Intraoperative blood loss may be associated with myocardial injury after non-cardiac surgery

Mean arterial pressure versus cardiac index for haemodynamic management and myocardial injury after hepatopancreatic surgery: A randomised controlled trial

BACKGROUND

Myocardial injury after noncardiac surgery (MINS) frequently complicates the peri-operative period and is associated with increased mortality.

OBJECTIVES

We hypothesised that cardiac index (CI) based haemodynamic management reduces peri-operative high-sensitive troponin-T (hsTnT) elevation and MINS incidence in patients undergoing hepatic/pancreatic surgery compared to mean arterial pressure.

DESIGN

A randomised controlled study.

SETTING

A single-centre study conducted in a university-affiliated tertiary hospital between June 2022 and March 2023.

PATIENTS

Ninety-one patients, who were ≥ 65 years old or ≥ 45 years old with a history of at least one cardiac risk factor were randomised to either mean arterial pressure (MAP) based ( n  = 45) or CI-based ( n  = 46) management groups, and completed the study.

INTERVENTIONS

In group-MAP, patients received fluid boluses and/or a noradrenaline infusion to maintain MAP above the predefined threshold. In group-CI, patients received fluid boluses and/or dobutamine infusion to keep CI above the predefined threshold. When a low MAP was observed despite a normal CI, a noradrenaline infusion was started.

MAIN OUTCOME MEASURES

The primary outcome was peri-operative hsTnT elevation. The secondary outcomes were MINS incidence and 90-day mortality.

RESULTS

The median absolute troponin elevation was 4.3 ng l -1 (95% CI 3.4 to 6) for the CI-based group, and 9.4 ng l -1 (95% CI 7.7 to 12.7) for the MAP-based group (median difference: 5.1 ng l -1 , 95% CI 3 to 7; P  < 0.001). MINS occurred in 8 (17.4%) patients in the CI-based group and 17 (37.8%) patients in the MAP-based group (relative risk: 0.46, 95% CI: 0.22 to 0.96; P  = 0.029). Two patients in group-MAP died from cardiovascular-related causes. One patient in group-CI and two in group-MAP died from sepsis-related complications (for all-cause mortality: χ2  = 1.98, P  = 0.16). MAP-AUC and CI-AUC values of the CI- and MAP-based groups were 147 vs. 179 min × mmHg ( P  = 0.85) and 8.4 vs. 43.2 l m -2 min -1  × min ( P  < 0.001), respectively.

CONCLUSIONS

CI-based haemodynamic management assures sufficient flow and consequently is associated with less peri-operative hsTnT elevation and lower incidence of MINS compared to MAP.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05391087.

Risk factors and prognosis of postoperative acute myocardial infarction in elderly hip fracture patients combined with coronary heart disease

INTRODUCTION

This article mainly studies the risk factors for postoperative acute myocardial infarction (AMI) in elderly hip fracture patients combined with coronary heart disease (CHD), constructs a prediction model, and evaluates the prognosis of all the patients.

METHODS

This article retrospectively collected elderly patients with hip fracture and CHD who underwent hip fracture surgery at the Third Hospital of Hebei Medical University from January 2019 to December 2021. Demographic data, laboratory indicators, and imaging examination results were collected from the medical case system. The risk factors of postoperative AMI were determined by univariate and multivariate logistic regression, and a nomogram prediction model was established. The ROC curve, calibration curve and DCA decision curve were plotted by R language software. The patients in the training set were followed up for 2 years to evaluate their survival situation.

RESULTS

1094 eligible patients were divided into a training set (n = 824 from January 1, 2019 to September 31, 2021) and a validation set (n = 270 from October 1, 2021 to December 31, 2022). In the training set, women accounted for 58.6%; The average age of the patients was 79.45 years old; The main type of fracture was intertrochanteric fracture. There were 64.7% patients taken B receptor blockers; A total of 166 (20.1%) patients underwent percutaneous coronary intervention (PCI); Hypertension accounted for 55.5%; 520 (63.1%) patients had a preoperative waiting time greater than 3 days; The average hemoglobin value upon admission was 101.36 g/L; The average intraoperative bleeding volume was 212.42 ml; The average surgical time was 2.5 ± 0.3 h; Reginal anesthesia accounted for 29.7%; 63 (68.5%) AMI patients had no obvious clinical symptoms; 68 (73.9%) AMI patients did not show ST-segment elevation in ECG; The risk factors of postoperative AMI were age, hemoglobin at admission, diabetes, chronic kidney disease, intraoperative bleeding, and reginal anesthesia. The AUC of the nomogram prediction model was 0.729. The AUC in the validation set was 0.783. Survival analysis showed a significant statistical difference in 2-year mortality between patients with AMI and without AMI, among all the patients with AMI, patients with ECG ST-segment elevation has higher mortality than patients without ECG ST-segment elevation.

CONCLUSION

Our research results found that the incidence of postoperative AMI in elderly patients with hip fractures and CHD was 11.1%. Age, diabetes, hemoglobin at admission, regional anesthesia, chronic kidney disease, and intraoperative bleeding are risk factors. The AUC of the nomogram in training set is 0.729. The 2-year mortality rate of the patients with AMI is higher than that of patients without AMI.

Prevalence, Location, and Variations of the Posterior Superior Alveolar Canal With Age and Gender in the Indian Population: A Cone Beam Computed Tomography (CBCT)-Based Retrospective Study

BACKGROUND

Enhancing the availability of bone in the vertical dimension for implant insertion is thought to be possible through implant site preparation using direct or indirect sinus lift. The posterior superior alveolar (PSA) canal is extremely vulnerable to trauma during this procedure. The anatomy of this region should be thoroughly evaluated to prevent traumatizing this artery and eventual perioperative bleeding. Due to a lack of relevant knowledge and the clinical importance of this problem, the position, diameter, detectability, and proximity of this canal to the alveolar ridge were assessed on cone beam computed tomography (CBCT) scans which were the main objectives of this study.

METHODOLOGY

A total of 240 CBCT scans were examined, and the position of the PSA canal, its diameter, the perpendicular distance from the inferior border of the PSA canal to the alveolar crest, and the perpendicular distance from the inferior border of the canal to the maxillary sinus floor was measured.

RESULTS

Intraosseous PSA canals were the most prevalent, followed by intrasinusal and extraosseous canals. Males had larger canal diameters and greater distances between the maxillary sinus floor and alveolar crest and the canal (P < 0.05).

CONCLUSION

CBCT was proven to be a useful method for assessing and localizing the PSA artery to prevent intraoperative bleeding and further complications.

Cardiac interventions on total knee arthroplasty: a national inpatient sample-based analysis

BACKGROUND

Comorbid cardiovascular diseases have been associated with poor outcomes in total knee arthroplasty (TKA); however, our understanding of TKA with prior cardiac treatment procedures has largely been undocumented. In this study, we examined TKA patients who had undergone different cardiac interventions that addressed their condition. The purpose was to characterize and compare outcomes for a growing patient population not yet analyzed.

MATERIALS AND METHODS

The 2016-2019 Nationwide Inpatient Sample database was queried for 558,256 patients who had TKA (ICD-10CM). Backgrounds significant for pacemaker [PM] (n = 8025), coronary artery bypass [CABG] (n = 12,683), heart valve surgery [HV] (n = 4125), or coronary stent [CS] (n = 19,483) were compared against those without, across demographics, admission information, and various complications.

RESULTS

Cardiac interventions were associated with increased age, male gender, length of stay, and cost of care. CABG, and Stent groups had more diabetics, but HV had significantly fewer (p = 0.008). PM and HV had significantly less tobacco use and, in addition to CABG, less obesity. Postoperatively, mortality was elevated in the PM [Odds ratio (OR) 2.89, p = 0.008], CABG (OR 2.53, p = 0.006) and CS group (OR 1.94, p = 0.018), but not HV. Myocardial infarctions were elevated in the CABG (OR 3.874) and CS group (OR 5.11) (p < 0.001). PM, HV, and CS had increased odds of periprosthetic fracture by 2.15-fold (p < 0.001), 2.09-fold (p < 0.001), 1.29-fold (p = 0.011) respectively. HV saw increased periprosthetic mechanical complications (OR 1.48, p = 0.006). CABG increased the odds of deep surgical site infection 14.23-fold and CS 9.22-fold (p < 0.001). Postoperative pneumonia was increased in PM, CABG, and CS groups (OR 2.15,), (OR 2.21,), (OR 1.64,) (p < 0.001).

CONCLUSIONS

Patients who have undergone cardiac intervention are generally at risk for adverse stays. Furthermore, risk factors and complications vary between the groups. Our analysis emphasizes the importance of individualized medical care and as a basis for electing and informing patients for TKA.

Troponin elevation as a marker of short deterioration and one-year death in a high-risk surgical patient cohort in a low and middle income country setting: a postoperative approach to increase surveillance

PURPOSE

Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate the clinical outcomes of a cohort of high-risk surgical patients according to high-sensitivity troponin T (hsTnT) in an LMIC setting.

METHODS

We conducted a prospective cohort study of 442 high-risk patients undergoing noncardiac surgery at a Brazilian hospital between February 2019 and March 2020. High-sensitivity troponin T levels were measured preoperatively, 24 hr, and 48 hr after surgery and stratified into three groups: normal (< 20 ng·L-1); minor elevation (20-65 ng·L-1); and major elevation (> 65 ng·L-1). We performed survival analysis to determine the association between myocardial injury and one-year mortality. We described medical interventions and evaluated unplanned intensive care unit (ICU) admission and complications using multivariable models.

RESULTS

Postoperative myocardial injury occurred in 45% of patients. Overall, 30-day mortality was 8%. Thirty-day and one-year mortality were higher in patients with hsTnT ≥ 20 ng·L-1. One-year mortality was 18% in the unaltered troponin group vs 31% and 41% for minor and major elevation groups, respectively. Multivariable analysis of one-year survival showed a hazard ratio (HR) of 1.94 (95% confidence interval [CI], 1.22 to 3.09) for the minor elevation group and a HR of 2.73 (95% CI, 1.67 to 4.45) for the troponin > 65 ng·L-1 group. Patients with altered troponin had more unplanned ICU admissions (13% vs 5%) and more complications (78% vs 48%).

CONCLUSION

This study supports evidence that hsTnT is an important prognostic marker and a strong predictor of all-cause mortality after surgery. Troponin measurement in high-risk surgical patients could potentially be used as tool to scale-up care in LMIC settings.

STUDY REGISTRATION

ClinicalTrials.gov (NCT04187664); first submitted 5 December 2019.

Prediction model for myocardial injury after non-cardiac surgery using machine learning

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.

Perioperative myocardial injury after elective neurosurgery: incidence, risk factors, and effects on mortality

Perioperative myocardial injury is an important reason of mortality and morbidity after neurosurgery. It usually is missed due to its asymptomatic character. In the present study, we investigated myocardial injury after noncardiac surgery (MINS) incidence, the risk factor for MINS, and association of MINS with 30-day mortality in neurosurgery patients. Patients with cardiac risk who underwent elective neurosurgery were enrolled to present prospective cohort study. The patients' demographics, comorbidities, medications used, medical history, and type of operation were recorded. The high-sensitivity cardiac troponin (hs-cTn) levels of the patients were measured 12, 24, and 48 h after surgery. The patients were considered MINS-positive if at least one of their postoperative hs-cTn measurement values was ≥ 14 ng/l. All the patients were followed up for 30 days after surgery for evaluation of their outcomes, including total mortality, mortality due to cardiovascular cause, and major cardiac events. A total of 312 patients completed the study and 64 (20.5%) of them was MINS-positive. Long antiplatelet or anticoagulant drug cessation time (OR: 4.9, 95% CI: 2.1-9.4) was found the most prominent risk factor for MINS occurrence. The total mortality rate was 2.4% and 6.2% in patients MINS-negative and MINS-positive, respectively (p = 0.112). The mortality rate due to cardiovascular reasons (0.8% for without MINS, 4.7 for with MINS, and p = 0.026) and incidence of the major cardiac events (4% for without MINS, 10.9 for with MINS, and p = 0.026) were significantly higher in patients with MINS. MINS is a common problem after neurosurgery, and high postoperative hs-cTn level is associated with mortality and morbidity.

Myocardial injury in noncardiac surgery

Myocardial injury is defined as an elevation of cardiac troponin (cTn) levels with or without associated ischemic symptoms. Robust evidence suggests that myocardial injury increases postoperative mortality after noncardiac surgery. The diagnostic criteria for myocardial injury after noncardiac surgery (MINS) include an elevation of cTn levels within 30 d of surgery without evidence of non-ischemic etiology. The majority of cases of MINS do not present with ischemic symptoms and are caused by a mismatch in oxygen supply and demand. Predictive models for general cardiac risk stratification can be considered for MINS. Risk factors include comorbidities, anemia, glucose levels, and intraoperative blood pressure. Modifiable factors may help prevent MINS; however, further studies are needed. Recent guidelines recommend routine monitoring of cTn levels during the first 48 h post-operation in high-risk patients since MINS most often occurs in the first 3 days after surgery without symptoms. The use of cardiovascular drugs, such as aspirin, antihypertensives, and statins, has had beneficial effects in patients with MINS, and direct oral anticoagulants have been shown to reduce the mortality associated with MINS in a randomized controlled trial. Myocardial injury detected before noncardiac surgery was also found to be associated with postoperative mortality, though further studies are needed.