exclusion criteria were assessed, and patients were grouped by enrollment criteria. Demographics, comorbidities, preoperative medications, prior interventions, and outcomes were then compared between non-eligible and eligible patient groups. Categorical variables were compared using Pearson's chi-squared tests. Normally distributed variables were compared via student t-tests while non-normally distributed variables were assessed using Mann-Whitney U tests. Kaplan-Meier curves were constructed for time-to-event analysis of outcomes.

RESULTS

Of the 159 patients who underwent revascularization, 17 (11%) met BEST-CLI enrollment criteria while 142 (89%) were ineligible. The primary reasons for exclusion were perceived patient ability to adhere to trial protocol (46%) which included patients who had planned follow up elsewhere or were unable to adhere to follow up appointments. A total of 36 (25%) patients were deemed excessive risk for open bypass, 26 patients (18%) were limited by an institutional policy excluding patients with limited English proficiency. Seventy-nine (56%) patients met a single criterion for exclusion, 52 (37%) patients met 2 criteria, and 11 (8%) patients met 3 criteria. Compared to patients eligible for BEST-CLI, non-eligible patients had significantly greater 5-year major amputation rate (p=0.02) and lower major reintervention rate (p=0.01), but no difference in all-cause mortality (p=0.63).

CONCLUSIONS

Most patients presenting with CLTI at an urban safety net hospital failed to meet BEST-CLI enrollment criteria. Non-medical factors played a role in exclusion of over half of these patients, which underscores the importance of accommodating these factors to better assess ideal management strategies in this hospital setting.

Management of older adults with severe aortic stenosis and indication of non-cardiac surgery for colorectal neoplasm: What do we treat first?

Severe aortic stenosis may increase risks and pose limitations in non-cardiac surgeries, sometimes requiring prior treatment. Surgery for colorectal neoplasms is frequently the priority indicated treatment as its delay can increase the risk of developing complications (e.g. bowel obstruction). The coexistence of both conditions in older comorbid patients may be challenging during the decision-making process. In this case series, four cases of older adults with severe aortic stenosis and colorectal neoplasms with surgical indication are presented. A description of the management of each case, with a revision of the current cardiovascular risk assessment guidelines, is done.

Patterns of Specialty Palliative Consultation for Patients Admitted to Surgical Services

Background: Historically, there have been perceptions that engagement with palliative care (PC) services may preclude potentially curative but high-risk operations. As such, we sought to investigate the relationship between specialty PC consultation and the care trajectory of surgical patients. We hypothesized that PC consultation would be associated with increased frequency of nonoperative treatments being chosen among surgical inpatients. Design: All general surgery and general surgery subspecialty patients receiving PC consultation at a single tertiary academic medical center from 2020 to 2021 were identified. Surgical operations were stratified as "elevated risk" in accordance with 2014 American Heart Association guidelines. Retrospective chart review was performed, and comparisons were made with univariable statistics. Results: We identified a total of 729 patients who received specialty PC consultation, 159 of whom were admitted to a surgical service. PC was actively involved in consultation for surgical decision making in 27% (43/159) of these encounters. PC assistance with surgical decision making was associated with a greater incidence of elevated-risk operative procedures during admission compared with patients without presurgical PC consultation (OR 3.29 [2.51, 7.16]). There was no association between PC involvement with surgical decision making and odds of discharge to hospice (OR 0.42 [0.18, 1.51]) nor death during admission (OR 0.66 [0.21, 2.10]). Conclusions: We found that specialty PC involvement in surgical decision making does not preclude the pursuit of disease-directed surgical treatment. Contrary to our hypothesis, our single institutional data demonstrate that early PC consultation can be synergistic with surgical disease management and does not preclude elevated-risk operative care.

Association between the preoperative triglyceride-glucose index and myocardial injury following non-cardiac surgery: a cross-sectional study

OBJECTIVE

An elevated triglyceride-glucose (TyG) index positively correlates with adverse cardiovascular events. However, its association with myocardial injury after non-cardiac surgery (MINS) remains unclear. This study aimed to examine the association between the preoperative TyG index and MINS.

DESIGN

A cross-sectional study.

SETTING

Meizhou People's Hospital.

PARTICIPANTS

Adult patients under general anaesthesia and with MINS.

MAIN EXPOSURE MEASURE

The preoperative TyG index, calculated using triglyceride (TG) and fasting blood glucose (FBG) levels.

MAIN OUTCOME MEASURE

The occurrence of MINS, defined using postoperative troponin measurements.

RESULTS

889 patients were included, with an 8.3% incidence of MINS (74/889). The median TyG index was 8.57 (8.13, 9.02). TyG exhibited higher discriminatory ability for MINS than TG and FBG, with an area under the curve of 0.624, 0.544 and 0.500, respectively. Fully adjusted logistic regression indicated that an elevated TyG index was independently associated with MINS (OR 1.75, 95% CI 1.21 to 2.52; p=0.003). A multivariate restricted cubic spline suggested a linear relationship between TyG and MINS (p value for non-linearity=0.059). Subgroup analyses showed results consistent with the primary analysis, with no significant interaction effects between subgroups.

CONCLUSION

An elevated preoperative TyG index is independently associated with an increased incidence of MINS. Monitoring the TyG index perioperatively may improve the management of patients at risk for MINS.

TRIAL REGISTRATION NUMBER

ChiCTR2400082834.

Perioperative neurocognitive dysfunction and role of dexmedetomidine in radical colon cancer surgery in elderly patients

This article explored the application of dexmedetomidine (Dex), a highly selective alpha-2 agonist, in managing postoperative cognitive dysfunction (POCD) in elderly patients undergoing radical colon cancer surgery. Aging is associated with a progressive decline in physiological functions and an increased risk of adverse surgical outcomes, including POCD, which encompasses many neurocognitive disorders that manifest during the perioperative period. The aging population is at a higher risk for POCD, which can lead to prolonged hospital stays, delayed recovery, and increased healthcare costs. Dex has neuroprotective, opioid-sparing, and sympatholytic properties, which reduces the incidence and severity of POCD. Dex was introduced for sedation in patients receiving mechanical ventilation but has since been adopted in anesthesia due to its multifaceted benefits. Its application extends to sedation, analgesia, maintenance of anesthesia, and controlling delirium. Its neuroprotective and anti-inflammatory effects have been explored in managing POCD. This article discussed the broad range of patient and procedure-related risk factors for POCD. Early identification and intervention are crucial to prevent the progression of POCD, which can have severe physical, psychological, and economic consequences. The article underscored the importance of a multidisciplinary approach in managing POCD, involving the optimization of comorbidities, depth of anesthesia monitoring, hemodynamic stability, and cerebral oxygenation monitoring.

Anal-cardiac reflex leading to coronary spasm and cardiac arrest during abdominoperineal excision of the rectum (MILES): case report and review of the literature

BACKGROUND

Coronary artery spasm (CAS) has been frequently documented during regional or general anesthesia. However, severe cardiac arrest induced by CAS as a result of anal-cardiac and vasovagal reflexes is relatively uncommon.

CASE PRESENTATION

This report describes a patient with a history of CAS and percutaneous coronary angioplasty (PTCA) who experienced coronary artery spasm and subsequent cardiac arrest during anal anastomosis in a transabdominal perineal radical resection of rectal cancer (MILES procedure).

CONCLUSION

This case study offers significant insights into the pathophysiology of cardiac arrest induced by surgical intervention in the anal region, which is densely innervated by the vagus nerve at the terminal portion of the rectum. This phenomenon may be associated with the anal cardiac reflex and vagus nerve reflexes. It is imperative to recognize the potential for catastrophic outcomes due to vagus nerve excitation during rectal end surgery, particularly in patients with a history of acute CAS.

Special Considerations Related to Race, Sex, Gender, and Socioeconomic Status in the Preoperative Evaluation: Part 1: Race, History of Incarceration, and Health Literacy

Patients anticipating surgery and anesthesia benefit from preoperative care to lower risks and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may either avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges is vital to reducing disparities in health and health care.

Machine learning-based predictive models for perioperative major adverse cardiovascular events in patients with stable coronary artery disease undergoing noncardiac surgery

BACKGROUND AND OBJECTIVE

Accurate prediction of perioperative major adverse cardiovascular events (MACEs) is crucial, as it not only aids clinicians in comprehensively assessing patients' surgical risks and tailoring personalized surgical and perioperative management plans, but also for information-based shared decision-making with patients and efficient allocation of medical resources. This study developed and validated a machine learning (ML) model using accessible preoperative clinical data to predict perioperative MACEs in stable coronary artery disease (SCAD) patients undergoing noncardiac surgery (NCS).

METHODS

We collected data from 9171 adult SCAD patients who underwent NCS and extracted 64 preoperative variables. First, the optimal data imputation, resampling, and feature selection methods were compared and selected to deal with missing data values and imbalances. Then, nine independent machine learning models (logistic regression (LR), support vector machine, Gaussian Naive Bayes (GNB), random forest, gradient boosting decision tree (GBDT), extreme gradient boosting (XGBoost), light gradient boosting machine, categorical boosting (CatBoost), and deep neural network) and a stacking ensemble model were constructed and compared with the validated Revised Cardiac Risk Index's (RCRI) model for predictive performance, which was evaluated using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), calibration curve, and decision curve analysis (DCA). To reduce overfitting and enhance robustness, we performed hyperparameter tuning and 5-fold cross-validation. Finally, the Shapley additive interpretation (SHAP) method and a partial dependence plot (PDP) were used to determine the optimal ML model.

RESULTS

Of the 9,171 patients, 514 (5.6 %) developed MACEs. 24 significant preoperative features were selected for model development and evaluation. All ML models performed well, with AUROC above 0.88 and AUPRC above 0.39, outperforming the AUROC (0.716) and AUPRC (0.185) of RCRI (P < 0.001). The best independent model was XGBoost (AUROC = 0.898, AUPRC = 0.479). The calibration curve accurately predicted the risk of MACEs (Brier score = 0.040), and the DCA results showed that XGBoost had a high net benefit for predicting MACEs. The top-ranked stacking ensemble model, consisting of CatBoost, GBDT, GNB, and LR, proved to be the best (AUROC 0.894, AUPRC 0.485). We identified the top 20 most important features using the mean absolute SHAP values and depicted their effects on model predictions using PDP.

CONCLUSIONS

This study combined missing-value imputation, feature screening, unbalanced data processing, and advanced machine learning methods to successfully develop and verify the first ML-based perioperative MACEs prediction model for patients with SCAD, which is more accurate than RCRI and enables effective identification of high-risk patients and implementation of targeted interventions to reduce the incidence of MACEs.

Bedside management of a knotted Swan-Ganz catheter - A case report and literature review

INTRODUCTION AND IMPORTANCE

Pulmonary artery catheters use remain invaluable in continuous invasive hemodynamic monitoring for patients with severe cardiopulmonary dysfunction and those undergoing major cardiac surgeries. It detects cardiac dysfunction and guides treatment decisions. Its utilization has declined due to common complications associated with its insertion. This article highlights a rare, rather an important complication of pulmonary artery catheter knotting and reviews techniques for its management. Prompt recognition of this rare complication by the clinicians allow immediate intervention minimizing morbidity and optimizing the outcomes. This manuscript follows the SCARE guidelines.

CASE PRESENTATION

A case of a 61-year-old man who was initially admitted to the cardiothoracic unit for mitral valve replacement for symptomatic severe mitral regurgitation secondary to a bi-leaflet prolapse. Intra-operatively, a pulmonary artery catheter was inserted for invasive continuous hemodynamic monitoring. It was noted on a routine postoperative chest X-ray coiling of the pulmonary artery catheter in the right atrium. The catheter was not repositioned. On postoperative day one, significant resistance was encountered while removing the catheter. A chest x-ray was done and showed a knotted catheter in the superior vena cava. After contingency planning, bedside removal was opted as the preferred management approach. The catheter was carefully pulled out to tighten the knot and decrease its diameter, allowing successful extraction through the insertion site at the neck.

CLINICAL DISCUSSION

Pulmonary artery catheter utilization remains essential; however its insertion is prone to complications, which includes pulmonary artery catheter knotting a rare but an important complication that warrants immediate recognition and management. Numerous approaches for the management of knotted catheter were described in the literature. Bedside removal of the knotted catheter may be considered if the knot is simple and more proximal. This approach carries the risk of venous injury and hematoma formation, thus thorough planning and preparation are needed to avoid complications. An endovascular approach is opted in more complex cases and has largely supplanted surgical methods. Innovative methods were described in the literature and include the introduction of guide wires or specialized catheters to untangle knots under fluoroscopic guidance. Retrieval baskets may also be used. Surgery is reserved for complex cases, when endovascular attempts fail.

CONCLUSION

While pulmonary artery catheter use provides significant benefits, its use demands meticulous planning and preparation to avoid complications. Catheter knotting requires immediate attention. If bedside maneuvers fail, endovascular or surgical approaches may be necessary.

Management of renin-angiotensin system inhibitors prior to major surgery: insights from the STOP-or-NOT trial

Strong recommendations on how to manage renin-angiotensin system inhibitors, including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, before surgery are lacking because of a lack of evidence, which is mostly limited to data from observational studies. The STOP-or-NOT trial was a large multicentre randomised trial designed to determine whether chronic renin-angiotensin system inhibitors should be continued or discontinued before major noncardiac surgery. As principal investigators of the STOP-or-NOT trial, we discuss the trial's results and how they contribute to the existing literature on management of renin-angiotensin system inhibitors before surgery.

Multicomponent Deimplementation Strategy to Reduce Low-Value Preoperative Testing

Importance

Routine preoperative blood tests and electrocardiograms before low-risk surgery do not prevent adverse events or change management but waste resources and can cause patient harm. Given this, multispecialty organizations recommend against routine testing before low-risk surgery.

Objective

To determine whether a multicomponent deimplementation strategy (the intervention) would reduce low-value preoperative testing before low-risk general surgery operations.

Design, Setting, and Participants

This study had a pre-post quality improvement interventional design using interrupted time series and difference-in-difference analytic approaches. The setting was a single academic, quaternary referral hospital with 2 freestanding ambulatory surgery centers and a central preoperative clinic. Included in the study were adult patients undergoing nonurgent outpatient inguinal hernia repairs, lumpectomy, or laparoscopic cholecystectomy between June 2022 and August 2023. Eligible clinicians included those treating at least 1 patient during both the preintervention and postintervention periods.

Interventions

All clinicians were exposed to the multicomponent deimplementation intervention, and their testing practices were compared before and after the intervention. The strategy components were evidenced-based decisional support, multidisciplinary stakeholder engagement, educational sessions, and consensus building with surgeons and physician assistants staffing a preoperative clinic.

Main Outcomes and Measures

The primary end point of the trial was the rate of unnecessary preoperative tests across each trial period.

Results

A total of 1143 patients (mean [SD] age, 58.7 [15.5] years; 643 female [56.3%]) underwent 261 operations (23%) in the preintervention period, 510 (45%) in the intervention period, and 372 (33%) in the postintervention period. Unnecessary testing rates decreased over each period (intervention testing rate, -16%; 95% CI, -4% to -27%; P = .01; postintervention testing rate, -27%; 95% CI, -17% to -38%; P = .003) and within each test category. The decrease in overall testing was not observed at other hospitals in the state on adjusted difference-in-difference analysis.

Conclusions and Relevance

In this quality improvement study, a multicomponent deimplementation strategy was associated with a reduction in unnecessary preoperative testing before low-risk general surgery operations. The resulting changes in testing practice patterns were not associated with temporal trends within or outside the study hospital. Results suggest that this intervention was effective, applicable to common general surgery operations, and adaptable for expansion into appropriate clinical settings.

Early Tissue Resection Versus Watchful Waiting After Revascularization for Chronic Limb-Threatening Ischemia: A Meta-Analysis

No consensus or guideline has been established regarding the optimal timing of tissue resection after revascularization in patients with chronic limb-threatening ischemia (CLTI). This study aimed to compare early tissue resection and watchful waiting after revascularization regarding the outcomes of patients with CLTI. We searched PubMed, the Cochrane Library, and EMBASE for relevant randomized trials and observational studies published from their inception to May 1, 2024. In total, five articles were analyzed. The results showed that the early tissue resection group had a higher wound healing rate than the watchful waiting group (I2 = 26%, odds ratio [OR] = 2.80, 95% confidence interval [CI] 1.32 to 5.92, P = 0.007). However, the rate of major amputation was significantly higher in the early tissue resection group than in the watchful waiting group (I2 = 5%, OR = 1.48, 95% CI 1.18 to 1.86, P < 0.001), and wound recurrence rate in the early tissue resection group was relatively higher than that in the watchful waiting group (I2 = 0%, OR = 2.42, 95% CI: 0.99 to 5.93, P = 0.05). No statistical significance was found in the rate of postoperative mortality (I2 = 2%, OR = 0.99, 95% CI: 0.69 to 1.41, P = 0.94) and wound healing time (I2 = 97%, standardized mean difference = -105.92, 95% CI -232.96 to 21.13, P = 0.10) between the early tissue resection and watchful waiting groups. For patients without signs of infection, a watchful waiting strategy could reduce the risk of major amputation.

Percutaneous coronary intervention-lobectomy for Lung Cancer hybrid surgery: an initial case series

BACKGROUND

For patients diagnosed with both lung cancer and severe coronary heart disease (CHD), the conflict between revascularization and lung cancer surgery remains to be settled to balance how to attenuate the cardiovascular risk for lung surgery and shorten the waiting time of anti-platelet therapy after revascularization. This study presents the percutaneous coronary intervention (PCI)-lobectomy for lung cancer hybrid surgery (PLHS), and its antithrombotic therapeutic strategy.

METHODS

From October 2020 to June 2023, 14 patients, with unstable angina and resectable lung cancer received PLHS. All procedures were performed in a hybrid operating room. Drug-eluting stents (DES) were implanted during PCI. Lobectomy was carried out within one hour after PCI.

RESULTS

Procedural success was 100%. All the patients subjected to PLHS were alive after 12 months of follow-up; 2 patients (14.29%) died due to distant metastasis within 12-24 months post-PLHS. There were no intraoperative complications, or 30-day- and 3-month-mortality. Except for one patient who suffered pneumothorax, no other postoperative complications, including severe bleeding, or in-stent restenosis, occurred in the 31.7 ± 10.9 months follow-up.

CONCLUSIONS

PLHS is a feasible and potentially safe option for patients with both lung cancer and severe CHD.

Preoperative Optimization Strategies in Elective Spine Surgery

» Although spine surgery is effective in reducing pain and improving functional status, it is associated with unacceptably high rates of complications, thus necessitating comprehensive preoperative patient optimization.» Numerous risk factors that can impact long-term surgical outcomes have been identified, including malnutrition, cardiovascular disease, osteoporosis, substance use, and more.» Preoperative screening and personalized, evidence-based interventions to manage medical comorbidities and optimize medications can enhance clinical outcomes and improve patient satisfaction following spine surgery.» Multidisciplinary team-based approaches, such as enhanced recovery after surgery protocols and multidisciplinary conferences, can further facilitate coordinated care from across specialties and reduce overall hospital length of stay.

Data Science and Geriatric Anesthesia Research: Opportunity and Challenges

With an increase in geriatric population undergoing surgical procedures, research focused on enhancing their perioperative outcomes is of paramount importance. Currently, most of the evidence-based medicine protocols are driven by studies concentrating on adults encompassing all adult age groups. Given the alterations in physiology with aging, geriatric patients respond differently to anesthetics and, therefore, require specific research initiatives to further expound on the same. Large databases and the development of sophisticated analytic tools can provide meaningful insights into this. Here, we discuss a few research opportunities and challenges that data scientists face when focusing on geriatric perioperative research.

Influence of preoperative blood pressure on postoperative bleeding complications following Mohs micrographic surgery

Background

Hypertension is a common comorbidity in patients undergoing Mohs micrographic surgery (MMS). Evidence in other surgical fields has suggested that high blood pressure increases the risk of perioperative bleeding, predisposing patients to complications such as hematomas, dehiscence, wound infection, and necrosis.

Methods

We reviewed medical charts of all 530 patients who underwent MMS at our institution in one calendar year to identify whether an association exists between preoperative blood pressure and bleeding outcomes in patients undergoing MMS.

Results

Perioperative variables, including history of diagnosed hypertension, preoperative systolic blood pressure >160 mm Hg, systolic blood pressure >180 mm Hg, anticoagulation/antiplatelet therapy, tumor type, and number of stages did not significantly increase the risk of overall postoperative complications, including intra- and postoperative bleeding.

Conclusion

Hypertensive patients and those on anticoagulation/antiplatelet therapy are not at significantly increased risk of bleeding or other complications following MMS.

Association of preoperative blood biomarkers with postoperative major adverse cardiac events and mortality in major orthopaedic surgery: a systematic review and meta-analysis

OBJECTIVE

The association between preoperative blood biomarkers and major adverse cardiac events (MACEs) as well as mortality after major orthopaedic surgery remains unclear. This study aimed to assess the association between preoperative blood biomarkers and postoperative MACEs as well as all-cause mortality in patients undergoing major orthopaedic surgery.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, the Cochrane Controlled Trials Register and Cochrane Database of Systematic Reviews from inception to 20 October 2024 were searched.

ELIGIBILITY CRITERIA

Observational or experimental studies reporting the correlation between preoperative blood biomarkers and postoperative MACEs-categorised as short-term (within 3 months) or long-term (beyond 3 months)-and all-cause mortality in patients undergoing major orthopaedic surgery.

DATA EXTRACTION AND SYNTHESIS

Data from studies reporting OR or HR and its 95% CI were pooled for analysis using random-effects model.

RESULTS

21 preoperative blood-based biomarkers from 80 studies with 226 468 patients were analysed. Elevated preoperative cardiac biomarkers were correlated with a heightened risk of MACEs within 3 months (natriuretic peptide: OR 3.37, 95% CI 2.07 to 5.47, I2=87.9%; cardiac troponin: OR 4.89, 95% CI 1.52 to 15.75, I2=69.5%) with significant heterogeneity. Only natriuretic peptide was associated with a high-risk long-term MACEs (>3 months) (OR 3.52, 95% CI 1.73 to 7.17, I2=86.2%). In contrast, cardiac biomarkers were not identified as having prognostic value for all-cause mortality in this patient cohort. Additionally, an increased risk of all-cause mortality was associated with preoperative abnormal levels of albumin (OR 1.15, 95% CI 1.06 to 1.24, I2=84.8%), creatinine (OR 1.54, 95% CI 1.12 to 1.95, I2=0), 25(OH)D (OR 1.58, 95% CI 1.01 to 2.14, I2=0) and glomerular filtration rate (GFR) (OR 1.12, 95% CI 1.06 to 1.17, I2=0), rather than cardiac biomarkers.

CONCLUSIONS

The study proposed that cardiac biomarkers assessed before surgery could offer prognostic insight into short-term MACEs, while preoperative abnormal levels of albumin, creatinine, 25 (OH)D and GFR might be prognostic valuable for all-cause mortality following major orthopaedic surgery.

PROSPERO REGISTRATION NUMBER

CRD42022352091.

Preoperative risk assessment and optimization integrating surgical and anesthetic principles and practices: a national survey for internists

BACKGROUND

The integration of procedure-specific risks into preoperative patient assessment and optimization are crucial aspects of perioperative care. However, data on internists' knowledge of surgical and anesthetic principles and practices are limited. We thus sought to identify internists' knowledge gaps in terms of surgical- and anesthetic-specific risk factors and characteristics.

METHODS

An open and voluntary e-survey was conducted via LimeSurvey between April and July 2021 to evaluate Canadian internists' knowledge of surgical and anesthetic principles and practices. The survey included the perceived importance and knowledge of several key surgical and anesthetic aspects, such as surgery duration, procedure-specific cardiac risk, bleeding risk, and thrombotic risk. It also assessed pre- and post-survey self-reported confidence levels in one's knowledge of these characteristics. Finally, we investigated how internists optimize some of the preoperative risks.

RESULTS

A total of 173 Canadian internists opened the survey link, and 121 completed it (completion rate 70%). While the majority of respondents considered surgical and anesthetic principles and practices as important, most identified knowledge gaps. Participants generally estimated surgery duration and procedure-specific cardiac risk adequately. However, they tended to underestimate procedure-specific bleeding risk for general (58%) and orthopedic (76%) surgeries and to overestimate procedure-specific thrombotic risk for vascular (63%) and genitourinary (60%) surgeries. Furthermore, there is a lack of consensus regarding the appropriate hemoglobin A1c target and 0% of respondents reported using the guideline-suggested hemoglobin threshold for investigation and intervention.

CONCLUSIONS

Overall, our findings identify significant knowledge gaps among Canadian internists in preoperative assessment of procedure-specific risk factors and can be used to inform both the development of educational initiatives and future research to improve the quality of preoperative patient care.

Clinical Tools to Assess Functional Capacity During Risk Assessment Before Elective Noncardiac Surgery : A Scoping Review

BACKGROUND

Functional capacity is critical to preoperative risk assessment, yet guidance on its measurement in clinical practice remains lacking.

PURPOSE

To identify functional capacity assessment tools studied before surgery and characterize the extent of evidence regarding performance, including in populations where assessment is confounded by noncardiopulmonary reasons.

DATA SOURCES

MEDLINE, EMBASE, and EBM Reviews (until July 2024).

STUDY SELECTION

Studies evaluating performance of functional capacity assessment tools administered before elective noncardiac surgery to stratify risk for postoperative outcomes.

DATA EXTRACTION

Study details, measurement properties, pragmatic qualities, and/or clinical utility metrics.

DATA SYNTHESIS

6 categories of performance-based tests and 5 approaches using patient-reported exercise tolerance were identified. Cardiopulmonary exercise testing (CPET) was the most studied tool (132 studies, 32 662 patients) followed by field walking tests (58 studies, 9393 patients) among performance-based tests. Among patient-reported assessments, the Duke Activity Status Index (14 studies, 3303 patients) and unstructured assessments (19 studies, 28 520 patients) were most researched. Most evidence focused on predictive validity (92% of studies), specifically accuracy in predicting cardiorespiratory complications. Several tools lacked evidence on reliability (test consistency across similar measurements), pragmatic qualities (feasibility of implementation), or concurrent criterion validity (correlation to gold standard). Only CPET had evidence on clinical utility (whether administration improved postoperative outcomes). Older adults (≥65 years) were well represented across studies, whereas there were minimal data in patients with obesity, lower-limb arthritis, and disability.

LIMITATION

Synthesis focused on reported data without requesting missing information.

CONCLUSION

Though several tools for preoperative functional capacity assessment have been studied, research has overwhelmingly focused on CPET and only 1 aspect of validity (predictive validity). Important evidence gaps remain among vulnerable populations with obesity, arthritis, and physical disability.

PRIMARY FUNDING SOURCE

None. (Open Science Framework: https://osf.io/ah7u5).

Outcomes of thoracoabdominal aortic aneurysm repair in patients with a previous myocardial infarction

OBJECTIVE

Many patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair have had a previous myocardial infarction (MI). To address the paucity of data regarding outcomes in such patients, we aimed to compare outcomes after open TAAA repair in patients with and without previous MI.

METHODS

From 1986 to 2022, we performed 3737 consecutive open TAAA repairs. Of these, 706 (18.9%) were in patients with previous MI. We used multivariable logistic regression to identify predictors of operative death. Propensity score matching analyzed preoperative and select operative variables to create matched groups of patients with or without a previous MI (n = 704 pairs). Late survival was determined by Kaplan-Meier analysis and compared by log rank test.

RESULTS

Overall, operative mortality was 8.5% and the adverse event rate was 15.2%; these were elevated in patients with MI (11.0% vs 7.9% [P = .01] and 18.0% vs 14.6% [P = .02], respectively). In the propensity score-matching cohort, the MI group had a greater rate of cardiac complications (32.4% vs 25.4%; P = .005) and delayed paraparesis (5.1% vs 2.4%; P = .1); however, there was no difference in operative mortality (11.1% vs 10.9%; P = 1) or adverse event rate (18.0% vs 16.8%; P = .6). Overall, previous MI was not independently associated with operative mortality in multivariable analysis (P = .1). The matched MI group trended toward poorer 10-year survival (29.8% ± 1.9% non-MI vs 25.0% ± 1.8% MI; P = .051).

CONCLUSIONS

Although previous MI was not associated with early mortality after TAAA repair, patients with a previous MI had greater rates of cardiac complications and delayed paraparesis. Patients with a previous MI also trended toward poorer survival.

Adverse outcomes after surgery after a cerebrovascular accident or acute coronary syndrome: a retrospective observational cohort study

BACKGROUND

Delaying surgery after a major cardiovascular event might reduce adverse postoperative outcomes. The time interval represents a potentially modifiable risk factor but is not well studied.

METHODS

This was a longitudinal retrospective population-based cohort study, linking data from Hospital Episode Statistics for NHS England and the Myocardial Ischaemia National Audit Project. Adults undergoing noncardiac, non-neurologic surgery in 2007-2018 were included. The time interval between a preoperative cardiovascular event and surgery was the main exposure. The outcomes of interest were acute coronary syndrome (ACS), acute myocardial infarction (AMI), cerebrovascular accident (CVA) within 1 year of surgery, unplanned readmission (at 30 days and 1 year), and prolonged length of stay. Multivariable logistic regression models with restricted cubic splines were used to estimate adjusted odds ratios (aORs; age, sex, socioeconomic deprivation, and comorbidities).

RESULTS

In total, 877 430 people had a previous cardiovascular event and 20 582 717 were without an event. CVA, ACS, and AMI in the year after elective surgery were more frequent after prior cardiovascular events (adjusted hazard ratio 2.12, 95% confidence interval [CI] 2.08-2.16). Prolonged hospital stay (aOR 1.36, 95% CI 1.35-1.38) and 30-day (aOR 1.28, 95% CI 1.25-1.30) and 1-yr (aOR 1.60, 95% CI 1.58-1.62) unplanned readmission were more common after major operations in those with a prior cardiovascular event. After adjusting for the time interval between preoperative events until surgery, elective operations within 37 months were associated with an increased risk of postoperative ACS or AMI. The risk of postoperative stroke plateaued after a 20-month interval until surgery, irrespective of surgical urgency.

CONCLUSIONS

These observational data suggest increased adverse outcomes after a recent cardiovascular event can occur for up to 37 months after a major cardiovascular event.

Perioperative Medicine for Ambulatory Surgery

Ambulatory anesthesia for same-day surgery is a fast-growing and ever-improving branch of modern anesthesia. This is primarily driven by the involvement of anesthesiologists as perioperative physicians working in multidisciplinary groups. These groups work together to improve patient safety, patient outcomes, and overall efficiency of both in-patient and out-patient surgery. Appropriate patient selection and optimization are critical to maintain and improve the foundational entities of best ambulatory anesthesia practice. In this review article, a selection of considerations in the field of ambulatory anesthesia are featured, such as the aging population, sleep apnea, obesity, diabetes, cardiac disease, substance abuse, preoperative medication management, multimodal analgesia, social determinants of health, and surgical facility resources.

Evaluating perioperative risks in total knee arthroplasty patients with normal preoperative cardiac stress tests

INTRODUCTION

While it is generally accepted that most patients undergoing joint replacement do not require a cardiac stress test, individuals with existing or potential cardiac conditions may be at an increased risk of perioperative complications following primary total knee arthroplasty (TKA). This study aims to analyze the immediate postoperative outcomes of patients who underwent primary TKA, comparing those who had a cardiac stress test with no abnormal results and subsequent cardiac interventions to those who did not undergo a stress test.

MATERIALS AND METHODS

This retrospective cohort study utilized the TriNetX Research Network. The first cohort included patients who underwent a stress test within one year prior to their TKA, had no abnormal results, and did not undergo cardiac catheterization within two weeks post-stress test (Normal Stress Test). The second cohort consisted of patients who did not have a stress test in the year preceding their TKA (No Stress Test). The study analyzed data collected between January 1, 2003, and January 1, 2024. To control for confounding variables, propensity score matching was employed. P < 0.01 was considered significant.

RESULTS

A total of 13,881 patients successfully matched in each cohort. Within 30 days following TKA, patients in the Normal Stress Test cohort exhibited a significantly elevated risk of several complications: Transfusion (RR: 1.702), Myocardial Infarction (MI) (RR: 1.908), Acute Renal Failure (ARF) (RR: 1.504), Acute Posthemorrhagic Anemia (RR: 1.245), Wound Dehiscence (RR: 1.549), and Pneumonia (RR: 2.051). These results were consistent at the 90-day follow-up. Notably, the risk of death was only elevated before propensity score matching (RR: 2.115).

CONCLUSION

Our findings suggest that the underlying conditions prompting the use of a cardiac stress test, including congestive heart failure and renal insufficiency, may themselves be indicative of a higher overall perioperative risk, regardless of the stress test results.

LEVELS OF EVIDENCE

Level III: Case-control study or retrospective cohort study.

Validity of estimated aortic pulse wave velocity measured during the 6-min walk test to predict anaerobic fitness before major non-cardiac surgery

BACKGROUND

This study aimed to assess the efficacy of estimated preoperative aortic pulse wave velocity (AoPWV) to discriminate between low and high 6 min walk test (6MWT) distance in patients awaiting major non-cardiac surgery.

METHODS

Prospective observational study in 133 patients undergoing non cardiac surgery. AoPWV and the distance walked during a 6MWT were assessed. Receiver operating characteristic (ROC) curve analysis was used to determine two different AoPWV cut-points for predicting a distance of 427 m in the 6MWT. We also calculated lower and upper AoPWV cut-points (probability ≥ 0.75) for predicting a distance of < 427 m, ≥427 m, and also 563 m in the 6MWT.

RESULTS

The ROC curve analysis for the < 427 m distance revealed an area under the curve (AUC) of 0.68 (95% confidence interval 0.56-0.79) and an AUC of 0.72 (95% confidence interval 0.61-0.83) for >563 m. Patients with AoPWV > 10.97 m/s should be considered high risk, while those with <9.42 m/s can be considered low risk.

CONCLUSIONS

AoPWV is a simple, non-invasive, useful clinical tool for identifying and stratifying patients awaiting major non-cardiac surgery. In situations of clinical uncertainty, additional measures should be taken to assess the risk.

Beta-Blocker Use in Patients Undergoing Non-Cardiac Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

The use of beta-blockers in the perioperative period has been widely investigated due to their potential to reduce the risk of major adverse cardiovascular and cerebrovascular events (MACCE) and mortality; yet their overall impact on various postoperative outcomes remains debated. This study constitutes a systematic review and meta-analysis of the impact of beta-blockers on mortality, MI, stroke, and other adverse effects such as hypotension and bradycardia in patients undergoing non-cardiac surgery.

METHODS

A comprehensive systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines. Searches were performed across PubMed, Cochrane, Web of Science, Scopus, EMBASE, and CINAHL databases; we included randomized controlled trials and cohort and case-control studies published from 1999 to 2024.

RESULTS

This meta-analysis included data from 28 studies encompassing 1,342,430 patients. Perioperative beta-blockers were associated with a significant increase in stroke risk (RR 1.42, 95% CI: 1.03 to 1.97, p = 0.03, I2 = 62%). However, no statistically significant association was found between beta-blocker use and mortality (RR 0.62, 95% CI: 0.38 to 1.01, p = 0.05, I2 = 100%). Subgroup analyses revealed a protective effect on mortality for patients with high risks, such as patients with a history of atrial fibrillation, chronic heart failure, and other arrhythmias. For myocardial infarction (RR 0.82, 95% CI: 0.53 to 1.28, p = 0.36, I2 = 86%), a reduction in events was observed in the subgroup of randomized controlled trials. Beta-blockers significantly increased the risk of hypotension (RR 1.46, 95% CI: 1.26 to 1.70, p < 0.01, I2 = 25%) and bradycardia (RR 2.26, 95% CI: 1.37 to 3.74, p < 0.01, I2 = 64%).

CONCLUSIONS

Perioperative beta-blockers show increasing rates of stroke events following non-cardiac surgery but do not significantly impact the incidence of MI or mortality. The increased risks of hypotension and bradycardia necessitate careful patient selection and monitoring. Future research should aim to refine patient selection criteria and optimize perioperative management to balance the benefits and risks of beta-blocker use in surgical settings.

Preoperative Testing

Preoperative medical evaluation can minimize inefficiencies and improve outcomes. Thoughtful use of preoperative testing can aid in that effort, but, conversely, indiscriminate testing can detract from it. The United Kingdom National Institute for Health Care and Excellence, European Society of Anaesthesiology, and American Society of Anesthesiologists (ASA) have all stated that routine preoperative testing is not supported by evidence. Testing is supported only when clinical indications are present. Particularly in low-risk patients, such as those with an ASA classification of 1 or 2 who are undergoing ambulatory procedures, evidence suggests that preoperative testing fails to reduce the risk of complications.

Current challenges and future perspectives in treating patients with NAFLD-related cirrhosis

Despite the slow, progressive nature of NAFLD, the number of patients with NAFLD-related cirrhosis has significantly increased. Although the management of patients with cirrhosis is constantly evolving, improving the prognosis of patients with NAFLD-related cirrhosis is a challenge because it is situated at the crossroads between the liver, the metabolic, and the cardiovascular diseases. Therefore, the therapeutic interventions should not only target the liver but also the associated cardiometabolic conditions and should be adapted accordingly. The objective of the current review is to critically discuss the particularities in the management of patients with NAFLD-related cirrhosis. We relied on the recommendations of scientific societies and discussed them in the specific context of NAFLD cirrhosis and the surrounding cardiometabolic milieu. Herein, we covered the following aspects: (1) the weight loss strategies through lifestyle interventions to avoid sarcopenia and improve portal hypertension; (2) the optimal control of metabolic comorbidities in particular type 2 diabetes aimed not only to improve cardiovascular morbidity/mortality but also to lower the incidence of cirrhosis-related complications (we discussed various aspects related to the safety of oral antidiabetic drugs in cirrhosis); (3) the challenges in performing bariatric surgery in patients with cirrhosis related to the portal hypertension and the risk of cirrhosis decompensation; (4) the particularities in the diagnosis and management of the portal hypertension and the difficulties in managing patients awaiting for liver transplantation; and (5) the difficulties in developing drugs and conducting clinical trials in patients with NAFLD-related cirrhosis. Moreover, we discussed the emerging options to overcome these obstacles.

Coronary Disease Risk Prediction, Risk Reduction, and Postoperative Myocardial Injury

For patients considering surgery, the preoperative evaluation allows physicians to identify and treat acute cardiac conditions before less-urgent surgery, predict the benefits and harms of a proposed surgery, and make temporary management changes to reduce operative risk. Multiple risk prediction tools are reasonable for use in estimating perioperative cardiac risk, but management changes to reduce risk have proven elusive. For all but the most urgent surgical procedures, patients with active coronary syndromes or decompensated heart failure should have surgery postponed.

An interrater reliability analysis of preoperative mortality risk calculators used for elective high-risk noncardiac surgical patients shows poor to moderate reliability

BACKGROUND

Multiple preoperative calculators are available online to predict preoperative mortality risk for noncardiac surgical patients. However, it is currently unknown how these risk calculators perform across different raters. The current study investigated the interrater reliability of three preoperative mortality risk calculators in an elective high-risk noncardiac surgical patient population to evaluate if these calculators can be safely used for identification of high-risk noncardiac surgical patients for a preoperative multidisciplinary team discussion.

METHODS

Five anesthesiologists assessed the preoperative mortality risk of 34 high-risk patients using the preoperative score to calculate postoperative mortality risks (POSPOM), the American College of Surgeons surgical risk calculator (SRC), and the surgical outcome risk tool (SORT). In total, 170 calculations per calculator were gathered.

RESULTS

Interrater reliability was poor for SORT (ICC (C.I. 95%) = 0.46 (0.30-0.63)) and moderate for SRC (ICC = 0.65 (0.51-0.78)) and POSPOM (ICC = 0.63 (0.49-0.77). The absolute range of calculated mortality risk was 0.2-72% for POSPOM, 0-36% for SRC, and 0.4-17% for SORT. The coefficient of variation increased in higher risk classes for POSPOM and SORT. The extended Bland-Altman limits of agreement suggested that all raters contributed to the variation in calculated risks.

CONCLUSION

The current results indicate that the preoperative risk calculators POSPOM, SRC, and SORT exhibit poor to moderate interrater reliability. These calculators are not sufficiently accurate for clinical identification and preoperative counseling of high-risk surgical patients. Clinicians should be trained in using mortality risk calculators. Also, clinicians should be cautious when using predicted mortality estimates from these calculators to identify high-risk noncardiac surgical patients for elective surgery.

Preoperative echocardiography and anesthetic drugs as predictors of post-induction hypotension during general anesthesia: a prospective observational study

Post-induction hypotension (PIH) during general anesthesia is a serious concern due to its high incidence and association with adverse postoperative outcomes and prognosis. We prospectively enrolled consecutive 1,603 patients scheduled for non-cardiac and cardiac surgery under general anesthesia. The primary outcome was defined as the lowest mean blood pressure from induction of general anesthesia to the start of surgery: post-induction blood pressure (PIB). Multivariable regression analysis was used to investigate the relationships between PIB and preoperative echocardiographic measurements, types and doses of anesthetic agents, and preoperative comorbidities and oral medication. Left ventricle regional wall motion abnormality (RWMA) and lower estimated glomerular filtration rate significantly associated lower PIB. Factors significantly associated with higher PIB were high BMI, beta blockers, high pre-induction mean blood pressure, and starting induction in the afternoon. Sevoflurane and prophylactic norepinephrine use were associated with higher PIB as anesthetic interventions. Significant interactions were found between sevoflurane and RWMA (P for interaction: 0.01). This is the first study to demonstrate the feasibility of intervening in the selection of anesthetic agents based on echocardiographic findings and to recommend the use of sevoflurane and prophylactic norepinephrine for the prevention of PIH, especially in patients with RWMA.

Most preoperative stress tests fail to comply with practice guideline indications and do not reduce cardiac events

BACKGROUND

There is wide variation in stress test utilization before major vascular surgery and adherence to practice guidelines is unclear. We defined rates of stress test compliance at our institution and led a quality improvement initiative to improve compliance with American Heart Association (ACC/AHA) guidelines.

METHODS

We implemented a stress testing order set in the electronic medical record at one tertiary hospital. We reviewed all patients who underwent elective, major vascular surgery in the 6 months before (Jan 1, 2022 - Jul 1, 2022) and 6 months after (Aug 1, 2022 - Jan 31, 2023) implementation. We studied stress test guideline compliance, changes in medical or surgical management, and major adverse cardiac events (MACE).

RESULTS

Before order set implementation, 37/122 patients (30%) underwent stress testing within the past year (29 specifically ordered preoperatively) with 66% (19/29) guideline compliance. After order set implementation, 50/173 patients (29%) underwent stress testing within the past year (41 specifically ordered preoperatively) with 80% (33/41) guideline compliance. In the pre- and postimplementation cohorts, stress testing led to a cardiovascular medication change or preoperative coronary revascularization in 24% (7/29) and 27% (11/41) of patients, and a staged surgery or less invasive anesthetic strategy in 14% (4/29) and 4.9% (2/41) of patients, respectively. All unindicated stress tests were surgeon-ordered and none led to a change in management. There was no change in MACE after order set implementation.

CONCLUSIONS

Electronic medical record-based guidance of perioperative stress testing led to a slight decrease in overall stress testing and an increase in guideline-compliant testing. Our study highlights a need for improved preoperative cardiovascular risk assessment prior to major vascular surgery, which may eliminate unnecessary testing and more effectively guide perioperative decision-making.

Perioperative Care for Bariatric Surgery

This review will start with a brief pathophysiology of obesity and the requirement for bariatric surgery, and it continues with a preoperative assessment, which includes a surgical mortality risk assessment, respiratory and cardiovascular assessments, and a psychological assessment. In-hospital postoperative care will be discussed, including which patients need a surgical intensive care unit and the monitoring tools required. The need for postoperative medications, postoperative complications, strategies for management, and a follow-up plan are also reviewed. This manuscript is written in a narrative review form with a chance of bias as a possible limitation.

Preoperative N-terminal Pro-B-type Natriuretic Peptide and High-sensitivity Cardiac Troponin T and Outcomes after Major Noncardiac Surgery: A Prospective Cohort Study

BACKGROUND

Patients undergoing noncardiac surgery have varying risk of cardiovascular complications. This study evaluated preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T to enhance cardiovascular events prediction for major noncardiac surgery.

METHODS

This prospective cohort study included adult patients with cardiovascular disease or risk factors undergoing elective major noncardiac surgery at four hospitals in China. Blood samples were collected within 30 days before surgery for NT-proBNP and high-sensitivity troponin T (hs-TnT) measurements. The primary outcome was a composite of any cardiovascular events within 30 days after surgery. Logistic regression models were used to assess associations, and the predictive performance was evaluated primarily using area under the receiver operating characteristics curve (AUC) and fraction of new predictive information.

RESULTS

Between June 2019 and September 2021, a total of 2,833 patients were included, with 435 (15.4%) experiencing the primary outcome. In the logistic regression model that included clinical variables and both biomarkers, the odds ratio for the primary outcome was 1.68 (95% CI, 1.37 to 2.07) when comparing the 75th percentile to the 25th percentile of NT-proBNP distribution, and 1.91 (95% CI, 1.50 to 2.43) for hs-TnT. Each biomarker enhanced model discrimination beyond clinical predictors, with a change in AUC of 0.028 for NT-proBNP and 0.029 for high-sensitivity cardiac troponin T, and a fraction of new information of 0.164 and 0.149, respectively. The model combining both biomarkers demonstrated the best discrimination, with a change in AUC of 0.042 and a fraction of new information of 0.219.

CONCLUSIONS

Preoperative NT-proBNP and hs-TnT both improved the prediction for cardiovascular events after noncardiac surgery in addition to clinical evaluation, with their combination providing maximal predictive information.

EDITOR’S PERSPECTIVE

Anesthesia Management of Hip Fracture Surgery in Geriatric Patients: A Review

Hip fractures are increasingly prominent concerns in healthcare, especially in light of a growing elderly population. These fractures contribute to mortality and morbidity in the elderly. Many hip fractures require emergent surgical intervention and may have consequences of serious postoperative complications. Multidisciplinary approaches of management have been utilized to optimize care and improve patient outcomes. Due to the myriad of multi-organ system comorbidities that are increasingly prevalent in the geriatric population, anesthetic management proves to be difficult to standardize. Enhanced Recovery After Surgery (ERAS) protocols have shown benefits for optimizing patient outcomes by focusing on premedication, nutritional support, and pain management; however, specific anesthetic management techniques are not discussed. This literature review aims to discuss ways to optimize hip fracture management in geriatric patients through effective preoperative evaluation, anesthetic considerations, and postoperative optimization and care. A review of currently available guidelines may help determine the optimal management for hip fractures in geriatric patients and improve immediate and lasting postoperative outcomes.

Does a delay to surgery for preoperative echocardiogram affect outcomes in patients with hip fracture?

Introduction

Delay to surgery >24 hours has been shown to correlate with mortality rates in patients with hip fracture when left untreated. Many of these patients have multiple comorbidities, including aortic stenosis (AS), and undergo workup for operative clearance, which may delay time to surgery. The purpose of this study was to examine whether preoperative echocardiogram workup affects time to surgery, complications, and mortality after operative fixation for hip fracture.

Methods

Our institutional hip fracture registry was retrospectively reviewed for inclusion over a 3-year period. Patients who had a preoperative echocardiogram (yECHO) for operative clearance were compared with those who did not (nECHO). Demographic data, time to surgery, overall complication rate, and mortality at 30 days, 90 days, and 1 year were collected.

Results

Two cohorts consisted of 136 yECHO patients (45.8%) and 161 nECHO patients (54.2%). Thirty-two yECHO patients (23.5%) had AS. Patients in the yECHO cohort were more likely to have a complication for any cause compared with nECHO patients (25.7% vs. 10.6%, P = 0.01) and have a higher mortality rate at 1 year (38.9% vs. 17.4%, P = 0.001). There was no association found between AS and all-cause complication (P = 0.54) or 30-day (P = 0.13) or 90-day mortality rates (P = 0.79). However, patients with AS had a significantly higher mortality rate at 1 year (45.8% vs. 25.1%, P = 0.03).

Conclusion

This study reinforces the benefits of ensuring less than a 24-hour time to surgery in the setting of a hip fracture and identifies an area of preoperative management that can be further optimized to prevent unnecessary prolongation in time to surgery. Patients with known aortic stenosis are not associated with increased 30-day or 90-day mortality or all-cause complications. Surgical delays in the yECHO cohort were attributed to preoperative medical assessments, including echocardiograms and the management of comorbidities. Therefore, the selective utilization of preoperative echocardiograms is needed and should be reserved to ensure they have a definitive role in guiding the perioperative care of patients with hip fracture.

Level of Evidence

III.

The Evolution of Risk Assessment in Spine Surgery: A Narrative Review

BACKGROUND

Risk assessment is critically important in elective and high-risk interventions, particularly spine surgery. This narrative review describes the evolution of risk assessment from the earliest instruments focused on general surgical risk stratification, to more accurate and spine-specific risk calculators that quantified risk, to the current era of big data.

METHODS

The PubMed and SCOPUS databases were queried on October 11, 2023 using search terms to identify risk assessment tools (RATs) in spine surgery. A total of 108 manuscripts were included after screening with full-text review using the following inclusion criteria: 1) study population of adult spine surgical patients, 2) studies describing validation and subsequent performance of preoperative RATs, and 3) studies published in English.

RESULTS

Early RATs provided stratified patients into broad categories and allowed for improved communication between physicians. Subsequent risk calculators attempted to quantify risk by estimating general outcomes such as mortality, but then evolved to estimate spine-specific surgical complications. The integration of novel concepts such as invasiveness, frailty, genetic biomarkers, and sarcopenia led to the development of more sophisticated predictive models that estimate the risk of spine-specific complications and long-term outcomes.

CONCLUSIONS

RATs have undergone a transformative shift from generalized risk stratification to quantitative predictive models. The next generation of tools will likely involve integration of radiographic and genetic biomarkers, machine learning, and artificial intelligence to improve the accuracy of these models and better inform patients, surgeons, and payers.

Is General Anesthesia for Peripheral Vascular Surgery Correlated with Impaired Outcome in Patients with Cardiac Comorbidity? A Closer Look into the Nationwide Danish Cohort

OBJECTIVE

General anesthesia (GA) may impair outcome after vascular surgery. The use of anticoagulant medication is often used in patients with cardiac comorbidity. Regional anesthesia (RA) requires planning of discontinuation before neuraxial blockade(s) in this subgroup. This study aimed to describe the effect of anesthesia choice on outcome after vascular surgery in patients with known cardiac comorbidity.

DESIGN

Retrospective cohort study.

SETTING

Danish hospitals.

PARTICIPANTS

6302 patients with known cardiac comorbidity, defined as ischemic heart disease, valve disease, pulmonary vascular disease, heart failure, and cardiac arrhythmias, undergoing lower extremity vascular surgery between 2005 and 2017.

INTERVENTIONS

GA versus RA.

MEASUREMENTS AND MAIN RESULTS

Data were extracted from national registries. GA was defined as anesthesia with mechanical ventilation. Multivariable regression models were used to describe the incidence of postoperative complications as well as 30-day mortality, hypothesizing that better outcomes would be seen after RA. The rate of RA decreased from 48% in 2005 to 20% in 2017. The number of patients with 1 or more complications was 9.7% vs 6.2% (p < 0.001), and 30-day mortality was 6.0% vs 3.4% (p < 0.001) after GA. After adjusting for baseline differences, the odds ratio (OR) was significantly lower for medical complications (cardiac, pulmonary, renal, new dialysis, intensive care unit and other medical complications; OR, 0.97; 95% confidence interval [CI], 0.95-0.98) and 30-day mortality (OR 0.98; 95% CI, 0.97-0.99) after RA.

CONCLUSIONS

RA may be associated with a better outcome than GA after lower extremity vascular surgery in patients with a cardiac comorbidity. Prioritizing RA, despite the inconvenience of discontinuing anticoagulants, may be recommended.

Patient selection for nonoperating room anesthesia

PURPOSE OF REVIEW

Given the rapid growth of nonoperating room anesthesia (NORA) in recent years, it is essential to review its unique challenges as well as strategies for patient selection and care optimization.

RECENT FINDINGS

Recent investigations have uncovered an increasing prevalence of older and higher ASA physical status patients in NORA settings. Although closed claim data regarding patient injury demonstrate a lower proportion of NORA cases resulting in a claim than traditional operating room cases, NORA cases have an increased risk of claim for death. Challenges within NORA include site-specific differences, limitations in ergonomic design, and increased stress among anesthesia providers. Several authors have thus proposed strategies focusing on standardizing processes, site-specific protocols, and ergonomic improvements to mitigate risks.

SUMMARY

Considering the unique challenges of NORA settings, meticulous patient selection, risk stratification, and preoperative optimization are crucial. Embracing data-driven strategies and leveraging technological innovations (such as artificial intelligence) is imperative to refine quality control methods in targeted areas. Collaborative efforts led by anesthesia providers will ensure personalized, well tolerated, and improved patient outcomes across all phases of NORA care.

Association between Preoperative Blood Pressures and Postoperative Adverse Events

BACKGROUND

The relationship between postoperative adverse events and blood pressures in the preoperative period remains poorly understood. This study tested the hypothesis that day-of-surgery preoperative blood pressures are associated with postoperative adverse events.

METHODS

The authors conducted a retrospective, observational study of adult patients having elective procedures requiring an inpatient stay between November 2017 and July 2021 at Vanderbilt University Medical Center to examine the independent associations between preoperative systolic and diastolic blood pressures (SBP, DBP) recorded immediately before anesthesia care and number of postoperative adverse events-myocardial injury, stroke, acute kidney injury, and mortality-while adjusting for potential confounders. The study used multivariable ordinal logistic regression to model the relationship.

RESULTS

The analysis included 57,389 cases. The overall incidence of myocardial injury, stroke, acute kidney injury, and mortality within 30 days of surgery was 3.4% (1,967 events), 0.4% (223), 10.2% (5,871), and 2.1% (1,223), respectively. The independent associations between both SBP and DBP measurements and number of postoperative adverse events were found to be U-shaped, with greater risk both above and less than SBP 143 mmHg and DBP 86 mmHg-the troughs of the curves. The associations were strongest at SBP 173 mmHg (adjusted odds ratio, 1.212 vs. 143 mmHg; 95% CI, 1.021 to 1.439; P = 0.028), SBP 93 mmHg (adjusted odds ratio, 1.339 vs. 143 mmHg; 95% CI, 1.211 to 1.479; P < 0.001), DBP 106 mmHg (adjusted odds ratio, 1.294 vs. 86 mmHg; 95% CI, 1.003 to 1.17671; P = 0.048), and DBP 46 mmHg (adjusted odds ratio, 1.399 vs. 86 mmHg; 95% CI, 1.244 to 1.558; P < 0.001).

CONCLUSIONS

Preoperative blood pressures both less than and above a specific threshold were independently associated with a higher number of postoperative adverse events, but the data do not support specific strategies for managing patients with low or high blood pressure on the day of surgery.

EDITOR’S PERSPECTIVE

Improving Compliance With Evidence-Based Laboratory Testing Recommendations and Monitoring Associated Patient Outcomes

A team comprising nursing, medical staff, and administrative leaders at an urban academic orthopedic hospital in the northeastern United States sought to revise a preoperative laboratory testing protocol based on evidence and practice guidelines. The goal was to decrease unnecessary tests by 20% without negatively affecting patient outcomes. After adding the revised protocol to the electronic health record, audits revealed that the target goal was not met and additional strategies were implemented, including educational webinars for surgeon office personnel who ordered tests, additional webinars for advanced practice professionals, and the creation of scorecards to track surgeons' progress. Overall, a downward trend in the ordering of unnecessary laboratory tests for patients without identified risks was observed, but a 20% reduction was not achieved. Surgical complications during the project were not associated with laboratory tests. Clinicians continue to use the revised preoperative laboratory testing protocol at the facility.

Cardiovascular disease among bariatric surgery candidates: coronary artery screening and the impact of metabolic syndrome

BACKGROUND

Obesity is known as a risk factor for cardiovascular disease (CVD). However, there is an absence of preoperative cardiac risk assessment in bariatric surgery candidates and the incidence of CVD among these high-risk patients is still unknown.

METHODS

A consecutive series of bariatric surgery candidates at two Chinese tertiary hospitals received coronary CT angiography or coronary angiography from 2017 to 2023. Patients were categorized as metabolically unhealthy obesity (MUO) and metabolically healthy obesity (MHO) based on the presence or absence of MetS. CVD was diagnosed based on the maximum intraluminal stenosis > 1% in any of the segments of the major epicardial coronary arteries. Obstructive CVD was defined as coronary stenosis ≥ 50%. Binary multivariable logistic regression was performed to analyze the association between CVD and metabolic status. The number of principal MetS components was categorized into zero (without glycemic, lipid, and BP components), one (with one of the components), two (with any two components), and three (with all components) to explore their association with CVD.

RESULTS

A total of 1446 patients were included in the study. The incidence of CVD and obstructive CVD were 31.7% and 9.6%. Compared with MHO patients, MUO patients had a significantly higher incidence of mild (13.7% vs. 6.1%, P < 0.05), moderate (7.4% vs. 0.8%, P < 0.05), and severe CVD (3.1% vs. 0%, P < 0.05). Following complete adjustment, compared with zero or one component, two principal MetS components was found to be associated with a notable increase in the risk of CVD (OR 2.05, 95% CI 1.18-3.58, P < 0.05); three principal MetS components were observed to have a higher risk of CVD and obstructive CVD (OR 2.68, 95% CI 1.56-4.62, P < 0.001; OR 3.93, 95% CI 1.19-12.93, P < 0.05). Each increase in the number of principal MetS components correlated with a 1.47-fold (95% CI 1.20-1.81, P < 0.001) and 1.78-fold (95% CI 1.24-2.55, P < 0.05) higher risk of CVD and obstructive CVD, respectively.

CONCLUSION

This study reported the incidence of CVD based on multicenter bariatric surgery cohorts. CVD is highly prevalent in patients with obesity, especially in MUO patients. Increased number of principal MetS components will significantly elevate the risk of CVD.

Preoperative evaluation profile of patients undergoing arterial vascular surgery in a tertiary hospital

BACKGROUND

Patients with peripheral arterial disease have an increased risk of developing cardiovascular complications in the postoperative period of arterial surgeries known as Major Adverse Cardiac Events (MACE), which includes acute myocardial infarction, heart failure, malignant arrhythmias, and stroke. The preoperative evaluation aims to reduce mortality and the risk of MACE. However, there is no standardized approach to performing them. The aim of this study was to compare the preoperative evaluation conducted by general practitioners with those performed by cardiologists.

METHODS

This is a retrospective analysis of medical records of patients who underwent elective arterial surgeries from January 2016 to December 2020 at a tertiary hospital in São Paulo, Brazil. The authors compared the preoperative evaluation of these patients according to the initial evaluator (general practitioners vs. cardiologists), assessing patients' clinical factors, mortality, postoperative MACE incidence, rate of requested non-invasive stratification tests, length of hospital stay, among others.

RESULTS

281 patients were evaluated: 169 assessed by cardiologists and 112 by general practitioners. Cardiologists requested more non-invasive stratification tests (40.8%) compared to general practitioners (9%) (p < 0.001), with no impact on mortality (8.8% versus 10.7%; p = 0.609) and postoperative MACE incidence (10.6% versus 6.2%; p = 0.209). The total length of hospital stay was longer in the cardiologist group (17.27 versus 11.79 days; p < 0.001).

CONCLUSION

The increased request for exams didn't have a significant impact on mortality and postoperative MACE incidence, but prolonged the total length of hospital stay. Health managers should consider these findings and ensure appropriate utilization of human and financial resources.

Preoperative coronary interventions for preventing acute myocardial infarction in the perioperative period of major open vascular or endovascular surgery

BACKGROUND

Postoperative myocardial infarction (POMI) is associated with major surgeries and remains the leading cause of mortality and morbidity in people undergoing vascular surgery, with an incidence rate ranging from 5% to 20%. Preoperative coronary interventions, such as coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI), may help prevent acute myocardial infarction in the perioperative period of major vascular surgery when used in addition to routine perioperative drugs (e.g. statins, angiotensin-converting enzyme inhibitors, and antiplatelet agents), CABG by creating new blood circulation routes that bypass the blockages in the coronary vessels, and PCI by opening up blocked blood vessels. There is currently uncertainty around the benefits and harms of preoperative coronary interventions.

OBJECTIVES

To assess the effects of preoperative coronary interventions for preventing acute myocardial infarction in the perioperative period of major open vascular or endovascular surgery.

SEARCH METHODS

We searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, and CINAHL EBSCO on 13 March 2023. We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) or quasi-RCTs that compared the use of preoperative coronary interventions plus usual care versus usual care for preventing acute myocardial infarction during major open vascular or endovascular surgery. We included participants of any sex or any age undergoing major open vascular surgery, major endovascular surgery, or hybrid vascular surgery.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes of interest were acute myocardial infarction, all-cause mortality, and adverse events resulting from preoperative coronary interventions. Our secondary outcomes were cardiovascular mortality, quality of life, vessel or graft secondary patency, and length of hospital stay. We reported perioperative and long-term outcomes (more than 30 days after intervention). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included three RCTs (1144 participants). Participants were randomised to receive either preoperative coronary revascularisation with PCI or CABG plus usual care or only usual care before major vascular surgery. One trial enrolled participants if they had no apparent evidence of coronary artery disease. Another trial selected participants classified as high risk for coronary disease through preoperative clinical and laboratorial testing. We excluded one trial from the meta-analysis because participants from both the control and the intervention groups were eligible to undergo preoperative coronary revascularisation. We identified a high risk of performance bias in all included trials, with one trial displaying a high risk of other bias. However, the risk of bias was either low or unclear in other domains. We observed no difference between groups for perioperative acute myocardial infarction, but the evidence is very uncertain (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.02 to 4.57; 2 trials, 888 participants; very low-certainty evidence). One trial showed a reduction in incidence of long-term (> 30 days) acute myocardial infarction in participants allocated to the preoperative coronary interventions plus usual care group, but the evidence was very uncertain (RR 0.09, 95% CI 0.03 to 0.28; 1 trial, 426 participants; very low-certainty evidence). There was little to no effect on all-cause mortality in the perioperative period when comparing the preoperative coronary intervention plus usual care group to usual care alone, but the evidence is very uncertain (RR 0.79, 95% CI 0.31 to 2.04; 2 trials, 888 participants; very low-certainty evidence). The evidence is very uncertain about the effect of preoperative coronary interventions on long-term (follow up: 2.7 to 6.2 years) all-cause mortality (RR 0.74, 95% CI 0.30 to 1.80; 2 trials, 888 participants; very low-certainty evidence). One study reported no adverse effects related to coronary angiography, whereas the other two studies reported five deaths due to revascularisations. There may be no effect on cardiovascular mortality when comparing preoperative coronary revascularisation plus usual care to usual care in the short term (RR 0.07, 95% CI 0.00 to 1.32; 1 trial, 426 participants; low-certainty evidence). Preoperative coronary interventions plus usual care in the short term may reduce length of hospital stay slightly when compared to usual care alone (mean difference -1.17 days, 95% CI -2.05 to -0.28; 1 trial, 462 participants; low-certainty evidence). We downgraded the certainty of the evidence due to concerns about risk of bias, imprecision, and inconsistency. None of the included trials reported on quality of life or vessel graft patency at either time point, and no study reported on adverse effects, cardiovascular mortality, or length of hospital stay at long-term follow-up.

AUTHORS' CONCLUSIONS

Preoperative coronary interventions plus usual care may have little or no effect on preventing perioperative acute myocardial infarction and reducing perioperative all-cause mortality compared to usual care, but the evidence is very uncertain. Similarly, limited, very low-certainty evidence shows that preoperative coronary interventions may have little or no effect on reducing long-term all-cause mortality. There is very low-certainty evidence that preoperative coronary interventions plus usual care may prevent long-term myocardial infarction, and low-certainty evidence that they may reduce length of hospital stay slightly, but not cardiovascular mortality in the short term, when compared to usual care alone. Adverse effects of preoperative coronary interventions were poorly reported in trials. Quality of life and vessel or graft patency were not reported. We downgraded the certainty of the evidence most frequently for high risk of bias, inconsistency, or imprecision. None of the analysed trials provided significant data on subgroups of patients who could potentially experience more substantial benefits from preoperative coronary intervention (e.g. altered ventricular ejection fraction). There is a need for evidence from larger and homogeneous RCTs to provide adequate statistical power to assess the role of preoperative coronary interventions for preventing acute myocardial infarction in the perioperative period of major open vascular or endovascular surgery.

Development and validation of the Ex-Care BR model: a multicentre initiative for identifying Brazilian surgical patients at risk of 30-day in-hospital mortality

BACKGROUND

Surgical risk stratification is crucial for enhancing perioperative assistance and allocating resources efficiently. However, existing models may not capture the complexity of surgical care in Brazil. Using data from various healthcare settings nationwide, we developed a new risk model for 30-day in-hospital mortality (the Ex-Care BR model).

METHODS

A retrospective cohort study was conducted in 10 hospitals from different geographic regions in Brazil. Data were analysed using multilevel logistic regression models. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), Brier score, and calibration plots. Derivation and validation cohorts were randomly assigned.

RESULTS

A total of 107,372 patients were included, and 30-day in-hospital mortality was 2.1% (n=2261). The final risk model comprised four predictors related to the patient and surgery (age, ASA physical status classification, surgical urgency, and surgical size), and the random effect related to hospitals. The model showed excellent discrimination (AUROC=0.93, 95% confidence interval [CI], 0.93-0.94), calibration, and overall performance (Brier score=0.017) in the derivation cohort (n=75,094). Similar results were observed in the validation cohort (n=32,278) (AUROC=0.93, 95% CI, 0.92-0.93).

CONCLUSIONS

The Ex-Care BR is the first model to consider regional and organisational peculiarities of the Brazilian surgical scene, in addition to patient and surgical factors. It is particularly useful for identifying high-risk surgical patients in situations demanding efficient allocation of limited resources. However, a thorough exploration of mortality variations among hospitals is essential for a comprehensive understanding of risk.

CLINICAL TRIAL REGISTRATION

NCT05796024.