APECx-Anaesthesia, Perfusion and Surgical Practices in Cardiac Surgery: Main Study Protocol of a Modular Multiphase Prospective International Multicentre Observational Study.

Insights from the thoracic surgery residents association early-career development series

Cardiac anaesthesia: the last 10 years.

Intraoperative Transesophageal Echocardiography During Coronary Artery Bypass Graft Surgery (CABG): A Major Step Toward Improving Outcomes in Cardiac Surgery

Literature review

Preoperative anemia management in the coronavirus disease (COVID-19) era

Cardiac Anesthesia: Principles and Clinical Practice, 2nd edition.

The Future of Cardiothoracic Anesthesia

Intraoperative Transesophageal Echocardiography for Cardiac Surgery: Experience in China

Neurological biomarkers in the perioperative period

Is it time to eliminate the use of opioids in cardiac surgery?

No pain, much gain?

The aging of the baby-boom population and the decreases in adult mortality seen in the last few decades will dramatically increase the age of Americans between 2010 and 2030. During that time, the population older than age 65 yr is expected to grow by 75%, whereas between 1995 and 2050, the cumulative growth of the population older than 85 yr is expected to exceed 400% (1). Furthermore, it has been reported that the increased demand for surgery in this population may exceed the rate of population growth (2). The implications of an aging population for the practice of anesthesiology are profound. Age-related changes in physiology and pharmacology can affect every aspect of perioperative care. The changes in surgical demographics will compel the anesthesiologist to become familiar with the physiology and clinical care of the aged. This review will serve as an introduction. First, some of the physiologic changes that occur with aging will be presented. Second, the preoperative assessment of the older surgical patient will be discussed. Third, some of the research related to intraoperative management of the geriatric surgical patient will be described. In the fourth section, we will discuss some geriatric-specific issues related to postoperative management. Physiologic Changes Relevant to Perioperative Care The most important generalization from physiologic studies of aging is that the basal function of the various organ systems is relatively uncompromised by the aging process per se. However, functional reserve and the ability to compensate for physiologic stress are reduced (Fig. 1).Figure 1: Schematic representation of the relationship between maximal (broken line) and basal (solid line) physiologic function. Functional reserve is the difference between maximal and basal function. Aging inevitably reduces functional reserve even in individuals who are physiologically "young." The configuration of the curve for basal function is adapted from longitudinal measurements of total (not weight-specific) basal metabolic rate. Reprinted with permission: Muravchick S. Geroanesthesia: principles for management of the elderly patient. St. Louis: Mosby, 1996 (Figures 1–3).Cardiovascular Changes Cardiovascular changes with aging have implications for anesthetic care. Changes in the vascular system and hemodynamics can affect every organ bed. The Framingham Heart Study documented a nearly linear increase in systolic blood pressure from age 30 to 84 yr (3). Age-related hypertension is attributable to a 50%–75% increase in arterial stiffness and a 25% increase in systemic vascular resistance (3,4). Increased sympathetic nervous system activity and decreased peripheral β-adrenergic responsiveness further contribute to the hypertension of aging (5). Ventricular hypertrophy develops in response to increased afterload, increasing wall stress, myocardial oxygen demand, and increasing susceptibility to ischemia. Although intrinsic contractility and resting cardiac output are unaltered with aging, ventricular hypertrophy and stiffening limit the ability of the heart to adjust stroke volume (6) and impair passive ventricular filling. In the elderly, changes in ventricular end-diastolic volume in response to either positive or negative changes in central venous pressure are typically half those seen in young or middle-aged subjects (7). At the same time, fatty infiltration and fibrosis of the heart increases the incidence of sinus, atrioventricular, and ventricular conduction defects (8). With aging there is also decreased myocardial responsiveness to catecholamines and a diminished heart rate response (6). These processes compromise the heart's ability to buffer changes in circulatory volume, resulting in a disposition to either congestive heart failure or hypotension. From the standpoint of perioperative hemodynamic stability, age-related changes in the autonomic control of heart rate, cardiac output, peripheral vascular resistance, and the baroreceptor response (7,9,10) are as important as the changes in the myocardium and vasculature. Age-related changes in the cardiovascular system involve alterations in both mechanics and control mechanisms; the same can be said of the pulmonary system. Pulmonary System Age-related changes in the pulmonary system parallel changes in the heart. With time, the thorax becomes stiffer, increasing the work of breathing and reducing maximal minute ventilation (11,12). Loss of thoracic skeletal muscle mass aggravates this process. Residual volume and functional residual capacity (FRC) both increase with age—5%–10% and 1%–3% per decade, respectively—whereas the forced expiratory volume in 1 s is reduced approximately 6% to 8% per decade (Fig. 2) (11,13). Because of reduced elastic recoil, the closing volume increases such that it exceeds FRC by age 65 (14). In the supine position, closing capacity may reach FRC by 44 yr of age (11). Inspiratory and expiratory functional reserve decrease with aging, and the normal matching of ventilation and perfusion decreases (15). The respiratory response to hypoxia also diminishes with aging (16); there is a decrease in ciliary function, and cough is reduced (11). Finally, pharyngeal sensation and the motor function required for swallowing are diminished in the elderly (17,18).Figure 2: Mean forced expiratory volume in 1 s (FEV1) versus age for men of differing ethnic groups. Reprinted with permission: Am J Respir Crit Care Med 1999;159:179–87 (Figure 1).Neurologic Changes with Aging Cardiopulmonary complications account for most morbidity and mortality in older surgical patients; however, neurologic morbidity affects a large number of patients, and age-related degenerative changes in the central and peripheral nervous systems contribute to a variety of other morbidities. Both the central and peripheral nervous systems are affected by aging (19). There is a decrease in cortical gray matter through middle age, resulting in cerebral atrophy (20). The ratio of gray to white matter decreases from 1.28 at 20 yr to a low of 1.13 at 50 yr, followed by an increase of this ratio to 1.55 at 100 yr of age. The latter increase appears to reflect a disproportionate loss of white matter in the latest decades (20). For the cortical gray matter, a decrease in neuronal volume appears more important than neuronal loss (21,22). There is also a reduction in the complexity of neuronal connections, a decrease in the synthesis of neurotransmitters, and an increase in the enzymes responsible for their postsynaptic degradation (20). Although cerebral metabolism, blood flow, and autoregulation generally remain intact (20), dendritic regression and the deficiency of neurotransmitters limit the ability of the older brain to integrate multiple neural inputs. Neuronal loss and demyelinization also occur in the spinal cord (23). Functionally, there are changes in spinal cord reflexes and reductions in proprioception. There are also important decreases in hypoxic and hypercarbic drive (11,24). Declines in visual and auditory function further complicate the ability of the nervous system to acquire and process information. This combination of changes can limit the ability of the older patient to understand and process information in the perioperative period. These changes are probably important contributors to postoperative delirium, drug toxicity, and falls. Aging is also associated with neuronal loss in the autonomic nervous system. Sympathetic and parasympathetic ganglia lose neurons, and there is fibrosis of peripheral sympathetic neurons. This peripheral neuronal adrenergic loss is associated with impairment of cardiovascular reflexes. At the same time, decreases in adrenoceptor responsiveness result in increased adrenomedullary output and plasma catecholamine concentrations (9,10,23). Circulating norepinephrine levels have been reported to increase approximately 60% (230 to 380 pg/mL) between age 20 and age 70 (10). Skeletal muscle innervation decreases, translating into a loss of motor units and a decrease in strength, coordination, and fine motor control (25). Joint position and vibration sense may be compromised, and the literature suggests some diminution in the processing of painful stimuli (26,27). However, this effect, if it exists, appears to be modest at best and does not affect all nerve types equally (27–29). Furthermore, given huge interpatient variability in nervous system function and in the experience of pain, alterations in subtypes of pain perception do not translate into a decreased need for analgesia in the elderly (29–32). Renal Aging is accompanied by a progressive decrease in renal blood flow (approximately 10% per decade after age 50) and loss of renal parenchyma (33). Furthermore, by the eighth decade, 10%–30% of remaining nephrons are sclerotic, reducing the functional capacity of the reduced nephronal number (34). Together these processes result in a progressive decrease in glomerular capillary surface area and glomerular filtration rate. However, because of loss of muscle mass, aging is not associated with an increase in serum creatinine. This physiologic, and often occult, aspect of senescence has practical implications in the perioperative period. The old kidney has difficulty in maintaining circulating blood volume and sodium homeostasis perioperatively (9,35). Fluid homeostasis is further complicated by alterations in thirst mechanisms and antidiuretic hormone release that frequently result in dehydration (35). Perioperatively, metabolic acidosis is also relatively common in elderly patients who are less efficient in the renal excretion of acid. Reductions in basal renal blood flow and a diminished response to vasodilatory stimuli (33,36) render the elderly kidney particularly susceptible to the deleterious effects of low cardiac output, hypotension, hypovolemia, and hemorrhage. Anesthetics, surgical stress, pain, sympathetic stimulation, and renal vasoconstrictive drugs may all compound subclinical renal insufficiency. Aging: Pharmacokinetics and Pharmacodynamics Our knowledge of the pharmacology of aging is limited by the fact that elderly patients are often systematically excluded from drug trials (37). This is a travesty because elderly patients are the largest users of prescription drugs. That said, certain predictions can be made about pharmacology in the elderly. With aging there is decreased lean body mass and total body water and an increased proportion of body fat; these alter the volume of distribution and redistribution of drugs and alter their rates of clearance and elimination. In a study of population pharmacokinetics for propofol, elimination clearance of the anesthetic was found to decrease linearly with age >60 yr, even correcting for changes in body weight (38). Furthermore, even though age-related changes in plasma proteins make generalizations about the pharmacokinetics complex, decreased protein binding and increased free fraction have the potential to increase the pharmacologic effect of drugs used perioperatively (39). Furthermore, alterations in cardiac output and renal or hepatic clearance may change drug plasma concentrations and their duration of action (40). Neuronal loss and decreased levels of neurotransmitters may increase sensitivity to anesthetics. The changes in pharmacokinetics that occur with aging make it difficult to identify an independent effect of aging on pharmacodynamics (41). However, age-related changes in the central nervous system appear to increase the sensitivity to a variety of anesthetics (42,43). This is probably best described for propofol, where elderly patients are approximately 30%–50% more sensitive than younger patients (44); this sensitivity is independent of the decreased clearance of the drug. Pharmacokinetic and pharmacodynamic changes, together with drug interactions and polypharmacy, conspire to make the elderly prone to adverse drug effects. There is an almost linear increase in adverse drug reactions with age (45,46), and the likelihood of adverse drug reactions increases with the number of drugs administered. The addition of several drugs, even short-acting ones, in the perioperative period makes adverse reactions likely. Implications What is clear from a review of the physiologic changes with aging is that even the fit elderly patient's ability to compensate for perioperative stress is compromised. The cardiac, pulmonary, neurologic, and neuroendocrine changes that occur with aging make hypotension, low cardiac output, hypoxia, hypercarbia, and disordered fluid regulation more commonplace in the perioperative period. Furthermore, because baseline cardiac, pulmonary, renal, and neurologic function is typically adequate in the absence of acute challenges, it can be very difficult to predict the effect of perioperative stress on the older patient. Preoperative Assessment of the Elderly Historically, preoperative assessment has served to alert the surgical care providers to physiologic conditions that may alter perioperative management and to determine whether medical intervention is indicated before proceeding. Two more contemporary uses of the preoperative assessment are to provide an index of risk and therefore contribute to decisions about the most appropriate intervention and to provide baseline data on which the success of a surgical intervention might be judged. Despite physiologic changes with aging and multiple comorbidities, even extreme age is not a contraindication to surgery (47–49). What is less clear is how to identify which patients will do well and which will do poorly. No area of perioperative anesthetic care and management requires more investigation. The preoperative assessment of the patient is composed of four interrelated functions: risk stratification, as defined by population-based studies; history and physical examination, including functional assessment of the individual patient; preoperative testing; and, in some cases, preoperative optimization. Population Studies. Because age itself adds little additional risk in the absence of comorbid disease (50), most risk factor identification and risk predictive indices have been disease oriented (51–55). These investigations have typically studied a broad age range of patients and in multivariate analyses identified the relative contribution of age, ASA status, specific surgical factors, intraoperative management, and comorbid conditions to surgical morbidity and mortality (52,53,56–60). The applicability of many existing risk indices to the geriatric population is unclear. Because of the prevalence of comorbid conditions, it is difficult to stratify the older patient population into smaller subsets with better-defined risk. The scarcity of population studies of perioperative risk and outcomes specifically in geriatric populations can make it difficult to provide good information or to choose the most suitable course of care. Furthermore, elderly patients have relatively unique risks. In addition to death, myocardial infarction, or congestive heart failure, older patients are unusually prone to postoperative delirium, aspiration, urosepsis, adverse drug reactions, malnutrition, falls, and failure to return to ambulation or to home. Therefore, preoperative assessment tools and the variables evaluated in outcomes trials require expansion for application to the geriatric surgical population. Once completed, epidemiologic studies that better stratify older patients would help to define the appropriate preoperative assessment. Functional Assessments. Functional evaluation of elderly surgical patients requires greater attention. This is important for several reasons. First, the evaluation of the "resting" patient does not indicate how the patient will respond to perioperative physiologic demands. Second, because of patient heterogeneity, functional assessments may be indicated to better characterize patient differences, whether it is for activities of daily living, cognitive and emotional status, or urologic function. Although these metrics have been applied successfully in orthopedic and thoracic surgery (61–63) and can have predictive value for longer-term outcomes (64–68), multidimensional assessment and perioperative functional assessment are largely lacking in the surgical literature. Preoperative functional assessment is important because the surgical goal should be to return the patient to at least the preoperative activity level. Tools such as the Short-Form Health Survey 36, with subscales for variables such as physical and emotional health, pain and health perception, and social functioning, can be used to measure health-related quality of life before and after surgery (Fig. 3). These types of multidimensional assessments have the potential to help redefine standards for the success of surgery and reset therapeutic priorities (61,62,69–71).Figure 3: Deviation from age- and gender-adjusted population-based Short-Form Health Survey 36 scores (subgroup scores by surgical procedure). ▵ = thoracic surgery for lung cancer; • = total hip arthroplasty; ○ = abdominal aortic aneurysm; dotted line = age- and sex-adjusted population-based value. Modified with permission from Blackwell Publishing: J Gen Intern Med 1997;12:686–97 (Figure 2).Preoperative cognitive and psychological evaluation of the elderly surgical patient deserves special comment. Although frank delirium or dementia at admission is very evident and is known to predict poorer acute and long-term outcome (72,73), subtle forms of cognitive impairment are much more common. Subtle forms of cognitive impairment can predict subsequent delirium (74) and worsened cognitive outcome in cardiac, orthopedic, and abdominal surgery patients (75–78). As such, a preoperative mental status examination (79) should be considered in all geriatric surgical patients. Preoperative depression and alcohol abuse are also relatively frequent and can affect outcomes (72,80,81); as with mental status batteries, a variety of assessment tools for depression are available. The effect of screening for mental status, depression, and alcohol abuse on perioperative management of elderly patients is a huge potential area of investigation. Preoperative Testing. The third area contributing to the preoperative preparation of the elderly surgical patient is preoperative testing. Although work in this area has been performed for large populations of mixed age groups, it is not clear whether preoperative screening tests have a different yield in the elderly or whether specific testing is indicated for elderly patient populations undergoing certain types of surgical procedures. In the general population, the bulk of routine tests are not indicated. Unfortunately, age-specific data are uncommon, and some small studies in elderly populations suggest a larger yield for specific tests. For the elderly surgical population, chest radiograph, electrocardiogram, and urinalysis may have a larger yield in patients undergoing certain types of procedures, even if these tests are not directly predictive of postoperative complications (82,83). In a small study of acutely ill elderly medical patients, the value of screening tests was evaluated (84). The most important finding in the screening battery was unknown urinary tract infections (16 of 50 patients; 32%). A different retrospective analysis (85) of 86 hip arthroplasty patients also determined that routine urine analysis was cost-effective in reducing hip infections in the elderly. Nutritional assessment can also be useful in subpopulations. The 44-center Veteran's Administration (VA) study found that albumin concentration was a predictor of surgical outcomes (86). However, because of wide confidence limits, laboratory assessments of nutritional status may make their application to individual patients less useful than to populations (87). As such, it may prove useful to combine laboratory tests with anthropomorphic measurements, such as body mass index, limb circumference, and weight loss (88–90). These instruments are simple and inexpensive, but their clinical yield has not been From these investigations and from work in younger become First, screening in a general population of elderly patients does not to information in the clinical Second, in a general population, the positive predictive value of on routine screening is Third, with a few screening tests have relatively little effect on the course of patient care. Despite those further research is required to better define the which certain tests should be Although the yield for routine screening is very it may be and cost-effective to for preoperative testing that are on the of types of surgery different types and of physiologic As such, the of a are to patients undergoing vascular Preoperative tests such as and can have predictive value and alter the course of care if applied to specific populations at increased risk nutritional assessment might be very useful before abdominal or orthopedic but it would have a much smaller effect for for urinary tract before orthopedic surgery or pulmonary function testing before thoracic surgery might be of laboratory testing. Because it is the of the patient and the surgical stress that specific testing might be equally indicated in a very physiologically older patient undergoing surgery and in the older patient undergoing surgery that physiologic studies in older patients will need to stratify patients as to of their risk or and specifically their with the specific surgical most common in the elderly. Preoperative In addition to an assessment of risk on population 2) functional data to help define surgical and specific information to perioperative management, the fourth of preoperative evaluation is to determine whether medical intervention is indicated before proceeding. Preoperative is an area in which relatively little geriatric research has been In specific populations undergoing the value of preoperative of cardiac and pulmonary status can be in nutritional status, preoperative or renal function has the potential to alter outcomes but has not been Preoperative management of and are other to There are also that preoperative might pain management and and delirium after some types of where success has been in these a with a specific geriatric care was Because anesthetic care is the for success are typically and are not related to mortality and of drugs and often variables such as and of the work specific to the elderly has been to evaluation of anesthetics. Although some of these studies have identified age-related alterations in the or is a drug may by 30 the clinical effect of these changes on patient outcomes is probably There is a for this of research in but research should probably be In addition to the studies on the pharmacology and in surgical patients, a area of research has been to and general for elderly orthopedic patients have been the in research in geriatric and general in elderly orthopedic patients has broad implications for research These studies have intraoperative cardiovascular in the elderly, and pain and cognitive of this literature was by Although a few studies reported that for orthopedic surgery was associated with better outcomes subsequent investigations have not this broad populations of patients Because most investigations have been for has been and trials that reported to at least 1 The to identify difference in mortality or blood loss by or general anesthetic there was a reduced incidence of in groups. of the data in and study more with the addition of additional trials and described reduced and mortality in hip patients other outcome measure The reduction in mortality was evident at or large studies have also not identified in morbidity or mortality by anesthetic in hip surgery patients. A was in the review The review by the effects of in trials that patients. A reduction in mortality and was in the with effect on mortality 1 Reductions in pulmonary respiratory depression, myocardial infarction, and renal failure also described with However, the of many of these outcomes was the analysis was on small subsets of patients. studies not for and data used that not reported in the Furthermore, studies for and orthopedic, and and information about age was Finally, it is to a practice on the of the review of because the of patients into the those spinal 2) general followed by postoperative general with intraoperative spinal and general with intraoperative From this it is difficult to determine whether the effects described in the review are and, if their is or to patients would In addition to the more outcomes several studies in orthopedic patients have the effect of anesthetic on cognitive or functional often patients for Although of the studies is study identified difference in cognitive outcome in elderly patients undergoing versus general for orthopedic The bulk of investigations identify difference Although not all studies are in be for and peripheral vascular surgery In there is a of a better outcome with a however, most investigations are retrospective or the effect of patient be the not identify an independent effect of anesthetic on The difficulty in a difference between and general has implications for the of research in geriatric First, because the most difference in the of anesthetic is whether the patient a or a general if little or difference in outcome can be the yield for outcome studies on differing anesthetics is to be Second, it that studies on anesthetic management and outcome will need to be to specific complications in patients to provide clinical Physiologic Although studies have the relationship between intraoperative physiologic management and of it appears that physiologic management a than a in The best is in cardiac in which the acute physiologic changes exceed those seen with other of Despite it has been difficult to a

Objective: To analyze the clinical outcomes of systemic lupus erythematosus (SLE) patients who underwent cardiac surgery and to investigate the appropriateness of cardiac valve surgery in SLE patients with lupus nephropathy-related chronic kidney disease (CKD) and valvular heart disease (VHD). Methods: It was a retrospective review to evaluate SLE patients who underwent cardiac surgery because of VHD or coronary artery disease (CAD) between January 2000 and January 2010. Clinical outcome measurements included in-hospital mortality rate and postoperative complications such as vascular events and infections. The outcomes of SLE patients with VHD who did not undergo cardiac valve surgery were analyzed simultaneously. Results: Seven patients who underwent cardiac surgery were identified: five women and two men. The median duration of SLE from diagnosis to the surgery was 7.3 years (range 1-20 years). The median age was 58 years (range 28-72 years). Five patients received cardiac valve surgery; all five demonstrated stage III, IV, or V CKD and New York Heart Association class III or IV heart failure. Three patients underwent coronary artery bypass grafting (CABG) for double-vessel CAD, one of whom received concurrent mitral annuloplasty. Twenty-six patients presenting with VHD who did not undergo cardiac valve surgery were also evaluated as control cases. Two of the seven SLE patients who underwent cardiac surgery died, giving a mortality rate of 28.6%. Two of the five SLE patients who underwent cardiac valve surgery died while hospitalized, giving a mortality rate of 40%. One of the three patients who underwent CABG who also received cardiac valve surgery at the same time died. Two of the SLE patients with VHD who did not have surgery died (p=0.02 compared with SLE patients with VHD who received an operation). Both the one-year and five-year survival rates were 92.3% among SLE patients with VHD without surgery and 60% in those who underwent cardiac valve surgery. Conclusions: Cardiac surgery is performed rarely in SLE patients. The poor outcomes of cardiac surgery probably reflect the older age, poor heart function, severe renal insufficiency, and more frequent hemolytic anemia. SLE patients often demonstrate lupus nephropathy-related CKD concomitantly with VHD with symptomatic heart failure, both of which share similar clinical manifestations, including fluid overloading and limited daily performance status. Before cardiac surgery, we should optimize medical treatment and cardiac rehabilitation for SLE patients with VHD and symptomatic heart failure.

Effect of Chronic and Acute Thyroid Hormone Reduction on Perioperative Outcome

BackgroundThe effects of perioperative statin therapy on clinical outcome after cardiac or non-cardiac surgery are controversial. We aimed to assess the association between perioperative statin therapy and postoperative outcome.MethodsElectronic databases were searched up to May 1, 2018, for randomized controlled trials of perioperative statin therapy versus placebo or no treatment in adult cardiac or non-cardiac surgery. Postoperative outcomes were: myocardial infarction, stroke, acute kidney injury (AKI), and mortality. We calculated risk ratio (RR) or odds ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses. We performed meta-regression and subgroup analyses to assess the possible influence of statin therapy regimen on clinical outcomes and trial sequential analysis to evaluate the risk of random errors and futility.ResultsWe included data from 35 RCTs involving 8200 patients. Perioperative statin therapy was associated with lower incidence of postoperative myocardial infarction in non-cardiac surgery (OR = 0.44 [95% CI 0.30–0.64], p < 0.0001), but not in cardiac surgery (OR = 0.93 [95% CI 0.70–1.24], p = 0.61) (psubgroup = 0.002). Higher incidence of AKI was present in cardiac surgery patients receiving perioperative statins (RR = 1.15 [95% CI 1.00–1.31], p = 0.05), nonetheless not in non-cardiac surgery (RR = 1.52 [95% CI 0.71–3.26], p = 0.28) (psubgroup = 0.47). No difference in postoperative stroke and mortality was present in either cardiac or non-cardiac surgery. However, low risk of bias trials performed in cardiac surgery showed a higher mortality with statins versus placebo (OR = 3.71 [95% CI 1.03–13.34], p = 0.04). Subgroup and meta-regression analyses failed to find possible relationships between length of statin regimens and clinical outcomes. Trial sequential analysis suggested no firm conclusions on the topic.ConclusionsPerioperative statins appear to be protective against postoperative myocardial infarction in non-cardiac surgery and associated with higher AKI in cardiac surgery. Possible positive or even negative effects on mortality could not be excluded and merits further investigations. Currently, no randomized evidence supports the systematic administration of statins in surgical patients.